General OR - Rocky Mountain Regional VA Medical Center
Locations
ORs: 3rd floor, F building, Take Elevator 1 to the third floor.
Anesthesia Office and Lounge: Immediately off the hallway connecting buildings F and H, F3-294
Pre-op: Adjacent to PACU through the double doors in the main hallway
PACU: Down the main hallway in the procedural area to the right the glass-walled OR office
Locker rooms/Scrub Pyxis: South end of the main hallway in Building F (code: 1-4-5-#)
SICU: Bridge to the ORs immediately next to the Anesthesia Offices (building H, floor 3)
Before you start
You will need an ID badge, scrub card, Omnicell access, and computer (CPRS and Innovian) access. This whole process will take several weeks, and likely 3-5 visits to the hospital. You should contact the department coordinator (Dolores Colella, Dolores.Colella@va.gov) at least 6 weeks prior to starting there to make sure things are in motion. There is a checklist of items you must complete, including fingerprinting, online computer training, and applications for credentials. This is a very harrowing process, and no one will be checking to make sure it is proceeding for you. If you stall (and sometimes even if you don’t), you will be stuck trying to get around without access for the first couple of weeks you are there. Not fun.
1-2 months prior to starting: go to the badging office and get your fingerprints done. You don’t need an appointment, but they close at 4pm. After you get your fingerprints done, go to HR to get your WOC letter or email Dolores to get a copy (you will need your passport AND driver’s license or social security card for this). Email the coordinator prior to doing this so he can fill out the paperwork to “sponsor” you.
1 month prior to starting: Go back to the badging office to get your ID – YOU WILL NEED AN APPOINTMENT (email the coordinator to have them arrange an appointment for you, you must have an appointment, or they will not do anything for your even if they aren’t busy). Also, at this point you need to start emailing the coordinator to make sure that they set up your computer access: you will need CPRS access (for patient notes/info), Innovian (Anesthesia EMR) AND Omnicell access (pharmacy/drugs access).
2 Weeks prior to starting: Email the coordinator again to confirm that you have CPRS access, Innovian, and Omnicell access. At this point you will need to make another trip to the VA (once you have your badge) and have the coordinator set up OR access for your badge. At this time, make sure they give you your Omnicell login information (last initial +last 4 of SSN). Go to a computer and make sure you can log in, also go to the Omnicell in the preop area and make sure you can login to this as well (these are the two most important things). To get fingerprint access, you will need to talk to the head Anesthesia Tech, Kathi Conner.
Before you start you should have (1) your badge, (2) Omnicell access (VERY IMPORTANT), (3) CPRS access, (4) OR access for your badge, (5) Scrub card (You may be able to get a scrub card from the outgoing resident, coordinate with them),
Your ID will grant you access to the north parking garage.
Again, having Omnicell access is essential prior to your first day (you really can’t do anything without it
Being the VA, emailing does not guarantee that that the coordinator will start getting everything set up for you. If you do not explicitly get a response from them, you should just stop by the VA and personally talk to them someone about getting everything started.
Write down your various codes – CPRS (Access/Verify and signature code), Innovian login, Computer PIV Pin number, Omnicell Login/Password
Kathy Connor (the absolutely amazing lead anesthesia tech) is responsible for resident Voceras (in house paging system). She will orient you to how they work/what commands can be utilized. You will need to sign these in/out to start and end the rotation.
Weekday Daily Workflow
The pace at the Rocky Mountain Regional VA Medical Center is a little more leisurely than it is at the other hospitals, but they are really trying to get cases started on time and speed up turnovers as much as possible. You can definitely help the process by putting gentle pressure on the OR nurses to get the room turned over, for example, by letting them know that you are ready to take the patient back (or once you get to know them better, suggest that you start taking the patient back “slowly”). On the plus side, the slower pace gives you more time for placing blocks and lines without feeling rushed (check with your attending, but many will appreciate getting an arterial line placed before heading back to the OR in order to save time; this is something to consider later in the year once you have done a bunch asleep).
The anesthesia techs here are very friendly, some of the best we work with. It is always appreciated if you set up your own arterial line for first case starts (either from a prepped aline bag in the workroom or put one together from the bottom drawer of your in-room Omnicell). Don’t worry, you will still not be the limiting factor for starting the next case.
Make sure to turn on and log into your Vocera each morning.
Pacer magnets are on the fridge in the anesthesia workroom. You will have many patients with pacemakers/AICD’s.
Printed schedules for the next day are in a file next to the printer in the anesthesia offices. They are usually available by lunchtime. Changes are frequent, so make sure to check the OR board for the latest schedule. Outside OR1 along the main hallway (in between entrances to the ORs and PACU) is the most updated OR board. The whiteboard in the anesthesia office will also have the day’s cases, assignments, and add-ons, as well as room for you to mark when you’ve gotten breaks.
