Anesthesia Resident Rotations
About Resident Rotations
Below is a sample of our core rotations. In addition, we have several electives that residents participate in throughout their time with us.
Upon completion of training, residents are eligible to enter the American Board of Anesthesiology certification process.
Over the last year we have focused on formally educating our residents on the fundamentals of ambulatory anesthesia care. Ambulatory anesthesia aims to care for patients in the outpatient setting in the safest, most efficient manner. Our faculty have developed the "Curriculum for Residency Training in Ambulatory Anesthesia” which emphasizes that ambulatory patients require a unique approach that does not constitute using a "standard" technique. Residents will gain experience in high turnover cases which require optimization of anesthetic techniques that minimize PACU lengths of stay.
“In your ambulatory rotation, you are usually on the East Campus scheduled in outpatient surgeries in a younger, healthier patient population. You are usually scheduled to a room with several cases and rapid turnover, giving you time to practice management and organizational skills - all of which help you prepare for private practice. This is a great rotation to practice your skills in preparing a patient for going home. Special attention is needed in thinking of how your management affects the patient experience. You work on establishing a patient relationship in a few brief minutes, controlling post-operative nausea/vomiting, maintaining effective pain control, timing smooth induction and extubation, placing of LMAs, utilizing monitored anesthesia care.”
The Division of Cardiac Anesthesia cares for over 850 patients per year with a wide diversity of cardiovascular pathology including complex valvular lesions, thoracic aortic disease requiring reconstruction, adult congenital abnormalities, and coronary artery disease. Didactic sessions dedicated to cardiac anesthesia topics occur throughout the year. All of the division's members are either certified by the National Board of Echocardiography (NBE), and the division is very active in TEE-related research and education. We work closely with the interventional cardiologists in performing complex endovascular valvular procedures and have developed a structural heart fellowship for advanced cardiac anesthesiologists.
“You do one month of cardiac anesthesia during our CA-1 year, giving you early opportunities to place invasive lines, learn invasive monitoring, management of vasoactive medications, and learn more about cardiovascular physiology. You do another month of cardiac anesthesia during the CA-2 year, and have the option of doing up to 3 months during the CA-3 year. You work one-on-one with the cardiac attendings for most cases, so a lot of teaching is done in the OR. There is a very thorough online syllabus that is an invaluable resource.”
The critical care subspecialty rotation is designed to provide a comprehensive fund of knowledge regarding the care of critically ill patients in the post-surgical or trauma setting. There are two surgical intensive care units (SICUs) with different patient populations - the Trauma Surgical ICU and the Surgical ICU. Residents care for complex trauma, thoracic, transplant, vascular, and general surgical patients. The Critical Care Division of the Department of Anesthesiology is very active at the hospital level and is responsible for over half of the coverage of the surgical ICUs. Residents are active participants of the care team, gaining expertise in management of ICU ventilators and severe respiratory failure, support of failing organ systems, care of trauma patients, and the use of invasive monitors and advanced resuscitation. Formal didactics occur frequently and senior residents are able perform at a fellow level in a CA3 elective.
“The ICU rotation offers a wonderful chance to work in a team environment. While the call schedule is intensive (either Q4 or Q3), the non-call days are great for didactic learning and procedures. The month is filled with the opportunity to place lines, work with cutting edge monitoring systems (PICCO2), use various ventilator modes (MMV, PS, AC, SIMV, etc.), and learn to manage patients in the post-operative setting.”
As a Level 1 Trauma Center, there are a large number of patients with severe central nervous system injury to both the brain and spinal cord. Our Department of Neurosurgery is renowned for surgical management of complex neurovascular, oncolologic, and movement disorders. Residents participate in endovascular and open neurosurgery, craniotomies including awake craniotomies, and complex spine cases.
“In your Neuroanesthesia rotation, you will be learning invaluable skills in intracranial pressure management, fluid management, and intra-operative neuro-monitoring. Many of these cases will need invasive monitoring and allow you daily opportunities for arterial and central line placement. The larger spine surgeries can be complicated by massive bleeding, which will require you to be very familiar with management of blood and component therapy. The Neuroanesthesia Division has created an interactive set of modules to guide your learning throughout the rotation.”
The obstetric anesthesia rotation is a busy and intensive experience in peripartum management. We support 5,000 births per year, many of whom are high risk, and we are a referral service for placenta accreta parturients. The residents are introduced in one-week and one-month blocks during their first year, during which time they will become proficient in the placement of epidurals and spinals, in conducting cesarean sections, and they will be introduced to neonatal resuscitation. There are daily didactics and informal instruction from attending staff and fellows. One week of the CA-2 month is spent in the neonatal ICU, a new addition to the curriculum.
