Nelson Nicolas Algarra MD (2011-12)
Assistant Professor,
Kansas University Medical Center,
Kansas City, Kansas

Vijay Kumar Ramaiah MBBS, MD (2011-12)
Clinical Instructor,
Stanford University School of Medicine

Sabry Khalil MD (2012-13)

Fellowship Training Program:
Fellowship in Neuroanesthesiology

The Neuroanesthesiology Fellowship at the University of Washington is a one-year program for trainees who have completed a three-year anesthesia residency training in an accredited program in the U.S. or an equivalent program. This clinical fellowship is based at Harborview Medical Center.

The goal of Neuroanesthesiology fellowship at University of Washington is to provide advanced clinical training in Neuroanesthesiology including monitoring techniques and to provide research and educational experience to develop leading academic Neuroanesthesiologists for the future. At the end of this program, the graduating fellows will become skilled in performing preoperative assessment of patients with neurological and neurosurgical diseases, developing and executing appropriate anesthetic plan including monitoring techniques and provide perioperative management for these patients. The fellows will gain the cognitive and psychomotor skills required for rationale selection and skillful utilization of various monitors and procedures including jugular bulb catheters, fiberoptic intubations, intraoperative evoked potentials monitoring (somatosensory, motor, visual and brainstem evoked potentials), and transcranial Doppler (TCD) ultrasonography. They will also learn basic interpretation of neuroradiological imaging including CT scans, MRIs and cerebral angiographies, intracranial pressure monitoring, regional cerebral oxygenation monitoring and TCD ultrasonography. They will be able to participate actively in the perioperative care of neurosurgical as well as critical neurological patients and will be able to function as part of a multidisciplinary neurocritical care team.

The Neuroanesthesiology Fellows will acquire necessary research skills to be able to plan and conduct clinical / basic sciences research in ethical and systematic manner and to write a manuscript suitable for publication in a reputed scientific journal. They will develop analytical behavior and will be able to review and critique published scientific literature and practice evidence based medicine and to participate in development of clinical guidelines and protocols. The Fellows will also enhance their teaching skills and will be actively involved in resident education in and out of the operative room environment.

Description

The Neuroanesthesiology training program primarily includes:

• Clinical experience with a variety of neurosurgical procedures
• Clinical experience of relevant neuroscience specialties including Neuroradiology and Neurointensive care
• Clinical research experience under faculty supervision
• Formal educational activities including didactics, journal clubs, case presentations etc.

Faculty fellows responsibilities will involve a 40 /60 division of time between clinical service work (40%) and fellowship activities.

Clinical Locations

All four teaching hospitals of the UW Medicine (UW Medical Center, Harborview Medical Center, VA Puget Sound HCS, and Children's Hospital) have neurosurgical procedures although the majority of them are conducted in the first two hospitals. The fellowship activities are primarily based at HMC, which is renowned for complex cerebrovascular surgery and is also a leading level-1 adult and pediatric trauma center. Open as well as minimally invasive surgery as well as endovascular treatment is offered for variety of complex neurosurgical diseases. HMC is also a Comprehensive Stroke Center. The UWMC is primarily involved with epilepsy and tumor surgery, skull base surgery and carotid endarterectomy.

Faculty

Recent Fellows

• Nelson Nicolas Algarra MD (2011-12)
  Assistant Professor, Kansas University Medical Center, Kansas City, Kansas
• Vijay Kumar Ramaiah MBBS, MD (2011-12)
  Clinical Instructor, Stanford University School of Medicine
• Sabry Khalil MD (2012-13)

Clinical Responsibility

Faculty fellows responsibilities will involve a 40 /60* division of time between clinical service work (40%) and fellowship activities (such as working with their faculty supervisors and mentors, teaching and research) (60%). * In certain cases this time may be flexible or negotiable depending on the educational needs and research interests of the individual fellow, and particularly if the fellow wishes to undertake a 2 year commitment.

