“How’s she doing?”
“Well…” I crossed my hands. Up to this point in medical school every patient or a parent was able to speak to me. Being intubated and unconscious, there was no chance I could ask her a question. I couldn’t even start a history and physical.
“What do you want to do next?”
“Ah, I think we should…”
Usually I would order a test and see it the following morning. I didn’t have the luxury of looking at UpToDate or waiting until my senior resident came back into the room.
My attending’s eyes glanced up at the monitor. I followed suit.
“…the heart rate looks low” I spoke softly. Lacking certainty, it came out like a question. Being vigilant, really vigilant, was also new to my experience. So was integrating all those numbers on the machine. So many numbers!
You see, when starting your anesthesiology clerkship, it 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 and how you apply those concepts, are fresh.
Here are some tips to maximize your learning, assist your resident and really start to appreciate the field.
1. Set Up the Room
You’re not expected to know how to do this your first day. But, ask your resident to show you. Then the following day get to the room about 15 minutes before you are supposed to meet your attending or resident and then repeat to yourself “MS MAIDS:” the mnemonic used to set up the room. It stands for:
- Machine check (start this one first because you can be doing other things while it is working)
- Monitors (EKG leads, BP, pulse ox, etc.)
- Airway (ET tube, Mac blade, Miller blade, LMA, bite block, bougie)
- IV kit (gauze, alcohol pads, tourniquet, 16G, 18G)
- Special (BIS monitor, ultrasound, Alaris pumps, a-line kit, seats)
If you are unsure about anything, go ahead and ask your resident. If he or she likes something in a certain way, then ask them about that as well. Ask them if there’s anything missing.
I remember one case in which I thought I had everything set up. “Nope, you forgot the bougie.” The bougie? I had never used one before, but I went and grabbed one. “So hey, when do we use this?” My resident explained it to me. I made a note to set the bougie up for every case. Turns out, we needed it for the very next case. It was gratifying to see my resident reach for it, properly placed and taped with the right end just hanging out, in order to intubate a man with a musculoskeletal disorder.
2. Know the Drawer
When you arrive to the room to set up the case, take a chance and open up each drawer. Now, you don’t need to know where every single drug is found! However, I would definitely make sure you know where these are:
- Zofran (ondansetron)
- 5-ml syringe
- 10-ml syringe
- Alcohol swabs
- ET tube (various sizes)
- Mac blade
- Miller blade
While commonly used, these won’t be readily accessible to you because they are controlled substances (read “habit forming”): morphine, fentanyl and midazolam. Take note of the things you use on a regular basis — they serve as the things to focus on during your readings at night. You could even quiz yourself: “What are we using the zofran for?” “Which one is the miller and which is the mac blade?” “What are the indications for succinylcholine?”
The less inefficiencies and fumbling around, the more time you can focus on the case and be taught by the resident.
3. Come Prepared
I personally thought the Stanford CA Tutorial was easy to read and packed with high-yield material. Pick out a chapter or two a day and discuss them with your resident.
In terms of what to carry in the operating room, I liked Pocket Anesthesia as a reference guide as well as Duke’s Anesthesia Secrets to anticipate the pimp questions and get a more general overview of the cases.
Before you leave for the day, ask for the next day’s schedule. Look up the patients and develop an anesthesia plan using the Anesthesiologist’s Manual of Surgical Procedures while using a pre-made template like this one here.
4. Ask Why
This one is absolutely crucial. Whenever you are applying any of the other tips, you should be thinking about this one.
To a casual and uninformed observer, anesthesiology is nothing more than intubating and propofol, right? Wrong. It is a highly cerebral field. In order to more fully appreciate the deep understanding of pharmacology, physiology and anatomy that the field requires, you should ask one key question throughout your elective — Why? Don’t settle for “Oh, we’ve always done it that way” or “Well that’s just how we do it here.” If you do that, you’ll be fantastic at masquerading but now is the time to build a strong fundamental knowledge base.
5. Help the Team Out
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. Of course, an immense amount of learning takes place with quick de-briefings or pre-op assessments. Another surprising area of learning is when I really became hands-on. 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 another sized LMA, getting more blankets or going to the pharmacy for an antibiotic. These moments are gems for teaching — if you take advantage of them.
6. Be Normal
There is something called a “3 a.m. test.” You could have stellar board scores, outstanding letters of recommendation and numerous publications, however, if I can’t stand working next to you at 3 a.m., then you have an uphill battle to face. Medical school is often highly competitive, and we become narrow and myopic in our pursuits. However, don’t forget to be normal! I’ve had refreshing conversations about skin care products, local hiking trails, Bob Dylan lyrics, deep dish pizza in Chicago, lakes in Vancouver and Bose sound systems.
I remember working with an attending who is a devout hockey fan. While working with him, we were in the midst of a historic feat by a player. The player somehow managed to score a goal or have an assist in every single game! A few months passed and the streak ended. I returned for an interview at that institution. I passed him while getting orange juice and a bagel in the break room and he immediately quipped, “What an incredible run — but it had to end someday, right?” Small talk and being normal won’t overcome lack of knowledge or incompetence. But it enriches the day and makes you better connected to those around you.
7. Be Patient with Yourself
If you’re around a good anesthesiologist, they will make things look easy. But, remember it took many hours of practice and dedication to get that way. When you’re starting out, you’re an infant. And, have you ever seen an infant try to walk? That’s how you’ll feel. But, be patient with yourself. “Simple” things like spiking an IV bag, programming an Alaris pump, putting on a tourniquet, mixing and diluting a medication, emptying a Foley and unlocking the bed before pushing the patient back can be perplexing at first. Don’t get frustrated. These are all learning opportunities. When you don’t know, ask for help. If you’ve done something “simple” enough times, ask for feedback on how you can improve. Seek out new ways to do it.
