Pediatric Anesthesia Fellowship

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Program Director, Dr. Ushma Shah

The Children’s’ Hospital LHSC is a tertiary referral centre. There are over 8200 anesthetic cases each year at Children’s Hospital including neurosurgical, craniofacial, thoracic, neonatal, major orthopedic and urologic, general, ENT, and plastic surgical procedures. Several clinicians have interest and experience in the delivery of Pediatric regional anesthesia. In addition, we have an active Pediatric Chronic pain program and Transitional Pain service that has a weekly multidisciplinary clinic.

New technologies have increased the requirement for ‘off-site’ procedures and the anesthesia department at Children’s Hospital currently provides anesthesia for children in ten locations within the Health Sciences Center and University hospital. We also have a dedicated Pediatric Anesthesia Pre-admission Clinic.

All anesthesiologists within the Section have university appointments within the Department of Anesthesia and some are cross appointed with the Department of Pediatrics. Most staff hold pediatric anesthesia fellowships from major pediatric centers like Sick Kids, CHEO and Great Ormond street. 

Fellowship Structure

  • Duration: This will be a 13-block fellowship, including 4 weeks of vacation. The remaining 48 weeks will comprise the clinical and academic time as detailed in the following sections. The fellowship will be organized into four-week periods, in order to be compatible with the residency program scheduling structure.
  • Number of fellowship positions: 1
  • Site: Fellowship training will take place at Victoria Hospital. Additional cardiac anesthesia training will take place at Sick Kids Hospital, Toronto.
  • Service commitment: 100 days per year. This service commitment will be in pediatric anesthesia. 

Eligibility for Canadian and Foreign Medical Graduates

Requirements for Application:

  • Candidates must possess a medical degree from a University recognized by the Medical Council of Canada (MCC)
  • The fellow must have successfully completed an Anesthesia Residency program, and have an independent licence to practice as an anesthesiologist.
  • International Medical Graduates do not need to write additional exams, but must be approved by the PGE Office at Western University
  • English Language Requirement for IMGs: Academic IELTS required to achieve a minimum score of 7 in each category.
  • All non-Canadian trained anesthesiologists will be required to pass an assessment period taking place over the first 4 - 8 weeks in order to continue with the fellowship (‘PEAP’ – Pre-entry assessment period).
  • Please refer to the Application and Requirements page for a more detailed description

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Goals and Objectives

The clinical and academic education objectives for our fellow will be described in the context of CanMEDS (Canadian Medical Education Directives for Specialists) framework below:

Medical Expert

  • The fellow will acquire an understanding of the anatomical, physiological, pharmacological and psychological differences between the neonate, child and adult in relation to anesthesia practice.
  • The fellow will develop the competence to function as an independent provider of anesthesia to pediatric patients of all ages and ASA classifications in elective and emergent circumstances. This will require:
    • The ability to perform an appropriate and age specific pre-anesthetic assessment including the evaluation of uncommon syndromes and complicated medical conditions and to develop a rational anesthetic plan.
    • Familiarity with adaptations to and specialized anesthesia equipment and monitors for use in children
    • Exposure to and development of expertise in the management of routine and difficult pediatric airways.
    • Understanding of the rationale for, placement and management of invasive monitors in pediatric patients.
    • Familiarity with indications and options for pre-operative sedation.
    • Understanding of the rationale for, placement and management of regional techniques, including specific blocks, spinal, caudal and epidural catheters for both anesthesia and peri-operative analgesia in children.
    • Recognition and management of anesthesia related complications and emergencies
  • The fellow will become competent in the provision of anesthesia services outside of the operating room, including offsite anesthesia and procedural sedation, acute pain management and pre-operative consultation.
  • The fellow will become competent in pediatric emergency resuscitation.

Communicator

  • The provision of anesthesia in the pediatric setting is unique as the caregiver must be able to communicate in an appropriate and age specific manner with the patient and their parents/legal guardian as well as other members of the health care team.
  • The fellow will demonstrate the ability to obtain an appropriate anesthetic history and communicate the relevant peri-operative issues as they relate to the specific anesthesia service to be provided.
  • The fellow will demonstrate an understanding of age specific peri-operative concerns and an ability to communicate in an age-appropriate manner with both patients and parents when soliciting information, answering questions, and providing information.
  • The fellow will develop the ability to effectively communicate pertinent anesthesia concerns to the surgical, nursing and adjunct staff.
  • Participation in Pediatric Anesthesia Teaching Rounds will allow the fellow to continue to develop the formal communication skills involved in presentation of a topic and responses to questions from peers.

