Surgical Subspecialty Wrap-Up Part 3 of 3: Anesthesia

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“The only difference between what we do every day and killing someone is that we keep breathing for our patients.” – Anesthesia attending physician

That’s a picture of my roommate, after he had clearly fallen asleep in my bed back in college. I was in my room on my computer for 5 full minutes before noticing he was there. Full-on under the covers and everything. At 3AM. It was a much simpler time. Ethanol is one hell of a drug.

Anesthesia – Eskenazi Hospital

On to the third and final part of this rotation: anesthesia. Jeez, the fact that this was pretty much 3 rotations in 1 has made for an incredibly long series. Thankfully, it’s the only rotation like this. Quick, what’s the first word that comes to your mind when someone says anesthesia? SleepThat’s what it is for me. Even before my time on anesthesia started, I was staring at them from “across the curtain” in the OR; there is usually a big surgical drape that not only covers the patient, but is clipped high above the patient’s head in order to give a sort of mini-tent from which anesthesia can work while being separated from the sterile field. I was staring at them with a bit of jealousy: they can touch their face when they want. They can sit down when they want. No matter how much I enjoyed surgery, there will always be a bit of jealousy at that.

First and foremost – anesthesiologists might be the chillest people in the hospital. One prevailing theory (read: my own) is that they might take some hits of the drugs they give people to put them to anesthetize them. I’m not complaining. They are easily the most laid back, friendly physicians in the hospital. Don’t mistake that for not taking their job seriously or something, because they do, but they just know not to sweat the small stuff. They are also awesome because they understand that anesthesia sits in the middle of the most time-intensive megablock (surgery) of our year, so they make sure this rotation is a bit lighter. And by that, I mean they make sure we go home before noon every day. Praise. The Anesthesia. God. My first day, I was sent home within 30 minutes of me being there because my resident would be doing something very basic and boring the entire day. Score.

I worked with a different resident almost every day. The unfortunate thing, from a learning perspective, is that at the start of July, all the new interns start. Interns are first year residents, freshly minted M.D.’s who graduated medical school in May. Anesthesia residency includes an intern year, where they don’t do anesthesia, before moving on to their Clinical Anesthesia I year, where they basically have no anesthesia experience. What this meant for me was that half the residents were as new to anesthesia as I was, effectively insuring that I didn’t quite get a lot of practice with things because the new residents needed it more than I did. However, I got to be with some upper level residents, which made the experience a bit smoother.

Cases (remember, those are surgeries) start at 7:30AM every day, so we had to show up a bit before that to see our first patients and prepare the OR. It was a great experience to get to see the other side of a surgery, one that is equally as important as the surgical side. What I learned from this is that despite how relaxed anesthesiologists are, most of them are extremely methodical and borderline compulsive in their organization. They set up their rooms and medications in a very specific way, with a specific order, all within their own system. It’s incredible to watch. They are very attentive to details, especially at the beginning and end of a case, as these are the times when something could go downhill very quickly.

The work of anesthesia is like this: a flurry of activity at the beginning and end of a case with a long period of dead space in between. Getting a patient in the room, set up on the bed correctly, hooked up to all the monitoring equipment, put under anesthesia, and then stabilizing and prepping them is a hectic time. Anesthesiologists are the Guardians of the Airway (movie patent pending), and they are responsible for the patient’s breathing at all times. This is important, because as one of my martial arts instructors always says, “Breathing has been proven to increase your lifespan”. This often involves placing what’s called an endotracheal tube: this is a tube that connects the breathing machine to the patient’s lungs, allowing it to breathe for them. Anesthesiologists are also responsible for closely monitoring blood pressure, heart rate, and paralyzing the patient, since no surgeon wants to get punched or kicked during surgery. What does this mean as far as the middle of the surgery goes? If the patient is stable, most of the time they can be pretty much left alone and be fine. Medications are given intraoperatively depending on how the blood pressure or movement is doing, but for the most part, the middle of the case is dead time.

This bring up my single biggest beef with anesthesia: downtime. A lot of anesthesia is sitting there and monitoring the patient, which a lot of times doesn’t have to be done all that closely. I had plenty of 15+ minute conversations with my resident or attending in which they didn’t have to do a single thing for the patient. This isn’t to knock anesthesiologists in any way, it’s just the reality of the specialty. They’ve become so good at their jobs and at the art of anesthesia that things are usually smooth as a baby’s butt. Anesthesiologists are also involved in Intensive Care Unit (ICU) management, doing regional anesthesia, placing epidurals, and managing chronic pain.

There are many different types of anesthesia. There is local anesthetic, which is where a substance like lidocaine is injected in an area in order to prevent the sensation of pain. Ever had a tooth operated on or have to have something stitched up? Chances are, they injected “numbing medicine” at that site. This is local anesthesia. Then, there is regional anesthesia, which is making an entire body region numb, unable to move, and unable to feel pain. Essentially, it means injecting medication around a specific nerve or bunch of nerves in order to render them unable to work for a period of time. This might also paralyze the said region. These drugs act by blocking the ion channels that your nerves use to fire electrical impulses. Finally, and most importantly, there is general anesthesia, which is the standard “going to sleep”‘ thing that people think of when they do anesthesia. You want to know something crazy? We really don’t understand how medications used in general anesthesia actually work. If that doesn’t come off as a bit terrifying, I’m not sure what will. We know the very loose framework for how they work, something something ion channels in your brain, but they are mostly a mystery. That’s not to say they are unsafe in any way, as there are years and years of data to back up their safety and efficacy; however, it is just one of those things that you wouldn’t really expect us, as a community, to not know. Don’t believe me? Go ask your friendly neighborhood anesthesiologist.

