SCVMC

For residents new to the Valley, we will give you a formal Orientation on the morning of your first day, however occasionally when it can’t be arranged, we may orient you “on the job” after you get your badge, codes, etc. You should receive an email about all this from our administrative assistant Joanne Vermy. (Joanne.Vermy@hhs.sccgov.org), 408-806-8106.

You’ll need your ID badge, computer access (EPIC) codes/Pyxis, a key for the drug lockbox, a meal card so that you can get free food in our café and cafeteria, and your parking decal (C-permit- please remember to turn in permit and the lockbox key at the end of the month!) 

If you are a returning resident to Valley, you will need to have your Windows/Epic login reset and get your lockbox key and meal card. You should receive an email with instructions before starting the rotation. If you have any concerns, please contact Joanne.

OR Start Time

• Patients should be in the OR by 7:30 (8:30 on Mondays). On Mondays you will attend (or Zoom) Grand Rounds at Stanford, but you are expected to come directly here ASAP once GR’s is finished. Your attending may start the case if you have not yet arrived. (We do not have separate Divisional GR’s here at Valley, so on those Mondays please attend the Stanford General OR teaching session and then come here.) 

• If Grand Rounds at Stanford is cancelled, then you are expected arrive here in time to start your cases as you would on any other day. 

Set up: 

• You are expected to be fully prepared for your cases – Although you are not required to call your attending the night before, you are absolutely required to be prepared for your cases by reading up on the patients and an anesthetic plan ready to present to your attending in the morning. (If it is a complex case or you are unsure of the plan, do not hesitate to ask for advice from any attending or your chief or fellow residents!). **Be sure to check your machine, monitors and suction, make your emergency drugs, set up your airway supplies, place the pre-op IV in your patient, etc.  

• Although most drug concentrations are the same as at Stanford, there are some that are different (notably atropine 1 mg/mL, neostigmine 1 mg/mL, KETAMINE).  Regardless, always always always check your vials to make sure you have the right drugs and the accurate concentrations. 

• Not having done a subspecialty rotation (such as Peds), is NOT an excuse for being unprepared. We understand that you may be out of your comfort zone, so please just ask for help ahead of time. Let your attending know so they can arrive early to help you!

Drugs/PYXIS: 

• Every OR has its own PYXIS machine/anesthesia cart.  

• In order to avoid NARCOTIC drug discrepancies, narcotics should be wasted with your attending before leaving the OR, or take them to PACU to waste in the PACU PYXIS.  (It is very important NOT to bring any old narcotics back to the OR where they could accidentally be used on a different patient).

• Ideally wasting should be done with your attending as a witness, and you must double-check that the amounts wasted at the PYXIS agree with those you charted in EPIC.

• Please do NOT transfer medications, unless directed by your attending.  And DO NOT return Narcotics to the Pyxis return bin (returning other drugs is okay).

• Also, remember to ASSIGN ALL drugs removed from the PYXIS to that particular patient in the Pyxis machine at the time you remove them, including all uncontrolled substances (although only the controlled substances need to be reconciled/wasted).  This keeps an accurate inventory of the medications and alerts pharmacy to restock as needed.  

• Drugs must ALWAYS be secure. When you are out of the OR, you must Keep your syringes and vials secured in the clear lock box that sits on top of your PYXIS cart, or in the “Anesthesia Kit” pop-out drawer of the pyxis. If end of case, throw all syringes, vials away before leaving OR.

• Please make sure that all syringes are clearly labeled with the drug name, concentration, your initials, and the expiration date and time.  (For most drugs, the expiration date/time is 12 hours from the time you draw it up, including Propofol).

• Be aware that hospital policy states that any drug discrepancy that cannot be reconciled will be reported to the DEA and can result in the loss of your license.  Please always make sure your documentation is correct and complete. We will track discrepancies- please take this very seriously as it is a matter of professionalism.  

Post-op:

• PACU: Most patients will go to the PACU after a procedure, although patients who have come from the ICU should return to the ICU directly from the OR. 

• ICU: If your pt is going to the ICU from the OR, your circulating nurse may ask you to fill out a pink “ICU report sticky note” so they can give verbal sign out to accepting ICU RN. Sometimes it is easier to call the ICU RN yourself prior to leaving the OR to coordinate the handoff. Please bring back any drugs and supplies you’ve taken for transport and bring back the anesthesia monitor to the anesthesia workroom where you can place it on the floor to be cleaned.

Documentation and Charting:

• Pre-op Evaluations: 

  • Outpatients are called by nurse practitioners in our anesthesia pre-op clinic (APO) in the Valley Specialty Center (VSC) and an electronic pre-operative evaluation can be found in HealthLink (EPIC). These patients have not been seen in person (post COVID world), so we must confirm preop info, examine, and consent the patient, and document all in pre-op note.

