Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine - Fellowships
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Neuroanesthesia Fellowship Core Curriculum

Rotation Duration Institution
Introduction- neurosurgical anesthesia 1 month BWH
Introduction- neurosurgical anesthesia 1 month MGH
Neurosurgical anesthesia (OR and non-OR) 1-2 months BWH
Neurosurgical anesthesia (OR and non-OR) 1-2 months MGH
Neurocritical care 2 months MGH/BWH
Pediatric neuroanesthesia 1 month CHB
Neurophysiology 1 month BWH/MGH
Academic 1 month BWH/MGH
Elective 1 month BWH/MGH
Vacation 1 month  


1. Neuroanesthesia rotations (5 months)



Objectives:
The training will begin with 1 introductory month in the neurosurgical operating rooms at each institution (MGH and BWH), during which time the fellow will gain familiarity with the environment, procedures and personnel. During this period, the fellow will do major cases solo under the supervision of an attending neuroanesthesiologist. The goal of this rotation is to immerse the fellow in the neuroanesthesia operating rooms so as assure a smooth transition and rapid learning curve. This experience will allow the fellow to quickly become familiar with the environment, surgeons, and staff and to develop the skills in neuroanesthesia necessary to subsequently supervise residents.

During the subsequent months, the fellow will supervise residents on their neuroanesthesia rotation under the close supervision of a neuroanesthesia attending. In addition, the fellow will be assigned to non-OR locations where neurosurgical procedures are performed such as the interventional neuroradiology suite and the AMIGO suite. During the latter half of the year, when the fellow is assigned to the neurosurgical operating rooms he/she will function as junior faculty, independently supervising and teaching a resident or nurse anesthetist with an attending anesthesiologist immediately available for backup in an emergency. During this period he/she will also be allowed to work 1 d/week as attending anesthesiologist in the main OR (3 clinical neuroanesthesia days per week, 1 academic day (including post call days, please see below), and 1 regular OR staff day).

Measureable knowledge/behavior:
The fellow will show competency in the investigation, evaluation and care of the neurosurgical patient; in the appraisal and assimilation of scientific evidence; and in improvements of the patient's perioperative care. Fellows are expected to demonstrate recognition of the anesthetic implications of the neurosurgical conditions and be confident in managing these patients, including management of peri-tumor edema, increased intracranial pressure, cerebral ischemia, and cerebral and spinal cord protection from surgical ischemia and trauma. They should facilitate the learning of students and other health professionals.

Available resources:

Our institutions have large and active neurosurgical services with approximately 3000 cases per year. Together, the neurosurgical services run 9-10 operating rooms per day, not including out of OR sites such as interventional neuroradiology and AMIGO (together about 4 additional sites per day). The case load is varied and includes supra- and infratentorial craniotomy for tumor, trauma, seizure foci, and "functional neurosurgery" (e.g. electrode implantation for Parkinson's disease); neurovascular procedures including intracranial aneurysm, AVMs, extracranial-intracranial bypass, and carotid endarterectomy; transphenoidal surgery; complex spine surgery with instrumentation; as well as more routine cases such as ventriculoperitoneal shunts, subdural evacuation, and routine laminectomy. Experienced neuroanesthesia faculties are always available for supervision and consultation. The anesthesia department maintains excellent libraries at each institution, and all major textbooks and journals on neuroanesthesia are available from the department library or through the Treadwell and Countway libraries.

Didactics:

MGH:
Neuronesthesia division conference: weekly, 45 min
Anesthesia Grand Rounds: weekly, 1h
Anesthesia Case conference: weekly, 1h
Anesthesia faculty lectures: weekly, 1h

BWH:
Neuronesthesia division conference: weekly, 45 min
Anesthesia Grand Rounds: weekly, 1h
Anesthesia Case conference: weekly, 1h
Anesthesia faculty lectures: weekly, 1h

Society of Neurosurgical Anesthesia and Critical Care Neurophysiologic monitoring workshop: 1 day

Society of Neurosurgical Anesthesia and Critical Care Annual meeting: 2 days Neurocritical Care Society Meeting: 4 days

Assigned reading: Cottrell and Young's Anesthesia and Neurosurgery, Chapters on Neurosurgical physiology and pharmacology, intracranial hypertension, Traumatic Brain Injury, Subarachnoid hemorrhage and intrcranial bleeding in Grossman's Principles of Neurosurgery. Connors' Interventional Neuroradiology

Faculty:
BWH: Linda S. Aglio MD, Gregory Crosby MD, Lisa Crossley MD, Deborah J. Culley MD, Daniel Dedrick MD, Laverne D. Gugino MD, Grace Kim, MD, Joshua Vacanti MD, Jay Zhou MD

MGH: Gregory Ginsburg MD, John Marota MD, PhD, Ala Nozari MD, PhD, Robert Peterfreund MD, PhD, Michele Szabo, MD

2. Neurocritical Care (2 months)


Objectives:
The fellow will work under the direction of a neuro intensivist with formal training and board certification in neurocritical care. He/she will be responsible for managing patients medically and preparing patients for upcoming cases in the operating room.

