| Department of Anesthesiology at UF |
| Subspecialty Rotations |
Acute and Chronic Pain Management
Faculty: Andre' Boezaart, MB, ChB, Clint Elliot, MD, F. Kayser Enneking, MD, Jill I. Freedman, MD, Meghan Hartzell, MD, Mark Larkins, MD, Linda Le, MD, Steven Lucas, MD, Andrea Trescot, MD
The Acute Pain Service (APS) at Shands Hospital cares for more than 2000 patients each year. The APS is staffed by an attending physician, a resident, and a nurse specialist and is covered 24-hours a day. Patients cared for by the APS are located on five different hospital wards, the SICU, the PICU, and the thoracic surgery ICU. Telemetered pulse oximetry available on each ward greatly increases the safety of epidural or intrathecal narcotic administration. Daily teaching rounds are conducted by the attending physician and are designed to prepare the anesthesiology residents and fellows to diagnose and manage perioperative pain in all types of surgical patients as well as acute pain in other non-surgical patients. Both residents and Pain Management Fellows are involved with caring for patients on the Acute Pain Service at Shands Hospital. Experience on the acute pain service occurs when residents are assigned to the preoperative evaluation clinic, the recovery room, and the Regional Anesthesia Rotation at Shands Hospital. Thus, residents are involved in the entire pain management process. First, they identify preoperatively which patients would be good candidates for specialized perioperative pain management while they are working in the Preoperative Evaluation Clinic. Next they are involved with the actual placement of the blocks that are used for postoperative pain management while on the Regional Anesthesia Rotation. Finally, the recovery room resident helps manage postoperative pain when the patients arrive on the recovery room. The team of residents from the preoperative clinic, the regional anesthesia rotation and the recovery room take call only for the acute pain service each night providing excellent continuity of care.
Residents in the core anesthesiology program gain experience by managing patients with acute perioperative pain primarily while rotating on the Regional Anesthesia rotation, the preoperative evaluation clinic, and the recovery room. Chronic pain management experience is obtained at the free-standing Pain Management Clinic associated with the VA Medical Center. This clinic, located off 39th Avenue in Gainesville, is staffed by our chronic pain management specialists. Working together with these faculty members, a plan is developed and treatment initiated. Approximately 2000 patients are seen at this clinic each year, and of these, over 1000 are new patients. Common pain problems treated are: upper and lower back pain, cancer pain, complex regional pain syndrome, postherpetic neuralgia, pancreatic pain, phantom limb pain, diabetic neuropathies, and central and neuropathic pain of all origins. Residents will be exposed to multiple procedures including among others: stellate ganglion blocks, thoracic and lumbar sympathetic blocks, celiac plexus blocks, continuous interscalene and axillary blocks, and epidural and spinal blocks. Residents will also become proficient in the use of pharmacologic pain control methods including narcotic analgesics, non-steroidal analgesics, antidepressants, anticonvulsants, hypnotics, and other relevant pain medications.
Advanced level elective rotations in pain management are available at both Shands Jacksonville and the VA. At Shands, the advanced level resident can receive exposure to more difficult management problems and treatment modalities including invasive pain management modalities such as spinal cord stimulators and radiofrequency ablations.
Faculty: Azra Bihorac, MD, Lawrence J. Caruso, MD, Andrea Gabrielli, MD, T. James Gallagher, MD,
A. Joseph Layon, MD, Carl Peters, MD
Anesthesiology residents have one to three rotations through the Surgical Intensive Care Unit, depending on their specific program. This unit is an 18-bed, multidisciplinary surgical intensive care unit area that admits over 1100 patients annually aged 18 years and older. Patients are usually admitted to this unit following major surgical procedures in all specialties except cardiothoracic. Critical care medicine is a division of the Department of Anesthesiology, and the program includes a fully accredited adult critical care medicine fellowship. The Surgical Intensive Care Unit at Shands Hospital is operated jointly by the Departments of Anesthesiology and Surgery. The care team at Shands Hospital consists generally of six anesthesiology residents, a surgery residentor an OB-GYN resident, a critical care medicine (CCM) fellow, a CCM attending, interns, and several medical students. All except one of the CCM attendings are specialists in critical care medicine as well as anesthesiology. One CCM attending is certified in internal medicine as well. The multidisciplinary approach provides a symbiotic relationship in which both the anesthesiology resident and surgical resident benefit from the other's knowledge and experience. The CCM rotation also includes a didactic program covering the broad spectrum of this subspecialty.
During this rotation the anesthesiology resident has the opportunity to provide supervised primary care to critically ill adults. Extensive experience is gained with patients having multisystem organ disease or failure and involves placement and interpretation of invasive monitoring, fluid and electrolyte management, mechanical ventilation, nutritional support, drug therapies, perioperative pain control, diagnosis and management of sepsis, and many other areas. One special area also covered by the Shands SICU team jointly with the division of plastic surgery is the 6-bed Burn Intensive Care Unit. This fully equipped unit also has an operating room used for burn debridements. With approximately one-hundred patients treated per year, our residents are experienced in both the intraoperative and postoperative problems of the severely burned patient. The Shands SICU rotation also includes experience in hyperbaric medicine. Shands Hospital has a fully functional hyperbaric chamber that is medically directed by the SICU team. Patients suffering decompression sickness as well as patients with problems such as gangrene are treated in this facility.
