Regional anesthesia at the Houston VA Medical Center is an extremely robust and well-organized service. This is an amazing rotation to improve your ultrasound guided nerve block techniques by working with several attendings with prolific regional anesthesia experience. Aside from you, the regional team consists of the attending and a CRNA; they switch weekly. Since we do so many peripheral nerve block catheters and those need to be followed up, there is the same attending and CRNA onboard for a week for consistency and patient care continuity. You will easily cover a wide variety of upper and lower extremity nerve blocks, learning to manage both single shot infiltrations vs continuous peripheral nerve block catheters. In addition, there is an opportunity to learn how to do ultrasound guided, paramedian thoracic epidurals (novel and atypical because epidurals are usually done anatomically) and take ownership of managing these epidural patients.
My typical day starts off at ~6:15 a.m. with chart checking the posted cases that would benefit from nerve blocks. Then, I go to the pre-op holding area where the nerve block cart and ultrasound are located. I start drawing up several syringes of local anesthetics, mixing additives as needed. The first case starts are definitely the most hectic part of the day because you have to get multiple blocks in a short time window while the intraoperative teams (nursing, anesthesiology, surgery) are also trying to assess and final prep the patients before surgery. Usually I rattle off my explanations and consents first, then line up my block supplies like an assembly line at bedside for patients interested in blocks. The CRNA helps with patient sedation and ultrasound set up. Then the attending supervises as I quickly, but accurately scan for anatomical landmarks and locate appropriate nerves to block. If it’s a single shot, I inject and we’re done. If, for example, the patient is getting a total knee arthroplasty, then we also thread in a peripheral nerve catheter and secure it. I scramble from patient to patient and eventually finish all the nerve blocks for first case starts.
After I document my procedures, I try to round on all the inpatient follow-ups; usually peripheral nerve catheters and epidurals. I make adjustments and/or refill pumps as needed. I also carry the regional pager to answer any pages from nurses, patients, or consults. For the rest of the day, I perform nerve blocks at a more relaxed pace whenever the next patients show up. However, sometimes unanticipated last second requests, consults, or cases do get posted. This can result in an afternoon rush just as busy as the early morning scramble. Since the regional anesthesia service educates and sends patients home with peripheral nerve block catheters, I intersperse outpatient follow-up calls to check on pain control and ensure proper catheter removal. When my blocks and follow-ups are done for the day, I hand off to the on-call, overnight CRNA usually around 3 p.m.
At the end of your VA regional rotation, you will be competent in all the bread-and-butter peripheral nerve blocks. In addition, you will have had exposure to some less common and more technically challenging regional anesthesia procedures. Overall, this is definitely one of the best rotations for improving your ultrasound comfort, directly managing postoperative patient pain, and learning a lot that will carry over for the rest of your anesthesiology career!
