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As fellows at Texas Children’s Hospital, we spend the majority of our year in the main operating room. This allows for exposure to a broad variety of patients and cases, ultimately forming the foundation of our excellent clinical training. Cases range from tonsillectomies to thoracotomies and spinal fusions, and it’s always enough to keep you on your toes! 

The night before, I contact the attending I'll be working with in order to go over the next day’s cases. Surgical cases start at 7:30 a.m. Monday through Thursday, so I typically wake up around 6 a.m. with plans to arrive at the hospital around 6:30 a.m. The anesthesia techs do a phenomenal job of setting up our workstations, so I usually only need to draw up medications and choose what laryngeal mask airway or endotracheal tube I'll need for my first case. I am usually done setting up my room by 7 a.m. At this time, I go to the preoperative holding area to meet the patient and their families. After getting consent, I have about 10 to 15 minutes to grab a coffee and muffin, which are free in the multiple doctor’s lounges. Sometimes if I am lucky, I can find the therapy dogs doing their rounds. 

Around 7:30 a.m. we will bring the patient back and perform a mask-induction unless they already have IV access. Once the patient is asleep, we proceed to gain whatever intravenous access is required. Afterwards, the patient’s airway is secured before surgical prep is done. Once the first case starts and the patient is stable, I am offered a morning break by my attending. We are guaranteed at least one morning break and lunch every day, though it is not uncommon to get more breaks, as we are often one-to-one with attendings for our cases. Depending on the case, there is often ample time for intraoperative teaching due to attendings seldomly covering multiple rooms. 

Lunch costs much less for Texas Children’s employees, and in addition to the cafeterias, we have an in-house Subway and Chick-Fil-A. After eating my chicken nuggets and waffle fries, I return to the OR and review the cases for the next day in my down time. From this point on, the attending and I will work together to take care of the patients in our assigned operating room. If the room is finished early, it is common to join another operating room. 

Due to the variable number of cases each day, I am relieved anywhere from 3 to 5 p.m. unless I am pre-call. When pre-call, we get out usually in the early afternoon. On Tuesdays, all fellows are guaranteed to get out by 3 p.m. to be treated to dinner at our weekly board prep sessions, which is usually one of the highlights of my week (free food and being with friends - what more can you ask for?) I will contact my attending for the next day’s cases when I get home, which is usually by 6 p.m. at the latest. This allows me to spend the rest of the evening as I please. I usually like to eat dinner with my girlfriend, spend time with my dog, and either watch Netflix or play some video games before going to bed at 10:30 p.m. As I drift off to sleep, I promise myself that I’ll eat less waffle fries and exercise the next day - which never happens.

During this fellowship year, we have two months of pediatric cardiovascular anesthesiology. As one of the top pediatric heart centers in the country, Texas Children’s Hospital is the destination for children and adults with congenital heart diseases. We are exposed to a simple ASD closure to more complex surgical procedures, palliative surgeries (Norwood, Glenn and Fontan) and heart/lung transplants. 

The night before, I'll contact the attending in my assigned room to go over the patient’s conditions and plan. I usually get there by 5:30 a.m. and grab the pre-ordered medications from the pharmacy. I will then set up maintenance fluid and infusions while making sure NO air bubbles are in any of my lines. The anesthesia techs do a great job of setting up our workstations, so I only need to choose what endotracheal tube and laryngoscope blade to use for intubation. I take a coffee break around 6:30 a.m. then go to the preoperative holding area to meet the patient and their families. Cases usually start around 7:30 a.m. 

Once in the OR, we carefully place the patient on standard ASA monitors and the NIRS to prepare for induction and intubation. This is perhaps the most stressful moment of the case since the patients are already vulnerable at baseline and very susceptible to the effect of inhaled anesthetics. After this part is accomplished, I will then proceed to place an arterial line or central line. It is not uncommon that we would place two arterial lines or two central lines. Afterwards, we insert the TEE probe and help position the patient for the surgery. The cardiology team is responsible for the TEE exam, and they are so wonderful at explaining their findings to me. Throughout the case, the attending makes sure that I am present for key portions such as coming off bypass. 

Most of time, we are done by 4:30 p.m. unless we're the designated late person or on call. By the time I arrive home, the schedule for the next day is posted and I can look up the patient and start contacting my attending. We have pediatric CV lectures on most Thursdays and a few special guest presentations on Friday.

What I really appreciate from this rotation is that my attending would go over the patient’s anatomy/pathophysiology, the reason why they need the surgery and what to expect after the correction. This ultimately helps build foundational knowledge in taking care of congenital cardiac patients whether for cardiac or non-cardiac surgery. Although it is stressful at times, I feel like I make a difference every day after a successful surgery to help babies grow or take part in a life-saving procedure (such as an emergency PDA stent or atrial septectomy/ Norwood/pericardiocentesis). All in all, I am very grateful for this experience.