Clinical Service Work (40%)

Faculty fellows will work in the capacity as a junior faculty (acting instructor) in the operating rooms at UWMC and HMC. In this role the faculty fellow will be work as an attending anesthesiologist supervising CRNAs, supervising and teaching residents, and on occasions as a solo attending for their own cases. The junior faculty commitment will consist of 92 clinical days (920 credits, typically 2 weekdays) in the OR and three 15-hour in-house calls (495 credits) per month. In the initial part of the fellowship year, this responsibility will involve non-neurosurgical procedures. Subsequently, as the fellows advance in their training and become proficient in Neuroanesthesia, they will start functioning as faculty for neurosurgical cases too. The faculty time will be based at Harborview Medical Center or University of Washington Medical Center, based on the divisional and departmental requirements. As a faculty clinician, faculty fellows will have membership and employment with University of Washington Physicians (UWP) and must obtain medical staff privileges at University of Washington affiliated hospitals. Information on the credentialing and orientation process is provided in the orientation policy.

Fellowship Activities (60%)

The fellowship activities account for 60% of time and are typically conducted 3 days a week. The fellowship activities depend on the specific rotation / module. The rotations include:

• Neurosurgical Anesthesia rotation: The goal of this rotation is to maximize direct clinical experience including invasive procedure. The fellows provide anesthesia for major neurosurgical cases directly supervised by a senior Neuroanesthesia Attending. The fellows are expected to discuss the cases with supervising attending, engage in academic discussions and perform post-operative follow up. The fellows will provide direct anesthesia care for complex neurosurgical procedures including but not limited to intracranial bypass procedures, aneurysm clippings, resection of AVMs, tumors and seizure foci, microvascular decompression, trans-sphenoidal resection of pituitary tumors, craniotomy for evacuation of intracranial hematoma, interventional neuroradiological procedures etc. Most major vascular neurosurgical procedures involve placement of jugular bulb catheters and intraoperative evoked potential monitoring. The supervising senior Neuroanesthesiologist will evaluate fellows. Fellows are encouraged to actively approach faculty for feedback.
• Transcranial Doppler (TCD) Ultrasonography laboratory rotation: Harborview Medical Center has a world-renowned TCD lab and many Neuroanesthesiology faculty are widely renowned for their expertise with this technique. Dr. Sharma personally supervises this rotation. The goal of this rotation is for the fellows to learn performing, reporting and interpreting TCD examinations. The fellows typically shadow the TCD lab technicians as they perform tests on in-patients and outpatients. The fellows also personally perform the TCD examinations and learn application of TCD for cerebral vasospasm, carotid endarterectomy, cerebral circulatory arrest, cerebral autoregulation and CO2 reactivity tests, emboli monitoring for stroke etc. They also participate in educational activities of the lab.
• Neuroradiology rotation: During this rotation, the fellows work with the Neuroradiology faculty and learn to interpret basic neuroradiological imaging including CT scans, MRIs and angiograms of brain and spinal cord for tumors, trauma and vascular lesions and to understand the principles and techniques of interventional neuroradiology. The fellows also participate in interventional neuroradiological procedures and participate in teaching activities / conferences of neuroradiology department.
• Intraoperative Neurophysiological monitoring rotation: During this rotation, the fellows learn the basic principles and technique of intraoperative evoked potential monitoring including somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), visual evoked potentials (VEPs), brainstem auditory evoked potentials (BAEPs) and electroencephalography (EEG) as well as their intraoperative use during brain and spinal cord surgery. The fellows work with intraoperative neurophysiology monitoring team to learn the essential skills.
• Research month: The fellows typically get one-month time to dedicate to the completion of their fellowship research project. The fellows are expected to complete at least one research project during the year under supervision of Dr. Sharma. They are also mentored by other faculty in the division of Neuroanesthesiology & Perioperative Neurosciences and have research support by regulatory specialists and biostatisticians. This one month is in addition to the one academic day that the fellows receive every week throughout the fellowship to pursue research as well as other fellowship related educational activities.
• Other rotations: There are also other rotations and their organization is flexible and tailored to suit individual fellows. These include rotations to Neurointensive Care, Neurosurgery, Stroke Unit etc.

