Transplant Surgery

Attendings


Faysal M. Elgilani, MD
Juan M. Palma-Vargas, MD
Juan M. Palma-Vargas, MD

The Service: Overview

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 Palma or Whiting. 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.

You are primarily responsible for the patients listed under Palma and Whiting. 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 be responsible for all of Whiting and Palma’s access. We’re still working out what to do with Hawkins, Herbert and other access on vascular.  You will also be responsible for general surgery cases on transplant patients done by Palma and Whiting. Whiting’s stuff is almost always on Tuesdays and Fridays, Palma’s is more variable.

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

If you don’t already know the nursing administration on R5, please introduce yourself to Marilyn Flanders.  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, you are responsible for the transplant; the senior on purple will do the living donor.  There may be times when you do both, but that means missing the exposure of the kidney. Your time will come for donor nephrectomy.  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 fellow. Each unit is comprised of a narrated PowerPoint never longer than 20 minutes, a summary, references and a quiz. There is a subsection of modules for residents but unfortunately, it doesn’t give you access to some really basic areas. Instead use whiting’s login.Go to ASTS.org.Log in username: Jwhitingpassword is 4020. On the top menu of education choose “academic universe”.Choose “courses/modules” from the top.Then on the left, they are now ordered logically. 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. Articles. See the Literature section of surg.me, under Transplant.
  5. MMC website. Our transplant website contains all of our protocols, algorithms and the like. Please look it over.Just google “Maine transplant program”
  6. 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: The objectives for 3 of the four modules on this rotation are available for download on this page: immunobiology, kidney transplantation, donation. Objectives for vascular access are in progress.

Module 1.

The first module of the transplant rotation is immunology 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.

The second module is Kidney transplantation- the operation and immediate postoperative care.  Again, please look at the learning objectives on surg.us.  They are a little over comprehensive and redundant with the donation ones.  We’ll sort this out as we go thru the rotation. In academic universe, Sanjay Kulkarni’s modules on “Kidney Transplantation: Surgical Procedures”  and “Kidney Transplantation: Surgical Complcations” 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. There is an ACS chapter on transplantation in general also on the Surg.us site. The section on kidney is pretty reasonable.  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” that is in Whiting’s office or available thru MMC library on-line

Module 3.

The third module is on donation, both living and deceased.  Sources are again varied. Most of the PowerPoints are way more than you need to know and most of the texts really don’t spend any time or break this out.  On deceased donors there really isn’t any one good source. The chapter in Schwartz is reasonable and that and the review paper mentioned below is probably adequate didactics for deceased donors. You could pick thru the summaries in academic universe, but going thru hours of PowerPoints is probably not worth it on this topic. On preservation, there is a good review paper posted on surg.us.  For living donors, Julie Heimbach’s module in ASTS academic universe titled “Evaluation of the Potential Living Kidney Donor” is a little wordy, but probably the best source and certainly goes beyond just evaluation.

Module 4.

This is on access and dialysis. It’s new that this is a formal part of the rotation. So we don’t have learning objectives yet, and the readings to send you to are mostly some articles. We’ll flesh these out over the rotation.  For PD caths, up to date has a couple of good sections to read and I did the PowerPoint in ASTS- give it a look.  For vascular access, I’ve never liked the ASTS units.  There are two good articles on steal syndrome and fistula maturation that I’ll send you.  We’re still working on a general reference for dialysis.

 

PART B: PRACTICUMS

Module 1.  You should spend ½ day in the HLA lab. 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.  We are working on having you shadow a donation coordinator for half a day. Still in the works.

Module 4. You should spend ½ day in the vascular access center with Zimmerman or Cosma. Scheduling this is something that should happen the first week on service. We are working on having you go to a dialysis clinic for ½ day.

As a second practicum, you will need to take a junior thru a vascular access. We would prefer an actual case, but if things don’t fall right, we will arrange for a simulation. YOU are responsible for looking for an appropriate case, arranging for a junior to help and alerting the attending beforehand.

 

Part C: PRESENTATION

You are responsible for one presentation per rotation.  For Judyta and Adam, you have been scheduled to give resident conference on transplant in September. We will work on the presentation when you get on service.  For the others, we will likely have you prepare, plan and lead a journal club.

 

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 Whiting and Palma. There will be a 360 evaluation filled out by others on the transplant team.   You are responsible for doing and logging at least 20 cases, ALL of these should be submitted to either Whiting or Palma thru 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.
 

 

MON

TUE

WED

THUR

FRI

AM

8am Huddle, Nephrology conference room followed by rounds.

 

Whiting office 887 Congress or Palma office 19 West St

7:30 OR, either transplant or Whiting’s access.  Palma occasional cases in here as well

8am Rounds-Extended Followed by 19 West office by On-service attending. May also see patients with Neph attending

Surgical Education till 10. Check in with team afterwards

Txp Rounds at 8. Usually OR to follow. Depending on schedule and patients, might be another extended rounds.

PM

Open- good time to work on project, or practicum

OR usually extends into afternoon

19 West St office

19 West St office

Sometimes OR

 

 Look for TCR, staff meeting or QAPI

 

½ of Wednesdays is another good time to pursue practicums or presentation

 

Look for TCR or QAPI