Here are the things you will need for your first day:  

• VA badge, unexpired. Everyone should have an active badge.  Please let the VA Chief, Ana Hammons, and Tammy Nogare know if you have issues and we'll sort it out. 

• CPRS/Vista login and password. Ana/Tammy will have your access codes available Monday. If expired or issues, it will require calling the VA help desk (x64767) on Monday AM. Don't be surprised if you need to make some phone calls.

• Windows/Network login and password. This is the vhapal…. login, However most people use their ID PIV card with PIN.   

• Omnicell login and password: These should be emailed to you by Doug Klahold (Douglas.Klahold@va.gov). If you have not received his e-mail please contact him and CC Tammy Nogare.  

• ScrubEx sticker (VA specific): let the VA Chief know if you don't have one and they'll have Ana send you a form to fill out and return before you start. If needed, there's a visitor card at the front desk that we can use. 

Pre-oping

Once the rotation has started, be sure to pick up a copy of the printed schedule for the following weekday (usually available by 10 or 11 am the day before) from the blue folder at the OR front desk and prep for your cases before you leave for the day. If you are post-call, I will email you relevant information – you are not expected to come to the VA to preop on a post call day. The attendings expect a text, call, or page to discuss cases the day prior, before 8:00 pm preferably.

Daily Schedule

First case on Monday room time is 8:30 am. First case on Tuesday-Friday room time is 7:30 am. The printed times on the OR schedule will say 9:00 am and 8:00 am, which reflect intended surgical start times. For out of OR locations (cath lab, endo, MRI, IR), please confirm the scheduled start time because these can be different. Also make sure the anesthesia techs are aware of the OOR case so they can bring any necessary equipment.

Call Schedule

• 1 call resident: 24-hrs in-house, cover ORs and airways/codes

• 2 call resident: weekday only, late call, first case start and work until down to 1 operating room

• CA1s begin taking call at the VA starting week 6 of the year.

VA Campus Details

VA Palo Alto Site Map

• Parking: does NOT require a permit. There are several staff lots, which are shown on the campus map in red circled, attached. There are also several bike racks out front of the main building for those who wish to bike.

• Campus Police: they are actual federal police, and are known to give tickets for speeding and/or rolling through stop signs (seriously, they can be aggressive…). Strict adherence to the 15mph speed limit and stop signs is recommended.

• OR Location: 3rd floor of Building 100, the main building at the end of the long driveway at 3801 Miranda Ave. See Campus Map.

• Anesthesia Offices: 3rd floor of Building 101. See Campus Map.

• Call Room: 3rd floor of Building 101, across from Anesthesia Offices. 

• Other Locations: Most patient care units are in Building 100, except for Spinal Cord Unit (Building 7) and Psych Inpatient (Building 520), which are common locations of E-Teams and Code Blues. See the map below to familiarize yourself with those locations.

Important Room Codes / Access Details:

• Anesthesia call room (A3 102): Code 4-3-2

• Anesthesia workroom / Supply room: 5-2-3

• OR Access: After hours, call nursing supervisor (x65960) or campus police (x65500) to unlock the OR for emergency cases or for supplies

• The login for the VA Amion is “pava” if you ever need to look up or page a service

• Refrigeration: There is a key to the Anesthesia Department in the resident call room. The Anesthesia Department has a microwave and refrigerator. 

Other Important Info

• Lockers: The men's and women's locker rooms each have free lockers reserved for anesthesia residents. Bring your own padlock to reserve an “anesthesia” or “visitor” locker for the month.

• Scrubs: The VA has its own scrubs. You should receive a ScrubEx access card on your first day with 2 credits. If needed, the OR front desk can provide you with temporary scrubs as well. If the access cards are unavailable on the first day, you may have to take a trip to the basement to the linens/scrubs office during one of your breaks.

• OR Dress Code: The VA is very strict about JCAHO guidelines, so personal cloth scrub caps must be covered by a VA-provided bouffant or skull-cap (or just forgo cloth hats while at the VA). Long-sleeves are also not permitted beneath scrubs, and must be covered with a full sterile OR jacket. Bags are also technically not permitted in the VA ORs. You may not have access to the OR locker rooms on the weekends to get scrubs unless there is an emergent OR case that needs to go, so plan accordingly.

