What can you tell me about your didactic program?

Our residents are postdoctoral students and as such, they should be experts at learning. We believe that our residents bear a large responsibility for their own learning. It is the faculty's job to guide them in this process. Therefore, we have a program of formal lectures, visiting professors, PBLDs and small group discussion sessions, journal clubs, workshops, practice oral boards sessions, and a very lively Clinical Case Conference (M and M). We also have an active simulation-based learning program. The curriculum (rotation-specific goals and objectives and recommended educational resources) is all on-line and can be accessed by residents at any time.

Our didactic program has been restructured to allow for dedicated educational time. Each Wednesday, a clinical anesthesia class is relieved from clinical duties to participate in core didactic activities for a day.

In addition, the ORs start late on Tuesday mornings to permit time for education and meetings for physicians, nurses, and other allied health personnel. Subspecialty didactics take place 6:30 to 7 a.m. on Tuesdays. Other than the one individual carrying the code pager, residents are not permitted to be paged-out of Tuesday conferences.

The didactic program is training level-specific:

• CA1 year is devoted to topics in basic clinical anesthesia (anatomy, physiology, physics, pharmacology, anesthesia basics). In January and February, the Tuesday morning teaching sessions are devoted to Board and In-Training exam prep (ABA basic written board examination is taken in June of the CA1 year).
• CA2 and CA3 residents have subspecialty-anesthesia modules. These modules also include research design/statistics and practice management.

The UI,  and Universities of Minnesota, Nebraska and Wisconsin Departments of Anesthesiology have partnered to share didactics related to practice management. Approximately four times per year, the residents have access to real-time presentations (including Q&A sessions) by local, regional, and national experts. We also have incorporated a wellness and resiliency component into our curriculum.

Grand Rounds, Clinical Case Conference (M and M), and visiting professor presentations are on Tuesday mornings from 7 to 8 a.m. Interns are invited and encouraged to attend these weekly conferences.

Simulator sessions are scheduled throughout the day. During the OR orientation (May and June of the intern year), there are additional simulation sessions.

The department regularly sponsors workshops and symposia such as:

• Basic TEE Review Course
• Obstetric Anesthesia Symposium
• Operations Research for OR Management
• Regional Anesthesia Study Center of Iowa (RASCI)
• Statistical Methods for Anesthesia

Twice a year, residents participate in practice oral exam sessions. The department has eight faculty members who are ABA oral board examiners and they help the faculty and residents prepare to pass the ABA applied examinations (oral boards) and OSCE (Observed Structured Clinical Exam).

Finally, residents have access to many online educational programs that are paid for by the department, including the Anesthesia Toolbox, PTE Masters echocardiography, Institute for Healthcare Improvement, and TrueLearn SmartBanks for Medical Exams.

How do you ensure that resident education is not sacrificed for service demands?

Our residents work hard; they cannot gain real expertise without it. But we never forget that there is more to learning than just doing a lot of cases. They need to be the right cases–and they need to be supplemented by didactics.

To ensure this, we carefully track and manage resident case mix and case load–not just duty hours. We have protected time for lectures and problem-based learning discussions (Tuesday mornings). Simulator time is scheduled, not just handled on an ad hoc basis. CRNAs and faculty are charged with getting as many residents as possible to workshops and simulations. Residents have non-clinical (academic) time (approximately four weeks) distributed throughout the three-year residency.

What is the teaching like in the OR?

We have about 80 faculty–which translates into 80 different teaching styles. Some give mini talks, some ask a lot of questions, some give practice oral boards, some discuss various topics or journal articles. Some never stop teaching–others need to be prompted by the residents. Some are tougher than others. But all of them want to teach–and the department places great emphasis on clinical teaching.

Residents can provide anonymous feedback to the faculty which plays a role in their annual review and promotions process. The education leaders can help faculty who have concerning feedback to come up with a plan to improve their teaching skills.

What kinds of teaching opportunities are there for residents?

Residents are involved with teaching on many levels. They teach each other (seniors teach more junior residents, particularly on call). They teach residents from other departments (orthopedics, otolaryngology, oral surgery, pediatric dentists, emergency medicine, etc.), medical students, and EMT students who are rotating in anesthesia.

In addition to the clinical teaching, there are many opportunities for residents to give demonstrations, participate in workshops and simulations, and make presentations to physicians and allied health personnel (during the internship and the clinical anesthesia years). CA3 residents are expected to make an educational presentation to the interns during the Advanced Clinical Medicine Rotation in May/June.

How do you orient new residents to the OR?

We have a very active orientation program for our new trainees. Interns spend one block on Advanced Clinical Medicine (ACM) in May and a month (June) administering anesthesia. The ACM rotation  incorporates lectures, workshops, case discussions, and simulations to provide the foundation for the upcoming clinical anesthesia experience. During the Anesthesia orientation block, interns learn to setup the OR, check out the anesthesia machine, draw up medications, complete a focused anesthesia H and P, obtain patient consent for anesthesia, start IVs, intubate, complete electronic operative anesthesia records, communicate necessary information for transition of care to another provider, and conduct a basic anesthetic from beginning to end.

Early in the rotation, anesthesia interns are paired with a more senior resident; later in the rotation, one or two interns are assigned to work with a single faculty member who has no other responsibility but to work with the orienting trainees. By the beginning of July, interns are usually ready to have more autonomy and faculty members simultaneously supervise up to two rooms of trainees. Therefore, during the anesthesia orientation month of June, interns are gradually provided more independence so they can become more prepared and comfortable without the continuous presence of staff.

What are your average duty hours?

Duty hours vary, depending on the rotation; for the last several years, the average duty hours have been approximately 52-55 hours per week.

