A Day in the Life of the Main Operating Room
By Kevin Duong, M.D.
I usually arrive to the OR around 6 a.m. to know which case I am in. If there is echo didactics (Wednesday), MM (Thursday once a month), or additional echo conference (Friday) I will arrive earlier to attend those at 6:30 a.m. Scheduling information is sent out by the overnight resident the night before to read in some capacity about the patient or case as you desire. Fellows are primarily in a cardiopulmonary bypass case, mechanical support case (VA & VV ECMO, Impella, LVAD), structural heart case (TAVR, MitraClip, LAA occlusion devices), or a high-risk cardiac patient undergoing non-cardiac surgery. We spend seven months of CVOR time during the 12 months on this service. There is robust effort from leadership that our time in the OR is preserved for high quality cases.
Arrival to the OR is approximately 6 - 6:15 a.m. depending on the length of setup required for the case. Since you are sitting your own cases you will draw up your own medications, check the machine, and prepare airway equipment. You are rolling in the room at 730 sharp or earlier if nurses are ready. You will not supervise residents and you will perform all the components of the case. The anesthesia techs will assist in all the other components necessary to start the case (transducer prep, echo in the room, EKG set up). Anesthesia ready time is aimed to be 15 minutes and by the end of the year. Our fellows consistently become expedient at arterial line placement, induction and central line with TEE placement independently of any assistance. The strength of the program is that you are sitting your own cases the entire year to work on your efficiency to become excellent CV anesthesiologists. You then perform a comprehensive echo and communicate salient findings to the surgeon as they are prepping the chest.
One of the workflow benefits of the fellow's schedule is we are given a breakfast break after timeout with complimentary food/coffee provided in the physician's lounge. Once we return we are usually going onto cardiopulmonary bypass by 9-10 a.m. and out of the room by 1-2 p.m.. Some days you proceed with another case and some days you are dismissed. We have a peel off system of dismissal throughout the day. While on CVOR, I probably am on home call 3-4 days out of the month and one weekend day. This can vary slightly but is certainly manageable. Since we have 10 fellows, we have adequate coverage to share the call responsibility. It is a well-balanced system that I believe is a great mix of independent time at home to study, spend time with friends/family while being occupied at work with high octane CV anesthesiology cases. I feel well prepared for any practice environment.
One month of CVOR at THI outperformed all combined months of cardiac in residency in terms of case quality and volume. The experience is second to none.
Day in the Life on the Cardiovascular Operating Room (CVOR) Rotation
By Lerin Rutherford, M.D.
I arrive at the hospital around 6 a.m. and head to my assigned OR for the day. Usually, I do a preliminary chart review of the patient and case to see what supplies I will need. Fellows are typically assigned to a pump case, commonly a CABG or a valve procedure. However, some days there will be large aortic procedures, cases involving mechanical circulatory support (devices such as ECMO or LVADs) or transplants. I make sure the OR is ready for the patient, going down my mental checklist for the case:
- Anesthesia machine check
- Suction apparatus ready
- Airway equipment ready (Laryngoscope, etc.)
- Arterial line transducer, A-line materials ready
- CVP transducer, Central line kit and materials ready, Swan?
- IV fluids ready
- Inotrope and Vasopressor infusions ready
- Case drugs prepared
- Ensure any imaging equipment needed is ready and available (TEE machine, ultrasound)
- Blood ready if needed
After all this is prepared, I head to the pre-op area where my patient is hopefully waiting. The patient’s medical history is taken, I make sure to clarify anything that was unclear in the chart and complete the pre-operative workup. I have a long discussion with the patient on what to expect; the risks, and benefits of the anesthesia and any interventions planned. After answering any questions, the patient signs the consent forms. Finally, we do a preliminary safety check with the OR nurse and ensure all the paperwork is in order prior to proceeding to the OR.
Once in the OR, final safety checks are performed. We will often start an arterial line for hemodynamic monitoring during induction of anesthesia. Once the patient is asleep, we intubate and start any necessary central lines for the case. Once all the necessary procedures and charting are done, I begin a preliminary TEE exam.
Any interesting findings will require a more in-depth investigation and often some echo teaching with the attending. The echo fellows will usually pop in to participate as well. After a morning break, I’ll manage the hemodynamics until it’s time to go on pump.
We are usually on pump before lunch, so the attending will relieve me briefly during the bypass run and I’ll return prior to coming off. We manage the hemodynamics and guide coming off bypass with echo. Immediately post-bypass we do a post-op echo assessment. We then correct any metabolic derangements or coagulopathy prior to surgery end and transport to the ICU. We give a comprehensive report to the ICU team and hand off care.
