A Guide to the Anaesthetic Rotation from ED

 

The Anaesthetic Rotation From ED

Below are some thoughts and experiences that might be helpful to kick you off on Anaesthetic rotation at Bendigo Hospital.

Technically, being a person in involved to provision of anaesthesia you would be required to do equipment checks before each list. Below is the link to the ANZCA website where the equipment checks are described. You would only need to do Level II and III checks. The list looks a bit long, but it is really simple and the whole Level II check takes 3-5min at the most, it is fun and makes you more comfortable with equipment. The anaesthetists or the techs will be able to help you with the orientation around the anaesthesia machine.

http://bit.ly/XPMyue

Below is a tabled equivalent from the UK society of anaesthetists. It is shorter, but equally covers the main points.

Power supply

  • Machine is plugged in
  • Machine is switched on
  • Backup battery is charged if present

Gas supplies and suction

  • Check gas and vacuum pipelines (connection)
  • Backup oxygen cylinder is filled and turned off
  • Flow meters are working
  • Hypoxic guard is working
  • Oxygen flush is working
  • Suction is working

Breathing system

  • The system is patent and is not leaking (use two-bag test)
  • Vaporisers are filled, not leaking, plugged in (Des)
  • Correct gas outlet is selected
  • Alternative breathing systems available

Ventilator

  • Working and configured correctly

Scavenging

  • Working and configured correctly

Monitors

  • Working and setup correctly
  • Alarm limits and sounds working and setup correctly

Airway equipment

  • Full range required present and spares available

The shifts:

There are three major shifts during the week:

07:30 – 17:30

13:00 – 23:00

22:30 – 08:00

On weekends the shifts are:

07:30 – 20:00

20:00 – 08:00

 

The daily stuff

The best way to find out what you are doing on the day is to refer to the roster – find your slot with anaesthetist and which theatre you are assigned to on the day. The theatres usually change after lunch (i.e. if you are doing OBGYN in the morning you will usually do something else after lunch e.g., Trauma). You can then quickly see the list of patients for your session. You can either quickly go on the wards to check whether the patients have been seen and whether anything additional is required before the case starts. The alternative is to check your list for the next day and quickly see your patients the day before. This strategy is unlikely to work if you are on Emergency or Trauma list the next day as the list usually fills up on the day. Also generally it is quite busy and you have very little time to slot in extra things.

Tip: To have the list printed – bring up your theatre list and press F2. This will print out the list.

ENDOSCOPY LIST:

If you are on the endoscopy list – you will need to see the patients from the list in the day surgery reception (second floor, next door to cafeteria) before the list starts (this can be fun as there are some nine patients that will need to be seen in the space of an hour), plus you will need to set up the theatre for the list i.e. drugs etc. The consultant often will help you – to see the patients, draw drugs etc. This is a fun list - very fast and interesting. Most consultants have their ways of providing sedation for endoscopies (from bare bone Propofol to LMA, to TIVA); you will get the chance to see and feel different drugs at play and perhaps choose your way of providing procedural sedation. You will also hone the skill of monitoring your patients during procedural sedation using ETCO2 and without ETCO2 (i.e., during FGS).

EMERGENCY LIST:

When you are on the emergency list – you will have the phone and every man and his dog will phone you for all sorts of problems – pain management, cannulation requests, epidurals etc. In the case of the request for cannulation – the requirement is that HMO/Intern and Registrar on the requesting unit must try cannulation before they call you. Either of them also must be present at the scene and you must “teach” them how to cannulate (this may involve them inserting the cannula in your presence (this is a bit odd, but this is essentially how Dr Ryley would like the service to be provided as BHCG is a teaching hospital and the anaestheic service is not just there to run around sticking cannulas in willy nilly). You will also have to attend all Code Blues and trauma in ED (Level 1 and 2) when you are on emergency list.

In the case of the request for epidural – ED regs usually are not supposed to insert epidurals, so you will need to speak with an Anaesthetic reg in training (via consultant) and get them to do the job (this usually is not a problem and often the consultant just goes and puts it in – no problems with that – no pucker faces there). It is different with spinal blocks/anaesthesia and the consultants usually will be happy for you to do those. Especially once they see that you know what you are doing.