Can you give me an overview of your clinical activities?

In FY 2021-2022, we did more than 48,900 anesthetics in locations divided between the main OR, UI Stead Family Children's Hospital, and Ambulatory Surgical Center. We are the only hospital in Iowa that has dual certification as an adult and pediatric Level 1 trauma center and the only center in Iowa doing kidney, liver, heart, and lung transplants.

The department also oversees nearly 3,000 ICU admissions (to a 50 bed SNICU/CVICU which is under the direction of the Department of Anesthesia), and manages 8,500 patient encounters by the chronic pain services and 7,000 encounters by the acute pain service.

Make no mistake - this is a very large, very busy, tertiary care hospital located in a near-perfect university community.

How often do residents take night call?

Call responsibilities vary, depending on the rotation. We have a night float rotation for OR call (beginning at 6 p.m. on Sunday and ending at 7 a.m. on Saturday). Night float is scheduled in two separate two-week blocks each year for CA1, CA2, and CA3 residents. OB has a separate night float call schedule. OB night float is approximately two weeks each year. In addition, residents take call (OB or OR) approximately four to six Saturdays and Sundays each year.

In the SNICU/CVICU, residents are on call roughly every third night - with specified days off to ensure compliance with duty hour rules.

Cardiac anesthesia residents take call from home approximately every three to five days (and share call responsibilities with the cardiac anesthesia fellow). Cardiac anesthesia residents get the next day off, even if they were not called-in to do a case.

Acute pain/regional residents take call from home. However, the in-house night OB resident handles simple problems (for example, changing the epidural infusion rate or replacing a pump battery).

CA1 residents generally do not start to take OR night call until October of their CA1 year.

Interns on the OR orientation rotation (June of the intern year) do not take call. Interns on non-anesthesia rotations take call according to the schedule of the primary service (Medicine, Surgery, PICU, SNICU/CVICU, etc.).

All services are expected to ensure that interns comply with ACGME duty hour rules. If interns (or residents) are having a problem complying with ACGME duty hour rules, they should contact the senior resident on the service, the anesthesia chief residents, or the Anesthesia Program Director. The Department of Anesthesia regularly monitors violations and works with the various departments to create solutions if chronic problems with violations exist.

Is a scholarly project required of your residents?

Yes, to comply with ACGME requirements, all anesthesia residents are required to complete an academic (scholarly) project. This can take many forms:

• Quality, safety, or performance improvement project
• Clinical study (retrospective or prospective)
• Bench research project
• Write a review article on an anesthesia (or subspecialty anesthesia) topic
• Simulation (create a new simulation teaching module and submit it for publication)

Projects are completed with a faculty mentor and the Department Resident Research Advisor (Drs. Kaczka and Loftus). Resident scholarly projects are expected to be submitted for publication.

Also, residents are required to present at MARC (Midwest Anesthesia Resident Conference) or an alternate regional or national meeting.

How do you ensure that residents have the independence needed to prepare them for practice after graduation?

Through the three-year residency, trainees are gradually given more independence and autonomy with OR cases and procedures. Senior residents in the SNICU/CVICU have responsibility for patient triage, mentoring junior residents and managing patients (especially on nights or weekends, as faculty take call from home). The senior elective in Des Moines (cardiac anesthesia) offers CA3 residents more autonomy.

Finally, we have a required senior rotation, TIPS (Transition to Independent Practice). CA3 residents are assigned to this one-month rotation late in their CA3 year. On this rotation, a group of three to four CA3 residents form their own "private practice." The CA-3 resident team leader (TIP Master) rotates each week and makes the OR room assignments for the team members. The TIP Master also assists the team members with patient preparation, obtaining informed consent, induction and emergence from anesthesia, provides breaks for the team members, communicates with the OR day coordinator, and assigns tasks to the faculty anesthesiologist. Faculty anesthesiologist input/patient management is kept to the minimum necessary for patient safety and medical/legal documentation. Staff are always present when medically necessary for patient safety. This rotation has been wildly successful, offering CA3 residents the most independence and autonomy (and the opportunity to work with their CA3 peers).

What is your pain rotation like?

Interns and CA-2 residents rotate on the chronic pain service. During this experience, they work largely with chronic pain patients in the outpatient pain clinic setting. Residents evaluate patients, make treatment recommendations, and participate in diagnostic and therapeutic procedures (depending on level of training). Interns and residents do not take call on the chronic pain rotation.

CA-1, CA-2, and CA-3 residents rotate on the Acute Pain Service (APS). During this experience, they work in the inpatient setting, evaluating patients and participating in performing perioperative peripheral nerve blocks and epidurals. They also round on inpatients on the APS for management of acute postoperative pain. Acute pain call is shared with the regional anesthesia fellows. This is home call. However, the resident taking in-house OB night call generally handles simple issues such as changing the epidural infusion rate or replacing a pump battery. 

What are the strongest subspecialties in your department?

Regional anesthesia (approximately 3,700 peripheral nerve blocks/year), surgical intensive care (3,000 admissions/year), orthopedics, otolaryngology, neurosurgery, general surgery (including transplant and trauma), and pediatrics (approximately 20% of our anesthetics involve patients under 18 years of age).

Your program seems to place a strong emphasis on critical care. Is this true–and why?

This is true. Our department has managed the Surgical and Neurosciences Intensive Care Unit (SNICU) and Cardiovascular ICU (CVICU) at the University of Iowa Hospitals & Clinics for decades. The goal of the department is to train outstanding physicians, not technicians.

One factor that defines the excellent anesthesiologist is his/her ability to care for the critically ill, both in and out of the OR. We feel strongly that critical care experience is crucial to meeting our goals. Our interns spend two months in the SNICU and CVICU; clinical anesthesia residents spend three months in the SNICU and CVICU.

