Transplant Surgery

Attendings

Faysal M. Elgilani, MD

Juan M. Palma-Vargas, MD

Goals and Expectations

Introduction

The transplant service runs as a multidisciplinary team. There is a surgeon and a nephrologist who co-lead it. Technically, it is two different services, but we purposefully muddle the lines between them. You should look at the transplant nephrologist the same way that you look at any of the two surgical attendings. There is a nurse practitioner, Debbie Hoch who covers the whole service. At times, there is a renal fellow and there is a medical intern. Marizela Savic is our pharmacist. We round as a team, at a minimum, there will be an attending surgeon, attending transplant nephrologist, pharmacist and NP rounding. Multidisciplinary rounding are scheduled for 8:30 on Mondays and 8:00 AM Tuesday/Wednesday and Friday’s).

You are primarily responsible for the patients listed under Elgilani and Palma. That means responding to calls, orders, notes, discharge summaries. You will find that Debbie will often have done a lot of it, and that she has particular ways of doing somethings (like a discharge summary, where certain information is needed for us to be able to go back and sort things out). Please follow her lead on these things. There are other patients on the medicine side of the service that you should be aware of, even if you aren’t writing notes or officially consulting: for example a patient that was recently transplanted and who is readmitted for graft dysfunction. We usually round on the “pure” surgical patients first, and then the team often goes to the medical patients with surgical issues, then the “pure” medical patients. We are going to have you spend some time rounding with the team on some of these patients, which is different than the past.

You will also be responsible for general surgery cases on transplant patients done by Elgilani and Palma.

We do problem based charting on transplant. If you’re not sure what I mean by that, please ask. Debbie, Elgilani or Palma and we can show you.

We have an extensive group of order sets. Please use them and don’t freelance. Many of the inane regulatory details that we are surveyed on by outside agencies are built into those order sets. Other times there are details relating to patient safety that might not be intuitively obvious to you. We are very much protocol driven. When to pull the drain, what tac level to shoot for, whether to give heparin or aspirin, all this and much more is written down and on our website. We do break them when it makes sense to do so, but our first instinct is to follow the protocol.

When there is a transplant resident on, nursing should know that you are a resource. If you happen to get a call about a medical transplant patient in error- “that’s not my patient” is NOT an appropriate answer. Please either redirect the nurse to the appropriate person (Debbie, Neph fellow, Med T intern or Transplant Neph Attending) or take the info and pass it on to the appropriate person yourself. You should know enough about all the patients to at least be able to do that amount of triage.

Weekly schedule: A model weekly schedule is attached at the end of this. The first day of your rotation, we should sit down and chart out the transplant meetings. You should attend all of them, especially the QAPIs and the Transplant candidate reviews. Note: we always start the week with a Monday am huddle at 8 am in the Nephrology Conference Room.

On transplant days with compatible pairs, you are responsible to assist on both surgical procedures (Donor nephrectomy and Recipient Transplant). Please try to recruit a junior resident or medical student to help with the recipient exposure and wound closure on the donor nephrectomy patient.

If there is an organ donor or a transplant on a weekend, or night, you have right of first refusal.

Transplant is usually a service of slow times with intermittent frenzied periods. We can usually handle duty hours by sending you home during the slow periods.

A last word about transplant patients. Just like anywhere else, some are more savvy than others about the health care system, but we do have a group of them that are very, very savvy having been involved with the system all their lives. Don’t ever try and BS a transplant patient. If they ask you a question that you don’t know the answer to, “I don’t know, but I can ask” is the correct response. (That advice should probably apply to more than just transplant patients, btw).

Educational Curriculum

We have broken the curriculum down into four modules. Yes there are four weeks in the rotation, but you don’t have to be that rigid, although they are in rough order of how you might want to go thru them. If you have chosen a vacation during the rotation, you still need to do all four. Some will certainly need to be mixed in, especially the access stuff. Lastly, the didactics listed are a MINIMUM.

PART A: DIDACTICS

Resources:

1. ASTS academic universe- an online curriculum for residents. It contains 6 units (Pharmacology and immunosuppression, Organ Procurement, Kidney Transplantation, Live Transplantation, Renal Replacement therapy and Pancreas transplantation).

Each unit is comprised of 3-7 narrated PowerPoint subsections, never longer than 20 minutes, a summary, references and a quiz.

For the purposes of this rotation there will be 4 mandatory modules as follows: Pharmacology and immunosuppression, Organ Procurement, Kidney transplantation and Renal replacement therapy.

To access ASTS academic universe first login into ASTS - American Society of Transplant Surgeons.

Username: jpalmavarg@mmc.org Password: Transplant@3.

After you log in, find the Member portal hyperlink on the right upper corner. A menu will open on the left side and click Academic Universe. Next, click on the Resident Transplant curriculum. The courses are all of good quality, up to date, and comprehensive, but some of the presentations are better used as a sleeping aid.