THE NIGHTS:

When you are on the night shift – you are essentially the point of contact for all the troubles in the hospital overnight which may require your service – cannulations, pain issues, Code Blue, trauma and assistance with airways in ED.  Generally consultants would like to know of major happenings overnight - airways, trauma level 1 etc. unless they advised you otherwise. In the case of epidural – you still need to phone them. If there is an emergency case that needs to be done there and then – the requesting registrar (surg/ortho/OBGYN) will let the after-hours coordinator know and they will organise the theatre nursing staff call back). Your responsibility is to contact your consultant once it is clear the case is imminent (e.g., CS, trauma etc.).

THE WEEKENDS:

If you are rostered to work on weekend – you will have to do the pain round and technically see the patients booked for the cases overnight or hang-ups from the day before. This sometimes can be quite daunting, especially if there are a few epidurals on the wards, pain issues, tap catheters and general chaos etc.  (That usually does not happen often). If there are tap blocks in ICU (topping up TAP catheters) – their doctors usually can do those, but with the wards – it is your chore.

BITS and BOBS

Do not think: “oh, I will never use this or that in my practice as ED doctor why do I need to do this”. Your attitude is important. Do not be a passenger in this rotation. You want to be at least an equal player to the anaesthetic registrars.

Ensure that, as you prepare induce a patient, provide sedation for FGC, FCS or ANY minor procedure you ALWAYS have ALL monitoring equipment on and attached to the patient (ECG – on and on the patient, sat probe – on and on the patient, BP cuff on and on the patient. ECO2 on and there is trace). ALWAYS. REGARDLESS who you work with. Do not rely on the anaesthetic technicians to have it all set up – they have their hands full. Trust no one, even yourself. Stick to the rules and standards.

For induction it often helps if you ask the anaesthetist what drugs they want prepared for induction and use in the case e.g., Fentanyl, Midazolam, Morphine etc. This helps to smooth the flow.

Think in advance about the case you about to embark on: what mode of anaesthesia you are going to use (e.g., LMA/ETT, GA, spinal, epidural regional etc.), what mode ventilation you are going to use, which gas, what drugs are you going to give to the patient before the case (e.g. antibiotics, antiemetics), when are you going to give the drugs. Entertain a WHAT IF scenario and have plan. Always have at least Plan B. Have plan for can’t intubate situation. When the gig is up – your ability to think critically shrinks. Make sure that you are familiar and comfortable with DAS protocols and guidelines:

http://bit.ly/gqhy3E

Majority of patients get additional drugs during the case for nausea and vomiting post op (Dexamethasone, Ondansetron) as well as simple analgesia (Paracetamol, Parecoxib). Most orthopaedic and surgical patients will have antibiotics IV prior to the case. It is a good habit to ask the surgeons whether they want the antibiotics given or not, they often won’t tell you unless you ask (bizarrely).

For patients who will have PCA, Epidural and TAP catheters post op as well as paravertebral catheters – there is a special form that needs to be filled out along with an “audit form” (for APS follow up the next day). The drugs are usually standard (Naropin, Fentanyl, Morphine). They have standard rates and doses of administration and dilution. You will be fine after a couple of cases. Often the forms are prepared during the case and the recovery nurses set the pumps and have them ready for action. You task is just to prepare the form and pass it to the recovery nurses. There are also a couple of other minor details with regard to paper work for post op pain management – you will get info on that on the job – they are just a technicality.

Know the principles of the anaesthesia machine and are comfortable operating controls. This will save your butt and make your comfortable during cases. Know the volatile gases (BHCG uses Sevoflurane and Desoflurane). Be comfortable with ventilation modes. The modes that are used are:

- Volume Control

- Pressure Control

- Pressure Support

- SIMV

Once you are comfortable with the modes – life is a joy.