Collaborator

  • The successful delivery of peri-operative care requires the effective collaboration of the pediatric anesthetist, surgeon, nurses, other trainees, respiratory technicians, anesthesia adjunct personnel and aides.
  • The fellow will demonstrate an appreciation of the roles of the other members of the operative team.
  • The fellow will be able be able to formulate and communicate an anesthetic plan to the other members of the team and work effectively with the entire team to implement that plan.
  • The fellow will demonstrate the ability to consult effectively with surgical and medical colleagues.

Manager

  • The fellow will develop an understanding of the provision of cost-effective anesthesia care with an understanding of the financial considerations and implications of specific anesthetic choices with respect to both anesthesia budgeting and global health care costs.
  • The fellow will develop skills in efficient time management in the operating room and peri-operative areas including timely patient assessments, efficient room set-up and induction, and emergence.
  • The fellow will be provided with the opportunity to co-ordinate and plan timing for both elective and emergency cases through collaboration with the charge nurse.

Scholar

  • The fellow will demonstrate the ability to appraise the literature critically, formulate pertinent questions, perform a focused literature review, and apply critical thinking skills to pediatric anesthesia problems. Opportunities to develop these skills will be met through:
    • Critical review of specific pediatric topics provided through a recommended reading list to be reviewed with designated pediatric anesthesia staff
    • Presentation of case presentations and topics at both Pediatric Anesthesia Teaching Rounds and The Department of Anesthesia Grand Rounds
    • The opportunity to utilize the Pediatric Anesthesia Database to perform audits, examine quality assurance issues and formulate potential research questions
    • The opportunity to submit a case report/ literature review for publication 5. Participation in a clinical research project will be encouraged but not requisite to fulfill the requirements for scholarly activity.

Health Advocate

  • The fellow will develop an understanding of the role of anesthesia in patient safety, risk reduction and education.
  • The fellow will become aware of the anesthesia advocacy role for effective pediatric peri-operative care.
  • The fellow will become aware of their role in patient/ guardian education regarding lifestyle choices and safety issues.

Professional

The fellow will be expected to deliver anesthesia care with integrity, honesty and compassion. The fellow will demonstrate the attitude, behaviours and ethical standards expected of a subspecialist practitioner of anesthesia.

Learning Opportunities

Clinical Exposure:

OPERATING ROOM(OR)

  • The fellow will be assigned to the OR for dedicated periods within the fellowship year. They will be assigned to ensure they have optimal opportunity to provide anesthesia for the full range of surgical services and for all ASA classifications of patients with emphasis on neonatal and other tertiary care procedures and level of patient acuity. A staff anesthetist will supervise the fellow. The degree of support will be based on the specific case and the fellow’s ability. Over the year, it is expected that the fellow will be given graded responsibility in managing cases such that by the end of the year they will be able to practice independently as a specialist pediatric anesthetist.
  • Out of OR rotation(OOR) provides extensive experience in off-site anesthesia practice. Locations include MRI, CT, angiography suite, radiation therapy, lithotripter(SJH), Dental Suite(Dental college), Nuclear Med, MPR, PMDU (Oncology LPs), PCPP.

The OOR rotation provides the fellow with an opportunity to gain experience in pre-operative patient care through the Anesthesia Pre-Admission Clinic and consultation service and post-operative pain management, regional anesthesia and complex and chronic pain consultations.
Off-site Rotations.

In order to provide the fellow with additional clinical exposure to cases in which experience at Children’s Hospital is absent or limited the fellow will have

  • A one-month rotation in pediatric cardiac anesthesia at an external site with emphasis on cardiac surgery and catheterizations

TEACHING SESSIONS

  • Teaching sessions will be held at LHSC with the list of topics being tailored to the fellows needs.
  • Topics will be covered in Pediatric Anesthesia Teaching Rounds or during scheduled discussions with assigned staff anesthetists.
  • The fellow will participate in resident/fellow seminar programs during off-site clinical rotations. We highly encourage fellows to take the PALS course prior to joining the program, if not already certified.