In addition to the above rotations, the fellows participate in various conferences and educational activities:

• Departmental Grand Rounds – every Wednesday 0630-0730 at UWMC
• Thursday morning anesthesiology educational conferences at HMC – every Thursday 0600-0645
• Neuroradiology teaching conference – every Thursday 0745-0830 at HMC
• Neuroanesthesiology Journal club – once a month 1600-1700
• Neuroanesthesiology academic / research meeting – twice a month 1600-1700
• Neuroanesthesiology Case Conference – once a month 1600-1700
• Faculty Fellowship evenings (once a quarter)
• Departmental academic evening (once a year)
• Other educational activities:
  • Participation in developing clinical guidelines
  • Teaching residents on Neuroanesthesiology rotation
  • Conduct oral exams for residents on Neuroanesthesiology rotation

Educational Objectives

1. Academic Objectives
1. Basic Knowledge Acquisition
1. Understanding of cerebral physiology (control of CBF, CBV, ICP, CPP, CO2 reactivity etc.)
2. Understanding of influence of anesthetic agents and techniques on the normal control mechanisms.
3. Understanding of the influence of disease pathology on normal cerebral physiology and pharmacology.
2. Research Experience
1. Understanding of basics of hypothesis formulation, literature review, experimental design, methodology, data acquisition, statistical analysis, interpretation of data, penmanship, peer-review process, and publication of results.
2. Participation in clinical research in neuroanesthesia.
2. Practical Objectives
1. Patient Management Skills
1. Understanding of anesthetic management of acute head injury.
2. Understanding of anesthetic management of cerebral vascular surgical procedures including aneurysms, arteriovenous malformations, carotid endarterectomy, extracranial-Intracranial bypass procedure.
3. Understanding of anesthetic management of supratentorial tumors.
4. Understanding of anesthetic management of posterior fossa lesions.
5. Understanding of anesthetic management of the seated position.
2. Technical Monitoring Skills
1. Proficiency in cannulation of the jugular bulb.
2. Proficiency in the use of transcranial Doppler ultrasonography
3. Proficiency in the use of EEG, somatosensory and brainstem auditory evoked potentials for interested parties. The Department of Anesthesiology & Pain Medicine does not actively participate in the monitoring program, but arranges with Department of Rehabilitation Medicine for this experience.

NOTE: Actual experience and knowledge acquired during the fellowship is variable, and is dependent on the fellow's own learning objectives, area of interest, level of motivation, enthusiasm and efforts put into it.

Application Process

The application process for all the faculty fellowships requires that interested applicants send the following information:

• Current Curriculum Vitae
• Application for Faculty Fellowship
• Letter of intent/personal statement
• Three current reference letters, including one from the residency program director or current director
• Copy of medical school diploma
• Copy of anesthesia degree (if applicable)
• Current medical license
• USMLE all three steps
• ECFMG documentation (if applicable)
• Documentation supporting citizenship status (if applicable)

Inquiries and applications should be directed to:

Fellowship Director

Dr. Deepak Sharma, MBBS, MD, DM Associate Professor & Chief, Division of Neuroanesthesiology & Perioperative Neurosciences Dept Anesthesiology & Pain Medicine Program Director, Neuroanesthesiology Fellowship Neuroanesthesiology Education Director Adjunct Associate Professor, Department of Neurological Surgery Professional Interests: Transcranial Doppler (TCD) Ultrasonography, Cerebrovascular physiology, Traumatic Brain Injury, Education in Anesthesiology. Harborview Medical Center Box 359724 325 Ninth Avenue, Seattle, WA 98104 Phone: 206-744-3669 Fax: 206-744-8090 Email: dsharma@uw.edu UW Medicine Bio

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