Anesthesia Resident Rotations

Several years ago, one of our dedicated residents took the initiative to create the Practice Management elective, a program designed to equip our trainees with an in-depth comprehension of billing, supervision, and clinical operations. This elective not only enhances their understanding of these essential principles but also empowers them to assume leadership roles as they prepare for careers as attending anesthesiologists. During their time on this rotation, residents shoulder significant responsibilities, including managing the board, triaging case assignments, overseeing room and team allocations, and offering crucial assistance during emergent cases in the operating room. They also take on the vital task of scheduling OR assignments for the following day, ensuring the smooth operation of our department. In addition, residents dedicate their time to supervising their fellow residents and Certified Registered Nurse Anesthetists (CRNAs) while simultaneously managing the oversight of two to three concurrent operating rooms.

Furthermore, our resident EQuIP (Education, Quality Improvement, and Patient Safety) Committee is diligently working to expand this valuable rotation from its current one-month elective during the CA-3 year to a comprehensive longitudinal experience throughout residency. This initiative aims to provide residents with an even more comprehensive understanding of practice management, ultimately preparing them for successful careers in the field of anesthesiology. Additionally, residents on this rotation collaborate closely with our Anesthesia Billing colleagues to gain insight into the intricate financial infrastructure of our anesthesia department, further enhancing their knowledge and skills in this critical aspect of medical practice.

The Division of Cardiac Anesthesia cares for over 900 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. We are a leader in structural heart interventional procedures and have an advanced structural heart cardiac anesthesia fellowship. We are most proud of our new heart transplant program, which our cardiac and critical care divisions were instrumental in implementing along with our cardiac surgical and cardiology teams. Didactic sessions dedicated to cardiac anesthesia topics occur throughout the year. All of the division's members are certified by the National Board of Echocardiography (NBE), and the division is very active in TEE-related research and education.

Resident Perspective

“As a BIDMC resident we get early exposure to cardiac anesthesia beginning in CA-1 year, as early as October of CA1 year - we learn cardiovascular physiology, place invasive lines, get accustomed to invasive hemodynamic monitoring and managing vasopressors. We do a second month of cardiac anesthesia during the CA-2 year, and have the option of doing up to 3 additional months during CA-3 year. We get graded exposure to the full variety of cardiac cases (CABG, single- or multiple valve repair/replacements, septal myectomies for HOCM, mechanical circulatory support - ECMO/Impella/VADs, heart transplants, TAVR/Mitraclips, etc.) throughout our cardiac rotations. There's a thorough online syllabus with educational material; attendings are one-on-one with residents and there's often a fellow also assigned to the room so there's plenty of intraoperative teaching. We also have a formal resident lecture series arranged by the attendings and fellows, and we're invited to the fellow didactic series as well. We get ample opportunity to learn TEE throughout the years with an option to complete an echo-focused elective during our CA-3 year.”

The ICU rotation offers an interdisciplinary and diverse approach to critical patient care while working in a team environment. This month offers a multitude of skill development, including ventilator management, invasive (via central line and arterial line placement) and non-invasive monitoring, intubation, bronchoscopy, and system-based patient care. Collaborating with nurses, respiratory therapists, nutritionists, and pharmacists, our residents have the opportunity to care for critically ill patients in a team-based approach that is unique to the ICU setting. Call schedules can vary from day/night shift with weekend call, to q3d call depending on whether we are rotating in the Surgical ICU or Trauma Surgery ICU. Overall an excellent month to gain a more holistic understanding of critical illness while developing procedural skills.

Our Department of Neurosurgery is renowned for surgical management of complex neurovascular, oncologic, and movement pathology. As a Level 1 Trauma Center and Comprehensive Stroke Center, residents will also be exposed to complex neurological emergencies including patients with severe brain and spinal cord trauma, code stroke and severe SAH management. During their Neuroanesthesia rotation, residents participate in endovascular and open neurosurgery, craniotomies—including awake craniotomies—and complex spine cases.

Resident Perspective

“Neuroanesthesia is a great rotation that builds hands-on and clinical management skills. It was an excellent opportunity to practice placing arterial lines daily! From deep brain stimulation to awake cranis the case mix is very good, giving residents at all levels a chance to do complex neuro cases. With the guidance of neuroanesthesia faculty who are very dedicated to teaching, the rotation helped me learn important skills like intracranial pressure management, fluid management, and intra-operative neuro-monitoring.”

The obstetric anesthesia rotation is intensive experience in peripartum management. Beth Israel Deaconess Medical Center supports approximately 5,000 births per year. As a Level IV Maternal Care Center (which includes the New England Center for Placental Disorders, Maternal-Fetal Medicine Specialists, Prenatal Genetics Specialists and Neonatologists) many of our parturients have complex medical history. Our obstetric division is also recognized as a Society of Obstetric Anesthesiology and Perinatology Center of Excellence.

