General Directions for Residents Rotating at Florida Surgical Center

Hello and welcome to a very small, busy place dedicated to taking good care of patients and you. Because it is different from other rotations here are a few directions for you.

Arriving at FSC

1.      You do not need a permit to park a car.

2.      Come in the back door. Ring the bell and someone will let you in. You can ask your attending

         for the code to get into the back door for the rest of your time at FSC

3.      You should arrive by 7:45am.

4.      Schedules are posted in multiple places (lounge, locker room, OR doors) to check your  

         assignment. If you can't find your name, check in with the charge nurse or any of the attendings

        to let them know you are there.

Starting the day  

1.      Check your machine!! Be aware of what gases are available in what rooms (ie. Heliox is only

        in rooms 1 and 2).

2.      Take a minute to review the cart and supplies. All carts are set up with the same supplies in

         the same place in each room. Carts are stocked nightly by an anesthesia tech and NOT in

         between every case. A blue basket is there for you to get extra supplies, but please do not

          overstock your carts.

3.      The anesthesia carts are locked and can be opened with your regular cart key. The charge

         nurse also has one of these keys.

4.      Set your room up as appropriate. If you are doing peds, set the IV solutions up.  Adults will

         have their IVs started in pre‑op. In general you should draw up drugs for only one case

          at a time.

5.      An appropriate sized endotracheal tube should be available for every patient.  Special tubes,

        i.e. laser tubes, are kept in the anesthesia supply area across from the instrument room.

        Please ask the circulator for help.

6.      Many cases are done with an LMA. These are available in the pharmacy room behind the

        charge nurse desk. FSC has a limited supply of LMAs so please only take what you need for

        1 case. If you need more during the day please ask your circulator.

7.      Laryngoscope blades are stored in the carts in the rooms, and additional blades can be

        found in the pharmacy room above the LMAs.

8.      Get your narcotics from the charge nurse. (PS we hope to change this system soon. See

        below for charting narcotic usage)

9.      Check with the pre‑op area to meet your first patient. Your attending will do most of the

        preops, but if has not been completed please start on it.

10.  If your first patient is going to have a block it will be done in the PACU. Ask the preop nurse to

        take the patient to the block area when the patient is finished in preop and checked-in. *The

          patient must be checked-in by the circulator or non-preop nurse before sedation can

          be given for any block. Please bring your drug bag with you.

First Case

11.  There will be a bright pink sheet on the front of your patient's chart if the patient's workup is not

       complete. Please look for this before you bring the patient back. When in doubt, ask the pre-op

       nurses.

12.  The techs and nurses are extremely helpful. Please take their assistance happily. They can help

      you with placing monitors, starting IVs, and getting supplies if you can't find them. However they do

       appreciate well-organized residents and appreciate having you check with them. If they say five

      minutes that means bring the patient back in five minutes don't wait for them to tell you OK, as long

      as they have checked-in the patient.

13.  Your attending must be present for induction and emergence. The circulating nurse will overhead

        page for your attending without you asking. Do not start unless given specific instructions to do so.

14.  Coordinate with the circulator in the room on all documented times (ie. Start anesthesia time, in

       room time, incision, tourniquet times) to ensure accurate data collection and documentation.

15.  The circulator should give you the post‑op orders during the procedure. The orders should be

       completed in the OR to save time in PACU. If you forget to complete the orders, the PACU nurse

       will call you and have you return to PACU to complete them.

 Between Cases

 16.  The average time for turnover at FSC is 10 minutes.

 17.  You are responsible for turning over your room and equipment for the next case. The circulator and

        techs will help you if you ask or need extra time between cases for set‑up. Between cases, please

        take the laryngoscope blade and/or LIVIA used during the previous case to the decontamination

        room at the end of the hall near the locker rooms. Place the dirty item in the proper labeled

        container after rinsing it in the hopper. DO NOT attempt to re‑use a blade or LMA after this step. If

        you need more LMAs or blades and you have checked the pharmacy and other rooms/residents

        for extras, then ask your circulator to sterilize one for you.

Problems:

• If you encounter a problem at FSC, please notify your attending.

• If you have a question or are unsure of a practice at FSC, please ask.

• If you cannot find an item that you feel should be on your cart, ask someone or leave a note on the dry-erase board for Ruth Ann, the anesthesia tech. She will be happy to find what you need or let you know if FSC has it.

• Any problem with any equipment should be reported to the charge nurse immediately as well as to your attending.  We cannot fix what we do not know is broken.

Tips for success:

• Don't put the BP cuff on the same arm as the IV and pulse ox. The leg works very well for many cases.
  

• Do not draw up more propofol then you will need in the next 30 minutes. It is wasteful to only use 5cc from a 20 cc syringe. If you only need 5 more minutes of anesthesia, consider using sevoflurane for 5 minutes instead. Propofol should be used within 6 hours of opening the vial; it is an egg based drug and can be dangerous if given after that time period. (Not to mention it costs $80 a vial!)
  

• Both ketamine (100/kg) and lidocaine (1 mg/kg) are useful to decrease burning associated with propofol. Ketamine is preferred because it provides analgesia. It should be given with versed. Lidocaine should not be used and not mixed in with the propofol if the patient has received a regional anesthetic. Remember we just pushed lots of local. |
  

• When Succinylcholine or Atracurium is taken out of the refrigerator, it must be used within 14 days; please put the date when it was removed from refrigeration on the vial and do not use 14 days after that date.
  

• Put the date that Zemuron (Rocuronium) was removed from refrigeration on the vial; unopened vials are good for 60 days, however, once opened, the vial must be used within 30 days.
  

• REMEMBER: We now have an anesthesia tech here at FSC during the day, so pretend like you are in private practice, plan ahead for supplies and turn-over, and ask the tech for help if you need it!! Communication goes a long way, especially in this small, friendly environment.

Revised 7/2004