Can you describe a typical OR day for your residents?

On Monday and Tuesday, patients are expected to be in the OR at 8:15 a.m. On Wednesday, Thursday, and Friday, the in-room time is 7:30 a.m. Residents typically arrive between 6 and 6:30 a.m. to set up their rooms and to perform regional blocks, etc. before moving their patients into the OR.

Residents typically get breaks in the morning and afternoon, and a break for lunch. Our ORs usually begin to wind down between 4 and 6 p.m.; the night-call team, late-day CRNAs, and evening shift resident work to get residents out of the OR by 6 p.m.

Although we follow ACGME duty hour rules, residents are expected to remain with critically ill patients or major cases as long as necessary (for patient safety or educational value). The ORs are particularly busy during the summer, but we do our best to relieve non-call providers.

If residents need to leave (for personal reasons) at some earlier time, they notify the OR Clinical Director and we do our best to get them relieved.

What kind of rotations do you have for the interns?

We take 15 interns each year. Their rotations include:

• 2 blocks in the SNICU/CVICU
• 1 block each in:
  • Emergency medicine
  • General medicine ward
  • Renal medicine consult service
  • Trauma surgery
  • Pediatric surgery
  • PICU (Pediatric ICU)
  • EKG course
  • Palliative care medicine
  • Safety and quality
  • Advanced clinical medicine
  • Anesthesia

Interns spend 2 weeks each on the inpatient cardiology service and an elective (chest radiology or chronic pain).

Interns are also invited and encouraged to attend Anesthesia Grand Rounds.

What are your 'weakest' rotations?

Our residents have no difficulties meeting their ACGME requirements in any area–so we really have no "weak" rotations.

We have a limited number of OB deliveries (about 2,100/year), but since these are frequently complicated pregnancies and because we have a very high rate of neuraxial labor analgesia, residents easily meet their case requirements without the need for an outside OB experience.

Like many other institutions, our cardiac surgical load (cases on bypass) is limited, but recent increases have eliminated the necessity for an outside rotation. However, we retain our very popular senior cardiothoracic elective rotation in Des Moines.

What electives do you have?

Away electives for seniors include:

• Cardiothoracic anesthesia in Des Moines
• International pediatric anesthesia in underserved foreign countries—on hold during the pandemic

UI Hospitals & Clinics anesthesia electives include:

• All surgical subspecialties
• Simulation
• ECHO
• Ambulatory surgery anesthesia
• Regional anesthesia
• Advanced clinical anesthesia
• Chronic pain
• Fluoroscopic pain anatomy
• Research
• Point-of-Care Ultrasound (POCUS)
  • We have 2 certified POCUS faculty who are passionate about teaching the skills to residents.

I've also heard that you have a very strong regional anesthesia program.

Absolutely true! We performed more than 3,700 peripheral nerve blocks last year. Many of our faculty have expertise in regional anesthesia–including ultrasound guidance for blocks. Given these numbers, it shouldn't be surprising that our surgeons enthusiastically accept regional anesthesia as a beneficial part of patient care.

CA1 and CA2 residents rotate through the regional anesthesia service. Senior residents can elect a regional anesthesia rotation. Residents also participate in a formal training course in regional anesthesia. Our graduates perform approximately 150 peripheral nerve blocks during their training.

Do you offer foreign mission trip experience?

Yes, our CA3 residents have opportunities to participate, with our faculty, in mission trips to Guatemala and Colombia.  We hope to expand our opportunities to include Zambia this year.

We offer this opportunity to four to six of our CA3 residents and continue to explore opportunities for more residents to participate in these valuable international mission trips. Unfortunately, the COVID-19 pandemic had halted our mission trips for two years, but we plan to start again in 2023.

What changes have you made recently?

All good programs make changes here and there. We want to continue to polish our strengths and improve our weaknesses. Additionally, we must keep up with changes mandated by the accreditation board.

Restructured didactic schedule

Our didactic program has been restructured to allow for dedicated educational time. Each week, one clinical anesthesia class is removed from clinical duties for a day to participate in core didactic activities. In addition, sub-specialty lectures are offered to those residents currently on those rotations. These include obstetric anesthesia, acute pain, chronic pain, neurosurgery, cardiothoracic, and pediatric anesthesia.

Evaluation changes

The evaluation system for residents was recently overhauled. The ACGME now requires programs to evaluate and document the progress residents make as they obtain the necessary competence to practice independently.

We have transformed our evaluation system such that faculty are asked "yes/no" questions about resident performance of important behaviors and skills. The questions are rotation-specific and permit the program to identify specific skills/behaviors that the trainee needs to become competent.

How is resident performance evaluated?

There are several aspects to resident performance evaluation. First, faculty evaluate resident performance on a regular basis.

Faculty use the six ACGME core competencies to evaluate performance:

• Patient care and procedural skills
• Medical knowledge
• Professionalism
• Interpersonal and communication skills
• Systems-based practice
• Practice-based learning and improvement

Feedback is provided verbally (directly to the resident) and through electronic questionnaires. The performance evaluation is submitted electronically to the program director (approximately daily).

Residents evaluate other residents (peer evaluations) with respect to communication and professionalism (SNICU/CVICU, OB and trauma/nights). Nurses evaluate residents (professionalism and communication) when they rotate through the pain clinic and postanesthesia care unit. Finally, patients evaluate residents (professionalism) in the pain clinic.

In addition to faculty, peer, and nurse evaluations, residents get feedback on their performance by taking the In-Training Exam each year and the Anesthesia Knowledge Test (Before, one month, six months, and 24 months into residency). Finally, residents participate in practice oral exams twice a year.

