Anesthesia

HOME BASE:

​OR (3rd floor). They can show you the break room and locker room (right by OR)


TEAM:

You are here to do intubations! This is well understood by all of the attendings. Nobody expects you to do anything else, and in fact, they highly encourage you to leave the room immediately after placing the tube, so that you can find the next room to intubate in (and they can document). Show up and introduce yourself to the anesthesiologists (they are all very friendly), and check the board to see which rooms have the most tubes. The printed OR schedule will have a note whether a case is general anesthesia or MAC. You will be running from room to room intubating people. You may have to compete for tubes with some anesthesia residents, SRNAs, students, and other residents. Be firm in this. It gets very difficult some months. Try to learn who the senior CRNA students are at the beginning so you can get their tubes (they've already done a bunch and are more willing to give up tubes). Also, once you are comfortable with basic intubations, some of the attending will let you practice with rescue devices such as LMAs, intubating LMAs (fast tracks), fiberoptic intubations, and bougies if you ask.


CALL SCHEDULE:

No calls


DAYS OFF:

You are off on weekends. Also, since conference runs until 1 on Wednesdays, generally you aren’t expected to be there since there are few tubes after 1-2PM. And, no elective cases are scheduled on holidays.


TYPICAL DAY:

7:00-7:15 am: Show up to scope out room which rooms may have tubes. Find the resident, attending, or CRNA in charge of the room and talk with them. [on Wednesdays, arrive at 8:30 am, as anesthesia and surgery residents have conference at LLU, so everything starts one hour later.]

7:45: patient to room (Check with circulator to see when room is ready)

All day: do cases. By “do cases,” we mean follow the patient into the OR, bag them, tube them, and go to another room. Repeat. If you were really feeling helpful, you could tape the tube to the lip.

  • Bring your reading/study material with you, as there are often looong breaks between the first round of tubes as everybody starts cases and the next set. Make sure you keep an eye on the board/pre-op area, to see how cases are progressing, and what patients are up next. It changes constantly throughout the day.
  • Plan ahead on where to go by looking at the board and make circles every half hour to 45 minutes. You can study in between.


Paperwork: Generally the attendings will do the paperwork, but since you’re there stealing all the tubes it’s certainly nice to help out. You can fill out the anesthesia record or post op orders.


Pearls: By the end of the month it may start feeling pretty routine. Play the “what would I do if” game about potential emergencies or complications to keep pushing yourself. Important drugs and dosages (you probably will never have to calculate or draw up, but it’s a good chance to test and reinforce your knowledge):

You can also try to get other procedures. There are quite a few art lines and peripheral IVs to be had.


EMERGENCY DRUGS (Pull out one set per day, re-draw for next case if any get used)

  1. Ephedrine (use 10cc syringe): Add 1cc ephedrine to 9cc NaCl. (Conc 5mg/cc).
  2. Phenylephrine (use 10cc syringe and 1cc syringe): Take 0.1cc phenylephrine, add to 10cc saline vial, use 10cc syringe to draw it all up. (Conc 100mg/cc).
  3. Atropine (use 3cc syringe): take vial directly into syringe . (Conc 0.4mg/vial)
  4. Succinylcholine : Typically 1.5-2mg/kg


COMMON BASIC DRUGS

  1. Versed (3cc syringe): Take 2mg vial into syringe (there’s also a 5mg vial). (Conc 1mg per cc).
  2. Fentanyl (3cc or 5cc syringe): Use 100mcg vial or 250 mcg vial=2-5cc. (Conc 50 mcg/ cc).
  3. Lidocaine (5cc syringe): Draw up 100 mg vial=5 cc. (Conc 20mg per cc).
  4. Propofol (use 20 or 30 cc syringe): Draw up 20 cc vial=200 mg. (Conc 10 mg per cc).
  5. Rocuronium (5cc syringe): Draw up 5cc=50 mg. (Conc 10mg /cc)
  6. Zofran (3cc syringe):Draw up 2cc=8mg. (Conc 4mg/cc)
  7. Decadron (3cc syringe): Draw up 1cc=4mg.
  8. Glycopyrrolate (5cc syringe): Draw up 5cc=1mg (Conc 0.2mg/cc)
  9. Neostigmine (5cc syringe):Draw up 5cc=5mg. (Conc 1mg/cc)

**Glyco and neo are for paralytic reversal. You can mix them together in a 10cc syringe or give separately. Make sure to give the same amount of each, and always give the glyco first to prevent bradycardia from neo.