There are many areas of ongoing research that welcome resident involvement. These areas include new types of ICU sedation, new modes of mechanical ventilation, hyperbaric medicine (small research chamber is available in our lab), new monitoring methods, and many others. An elective rotation is also available in the cardiothoracic intensive care unit. An ACGME Accredited fellowship in Adult Critical Care Medicine is also available
Faculty: Larry S. Berman, MD, F. Kayser Enneking, MD, Jill I. Freedman, MD,
Megan Hartzell, MD, Linda Le, MD, Timothy Morey, MD, Harshdeep Wilkhu, MD, Gang Zheng, MD
In keeping with the ever-expanding field of ambulatory surgery, the Department of Anesthesiology provides excellent opportunities for residents to gain experience in this exciting subspecialty. Residents encounter the dilemmas and issues associated with an ambulatory practice as well as master the management techniques designed to ease rapid and uneventful recovery. The resident will become familiar with the new anesthetic agents, muscle relaxants and sedatives that have greatly improved the outpatient general anesthesia or monitored anesthesia care experience. In addition, the resident will learn to use regional anesthesia for both outpatient surgical procedures and for postoperative pain control. Outpatient procedures are performed both at the Florida Surgical Center where approximately 4000 procedures are performed annually, and Shands Hospital, where that number is approximately 3500 annually. Florida Surgical Center is doubling its capacity, effective September 2007, and will relocate to a brand new facility approximately 5 miles from the health center at that time. Overall, approximately 25% of all cases performed by our residents are outpatient procedures. Cases performed at Florida Surgical Center are primarily orthopedic and pediatric outpatient procedures. All of our residents have a one-month rotation block at Florida Surgical Center where they have a concentrated exposure to ambulatory anesthesia. In addition they can elect to rotate to the facility for additional regional anesthesia and pediatric anesthesia exposure. The environment is similar to most busy private practice settings, and as such will give the residents the experience of rapid turnovers with experienced operating room personnel.
Faculty: Larry Caruso, MD, Laurie K. Davies, MD, Nicole Dobija (Pediatric CV), Andrea Gabrielli, MD, Nikolaus Gravenstein, MD, Gregory Janelle, MD, Rama Kulkarni, MD, Emilio Lobato, MD, David A. Paulus, MD, Yonggang Peng, MD, Albrecht Wobst, MD, PhD
A wide spectrum of learning opportunities in cardiothoracic anesthesia is available to the anesthesia resident. The rotation at Shands Hospital provides an emphasis on congenital heart disease, with a substantial percentage of the caseload being pediatric. The resident also will gain exposure to patients undergoing coronary revascularization, valve repair/replacement, electrophysiologic surgery, thoracic surgery, and heart transplantation. Residents will develop skill in advanced hemodynamic monitoring and interpretation with state-of-the-art equipment. The Veterans Affairs Medical Center cardiothoracic rotation provides further training in the care of adult patients undergoing cardiac, thoracic, and vascular surgery. The cardiac catheterization laboratory enables the resident to gain expertise in the care of patients undergoing invasive cardiologic therapies.
An elective rotation at Shands in transesophageal echocardiography (see Unique Educational Opportunities link below) provides an opportunity for the resident to develop expertise in this new monitoring modality.
Faculty: Dietrich Gravenstein, MD, Nikolaus Gravenstein, MD, Mary Herman, MD, PhD, Michael E. Mahla, MD,
Christoph N. Seubert, MD, PhD, Steven Robicsek, MD, PhD, Cheri A. Sulek, MD
There are approximately 2000 neurosurgical cases performed each year at Shands Hospital with additional cases available at the V.A. Medical Center. Since most of the cases are performed at Shands Hospital and the V.A. Medical Center, all of the formal neurosurgical rotations are performed at these 2 institutions. The neurosurgery service is one of the busiest surgical services at the medical center, and there are three or four designated neurosurgical operating rooms each day at Shands. The formal neuroanesthesia rotation is one month long and will be completed generally during the CA1 or CA2 year. Additional 1-month rotations may be elected during the CA3 year. A six-month block in neuroanesthesia research is also available in the CA3 year and the resident must select the clinical scientist track. Six to nine-month blocks of clinical neuroanesthesia are also available in the CA-3 year with approval from the education committee. A formal neuroanesthesia fellowship training program involving research and clinical neuroanesthesia experience is available as well.