  • Inpatient pre-ops are seen by a resident or attending and placed in EPIC. (Inpatient pre-op instructions below.)

• OR Cases: For most cases in the main OR as well as C-sections done on L&D, charting is done all in EPIC. Occasionally we will chart on PAPER for out of OR cases if needed or if computers are down.

• Labor Epidurals:  You must enter the Anesthesia Pre-op Note and L&D Epidural orders into EPIC, and have the pt sign a written paper consent.  The L&D RN should have the consent ready for you at the bedside.  

• Epidurals placed in the OR: If you have placed an epidural in the OR to be used for post-op pain management, be sure to document the epidural placement in EPIC so that other providers can see and refer to it, and add the patient to the Regional/Pain list. The Regional attending of the day will follow-up the next day. You will also place appropriate Post-op Epidural orders in EPIC.

Regional Team and Coordination:

There is a Regional attending of the day (listed in AMION) as well as a Regional nurse who carries the Block phone 74015 from 6am-2pm. The Regional attending will be doing pre-op blocks and intraoperative blocks (such as trunk or breast blocks placed just after induction). If you are in an OR that has potential blocks, it is very helpful to keep communication with the Regional team. It is also very helpful to consent the patient for the block while you are consenting for the general anesthesia! We will try to involve residents in blocks for teaching whenever possible. 

Places to Eat at VMC:

• Café: 1st floor M building below OR’s. Hours 7am-1pm. They have soup, continental breakfast stuff, pre-made sandwiches and salads, coffee, sodas, and cookies.  (Closed since Covid)

• Cafeteria: 2nd floor of the old part of the hospital. Opens 7:00am, lunch 11:15am, and closes at 6:45pm. 

At the End of the Day:

• Please check in with the Anesthesia scheduler (Floor Manager) du jour.

• The SCHEDULE for the next day is usually assigned in EPIC by late afternoon. Ideally you should obtain remote access so that you can look up your cases if you are DAC (Remote access instructions are at end of this document.) If you are here, you may touch base with your attending for the next day.  You may always call or page your attending for the next day to discuss your patients if you have any questions, but we do not require calling your attending the night before. 

• *EPIC TIP: don’t rely on the “My Cases” tab for your assignments, as sometimes you are assigned to an add-on room instead of a particular case. Look at the Status Board or “OR Cases” tab to see staff assignments.

Inpatient Pre-ops:  

When there are inpatients scheduled for surgery as add-ons or for the next day, the Floor Manager will assign these pre-ops to available staff sometime in the afternoon. Any preop assigned to you should be discussed with an attending that day so that nothing is missed and we can avoid any delays or cancellations. Also, if you order any pre-op tests or there are any other PENDING issues, make sure to communicate that directly to the Floor Manager so he/she can follow up prior to sending for the patient.

• • COVID testing: all outpatients must have a COVID test within 3 calendar days. Inpatients must be re-tested every 7 days. 

  • EKG: All patients aged 60 and older or based on co-morbidities. 

  • U-preg: All women of childbearing age need a pre-op urine pregnancy test.  (Exception for hx of sterilization procedure.)

  • UTOX: Patients with a history of methamphetamine, cocaine, or PCP positive urine tox in their chart need a DAY OF SURGERY preop urine tox screen.

  • Pacemakers: need interrogation preop; be sure to document the type, check the chart for interrogation, and call the manufacturer rep if needed.  

  • Tuberculosis: Ask all patients about their PPD status.  If PPD+ they must have a quantiferon test or CXR in the system within 6 months of their surgery date, even if treated.  If there is a clear CXR within the past 6 months, then document this.  If not, order one and advise the scheduler that it needs to be followed up.  (If the patient does not know their PPD status and does not have risk factors or known exposure, then they may proceed with surgery without a CXR.) **We are soon moving to all Quantiferon testing so if this comes up, just ask.

  • DNR/DNI orders are NOT automatically suspended for OR procedures. Our policy is to have a thorough discussion with surgeon and the patient/patient’s decision maker and document in the pre-op the exact wishes, including specifics: intubation? compressions? how long after OR will the reversal of DNR/DNI last (typically through PACU stay). Be sure to alert the floor AND thoroughly document!

  • Consent and Competency:  if a patient is not competent to sign their own consent, we must make sure the appropriate decision-maker gives consent, and with whom we can perform our Anesthesia Consent discussion. (A surgery deemed an emergent case by the surgeon would be the exception and we should document this in our anesthesia pre-op).  Please document.

