General OR - Denver Health Medical Center
Denver Health is our Level 1 trauma and community hospital here in Denver. It is a resident favorite rotation; the attendings are very helpful, nice, and funny. This is where you will get a lot of your trauma experience so try to jump in on as many as you can!
Before you start
Dr. Arboleda should send you an email outlining the following, but if not. Speak to Veronica at least 2-3 weeks prior to your arrival to arrange the following: parking tag, ID badge, scrub machine access, who to call for computer access codes and Pyxis access code.
Resident parking is located at the Acoma Garage (550 Acoma) during regular hours, when overnight or the weekend you can park in the upper levels of the Delaware Street Garage
You can contact the Help Desk for passwords at 303-436-3777.
Before you start for the first time, you need to tour and check that all of your access work. . If Dr. Arboleda should arrange this to ensure you can get scrubs, access the pyxis, badge in, and access the computers.
Have someone show you how to navigate DH Epic (it is similar, but not the same as the University Epic). This will make reviewing patient records much easier for your pre-ops.
Preparing for the Weekday Daily Workflow
If on the schedule you are listed as “Res DH OR”, that is the designation for a normal, non-call weekday. Arrive at the usual time in the morning and you will generally be relieved around 3-5 PM.
If on the schedule you are listed as “late” (C2), arrive at the usual time in the morning and you will work 7AM to 7PM. You typically are relieved when the night resident arrives at 7pm unless there are more than 2 rooms running after 7 pm (rare).
The OR schedule for the next day is usually assigned on EPIC by 2-3PM the day prior, usually earlier. The patient, surgical procedure, anesthesia and surgical attending, and OR # will be listed for you. If you are post-call, you can access EPIC and complete your pre-ops from home, (see instructions below).
Some patients may go to the pre-op clinic prior to their procedure and the pre-op assessment on EPIC will be completed for you by one of the APPs, though these are normally just copy and paste and often lack information. Most of the time, you will need to do it yourself. If you are scheduled to take care of an INPATIENT, you MUST see the patient in person, perform a focused H&P, obtain consent from the patient and complete the pre-op assessment in EPIC before you head home the night before.
You should call your attending the afternoon/early evening the night before your case to discuss your anesthetic plans for the day.
Make sure to arrive with enough time prior to the morning conference (0630-0655) to set your room up in the morning and possibly consent if planning to do a pre-op block.
Conference & Education
Mondays- Grand rounds are teleconferenced to DH at 6:45 a.m. on Education channel 2.
Typically watched in the Anesthesia Lounge
Lectures on Tuesday, Thursday, and Friday are from 6:30-655 a.m. in conference room A 2537 (this is behind the surgical waiting area). Dr. Stein or Deis should email you the schedule
Each Friday lecture will be assigned to one of you to give a presentation.
Getting ready for the OR
Get all medications (including narcotics) out of the Pyxis in your OR room.
Currently, Propofol is NOT considered a scheduled drug at Denver Health like it is at UCH.
You must remember to label all medications w/ the date, time, and your initials that you keep in the next case drawer of your Pyxis as they may get thrown away by Pharmacy if not and it is a JCO violation.
Remember to lock your Pyxis whenever you leave the OR for any reason. Do not leave any controlled mediations on the top of the Pyxis.
Some meds (remi, sufent, P50s, Precedex, Norepi poppers) are found in the pyxis in the anesthesia workroom across from the RN charge/status board.
Also, if you take a non-controlled med, make sure you click it on the pyxis touch screen, otherwise pharmacy will not refill it which is a huge headache in the evening and overnight.
After conference, see your patient in pre-op. There is a large monitor in pre-op with your patient’s name and the assigned bay number . Finish the pre-assessment on EPIC (physical exam, anesthetic plan), consent the patient, and make sure to click the Anesthesia Ready for Procedure (located under the pre-procedure tab at the bottom) button once you have finished with the pre-op assessment/consent/etc.
Consents are done virtually, you open it on the pre-eval tab, and make sure it is associated with the current procedure. You click to sign for the patient or have them sign on your phone.