“Before your OB month begins, every CA-1 does a one-week intensive block in OB. This gives you a chance to become oriented to L&D before you start taking OB call (which you take throughout your three years). During your one-month block, each day you will generally do at least one c-section, up to five epidurals/spinals, and learn to manage the side effects of neuraxial anesthesia. There are usually two attendings and three residents that divide up the daily work for L&D. It offers a rare opportunity to work and learn with a small group of your colleagues.”
The Post Anesthesia Care Units (PACUs) are designated areas to care for patients post-operatively and also serve as an overflow area for patients from the surgical critical care units. Residents complete a two-week rotation in the PACU during their training. They are supervised by and work closely with an anesthesia critical care attending and are directly responsible for the clinical care of all the patients in consultation with the respective surgical staff. They are exposed to a wide variety of patients at all levels of complexity and learn the management of immediate postoperative problems first-hand, serving as a prelude to their subsequent exposure to the surgical critical care units. During this rotation they are also called to assist the ICU attending at codes and emergent airway cases on the floors.
“As a CA-1, you spend two weeks in the PACU (from 10:00 a.m. - 8:00 p.m.). This is an opportunity to really see how your intra-operative care affects the patient's post-operative condition. You learn to manage post-operative pain, PONV, fluid shifts, hemodynamics, respiratory status, etc. You are responsible for the care of up to 22 post-operative patients at any given time. There is always an attending supervising if there are major issues, but the nursing staff will look to you first for all management issues.”
The Arnold-Warfield Pain Management Center at BIDMC provides comprehensive diagnostic and treatment plans for patients with acute and chronic pain. A multidisciplinary approach is used to provide optimal care for complex patients. As our Pain Division focuses more on opioid-sparing techniques, residents will gain experience in performing commonly utilized invasive procedures including epidural steroid injections, trigger point injections, selective nerve root blocks, placement of spinal cord stimulators and implanted epidurals. Residents participate in the daily, formal didactic sessions during their pain rotation. Two months on the pain service are completed during the first 2 years of residency, with an option to complete up to an additional 6 months as a CA-3.
“The pain rotation is divided between the acute pain service and the chronic pain service. The acute pain service manages pain in the immediate post-op period, with an emphasis on management of epidurals, PCA, and IV infusions. You take pager call from home during the acute pain service (APS) rotation. Most calls for APS can be managed from home, occasionally you will come into the hospital to assess a patient. You work 2 weekends during the pain rotation month, which mainly involves rounding on the pain service patients. On the chronic pain service you work in the pain clinic and participate in procedures. Interested residents can also learn acupuncture, which is taught by a certified acupuncture specialist.”
We maintain a close relationship with the world-renowned Boston Children’s Hospital, which is just up the street. Residents spend three consecutive months doing pediatric anesthesia there during the CA-2 year. Residents may return for up to two additional months during their CA-3 year. Residents will learn basic principles of pediatric anesthesia in dealing with healthy children undergoing elective procedures, and will also care for children with complex medical problems. The rotation gives BIDMC residents a chance to meet residents from other Harvard hospitals who also rotate at Boston Children's Hospital and also offers opportunities to develop relationships with faculty for those residents interested in pediatric fellowship.
“You do a variety of cases at Boston Children's Hospital; examples include ENT cases, tonsillectomy/adenoidectomy, hernia repairs, genitourinary procedures, surgery for pyloric stenosis and duodenal atresia, and appendectomies. You are also involved in simple and complex surgeries on some very medically complicated pediatric patients. You take 24 hour overnight call at Boston Children's Hospital; the call team consists of 2 residents, one pediatric anesthesia fellow, and one attending. Common cases on call include orthopedic cases e.g. for fractures, and removal of foreign bodies from the airway. This is a unique opportunity to work with children from newborns to teenagers, and manage all the anesthetic and social issues that arise from the different age groups.”
Residents incorporate regional techniques throughout their training in obstetrics, pain management, and thoracic surgery. The regional rotation provides dedicated time for gaining a strong foundation in regional anesthesia. The regional service has expanded to include orthopedics, plastics, thoracic, surgical oncology, and thoracic surgery. Block numbers have grown to support a regional fellowship and we are looking to expand regional opportunities to include high throughput areas at our affiliate hospitals.
