BOX HILL HOSPITAL DEPARTMENT OF ANAESTHESIA AND PERIOPERATIVE MEDICINE HANDBOOK FOR REGISTRARS, RESIDENTS AND INTERNS
T A B L E O F C O N T E N T S 1. THE DEPARTMENT 2. WHO`S WHO 3. THEATRE SET UP 4. HOURS OF WORK 5. HOW DO I FIND WHERE I AM WORKING 6. WARDS / PLACES OF SPECIAL INTEREST 7. DEPARTMENTAL LIBRARY 8. PROTOCOL AND POLICY MANUAL 9. SENIOR IN CHARGE ANAESTHETIST 10. REGISTRARS 10.1 REGISTRAR RESPONSIBILITIES (i) Pre-operatively (ii) Intra-operatively (iii) Post-operatively (iv) Acute Pain Service (v) Off floor anaesthetist (vi) Out of hour responsibilities (vii) Labour Ward Calls (viii) Line Service (a) Peripheral Lines (b) Central Lines, Arterial Lines and Intubation (c) PICC Lines (ix) Hypotension (x) Other (xi) Special Interest Forms 10.2 CONSULTANT ON CALL 10.3 REGISTRAR EDUCATION 11. EMERGENCY MEDICINE REGISTRARS 12. RESIDENTS 12.1 Objectives 12.2 Study Questions 13. INTERNS /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 2 31-01-07
1. THE DEPARTMENT Is situated on the 3rd floor of Box Hill Hospital, on the corridor to ward 3 north. Address Department of Anaesthesia Box Hill Hospital Nelson Road Box Hill 3128 Postal address PO Box 94 Box Hill Victoria 3128 Phone 9895 3164 Fax 9895 3152 Switchboard 9895 3333 Paging Any hospital phone 8, wait for tone, then enter pager number, enter #, then enter phone number, then #. Box Hill is a 320-bed hospital, which does approximately 9800, cases a year including Obstetrics & Gynaecology, Vascular, General Surgery, Urology, Thoracics, Paediatrics and Orthopaedics. Notice boards for information: In the reception area in the anaesthesia offices and on 4 th floor. 2. WHO`S WHO IN THE DEPARTMENT The Department consists of: Name Phone Director Dr David Beilby 3456 Deputy Director Dr Clive Rachbuch 3449 Supervision of Training Dr Clive Rachbuch Staff Anaesthetists Dr Tony Chow 3632 Dr Peter Girdlestone 3632 Dr Con Kolivas 3435 Dr Gerard Bunsee 3632 Senior Anaesthetist Dr Greg Stewart Pre Admission Clinic Dr Michael Tronson 4980 Senior Registrar Matthew Matusik 6/12 & Carmen Dang 6/12 Acute Pain Nurse Consultant Fiona Normand Pager 3635 Secretaries (job share) Debra Milroy & Pat Sterling Ext. 3164 Program Director, Surgical Services David Plunkett Nurse Unit Manager, Operating Suite Robin Riley 3167 Scrub Scout Nurse Unit Manager Kerri Pikard 3168 Anaesthetic/Recovery (acting) ANUM-PACU Moira Park ANUM Anaesthetics TBA Front Desk Staff Justine, Rosemary and Gail 3165, 3160 OR Administrative Assistant Max Sutton 4912 In Charge Nurse Coordinator Various 3171 /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 3 31-01-07
3. THEATRE SET UP There are 6 theatres in Box Hill on 2 levels. (i) Theatres 1-4 are located on the 4 th floor as are the change rooms. (ii) Theatres 5 & 6 are located on the 2 nd floor of the same building, however the change rooms are in the 3 rd floor through the Occupational Therapy department. Access is gained via the stairs in the tearoom. (iii) Endoscopy & ECT are performed on the 2 nd floor. Changing into theatre attire is not required for these procedures. Admission is gained via the 2nd floor entrance. 4. HOURS OF WORK: Your official hours are 0800-1800 for day shifts (though they usually run from around 0730 to 1730) 1700-0800 for night shifts 0800-2000 weekend day shift 2000-0800 weekend night shift An 0800 1800 shift exists for Christmas. The Evening shift then becomes 1800 to 0800 the next day. NOTE: Approval must be gained from your supervising consultant prior to claiming for any extra hours (overtime). This is a Medical Administration requirement. In the main you will be able to claim time where your help is essential (eg AAA, transports). For other cases which go over time you might want to stay for interest s sake but there will be no obligation. SICK LEAVE NOTIFICATION If you are unable to work due to illness, please notify the Department of Anaesthesia on 9895 3164 and Theatre Reception on 9895 3165 as early as possible. Medical Administration requires that you inform the hospital at least two hours prior to your shift commencement. 5. HOW DO I FIND WHERE I AM WORKING: (i) The master roster will let you anticipate what nights you are working. (ii) The weekly roster will inform you as to what specific lists you are doing (subject to change if there is sick leave). (iii) The patient lists for the following day are published at the front desk around 2-3pm. However, if you ask really, really nicely then the girls will be able to give you some idea earlier in the morning (i.e. around 0830). If you are phoning from outside, the number to the front desk is 9895 3160 or 3165. /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 4 31-01-07
