A typical day in labor and delivery (L&D) starts between 6:15-6:30am. I start off the day by relieving my colleagues who were on-call overnight. I receive the OB pager and report from them regarding what epidurals are in place, if there are any patients on the floor that we need to pay particular attention to, or potential c-sections. I then go from OR to OR to check my anesthesia equipment and drugs to prepare for the c-sections to come. At 6:45am, I go downstairs to attend our daily morning didactic lecture and have a nice cup of coffee to start off my morning. At 7:15, it’s time to get to work. I walk into the amnio room, to see how many c-sections/BTLs are scheduled and start interviewing the patients one by one. As soon as the patient, nurses, scrub techs, and OBs are ready, I roll our first patient back to the OR (usually by 7:30am). Once I place the spinal, check the level, and have the patient draped, one of the family members is allowed to come and join us for the miraculous occasion. After the delivery of the baby, with the pitocin running, I know that that the patient will soon be going to the PACU. Once she’s in the recovery room, I give report to the nurse, make sure the patient is stable, and congratulate the patient as I move on to the next patient.
Throughout the entire day, the OB pager gets passed along from resident to resident like a hot potato. We work as a team to fulfill the needs of the L&D and Birth Center patients. The order of cases are unpredictable due to emergencies/urgencies, crash c-sections, double set ups, etc. Therefore, we have to remain patient, flexible, and prepared for any case that rolls back to the OR. The OB team, consisting of 3-4 residents, take turns in the OR, while the rest are taking care of placing, checking, or pulling epidurals.
While I’m out of the OR, I’ll receive pages for epidural requests. I’ll roll my epidural cart to the patient’s room, preop her, and place her epidural. I stay with this patient for the next 30 minutes to monitor her blood pressures to make sure she does not experience hypotension. During this time period, I confirm that the epidural is working. It’s also during this time frame that the patient shows their gratification for my services in taking away her labor pains. Many times, there are medical students or PGY-2 residents that I can teach while doing my procedures. This is a great way for me to educate others while re-confirming my own knowledge. If there is down time, we take advantage of it, and sit together as a group to have a lecture regarding OB anesthesia by one of our faculty. The rest of the day is filled with c-sections, BTLs, epidurals, which make the time fly by so quickly. There is a lot of hustle and bustle, and soon enough 4:30pm rolls around. By this time, the call team has arrived to take over for the rest of the evening. I give report and head home to rest up for another exciting day up in L&D.
Grace Huang, MD
As the PGY-3 residents on the PACU/regional rotation, we definitely get a “well rounded” experience. Our day starts at 6:45 with taking the code pager from the senior resident on call overnight and attending the daily morning lecture. We are also responsible for providing airway management for the codes throughout the hospital. This experience gives you autonomy and the confidence to manage emergency airway situations. One of us is often asked to assist junior residents to start more challenging cases, transfer intensive care patients to and from the operating suites, or help with preoperative evaluation of cases that are added on during the day.
Finally, we attend to PACU issues such as pain control, nausea, hemodynamic management, or any other post anesthesia care. At the end of the day we will review the next days OR schedule to prepare for first case blocks the following morning. At 4:30, we hand the code pager off to the senior resident on call and give them report on the day’s activities.
Albert LaCasse, MD and Stacey Warner, MD
Anesthesiology Pain Service
Pain is a very unique rotation for Anesthesia residents at UTMB. It has components of in-hospital clinic, consult service, post-op pain coverage in the PACU, and OR pain procedures. It all adds up to a very lively day.
In the mornings, I start off with departmental lecture at 6:45. Pain lectures will also follow departmental lectures once or twice a week. These are given by Pain faculty, the Pain fellows, or residents currently active on the Pain service.
After lecture, I see the patients that are currently on our consult list. These patients come from all over the hospital-- surgery, gyn, medicine, etc... I usually round on these patients with the fellows and we formulate our plans before presenting to faculty later in the day.
After rounding, I meet faculty in clinic at 9am and we start seeing our clinic patients. I first see patients one-on-one and then present the patient to faculty with my plan which is then critiqued before we both go in to see the patient together. Clinic is a fun combination of patient interviews, procedures, and a constant barrage of good humor and "PIMPage" by the pain faculty and fellows.