Our residents are introduced to obstetric anesthesiology subspecialty in one-week and one-month blocks during their first year. During this time, trainees will be introduced to neuraxial procedures for labor analgesia and cesarean deliveries, anesthesia for peripartum and postpartum surgical procedures, as well as neonatal resuscitation. There are daily didactics and instruction from attending staff and fellows. During second year, one week of OB Anesthesia month is spent in the neonatal ICU. In addition, our senior residents participate in obstetric anesthesia consults and multi-disciplinary meetings for our high risk parturients.

Resident Perspective

“Over the course of your residency, you have one dedicated OB anesthesia month during your CA-1 year and your CA-2 year, with an option to add an OB elective during your CA-3 year. 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 and to learn more about the most important topics that you will encounter on the L&D floor. Following this primer week, you’ll start taking OB call, which then continues throughout your three years of residency.

“During each day of your dedicated one-month OB blocks, there are two OB anesthesia attendings and usually three other residents (sometimes two other residents and one OB anesthesia fellow). You will usually divide the daily work on the L&D floor between all of your co-residents and/or fellow. Generally, in a day, you’ll end up doing at least one c-section, up to five epidurals/spinals, and learn to manage the side effects of neuraxial anesthesia. It offers a rare opportunity to work and learn with a small group of your colleagues.”

Residents undergo a formal 2-week PACU rotation as a CA-1, and also may be assigned to PACU for one week at a time as a senior (CA-2/CA-3) resident. The PACU resident is seen as the "go-to" person by the PACU RN staff in case there are any difficulties with their patient, and is responsible for management of commonly encountered post-operative issues such as hemodynamic instability, respiratory depression, assessment of volume status, and treatment of post-operative pain and PONV. Additionally, the PACU resident will sometimes be responsible for providing anesthesia for cardiology patients undergoing cardioversions or TEEs in the cardiology procedural suites. Ultimately, the rotation provides an opportunity to learn about perioperative management outside the of OR setting, work closely with RN staff, and gain experience with diagnostic skills such as bedside POCUS exam, EKG, and imaging interpretation.

The Arnold-Warfield Pain Management Center at BIDMC offers comprehensive diagnostic and treatment plans for patients dealing with acute and chronic pain. We adopt a multidisciplinary approach to ensure the highest quality care for complex cases. Notably, our Pain Division is actively expanding, with a particular emphasis on opioid-sparing techniques. We are proud to collaborate with national pain programs, such as Boston Children's Hospital, which is conveniently located just across the street from our primary clinic site.

In response to the growing demand, we now offer an ever-increasing range of interventional procedures, including SCS trials and implants, Kyphoplasty, VIA disc, MILD, PNS, and Tenex Tenotomy. During their time on the pain service, residents have the opportunity to gain hands-on experience in performing commonly used invasive procedures, such as epidural steroid injections, trigger point injections, selective nerve root blocks, placement of spinal cord stimulators, and much more. Residents also actively engage in daily, formal didactic sessions as part of their pain rotation. Typically, two months on the pain service are completed within the first two years of residency, with an option to extend this experience for additional months during the CA-3 year. Our residents find a balanced mix between clinical and procedural exposure, spending approximately 50% of their time in clinic and the remaining 50% in our state-of-the-art procedure rooms. Furthermore, our fellows benefit from robust and engaging guidance and education, ensuring their professional growth and development.

Excitingly, we recently welcomed Dr. Narang, our new Co-Director of the Spine Center, who brings a wealth of experience in cancer pain management, further enhancing our services. This appointment aligns with our partnership with the Dana Farber Cancer Institute, solidifying our commitment to advancing pain management and patient care.

Resident Perspective

“Boston Children's has been one of my favorite rotations. It is a unique rotation since residents from 7 institutions all work together to provide great pediatric care. Consistently attendings have given great feedback to all the BI rotators. You will spend 3 months as a CA2 doing mainly bread and butter pediatrics such as tonsillectomy/adenoidectomy, dental rehabilitation, craniotomies, spine surgery, hernia repairs, GU procedures, and anesthesia for MRI and CT scans. Being Boston Children's, these patients are often complex with uncommon congenital disorders, congenital heart defects, and behavioral and developmental delays. The attendings are great (some having written our textbooks) and will give you safe but gradual responsibility to lead your own cases. In addition, the support staff is superior, facilities are top notch, and overall vibe is positive. You will take late call and 24 hour call (2 residents, 1 fellow, 1 attending overnight) but still have most of your weekends free. This is a unique opportunity to work with children from newborns to teenagers and manage all their anesthetic and social issues unique to each demographic. You will have no issue reaching your case number requirement.”

Our dedicated regional anesthesia rotation allows residents to focus on building a strong skillset in nerve block procedures and epidural placements. Currently, regional anesthesia is a routine practice for perioperative care of patients undergoing orthopedic, thoracic, trauma, general, plastic/reconstructive and oncologic surgery. As we continue to expand our services, we also expand training opportunities for residents. Exposure to regional anesthesia occurs as early as October of CA-1 year. Residents are prepared using simulation training and hands on skills clinics with model patients. As residents progress through their training, many will rotate through a dedicated month-long rotation at a subspecialty orthopedic hospital which will allow them to solidify their skills. For residents looking to further their training and focus on academics, a dedicated regional anesthesia and acute pain fellowship program is available.