Residents also evaluate the faculty, rotations, and the program on a regular basis. This confidential evaluation process is in place to make us all better–we strive for excellence in ourselves and our trainees.

How did your residents do on the ABA Basic Exam?

Since the first year of the ABA Basic Exam (2014), nearly every resident has passed on the first attempt (98%).

How do your residents do on the In-training Exam?

Our residents have extremely high ITE scores. For the last several years, our residents have performed at or above the national average.

Tell me more about the role that simulation plays in your program.

Simulation training at the University of Iowa is active and varied. We offer:

1. Lab-based simulations (uncommon OR problems or common problems with potentially devastating outcomes)
2. Actor-based activities (incorporating professionalism, communication, and delivering bad news)
3. Team-based, Crisis Resource Management (in-situ scenarios in the Emergency Department, OB, PACU, SNICU/CVICU and other locations throughout the hospital)

We have established a set of simulation scenarios that all residents must complete before they graduate from this residency training program. In addition, we also have a set of scenarios that are tailored towards the novice/orienting trainee.

Simulations are scheduled Monday through Friday. Multiple simulation activities occur each day. Residents who are not on OR rotations are scheduled to participate in simulations frequently during the non-OR rotations.

The ACGME requires participation in at least one simulation per year. Residents at Iowa can expect to participate in 25 to 40 simulations throughout the residency (either as teacher, "primary care provider," or as the expert who comes "to help" when the primary care provider needs assistance.

In addition to the Department Simulation Center, the University of Iowa is developing a multi-departmental simulation center scheduled to open in the near future.

When is the next program evaluation due?

The most recent program site visit by ACGME was in February 2011–and we were re-accredited for 4 years. We anticipate a site visit in April 2022 as part of the ACGME Next Accreditation System (NAS).

Do you have an electronic anesthesia record?

Yes, since November 2010 the department has used the Epic Intraoperative Anesthesia record for all of our cases–which substantially reduces the amount of "secretarial" work done by our providers.

Since May 2009, the entire hospital has been using the electronic medical record (Epic).

Do residents have an educational fund?

Yes. All residents receive $3,000 over four years to use for books, iPads, journal subscriptions, exam fees (USMLE/COMLEX and ABA Board exams), meeting registration fees, review courses, travel expenses for meetings, etc.

The department also rewards residents who perform well on the annual Anesthesia In-Training Examination by providing additional educational funds.

University of Iowa does not permit in-house moonlighting. However, the Department of Anesthesia supplements the educational fund of non-call residents when they stay late (past 6 p.m.) in the OR.

You have a student nurse anesthesia program at Iowa. Don't these nurse anesthesia students compete with residents for cases?

Not really–the SRNA program is currently 36 months long, with 24 months spent in clinical training. Of the 24 months, approximately 18 months (75%) are spent at the University–the other six months are spent at outside hospitals.

SRNAs do not perform OB anesthesia, peripheral nerve blocks, or epidurals at UI Hospitals & Clinics. SRNAs who need cardiac anesthesia experience are paired with the cardiac anesthesia fellow.

Our SRNAs (and our CRNAs) are invaluable partners in our anesthesia care team–they take call, help with late cases, work with faculty to provide breaks, and get residents out for academic activities.

Our CRNAs are a major reason we can provide educational opportunities for residents–and why our residents are treated as more than just a source of clinical manpower.

What kind of fellowships do you offer?

Our ACGME-accredited fellowships include:

• Critical care (4 fellows)
• Chronic pain (4 fellows)
• Regional anesthesia and acute pain management (2 fellows)
• Pediatric anesthesia (1 fellow)
• Cardiac anesthesia (1 fellow)

Over the last 11 years, more than 40% of our graduates entered fellowships (pain, regional, cardiothoracic, critical care, pediatric anesthesia), either at Iowa or at other great programs across the country.

University of Iowa Anesthesia Residents Entering Fellowships

Do your residents have any difficulty finding jobs?

Absolutely not! No resident in the last 10 years has had any notable difficulty finding an excellent position. Many residents have multiple job offers (some as early as the CA1 year).

Where do your residents practice?

Residents completing their training in the last 10 years practice in 17 different states, with about 60% in the Midwest. About 10% entered academic jobs and 40% entered fellowships. The rest are in private practice or military service.

Where did our graduates go?

What percentage of your graduates pass the American Board of Anesthesiologists (ABA) Exam?

153 individuals graduated from our program between 2006 and 2017 (and have had time to take both written and oral exams). Our ABA certification rate is greater than 97%.

The Department of Anesthesia is committed to the development of anesthesiologists skilled in the practice of critical care. The Surgical Neuroscience Intensive Care Unit/Cardiovascular Intensive Care Unit (SNICU/CVICU) at University of Iowa Hospitals & Clinics has been medically directed by the Department of Anesthesia since the 1970s.

The 40-bed SNICU is a major referral center for support of critically ill patients in Iowa and surrounding states. Typical SNICU patient problems include:

• Trauma
• Post-surgery
• Post-organ transplant:
  • Liver
  • Kidney
• Septic shock
• Multi-system organ failure
• Peri-operative complications
• Acute neurological injuries
  • Head injuries
  • Spine injuries
  • Stroke

The SNICU is located in close proximity to the main operating rooms and the Critical Care Laboratory, enhancing efficiency of patient care. More than 3,000 patients per year are admitted for care in the SNICU/CVICU.

The CVICU is a combined medical and surgical ICU and located one floor below the SNICU. Anesthesia trainees on this rotation cover only the surgical patients, but are immediately available to help with the management of airways or lines on the medical patients.

