Anesthesiology Residency Program – Clinical Subspecialty Rotations

The cardiac anesthesia department at Tufts Medical Center (Tufts MC) works closely with a robust cardiac surgery division recognized as being 1 of the region’s largest heart transplant and VAD programs, as well as structural heart and ECMO cases. 

Our dedicated cardiac anesthesiologists are certified in advanced perioperative Transesophageal Echocardiogram (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 managing 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. 

During the neuroanesthesia rotation, the resident takes care of patients undergoing intracranial and spine surgeries. Tufts MC has a large population of neurosurgical procedures, which provides residents with a diverse and challenging caseload. Residents are assigned 1 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 of brain tumors, aneurysms, arteriovenous malformations (AVMs), spinal disorders, and carotid artery disease. Additional rotation highlights 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.

Residents in the anesthesiology department now rotate at Boston Children's Hospital, a world-renowned pediatric center, along with other residents from nearby anesthesia programs such as Brigham Women’s Hospital, Beth Israel Deaconess and Lahey. Working alongside a world-class team of experienced anesthesiologists, residents have a unique opportunity to gain experience in a wide range of pediatric surgical procedures in a diverse patient population. The hospital is located in the Longwood Medical Area of Boston and is only 3 miles away from Tufts MC.

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. 

The objective of the vascular and thoracic anesthesia rotation aims 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 mastered basic technical skills and anesthesiology knowledge. 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 the challenging patient population, there are ample opportunities to practice the 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 grows, 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.

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 before their rotation to obtain regulatory approval for the project, as appropriate. This will usually include writing and submitting a protocol to the IRB. With the guidance of their mentors, residents enjoy developing research questions, practicing literature reviews and data collection and 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.

During their rotation in Acute Pain Service (APS) and Regional Anesthesia, residents are exposed to a comprehensive service that takes a multimodal approach to managing 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 and coordinate and communicate with the primary, surgical and anesthesiology teams.

Residents learn to provide comprehensive anesthetic care to pregnant women during this rotation. 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 and 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 3 years of training. As they become more experienced in managing 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.

The Division of Obstetric Anesthesia at Brigham and Women’s Hospital (BWH) 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.

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 2 units: Phase 1 PACU and Tufts MC main PACU. 

Phase 1 PACU is located in South 5 and has 14 recovery spaces, all specialized to recover day surgery cases. The main PACU is located in Floating Building 5 and has 17 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 presenting 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.

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 thoracoabdominal 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 integral members of a multidisciplinary team that fosters and develops their communication skills, teaching skills and leadership skills. The multidisciplinary team of cardiothoracic surgeons, critical care/cardiothoracic fellows, physician assistants, critical care pharmacists, critical care nurses, respiratory therapists and Extracorporeal Life Support Organization (ELSO) specialists.

Located in the South 5 Building, the center evaluates around 5,000 patients a year. The residents work with a multidisciplinary team to learn how to complete a comprehensive assessment and optimize patients prior to 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.

Tufts MC residents in their CA-3 year are invited to rotate at the VA hospital in West Roxbury for 4 weeks. A mix of complex cases across several specialties, including thoracic, general surgery and vascular, provides 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 troubleshooting 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, 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 and conferences. Beyond the practice of anesthesia, residents will have the chance to work with some of the most remarkable patients within a unique culture that fosters independence, critical thinking and teamwork.