8. Bring a Notebook
Just a little one that can fit in your scrub pocket. Jot down pearls that the resident tells you. Scribble questions you want to ask but can’t because it’s not the right time during the case to divert the attending’s attention. Now, don’t just sit there and write all day, Hemmingway, but there is downtime and slower moments where you can let your resident focus on something else and you can take out your notebook.
I tried to pick out one or two high yield topics to discuss with my resident or attending the next day. When I read that night, I would jot down a few key notes and specific questions. When the following day rolled around I would quickly skim the notebook in the locker room and then head into the OR. Over time, as I would learn more about that topic, I would add to that section in my notebook. It reminded me of how the information is added slowly and cannot be taken in all in one setting. It made me reflect on the many teachers I had along the way that contributed something. And finally, it made me think about the patients who I had the pleasure to help take care of that contributed to my notebook, as well.
Did you hear them mention they want an a-line during the pre-op plan? Then, grab the kit and some sterile gloves. Does the case require frequent arterial blood gas (ABG) draws? Get an ABG syringe, make the labels and learn how to draw it up every hour. Notice the beeping on the Alaris indicating the propofol is running low? Ask to draw up some more. See that transesophageal echocardiogram? Pimp yourself which ventricle is in the middle of the screen. You know how that beep comes for the blood pressure every three minutes? Take a peek at the reading. Write down the estimated blood loss, fluids in and urine output on the patient’s sticker and give it to the surgery resident sitting on the stool dictating the case.
You could passively observe everything that happens, or you can immerse yourself in the action. You’ll maximize your learning, help your resident and come to appreciate the sometimes mundane tasks that have significant consequences. You’ll slowly learn to build a Plan B (C, D and E) when things don’t get quite as planned.
2. Do Signout to PACU and ICU Staff
These always made my residents smile. Just like a news anchor, I was eager to give a recap on the case and provide highlights. Attached is the template I used. It kept me engaged during the case. It provided an organized summary and was fertile ground to ask “why” about certain things that occurred during the case. It was pure gold when it came to debriefing. And, it helped me learn to talk the talk and appreciate what other people value.
3. Make It Look Smooth
Building a strong foundation of knowledge is essential. The following tips make you look like you’ve done a few cases before. And bonus: there’s usually a reason why!
Make sure to grab a “party hat” while rolling a patient back. No one likes to stop in the hallway and stretch out to grab one. Besides, you’ll decrease the risk of contamination and protect the sterile environment.
“A-I-M” is a mnemonic I used to remember how to arrange things from top to bottom: airway, IV, monitoring. If things get tense in the OR and you need to move the patient, insert another line or push a medicine, this will ensure things are well organized. And while you’re at it — make sure to label the lines. For example, write “20G R forearm” on tape and stick it to the bed. If you need to provide fluid resuscitation during the case, you won’t have to peek under the drapes, trace the line, and see what color it is. You’ll know right away.
Are you getting a crack at intubating? Do you remember how relaxed and calm your attending looked? Take a deep breath, relax those shoulders and speak in a confident tone about what you are seeing. Think you got it? Say that you see bilateral chest rise, see condensation and hear bilateral chest sounds. By staying calm you’ll keep your mind more open so that you can troubleshoot any problems that come up.
4. Closed-loop Communication
This shows you understand the dynamics of communication. If you heard “bed up,” repeat back something along the lines of “bed going up.” Why? Because the surgeon is holding a scalpel and it would be nice to know when the bed was moving.
Let your resident know what you drew up. Perhaps you’ll catch an error. Or, you’ll become more familiar with the usual doses.
5. Meet With People
I had the privilege of working with humble, intelligent and well-rounded anesthesiologists. I remember one in particular, who offered to sit down with me for an hour and talk about my personal interests in the field, the current state of the 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 of the field.
To me, personal connections really enrich my life and day-to-day activities. People make the institution. Ask various residents, chiefs and faculty why they decided to go to that institution, and what they like and dislike about it. You’ll get a sense of the culture and values.
If your resident allows you to do so, go ahead and chart throughout the case. Not only does this free up the resident to focus on the patient, but it also provides nuggets of information. I got a better sense of the duration of certain opioids, what a typical epinephrine dose was, the frequency of a certain antibiotic dose and what special agents were given during the case. It is another simple yet effective way to get involved and immerse yourself in the action while optimizing your learning and assisting your resident.
7. Get Out of the OR
Anyone can put someone to sleep — the good ones can wake them up, too. Make sure to carve out some time to see the wide diversity that the field has to offer. Want to troubleshoot a-fib, hypotension and decreased respirations? Check out the PACU. Care to do flouroscopy-guided procedures? Check out the pain service. Did you want more of an office based setting with regular hours and a traditional “doctor” type role? Outpatient pain might be for you. Want to set vent settings, learn about pressors and have end of life discussions and take care of really sick patients? The ICU is calling your name. The point isn’t to argue for one over the other. The point is to get exposure.
Daniel Orlovich, MD, PharmD is a resident physician in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University. He attended medical school at the University of California Irvine. He has written for the American Society of Anesthesiology, California Society of Anesthesiology, Anesthesia Patient Safety Foundation and Anesthesiology News.