A day managing acute pain
Acute Pain Service
The Acute Pain Service (APS) is a well-organized rotation at UVA with a nice blend of developing leadership skills, technical skills, and teaching from some of the leaders in the field of pain medicine. Primarily responsible for placing and managing perioperative thoracic epidural catheters for various abdominal and thoracic surgeries, APS is a busy service, with never a dull moment. We are fortunate to have a large volume of complex thoracic surgical procedures at UVA. The APS rotation is a 7-day rotation and we typically do one week as a CA-1, two weeks as a CA-2, and have the option of doing more weeks as a CA-3 with elective time.
Kristi Rose, CA2
A day managing inpatient pain
The APS team—a resident, an attending and Steve, the nurse coordinator—begins the day at 7 AM. We meet in the anesthesia workroom to scan the OR schedule for potential epidural placements for that day. Once we’ve outlined our plan for these cases, we head out the door to begin rounding on all the patients who have had epidurals placed earlier. Epidurals for the first starts are placed by the anesthesia resident and attending actually doing the cases, to allow the APS team time to complete their rounds. Thereafter, cases with epidural requests are placed by the APS team, coordinated between the surgeon and primary anesthesia team responsible for the case.
By 9 to 9:30 we are typically finished rounding and we start getting pages from anesthesia teams requesting epidurals for their upcoming cases. We spend the remainder of the morning and early afternoon placing epidural catheters. On average, approximately 3 to 5 catheters are placed each day.
Epidurals are placed in the Surgical Admission Suite prior to patients’ going back to the OR. Putting in thoracic epidurals is technically very challenging, and therefore it’s especially gratifying when a well placed catheter is successful. After inserting the epidural catheter, we will deliver a pump for continuous infusion to the OR where the primary team has the option of beginning the infusion as adjuvant anesthesia throughout the case. Once surgery is over, we see the patient immediately post-op in the PACU to assess for a working catheter. Trouble shooting the epidural to achieve adequate pain control for the patients is all part of the learning process. We will then continue to follow the patients daily during our morning rounds, until the epidural is removed.
By 3 to 3:30, all potential epidurals have typically been placed and we do quick afternoon rounds on the patients to follow up any changes that were made during our morning rounds. Once everyone has come out of the OR and been seen post-op, the day wraps up. We sign out around 5 to 5:30 to the OB night call resident, who has experience with managing and troubleshooting potential epidural problems that may arise overnight.
The opportunity to work closely with a variety of attendings, who are continually teaching throughout the day, is rewarding. The service is a busy but certainly an enjoyable rotation. The interaction between the nurse coordinator, the attending, and the resident is always friendly and upbeat, another example of the collegial relationships so typical of UVA.