Department of Anesthesiology

Day in the Life of Cardiovascular Anesthesiology Fellows

Master
Content

Day in the Life in the CVOR rotation

By Kevin Duong, M.D.

I get to the hospital at around 6:15 a.m. I go to the blue room to check my assignment and proceed to the OR to set up my room. I review the patient’s chart, draw up drugs, check the machine, and program my drips. The pressure lines, hotline, and cold line is usually set up by the anesthesia techs and ready to go. Sometimes there is an anesthesia assistant student that helps set up the room. I then touch bases with my attending before going to the pre-op holding area to see the patient. Clases normally start at 7:30 a.m..

When the patient gets to the OR, we hook the patient up to monitors, throw in an arterial line, induce, intubate, and then put in a central line (typical for a CV case). We then do our surgical time out and the operation begins. We do our echo and communicate with the surgical team if there are any abnormal or interesting findings. After a morning break, we go on pump. Later an attending relieves me for lunch. Once I return, the aortic clamp comes off and we prepare the patient to go off pump. At the end of the case, the patient is transported to the CV recovery room and I give handoff. I then check in with the board runner and depending on where I am on the release list, I either get dismissed or assigned to another case.

Day in the Life on the CVOR Rotation

By Lerin Rutherford, M.D.

I arrive at the hospital around 6 a.m. and head to my assigned OR for the day. Usually, I do a preliminary chart review of the patient and case to see what supplies I will need. Fellows are typically assigned to a pump case, commonly a CABG or a valve procedure. However, some days there will be large aortic procedures, cases involving mechanical circulatory support (devices such as ECMO or LVADs) or transplants. I make sure the OR is ready for the patient, going down my mental checklist for the case:

  • Anesthesia machine check
  • Suction apparatus ready
  • Airway equipment ready (Laryngoscope, etc.)
  • Arterial line transducer, A-line materials ready
  • CVP transducer, Central line kit and materials ready, Swan?
  • IV fluids ready
  • Inotrope and Vasopressor infusions ready
  • Case drugs prepared
  • Ensure any imaging equipment needed is ready and available (TEE machine, ultrasound)
  • Blood ready if needed

After all this is prepared, I head to the pre-op area where my patient is hopefully waiting. The patient’s medical history is taken, I make sure to clarify anything that was unclear in the chart and complete the pre-operative workup. I have a long discussion with the patient on what to expect; the risks, and benefits of the anesthesia and any interventions planned. After answering any questions, the patient signs the consent forms. Finally, we do a preliminary safety check with the OR nurse and ensure all the paperwork is in order prior to proceeding to the OR.

Once in the OR, final safety checks are performed. We will often start an arterial line for hemodynamic monitoring during induction of anesthesia. Once the patient is asleep, we intubate and start any necessary central lines for the case. Once all the necessary procedures and charting are done, I begin a preliminary TEE exam.

Any interesting findings will require a more in-depth investigation and often some echo teaching with the attending. The echo fellows will usually pop in to participate as well. After a morning break, I’ll manage the hemodynamics until it’s time to go on pump.

We are usually on pump before lunch, so the attending will relieve me briefly during the bypass run and I’ll return prior to coming off. We manage the hemodynamics and guide coming off bypass with echo. Immediately post-bypass we do a post-op echo assessment. We then correct any metabolic derangements or coagulopathy prior to surgery end and transport to the ICU. We give a comprehensive report to the ICU team and hand off care.

Depending on the day and the caseload, I’ll most likely relieve a colleague on another case or be done for the day.

Day in the Life on the TEE Rotation

By Gavin Best, M.D.

While you get experience with transesophageal echocardiography (TEE) throughout the year, we get two months dedicated solely to TEE. The echo rotation starts a little later since there is no room setup needed. I usually arrive at 7:30 a.m. to set up the probes and review the cases for the day. Each day you can expect anywhere from five to nine cases that will need echocardiography – between the CVOR’s and the Cath Lab. After the OR fellow has induced and lined up the patient, they will call or text the two echo fellows. These start rolling in between 8 a.m. and 9 a.m. I’ll then head to the OR with my co-fellow and the attending assigned to cover echo’s for the day. We will go room to room performing the preoperative assessments for the valves, transplants, CABGs and aortas in the ORs. The attending will cover echo concepts relevant for the boards and you do full exams on every patient. They’re usually done with your co-fellow, but when there are too many at once, we will split them up to keep the operating rooms running efficiently. By the time those assessments are complete, any TAVRs and Mitraclips in the Cath Lab are usually ready for their echo’s. After that, we’ll have lunch and finish any outstanding notes, then we head back to the ORs for post-procedure exams. We usually head out of the hospital sometime between 3 p.m. and 5 p.m. On Fridays, we’re responsible for running Echo Conference, where we review interesting echo’s from the week with the rest of the fellows and assigned faculty. All told we average 90-100 self-performed TEEs in each assigned echo month. Great Experience!

Day in the Life in the ICU at Baylor St. Luke’s Medical Center

By Scott Oldebeken, M.D.

As, a CV Anesthesiology fellow, you’ll rotate for one month in the Baylor St. Luke’s Mechanical Circulatory Support ICU. The MCS-ICU is specialized in caring for critically ill patients who require circulatory support devices including VADs, ECMO and Impella’s, as well as patients undergoing cardiac transplantation. During this rotation, you will gain invaluable experience in caring for these often complex patients. You will further develop your bedside tool like point-of-care echocardiography and interpretation of invasive monitors to ask and answer questions about each patient’s cardiac function. Learning to identify common patterns of pathology in a patient with an MCS device will guide your interventions in both the OR and ICU.

The MCS-ICU is staffed by renowned echocardiographers, anesthesiologists, intensivists and cardiothoracic surgeons. The house staff in the MCS ICU are comprised of four to five CV Anesthesiology fellows, Critical Care Fellows and Anesthesiology residents. Days typically start at 6 a.m. for a morning sign out from the post-call resident/fellow, then pre-rounding from 6 – 7 a.m. Formal ICU rounds with the attending on service start at 7:30 a.m. and usually last for a few hours, as in most ICU’s, but this is very dependent on the volume and complexity of the ICU census. After morning rounds, we typically catch up on new orders, procedures, and notes. During the early afternoon, our attending’s will often give lectures on topics related to MCS devices, as well as POCUS teaching to translate the lecture topics into clinical practice. We meet again at 3 p.m. for afternoon rounds to ensure that we address new patient problems and track the effects of our interventions. Following afternoon rounds, we finish up any pending tasks or issues and then sign out to the on-call resident/fellow.

Day in the Life on the Texas Children’s Rotation

By Daniel Jacobs, M.D.

I ride into work around 5:30 a.m. to get there by 6 a.m. I live only two miles away. I head to the pharmacy first thing, where I grab meds that I ordered from the pharmacy the night before. I then head to my OR and start setting up. Once done, I go to see the patient in pre-op; that’s usually where I meet the attending. I get consent from the patient’s parents and have time to grab a cup of coffee before the start time. Once in the OR, monitors are sometimes placed and usually induction with a volatile anesthetic is done before placing an IV. ETT is placed and then the lines. We do a lot of femoral lines on the smaller babies. At some point, I will take a break and later lunch. After a successful procedure, the patient is then taken to the ICU. Sometimes there may be another case to start or take over, but we are usually done by 5 p.m. unless you’re on-call for the day. During the month we probably have a late call day once a week and a weekend call once a month. By the time I arrive home, they have posted cases for the next day. I look up the patient, order meds and send the attending a quick email with my plan of care. All in all, Texas Children’s is a great learning opportunity and I am glad I chose it as an elective.