Clinic ends eventually and, of course, leads to the most important session of the day....lunch. If I've been relatively well-behaved, faculty often take me out to lunch. About once or twice a week, they are let off the hook by pharmaceutical company representatives that feed and educate us as to why their drugs are better, more effective and cheaper. Often, this provides incentive to finish at noon, before the food gets cold!
After lunch, I round on our floor patients again, but this time, with faculty. In short, this is my time to shine! I discuss treatment goals and activate plans with faculty, to help the primary teams control and treat pain.
The one exception to the schedule is Wednesdays. This day is reserved for resident pain procedures in the OR (the other days are covered by the fellows.) On my OR days, I have the opportunity to do sacro-iliac joint injections, facet joint injections, cervical epidural steroid injections, and many other procedures commonly and uncommonly performed by pain specialist.
My months on the Anesthesiology Pain Service are a very rich and rewarding experience. It is a fantastic learning experience that takes you through the hospital floors, clinic, and the OR, couple that with our humorous and engaging faculty and fellows and you have one of the most rewarding months in residency training here in the Dept. of Anesthesiology at UTMB.
Vu Tran, MD
"On-Call" in the Operating Room
OR call at UTMB usually occurs 4-5 times per month and can best be divided into two types of call: "Bubba" call and SR (senior resident) call. On weekdays call begins at 4:30 PM and ends promptly by 7:15 AM; on weekends call begins at 6:45 AM.
Cases that begin after or run past 4:30 PM are referred to as "late rooms." It is the on-call team's responsibility to relieve their colleague’s working in these late rooms and staff cases which are still pending. Additionally, the on-call resident will staff emergency and trauma cases during the night. The on-call team usually meets 15 minutes prior to the start of call to discuss room assignments and plan for upcoming cases.
The in-house OR call team consists of:
- 1 Faculty (supervises the SR and bubbas and pay for dinner)
- 1 SR
- 2 Bubbas
Bubbas" function under the direction of the SR and faculty and are the worker bees for the on-call team. Don't get me wrong though, being a bubba can be great! Bubbas only carry one pager and when cases are not in progress can be found chatting in the lounge or sleeping.
The SR resident acts a bridge between the on-call faculty and the bubbas. It is the SR's responsibility to carry a staggering amount of pagers including the code pager for airway emergencies, the "pain" pager for issues arising with the pain service's patients, and their personal pager. The SR coordinates and prioritizes the cases for the evening, delegates room staffing assignments to the bubbas, does the preoperative assessment of patients, develops the anesthetic plan, and responds to the code and pain pagers. Additionally, the SR is available throughout cases should any problems arise. In this way, the SR gains invaluable experience acting as a faculty.
What happens during OR call can be quite variable. In the worst-case scenario, the bubba stays in the OR all night, leaving only to eat dinner and for the occasional coffee and restroom break. At UTMB, this rarely occurs. In the best-case scenario, the residents sleep the day away, awaken for dinner and the occasional movie, and go back to bed for the rest of the night. At UTMB, this rarely occurs...but when it does, it's glorious! Most of the time, we have enough cases to stay busy, punctuated with an occasional hour of downtime.
In my experience, call at UTMB has been great. Sure, I've had my share of "bad calls," but I've learned a great deal from them. Call is one of the rare times where I have been able to work in cases usually reserved for upper level residents and in doing so have grown as an anesthesiology resident. I enjoy the camaraderie of the on-call team and am always impressed by my fellow UTMB residents, who will pop in my room to give breaks or keep me company when they are not busy with a case.
Nicholas J. Defilippis, MD
I have found the SICU months at UTMB particularly educational. The SICU faculty (4 anesthesiologists and 1 surgeon) spend a good deal of time teaching on rounds and during afternoon 'mini-lectures.' On a typical day I start seeing patients at 7:30am after morning lecture. Patients can be on a number of services: CT, neurosurgery, general surgery, trauma, orthopedics, transplant, gynecology...
Rounds generally start at 9 am and end later in the morning. Typically all of the work is done by 3 or 4 in the afternoon and after then only the call person stays. Most calls are pretty benign, but occasionally you'll be busy with codes, lines, or intubations. Post-call you can expect to leave immediately after rounds. The ICU months are some of my favorite months at UTMB!
Robert Vela, MD