Each subspecialty is directed by a member of the anesthesia faculty. Every rotation is educationally structured, monitored, and periodically evaluated. Case assignments are based on clinical needs as well as educational objectives.
Adult Cardiac Anesthesia
The cardiac anesthesia department at Tufts Medical Center works closely with a robust cardiac surgery division that is recognized as being one of the region’s largest heart transplant and VAD programs, as well as structural heart and ECMO cases. Our dedicated cardiac anesthesiologists are all certified in advanced perioperative TEE and many are also dual-board certified in critical care. The rotation focuses on education on cardiac physiology, pharmacology, echocardiography, and the mechanics of cardiopulmonary bypass. Residents begin rotating through the service in their CA-1 year with graduated goals and objectives designed to allow for progressive skill development and independence. Residents are exposed to an impressive breadth of cases, including CABGs, valve replacements, heart failure surgery, and major aortic operations. The residents are supervised directly by faculty members or fellows in our cardiothoracic anesthesiology fellowship. Residents are provided with specific keywords tailored to their year of training as a framework for intra-operative education. During the CA-1 year the focus is on physiology and pharmacology, while in the CA-2 year the emphasis is on the management of different pathologic conditions including multi valve disease. Training in echocardiography is incorporated into the CA-2 and CA-3 years, however residents also have the option to complete an advanced elective in echocardiography.
Neuroanesthesia
During the neuroanesthesia rotation, the anesthesia resident takes care of patients undergoing intracranial and spine surgeries. Tufts Medical Center has a large population of neurosurgical procedures which provide residents with a diverse and challenging caseload. Residents are assigned to one month of neuroanesthesia during their CA1, CA2, and CA3 years. An extra elective month can be tailored to the needs and experience of each resident.
Our residents are engaged in providing anesthesia for numerous complex procedures, including the treatment for brain tumors, aneurysms, arteriovenous malformations (AVMs), spinal disorders, and carotid artery disease. Additional highlights of the rotation include skull base surgeries, pediatric neurosurgical cases, and awake craniotomies. Our neuroanesthesia division is proud of its collaborative relationships with team members involving neuro-intensivists, neurosurgeons, neurologists, and neurophysiologic monitoring personnel.
Pediatric Anesthesia
At Tufts Medical Center, our residents are given a longitudinal experience in pediatric anesthesia from CA-1 to CA-3 year consisting of three 4-week rotations. This provides the residents with early exposure in their CA-1 year that continues throughout their training. This is complemented by additional pediatric call in the CA-2 year that allows our residents to gain experience caring for high acuity patients as well as pediatric and neonatal emergencies.
Our residents are supervised by pediatric anesthesiology faculty. Care is provided in a variety of clinical settings including the general ORs, MRI, endoscopy suite, CT scan, and interventional radiology. CA-1 residents learn basic pediatric anesthesiology principles, progressively acquiring more knowledge and clinical experience so that by their CA-3 year they will have had varied and in-depth pediatric anesthesia training.
Vascular and Thoracic Anesthesia
The objective of the vascular and thoracic anesthesia rotation is to provide residents with the opportunity to acquire hands-on technical skills while expanding their knowledge and understanding of these disciplines.
Residents start their first month of the thoracic rotation during their CA-2 year of residency after they have already mastered basic technical skills and knowledge of anesthesiology. Residents are introduced to a variety of thoracic surgical procedures such as bronchoscopy, mediastinoscopy, lung volume resection (open, video assisted or robotic), and esophageal surgery for hiatal hernias or cancer treatments.
In coordination with their faculty the residents participate in the anesthetic management to perform lung isolation, navigate fiberoptic bronchoscopy, and develop a pain management plan in these often high-risk patients. Close intraoperative supervision allows for in-depth discussions about relevant topics and maximum resident education.
The first month of the vascular anesthesia rotation occurs early in the CA-1 year. Our residents provide anesthesia for a diverse array of surgeries including carotid endarterectomies, revascularization procedures, and aortic aneurysm repairs with spinal cord protection. Due to the nature of these procedures and challenging patient population, there are ample opportunities to practice insertion and interpretation of hemodynamic monitoring devices. Intraoperative teaching focuses on cardiovascular physiology, pharmacology, coagulation systems, and blood transfusion management.
As the level of competence and knowledge base in our residents grow, so does the level of independence in their decision-making and practice. This transforms their advance rotations during CA-2 and CA-3 into a distinctly different experience, where they can enjoy a great deal of independence in navigating patient care in coordination with other services through analytical thinking, self-assessment, and practicing evidence-based medicine.