• Omnicell: The VA utilizes Omnicells for drug storage (just like Stanford). We’ll make sure you have logins and passwords, and that your fingerprints get enrolled once you get here.

• Anesthesia Machine Checks: The anesthesia machines are old, and different from the ones used at Stanford. The anesthesia techs DO NOT run the machine checks for you. You should run a full anesthesia machine check every morning when you arrive in your room. Senior residents, attendings, and anesthesia techs can show you how to do this.

• Charting: Pre-op notes and PACU orders are through the VA CPRS system. OR charting occurs in a program called PICIS. Your attendings should walk you through the details of both systems and help with charting for the first few days. 

• Logins: The IT Help Desk can usually activate these for you easily over the phone - the Help Desk phone number is 64767 and should be available 24/7. You'll need two sets of login names and passwords (one network log in to get into a locked computer, and one to open the electronic medical record/CPRS) as well as a "signature code" which is a password you enter to sign orders. If you return after one year, you may have to complete the “refresher” MTT training and forward a certificate to the administrative office to show completion to the VA Anesthesia administrative office.

• I-Stat Training: This will be discussed on the first few days of your rotation. You must use your own I-Stat barcodes and scan the patient's armband or else you will lose privileges. The in-person training session is about 20 minutes and will take place on one of your first few days here. Please complete the TMS training or whatever training/orientation that Tobi Hunter emails you about before the rotation.

• Food: There is no free breakfast buffet. There is the Canteen cafeteria and a Starbucks cart on the first floor. Hours are limited and you might want to bring your own food (including utensils as the plastic ones run out frequently in the break room!). I think both are closed on the weekend now with the COVID situation. They also both close very early, so remember to bring food or plan to Doordash/UberEats, etc for dinner on call days. 

• Phone/wifi/internet: Cell service in the ORs is very limited which can drain your phone battery. Wi-fi works ONLY (sometimes) in the OR break room. Internet doesn’t exist in the ORs, so plan accordingly.

Airway Coverage

• On weekends, hand off the airway Vocera at 7am unless you work out another time among yourselves

• On weekdays, hand off the pager to the chief whenever you want. I will usually be there by 6:45 am

• When done in the OR, take one small suitcase, one large suitcase, and one GlideScope to your call room and return them to the anesthesia workroom in the morning for restocking (even if not used). Check the call room before bringing another suitcase from the OR's-- usually there is one set of suitcases and a Glidescope living in the call room that don't need to be exchanged if they are not used. 

• Make sure the airway bags are fully stocked when starting your call shift.

• Make sure you have airway stuff in the call room on Fridays/weekends, you will need to call security at 65891 to get in to the OR's if you need additional supplies.

• Code meeting is at 7:50 am in the IICU conference room and 10 pm in the MSICU conference room. Try to be there for the code meetings on the weekends (in am and pm) and on the weekdays (in the pm).

• Respond to Code Blues and E-teams no matter where they are (including the psych ward which is Building 520 and SCI unit which is Building 7)

• After hours, your attending will typically be off-campus. Unless it is a true code blue (in which case you should go ahead and intubate), inform your attending of an impending intubation as early as possible to give them time to come in or to discuss the plan if they would like for you to proceed solo. Do not push drugs in a patient with a protected airway without your attending’s presence or explicit permission to proceed without them present. If you do not feel comfortable proceeding solo, let them know you would prefer they come in. It is their job to be available.

• You are not expected to go to grand rounds or other conferences post-call.

• If the overnight MSICU resident is an anesthesia resident (and therefore can handle airways), you would  take 1 call from home but MUST be available to come in for emergent cases within 30 minutes. On average, residents usually end up with one 1 call being home call each month but no guarantee. It is completely random whose call coincides with the ICU anesthesia resident as these schedules are made independently of each other. 

• For COVID intubations (aka Code 95s), you will NOT enter the patient rooms. Please notify the COVID airway attending (designated as “DAB”) to coordinate. Typically we will have two attendings don and enter the room to intubate, while the resident on call acts as the “safety officer” and coordinates from outside the patient room.

Weekend post-ops, general info:

The Saturday on-call person will be responsible to see post-ops. The list of patients will be waiting for you in the call room. If there are Saturday OR cases and you are busy all day, please hand off the names to Sunday call resident to do a post-op on them.