While on the Regional Anesthesia rotation at Texas Children’s Hospital, we are exposed to a variety of nerve blocks and neuraxial techniques to help our diverse and growing patient population with peri-operative and non-operative pain. One unique aspect about pediatric regional anesthesia is that most of our blocks are performed after the patient is induced with general anesthesia, as most would not tolerate the procedure awake. The bulk of our procedures are provided to orthopedic, urologic, pediatric surgery, and medical inpatients. We spend a total of 6 weeks on Regional Anesthesia throughout the year with a variety of faculty members who each have tips and tricks to share along the way. We also stay in close contact with our wonderful Pain team regarding any catheters we place or inpatients who may need our help.  

As the fellow on service, I prepare a daily list of patients who are candidates to receive regional anesthesia. The list consists of pertinent patient information, surgical procedure or medical condition, and the type of block we plan to do. Some patients are candidates for multiple blocks depending on the complexity or laterality of the procedure they are having done. On Monday – Thursday, surgical cases begin at 7:30 a.m., so I arrive at 7 a.m. to begin obtaining consent and setting up my equipment. This typically includes an ultrasound, nerve block solution, needle, and/or epidural kits. If I am planning to do a lumbar plexus block, a popular choice for hip or leg surgeries, I also remember to grab a nerve stimulator box to use in tandem with an ultrasound.  

After the first round of blocks are done, my attending and I will usually grab coffee and snacks from a Starbucks located within the hospital or one of the physician lounges. Depending on when our next block is, there can be downtime to follow up on the blocks we have already done, teach, study, or prepare the list for the next day. Sometimes we will get add-on blocks, which may include urgent or emergent surgical cases or inpatients, such as patients experiencing a Sickle Cell crisis that is not relieved by other modalities. We might also even get a rare blood patch request to treat a post-dural puncture headache. For lunch, you may get to enjoy food from one of the many restaurants down the street. My favorite has to be the Chipotle burrito bowl!  

As the day winds down, the attending and I will review the block list for the next day and send out any necessary emails to the surgical teams. After the last block is finished, I am typically relieved to enjoy the rest of the evening and think about all the amazing blocks I get to do the next day. I feel that this rotation is a great learning experience which is a highlight of our program.

As a fellow at TCH, I have the unique opportunity to undertake a 4-week Non-Operating Room Anesthesia rotation, which aims to expose fellows to various off-site anesthesia locations. The NORA schedule, provided at the beginning of the rotation, encompasses diverse assignment locations, including GI Procedure Suites, Interventional Radiology, CT/Rad-Fluoro, MRI, Magnetoencephalography, Nuclear Medicine, and the Mark Wallace Tower Treatment/Procedure Rooms, where lumbar punctures and intrathecal chemotherapy procedures are performed.

When assigned to an MRI location, the night before, I review my assigned patient's chart and communicate with my attending to discuss pertinent medical history and anesthetic considerations for the upcoming imaging study. Procedures usually commence at 7:30 a.m., prompting my arrival at the hospital around 6:45 a.m. to allow sufficient time for room setup and obtaining patient consent. The NORA anesthesia techs play a crucial role in assisting with room setup, leaving me with minimal tasks such as a machine check, confirming appropriate airway equipment, and preparing medications.

Around 7 a.m., I meet the patient and their family at the bedside to review the pre-op assessment, usually completed the day prior by our nurse practitioner from the pre-op clinic. Following consent, I usually find some time to grab a morning snack/coffee or engage with nurses and/or radiology staff until it's time to proceed. After completing a safety check, inducing the patient with parental presence, and settling them into the MRI scanner, my attending often grants a morning break. Given the length of these scans, it's an ideal time to delve into a new topic or conduct a mock oral board exam with my attending, some of whom are board-certified examiners, providing valuable feedback during the oral board prep season.

By the time I finish reviewing a mock case, it's usually time for lunch, which I typically bring from home. I spend this break in the dedicated fellow's office, catching up with co-fellows or nearby office suite mates. I then typically return to MRI for any additional cases that may be on the schedule. Once all cases are complete, I am typically relieved and not required to cover any additional sites, allowing me to finish around 3 - 4 p.m. This enables me to return home at a reasonable time with enough energy to either hit the gym or indulge in a Netflix binge, depending on my mood. I then review the next day's assignment once I am settled in for the evening and prepare for another fulfilling day.

Management of patients in the PACU is an often-forgotten aspect of anesthesiology. As a trainee, post-operative care is typically spearheaded by the PACU nurses and our attendings. However, there are valuable lessons to be learned about perioperative management based on patient management from the PACU.

Our PACU rotation is a two week block paired in conjunction with two weeks of PICU. After two weeks of intensive care, it was a great experience to care for kids in our day surgery tower— Mark Wallace Tower.

On a typical day of PACU, I arrive to Mark Wallace Tower. I say hello to our lovely PACU nurses and let the PACU charge nurse know all airway emergencies and problems should be directed my way. There is a little computer workstation set up for us as well in the corner of PACU so we never have to be far.

