Ask an Attending Anesthesiologist Anything!

[HomeSkool]

Pretty much what the title of the thread says. I reserve the right to ridicule anyone who posts obnoxious, unfunny jokes.

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[Matthew9Thirtyfive]

Pretty much what the title of the thread says. I reserve the right to ridicule anyone who posts obnoxious, unfunny jokes.

Where did George Washington keep his armies?

Spoiler

In his sleevies!

 

[HomeSkool]

Where did George Washington keep his armies?

Spoiler

In his sleevies!

I meant unfunny jokes about anesthesiology.

 

[MedScat]

How competitive is it to match to anesthesiology? I always hear mixed reviews about how its super competitive, moderately competitive, not competitive at all. What is your daily schedule like (what time does your day start? end? does it vary?) Do you enjoy your job? Do you get a lot of patient interaction? Is there any longevity with your patients (do you get to know them personally at all?) Sorry if these are silly questions I've just been wondering since I know very little about the lifestyle of being in this specialty

 

[Matthew9Thirtyfive]

I meant unfunny jokes about anesthesiology.

What kind of monster jokes about passing gas?

 

[Matthew9Thirtyfive]

Serious question though: did you enjoy patient continuity in med school? I love the idea of anesthesiology, but I am concerned I would miss the continuity of care that comes with primary care (and other specialties).

 

[BellaWriterChic]

Do you work more with a particular specialty or does your cases vary? I have heard some work more exclusively with certain specialties and I am curious as to what leads you to the cases that you regularly see.

 

[Stuck on CCL2]

Did it feel good to use that alliteration in the title?

 

[FlavivirusProtease]

How active are anesthesiologists during surgeries? Obviously I've heard all the jokes about anesthesiologists taking naps, but I'm assuming those are just hyperbole.

How does the average surgery go for you? What do you usually do when the patient is under, do they need direct attention at all times? What about in a really long surgery that's like 10+ hours?

Do you think there will be decreasing anesthesiology positions in the future due to NPs taking up some positions? How much overlap is there in what an NP can do vs what you can do in terms of anesthesia?

Do all anesthesiologists work solely in surgeries, or are there other fields for them?

Edit: Sorry, I actually had a bunch more questions.

 

[RockMcat520]

What does it take to match into a competitive Anesthesiology residency program? Does EC's matter in med school? Or research and step 1 are weighed heavily?

 

[deleted804295]

What do you call a person who puts someone to sleep?

Spoiler

An Anesleepyologist...
.
.
.
Okay I tried

Is it fun doing anesthesiology? I'm just a pre med so I haven't done much research but from what I've heard it just seems like all you do is inject sleepy medicines into patients and never see them again.

 

[getdown]

Serious question though: did you enjoy patient continuity in med school? I love the idea of anesthesiology, but I am concerned I would miss the continuity of care that comes with primary care (and other specialties).

I can't answer for HomeSkool but I personally was never too worried about patient continuity and that's why I chose this specialty. Hated clinics and having to dress up. I do wonder sometimes what happened to some of my sick patients in residency but as an attending at a VA now I can actually do a little bit more continuity. I staff the preop clinics once or twice a week, and sometimes get them in the ORs and I take time to follow up my sick patients in the ICU since it's staffed by my colleagues anyway. It's definitely more gratifying as an attending since you're personally responsible for the outcomes and you have more time to follow up on patients vs a resident stuck in the ORs all the time. Then again, maybe I have a unique experience since I'm at a VA vs private practice.

 

[HomeSkool]

How competitive is it to match to anesthesiology? I always hear mixed reviews about how its super competitive, moderately competitive, not competitive at all.

From Charting Outcomes 2017:
803 of 1,075 US seniors who applied to anesthesiology matched (74.7%). For comparison, Family Medicine 84.2%, Emergency Medicine 86.8%, categorical General Surgery 72.7%, categorical Psychiatry 86.5%, categorical Pediatrics 89.9%, categorical Internal Medicine 84.6, Otolaryngology 92.1%, Orthopedic Surgery 79.1%, Diagnostic Radiology 12.8%, Dermatology 11.1%. Obviously, that doesn't paint the whole picture; everyone knows ENT is more competitive than the 92.1% match rate would suggest. The most reasonable explanation is many interested students choose not to apply to competitive specialties after earning noncompetitive grades and board scores; such students would be invisible to the above statistics. We also know that some specialties generally involve a medical, surgical, or transitional internship, during which the resident will apply for a PGY-2 spot in their desired specialty. That's the case for some anesthesiology residencies (in 2017, 864 USMGs applied for 441 PGY-2 anesthesiology positions and 229 of them matched for a rate of 26.5%); clearly it's the case for derm (the 11.1% statistic is for the 216 seniors who applied for 24 derm PGY-1 spots, but there are obviously more than 24 derm residents in the country per PGY; those are shown by the 479 USMGs who applied for 423 PGY-2 spots and achieved a match rate of 346/423, or 81.8%). The average Step 1 score for those who matched to anesthesiology was 232, and the average Step 2 score was 242. Based on these and other statistics, I consider anesthesiology a moderately competitive specialty.