Inpatient Post-ops:

Seeing your own post-op patients is a good habit to form early in your training. Although not formally required, assessing how the patient responded to your anesthetic can be very educational.  Also, if you ever have a complication during an anesthetic, then see patient postop and insure the attending of record is aware, so you can formulate a plan, follow-up, and document appropriately.

Resident Lectures:

Stanford is hosting lectures in-person and over Zoom. When residents are required to physically attend the meeting at Stanford, please let the Floor Manager know in the morning so that he/she can plan to let the resident out in time to drive to Stanford. 

Call Responsibilities

Your first day of call can be a little bit overwhelming. Your responsibilities are great, but you’re not alone.  You will be taking call with two attendings every night. (Attending N1 will be covering you until 1 am and N2 after 1 am… similarly on weekend days, the D1 attending is primary 7am-1pm and D2 is primary from 1pm-7pm).

• First call (“1” call on the schedule) means overnight 3pm-7am. Please allow yourself enough time to find parking on these call days, change into scrubs and be ready to work a few minutes before 3PM and check in with the Floor Manager for your assignment.  On the weekends and on holidays, your call starts from 7am-7pm (D call) or 7pm-7am (N call).  Note that for Sunday N calls, you may have to stay until 8am on Monday due to the late OR start on Monday mornings (however, we try to get you out by 7 when we can!)

• Second call (“2” call) means you are the late resident, so you may be kept later than your fellow residents to help finish cases. Typically you are relieved between 5 and 7pm, but rarely later.

In addition to main OR cases on call, you will:

• Carry the OB/Resident Phone 7-4016, which is also the CODE/Airway Phone

• Cover L&D for labor epidurals and C-sections

• Respond to all CODE BLUE and CODE WHITE (Pediatric CODE BLUE) overhead pages. (We do NOT go to rapid response “RRT” or stroke codes.) 

CODE BLUE and Emergency Airway Calls: 

For emergency intubations (either wards or ICUs), there are intubation modules (which include LMA’s, bougies, etc.) on all of the code carts in the hospital. For Pediatric codes or emergent intubations, you can grab a Pediatric Airway Box (from the shelf in the workroom closest to the door on the OR side of the workroom) to take with you.  However, we will always try to put you in the lowest acuity situation on call (e.g. if you hear a code on call, run back to the stable appendectomy in the OR and your attending will go to the code.) Also when techs hear a code they often show up with a Glidescope just in case, or you can call them to bring additional supplies if needed.

Inpatient Pre-ops for the Next Day

As mentioned previously, the next day’s OR schedule will have inpatients listed who are usually seen by available staff as assigned by the floor manager in the afternoon. However, as add-ons are continuously added to the schedule throughout the evening, they must be preop’d by the on-call team. Our policy is that all inpatients scheduled prior to 11 PM are seen before the next morning, or sooner if it is a special case such as known preop work-up that needs to be done urgently so that patient will be ready for the next day’s procedure.

…and all pre-ops should be discussed with an attending. 

Things to Check When on Call

1) Trauma and Neuro Room Set-up: OR #10 (Neuro) and OR #11(Trauma).  

• A clean circuit on the machine

• At least two IV set-ups (one blood pump that has a hotline already attached and a regular IV set)

• Suction that works

• Laryngoscopes, ETTs, oral airways

• An arterial line set-up +/- CVP set-up

• Belmont rapid infuser available 

2) L&D OR Set-up for C-sections:.  Combo code to the OR is 1-2-3-6-9.

Make sure that you have BOTH rooms set-up for that occasional STAT C-section:

• A clean circuit on the machine

• Suction that works

• Laryngoscopes, ETTs (6.0 and 7.0) and a 7.0 with Glidescope stylet 

• Glidescope lives in the hallway directly between the two OB OR’s

• Occasionally there is NO anesthesia tech overnight or on weekends, in which case you must immediately turn over the room yourself (wipe down the tabletop, cables, pyxis etc, and replace the monitors, airway equipment, circuit if it was used, suction and canister, tubing, Yankauer).  

• Emergency Drugs locked in lockbox: (drugs and syringes ready but not drawn up)

  • • 20mL Propofol 10mg/mL (unopened vial)

    • 10 mL Succinylcholine 20 mg/mL (unopened vial) 

    • 10 mL Neosynephrine 100 mcg/mL (premade syringe)

    • 10 mL Ephedrine 5 mg/mL (unopened vial)

    • 2 vials of 2% lidocaine (the provider can add 1:200K epi + 2mL NaHCO3 if they wish directly before use.) to quickly dose an existing epidural for an urgent C-section.

