Regional Anesthesia Rotation
Training in regional anesthesia is one of the strengths of our residency program. A group of dedicated faculty concentrates their clinical time instructing residents in the principles and practice of regional anesthesia. The Department of Orthopedic Surgery at Columbia University Medical Center (CUMC) is consistently ranked one of the best in the country, and surgery involving the extremities, including all types of open fracture repair, corrective procedures of the hands and feet, and joint arthroscopy, are performed daily, virtually all of them under regional anesthesia. The combination of a varied caseload, a dedicated anesthesia faculty, and a high level of patient and surgeon satisfaction with regional anesthesia, makes this a wealthy and rewarding clinical experience and is one of the clinical rotations consistently requested by our residents.
Residents are first exposed to regional anesthesia in their CA-1 year, gaining experience with neuraxial blocks (epidural, spinal, and combined spinal-epidural techniques) as well as a broad selection of upper and lower extremity peripheral nerve blocks for routine orthopedic procedures. Residents will gain experience performing these blocks under ultrasound guidance. A peripheral nerve stimulator may be added as an additional tool as well as for educational purposes. Skills in managing moderate to deep sedation as an adjunct to regional anesthesia is developed during the year. CA-1 residents also complete a rotation in acute perioperative pain medicine, caring for postoperative patients with acute pain and managing neuraxial and peripheral catheters and their infusions. A daily faculty and fellow-led didactic series provides an introduction to acute pain and regional anesthesia topics during this month, including the anatomy and clinical application of peripheral and neuraxial blocks.
In the second year, the resident is expected to decide independently which blocks will be appropriate for the planned procedure as well as which agents to use, and to defend their choice with the attending anesthesiologist. They are expected to identify ultrasound-related anatomical landmarks for performance of regional techniques with minimal assistance and initiate blocks for postoperative pain management. In addition to reviewing previously covered topics, new topics are introduced, including considerations for hip and knee replacement, thromboembolic prophylaxis, blood sparing techniques, and orthopedic oncology, as well as spinal trauma and surgery.
The CA-3 resident is the “block room resident” and gains additional experience in regional anesthesia. The CA-3 resident is expected to have mastered basic knowledge related to regional anesthesia and should be able to perform regional techniques and manage patients during surgery with minimal assistance. The senior resident is introduced to controversial topics in regional anesthesia and exposed to relevant articles in the literature, and is encouraged to discuss pertinent issues with their attending in an "oral board" format. The Anesthesia Toolbox website is used to provide an online platform for supplemental resident education and to organize a daily regional didactic series that is proctored by the faculty and fellows. The Toolbox website is also used to log assessments, such as weekly quizzes and procedure skills assessments, allowing the resident to develop a “portfolio” demonstrating their learning and skills in regional anesthesia. The regional and acute pain residents will also participate in a monthly journal club that is both shared collaboratively online via the Anesthesia Toolbox and presented in person alongside faculty and fellows.
Unique educational experiences for anesthesia residents and fellows include the opportunity to teach in the CUMC anatomy laboratory. Residents and fellows teach the medical students about the clinical applications of the brachial plexus, lumbar, and sacral plexus and also have the opportunity to help dissect cadavers for a greater understanding of human anatomy. Additionally, during the PGY-1 year, residents have a one-day symposium taught by CUMC anesthesia faculty on the use of ultrasound in clinical practice. This course includes lectures on regional anesthesia, hands-on scanning opportunities, and phantom needling practice, as well as access to a full online curriculum.