A Day of TEE
2016 TEE update provided by Mark Etter, CA-2
In addition to performing intraoperative TEE’s, we also have key roles in helping start cardiac cases on time, giving breaks to the cardiac residents, and helping transport patients post-operatively. We perform a lot of cardiac surgeries at UVA, so a lot of teamwork and coordination are involved to ensure the day runs smoothly.
06:45: See the patient in the pre-op area with the primary anesthesiology team and help transport the patient to the OR by 7:00am (morning cardiac cases are always 7:00 start). Once in the OR I place all the monitors (ECG, pulse-ox, BP cuff, cerebral oximetry, and BIS), FAST patches, and pre-oxygenate the patient. Since this morning’s patient has severe aortic stenosis, induction will be done after an arterial line is placed because maintaining (and thus, monitoring) appropriate blood pressure throughout induction is critical for proper anesthetic management and patient safety. While I pre-oxygenate the patient, the cardiac resident places the arterial line – first stick, nice job! Now it’s time for the patient to go to sleep – while the attending and myself induce and intubate the patient, the cardiac resident has gowned and prepped for central line placement. I then position the patient and sterilize the patient’s right neck, and the cardiac resident perfectly places and dresses the central line. Once the central line is in, I can place the TEE probe and start the exam. Since this is my first TEE rotation the attending helps by tweaking probe positioning to maximize image clarity for a variety of the views – by CA-3 year I should gain enough experience to independently see all 12 views without any assistance. It’s great to work with attendings who are so good that they can take one look at a non-optimized view and immediately know which way I need to move the probe. Once our exam is done, we page the cardiology fellow to come and perform their formal exam.
08:30: go to the 2nd cardiac room (we usually have 2 adult cardiac rooms running, sometimes 3) and perform the TEE on that patient (who, of course, has already been intubated and lined up with someone else’s assistance).
I also often give a morning break and lunch break to the residents in the 2 cardiac rooms. Once the operative repair is complete we perform our post-repair intraoperative TEE, then once the case(s) are completed I help transport the patient to the cardiac ICU. These patients typically have a lot of lines, monitors, and infusions running so an extra set of hands is quite helpful to the primary anesthesiology team.
1:00: after grabbing a quick lunch, I repeat the morning routine for the 2nd start cardiac cases – induce and intubate while the cardiac resident lines the patient up, perform the intraoperative TEE’s both pre-repair and post-repair, and give a couple of breaks. Before long, it’s time to head home for some dinner and rest, and prepare for tomorrow. A day of TEE is a fun combination of staying busy and doing cool stuff – I’m often bouncing from room-to-room and up the ICU and back, and doing interesting things like echo exams while in the OR. On our TEE rotation we are typically able to leave the hospital by about 5:00, provided the cardiac rooms have someone else available who can help the resident transport the patient up to the ICU.
We perform enough cardiac surgeries at UVA that anyone who wants to obtain at least basic TEE certification has the option to do so, and will easily have enough cases by end of CA-3 year. Part of this certification involves reading a minimum number of TEE’s that were performed by someone else – so one of the things that our attendings do to facilitate this is hold TEE reading sessions every 1-2 weeks where they bring TEE images from a variety of other cases and show them via projector. We read several TEE’s as a group to gain experience, and have time to ask questions without being under time pressure in the OR.