6. WARDS/ PLACES OF SPECIAL INTEREST: i) OVERNIGHT ROOM: - is located on the 6 th floor of the Clive Ward Block. - The room is in the residents quarters, down the hall on the right, and marked. (the code to enter the building is the same as that which lets you enter the residents quarters) 3581 E. - This room is sometimes claimed by the consultant on call. Unfortunately despite our attempts Medical Admin cannot allocate an extra room. ii) iii) iv) BIRRALEE: The obstetric unit - is aboriginal for Mother and Baby - is located on the 1 st floor in the west wing. - The wards are designated Green & Ruby but the beds are all numbered in ascending order, so just remember the bed number and you cannot go wrong! PAEDIATRIC WARD - is located in ward 2 West SURGICAL ADMISSION CENTRE 1 North - On level one outside Cafeteria. Patients being admitted on day of surgery will be admitted to this ward. - is the most important ward, where you will find all the patients admitted on the day of surgery (i.e.>80% of your patients). - It needs more interview rooms as you will find out. - Patients for morning lists arrive ~0700, for afternoon lists at 1100. v) ICU/ HDU: - is located in the west building, just outside the 2 west ward - take both ICU and HDU patients vi) vii) 2 SOUTH: - there is a small area (beds 29 32) which function like a major surgical / step down unit. - Whilst they will have patients with epidurals, they are unable to monitor CVP or arterial lines. PRE-ADMISSION CLINIC: - is located on 4 th floor West Wing 7. DEPARTMENT LIBRARY: Books are not for loan outside of the Department books need to be returned to the library as soon as finished. 8. PROTOCOL AND POLICY MANUAL: Nursing policy and protocol manual can be found on the Intranet. The Department Policy and Procedure manual is in the Department. 9. SENIOR IN CHARGE ANAESTHETISTS: Each session there will be a designated in-charge senior anaesthetist. Is responsible for the anaesthetic man power management as well as the booking of cases between 0800-1800hrs. If you are sick or have any queries these should all be done via the senior anaesthetist. Should your list finish early you must obtain permission from the senior in charge should you wish to leave the hospital early. /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 5 31-01-07
10 REGISTRARS (all), Residents. 10.1 REGISTRAR RESPONSIBILITIES when in doubt ask : At any one time there are a number of registrars with varying experience and abilities. Junior registrars, ED registrars, residents and interns will always be working with a supervisor. Supervision requirements are set out in the Department Policy on supervision of registrars. However, even with one to one supervision, registrars and residents will be left for periods of time without direct supervision by a consultant in the theatre. Always ask if worried or unsure. Some may be tempted to push the boundaries of their ability to manage independently without consultation or supervision, in order to impress the consultant. Resist the temptation. Appropriate calling for help (i.e. demonstrating good judgement) and ensuring that the consultant is aware of the situation and above all ensuring safety of the patient is a most important skill to learn. (i) PRE-OPERATIVELY: Pre op assessment. Registrars and HMO3/4 s are expected to see patients in wards prior the patient coming to theatre. It is there that patients can be assessed and allowed to ask questions in a less threatening environment (than at the theatre door). They can then discuss cases as required with their consultant anaesthetist. Although Emergency cases are an exception to this rule, where possible it is better to see these patients in the ward as well. Consent. There is no specific anaesthesia consent, however, it is usual to discuss the anaesthetic with the patient, with the attendant risks and benefits, and this discussion should be documented on the anaesthetic chart. In particular it is expected that you talk to the patient on the risk of dental injury (where relevant) and risks involved with invasive monitoring and nerve blocks. This discussion needs to be documented on the front of the anaesthetic chart. Lack of surgical consent: Do not do surgical consent. Do not sedate or start lines until consent is done. Sometimes an assessment is done in the holding bay eg the add on or emergency case. Be mindful of patient privacy. Interns are not required to see patients for pre-operative assessment, however, they may gain more from their experience if they know the patient and have some rapport. **Pre-operative assessment by the Preadmission Clinic