Today’s inane image of the day:
As my Transitional Year internship progressed, my anxiety about starting my first year in clinical anesthesia increased exponentially. By June, I was frantically searching the depths of the internet for resources [e.g. how does one DO anesthesia!? what IS anesthesia?] to prepare for the mysteries that lie behind the drapes. At the end of my internship, I felt comfortable entering senna/colace orders, the periodic ABG [arterial blood gas] stick, and pontificating about my differential diagnosis in a SOAP [subjective, objective, assessment, plan] note, but the thought of being able to safely anesthetize a patient for surgery made me nauseous. I also started second-guessing my decision to pursue anesthesiology; during my TY year, I thoroughly enjoyed my inpatient medicine months and was prepared to switch to medicine if I didn’t end up liking anesthesia. Looking back, I can see now that I would have been happy doing a medicine residency, but I’m definitely happier and overall more satisfied in the field of anesthesiology.
Tutorial [or bootcamp, orientation, introduction]
Anyway, back to the beginning of CA1 [clinical anesthesia] year. It’s standard practice across the country for incoming anesthesia residents to start in a tutorial/bootcamp/orientation/introduction month filled with shadowing, simulation, skills labs, discussion groups and one-on-one training with either a senior resident or attending staff member. I promise you, after your introductory month, you will have the knowledge base and skills to perform a basic general anesthetic. This being said, there’s a reason our residency is 4 years; I believe that crafting an efficient, safe, and elegant anesthetic for individual patients is an art that takes decades of experience to become truly proficient in. At the end of 4 years, you will have enough experience to know that there’s a lot you don’t know and will have to learn while in practice. That’s okay.
Our tutorial is 5 weeks long. The first week involves shadowing, simulation, and discussion groups. This is followed by two weeks one-on-one with an attending [your “tutor”] then another two weeks one-on-one with another attending [often someone who is the polar opposite in anesthetic style, training or personality from your first tutor]. During tutorial, we use a checklist of procedures and anesthetic types to guide our exposure and learning. As tutees, we were given the first pick of cases before any of the other residents, CRNAs or staff members were assigned. This allows us exposure to a broad range of sub-specialty areas; my first tutor was a pediatric anesthesiologist so I requested a pediatric day along with a wide variety of main OR cases.
My year, they hadn’t started tutorial off with shadowing senior residents so I learned my basic OR setup from my first tutor. Now that they’ve revamped tutorial to include time with senior residents, our incoming CA1s have an opportunity to ask any question about a basic OR setup. We literally don’t expect you to know anything, so take this opportunity to familiarize yourself with where important equipment lives in the OR, machine checks and common areas to check on [e.g. is your backup oxygen cylinder full?]. Practice priming IV bags, learn common vasopressor concentrations [e.g. our phenylephrine concentration is typically 80 mcg/mL for infusions, however many institutions use 40 mcg/mL], and figure out where to get missing supplies. Ask about rationale for induction agents and access. Learn tricks for the electronic medical record [but don’t focus on this; there’s always time to chart after patients are in a stable plane of anesthesia]. Determine appropriate ways to participate in patient care without being obtrusive.
Reflecting upon starting my anesthesia training made me recognize that the book knowledge is important, but usually not the area that new residents start with. Yes – you should make an effort to read your favorite anesthesia textbook [see my entry on prepping for ITE/BASIC for examples] to learn important physiologic and pharmacologic concepts that impact your practice and understanding. But how many times have you gotten the feedback, “keep reading”? I thought back to the subjective things I wished someone had told me when coming up with the tips below – hopefully this addresses some of your concerns and assuages some of your fears as you enter anesthesia training! [Warning: this entry contains 2700 words – sorry, I talk a lot!]
Ask questions [even seemingly “stupid” ones]
There really is no such thing as a stupid question, especially as a trainee. It took me a while to recognize the value in asking about everything, but once I did, I found pearls of knowledge hiding in plain sight. Asking questions is especially important when you are learning a new skill [e.g. how to be an awesome anesthesiologist]. Simple things like labeling syringes in a certain fashion [anesthesia often attracts a certain level of Type A personality, but seriously, having all your labels facing the same direction makes grabbing the correct medication much more likely] or propping up the drape to have full view and access to patients can have a big impact on your future practice. Asking about practice patterns [e.g. asking about dexamethasone for PONV] can also lead to learning opportunities [e.g. discussion of the paper showing the efficacy in general anesthetics and other additional benefits such as analgesia]. There’s also value in asking questions of other operating room staff – the circulating nurse and scrub tech often know where the closest tube station and warmest blankets are. When you’re just starting off in anesthesia, most of the staff in the operating room have been there longer than you – take advantage of the opportunity to learn from them by asking questions [but have situational awareness; asking for a warm blanket when the surgeon is frantically trying to clamp a bleeding vessel may not be taken well].