2. SCORE. Unfortunately the transplant/immunology and access resources on SCORE are spotty: good for somethings, crappy for others.

3. Texts. Schwartz is terrible on transplantation. Greenfield is pretty good, but not linked thru SCORE. The best chapter is in Sabiston for immunology, it’s written by Alan Kirk who did the immunobiology sections in academic universe. The writing is clear and covers the essentials. He puts things in an evolutionary context, which is helpful. In person he’s a great speaker, unfortunately, you wouldn’t know that from the narrated PowerPoints.

4. Maine Transplant program protocols, algorithms and the like can be found here Policy Manager - MCN Healthcare

5. http://www.srtr.org/ Scientific Registry of Transplant Recipients - we’ll go thru this.

http://www.kidneyregistry.org/?cookie=1 National Kidney Registry

Learning objectives

Each module within each unit has the objectives listed under overview.

Module 1 - Pharmacology and Immunosuppression

Look over the learning objectives. There is one summary talk in ASTS entitled “Immunobiology of Transplantation” It covers the important concepts and has a good summary. The monotone will kill you. There is also a more comprehensive series of lectures by Alan Kirk. They all start off with “Basic”. They are well organized, very comprehensive, beautifully developed and ….stultifying. But if you are an auditory learner, they will cover what’s needed. The best chapter is from Sabiston, it’s available thru MMC library. As mentioned above, it’s also written by Alan Kirk (you don’t need to spend much time on “new areas” or “xenotransplantation”. Please educate yourself with one of these three modes before Monday am.

Module 2 - Organ Procurement:

The main didactic topics are included in the Academic Universe as well. Please review Organ preservation 101, Donation after Cardiac death and abdominal organ recovery from Deceased donors. This last topic review will help you in case you will assist us (or surgeons from New England Donor Services) in a future deceased organ procurement.

Module 3 - Kidney Transplantation

In academic universe Sanjay Kulkarni’s modules on “Kidney Transplantation: Surgical Procedures” and “Kidney Transplantation: Surgical Complications” are excellent summaries and will hold your attention. The Sabiston section on Kidney is so short as to be worthless. Here, the Schwartz chapter is better. My recommendation here is to review the PowerPoints on the ASTS site and then flesh out any detailed areas either with other PowerPoints in that module, or with chapters from Peter Morris’ text “ Kidney Transplantation” available thru MMC library on-line.

This module also include the evaluation of the potential living kidney donor and finally the pre-transplant evaluation of the kidney recipient.

Module 4 - Renal replacement therapy

This is on access and dialysis. Again, please review the 3 sub-sections contained in this module. The Peritoneal Dialysis catheter section was created by no other than Jim Whiting. If you miss him at least you can hear his voice on this section !

PART B: PRACTICUMS

Module 1

You should spend ½ day in the HLA lab with Dr. Nicole Valenzuela. This is not new, they are used to residents doing this. The best time would be either Wed am or pm the first week that you are on. The HLA lab number is listed at the end, please call them and tell them that you are the surgical transplant resident and need to arrange a visit. It won’t be a surprise to them.

Module 2 

No specific practicum at this time.

Module 3

This is the core of your rotation and includes your participation in the transplant clinic doing recipient and donor evaluations. You are also participate in all the surgical elective transplant surgical cases generated during your rotation.

Module 4

We have a PD clinic imbedded in the Transplant clinic. Usually Mondays or Wednesdays. The volume is low but you will participate in the patient evaluation, selection and surgical procedure.

PART C: PRESENTATION

You are responsible for one presentation per rotation. The format and venue is still TBD. (Open to suggestions).

PART D: EVALUATION

Your evaluation for the rotation will be based on a number of sources. First there will be a global evaluation filled out by Elgilani and Palma. There will be a 360 evaluation filled out by others on the transplant team.

You are responsible for doing and logging all the cases you will participate on, ALL of these should be submitted to either Elgilani or Palma via SIMPL.

Third, there will be a written exam at the end of the rotation. You are expected to achieve at least 80% correct. If you don’t achieve that score, we’ll send you the questions that you got wrong and you’ll be expected to look them up and provide critiques.

Patient Care

1. Involve yourself in the pre and postoperative care of renal transplant recipients
2. Involve yourself in the operative management and care of renal   transplant recipients (surgeon junior on renal transplants and

Medical Knowledge

1. Complete units 1-4 in the Canvas Curriculum

Practice Based Learning and Improvement

1. Contribute to Surgical Complication Database and transplant teaching rounds
2. Complete Canvas Quiz and address any deficiencies (incorrect answers)

Interpersonal and Communication Skills

1. Participate in the consent and counseling of patients on the transplant service
2. Contribute to team communication on the transplant service

Professionalism

1. Model appropriate and ethical behavior in interactions with nursing, peers, attending, patients and other medical staff

Systems Based Practice

1. Understand and participate in the multimodality interactions of the modern transplant patient
2. Attend and partipate in Transplant Candidate Review and Transplant QAPI