does not obviate the need for assessment by list anaesthetists. Beware the service case. These cases are where the surgeon performs a technical service for another unit, usually a medical unit. Eg lung biopsy. These patients are not as well known to the surgical unit and may not be worked up as well. Beware of the add on case. These patients are usually emergency cases and may not be as well worked up. Machine check as per college policy document at the start of each list and between patients if alteration to circuit/ monitoring. Prep time allow 15 mins for standard monitoring and IV insertion, add 15 mins for each of art line, CVC and epidural. Allow 30 mins for establishment of regional blockade. There is an anaesthesia set up request form at theatre reception that will allow you to order anaesthesia such as CVC s, arterial lines etc. You can also request the time you want the patient brought up. Note that list start times 0830 and 1330 means ready to induce GA or regional block is in and ready for surgical start. Registrars must give themselves plenty of time to prepare patients for anaesthesia and surgery. /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 6 31-01-07
Punctuality is a good habit to get into (ii) INTRA-OPERATIVELY: Appropriate care for the patient as described by the college in the document D19. i.e. (a) it is not appropriate for the patient to be left without supervision by medical staff during general anaesthesia, regional anaesthesia or sedation. (b) Reading material, outside of that related to direct patient care, is discouraged. Record Keeping should be of a level as indicated in the college policy document Remember, that this will be your legal document should any misadventure occur intra-or post operatively. (iii) POST-OPERATIVELY: Ensure your records are of an appropriate standard. Ensure suitable analgesia for your patient (oral, IMI, IV infusion, PCA, epidural) Ensure adequate fluids for the next 24 hours, where possible. *for epidurals & PCA`s ensure that patient name and ward are entered in the pain service audit sheet and handover book for the pm anaesthetist. Care in the PACU is a joint responsibility with the surgeon. (iv) ACUTE PAIN SERVICE: Communication is via Audit sheet found in the Acute Pain Service book and by verbal handover. There are 3 ward rounds per day: 0830 Emergency off floor anaesthetist accompanied by the Acute Pain Nurse 1700 on call registrar 2300 on call registrar 0800, 1700 Handover to following emergency anaesthetist either (i) Notes on audit sheet Acute Pain Service book (ii) oral handover if necessary /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 7 31-01-07
(v) OFF FLOOR ANAESTHETIST Monday to Friday mornings this anaesthetist will be available for call back from 0600 to 0800. If you are rostered to Off floor duties you will be required to attend at 0800. Normally your first duty will be to do the pain round with the APS nurse. You will also be required to attend ward consults, labour ward epidurals and other off floor duties. (vi) OUT OF HOURS REGISTRARS RESPONSIBILITIES: Obtain pain book and do an acute pain management round of all the epidurals & PCA`s. Obtain list of the out of hours cases from the front desk and see patients for the evening lists which usually starts ~1830 hrs. There is sometimes insufficient time to see everyone. Registrars should prioritize who is seen on a basis of urgency and how unwell the patient is. However, epidural patients must be seen (and documented in the Pain Folder). Once this is performed (depending on time) contact the on-call anaesthetic consultant and inform them of the evening s work and patients. (vii) (viii) LABOUR WARD CALLS Referrals will be made by nurses or residents. The obstetric resident should have been consulted and will have inserted an IV prior to your attendance. All anaesthetic registrars will be trained in insertion of epidurals and will need training prior to doing epidurals solo. ED registrars, HMO s and interns are not taught epidurals. You will need to do 10 successful supervised epidurals before going solo. This usually takes about 3 months. Those with previous epidural experience will be assessed prior to going solo. LINE SERVICE The Department of Anaesthesia provides a technical expert service for placement of peripheral IV s, arterial lines and central lines. (a) PERIPHERAL LINES Interns must consult their registrar prior to paging the anaesthetic registrar. It is usual that the intern, then the registrar attempts IV placement prior to calling the Anaesthetic Department. The referral for IV insertion should come from another Doctor. It is not the Department s