As this is a day surgery area, the first patient can enter the PACU as soon at 7:45 a.m.; it’s not uncommon for 2-3 ENT rooms to be running on any particular day. As patients come out of the OR, I make my rounds and receive the handoffs. I make note of specific concerns from the OR anesthesiology team and help form a post-operative plan. When patients have met discharge criteria, I do a final assessment, touch base with the OR anesthesia attending, and create the discharge note.

During my two weeks, I was treated to breakfast with the PACU nurses, shared birthday cake, and was added to their thanksgiving potluck. Besides my expanding waistline, I also expanded my anesthesia toolbox by learning management of emerging patients, airway obstruction management, and making the difficult decisions regarding observation, admittance, and discharge of patients. This experience was a great way to also look into the other responsibilities of an attending that we don’t always get to see as a trainee. All in all, a terrific rotation to break up the standard OR months and a great learning experience!

Fellows at TCH have the fascinating and unique opportunity of rotating with our Maternal Fetal Anesthesia service. This provides us with the challenge of taking care of two (or more!) patients at once in the same operating room while keeping our OB anesthesia knowledge and skills up to par during the pediatric anesthesia fellowship. TCH is one of only a handful of centers across the nation offering minimally invasive, open, and hybrid fetal interventions, as well as performing EXIT procedures.

This rotation is frequently described as “feast or famine,” so a typical “day in the life” is hard to describe.

For days without a scheduled fetal intervention, we usually arrive around 7 a.m. to start getting ready for the day. Most days, there is some form of multidisciplinary conference scheduled in the morning, whether it be the weekly case review, fetal anomaly review, or fetal case conference. Much time is spent preparing for upcoming scheduled cases, in the form of formal consults with patients and multidisciplinary team planning. Downtime between meetings and planning conferences is most frequently used for daily didactics covering fetal surgery and fetal anesthesia, but also a good opportunity for research or preparation for the oral boards. You will also become Neonatal Resuscitation Program certified and have the opportunity to partake in perinatal bereavement training. Lastly, there are wonderful opportunities to join our colleagues in the spina bifida and fetal intervention clinics to get a better sense of how patients are evaluated and counseled before they go to the OR.

For a large, scheduled intervention (i.e. cardiac intervention, neural tube defect repair, EXIT procedures, etc.), we arrive around 6 a.m. to start preparing the OR and preparing medications for both the pregnant patient and the fetus – we are responsible for directing the administration of medications directly to the fetus, too! Depending on the case, we may provide MAC sedation, neuraxial anesthesia, general anesthesia, or some combination of the above. After the case is complete, we continue on with our usual activities of participating in planning meetings and patient consults, while always staying vigilant for a case that may need to be added on. For patients who have had interventions, we follow along for at least the first day for pain management. This means you get to be the anesthesia team, the regional team, and the pain team – all for one patient!

The maternal fetal anesthesia elective is a unique one with regard to call responsibilities. Because of the nature of the cases, the fellows are expected to be available on nights and weekends for cases that arise. However, the fetal intervention team is exceptionally good about keeping in contact, meaning you will likely know about a possible overnight case well in advance of needing to go to the OR.

All this to say, there is no typical “day in the life” for the maternal fetal anesthesia service, but each day is new and rewarding in its own regards.

The “Supervision, Preoperative Clinical Rotation” prepares us to practice independently, supervise other members of the pediatric anesthesia care team and manage staffing resources appropriately. While on this rotation, we also respond to hospital wide-emergencies and actively manage preoperative clinic patient concerns.

The day starts off by checking in with the Main Operative Room supervising faculty member (also known as, GOAT) by 7 a.m. The supervising faculty member will often try to tailor the week to what will be applicable to your future practice. Depending on your career goals and your previous experiences throughout the month, there are many opportunities to supervise up to two main OR locations. 

When supervising ORs, we have a lot of autonomy to work independently with CA-2s, CRNAs and/or AAs while always having a supervising faculty available to assist us or answer questions. During the rotation there are also many opportunities to assist with board runner responsibilities. These include learning how to manage OR personnel assignments and being immediately available to respond to intraoperative, hospital-wide and PACU Anesthesia STAT/Airway assistance calls. 

Midday, I usually take a 30-minute lunch break ,as well as help the board runner give lunch breaks to the other faculty in the OR. Throughout the day, we also learn how to address calls from the preoperative nurse practitioners regarding preoperative clinic patients concerns. We discuss their management with the GOAT faculty member and determine if patients are optimized to proceed with surgery or require further work up and/or delay to their surgery. 

The day usually finishes around 3 p.m. by assisting the GOAT with preparing to hand off to the on-call team. This rotation is great for preparing to be an independent pediatric anesthesiologist whether you plan on staying in academics or pursuing a career in private practice!