After all consents have been signed and the circulator and pre-op RNs have completed their handoff, the patient can have pre-medication and can be brought back to the OR.
At DH, you transport your own patients to the OR, except for first case starts.
Don’t transport patients past the main OR bridge (as it violates HIPPA w/ patient identifiers listed on the computer monitors on the wall), you must go the long way around.
Call or overhead page your attending when you are in the room if you have not already seen so that you can perform timeout. Unlike other sites, the anesthesia attending much be present for timeout
At DH, they do not have Cisco, so you will overhead page or use your cell phone.
I recommend calling your attending on their cell
To overhead page: After picking up the phone, press the “OH page” button and then say your message (“Dr. Chandler ready for timeout/waking up in OR 5” or “Anesthesia tech, please bring the Glidescope to room 1”) then hang up the phone. If you pick up the phone, press “OH page,” then hear a busy signal, then someone else is paging overhead at that time, so just try again in a few seconds.
You can get the Anesthesia Tech by using the mounted, in room phone and call Vocera. Then say “Anesthesia Tech” and it will connect you
If you want to leave the room, you need to write your personal on the board or communicate a plan with the circulator.
Upon arrival to the PACU, you should give a detailed report of your patient’s intra-op course to the PACU RN (PMHx, anesthetic used, meds given, EBL/fluids/UOP, etc). Under the post-procedure tab, you should click both the Handoff to Receiving Nurse AND the Anesthesia Stop buttons. You do not have to fill in a post-procedure evaluation note like you do at the University as your attending will do this for you.
Wasting Narcotics
They make a big deal of this, because we always mess it up
Unused narcotics must be “wasted” utilizing special numbered tamper-proof waste bags from the pharmacy.
These bags are on top of the disposal bins next to the anesthesia machines in the OR or in PACU.
Record your medication dosing in the Pyxis (select “all” if you drew meds from multiple pyxis).
To return meds, requires a witness and you will place the medication directly (no bag) into the disposal bin.
Transferring meds also requires a witness and is generally frowned upon because it leads to errors.
Have the attendings do this with you the first couple times to make them happy and ensure compliance.
Eating at DH:
The cafeteria (including Starbucks) is in the basement of the hospital.
Arguably the best cafeteria of the sites we rotate at for price and quality
Veronica will give you a cafeteria meal card at the beginning of your rotation.
Vending machines are located near the elevators between PAV A and PAV B on the second and ground floor. There is a resident lounge on the 1st floor next to the pre-op clinic/Pav A elevators. The door says, “staff only” and the code is 5210*. There are TVs, couches, and a mini fridge stocked with juice, milk, sandwiches, etc.
Sometimes we get a meal card for the Subway located on the 1st floor near the hospital entrance. Subway is open 24 hours and is the place to go for late-night food when on call (the cafeteria closes at 6PM on weekdays and around 1-2 PM on weekends).
There is also an all-staff RISE (resilience in stressful events) lounge with snacks and massage chairs etc. Located on the 1st floor between the Subway and the gift shop.
Computer programs for patient information:
EPIC: EMR that you will use at Denver Health (intra-op charting, pre-op assessments, intubation notes, etc). You will have EPIC training during your orientation week at the University. There are small differences between EPIC at UCH and Denver Health, but for the most part, it is very intuitive and easy to navigate.
You should have instructions for remote access ((https://dhremoteaccess.dhha.org) from Dr. Arboleda, but in short you need to request access from the Help Desk. Contact them if you have any issues.
You can also get it for Haiku; you just have to switch configurations.
Call Nights/Weekends
Call (C1/C1P) - 7 pm-7am. Check in with the charge attending to see where to go when you first arrive. Nights at DH can be very busy, so do not expect much sleep. You do not switch off with the CRNA like at University, so you will provide anesthesia for all the cases unless a second OR opens which the overnight CRNA will cover.