What is your daily schedule like (what time does your day start? end? does it vary?)

On a typical day, I'm seeing my first patients at 6:30. I manage two to four ORs throughout the day, guiding anesthetic management and troubleshooting critical events. I'm present for every induction and emergence from anesthesia. I perform preoperative assessments of patients whose cases will follow in my ORs, and I assist my colleagues when they need extra hands. Depending on my OR assignment, I may perform perineural blocks or place epidural catheters. Postoperatively, I manage patients' PACU care. My workday usually runs until between 3 and 5 pm, though it often goes until 7 or even later if I'm assigned as the "late" guy that day. In my hospital, attending anesthesiologists have a night float system in which a single attending works seven consecutive twelve-hour overnight shifts; in other practices, attendings may split duties for 24-hour calls.

Do you enjoy your job?

Hells yes!

Do you get a lot of patient interaction?

I meet and evaluate every patient preoperatively, and I manage their intra- and postoperative care either myself or through management of other anesthesia personnel. My job requires me to establish rapport very quickly: I meet my patients and have only a few minutes to establish sufficient rapport for them to let me poison them with the expectation that I know what I'm doing and can see them through it safely.

Is there any longevity with your patients (do you get to know them personally at all?)

Serious question though: did you enjoy patient continuity in med school? I love the idea of anesthesiology, but I am concerned I would miss the continuity of care that comes with primary care (and other specialties).

There's generally not much continuity of care in my job, although certain subspecialties (critical care and chronic pain come to mind) involve more. In my case, that was fine: I didn't care too much about continuity, and there are many benefits to being a permanent consultant.

Do you work more with a particular specialty or does your cases vary? I have heard some work more exclusively with certain specialties and I am curious as to what leads you to the cases that you regularly see.

I'm a general anesthesiologist. On a normal day, my caseload includes general surgery (including trauma), ortho, ENT, gyn (both benign and gyn-onc), uro, ophtho, GI, IR, rad-onc, plastics, and non-cardiac transplant. When I take call, such as overnight or on weekends, I also do vascular, non-cardiac intrathoracic, peds (except for very young children), and neurosurg...really, everything except hearts and very young peds.

Did it feel good to use that alliteration in the title?

It was devilishly deliciously delightful!

 

[BellaWriterChic]

I'm a general anesthesiologist. On a normal day, my caseload includes general surgery (including trauma), ortho, ENT, gyn (both benign and gyn-onc), uro, ophtho, GI, IR, rad-onc, plastics, and non-cardiac transplant. When I take call, such as overnight or on weekends, I also do vascular, non-cardiac intrathoracic, peds (except for very young children), and neurosurg...really, everything except hearts and very young peds.

Thank you for your response! What drew you to general anesthesiology vs. a specialized career?

 

[usernamesaredumb]

what rank are you in hearthstone

 

[dj-Roomba]

Where do you see the profession in 5-10 years in regards to CRNAs and AAs? Did you consider a fellowship after residency? If yes, why did you choose to forego?

 

[THEBACKANDFORTH]

Why don't humans hibernate? What are the physiological concerns with human hibernation?

 

[M1i]

1) Procedures outside of the OR? Do you do many of them, and if so could you name a few of the more interesting ones.
2) Will you pursue a fellowship, and if so which one? (Even if the answer is no what type of fellowship is appealing to you)
3) Lastly, only been a member on SDN for a few months, however I have noticed your input a lot on the site. But you’re just now posting a “AMA” for an anesthesiologist attending. Does that mean you just recently became an attending? Or just now decided to post this?

 

[Gilakend]

Were you considering any other specialties?

Would you recommend CAA or CRNA to someone who didn't want to go to med school or couldn't get in?

 

[HomeSkool]

How active are anesthesiologists during surgeries? Obviously I've heard all the jokes about anesthesiologists taking naps, but I'm assuming those are just hyperbole.

If I'm sitting a case myself (i.e., in the room 100% of the time managing things personally), it's because the proverbial excrement has hit the proverbial ventilation system and I've taken things into my own hands. In those cases, the tenuousness of the patient's status keeps me very active. Other times, I'm less active, working in a supervisory leadership role as CRNAs or residents sit the cases.

How does the average surgery go for you?