There are seven attending physicians specializing in neuroanesthesia. There are eleven full-time neurosurgery faculty with specialty interests including pediatric neurosurgery; neurovascular surgery (including endovascular neurosurgery); epilepsy surgery; spine reconstructive surgery; stereotactic neurosurgery; posterior fossa surgery including acoustic tumors and microvascular decompressions; movement disorders; and general neurosurgery. In addition, there is a very active interventional neuroradiology program at Shands Hospital, and residents will frequently provide anesthesia for these procedures. Shands Hospital is also a major referral center for patients suffering subarachnoid hemorrhage, and residents receive extensive experience both in the intraoperative and postoperative management of these complex patients. There is a very active neurologic monitoring program at Shands Hospital, and residents in neuroanesthesia as well as in other areas of the operating room will gain a basic understanding of both EEG and evoked potential monitoring. The anesthesiology department manages the neurologic monitoring service. An elective in neurologic monitoring is available for CA3 residents (see below). A fellowship in neuroanesthesia is available.
Faculty: Donald Caton, MD (emeritus), Tammy Y. Euliano, MD, Gordon L. Gibby, MD, R. Richard Schultetus, MD, Adam Wendling, MD
The obstetric anesthesia service of the department was formally established in 1969. Since that time, the number of deliveries has increased to approximately 2500 per year. We expect the number of births per year to increase substantially during the next decade. Approximate 20% of the patients are "high risk," many referred from the northern half of the state and from southern Georgia because of our obstetrical facilities and our 33-bed Neonatal Intensive Care Unit.
Presently, the anesthesia department covers Labor and Delivery with two residents during each four-week rotation to OB anesthesia. Each resident works Monday through Friday with no weeknight call. Each resident will work 2 weekend Friday / Sunday calls during the month. OB night coverage (Monday - Thursday) is provided by a night-float system with a resident who has previously completed a rotation in OB anesthesia. Saturdays are also covered by a resident who has previously completed a rotation in OB anesthesia.
During the regular workweek, each morning begins with clinical rounds in which residents, faculty, and medical students join in a discussion of clinical problems as well as pertinent aspects of reproductive physiology and pharmacology. The division also offers opportunities for clinical and research rotations for residents in the CA3 year who want extra experience.
Faculty: Lawrence S. Berman, MD, Nicole Dobija, MD, Alexander Matveevskii, MD, Segundina S. Saga-Rumley, MD, Sno E. White, MD
Approximately 30 percent of all cases performed in the Shands Healthcare system are children, and residents are exposed to pediatric anesthesia both at Shands at UF and Shands at Alachua General Hospital (also in Gainesville). Every pediatric surgical subspecialty is represented and active. There are 2 designated rotations in pediatric anesthesia during the CA-2 year. However, extensive exposure occurs while on general operating room rotations. Our residents have generally completed nearly all pediatric anesthesia program requirements, except for the neonatal and premature infants, prior to starting the pediatric anesthesia rotation in the CA-2 year. The intense dedicated pediatric anesthesia rotation supplemented with continuous reinforcement throughout the training program provides the ideal learning milieu for pediatric anesthesia care.
The resident benefits from the experience of five full-time pediatric anesthesia faculty. Four pediatric general surgeons and additional pediatric specialists in neurosurgery, cardiothoracic surgery, orthopedic surgery, otolaryngology, ophthalmology, urology, and plastic surgery provide a steady and abundant supply of interesting cases from hernias to liver transplants. These cases are performed at our main hospital as well as at Shands Childrens Hospital at Alachua General Hospital approximately one mile away from the health center.
The collegial interaction among those who care for children is a phenomenon that we value and enjoy, and is a testament to the complete commitment to children's care. Many of our graduates become the local pediatric authority in their private practice groups as their skill and comfort with these cases becomes readily apparent.
Faculty: Andre' Boezaart, MD, Clint Elliot, MD, F. Kayser Enneking, MD, Jill I. Freedman, MD, Meghan Hartzell, MD, Linda Le, MD, Steven Lucas, MD
Anesthesiology residents have at least one
rotation exclusively dedicated to the management of patients having surgical
procedures under regional anesthesia. Residents work one-on-one with faculty
assigned to our block room. The vast majority of patients having regional
anesthesia will come first to our block room located on the 2nd floor of the
hospital near the operating room. After consulting with the OR team assigned to
the case, the regional anesthesia resident and attending will prepare the
patient, place the block, and monitor for complications. This procedure gives
the block plenty of time to set up before the patient is actually in the
operating room with the surgeon being impatient to start the procedure. On
average, residents assigned to the block room will do 6 to 10 block procedures
in a given day. Typical block procedures include: cervical, thoracic and lumbar
epidural catheters; interscalene, supraclavicular, infraclavicular, and axillary
blocks of the brachial plexus; lumbar plexus blocks; femoral, sciatic, lateral
femoral cutaneous, obturator, popliteal, and ankle blocks. Residents on the
regional anesthesia rotation also play a major role in the acute pain service.
They will make teaching rounds every day with the regional anesthesia attending,
and form part of the call team that will cover the acute pain service at night.
Residents completing this rotation have excellent skills in regional anesthesia
as well as a good understanding of the management of postoperative pain and the
impact of regional anesthesia on postoperative pain management.
| RESIDENCY TRAINING OPTIONS AVAILABLE |