In both intensive care units, patient care is directed by board-certified intensivists who are physicians with primary certification in anesthesia, internal medicine, surgery, or emergency medicine. Patient care is provided directly by residents, fellows, and supported by other health care providers, including critical care nurses, pharmacists, respiratory therapists, dietitians, social workers, and physical therapists.

Mid-level practitioners (PAs and ARNPs) work with residents and fellows to facilitate safe, effective, and efficient patient care. The mid-level practitioners help residents with activities such as documentation of patient care (writing notes in the electronic medical record) and writing orders. We believe that close professional relations between specialists and optimal patient care result from this team approach to clinical service and teaching.

The didactic program emphasizes evidence-based practice and includes lectures, mechanical ventilation laboratories, journal clubs, morbidity and mortality conferences. Residents get significant experience in critical care procedures, including emergency airway management, mechanical ventilation, fiberoptic bronchoscopy, echocardiography, and broad aspects of hemodynamic monitoring. With graded levels of responsibility during the training process, residents develop the expertise and confidence to handle any patient care emergency in the OR or in the ICU.

The first several weeks of anesthesia training are spent working very closely with fellow trainees and anesthesia faculty. The case selection is aimed to provide basic experience in patient evaluation, anesthetic selection, and anesthetic management.

You will develop competence in:

• Airway management, including;
  • Bag-mask ventilation
  • Direct laryngoscopy with placement of oral and nasal endotracheal tubes
  • LMA placement

Typical cases include:

• Laparoscopic cholecystectomy
• Plastic surgery procedures
• Hysterectomy
• Thyroidectomy
• Bowel resection
• Ureteroscopy/cystoscopy
• Electroconvulsive therapy (ECT)
• Bone fracture repair

Case selection is expanded over the first several months to include a broader variety of patient disease states and more complicated surgical procedures (for example, cases prone to acid-base abnormalities and significant blood loss).

Skills learned include:

• Subarachnoid blocks
• Placement of intra-arterial catheters
• Central venous catheters
• Combined epidural-general anesthetics

New patient positions (lateral, prone and beach chair) are included. By the end of basic anesthesia training, you will be prepared to take on the subspecialties.

UI Stead Family Children's Hospital opened in April 2017. This hospital is physically connected to the UI Hospitals & Clinics and includes 8 pediatric operating rooms, a 5-room procedural sedation suite, and 2 pediatric cath labs.

In 2017-2018 we provided anesthesia care for more than 8,800 children. Our team includes 16 pediatric anesthesia faculty (most are fellowship trained) and 8 core CRNAs.

The variety of medical and surgical diseases encountered in our patient population exposes residents to a wide spectrum of patient care challenges from healthy children having outpatient procedures to premature neonates undergoing complex surgical procedures. The care of these patients extends from the preoperative evaluation and education of the family to intraoperative planning and patient management to postoperative care (including pain management).

UI Hospitals & Clinics provides anesthesia care to children for both diagnostic and therapeutic procedures from all specialties including pediatric general surgery, urology, neurosurgery, orthopedics, cardiac, ENT, ophthalmology, burns and satellite cases. Pediatric cases are performed primarily in UI Stead Family Children's Hospital, but also in the Ambulatory Surgery Center, and satellite locations (such as radiology, dermatology, cardiac cath lab and radiation therapy). Residents are exposed to regional techniques in the pediatric population and receive advanced airway training to handle difficult pediatric airways.

Senior residents also have the opportunity to participate in an international mission trip with a pediatric anesthesiologist.

Apart from their direct patient care and teaching responsibilities, the faculty is involved in several clinical studies. One interesting example is the study evaluating the neurodevelopmental effects of exposure to anesthesia at an early age. Residents are encouraged to participate in our ongoing projects.

UI anesthesia residents gain experience in the management of a large variety of neurosurgical cases. The Neurosurgical Anesthesia Division performs more than 2,100 anesthetics per year. The level of complexity ranges from the simplest lumbar laminectomy to the most complex intracranial vascular or craniovertebral/skull base procedure. These procedures may be elective or emergent.

Common neurosurgical procedures at the UI Hospitals & Clinics include:

• Supra- and infratentorial craniotomy for tumor resection
• Vascular malformations and aneurysms
• Cranioplasty
• Trans-oral resection of the odontoid process
• Spinal fusion surgery
  • Cervical
  • Thoracic
  • Lumbar
• Deep brain, peripheral nerve, and spinal cord stimulator implantation
• Minimally invasive and endoscopic procedures
• Burr holes
• Clot evacuation procedures
• Neuro-interventional procedures

Our neurosurgeons also perform a large number of procedures in children, including:

• Posterior fossa procedures
• Surgery for craniosynostosis
• Tethered cord repair
• Meningomyelocele repair
• Ventriculoperitoneal shunts

Residents on this rotation gain valuable experience performing awake and asleep fiberoptic-assisted intubation. Residents also learn to manage anesthesia in combination with specialized monitoring modalities such as processed EEG and somatosensory evoked responses.

Each year, approximately 1,100 adults and children undergo anesthesia for cardiopulmonary bypass and corrective cardiac surgery at the University of Iowa Hospitals & Clinics. During their cardiovascular anesthesia rotation, residents care for patients with ischemic, valvular, and congenital heart diseases.

Anesthesia residents are exposed to the pathophysiology of heart disease and gain familiarity with inotropic, antiarrhythmic and vasoactive medications. They evaluate critically ill patients and formulate thorough anesthetic plans for a wide variety of cardiac procedures.

Residents also gain an in-depth understanding of the complex physiology of cardiopulmonary bypass and develop proficiency with a variety of invasive monitoring techniques, including arterial pressure monitoring, central venous and pulmonary artery pressure monitoring, transesophageal echocardiography (TEE). Faculty assignments are one-on-one and allow for intensive resident/faculty interaction.