A variety of gases and IV drugs are used in order to keep a patient asleep, along with many other drugs. Anesthesiologists are masters of pharmacology and physiology, the two topics they are deepest involved in. They ride a fine line between life and death, as their medications could easily kill a person. The quote in the beginning of this post attests to that fact, “The only difference between what we do every day and killing someone is that we keep breathing for our patients.”

That’s a pretty profound statement. While I was with anesthesia, their life was literally in our hands. Speaking of hands, anesthesia is a very hands-on specialty. It’s a great way to get into a fairly procedural specialty without going the surgical route. Anesthesia sits in its own special category, it’s different from any other specialty. It involves no clinic work, a lot of OR time, no long-term following of patients or seeing a patient again and again, a lot of hands on work, and shift work. Heck, they even get breaks! That is a far-out notion in the rest of medicine, at least from a physician perspective. Nobody on my surgery rotations asked a resident if they’d gotten a lunch break or if they needed a bathroom break. It was almost a foreign language when I heard the residents ask each other if they needed a break. Wat.

While maybe my perspective of the specialty was skewed by how awesome the people were and getting to go home before noon every day, I still think it was a great rotation. And I’ll admit that I stayed past noon on a few occasions because the female residents I was with were awesome and attractive, which is generally a winning combination. I mean obviously they were engaged or married (like pretty much 99% of female residents/nurses/etc), but it was still nice. I think I’ve done anesthesia justice and explained enough of it, so it’s time to grade it in terms of Zzzz’s:

Anesthesia, Graded:

Cool factor: 8/10 Zzzz’s. Anesthesia arguably has the most responsibility for a patient’s life in surgery, averaged out over the long term. They keep the vital signs, AKA what you don’t want to have trouble with, stable throughout an entire surgery. They get to do procedures a lot of the time, see patients with all kinds of ailments, and pretty much get to be wizards with mixing their “potions” of anesthetics. Come to think of it, I’m going to start calling them wizards. They also get to know and interact with all of the surgical specialties.

Type of work: 6/10 Zzzz’s. The only thing that knocks this score down is the amount of downtime. That alone is a big factor in believing I would be bored if I chose to practice anesthesia. That’s not to say it is a boring specialty, but that I wouldn’t find maximal enjoyment in it. It’s awesome in that there are a lot of procedures, they see patients with all kinds of different conditions from all areas of surgery, and they get to spend most of their time in the OR. However, it can also be repetitive in that the exact same steps are followed for every case, just with adjustments depending on the nature of the patient and their airway. A big upside and downside is they don’t have long-term follow up with patients.

Lifestyle: 9/10 Zzzz’s. This is about the best type of lifestyle that happens in medicine. Anesthesiologists don’t have to routinely follow up with patients, they get to (for the most part) do shift work, finish the day when surgeries end (instead of having to round or see other patients), and they get breaks during cases, even breaks to eat lunch! The only downside is having to take call and sometimes work odd hours; if there is a surgery to be done, an anesthesiologist must be there. That’s the one thing keeping it from a 10/10. They work fairly decent hours and are paid fairly well. Working in anesthesia is great for actually having a life, and not being 100% married to the hospital.

Ease of attaining residency: 6/10 Zzzz’s. Anesthesia is near the averages in competitiveness as far as board scores go, and there are a lot of residency spots available. That’s what bumps this score up from just average. It’s not the easiest, but it’s definitely not the hardest. Just think, for every surgeon, there likely has to be at least one anesthesiologist. The program directors (like the residents) are also super nice, as is everyone, which brings me to the next category:

Bonus Category – the people: 10/10 Zzzz’s. They’re just awesome, friendly, relaxed, and compassionate people. All of them love to teach and actually have the time to do it. It was a great rotation to go through, and I felt that I learned a whole lot from this rotation, even though I spent half the amount of time per day on anesthesia than on plastics or vascular. Plus, the female residents were really cute, so that was a +1 point. I’m going to just assume it’s that way everywhere.

Pros: Great lifestyle, very procedural, compensated well, awesome people, relaxed atmosphere, being in the OR, variety of patients, lack of long-term follow-up.

Cons: Too much downtime, can be boring, don’t have their “own” patients, no clinic time, no long-term follow up, repetition, can have moments of sheer terror if a patient is having trouble waking up.

Overall likelihood of me choosing this specialty – 6/10 Zzzz’s. Anesthesia (I’m so sick of typing that word. It’s a difficult one to type) is overall a pretty good specialty. It’s got the great lifestyle, the procedures, the drugs, and the OR time. Bottom line, while I was on this rotation, I wished that I was on the other side of the curtain with the surgery team. I enjoyed my time with anesthesia and I hope to make a lot of great friends among them someday, but I think my people are on the other side.

-Brandon

My song of the week is with rappers Logic and Big Sean, give it a listen:

Logic ft. Big Sean – Alright

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