Research
The research month is a protected time for participation in basic or clinical research projects. Residents are provided a week in the CA-1 year to identify a proposed project prior to their rotation to obtain regulatory approval for the project, as appropriate. In most cases this will include writing and submitting a protocol to the IRB. With the guidance of their mentors, residents enjoy developing a research question, practicing literature reviews, and data collection as well as learning basic biostatistics and data analysis relevant to their research. Multiple residents have presented their work at national meetings and written papers for publication in medical journals.
Regional Anesthesia
Residents during their rotation in Acute Pain Service (APS) and Regional Anesthesia are exposed to a comprehensive service that takes a multimodal approach for the management of perioperative, acute, acute-on-chronic, and chronic pain patients. Residents exercise up-to-date, evidence-based interventions, including neuraxial and ultrasound-guided regional nerve blocks. They learn how to build multimodal analgesia plans to optimize patient comfort in our challenging complex patient population as well as how to coordinate and communicate with the primary, surgical, and anesthesiology teams.
Obstetric Anesthesia
During this rotation, residents learn to provide comprehensive anesthetic care to pregnant women. It includes both analgesia options during labor and anesthesia for cesarean delivery. Residents also learn how to provide anesthetic techniques for non-delivery procedures e.g. external version, cervical cerclage, bilateral tubal ligation. Rotators conduct multiple consultations for high-risk and complex medical pregnant patients and become comfortable in managing patients with post-partum complications. Residents participate in the obstetric anesthesia service throughout the three years of training and as they become more experienced in the management of the obstetric patient, they are given increasing responsibility in clinical care. All residents engage in a highly valued obstetric anesthesia rotation at the Brigham and Women's Hospital in their CA-2 year.
Advanced Obstetric Anesthesia
The division of obstetric anesthesia at Brigham and Women’s Hospital oversees the delivery of nearly 10,000 babies per year. In addition, we provide anesthetic services for an active in-vitro fertilization (IVF) program that performs over 1,500 egg retrieval procedures per year. We also provide anesthesia coverage for approximately 1,000 D&E procedures for early pregnancy miscarriages, as well as other pregnancy related procedures such as post-partum tubal ligation and cervical cerclage. We also have an active in-utero fetal surgery program where we provide anesthetic care to women undergoing a variety of fetal intervention procedures. A large number of the patients we care for on the obstetric service at BWH have one or more co-morbidities and complications of pregnancy. Common obstetric problems encountered include preeclampsia, prematurity, multiple gestation, placenta previa and placental abruption. Common medical co-morbidities include obesity, cardiopulmonary disease, diabetes, hematologic, neurologic, and hepatic disease, as well as drug abuse, extremes of maternal age, and other assorted medical and obstetric conditions. We supervise an active antenatal high-risk anesthesia consultation service where we see a variety of patients during gestation and before their presentation in labor. We use this consultation service to evaluate the various medical and obstetric problems, arrange appropriate consultations, and discuss the plan of care in a multidisciplinary manner with the patient’s other medical, obstetric and nursing care providers.
In this advanced obstetric anesthesia rotation, residents will become involved with more complex cases, such as those manifesting the co-morbidities noted above. Residents will also perform some of the high-risk antenatal consultations and preferentially perform the anesthesia for more complex cesarean deliveries, such as those where major hemorrhage or other difficulties are expected or for fetal surgery cases. Residents will also provide anesthetic care for the more complex laboring patients, such as those with morbid obesity, cardiac and pulmonary disease, and preeclampsia with severe features. In addition, BWH offers an intensive didactic program, including twice daily lectures on a variety of topics related to obstetric anesthesia.
Post Anesthesia Care Unit (PACU)
The Post Anesthesia Care Unit (PACU) is the area where patients recover after having received anesthesia for a vast array of procedures. The PACU is divided into two units: Phase 1 PACU and Tufts Medical Center-main PACU. Phase 1 PACU is located in South 5 and has fourteen recovery spaces all specialized to recover day surgery cases. Whereas the Tufts Medical Center-main PACU is located in Floating Building 5 and has seventeen recovery spaces, all specialized for inpatient recovery.
The PACU resident and attending are involved in the postoperative care of patients, managing issues and complications that may arise and ensuring that patients are stable and ready for discharge to either home or the floor. The resident also participates in nursing education by giving a presentation to the nursing staff. The PACU anesthesia team attends all trauma calls that pass through the emergency department and provides airway and resuscitative support throughout the hospital. The PACU anesthesia team also supports broader critical needs in the institution as well.