The fellow will be responsible for the following teaching activities (Minimum):

  • One Anesthesia Grand Rounds
  • One Pediatric anesthesia journal club
  • One anesthesia resident seminar
  • Clinical teaching of residents and students in the OR

RESEARCH / CRITICAL APPRAISAL

  • The fellow will have academic days during the rotation for research.
  • By the end of the fellowship, the fellow will be expected to complete an academic scholarly project. The types of activities that will be considered to suffice as academic projects include: a review article, submitted to a peer-reviewed journal; a clinical audit, to be designed, formulated, and accompanied by recommendations; a research paper, submitted to a peer-reviewed journal.
  • There will be opportunities for the fellow to become involved in research already in progress, or to develop an original project. In either case, mentorship will be arranged. If an original project is planned, the research protocol must be submitted in time to get the project done in the time frame of the fellowship. It will be discussed prior to the fellow starting the fellowship, which of the above alternatives the fellow would like to pursue.
  • The fellow will be given the opportunity to attend all Department of Anesthesia and Section of Pediatric Anesthesia Journal Club meetings.

EVALUATION

  • The Fellowship Program will be using the Entrustable Professional Activity forms (EPA) for assessment of pediatric anesthesia fellows. These will be in keeping with EPA’s used at other pediatric anesthesia teaching sites across Canada with a goal to ensure national standards are met. Fellows will evaluate their staff and rotation on a regular basis.

STAFF ASSESSMENT

  • Staff will be required to fill out an in-training evaluation report (ITER) each period Offsite anesthesia- An evaluation form will be provided for completion at the end of the fellow’s rotation
  • The quarterly ITER, a compilation of on-site and off-site rotation evaluations, will be filled out by the fellowship coordinator and discussed with the fellow at a quarterly evaluation interview.
  • The Final in-training evaluation report (FITER) will be forwarded to the PGME office at the end of the fellowship, after a final evaluation interview with the coordinator.

RESEARCH ASSESSMENT

  • The research project will be monitored by the mentor on a regular basis at intervals appropriate to the project. A final written assessment, to be appended to the FITER will be discussed with the fellow at completion of the project.

LIST OF PEDIATRIC ANESTHESIA FELLOWSHIP TEACHING TOPICS

  • To be covered during Pediatric Anesthesia Teaching Rounds or scheduled discussion periods. Assume cardiac and major craniofacial topics covered elsewhere.
  • Pediatric Equipment, circuits and ventilators
  • Neonatal emergencies: general concepts; gastroschisis, omphalocele, PDA
  • Neonatal emergencies: tracheoesophageal fistula
  • Neonatal emergencies: congenital diaphragmatic hernia
  • Neonatal emergencies: meningomyelocele, hydrocephalus
  • Blood component therapy
  • Coagulation disorders and Sickle Cell anemia
  • Difficult airway
  • Microlaryngoscopy / LASER airway procedures
  • Bronchoscopy
  • Biliary atresia
  • Mediastinal mass
  • Neuromuscluar disorders (Duchenne’s, myasthenia gravis)
  • Genetic Metabolic diseases (lactic acidosis)
  • Pediatric neuroanesthesia
  • Renal transplantation
  • Burns
  • The severely handicapped child
  • Epidural and caudal analgesia
  • Spinal anesthesia
  • Off-site procedures
  • Sleep apnea
  • Epidural analgesia – pediatric issues
  • Infant pharmacology e.g. opiates, NMB, local anesthetics
  • Fundamental pediatric anesthesia concepts will be discussed as part of clinical experience.

Logistical Items

CMPA COVERAGE

  • Fellow will pay and will need full coverage.

TRAVEL / EDUCATION

  • Funding will be available to be used in accordance with the Fellowship Travel / Education Funding policy
  • Membership of Societies (SPA, CPAS) is encouraged and to be self-funded.

DISABILITY

  • The fellow is responsible for his or her own disability insurance.
  • Medical Insurance- Fellow is responsible for their medical insurance in their first three months until OHIP covered (if the fellow does not have OHIP)

TERMINATION OF THE FELLOWSHIP

  • The Fellow may withdraw from the program at any time and for any reason, one month after providing to the Fellowship Program Director a written notice of intent to withdraw.
  • The Fellowship Program Director may terminate the program in the event of an interim evaluation being assessed as demonstrating unacceptable performance, or at any time in the event of professional misconduct. The Fellowship Program Director must seek the opinion of the Postgraduate Committee, Department of Anesthesia prior to terminating a Fellows training.

DISPUTE RESOLUTION

  • All disputes between the Fellow and the Department of Anesthesia will be resolved in accordance with the by-laws of University of Western Ontario.

CLINICAL AND ACADEMIC LOGBOOK

  • The fellow will be expected to maintain an up-to-date clinical and academic log book as per Departmental policy. In addition, the Pediatric Anesthesia Database Report will compile the ages of patients, techniques, and complications each period. This information will be used to guide OR assignments.

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