Residents on this rotation also provide anesthesia for patients undergoing thoracic surgery. Anesthetic management in these patients requires a clear understanding of "one lung" physiology and the important techniques of single lung ventilation, fiberoptic bronchoscopy, and central neural-axis analgesia.

Intra-operative TEEs are formally reviewed and interpreted each week by members of our cardiac anesthesia group. TEE reading sessions are open to all residents. Consultation is readily available from both the adult and pediatric cardiology echocardiography service.

Any anesthesia resident at Iowa has the ability to perform and interpret the number of TEE exams necessary to qualify for the Basic PTEeXAM (Basic perioperative transesophageal exam). This certification requires ABA board certification and a permanent medical license (not a training license), but a "preliminary" (Testamur) status can be achieved by passing the written exam and conducting/interpreting the required number of TEE exams. Once you complete ABA certification and have a permanent license, you can convert from Testamur to Certified status.

Didactic material is presented as part of the morning lecture series. A variety of recurring conferences are available, including pediatric surgical indications conference, adult cardiology echo conference, cardiothoracic lectures, and anesthesia TEE conference. Finally, the Department of Anesthesia has a TEE simulator that residents and fellows use to practice ECHO skills.

The Department of Anesthesia provides an excellent clinical and educational experience encompassing all aspects of anesthesia for labor and delivery. Residents spend two months providing anesthesia in labor and delivery. Senior residents have the opportunity to do an OB elective.

Approximately 2,200 babies are delivered each year at the University of Iowa Hospitals & Clinics. We take care of most of eastern Iowa's high-risk obstetrical patients, including patients with congenital heart disease, diabetes, preeclampsia, multiple gestations, and premature labor. Our facilities include combined labor-delivery rooms, modern operating rooms, and an adjoining NICU (all close to the main OR). Because of this experience, our residents are familiar with the special needs of these challenging patients.

At UI Hospitals & Clinics, a high percentage of laboring patients request epidural anesthesia, and most non-emergent (and some emergent) cesarean deliveries are performed under spinal or epidural anesthesia. In addition to the regional anesthesia cases, a number of other procedures (both emergent and non-emergent) are performed under general anesthesia or conscious sedation. Residents also help with pain management for patients unable to receive regional anesthesia, use invasive hemodynamic monitoring in selected patients, and serve as consultants in the management of patients with complex medical conditions.

The resident Monday/Tuesday morning didactic curriculum covers the important topics related to OB anesthesia. In addition, there are computer-based lessons, simulations, lectures, conferences, and daily discussions during the rotation. The extensive use of regional anesthesia in labor and delivery provides ample opportunity for residents to become comfortable and proficient with spinal and epidural anesthesia. In addition, residents learn techniques such as combined spinal-epidural anesthesia, patient-controlled epidural anesthesia, "walking epidurals," and placement of epidural and intrathecal narcotics.

Over the course of a year, the regional service performs approximately 2,600 peripheral nerve blocks. The average anesthesia resident performs around 110 peripheral nerve blocks during the course of the three-year residency.

Residents are exposed to a wide variety of peripheral nerve blocks and a significant number of approaches to a given nerve block (including ultrasound-guided). Each faculty instructor brings a unique perspective to blocks, which enhances the learning opportunity for our trainees.

The regional anesthesia rotation can be viewed as two complimentary halves of a whole. The first half is in the main OR, where residents are exposed to a number of complex blocks and catheter-based regional anesthetic techniques.

The other half is the Ambulatory Surgery Center (ASC) experience where there are more blocks with a more rapid turnover. The ASC experience encourages residents to use neuraxial blocks, both epidural and intrathecal, to cover a wide variety of lower extremity procedures. The pace is much quicker in the ASC (compared to the main OR); consequently, residents become proficient and develop the ability to prioritize the order in which blocks should be performed.

Residents rotate onto the regional service during both the CA1 and CA2 years. In addition, senior residents can elect a regional rotation during their last year of training.

From the first day on the regional service, residents do blocks. Residents are given increasingly more difficult blocks as they demonstrate the ability to safely and efficiently perform blocks and explain the reasons for a given block in a particular patient. CA1 and CA2 residents spend half their time in the main OR and half in the ASC. During the CA3 elective, residents generally spend more time in the ASC.

The Department of Anesthesia is committed to the development of anesthesiologists skilled in the practice of critical care. The Surgical Neuroscience Intensive Care Unit/Cardiovascular Intensive Care Unit (SNICU/CVICU) at the University of Iowa Hospitals and Clinics has been medically directed by the Department of Anesthesia since the 1970's. The 36-bed SNICU is a major referral center for support of critically ill patients in Iowa.  Typical SNICU patient problems include: trauma, post-surgery, post-organ transplant (liver, and kidney), septic shock, multi-system organ failure, peri-operative complications, and acute neurological injuries (head and spine injuries, stroke). The SNICU is located in close proximity to the Main Operating Rooms and the Critical Care Laboratory, enhancing efficiency of patient care.

The CVICU is a combined medical and surgical ICU and located 1 floor below the SNICU.  Anesthesia trainees on this rotation cover only the surgical patients, but are immediately available to help with the management of airways or lines on the medical patients.  In addition, residents manage the airway and ventilator of adult burn unit patients requiring mechanically-assisted ventilation. 

In both units, patient care is directed by board-certified intensivists who are physicians with primary certification in anesthesia, internal medicine, surgery, trauma, emergency medicine, or neurology. Patient care is provided directly by residents and fellows and supported by other health care providers including critical care nurses, pharmacists, respiratory therapists, dietitians, social workers, and physical therapists. Finally, mid-level practitioners work with residents and fellows to facilitate safe, effective and efficient patient care. The mid-level practitioners help residents with activities such as documentation of patient care (writing notes in the electronic medical record) and order-writing. We believe that close professional relations between specialties and optimal patient care result from this team approach to clinical service and teaching.