Learn when, who & how to call for help
When to ask for help will evolve as you progress through training. During my first week of tutorial, I felt no shame in asking for help when the oxygen saturation fell to 95% or the blood pressure was trending in the wrong direction. Earlier on, your attending or senior resident will be in the room most of the time. But as you grow more confident and competent, they will lengthen the leash. This also means that you will encounter clinical situations where you have to decide as you’re managing the patient whether it’s prudent to call for an extra set of hands or for clinical support.
While your attending is often the first person you should ask for help from, sometimes they might be tied up in another room with induction, giving a break, or managing a critically ill patient. If you run into trouble, knowing who else is around that could lend a hand can be helpful. In our institution, it’s often the “floor walker” [the person who manages that specific area’s staffing] or our staff administrator [often known as the “board runner”]. If you encounter an emergency, there is no shame in calling an “anesthesia stat”- especially in code situations, you need all the extra help with chest compressions, securing invasive lines and overall management.
We have public walkie-talkies [Vocera] for communication between all operating room staff [except for the surgeons]. Many places carry phones or require overhead paging to reach staff members. As you progress through your anesthesia training, you may find it helpful to ask your attendings before you work with them when they like to be called/notified. Some of them will want to know about all episodes of hypoxia or hypotension while others are comfortable with just being paged when you’re ready to extubate. Make sure you’ve had this conversation ahead of time to ensure open lines of communication.
Develop a setup checklist
Many of us have a mnemonic that helps us consistently setup the same way every time – mine is SOAP-IM:
S: Suction – This is self-explanatory but often the first thing new residents miss. Make sure that you have a Yankauer/orogastric tube ready and that your suction is on.
O: Oxygen – Check that your oxygen source to the wall is connected and a full backup oxygen tank is hooked up to your anesthesia machine. Try to learn how to exchange the backup oxygen tank yourself. Remember, if for any reason your pipeline oxygen pressure is lost or disconnected, this tank will be your source of oxygen.
A: Airway – Ensure that appropriate airway equipment is setup or available. Even for a MAC, I always have an oral airway, backup endotracheal tube, and laryngoscope ready. Make sure backup equipment for unanticipated difficult airways is also available. I cannot tell you how frustrating it is to be in a situation where you feel confident that you could secure the airway with a Bougie but it isn’t readily available. Also – laryngeal mask airways [LMAs] can seriously save lives in a situation where a patient is difficult to mask. Always make sure your room is adequately stocked with them. Know how you can obtain a video laryngoscope or bronchoscope if necessary.
P: Pharmacy – Consider stopping by the pharmacy or central Omnicell/Pyxis on the way into your OR to obtain medications that are not readily available in the room. I typically make sure that I have emergency medications within arm’s reach [typically that means lots of purple-labeled syringes live on top of my ventilator].
Dr. Henry Jay Przybylo [pediatric anesthesiologist at Northwestern University in Chicago] describes this concept well in his book, “Counting Backwards: A Doctor’s Notes on Anesthesia”:
There’s one last item in my setup: the mother of all drugs, the resuscitator extraordinaire, the last ditch effort to retrieve a life trying to end – epinephrine. It deserves a special place in my anesthesia next – a place I call the “Oh Shit Shelf.” It’s on top of the anesthesia machine, immediately to the right of the flat-screen monitor. Whenever anyone in the room says “Oh shit,” I reflexively reach high and to my right, and grab the only syringe ever placed there, the epinephrine. [If you haven’t checked out this book, you should – while it’s written to be understood by non-medical readers, it has pearls and anecdotes that are worthwhile to consider by practicing anesthesiologists.]
Often, the missing medications in the room are high-level antibiotics [e.g. meropenem, linezolid], non-standard neuromuscular blockade [e.g. cisatracurium, mivacurium], preoperative oral medications [e.g. acetaminophen, gabapentin, celecoxib], and local anesthetics for neuraxial or peripheral nerve blocks [e.g. lidocaine/bupivacaine with epinephrine, ropivacaine, mepivacaine, epidural mixes].
I: IV – Ensure that you have the appropriate IV fluid bag[s] and sizes ready [e.g. normal saline/mannitol for a neuro case, smaller volume dextrose-containing fluids for tiny babies, etc] and IV start materials available [e.g. have a kit with the appropriate sized angiocatheters as well as subcutaneous lidocaine drawn up if you plan to use it]. If you’re on pediatrics, consider whether you need a Buretrol [good rule of thumb is babies < 10 kg] or just a microdripper to deliver the fluid. Ensure you know where the filters are for patients with intra-cardiac defects.
