Coronary Care Unit Rotation

Upon completion of the Otolaryngology rotation, the neurosurgery resident shall be able to:

PREAMBLE

Cardiovascular medicine is an integral part of the managing Neurosurgical patients in the NICU. Ability to recognize and manage neurogenic ECG changes, BP, arrhythmia, heart failure, vaso-reactive medications and volume status is critical in certain perioperative situations.

The Coronary Care Unit affords exposure to a wide variety of cardiovascular disease in a supervised setting. This setting allows for graded independence as the trainee gains more comfort and knowledge of specific cardiovascular diseases.

Trainees also need be knowledgeable regarding the criteria for their appropriate referral to Cardiology and CCU.

Postgraduate trainees need to be aware of the indications and appropriate use of common cardiovascular therapeutics and diagnostics, including their limitations and contraindications.  Trainees also require competence in the cardiovascular physical exam and interpretation of electrocardiograms.  The CCU can provide an environment in which trainees can gain more comfort in both these areas.

MEDICAL EXPERT

a. ISCHEMIC HEART DISEASE

  • Demonstrate an understanding of the pathophysiology, and natural history of atherosclerotic coronary artery disease (CAD)
  • Demonstrate expertise in the recognition and appropriate triage of CAD patients who present with an unstable acute coronary syndrome (ACS), which comprises non-ST elevation and ST elevation myocardial infarction and unstable angina
  • Promptly recognize an STEMI and appreciate the importance of timely pharmacological or mechanical reperfusion
  • Elicit, present, and document a complete chest pain history in order to diagnose chest pain as a result of an unstable cardiac condition and be able to provide a rational and cogent differential
  • Apply knowledge regarding the use of ancillary biochemical testing or other imaging techniques in order to appropriately triage such patients for appropriate medical therapy and/or revascularization techniques with ACS.
  • Be able to differentiate the various clinical conditions aside from ACS that result in troponin elevation
  • Demonstrate an understanding of the common ECG patterns of unstable cardiac disease, and the limitations of this technique in diagnosing patients with ischemic type chest pain
  • Demonstrate an understanding of the risks and benefits for anticoagulant and antiplatelet agents commonly used to treat unstable coronary syndromes

b. CRITICAL CARE CARDIOLOGY

  • Demonstrate expertise in the diagnosis and initial management of cardiogenic shock
  • Demonstrate an understanding of normal and shock cardiovascular physiology, and ability to differentiate cardiogenic shock from shock states of other etiologies
  • Demonstrate an understanding of the supportive technologies for the treatment of cardiogenic shock, including right heart catheterization and intracardiac pressure monitoring, intravenous inotropic and vasoactive medications and intra-aortic balloon pumps

c. VALVULAR HEART DISEASE

  • Demonstrate understanding knowledge in the diagnosis of common valvular and peri-valvular heart lesions including mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, mitral valve prolapse and hypertrophic obstructive cardiomyopathy.
  • Demonstrate an understanding of the natural history of these conditions, their appropriate medical therapy and the indication and timing of definitive mechanical intervention if appropriate

c. ARRHYTHMIAS

  • Demonstrate the ability to consistently and accurately recognize a normal ECG
  • Apply knowledge and expertise in the electrocardiographic interpretation of common atrial and ventricular arrhythmias including, but not limited to, atrial fibrillation, atrial flutter, ventricular tachycardia, and bundle branch blocks.
  • Demonstrate an understanding of the pharmacological management of common tachyarrhythmias
  • Demonstrate an understanding of the indications for, and the ability to apply the techniques of, emergent DC cardioversion for hemodynamically significant tachyarrhythmias

d. HEART FAILURE

  • Demonstrate expertise in the ability to define and diagnose the clinical features of diastolic and systolic heart failure
  • Demonstrate an understanding of the underlying pathophysiology and etiologies that can result in systolic or diastolic dysfunction, and the ability to formulate a rational diagnostic approach to the heart failure patient
  • Demonstrate the ability todiagnose and manage acute heart failure, including the use of pharmacotherapy of chronic heart failure
  • Recognize basic hemodynamic tracings from right heart catheterization in acute heart failure and how to utilize these tracings to guide management

COMMUNICATOR:

  • Demonstrate effective consultant skills, including the ability to generate and present a competent consultative report, both in written and oral forms
  • Demonstrate the ability to care for their patients diligently and accurately track their progress in the medical chart, which in turn should reflect a high level of clinical thinking
  • Demonstrate the ability to generate a complete and cogent discharge summary

COLLABORATOR:

  • Demonstrate the ability to work alone and in a group setting, and be aware of when to ask for help from superiors
  • Identify, describe and respect the roles of other members of the CCU health care team, including but not limited to nurses, physiotherapists, respiratory therapists and social workers

LEADER:

  • Implement patient care practices consistent with the goals of care in patients considering available health resources

HEALTH ADVOCATE:

  • Educate patients and families about and promote the importance of long-term healthy behaviors and preventive cardiology
  • Demonstrate an understanding of the concept of primary and secondary prevention for atherosclerotic heart disease
  • Apply knowledge and expertise in the risk stratification of patients at risk for coronary artery disease, and the appropriate titration of medications to prevent acute events
  • Demonstrate an understanding of the evidence based pharmacological and non-pharmacological therapies that reduce the risk of recurrent events following an acute coronary syndrome

SCHOLAR:

  • Demonstrate the ability of continued self-learning and self-assessment and knowledge acquisition. Formal and informal bedside and didactic teaching made available to residents should serve as a starting point for residents

PROFESSIONAL:

  • Demonstrate the ability to care for patients assigned to their care in a responsible and professional manner
  • Demonstrate the ability to work collegially within a team setting