    • COVID + C-sections should be done in L&D OR 2

Your First Call from 5-6400…

Welcome to the world of OB Anesthesia on the Labor & Delivery unit! We won’t write much about that here because your experience will be your main source of education up on the 3rd floor.  All we will say is that the first (and most likely your second, third, fourth…) time you get called to OB, make sure you bring an attending with you to place a labor epidural and definitely to do a C-section.  An attending needs to be notified for all epidural placement and all C-sections.  As you gain experience, some of the epidural management issues you may be able to handle without your attending present (e.g. breakthrough pain or one-sided pain).  With time, you also will be able to evaluate a patient, complete a pre-op and setup for the epidural on your own, although an attending should always be present for the epidural placement itself.  

• Epidural anesthesia cart combination: 1-3-5

Both ORs on Labor and Delivery must be ready for a STAT C-section at all times.  This means the machine is on and checked out, airway supplies ready, monitors prepared, emergency medications (listed above) are ready in the lockbox.  (When there is a C-section, most necessary medications are obtained from the PYXIS, although some must be obtained from the circulating nurse, including methergine and hemabate, as well as a premixed bag of Pitocin.)  As discussed above, if you have just finished a C-sxn, you must make sure that the OR is immediately turned over and thereby ready for another stat C-sxn if one were to occur.

Reminders for OB C-sections

Neuraxial opioids- provide better pain control and allow the patient to get up and around faster so they can take care of their new baby and focus on breastfeeding etc. Due to the risk of delayed respiratory depression these patients are on pulse ox monitoring for 24hrs after neuraxial opioids- use the order set “IP ANE POST CS MICC” (this is the post-C-section order set for the MICC unit where the mothers go after delivery.) in addition to writing the standard “General Anesthesia PACU Orders”.

• Epidural morphine 3mg for an epidural in situ going for C-section 

• Spinal morphine 100mcg for C-section under spinal. 

Troubleshooting Epidurals

You will be called to assess and troubleshoot epidurals. You want to make sure any questionable epidural is fully assessed and replaced if necessary, so that it may be used in case the patient needs an urgent C-section! (We want to avoid putting laboring patients under general anesthesia for Csxn if at all possible- so this is a CRITICAL responsibility.) 

A resident new to OB should always call their attending to help with any epidural issues. If a more seasoned resident is comfortable with troubleshooting and bolusing epidurals in the night without calling the attending, that may be okay… just make sure you’ve discussed with your attending what their preferences are at the beginning of the call so everyone is on the same page.

Epidural boluses/assessments must be charted in EPIC as a “Facetime” note: document the assessment, and plan as well as typing in your name (EPIC does not record the documenter’s name when using a “Facetime” note). Also you must document the medication/dose in the Intraop portion of the Epidural record.

Don’t be nervous. Your attending should be present for all procedures. Just remember to speak up when you don’t feel comfortable with what you’re doing.  This is true as a starting first year and remains true when you’re a graduating third year resident!

The Resident Call Room

The call room is located behind the locker rooms. The call room is locked and requires your ID badge to access. Keep your valuables in your locker when possible. Do NOT bring any meds or syringes in the call room. (This is a HUGE liability for our department and the hospital at large if ANY medications (even non-narcotic) are unsecured at any time. Thank you in advance for taking this very seriously!

If you are called for something STAT in the middle of the night, just KNOCK on your attending’s door and wake us up. We should be able to hear overhead STAT pages, but sometimes you’ll get the call on the x74016 phone first. 

When CA1s begin taking call

CA1s begin taking call at the alley beginning week 3 of Block 1.

SCVMC Attending Contact Information ~ Will require Stanford email/SUNet ID for security purposes!

See your introductory email for updated numbers for Valley attendings!

• Anesthesia Floor Manager: 793-4233

• OB Anesthesia/Resident Phone: 947-4016

• Anesthesia Techs: x74071 - x74074

• OR Charge RN: x34232

• OR Front Desk: x53140

• ASU (Check-in): x52141

• Pre-op: x52140

• PACU: x55242

• L&D Floor: x56400

• L&D Charge RN: x74026

• Trauma Surgeon: x74087

• Anesthesia Breakroom Door: 1-3-5-7-9-#

REMOTE ACCESS

Some residents would like remote access to EPIC. (I would recommend having it so that you can better prepare for your cases and not be scrambling to get ready in the morning. It will also help guide you in what to read about the night before!). Here is the remote access link: https://scvhhsremote.sccgov.org. You will need to download the RSA Security Token app and you may need to call the IT Help Desk @ 408-885-5300. We will provide you the Remote access request paperwork to sign at the beginning of the rotation.

WIFI

You can get onto the HHS Guest Wifi.  You may want to choose Auto-Join on your settings so that you may more easily stay logged on. Alternatively, you can try to get SCC Employee Wifi… call IT Helpdesk for access.