Because of CPRS (and limited ability to access it at home), preop your patients before you leave the VA for the day. Most of the attendings prefer a quick discussion in person instead of a phone call later in the evening. You should try to look up at least your first case during lunch so you can talk with them before they head home for the day. The VA computer system is archaic, but very thorough once you get it figured out. You can now access CRPS from home, but connectivity is sometimes questionable so do not depend on this for your initial lookup.
Take the time to read old anesthesia records, discharge summaries, cardiology notes, TTE’s, etc. on your own to make sure nothing important has been missed. Ask for a brief run through from a co-resident of the CPRS system to be able to find what you’re looking for while pre-opping.
Cases start at 08:30 on Monday, and 08:00 Tuesday through Friday. PIVs are placed in pre-op, but most of the time they are smaller than we want (20g or less), so be aware if you think you need large-bore access. Also, plan for time to do any blocks or epidurals if indicated (see below). The surgeons include anesthesia consent into their own, so you don’t need the patient to sign anything. However, since the surgeons typically have no idea what we actually do, you should still review your anesthetic plan and major risks with the patient when you meet them that morning.
You will do all your own nerve blocks and epidurals at the VA. You should plan to start the procedure right after morning lecture (around 7:35 on days you have lecture). This means that before you go to lecture, you need to have your room ready, a functioning IV, and the patient needs to be on monitors with nasal cannula flowing before your attending arrives. There is a dedicated block room (Bay 13 in preop) with all supplies and an ultrasound. Try to let the pre-op nurses know that you will be doing a regional procedure and confirm with your OR nurses before you start that it’s ok to block the patient.
Equipment and most medications for peripheral nerve blocks are in the block cart.
Ultrasounds are either in the tech room or in the block room in pre-op (Bay 13).
Once you’re done with a block, let the anesthesia techs know so they can turn over the block room.
There are four groups that must see a patient before any sedation is administered - pre-op holding nurse, surgeon (consent/marking), OR nurse, and anesthesia attending. Notify the OR RN if you would like to proceed with a block that requires sedation and they have not seen the patient. Anesthesia can site mark/verify laterality for a block if a surgeon is not available.
Lectures: Mondays 06:45-07:45 is Grand Rounds (virtual). If you are the on-call resident, you should plan to be in the VA building by 7am in case a room needs to start urgently.
All other days, lectures start at 07:00 and finish around 07:30. This takes place in the Columbine room – outpatient 3rd floor, right across from elevator 3.
To contact your attending, have the OR nurse Vocera/call overhead if urgent/emergent. If an FYI, Vocera or call/text your attending (cell service is spotty).
All patients with planned admissions to the SICU go directly there after the case, even if they are stable and extubated. This includes all patients with epidurals. Also, after hours and weekends, patients will go to SICU for wake up because there are no evening/weekend PACU nurses. The SICU should send their own transport monitors with the bed (we have the same monitors available in the OR, but they inevitably go missing upon arrival to the SICU, which the anesthesia techs will give you a hard time about).
On non-call days, you usually go home around 1530 - 17:00. On call days, you stay until the last room is finished. If you stay beyond 10:00pm, you will get at least 10 hours of rest/recovery and most likely a post-call day. Be available by phone 10 hours after you leave or communicate with the charge attending before making plans.
Since you won’t be able to look patients up in the OR or from home, the residents need to help each other out with pre-ops. For example, if the resident on call is going to have a late night in the OR, the other co-residents should try to look up their cases for them. The same goes when residents are on vacation, and need their cases looked up for Monday, as well as oncoming residents for the next rotation. Be a friend- it makes life at the VA so much better.
Except for epidural orders (discussed below), residents don’t place any orders while at the VA, so no pre-op/post-op orders are needed.
There is a list normally hanging on the whiteboard in the anesthesia lounge that contains inpatients anesthesia took care of the day before. If one of your patients is on that list (AKA they were admitted after surgery), it is your responsibility to see them and write a quick anesthesia post op note. Often times this can be done on breaks or during turnovers, and you can let your attending know that you are going to see the post op. Once you’ve seen them, you can cross them out on the list.
Acute Pain Service
The VA is the only hospital that has you follow your patients outside of the OR as an acute pain consultant. This means you will need to round on all peripheral nerve and epidural catheters that you place while those patients are in the hospital.
The APS is only for blocks/neuraxial we have placed for the OR. We do not staff pain consults routinely from the medicine service or ED. This is at the discretion of the APS attending (days) or on call attending (after hours), so communicate with them.
