Anesthesiology: More than intubating and propofol

by
  • Orlovich, Daniel, MD, PharmD
| Jun 21, 2016
Karen_Sibert

Editor’s Note:  Did you ever wonder what medical students think when they start their first anesthesia rotation?  It must seem overwhelming. Daniel Orlovich, then a fourth-year medical student at the University of California, Irvine, wrote down these observations about his first days on our side of the ether screen. For me, his essay is a great reminder of how remarkable everything looks through fresh eyes, and how every new task may be a learning experience. Dr. Orlovich is now about to begin his anesthesiology residency at Stanford. We hope he will keep us posted on his progress!


Orlovich-Daniel

“How’s she doing?”

The attending anesthesiologist asked me that question about the intubated and unconscious patient on the operating room table.

stock1“Well…”  I crossed my hands. Up to this point in medical school, every patient or parent I met was able to speak to me. But there was no chance I could ask this patient a question. I couldn’t even start an H & P.

“What do you want to do next?”

Usually I would order a test and check it the following morning. But now I didn’t have the luxury of looking for answers in “Up To Date”, or even waiting until my senior resident came back into the room. My attending glanced up at the monitor. I followed suit.

“Uh, I think we should…the heart rate looks low?” I said softly. Since I lacked certainty, it came out like a question. Being vigilant—really vigilant—was new to my experience. So was integrating all those numbers on the machine. So many numbers!

Starting an anesthesiology clerkship feels as if you are learning a completely new skill set and knowledge base. Of course you are drawing on common principles in physiology, pharmacology, and anatomy. But how they play out is more immediate, and how you apply those concepts is fresh.

stock2To a casual and uninformed observer, anesthesiology is nothing more than intubating and pushing propofol, right? Wrong. Anyone can be trained to do those tasks. It is a highly cerebral field. Formulating a plan, applying sound judgment, and integrating a multitude of variables are abilities that make a good anesthesiologist good.

I recognized that the residents and attending physicians I worked with took on added duties to be patient with me and teach me throughout the day. There were quick preop assessments and de-briefings. But a surprising amount of learning took place with hands-on tasks. I’m not talking about doing more exciting things like intubating or placing an IV. I mean transporting the patient to the table, draining the Foley, labeling the IV lines, drawing up the medications, running to go get a different size LMA, getting more blankets, or going to pharmacy for an antibiotic.

When I was “pimped” on the effects of mannitol, I knew right away that one of them is increased urine output. I remembered draining a lot of urine from the Foley at the end of a case in the neuro room a few days before. Of course I had read about mannitol too, but the hands-on work made a connection that stuck in my mind. These moments are subtle but really foster opportunities for learning.

There is nothing exciting about transporting a patient from the gurney to the OR table. But it can be highly educational if you’re paying attention. Once, I caught a glance at the CT anesthesiologist while I was helping to move a patient onto the table. He noticed me and nodded his head toward the monitor screen. Later in the case, I asked him what he was referring to. “You see,” the attending said, “when you raised the patient’s legs, that brought back volume to his heart. His heart isn’t compliant. How do I suspect that? Well, the PA waveform went up more than I would expect. We better get ready.”  Amazing!

stock3If you’re around a good anesthesiologist, things look easy. But it took many hours of practice to get that way. When you’re starting out in anesthesia, you’re like an infant trying to walk. You have to be patient with yourself. “Simple” things—like spiking an IV bag, programming an Alaris pump, putting on a tourniquet, mixing and diluting a medication, and unlocking the bed—can all be perplexing at first. I had to remember not to get frustrated.

Charting throughout the case provided surprising nuggets of information. I got a better sense of the duration of certain opioids, what a typical epinephrine dose was, the frequency of antibiotic administration, and what special agents were given during the case. It was a simple way of getting involved and immersing myself in the case.

One anesthesiologist offered to sit down with me for an hour and talk about my personal interests, the current state of anesthesiology as a field, and local opportunities. He spoke candidly and provided information not found on websites and brochures. His insights were thought-provoking, and added another dimension to my understanding.

Anesthesiology is on almost every floor of the hospital. For a medical student, the PACU was a great place to see how to troubleshoot a-fib, hypotension, and decreased respirations. To see fluoro-guided procedures, check out the pain service. For a refresher course on the brachial plexus, join the regional team and watch the ultrasound. To learn ventilator settings, how to manage pressors, and take care of really sick patients, go on rounds in the ICU. The point for me was to get exposure to all these areas, and see the wide diversity that the field has to offer.

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