One piece of advice during a case: Ensure that all monitoring and adjuncts ALWAYS run underneath the airway tubing. NOTHING sits on top or runs over the airway lines. Make sure you NEVER step over airway lines if you need to get to the other side of the table/patient. Even in emergency.  NEVER. It is a taboo. May sound a bit bizarre, but losing airway mid-case is the last thing you want to happen to your patient.    

Among the muscle relaxants the most commonly used in the theatre at BHCG are:

- Suxamethonium

- Rocuronium

- Atracurium

Ensure that you are familiar with these drugs, onset, and duration of action, features of metabolism and reversal practices.

At BHCG, for reversal, most anaesthetists will use Neostigmine 2.5mg and Glycopyrrolate 400mcg at the end of the case (but other guidelines include Neo 0.04-0.08mg/kg + GP 0.2mg/1ng AChEI).

There are a number of “emergency” drugs that might be used during a case:

- Ephedrine

- Metaraminol

- Atropine

- Ketamine (not really an emergency drug)

- Morphine (ditto Ketamine)

There are useful dilutions below:

  • Morphine 10mg/1mL + 9mL NS = 10mg/10mL = 1mg/mL
  • Ephedrine 30mg/1mL + 9mL NS = 30mg/10mL = 3mg/mL
  • Atropine 600mcg/1mL + 5ml NS = 600mcg/6mL = 100mcg/mL
  • Atropine 1200mcg/1mL + 2mL NS = 1200mcg/3mL = 400mcg/mL
  • Atropine 1200mcg/1mL discard 0.5mL (600mcg), + 5.5mL = 600mcg/6mL = 100mcg/mL
  • Metaraminol 10mg/1mL + 19mL NS = 10mg/20mL0.5mg/mL
  • Ketamine 200mg/2mL + 18mL NS = 200mg/20mL = 10mg/mL

 

This is how most anaesthetists have those drugs prepared.

For a paediatric case – it is best if you have rescue drugs set aside (i.e. Atropine, Metaraminol, Suxamethonium).

For spinal anaesthesia – have Metaraminol at the ready as commonly patients drop the blood pressure within minutes post injection. With chronologically gifted patients be more proactive with the hypotension and careful with how you use Propofol. Anaesthetists would usually give Metaraminol when sBP decreases to 100mmHg in an elderly patient.

Occasionally you will be assigned to Pain Round. Jenny Furness is the APS nurse. You will work with the Pain round consultant and Jenny to do the pain round. Sometimes it will be just you and Jenny, so you will need to make some decisions. If in doubt – phone your consultant for advice.  Below is the link on the evidence based management of acute pain brochure on the ANZCA website:

http://bit.ly/118IxJa

This will get you started on the topic.

Once in a blue moon you will wind up in the Anaesthetic Preadmission Clinic where you will see the patients prior to elective surgeries. Not much fun, but important part of the service, although not necessarily the type of activity you will be involved in as an ED doctor. This is on the ground floor in the outpatients department.

For all trouble in the recovery – once the patient is awake and here are no anaesthesia related complications – the home team registrar should be involved in taking care of the patient. As in if a patient has developed rhythm abnormality and medical consult is required - the home team registrar usually arranges the medical consult.

Be careful with emergency scope cases for GIT bleeding. Every now and then the patients are badly anaemic (the lowest Hb I have seen was 63, this young man would arrest from just looking at Propofol) and there is no blood prepared or cross matched. Beware when asked to arrange anaesthesia for an urgent case. The patient who is septic or hypovolaemic with pH 7.01 and sBP ~90-100 who needs to be resuscitated before induction if you want to see them awake after they are “fixed”. Make sure you check all electrolytes and other biochemistry before you say yes sir. Any problems with resuscitation before surgery – communicate with your consultant, involve ICU and make it someone else’s problem before you undertake full responsibility.

I have been told that the guys in anaesthetics like ED registrars on the whole as we do not bum around – if there is a problem – we go and fix it without requests and reminders, we know how to do things, can do things and are able to function independently.

Overall it is a great rotation, busy, fun and rewarding – a lot to learn and it is your attitude that will shape this rotation for you. Good luck.