The attendings understand that most CA-1’s will not have had an APS rotation yet, so they expect you to ask them about pretty much everything. Don’t feel stupid asking ANYTHING.
Any issues over night or on weekends will be handled by the on-call team. Sue or the attending covering the Pain service will find you and sign out around 1500.
It is a good idea for the on-call resident to check on the epidurals before leaving for the night- this can prevent many phone calls at home and even having to return to the hospital later. Some attendings will grab you and round on epidurals before leaving so you are both on the same page as far as a plan, which is very helpful in the middle of the night. Make sure to ask about how to write epidural orders before going home on your first call. CPRS is NOT intuitive.
Epidurals can only be managed in the SICU, so patient transfers to the floor may be an indication for you to pull it. Peripheral nerve catheters can go to the floor in place. It is likely that your peripheral catheters may go home with an On-Q system for continued pain control.
Rounding: It is definitely encouraged to follow-up and help with seeing an epidural or nerve catheter that you placed, however, there is now a team (consisting of a nurse named Sue or Wyatt) and an attending that will round and write daily notes on these patients during the week. For the weekends, there is a sample note in the binder they give you, and this can be used to figure out what you need to know on rounds (pain at rest/exertion, PRN narcotic requirements, DVT prophylaxis, dermatome levels, infusion rate, LE symptoms, acute events over night, etc). The peripheral catheters are less complex to round on—big things here include DVT prophylaxis and ensuring that you haven’t given a dense motor blockade that might put them at a fall risk (eg. assess quadriceps function on femoral nerve catheters). You will then staff your catheter with the attending that placed it with you, or the attending on call. Finally, write a brief note following the template in your packet.
Some peripheral nerve catheters go home with the catheter and a “pain ball.” You need to call them every day, and eventually walk them through pulling the catheter themselves over the phone. You still need to staff these patients with an attending and write a quick “phone note” each day. There is not an acute pain pager.
Over the weekend, the call person rounds on all catheter patients (see below).
There are both anesthesia intensivists and pulmonary/critical care intensivists that cover the SICU. The former will do most of their own epidural troubleshooting, as they understand you are in the OR most of the day. The latter are mostly clueless when it comes to epidural management, so it is particularly useful to see patients early when they are on service.
The attendings understand it is nearly impossible to manage epidurals from the OR, so don’t be afraid to ask them to cover your room briefly while you go troubleshoot.
It is easiest to plan to pull epidurals around 10:00 am (4 hours after morning heparin, 2 hours before the afternoon dose). Some of the nurse practitioners in the SICU will pull epidurals for you, so good coordination and rapport with them can save you some work.
VA Computers
Get all codes for general access and CPRS access. Codes expire after 1 month, so if this is a repeat performance at the VA, you need to come in ahead of time to get new codes. An application for your access needs to be submitted by the department coordinator, so make sure this is done before you show up.
Make sure to set up a signature code in order to be able to sign orders and your notes.
Talk to pharmacy if you are unable to write orders, you may need to sign some narcotic paperwork through the pharmacy office.
Paperwork
Intra-op: We use Innovian for intraop charting at the VA. Your attending will orient you on your first day.
Blood gases are uploaded into the computer, but if you are going to check a few, it is also nice to have the anesthesia techs print them out for you. You don’t have access to run blood gases, so you’ll need to call the anesthesia tech or your attending to help you use the iStat machine.
Check VISTA Imaging (Tools>Imaging Apps>VISTA Imaging) in CPRS for previous anesthesia records. Also, if the patient has had an operation within the last calendar month, you can check CPRS. Occasionally when a case is cancelled (frequently at the VA), someone has done a pre-op already and it’s accessible in Innovian.
Post-op Orders will be placed by your attending.
The VA is the only site with IV Acetaminophen (and albumin) at your disposal.
Pharmacy
The Omnicell in the OR has most of the medications you will need, including narcotics.
Any Omnicell can be accessed with your same codes.
The wasting process is different than at the other hospitals; make sure you waste with your attending ASAP (most prefer to do so right before extubation or leaving the room) so as not to get things mixed up. Even if you use all the controlled drugs that you pull up, the amount of each that was given still needs to be entered into the Omnicell (does not need to be witnessed by an attending if everything was given and nothing needs to be wasted). Have the attending walk you through this the first time.
Equipment and most medications for peripheral nerve blocks are in the block cart and nearby cabinets in pre-op. Code for the block cart and the blue cart in room is 1-2-3-4.