role to provide an IV service. (b) CENTRAL LINES, ARTERIAL LINES AND INTUBATIONS Depending on technical ability of the referrer, the ability of the registrar and the urgency, this may require consultant attendance. These patients are often unwell and require careful evaluation. (c) PICC LINES These are done by Radiology with ultrasound and x-ray screening. (ix) HYPOTENSION There is a protocol for managing hypotension in surgical patients. Anaesthetic registrars will be called if hypotension is in association with an epidural or Naloxone has been administered. Always be aware that hypotension may be from hypovolemia secondary to concealed haemorrhage. (x) OTHER /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 8 31-01-07
Code White is a trauma patient. Only attend after ensuring your patients are safe and appropriately supervised. Code Blue is a cardiac arrest. see Code White. Code Green This is a "Crash Caesar". Patient already on the way to 4 th floor theatres for a caesarian section to be done "immediately". The standard is to achieve delivery at a maximum time of 30 minutes from decision to do caesar. DO NOT be pressured to start the case if you are not cleared to do caesars solo. Transport of critically ill patients to other hospital etc: This falls under the domain of the responsible area i.e. (1) In casualty it is the responsibility of the A&E department. (2) In theatre it is our responsibility. You should inform the consultant on call and keep them suitably notified as to your activities. Cardiac arrest on a ward patient We attend and help with airway management. If the patient needs transport to another ICU we get involved and do the transport. If there are other pressing duties, call the senior in charge anaesthetist or the consultant on call (after hours). Cath lab arrests or cardiac call post arrest We manage ventilation and in conjunction with the cardiology team manage haemodynamics (they usually control the haemodynamics, though). We need to provide sedation then transport post cath lab. (xi) SPECIAL INTEREST FORMS (Pink Sheet) These forms are kept in PACU. All staff are encouraged to fill out a special interest form for interesting cases or for morbidity or mortality of interest to Anaesthetists. Every anaesthesia related mortality and all serious anaesthesia morbidities must be reported. 10.2 CONSULTANT ON CALL 1 **Call hours are: 0600 1800 (day) and 1800 0600 (Night) 2 Between 0600 and 0800 you should call the emergency anaesthetist for the day (rather than the one for the night) 2 nd call is to be called in at discretion of the 1 st call anaesthetist (or should the 1 st consultant be uncontactable. All after hour cases are booked with the registrar: Supervision In summary: 1 st year registrar 6 months direct supervision then assessment 2 nd to 4th year registrar PRN Provisional Fellow PRN Residents and ED registrars are always supervised. There is a policy for level of supervision. Note all ED registrars must work supervised. Caesarean sections, ICU cases and paediatric cases (age < 10) must have a consultant present for first year registrars, however if you have Completed the Obstetric Module may do caesareans alone at consultant s discretion. Completed the Paediatric Module may do paediatric cases at consultant s discretion. /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 9 31-01-07
10.3 REGISTRAR EDUCATION Involves many facets including: a) Tutorial programme mainly on Wednesday afternoons b) CME program consisting of rotating roster of CME, M&M, Journal club and consultant staff meeting ( registrars have a bye first week) c) Please fill out the Special Interest Forms should problems occur pre, intra, or post-operatively. As well as preparing for your tutorials, you will be called upon to present topics at the other meetings. /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 10 31-01-07
11 EMERGENCY MEDICINE REGISTRARS Emergency Medicine or AE Registrars usually spend 3 months in the department. During this time they occupy an Anaesthesia Registrar position and are expected to act as a Junior Anaesthesia Registrar. Supervision will always be on a one to one basis. Your rotation in Anaesthesia will allow you to develop certain skills: Patient assessment, including assessment of the emergency patient Airway management and assessment; Bag and mask ventilation, Intubation, laryngeal mask insertion, difficult airways Lines such as IVs, arterial and central lines. The last unfortunately is infrequent. Spinal tap in the process of learning to do spinal anaesthesia. Epidurals are not taught to AE Registrars Blood and fluid resuscitation Anaesthesia drug management, including the use of muscle relaxants The use of Vasopressors You will not be rostered on for your Thursday Afternoon tutorial time. Previous AE registrars usually enjoy their anaesthesia rotation and learn a lot from them. We hope you do too. /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 11 31-01-07