Depending on the day and the caseload, I’ll most likely relieve a colleague on another case or be done for the day.
Day in the Life on the Transesophageal Echocardiography (TEE) Rotation
By Gavin Best, M.D.
While you get experience with transesophageal echocardiography (TEE) throughout the year, we get two months dedicated solely to TEE. The echo rotation starts a little later since there is no room setup needed. I usually arrive at 7:30 a.m. to set up the probes and review the cases for the day. Each day you can expect anywhere from five to nine cases that will need echocardiography – between the CVOR’s and the Cath Lab. After the OR fellow has induced and lined up the patient, they will call or text the two echo fellows. These start rolling in between 8 a.m. and 9 a.m. I’ll then head to the OR with my co-fellow and the attending assigned to cover echo’s for the day. We will go room to room performing the preoperative assessments for the valves, transplants, CABGs and aortas in the ORs. The attending will cover echo concepts relevant for the boards and you do full exams on every patient. They’re usually done with your co-fellow, but when there are too many at once, we will split them up to keep the operating rooms running efficiently. By the time those assessments are complete, any TAVRs and Mitraclips in the Cath Lab are usually ready for their echo’s. After that, we’ll have lunch and finish any outstanding notes, then we head back to the ORs for post-procedure exams. We usually head out of the hospital sometime between 3 p.m. and 5 p.m. On Fridays, we’re responsible for running Echo Conference, where we review interesting echo’s from the week with the rest of the fellows and assigned faculty. All told we average 90-100 self-performed TEEs in each assigned echo month. Great Experience!
Day in the Life in the ICU at Baylor St. Luke’s Medical Center
By Scott Oldebeken, M.D.
As, a CV Anesthesiology fellow, you’ll rotate for one month in the Baylor St. Luke’s Mechanical Circulatory Support ICU. The MCS-ICU is specialized in caring for critically ill patients who require circulatory support devices including VADs, ECMO and Impella’s, as well as patients undergoing cardiac transplantation. During this rotation, you will gain invaluable experience in caring for these often complex patients. You will further develop your bedside tool like point-of-care echocardiography and interpretation of invasive monitors to ask and answer questions about each patient’s cardiac function. Learning to identify common patterns of pathology in a patient with an MCS device will guide your interventions in both the OR and ICU.
The MCS-ICU is staffed by renowned echocardiographers, anesthesiologists, intensivists and cardiothoracic surgeons. The house staff in the MCS ICU are comprised of four to five CV Anesthesiology fellows, Critical Care Fellows and Anesthesiology residents. Days typically start at 6 a.m. for a morning sign out from the post-call resident/fellow, then pre-rounding from 6 – 7 a.m. Formal ICU rounds with the attending on service start at 7:30 a.m. and usually last for a few hours, as in most ICU’s, but this is very dependent on the volume and complexity of the ICU census. After morning rounds, we typically catch up on new orders, procedures, and notes. During the early afternoon, our attending’s will often give lectures on topics related to MCS devices, as well as POCUS teaching to translate the lecture topics into clinical practice. We meet again at 3 p.m. for afternoon rounds to ensure that we address new patient problems and track the effects of our interventions. Following afternoon rounds, we finish up any pending tasks or issues and then sign out to the on-call resident/fellow.
Day in the Life on the Texas Children’s Rotation
By Daniel Jacobs, M.D.
I ride into work around 5:30 a.m. to get there by 6 a.m. I live only two miles away. I head to the pharmacy first thing, where I grab meds that I ordered from the pharmacy the night before. I then head to my OR and start setting up. Once done, I go to see the patient in pre-op; that’s usually where I meet the attending. I get consent from the patient’s parents and have time to grab a cup of coffee before the start time. Once in the OR, monitors are sometimes placed and usually induction with a volatile anesthetic is done before placing an IV. ETT is placed and then the lines. We do a lot of femoral lines on the smaller babies. At some point, I will take a break and later lunch. After a successful procedure, the patient is then taken to the ICU. Sometimes there may be another case to start or take over, but we are usually done by 5 p.m. unless you’re on-call for the day. During the month we probably have a late call day once a week and a weekend call once a month. By the time I arrive home, they have posted cases for the next day. I look up the patient, order meds and send the attending a quick email with my plan of care. All in all, Texas Children’s is a great learning opportunity and I am glad I chose it as an elective.