Cardiothoracic Unit (CTU)
The Cardiothoracic Intensive Care Unit provides perioperative care to critically ill patients with complex cardiac surgical issues. During this rotation, residents are exposed to a wide variety of clinical pathology and learn the complexities of managing cardiac patients with coronary artery disease, hypertrophic obstructive cardiomyopathy, valvular disease, and end stage heart failure.
The primary objectives of the rotation include achieving competence and adeptness in the perioperative management for patients undergoing many different surgical procedures including coronary artery bypass grafting (CABG), cardiac valve/repair/replacement (including minimally invasive techniques), surgical management of hypertrophic cardiomyopathy/myectomy, surgical treatment of arrhythmias, aortic reconstruction, and thoraco-abdominal aortic aneurysm repair, and heart transplant. Additionally, residents will develop proficiency in the management of patients requiring the initiation, management, and weaning of a myriad of mechanical circulatory support devices including veno-arterial (VA)/veno-venous (VV) extracorporeal membrane oxygenation (ECMO) and right/left ventricular assist devices.
The residents benefit from being an integral member in a multidisciplinary team which fosters and develops their communication skills, teaching skills, and leadership skills. The multidisciplinary team of cardiothoracic surgeons, critical care/cardiothoracic fellows, physicians assistants, critical care pharmacists, critical care nursing, respiratory therapists, and Extracorporeal Life Support Organization (ELSO) specialists.
Center for Preoperative Assessment (CPA)
Located in the South 5 Building, the center evaluates around 5,000 patients annually. The residents work with a multidisciplinary team to learn how to complete a comprehensive assessment and optimize patients prior for surgery. This includes the implementation of various pre-, intra-, and postoperative ERAS and departmental protocols. Residents conduct a patient-centered encounter where they use resources such as laboratory testing, EKGs, and interdisciplinary consultation to complement their physical exam. The dedicated CPA team consists of attending anesthesiologists, nurse practitioners, registered nurses, medical assistants, and administrative staff. The anesthesia resident gains experience in collaborative decision making and how to provide more in-depth consultations when they assist in determining the type of anesthesia and risks involved for each case.
West Roxbury - VA Thoracic Rotation:
Tufts residents in their CA-3 year are invited to rotate at the VA hospital in West Roxbury for four weeks. A mix of complex cases across several specialties including thoracic, general surgery, and vascular provide many opportunities to develop advanced anesthesia skills. Thoracic anesthesia ranges from straightforward VATS procedures to esophagectomies. Residents will have several opportunities to master regional anesthesia techniques including thoracic epidurals, blocks, and multimodal analgesia. Intraoperatively, residents will become proficient at achieving adequate lung isolation using double lumen tubes or alternate devices and troubleshoot one lung ventilation issues. Vascular surgery cases include endovascular and open techniques, including frequent open AAAs. Residents may also participate in the busy acute pain service which is responsible for placing single shot blocks as well as peripheral nerve catheters and perioperative pain management.
VA patients are by nature complex, often presenting with severe disease and multiple comorbidities. Add to this, complications such as PTSD, substance abuse, and spinal cord injuries, the residents are challenged to create best-in-class approaches to perioperative care along with developing intraoperative skills. Educational opportunities include working with staff engaged in research and publishing, as well as conferences. Beyond the practice of anesthesia, residents will have the opportunity to work with some of the most remarkable patients within a unique culture that fosters independence, critical thinking, and teamwork.
West Roxbury - VA ICU Rotation:
The primary mission of the Veterans Hospitals and our unit is to provide the best care to American veterans. Residents will be part of this great effort and dedication to serve their needs. The VA Boston Healthcare System encompasses three main campuses and five outpatient clinics. Your rotation will be only at West Roxbury Campus located on the West Roxbury VA hospital.
The Surgical ICU team takes care of patients from a variety of surgical subspecialties including General, Vascular, Thoracic, Neurosurgery, ENT, Orthopedics, and Urology. Our team is responsible for the overall care of patients in both SICU, and PCU (stepdown unit). This one-month rotation’s purpose is to provide residents with the knowledge and skills necessary to care for critically ill patients in the perioperative period. Residents will learn the basic tenets of stabilization of critically ill postoperative patients and understand the differential diagnosis and appropriate diagnostic workups for a wide spectrum of perioperative complications. Residents will function within a multidisciplinary team to provide care that is timely and appropriate.
