Cardiac

Cardiac anesthesia is an intensely challenging and immensely rewarding rotation, introducing you to myriad new skills involving the management of high acuity, medically complex patients undergoing extensive surgical procedures. Cases can be very exciting, and you will learn a tremendous amount in a short period of time. The unfamiliar environment and rapid pace of the cardiac OR is busy and may, at times, feel overwhelming. Nevertheless, be assured that cardiac anesthesia is truly a team sport and you are an integral part of that team. Together we will care for some of the sickest patients in the hospital. 

Given the steep learning curve and busy days, it is important to soak up knowledge in every way you can. In the OR, you will be busy: doing procedures, managing the patient, learning about and paying attention to the surgery (here like nowhere else in the OR, what the surgeon is doing directly affects our management), and interacting with a whole new set of specialists – the perfusionists. Read whenever you can – about your patients’ cardiac lesions, about the surgical procedure, about cardiopulmonary bypass - using whatever modern learning tool you prefer. Aside from getting to know the complex interplay between disease pathophysiology, comorbidities and anesthesia, a key component of cardiac anesthesia is knowing what the surgeon is doing, is about to do, and will be doing before the end of the case. Pay attention to the other side of the drapes at all times.

Please review these materials before you start preparing for your first case. This is designed to assist in your transition from the general ORs to the cardiac ORs, and other resources will be necessary for specific case preparation and knowledge acquisition.

Welcome to the cardiac anesthesia team.

Perin Kothari ~ Cardiac Rotation Director

Location

Your cardiac rotation will take place in the Stanford ORs, although residents may rarely be required to staff cardiac cases at SCVMC (Valley) as well.

Echo Rotation

You will be scheduled on "Echo" for a 2 week period prior to starting your 2 month cardiac rotation in order to become familiar with and learn TEE skills. This is an awesome opportunity where your learning is prioritized over all else and fellows/attendings are dedicated to teaching. A few tips for success:

1. Enjoy, soak in, and take advantage of these two weeks! You have the freedom to stay as late as you want, walk into any case that interests you, and have a dedicated 1 on 1 teaching session every day with a cardiac attending (anywhere from 1-2 hours long) 

2. Track your TEEs from the very beginning if you have any interest in possibly pursuing the Basic TEE certification (there are reasons that it may/may not be useful for you depending on your career goals - ask around to gain more information). To track TEEs, make a table that includes the date, MRN, attending, pathology, surgery and whether you observed vs performed the exam yourself. Full and partial studies count. To sit the Basic Certification exam you need to have observed 100 and performed 50 yourself.

3. Logistics: 

• It's possible that Echo residents need to be pulled for cases if the cardiac service is really busy. This means that you technically should arrive in time to fill in for a first case start in rare circumstances (not a pump case, but usually cardioversions etc.), which means arriving by ~7am. However, you don't need to actually go into ORs to perform/review TEEs until ~8am since the OR team will be intubating and placing lines until then

• Once you arrive, log into Epic and see which rooms are the pump cases for the day. You're welcome to enter those rooms whenever and see if the team wants your assistance with anything, but generally speaking you should go in whenever the CVP tracing pops up in the intraoperative record or you see them performing a TEE when you walk past. 

• Go into however many rooms you can/want throughout the day and just realize that this is all for your learning, so if you're not getting anything out of a certain room anymore, move onto the next or self-study until more cases start

• Text whomever is listed for the attending on "TEE" on Ether sometime in the late morning to see when/where they want to do teaching that day

• Call/text the cardiac scheduler anytime after 2pm to see if they need any help with anything before you go home

4. Call: you will be responsible for covering one weekend 2 call shift, typically on the second weekend to ensure enough time getting familiarized with cardiac.

Call Schedule

• 1st Call: 24-hr call

  • Weekdays: first case start (7a) - last OR finishes, then home call. Can be full 24 hours in-house. DAC the following day regardless of departure time from the ORs.

  • Weekends: home call from 7a-7a (24 hrs), 1st call cardiac attending + OR front desk will contact you directly for cases

• 2nd Call: 

  • Weekdays: first case start (7a) - third-to-last OR finishes. Pager call from home until the following morning. No DAC the following day (unless you work overnight -- exquisitely rare!). If the day lasts beyond 8 PM, ensure that you have 10 hours off between shifts - notify the 1st call attending and your AM attending of your potential late start the following day.

  • Weekends: home call from 7a-7a (24 hrs), third on the list to be called in (1st call resident, 1st call fellow, then you).

Cardiac Anesthesia Attending Contact Information ~ Requires Stanford email/SUNet ID for security purposes!

Residents are expected to demonstrate proof of an ACTIVE ACLS credential upon initiation of their Cardiac Anesthesia rotation. In order to facilitate this, we have included an instructional manual for how to sign up for one Stanford's *FREE* ACLS re-certification courses. You will be given protected time on your TEE rotation to complete this, but there are a couple stipulations to follow (see below). 

Read the document below for more details!

ACLS Re-Certification Instructions 

1. Step: 1 Sign up for an ACLS recertification course, using the document below as a guide.

   • Only schedule an afternoon ACLS course so as not to miss morning TEEs

   • Let the cardiac scheduler and the TEE attending know the day before your ACLS course

2. Step 2: Complete online module: 2-3 hours

3. Step 3: In-person skills check: 1 hour

4. Step 4: Send proof of completion/your new ACLS e-Card to Dr. Perin Kothari (perin@stanford.edu) before starting your cardiac rotation.

Excellent resource from the University of Utah with TTE/TEE image interpretation: Periop Echo Anesthesia Resource 

Dr. Zimmerman (the guy who runs it) also has a echo question of the day that he emails out to anyone on his list-serve that is super cool - sign up info here: Question of the Day 

Tips from Dr. Feng on how to increase opportunities for residents to perform TEE exams on the rotation:

1. Show up early - it is often first come, first served for performing exams, even for our fellows. The earlier you show up, the more likely you will have a chance to touch the probe vs. showing up right when we are about to go on pump or when a fellow has already started the exam.

2. Pick cases that have a resident rather than a fellow. If you see a fellow already performing an exam, choose a different room. It is totally fine to bounce around.

3. Introduce yourself and ASK the faculty if you can perform an exam after the faculty is done. The likelihood of performing an exam increases drastically if you demonstrate to the faculty that you are very interested in performing an exam instead of just observing. It is not always obvious to us who actually wants to do an exam and who is not as interested. If you are in a room and the faculty is taking too long, or the faculty says no, then politely excuse yourself and find a different room. Just mention you are going to a different room to try to get hands on experience.

4. If there is more than one echo resident on the rotation, don't travel in pairs. Instead, discuss amongst each other and choose separate rooms to increase individual exposure to performing exams.

5. Oftentimes, the non-pump rooms have TEE probes in place (washouts, ECMO decannulations, TEVARs, laser lead extractions, etc.) and no one shows up to use it. These are great opportunities as fellows are less likely to want to do the exams as they are "less interesting".

6. Similarly, stay late to perform exams after coming off bypass, or for cases starting in the afternoon.

7. Go to as many rooms as possible. Naturally, the more rooms you go to, the more opportunities for hands-on time there will be.