The didactic program emphasizes evidence-based practice and includes lectures, mechanical ventilation laboratories, journal clubs, morbidity and mortality conferences. Residents get significant experience in critical care procedures, including emergency airway management, mechanical ventilation, fiberoptic bronchoscopy, echocardiography, and broad aspects of hemodynamic monitoring. With graded levels of responsibility during the training process, residents develop the expertise and confidence to handle any patient care emergency in the OR or in the ICU.

CA1 residents (later in the year) and CA2 residents are assigned two-week rotations in the PACU. The PACU resident is expected to ensure safe and efficient flow of patients through the recovery phase of anesthesia. PACU residents may be called by the nurses for problems such as airway emergencies, pain management, hemodynamic or cardiovascular alterations (for example, rhythm disturbances or ischemia), neurological changes, nausea and vomiting, and evaluation of possible post-surgical complications. They are expected to arrange for consultations for workup of postoperative problems and communicate with the anesthesia team, PACU nurse and the primary surgical service.

In addition, the PACU resident is expected to accompany the 3911 senior resident to "codes" (in the hospital) and trauma activations in the Emergency Department. Cardiac arrests and severe traumatic injuries in the Emergency Department provide valuable learning opportunities for the junior residents, teaching opportunities for the senior residents and another pair of hands to assist with patient management in less than optimal circumstances.

By the end of this rotation, residents will have the knowledge and skills to observe, recognize and treat problems that commonly occur in the PACU.

The educational experience at the Pain Management Clinic is very active and diverse. Anesthesia residents rotate for a total of 12 weeks during the CA1-CA3 years.

Residents on the Pain Medicine rotations gain experience in acute, chronic, and cancer pain management.

Chronic Pain Medicine Service

The Pain Management Clinic serves patients with a wide array of chronic benign ailments as well as cancer related pain conditions. Our clinic staff includes physicians, nurses, and a clinical pharmacist, and we work closely with psychology and physical therapy.

Residents are exposed to conservative treatments, blind and ultrasound-guided procedures (such as trigger point injections, peripheral nerve blocks, and joint injections), as well as to interventional fluoroscopically-guided procedures such as spine injections (epidurals, facets, sacroiliac joints), sympathetic blocks and chemical and thermal neurolysis. In addition, intrathecal drug delivery, spinal cord stimulation and cryoablation may be performed in select patients.

There is close collaboration with other department specialties such as neurosurgery, orthopedics, psychiatry, neurology, oncology, and palliative care.

Acute Pain/Regional Anesthesia Service

The Acute Pain/Regional Anesthesia Service actively manages postoperative pain in the in-patient setting. The service also serves as a resource when clinicians from other disciplines have complex pain questions.

Common modalities used for postoperative pain control include:

• Multimodal treatments that include intermittent, continuous intravenous drugs
  • Nurse controlled or patient controlled
• Oral medications from differed drug classes
• Thoracic and lumbar epidural catheters
• Peripheral nerve/plexus catheters

The educational program is multifaceted and includes in-depth clinical exposure, as well as teaching of medical students.

Diverse teaching activities take place:

• A weekly didactic lecture series (in collaboration with other departments)
  • Includes dedicated time for pain medicine topics
• Pain Medicine Morbidity and Mortality Conference
• Pain medicine journal club

Residents on the pain rotation take call from home approximately every sixth night. The resident on pain call is expected to come into the hospital when epidural catheter placement and/or additional analgesia are required for postoperative pain management. An attending physician is accessible for questions and available to come into the hospital if needed. The OB resident on in-house night call generally handles simple patient problems (changing the PCA settings or changing the pump battery). On weekends, the call resident and the attending pain staff round together in the mornings.

The Anesthesia Preoperative Evaluation Clinic (APEC) provides a centralized location for completion of outpatient pre-operative evaluations. This area consists of a reception area, seven examination rooms, and a shared nurse-physician work area.

APEC has been designed to provide an attractive and efficient facility for the completion of histories and physicals, anesthesia evaluations, laboratory testing, electrocardiograms, nursing assessments, and patient teaching. The APEC is staffed by a faculty anesthesiologist, a nurse anesthetist, advanced registered nurse practitioners, anesthesia residents, nurse anesthetist trainees, and registered nurses (RNs).

All patients scheduled to receive anesthesia are either seen in APEC or receive a telephone call from one of the providers or RNs. Patients who need to be seen in clinic are determined by a screening process that helps to identify those with conditions most concerning to anesthesia or those with a history of complications related to anesthesia.

On average, APEC sees 20 to 40 patients per day, which includes 5 to 10 add-ons. Patients are scheduled by the individual surgery clinics. Appointment durations are determined by the number of medications the patient is prescribed. By scheduling in this manner, patient satisfaction and efficiency are optimized.

Residents at the CA1 or CA2 level are scheduled on this two-week rotation. Trainees learn to evaluate and educate patients before surgery. Evaluation of patients may include ordering pre-operative tests, interpreting test results, and collaboration with other medical specialties.

CA2 residents have a required rotation in the Ambulatory Surgery Center (ASC), which is located adjacent (but connected by a covered walkway) to the main hospital campus. CA3 residents often take this as a senior elective.

The ASC was designed to emulate a private practice environment, implementing a teamwork approach where we all work to create a high level of patient and family satisfaction. Care is provided by anesthesiologists, CRNAs, surgeons, and nurses specially trained in outpatient perioperative care. The physical status of ASC patients ranges from healthy children and young athletes to octogenarians with a number of comorbidities.