The OR pharmacy is not as available or efficient as the other hospitals. If you are going to need a special infusion for a case the following day (eg. Octreotide), let them know the day before the case. You can Vocera “OR Pharmacist” to ask for special meds or drips. They typically will deliver them to the room. They are usually gone during lunch and for the day by about 3:00 pm and are not there on weekends. There is an Omnicell in the sterile core with various medications like antibiotics/Heparin SQ that the circulator nurse can access for you. There is an additional Omnicell in the anesthesia work room with more “fancy” anesthesia medications (vasoactive drugs, etc). Of course, you have access to all these Omnicells and can remove medications on your own when you are not in the OR. Look at both of these during your first week to get a sense of their contents.
There is a refrigerator in the anesthesia workroom with phenylephrine gtts, insulin, and cisatracurium.
You will make your own precedex infusions (except for cardiac cases). Precedex is available in the Pyxis in the Tech room and in most ORs. If your patient is going to the ICU on gtts, Vocera “OR Pharmacist” to have them make you a drip, otherwise the ICU has to dispose of them after arrival because they are not sterile.
Nitroglycerin is in the Pyxis in the tech room.
Call & Weekends
Call at the VA is HOME CALL. Your cell phone number will appear on AMION (pw: VADEN) the day you are on call. It’s also worth making sure the nurses of patients with epidurals have the correct number when you tuck them in for the night.
When you are on call, you may receive calls regarding catheters/patients during the day. Your number is listed on AMION (the call system) for that day and night, meaning sometimes you get random calls asking about anesthesia things. If you are in the OR, just let your attending know the situation and they will help orchestrate a solution.
Get a copy of the call schedule from the bulletin board at the beginning of each month- it has phone numbers for all the attendings.
First: The surgery resident will call you when a case needs to go at night or on the weekend. Your involvement in this step is essential for preventing delays. Ask about any major medical problems, vitals, and lab abnormalities. Depending on the case, this is the time to make sure the surgery resident has ordered appropriate blood products. It is also important to make sure the resident has spoken to the surgery attending (this ensures that the patient actually needs surgery, and that you won’t have to wait an hour for the attending to show up to the hospital). Some surgical residents will call just for a “heads up” about a possible case- clarify their intentions. You also need to make sure that the surgery resident has called the nursing supervisor to mobilize the OR staff (the surgery resident should do this! Do NOT let them try to make this your job.) Finally, ask which OR the nursing supervisor is planning to use, so that you know which one to set up once you arrive. If this is not clear and you have a big set-up, begin setting up an OR and let the team know which OR you have set-up.
Second: Only call your attending about cases that are WITHOUT A DOUBT going to the OR. They do NOT want to hear about possibilities for later.
You are expected to be within 30 minutes of the hospital while on call, and ready within 60 minutes for a case start.
Rarely, you will get calls for ED anesthesia or difficult airways. These should be immediately discussed with the attending (do not come in first). When in doubt, call your attending in this situation.
Try to clean up your anesthesia machine after night/weekend cases (pick up monitors, throw away drugs, etc.). All drugs not stocked by pharmacy need to be removed from your work area at the end of the day.
Weekend call is also Home Call. You are expected to come in each day to round on ANY catheters and epidurals that were placed during the week.
On-call Acute Pain Service: Consider showing up to the hospital around 09:00 on weekend days, so that you can evaluate patients and be able to pull catheters without issues involving their heparin dosing. You may need to come into the hospital to troubleshoot epidurals, especially if a pulm/critical care attending is covering the SICU. Do NOT try to work through issues over the phone, unless an anesthesia intensivist is involved. When in doubt, drive in to go see the patient. Call attendings with any issues (while they will get annoyed by phone calls about “possible” OR cases, they expect phone calls about issues with catheters). Note that calling an attending with trouble-shooting questions is probably an indication for you to physically be at the hospital (an anticoagulation question is a common exception to this rule). As you get more comfortable with the process and various attendings, you will likely just send them text messages with updates on the weekends.
In general, Anesthesia is not responsible for intubations/codes outside of the OR. There are some circumstances when we do get involved. If you have any questions, call your attending.
Random Tips
There are new Drager anesthesia machines at the VA now different from any machines at UCH, CHCO, or DH. Ask a tech to go through the machine check with you.
Don’t leave any drugs out on the carts.
Don’t forget to utilize your classmates that have recently rotated at the VA, things change frequently, and they are an invaluable resource.
Check, re-check, triple check that your codes, badge, access is rolling before Day 1 start- this system is a quagmire, but you will emerge victorious if you are persistent!
There often are anesthesia lockers available that get rotated through the residents there.
Lactation Rooms at RMR VAMC:
Location: K2-104 (No fridge), K3-104 (fridge) and DS-144 (fridge)
RMR VAMC Code: 3265