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Electives - General Surgery

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Transplant Surgery

Elective Number: (Oasis E76u) 3027

Rotation Supervisor: Dr. Avinash Agarwal

Coordinator: Heather Trainium

Duration: Maximum 4 weeks, Minimum 2-weeks

Available: Rotations 1-8

Report to: Inpatient Transplant Surgery Fellow

Time to Report: 6:00 am

Place to Report: 5 West Physician workroom

Typical day: 6:00 am - 4:00 pm

Attendance: Attendance at elective activities is mandatory.

Number of students per rotation:

Course Description: The Transplant rotation provides the student with an understanding of the common problems of patients with end stage organ disease pre and post transplantation and basic clinical decision-making skills in this patient population applicable to their future practice. The student will function as an intern in the day-to-day care of all in house patients, including the evaluation of all potential organ recipients, assist with donor organ recovery, assist with all transplant operations, see patients in clinic, participate in all transplant conferences, and guide third year medical students regarding their duties.

Learning Objectives:

1. Recognize the following common clinical problems and construct appropriate diagnostic and management algorithms for each condition:
Ascites
Variceal bleeding
Hepato- renal syndrome
Encephalopathy
Substance abuse

2. Assess the suitability for transplantation of a patient referred with ESLD with reference to:
MELD scoring system (Model for End stage Liver Disease)
UNOS listing criteria (United Network for Organ Sharing)
Absolute and relative contraindications

3. Outline a management plan with particular reference to the increased risk of surgery for patients with ESLD who develop the following common general surgical problems:
Umbilical hernia
Inguinal hernia
Gallstones

4. Obtain informed consent from a patient undergoing kidney, liver, or pancreas transplantation

5. Develop a differential diagnosis and a management plan appropriate to their level of training for the following clinical scenarios in the early post liver transplant patient:
Bleeding / coagulopathy
Decreased urinary output
Abnormal liver function tests
Volume overload / ascites
Fever

6. Recognize and outline a management plan for each of the following categories of post liver transplant complications:
Graft dysfunction / non-function
Infection: bacterial, viral and fungal
Rejection: acute / chronic
Technical: Bleeding, biliary, arterial, wound related

7. Recognize and outline a management plan for each of the following medical complications:
Diabetes
Renal Failure
Drug toxicity
Neurological problems
Altered mental status

8. Recognize the most common post liver transplant problems that require immediate referral to a transplant center:
Fever
Vomiting / diarrhea
Dehydration

9. Evaluate the post-transplant patient for post-operative complications

10. Describe the different forms of dialysis access and their indications, advantages and disadvantages.

11. Explain the difference between dialysis and hemofiltration, and the basic mechanisms of peritoneal and hemodialysis

12. Describe the role of vascular ultrasound in the evaluation of a patient for vascular access

13. Describe the diagnosis, evaluation, and treatment of the common complications of angioaccess

14. Develop an algorithm for selecting an appropriate form of angioaccess

15. Conduct an initial evaluation for hemodialysis access

16. Educate a patient on the different forms of renal replacement therapy, including the pros and cons of each.

17. Describe and discuss the indications and contraindications for kidney transplantation

18. Describe and discuss the diagnosis and management of the following common categories of complications from kidney transplantation:
Technical
Medical
Infective
Immunological
Drug related

19. Describe and discuss the indications and contraindications of pancreas transplantation

20. Describe and discuss the diagnosis and management of the following common categories of complications from pancreatic transplantation:
Technical
Medical
Infective
Immunological
Drug related

21. Describe the criteria for brain death and define donation after deceased cardiac death

22. Assess suitability, indications and contraindications for patients undergoing living donor nephrectomy or hepatectomy

23. Develop a differential diagnosis and management plans appropriate to their level of training for the following clinical scenarios in the post-operative liver donor:
Pain management
Fever
Decreased oxygen saturation
Elevated liver function tests

24. Identify the indications and contraindications for deceased organ donation

25. Distinguish the following categories of deceased donors
Directed donation
Marginal donors
High risk donors
Deceased cardiac death (DCD)

26. Describe with relation to organ allocation
Role of UNOS
Role of LifeNet
Virginia Consent laws

27. Discuss the following ethical dilemmas / issues
Informed consent
Autonomy
Solicitation
Coercion

Student Responsibilities: Medical students should participate in all inpatient & outpatient clinical activities and educational activities but are particularly responsible for:

1. Following the day-to-day care of all in house patients, including the evaluation of all potential organ recipients.Patients should be presented to the attending on rounds. Use the following format when presenting:

a. Introductory statement (for example): "Mr. S is a 49 year old man POD (post operative day) #3 sp (status post) kidney transplant"

b. His issues in the last 24 hours are ......

c. Subjective.......how is the patient feeling?

d. Objective..... examination, lab & radiology finding

e. Analysis..... assimilate the data and discuss the reasons for the above findings

f. Plan ..... present a plan of care that should include immediate and long-term (discharge) needs

2. The organization of flow-sheets, coordination of daily lab values and immunosuppression orders under the direction of the Surgery Attending on Service. Be prepared to comment on changes in the patient's graft (organ) function and to answer questions about lab trends on rounds.

3. Performing H&P as requested in clinic. Please use the pre-printed H&P sheets for this.

4. Assist with donor organ recovery.

5. Assist with all tranplant operations.

6. Attend weekly Transplant Conference in Kidney Conference Room 8-9:00am Fridays.

7. Complications will be presented by residents at the weekly mortality and morbidity conference. Attendance is mandatory for medical students.