In order to write a post-op note, first change the location to Post-op PAD, click New Note, choose Anesthesia Post-op as the note title, and follow the template prompts. These are simple notes specific to anesthesia complications and recovery. If you are concerned about other medical or surgical issues, please contact the primary team. Put your on-call attending as cosigner if you need a cosigner. 

Add-on cases

• If a surgical resident pages you about an add-on, first make sure that their attending is aware and agrees with the need for surgery. Assess urgency, discuss NPO status, have the surgical team order a rapid COVID test, and use your clinical judgement for if/when you think the case needs to go.

• Then please call or page (or ask the surgeons to call/page) the nursing supervisor at 65626/pgr or 11546 so they can mobilize the OR nursing staff.

• Call security at 65891 to have them open up the OR so you can set up (if the OR is locked, sometimes it isn’t)

• Let your attending know!

• Evaluate the patient and write a pre-op note (or if it’s a Saturday add-on for example, ask the in-house resident to see the pt if you are already home for the day on a Friday evening. Nurses only call one resident, never assume an attending or the in-house resident has been informed of the add-on).

• Write the patient's information down and so they can get a post-op evaluation for the following day.

• VA Operator: (650) 493-5000, x1, x1

  • Blood Bank: x65842

  • IT/CPRS Hotline: x64767

  • Nursing Supervisor: x65960

  • OR Front Desk: x66024

  • Pharmacy: x64296

  • Security: x65891

VA Remote access

• It is best to start this early - when you go to get your updated PIV card they will let you test your login and password, I recommend doing this a week before the rotation and you can submit the VPN request at that time

• Go to: https://vpnportal.vansoc.va.gov/SelfService/ (this must be done at the VA)

• Click Request VPN Account

• Type in your secondary email, the last 4 of your social security and select Personally Owned Equipment, and for justification state “Resident physician requiring remote access to patient medical records for when on-call at the VA.”

• Click Continue. Select facility California and VA Palo Alto Health Care System. Click Continue.

• Select VA Employee and then <NEW LAST NAME>; Milo Lochbaum as the supervisor

• Check the box and then click Submit Request

• You will be notified when your account is approved and they will send you instructions on how to access.

• You will also need to get a PIV card reader for use at home, this can be accomplished by putting in a request through the Help Desk (Call 64767). If this does not work you can call the Help Desk and apply for PIV exemption - they will grant the exemption temporarily (although she said that it was likely indefinite because she didn’t set a date to expire). PIV exemption can formally be requested through Hansni which is something you should ideally do because it allows you to access PICIS

• Once you are approved, go to https://raportal.vpn.va.gov/ and login by clicking on the Windows logo and using your VHA username and password

• Click Citrix (CAG) > Media

• Click CAG StoreFront Windows and Mac OS User Guide

• Plugin the card reader and your PIV and then login, this may be different for you depending on your machine - call Help Desk if in needed

Access PCIS (Critical Care Manager)

• Open CPRS > Double-click any patient > Click Tools > Click Specialty Applications > Click PICIS Remote Application

• Citrix Receiver will open > Sign-in with your vhapal… login and password (Note: If you have not requested PIV exemption you must request by calling the Help Desk or talking with Hansni) > Click Log on > Click Smart Card Bedside > A remote desktop instance will open which is under Windows > Double-click Critical Care Manager shortcut on the Desktop

• Select (640) Palo Alto > Click OK

• Sign-in with CPRS login and password

• Select the patient that you wish to access and then Click Remote View on the right aspect of the menu

Access ER Status board

• Open CPRS > Click Tools (on superior toolbar) > Click Specialty Applications > Click EDIS

• Sign-in with CPRS login and password

• Click Display Board

• This is the ER board that you see when you walk down, this is nice because you can then lookup potential consults before going home

• Unfortunately, you can’t look-up patients through this system so you must go to CPRS > Click Files (on superior toolbar) > Click Select New Patient… > Click the bubble selector next to Clinics > Type er in the search box > Select Er-Day(pad) | Er-Eve(pad) | Er-Night(pad) depending on what time of day it is and then find the last name of the patient on the list so that you can access their chart