M: Monitors/Machine – At our institution, EKG cables and blood pressure cuffs are often taken to recovery with the patient, so as part of my setup, I make sure I have a set in the room. I double-check on the cables I need [e.g. arterial line, central line, temperature] and the disposable components [e.g. EKG stickers, temperature probe, pressure bag/transducer for invasive lines]. For the machine, I do the full check in the AM then make sure that the leak test was done between cases or anytime a new circuit is attached.
At the start of residency, I ran through the mnemonic in my head with every setup to ensure that I didn’t forget anything. As you progress through training, your setup becomes routine and you can often do multiple portions of your setup simultaneously [e.g. have the machine check running as you take out airway equipment and monitors].
Explore your surroundings
Anesthetizing locations can vary in their machines, setup, supplies, and tech support. Often, to be an effective anesthesiologist, you must be nimble and fit into tiny spaces; we are usually competing with radiologic equipment, booms [big semi-moveable pillars with built-in computers, equipment, and/or electrical outlets], and cables from all directions. Knowing the best path around the OR [or purposely creating that path around the equipment as it gets brought in] can be helpful if you need an extra set of hands or to get in/out for breaks. When we go to off-site locations [i.e. endoscopy, radiology, etc], our carts have different setups and usually a different ventilator. During away rotations [we also rotate at the VA, Northshore Medical Center, Mass Eye & Ear, Children’s Hospital], you may encounter completely different branded equipment and supplies in your carts. Make it a habit to open every drawer and always take note of where airway equipment, emergency medications and peripheral IV sets can be found.
Introduce yourself & develop a standardized script
Most large academic institutions have a lot of OR staff, sometimes making it difficult to get to know OR personnel. You may be working with a different set of people every single day. As a result, you should start each day with an introduction.
The patient interview is another area where it’s important to build rapport and ensure all important information is gleaned from the patient. Try out different ways to introduce yourself and interview patients. To stay consistent between patients and avoid missing important information, I use the back of our anesthesia consent form as a template to ask questions. This ensures that salient questions are asked [i.e. past problems with anesthesia, NPO status, medication allergies]. At the start, your patient interview will be longer – that’s how it should be! Unless it’s an emergency, it’s better to be thorough in your assessment. As you progress, time limitations may dictate your interviewing priorities and experience will help you hone in on what history you absolutely want to elicit from every patient.
Expect to be exhausted
My first few weeks of tutorial were absolutely exhausting. It felt like there was an unsurmountable amount of information to learn and integrate into my practice. Even when I thought I had a good grasp of a “simple” general anesthetic [e.g. young, healthy patient undergoing an uncomplicated procedure], I would encounter learning points for improving my practice. This process of continuous self-improvement and learning takes a physical and emotional toll. Don’t be surprised if your bedtime suddenly moves up [I am not ashamed of going to bed at 8PM – ha] – you should be well-rested to absorb all the new information involved with learning the practice of anesthesiology!
Identify mentors
At our program, we are asked to select one of our two “tutors” to be our formal mentor. When I realized I wanted to do critical care, I switched my mentor to someone I respected and received sage advice from. While it can be frustrating to work with new attendings daily [i.e. learning different preferences], the flip side is that exposure to different individuals opens opportunities for mentorship and career guidance. We work one-on-one with attendings that have pearls for managing both clinical and life crises; make sure to take advantage of this resource.
Never settle & be flexible/adaptable
After a few months of main OR assignments, sometimes the practice of anesthesiology can feel mundane. As the SDN Anesthesia forum alludes to, “prop, sux/roc, tube” is an appropriate anesthetic for most situations. Don’t let this prevent you from branching out and trying new techniques. Ask your attendings for ideas on new approaches or equipment to try [e.g. the most common area to pick up new techniques lies in securing the airway; often people mention using a Miller blade after becoming comfortable with a Mac, but what about using a bougie, C-Mac, Glidescope or fiberoptic? What about using the Arrow system or through-and-through technique for arterial line placement? How about high-dose remifentanil instead of paralytic? There’s always something new you can introduce into your practice!].
You will quickly learn that no anesthetic plan is carried out exactly as created and that’s where the art of our practice comes into play. You must learn to be flexible in your plan and anticipate where things may not go as expected. If your senior resident or attending suggests another approach, stay open-minded and discuss how you will carry it out. Remember to be responsive to the environment, the surgical field, and overall feeling in the room.
This entry contains a lot of words – kudos to those of you that made it this far! Am I missing anything? What other things do you wish you knew before starting CA1 year?