Measureable knowledge/behavior:
Management of severely compromised neurosurgical patients including those with traumatic brain injury, spinal cord injuries, neurovascular catastrophes, intracranial hypertension and coma. Assessment of the neurological symptoms and knowledge of various neurological diagnostic modalities including computerized tomography, magnetic resonance imaging, and angiography.

Available resources:
The Neurocritical Care Units at the Massachusetts General Hospital and Brigham and Women's Hospital include all neurointensive care specialties delivered by experienced physicians and nurses. With over 20 years of experience, these ICUs excel in state of the art acute vascular management, neurological treatments, and advanced monitoring equipment.

Didactics:
Neurocritical Care division conferences: weekly, 1h
Department of Neurology Stroke/neurovascular Conference: weekly, 1h
Neuronesthesia division conference: weekly, 45 min
Anesthesia Grand Rounds: weekly, 1h
Anesthesia Case conference: weekly, 1h
Anesthesia faculty lectures: weekly, 1h

Assigned reading: Decision Making in Neurocritical Care (J Frontera), Neurocritical Care (M Wijdicks and F Eelco). Board Review in NeuroCritical Care (United Council for Neurological Specialties).
Faculty:
Jonathan Rosand MD, Eric Rosenthal MD, Taylor Kimberly MD, Ala Nozari, MD, PhD

3. Pediatric Neuroanesthesia (1 month)


Objectives:
Fellows will refine their knowledge and skills in the perioperative care of children with neurosurgical and spine pathologies. They will participate in the perioperative care of pediatric patients of all ages, under the supervision of experienced pediatric anesthesiologists at the Children's Hospital in Boston (see letter).

Available resources: Children's Hospital, Boston provides highly specialized care for infants, children and adolescents with diseases, disorders or injuries that affect the brain, spine and central nervous system. Cases include brain injury, CNS malignancies, cerebrovascular disorders, functional neurosurgery, vascular anomalies, craniofacial anomalies, congenital anomalies, neurofibromatosis, epilepsy, and spine surgery (including scoliosis, spina bifida and tethered spine). The fellow will participate in the preoperative assessment of the patients and manage them intraoperatively under the supervision of an experienced pediatric neuroanesthesiologist. Children's Hospital provides extensive educational resources and a wide range of lectures on care and current research in pediatric neuroanesthesia and pediatric neurological and neurosurgical disease.

Didactics: Weekly conferences include Grand Rounds and risk management conferences, anesthesia research conference, fellow's seminar journal club and tutorials. Fellows will be expected to participate in these activities as requested. Assigned reading: A Practice of Anesthesia for Infants and Children, Cote JC, Lerman J and Todres ID. Chapter: Pediatric neurosurgical anesthesia


Faculty:
Sol Soriano, MD, Mark A Rockoff MD

4. Neurophysiology (1 month)


Objectives:
A large percentage of neurosurgical procedures utilize intraoperative neurophysiologic monitoring. Therefore, one month is dedicated to understanding and interpreting EEG and evoked potential monitoring. The fellow will work closely with the anesthesiologist or neurologist / electrophysiologist supervising that activity in the OR on both the cognitive aspects of such monitoring (e.g. rationale for monitoring; choice of monitors; waveform interpretation; anesthetic confounders) as well as the practical considerations such as lead placement and troubleshooting of problems.

Measureable knowledge/behavior:
Can recognize and troubleshoot routine problems (e.g. electrical interference); interpret output of neurological monitoring including electroencephalogram, somatosensory-evoked potentials, brainstem auditory-evoked potentials, and motor-evoked responses viz a viz physiologic and anesthetic effects and impact of surgical procedures.

Assigned reading: Russell's Primer of Intraoperative Neurophysiologic Monitoring

Faculty:
Linda S Aglio MD, Laverne D. Gugino MD, PhD, Mirela V. Simon MD

Electives:
Elective time can be used to gain further proficiency in any of the major areas within neuroanesthesia, including neurovascular procedures, neurocritical care, neuromonitoring, pediatric anesthesia or interventional radiology. It can also be used to gain further experience in clinical or basic science research.


 
Office Information

Department of Anesthesia,
Critical Care and Pain Medicine
Gray-Bigelow 444
55 Fruit Street
Boston, MA 02114

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