OTHERS:

  1. Mivacurium: Short acting paralytic (about 15 in compared to 45 for roc) for short cases. Can cause histamine release. Usually doesn’t need reversal.
  2. Etomidate: Can use for induction instead of propofol Draw up 10 cc, (2mg/cc) induce with 10-20mg.


EMERGENCIES:

  1. Patient bucking: This means they’re getting too light. Switch off vent (powerful stimulus to buck), push a few cc’s of propofol if any is left, or turn up the gas and bag the patient to get the gas on board. Don’t forget to turn vent back on when patient calms down.
  2. Hypotension: From gas, propofol, etc. Usually you can just watch it, but if drugs needed:
  • Ephedrine: Give 5mg (1cc mix) if both BP and HR low.
  • Phenylephrine: Give 100mg (1cc of mix) if BP low, not HR.
  • 1 reason for hypotension is too much gas, so decrease N20 and other gases, and can also give fluids if they’re dry. Don’t jump to give these meds, you may end up chasing your tail.


TIPS FOR GETTING THE MOST OUT OF YOUR ANESTHESIA ROTATION:Click here for a list of Loma Linda VA Anesthesia faculty with some pictures (select "Anesthesiology" in the drop down menu for "Field").

Being able to speak the language goes a long way in any off service rotation. Review 3 important classification systems related to anesthesiology:

Mallampati classification for grading open mouth view to predict intubation difficulty:

(Image from Rich, 2005)

Cormack-Lehane classification for grading laryngoscopic view of glottis:


(Image from Roberts and Hedges, 2014)

ASA classification for assessing physical status prior to surgery


​FOAM resources:

Life in the Fast Lane's Airway Assessment

Life in the Fast Lane's Own the Airway

Rich Levitan's Airway Cam Videos (the entire series is available to watch in the Sim Center on the Mac computer in the walkway).


One resident's tips for success:

The month is what you make it. The more you show that you want to be there and you are committed, the more likely you are to get intubations. Here are the tips that I felt helped make my month successful:

1) Get there early. Surgeries start around 8am. Instead of showing up at 7:55 and expecting to intubate, Arrive at 7:15-7:30 and take a look at the board for the day to scout which rooms will likely be good ones for you.

2) Be proactive. After picking the rooms that look like they will be intubation cases (thoracic, abdominal, etc), go interview those patients. Confirm what surgery they are having done, get a basic history (PMH, PSH, allergies, etc) and then ask things anesthesia cares about (did you eat this morning?), do a physical (heart, lungs, mallampati). After talking to the patients that you think will be intubated, go find the attendings who will be in those rooms (they are listed on the board) and present to them. If you cant find the attending, talk to the resident (also listed on the board) and show them you were proactive.

3) Know your stuff. When presenting to the attendings, impress them. Tell them why this patient should be RSI (history of GERD), or why the patient should have spinal precautions when being intubated (history of cervical spine disease).

4) Let the residents and CRNAs know you are there and want intubations. If they are impressed with you, they will be more willing to give you intubations. If there are inexperienced students rotating with you, this can be harder, but if the attendings or anesthesia residents really like you they may fight for you to get the tube.

5) Try to get more than one intubation per round of surgeries. If the attendings know you are intubating a patient in another room, they may be willing to wait a few extra minutes for you in their room, especially if you have already impressed them (Dont expect them to wait too long though).

6) Ask if you have questions. Always ask if there are any other rooms that look like you could learn from them. Ask if any other rooms are doing intubations that you overlooked. Ask about physiology, pharmacology, etc. Over time, as you work with certain attendings more and more, ask if you can do different styles of intubations such as glidescope, bougie, miller blade, etc.

7) Stick around. You cannot get intubations if you are not around. Study in the locker room between cases. It is easy to check on the board from there and you will never be far away. That way, if a case goes faster than expected, you wont miss the next intubation in that room.

8) Be willing to do things besides intubations. Do LMAs, A-lines, local anesthesia/nerve blocks.

9) Always learn. If someone tells you "this is a tough intubation, I think I will take this one", politely point out that you will have to deal with that in the ED, and that you'd still love to give it a try. If they still want to do it, go and watch, ask them to teach you what to do if a patient like this comes to the ED and you need to intubate them. If they feel like you learned something from them, it is very possible they will let you try on the next "tough intubation".

10) Speak with the EM resident who rotated on anesthesia the month before you about their tips for success. Pass on your tips to the EM resident rotating after you.