12 RESIDENTS Welcome to the Box Hill Department of Anaesthesia for what we hope will be an educational and enjoyable three month rotation. These three months will provide you with some grounding in anaesthesia, general surgery and general medicine. For those of you who are thinking of a career in anaesthesia, the rotation provides a good introduction into the anaesthesia profession. Such residents are keen and want to learn as much as possible. The Department recommends those with a small amount of anaesthesia experience concentrate on the clinical skills of giving an anaesthetic, and read around this subject. It is only appropriate for those who have had more than 6 months experience of anaesthesia, and are hoping to enter into the program to spend time studying for the anaesthetic primary. Those of you who have different paths in mind will gain valuable insights into the pre-, peri- and post-operative management of many different pathologies and co-existing diseases. The following is a suggested list of study / skills objectives that you can work towards. 12.1 OBJECTIVES Your objectives for this term include: GENERAL PATIENT ASSESSMENT (and management of co-existing diseases) AIRWAY ASSESSMENT ANATOMY PHARMACOLOGY PHYSIOLOGY ANAESTHETIC AND TECHNICAL SKILLS 12.2 STUDY QUESTIONS These questions are to help direct learning. They are directed more towards those who are not going to make a career of anaesthesia. GENERAL PATIENT ASSESSMENT What, if any, are this patient s co-existing disease? How may the patient s co-existing diseases be optimised? What is meant by the term ASA status? How will these diseases affect the anaesthetic management of this patient? What is my management plan for this patient in the pre-, intra-, and postoperative period? AIRWAY ASSESSMENT How do we assess a patient s airway and why is this important? What things may indicate a potentially difficult airway? How might we manage a difficult airway problem? What is meant by a Mallampati score? ANATOMY /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 12 31-01-07
What regional technique may be utilized for this procedure? What structures are at risk during the procedure? Why do the various positions of patients during surgery cause differing concerns? How do epidurals and spinals differ and how are they assessed for effectiveness? PHARMACOLOGY What are induction agents, muscle relaxants and volatile anaesthetic agents and how do they work? What is the difference between a non depolarizing and a depolarizing muscle relaxant? What are our choices for post operative analgesia and what are the risks and benefits of each? How do we manage the patient with severe post operative pain? PHYSIOLOGY How will the different drugs we use alter the patient s physiology? How do the patient s co-existing diseases alter our management? ANAESTHETIC AND TECHNICAL SKILLS How and why do we choose between a laryngeal mask and an endotracheal tube? What is cricoid pressure and when do we use it? Do I have a confidence with large IV cannula insertions? Am I able to intubate quickly and confidently? How do I assess whether my endotracheal tube is correctly situated? (without capnography) What do I do if I am unable to intubate? /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 13 31-01-07
13 INTERNS (No interns from 2007. This is kept for future reference) You may be rotated through anaesthesia for two weeks in order to give you a taste of anaesthesia. Here you can improve your IV cannulation skills, learn airway management, and even intubate a few patients. Pain Service ward round will help them learn about pain management. Interns are not expected to do preoperative visits on patients prior to attending the theatre list. They are expected to arrive to theatre on time which means attendance 15 30 minutes ahead of a list start time. In theatre they will be supernumerary and under direct supervision of a registrar or consultant. They will be encouraged to ask questions and be involved. Hours Monday to Thursday 0800-1800 hours. Interns are sometimes asked to cover an intern somewhere else in the hospital. Should this occur please notify the senior anaesthetist-incharge or the list anaesthetist. The anaesthetic intern receives a pager to use during their rotation. /home/con/documents/work/2007/anaes Dept Handbook 07.html Page 14 31-01-07