When you arrive for call, ensure that the Trauma ORs (OR 1, 9 or 10) and Neuro OR (OR 5) have been set-up. Confirm rooms with RN charge as they have been mixing it up. Make sure that both trauma rooms have at least the following items available:
Arterial line setup, Central line supply kit, IV setup
ETTs (7.0, 8.0) w/ stylet & 10 cc syringe, Oropharyngeal Airways, OGT/NGTs
Laryngoscope X 2 (ensure blade light works)
Level 1 fluid warmer w/ available NS fluid bag (don’t wet down until the trauma arrives in the room)
Alaris Infusion pumps (located in anesthesia supply room)
Glidescope / video laryngoscopes (located in anesthesia supply room)
Forced Air Warmer, Temp probe.
Emergency medications stocked (succinylcholine, etomidate, vasopressors, etc.). Most emergency medications are in prefilled syringes. Please do not draw up other medications until you are planning to use them as DH has a tight budget and we want to minimize waste.
Syringes
It is important to have the trauma ORs set-up ahead of time. You are more likely to crash up here, so you may be limited on time.
The anesthesia techs will usually stay until 10-11 PM on the weeknights and 3-4PM on the weekends. It is your responsibility to turn over your anesthesia workstation (replace the breathing circuit and suction, Caviwipe down monitor wires, etc.) once the anesthesia techs go home for the evening. Transport monitors that have been used to transfer patients to the SICU from the OR should be placed in the soiled utility room for cleaning located near the main ORs behind the charge desk.
The call room is in the main hall by the elevators near the hospital chapel. Room number is B285. Code to the room is 89999#. Have another resident/CRNA show you where this room is on your first day.
On-Call Resident Phone (28994):
You will carry this when you are on call. The float CRNA/on-call resident will give it to you when you arrive, and you can hand it off post-call to the new float CRNA/senior resident.
Always call yourself when you first get the phone to ensure that it is functioning - if not, give your cell phone number to the charge nurse (you can also write it on the whiteboard underneath the computer monitors at the charge desk). The OR charge nurse also has the number to the call room if they can’t get in touch with you by resident phone or cell.
Often the attending will have you take or forward the pain service phone as well. Discuss their expectations for how they want you to handle this
The attending also carries a phone while on call. They can be reached at 28999. Call your attending when you get called to codes and emergent airways. Let them know where you are heading. They will also need to be called before starting emergent over-night cases.
Airway box - It is just inside the anesthesia workroom to the right on top of the shelf when you walk in (grey tacklebox). There is also a peds airway box so make sure you grab the correct one. The Glidescope and Fiberoptic cart are also stored in this room. You should grab the airway box prior to heading to any code/emergent airway page. The ICUs will usually have an intubation tray with emergency drugs as well as a glidescope waiting for you so the airway box will usually not even have to be opened. However, if you called to the floor you need to bring the airway box and videoscope. If you do open the airway box, make sure you or the anesthesia tech replace whatever was removed so that it is ready for the next code/airway you are paged to. It is wise to carry a stick of succinylcholine, etomidate and phenylephrine in your pocket, just in case. You should always ask when the patient has last eaten and what their most recent K+ level is prior to emergent intubations in the ICU or on the floor. MICU door code is 1-5-9, everywhere else is accessed using your DH badge.
You will also carry the trauma pager when you are on call. This pager should only alert you for TRAUMA ACTIVATIONS and CODE BLUEs. If you are not in a case, go down to the ED to see the flow and ascertain if you will be crashing up to OR. You are also on standby for airway assistance, but generally the ED handles this and you just want to stay out of the way.
To get to the ED, you can take the elevator in the ORs or you can take the stairwell near the OR board.
Pretending/AIC
CA-3s have the opportunity to “pre-tend” while at DH. You split your time between being in a room or supervising CA-1s. You usually get the first pick of cases for the day if you are in a room. When you are not in a room, you will round on APS patients and act as first call for any blocks, or traumas that arise. You will be given priority for awake intubations. With this comes the responsibility of staying aware of what is going on in the ORs at all times so that you can be in the room at the right time.
AIC residents will also hold the pain service phone. Ask the attending your first day to add you to the shared list for pain patients. You are expected to round on these patients and write daily progress notes. You are also expected to see new consults as they arise.
Resources
- To be added