The focus of this rotation includes safe and efficient patient care and the application of protocol-driven anesthesia to reduce variation in care and to optimize safety and patient outcomes.

Methods for accomplishing this include:

• Regional anesthesia and analgesia (spinals, epidurals, or peripheral nerve blocks)
• Application of multimodal analgesia
• Total IV anesthesia
• Avoidance of opioids
• Avoidance of post-operative nausea and vomiting

All of these items help to facilitate ambulatory anesthesia goals, including:

• Smooth timely induction
• Rapid emergence
• Post-anesthesia care unit bypass
• Excellent pain control
• Very low rates of postoperative nausea and vomiting
• High level of patient and team satisfaction

The ASC at the University of Iowa Hospitals & Clinics has 12 ORs with state-of-the-art technology; children and adults have separate care areas with private pre-op and post-op rooms. With the opening of the UI Stead Family Children's Hospital, most of the pediatric patient anesthesia has been relocated there.

CA-2 residents have a required two-week echocardiography (ECHO) rotation; CA3 residents may elect additional ECHO time.

The rotation focuses on intraoperative transesophageal echocardiography for estimation of ventricular and valvular function. Residents on the echo rotation participate in intraoperative echo assessment of cardiac surgical patients; additionally, they are encouraged to attend the weekly cardiology echo conference and participate with transthoracic and transesophageal exams in the cardiology echo clinic.

This is a popular required and elective rotation for UI residents. It is possible for residents to perform sufficiently well that they qualify for (and pass) the Basic PTE exam.

CA3 residents are required to select at least two ACA rotations.

One rotation is a general rotation with patients from any specialty of surgery. The other rotation can be another general rotation or selected from any of the surgical subspecialties.

Residents on the ACA rotation can select their own cases to get more experience in areas of interest or weakness.

Residents are expected, whenever possible, to select the more complex procedures or challenging patients.

This CA3 rotation is arguably one of the residents' favorite senior rotations. The residents complete two months of this rotation and each month is broken up into two weeks of days and two weeks of nights.

The primary role of the 3911 resident is to respond to codes, traumas, and emergent airways throughout the hospital. The 3911 resident is also available to help start both emergent and elective cases, assist with invasive line placement and help the PACU resident manage complications in the recovery room.

The 3911 resident also makes the preliminary resident OR case assignments, which ensures residents are getting an appropriate variety and complexity of cases. This responsibility is rather unique and the challenge to optimize resident learning is a matter of pride for our seniors.

Finally, both in the afternoon and overnight, the 3911 resident is responsible for running the "board" in our very busy OR. CA3 residents with faculty oversight determine priority of add-on emergency cases and assign providers. Additionally, they collaborate with the CRNA and faculty to assign relief to clinicians who are late but not on-call. Our 3911 residents are truly leaders both in the OR and throughout the hospital.

Senior residents have the opportunity for an elective cardiovascular rotation at Iowa Methodist Medical Center in Des Moines. We are privileged to have so many of our alumni practicing there and appreciate the opportunity to have our trainees learn at this off-campus site.

Senior residents typically elect a four-week rotation at Methodist. We provides an efficiency apartment close to the Methodist campus so that residents do not need to commute between Des Moines and Iowa City.

Residents typically do cardiothoracic cases and have significant autonomy. On days when there are no cardiothoracic cases, residents are expected to select other challenging rooms/cases.

This rotation enables residents to do more cardiothoracic cases, with significant autonomy and exposes residents to a true private practice anesthesia group. The rotation has been very well received and is one of the high points of the final year.

CA3 residents on this elective rotation help to orient the new CA1 or CA2 resident to OB anesthesia.

They also serve as senior mentors to the junior residents to learn the basics of patient management and procedural techniques (epidurals, spinals, combined spinal/epidurals).

Senior residents are intimately involved with emergency procedures and the more complex pregnant patients.

This CA3 rotation is designed to more closely simulate a private practice environment. It consists of a four-week block later in the CA3 year.

Three or four CA3 residents are assigned to this rotation at one time. These individuals form a “private practice” anesthesiology group. The group forms its own administration and manages its own clinical assignments.

Each week, one resident is the “master” and is charged with making the daily OR assignments, helping with breaks and lunches, and ensuring a smooth and efficient case flow.

The residents develop their own anesthetic plans and carry them out with faculty involvement limited to those activities that are CMS regulations and when medically necessary for patient safety. Faculty are specially selected for their willingness to participate and support the goals of this rotation.

POCUS (Point of Care Ultrasound) has become an important part of an anesthesiologist’s toolbox. Our department had incorporated a formal and structured POCUS rotation, taught by ultrasound trained anesthesiology intensivists, even before the ABA incorporated POCUS in the residency training requirements.

Anesthesiology residents are trained in both the skills of hands-on sonography to be able to obtain the ultrasound pictures, as well as the art of image interpretation to be able to apply the information to a clinically relevant scenario. The residents undergo both simulation/manikin as well as real patient sessions during this rotation.

These sessions are held every month and are aimed at training the residents in Transthoracic Echo (TTE), FAST, Lung and Vascular Ultrasound techniques, to become adept at obtaining images independently, and to use them for interpretation.

With the help of ultrasound machines in the SNICU, CVICU, and the PACU, along with the portable Butterfly IQ probe that connects to an iDevice, converting it to an ultrasound machine, residents develop the ability to use critical ultrasound skills in many patient care scenarios. Whether it is estimating an Ejection Fraction in the preoperative area, estimating fluid responsiveness in the ICU, or looking for intra-abdominal fluid or bleeding, ultrasound training helps our residents make better clinical decisions.