Usually, surgery goes very uneventfully. I'm present in the room for induction of anesthesia and airway management, then leave after my CRNA or resident is squared away and happy. I come back periodically through the case, more or less often depending on how sick the patient is and how much potential for badness the surgery entails. And I'm present in the room for emergence and extubation. Like I said above, though, when the crap hits the fan I'm in the room the whole time, occasionally to the point of asking a colleague to assume command of my other rooms until things settle down.

What do you usually do when the patient is under, do they need direct attention at all times? What about in a really long surgery that's like 10+ hours?

Here's the seal of the American Society of Anesthesiologists:

Note that the motto of the ASA is a single word: Vigilance.

Do you think there will be decreasing anesthesiology positions in the future due to CRNAs taking up some positions? How much overlap is there in what a CRNA can do vs what you can do in terms of anesthesia?

I fixed your question for you. This is a thorny topic and one that has been discussed to death in the Anesthesiology forum. Just like NPs and PAs in other specialties, CRNAs push for more autonomy and we push to maintain the physician-led team model. And people have been screaming about the sky falling for decades. Many anesthesiologists are doing fellowships, which helps them stake out their turf; in my case, my MBA was my fellowship.

But to answer your question: my training is deeper and broader than that of the CRNAs, and I'm able to practice independently and function as a team leader managing multiple cases simultaneously. However, I see CRNAs as an invaluable part of the perioperative care team: the training pathways for physicians and nurses are very different and they lead to different perspectives on patient care; by bringing the best of both pathways together, we can provide better care for the patient. I believe in the Anesthesia Care Team model: most of the time, my CRNAs are just fine and don't need me micromanaging them; other times, the extra depth and breadth of my training and experience makes a life-saving difference. We're both critically important to patient care.

Do all anesthesiologists work solely in surgeries, or are there other fields for them?

Anesthesiologists basically invented Critical Care as a subspecialty, and in many places the Anesthesia Department runs the ICU. Anesthesiologists can also do fellowships in chronic pain management. There are other things we can do, too, but those are the most common.

What does it take to match into a competitive Anesthesiology residency program? Does EC's matter in med school? Or research and step 1 are weighed heavily?

As an HPSP student who went into a military residency, my experience was a bit different. I'm going to defer to @getdown on this one (and any other anesthesiology folks who care to reply).

Is it fun doing anesthesiology? I'm just a pre med so I haven't done much research but from what I've heard it just seems like all you do is inject sleepy medicines into patients and never see them again.

It's a lot of fun! I get to do real-time acute care involving both healthy and diseased physiology, pharmacology, procedures, blood and fluid management, and other things. I have to multitask and critically evaluate multiple data streams simultaneously, and I get to see the acute and subacute effects of my management decisions.

Hated clinics and having to dress up.

^THIS. Also, I hated rounding with the fury of a thousand fiery suns.

What drew you to general anesthesiology vs. a specialized career?

I enjoyed doing general anesthesiology cases enough that I couldn't justify spending another year of my life in training. Besides, I get to do all the subspecialty stuff I want when I take weekend and night shifts!

Where do you see the profession in 5-10 years in regards to CRNAs and AAs?

I'm going to sidestep this a little bit (again, done to death in the specialty forum) by saying that depends more on the overall direction of US healthcare. But here's some food for thought: I think whatever level of autonomy CRNAs achieve will be quickly replicated by NPs and PAs in other fields. Many people consider APP/physician struggles to be a characteristic of anesthesiology, but they actually extend far beyond that.

Did you consider a fellowship after residency? If yes, why did you choose to forego?

I consider my MBA my fellowship. I wish to ultimately have a dual clinical/administrative role, and and MBA will facilitate that. As far as my reasoning for not pursuing a subspecialty within anesthesiology, there wasn't any one aspect of the job or type of patient/case that I loved above all others.

Why don't humans hibernate? What are the physiological concerns with human hibernation?

Humans do hibernate, but we've become so fixated on immediacy and instant gratification that we've allowed extraneous activities to crowd that out and break our hibernation period into 365 smaller chunks. It's all a symptom of our dysfunctional modern culture. In the future when animals rule the world, I predict we'll get back to sleeping for six straight months the way we should.

1) Procedures outside of the OR? Do you do many of them, and if so could you name a few of the more interesting ones.

Our most common out-of-OR procedures are emergency intubations, epidurals, and perineural blocks. In my current role, I staff a lot of intubations but defer to my regional anesthesia-specialized colleagues to do the other procedures. In a smaller or nonacademic practice, I would most likely either perform or staff those things myself.

2) Will you pursue a fellowship, and if so which one? (Even if the answer is no what type of fellowship is appealing to you)

If I were to do a fellowship in an anesthetic subspecialty, I would most likely choose pediatric anesthesiology. But I consider my MBA to be my fellowship.