“As a resident, you complete a regional rotation as a CA-2 and are given the opportunity to do an elective rotation as a CA-3. If you are scheduled as the "Block Resident", you spend the day placing regional blocks for all the patients on either the East or West campus. Most of these blocks are done under ultrasound guidance with one-on-one attending supervision. To offer the most time to establish your skills at regional anesthesia, you are not scheduled for any OR cases on your block days. This is one of the most popular senior rotations. Additional regional block experience is obtained on the West campus when residents rotate on the acute pain service. The busy orthopedic trauma service creates opportunity for catheter-based regional techniques.”
In addition to the Center for Medical Simulation in Cambridge which has been operational since 1993, BIDMC has its own on-site state-of-the-art simulation center, the Carl J. Shapiro Simulation and Skills Lab. Furthermore we have an Education Lab solely dedicated to our department. Anesthesia residents participate in regular simulation sessions early in their CA-1 year and throughout residency. Senior residents can participate in an Education elective, where they write and carry out a simulation scenario for their co-residents and also participate in education initiatives throughout the month. The simulation center consists of multiple rooms linked by advanced AV equipment, including a realistic OR replica complete with anesthesia machine and patient mannequin which responds to interventions and alters its physiology accordingly. The Education Lab has task trainers in ultrasound, regional, spinal/epidural placement, bronchoscopy, airway management and invasive lines. These experiences help our residents train in crisis resource management, procedural skills, group dynamics, and effective communication skills.
“As a resident, you participate in sessions at the simulation center and education lab during the CA-1 orientation and throughout residency. It is a great place to learn procedural and technical skills before encounters with real patients. The scenarios you participate in range from routine interviewing of patients preoperatively to managing complications in the OR, some of which may be catastrophic. The technology we have is truly state-of-the-art, and the attendings who facilitate the sessions and debriefings are top notch. CA-3s who take the education elective have a leadership role in developing, preparing, refining and validating scenarios for future use at the center.”
The Division of Thoracic Anesthesia provides services for all intrathoracic non-cardiac surgery and for procedures involving the airway. The volume of interventional pulmonary medical procedures including rigid bronchoscopies and stent placements has increased dramatically over the past few years. The addition of a tracheal reconstruction surgeon was accompanied by a rise in reconstructive procedures, making BIDMC a national referral center for tracheobronchoplasties. Residents complete a one-month rotation as a CA-2, and may return for further experience as a CA-3. Just prior to the rotation, residents complete training in bronchoscopy through our Education Lab, so they are adequately prepared on day one.
"“This is a great rotation for CA-2 and CA-3's. Many of the patients will need arterial lines, thoracic epidurals, double lumen tubes, bronchoscopy, and central lines - all of which are done by the resident. There is often one-on-one attending coverage, offering residents a wonderful learning opportunity in the clinical setting. Cases can range from VATS to esophegectomies to tracheobronchioplasties.”
BIDMC residents enjoy an extensive experience in transplant anesthesia. Senior residents have the opportunity to participate in both cadaveric and living donor liver transplantations. Residents at all levels of training will be involved with renal and pancreas transplantations. Residents also have the option of participating in Heart Transplants as part of a third year elective program.
“As a senior resident, you take beeper call from home for the transplant service, usually starting at the end of the CA-2 year or beginning of the CA-3 year. Call usually averages about once per month; residents will come in to the hospital if a liver transplant is to be done. The number of cases done during a typical call can vary widely, but typically residents will have done between 1 to 5 liver transplant cases by the time they graduate. The resident on call works one-on-one with the transplant call attending during the case; setting up the room, preoperatively assessing these critically ill patients, and managing the case. These cases give you experience in placing invasive lines including large trauma lines, managing hemodynamics, dealing with the physiology of large fluid shifts, and the pathophysiology of the underlying liver disease as well as learning management of massive transfusion.”
The Vascular Anesthesia team provides anesthesia for the largest volume of vascular surgery in Boston including open and complex endovascular repair of abdominal aortic aneurysms. The education program in vascular anesthesia includes a monthly lecture series, pre-rotation training in high risk line placement, spinal drains, and point-of-care ultrasound, and an extensive syllabus used to teach residents about the complex issues involved in anesthesia for vascular surgery. The Vascular Anesthesia Division is actively involved in many research projects and a vascular anesthesia fellowship is also available.
“BIDMC anesthesia residents rotate through vascular anesthesia for two months during their first two years. The cases include open and endovascular repair of abdominal aortic aneurysms, carotid endarterectomy, femoral-popliteal and femoral-tibial artery bypass grafts, and other endovascular procedures. The patients tend to have more comorbidities and are generally more complicated, so it helps residents gain competence and confidence in taking care of these complicated patients. The vascular rotation during the CA-1 year, like the CA-1 cardiac rotation, provides you with an early opportunity to learn about management of hemodynamics, invasive line placement and monitoring techniques.”