Resident Perspective

“Regional anesthesia remains one of the most popular rotations during anesthesia residency here at BIDMC. As residents we get early exposure to regional anesthesia in CA1 year via the Pain rotation by working on the Acute Pain Service. Dedicated time is spend during CA-2 year during the Regional month where you are paired one on one with a regional attending and get to perform all the regional procedures on east campus, ranging from thoracic epidurals to single shot blocks as well as peripheral nerve catheters. This time is protected and you are not assigned OR cases. Additionally, there is still a component of acute pain management as we cover all APS patients on that side of the hospital. Further options for a CA-3 regional month at BIDMC and recently at New England Baptist are very popular to help find tune our regional skills before graduation from residency.”

As a resident, your engagement with our simulation program is a cornerstone of your training journey. From your initial CA-1 orientation and throughout your residency, the scope and significance of our Medical Education month have expanded dramatically. As of 2023, it stands as an indispensable component of our dedicated Tuesday Educational Days and Thursday real-time intraoperative simulation sessions.

Our simulation center and Anesthesia Skills Lab serve as invaluable environments for honing procedural and technical skills, offering a secure space for learning and clinical practice prior to real patient encounters. The scenarios that residents cover a broad spectrum of high yield clinical scenarios, ranging from routine patient preoperative interviews to the intricate management of potentially catastrophic complications in the operating room. This state-of-the-art technology enriches your experience, allowing for realistic and immersive training experience.

Our simulation program offers the opportunity to work with high-caliber of attendings and senior residents who lead the sessions and facilitate debriefings. Their expertise and guidance ensure that you receive the highest level of education and feedback, enhancing your proficiency and confidence in various clinical scenarios. Moreover, CA-3 residents who choose the Medical Education elective play a pivotal leadership role within the program. They contribute significantly by developing, preparing and refining scenarios that will benefit future trainees. This collaborative effort not only strengthens their own skills, but also enriches the educational experience for all residents, underscoring our commitment to excellence to education in our anesthesiology training program.

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 tracheobronchoplasty. Residents complete a one-month rotation as a CA-2, and return for advanced experience as a CA-3. Just prior to the rotation, residents complete training in bronchoscopy through our Anesthesia Skills Lab, so they are adequately prepared on day one.

Resident Perspective

“This is a great rotation for CA-2 and CA-3's. Many of the patients need arterial lines, thoracic epidurals, double lumen tubes, bronchoscopy, and central lines - all of which are done by the resident. The teaching on advanced pulmonary physiology and ventilator management is great, offering residents a wonderful learning opportunity in the clinical setting. Cases can range from VATS to esophagectomies to big reconstructive cases like tracheobronchoplasty.”

Our liver transplant service has nearly tripled its surgical volume in less than a year—we are currently on track to have performed 80-100 liver transplants this year, in addition to kidney and pancreas transplants. Our cardiac division has also just recently started performing heart transplants. These expansions not only expose residents to a wider spectrum of complex cases, but also emphasize the pivotal role of transplant and cardiac anesthesiologists in managing these high-acuity patients. Residents are able to actively contribute to the enhancement and expansion of both services, participating in cutting-edge medicine while fine-tuning their procedural and clinical management skills, in a challenging yet rewarding environment.

Resident Perspective

“Senior residents are eligible to begin on the transplant service halfway through CA-2 year. As the transplant resident you take beeper call from home approximately twice a month and can expect to be called in if there is a liver transplant to be done, or a post-transplant patient requires additional surgical care shortly after their transplant. The number of cases done during a typical call can vary from 0-2 transplants, and with our institution's recent increase in transplant volumes, residents can expect on average 5-10 transplants by graduation. When called upon, the transplant resident works one-on-one with their attending throughout the case with a transplant-oriented focus on room set-up, preoperative assessment, and peri-operative management. These cases are notable for their educational opportunities including multiple line placements (such as intra-arterial and several large trauma lines), management of sudden hemodynamics swings, anticipating the physiology of large fluid shifts, and delivering effective transfusion care to the patient including massive transfusion protocol when appropriate. Residents can expect to emerge from their transplant experience with a comprehensive understanding of advanced liver pathology, its implication on their anesthetic, and the ability to deliver effective peri-operative care for a transplant patient.”

Resident Perspective

“BIDMC anesthesia residents rotate through vascular anesthesia for one month in CA-1 and CA-2 years, with an option to have a 3rd month CA-3 year. Cases commonly encountered on this rotation include open and endovascular repair of abdominal aortic aneurysms, carotid endarterectomy, lower extremity arterial bypass grafts, and a variety of other endovascular procedures. Patients on vascular tend to have multiple medical comorbidities and are generally more complicated, so the rotation helps residents gain competence and confidence in their ability to care for more complex patients. Overall, the rotation presents residents with an early opportunity to learn about stringent hemodynamic management, practice procedural skills such as invasive line placements and thoracic epidurals, and use special monitoring techniques such as cerebral oximetry and ACT monitoring.”