3) Lastly, only been a member on SDN for a few months, however I have noticed your input a lot on the site. But you’re just now posting a “AMA” for an anesthesiologist attending. Does that mean you just recently became an attending? Or just now decided to post this?

Just decided to post it. I've been an attending for several years.

Were you considering any other specialties?

Read this: Gas Words: The dance.

Would you recommend CAA or CRNA to someone who didn't want to go to med school or couldn't get in?

It depends on the person. I know that's a cop-out, but it's the truth!

 

[Saifa]

Here's the seal of the American Society of Anesthesiologists:
View attachment 230649
Note that the motto of the ASA is a single word: Vigilance.

As a person interested in these sorts of iconography-- what a cool symbol for this profession. I never noticed before.

 

[DubbiDoctor]

Are there any tasks you perform that a CRNA cannot perform? If CRNAs obtain independence - like they've tried to seize in the VA - could they directly compete for your job?

 

[Matthew9Thirtyfive]

Are there any tasks you perform that a CRNA cannot perform? If CRNAs obtain independence - like they've tried to seize in the VA - could they directly compete for your job?

They already have independence in Texas.

 

[Matthew9Thirtyfive]

@HomeSkool
Do you enjoy the supervisor role that it seems like anesthesiology is moving to in many places, i.e., managing multiple CRNAs across multiple rooms while being present mostly for induction/emergence or for really complex stuff? I've heard from a lot of anesthesiologists that they went into the specialty to pass gas and were disappointed with how hands off they are compared to their perception.

Disclaimer: this isn't a knock on anesthesiology--I actually don't mind that sort of role.

 

[Govols22]

What specifically got you interested in or like the most about Anesthesiology?

 

[ekmf27050]

Thanks for doing this!

Okay, one kind of dumb question:
1) Whenever I try to read into anesthesia medications, the actual pharmacology is way over my head, but I've always been curious-- is anesthesia more making people forget the surgery, or keeping them from being aware that surgery is happening in the first place (forming the memories)? Or does it depend on the drugs? Hopefully that makes some kind of sense.

Other slightly less dumb questions:
2) Is there a lot of variability in the quantity and type of medications used in anesthesia? I know that patients' metabolisms are obviously different from one another, but are they different enough that meds have to be specifically adjusted?
3) Do you see anesthesia in general increasing the types of cases using regional anesthesia or monitored sedation type anesthesia instead of GA? I've noticed that for some specialties they seem to be moving in that direction, but I can't tell if that's because it's less costly for the facility (usually surgicenters/non-hospital) or because it's better for patients to not get GA if they don't need it.

 

[907906]

Hey! Thanks for doing this thread!

1) How are surgery and anasthesiology related? I read this saying here on SDN (not sure if it goes exactly like this): Choose surgery, if theres no other place on earth you'd rather be than in the OR. Choose anesthesiology, if theres no other place in the hospital you'd rather be than the OR. I'm not sure what the point there was, but did you ever consider surgery? If you did, why did you change to anesthesiology?
2) What are the pros and cons of your career as an anesthesiologist?
3) Is there anything you think people interested in your field should know of?

Hmmm.. I had so many other questions but forgot them already! I'll check back later if I recall them!

Thanks!

 

[aymar]

What advice do you have for medical students who don't have a home program? Just finishing M1, but want to make sure that I'm preparing for any possible obstacles this will pose come application time.

Edit: sorry just realized this was the pre-med forum but maybe the answer can be helpful for pre-meds who end up at smaller med schools

 

[getdown]

Thanks for doing this!

Okay, one kind of dumb question:
1) Whenever I try to read into anesthesia medications, the actual pharmacology is way over my head, but I've always been curious-- is anesthesia more making people forget the surgery, or keeping them from being aware that surgery is happening in the first place (forming the memories)? Or does it depend on the drugs? Hopefully that makes some kind of sense.

Other slightly less dumb questions:
2) Is there a lot of variability in the quantity and type of medications used in anesthesia? I know that patients' metabolisms are obviously different from one another, but are they different enough that meds have to be specifically adjusted?
3) Do you see anesthesia in general increasing the types of cases using regional anesthesia or monitored sedation type anesthesia instead of GA? I've noticed that for some specialties they seem to be moving in that direction, but I can't tell if that's because it's less costly for the facility (usually surgicenters/non-hospital) or because it's better for patients to not get GA if they don't need it.

1. All the different medications we have to deal with can be overwhelming at times, even for new residents. But it becomes second nature once you use it everyday and you see the effects directly. Oddly enough, although we know the mechanism of action we still don't truly know how those medications produce their effect. With regards to your question the ideal medication used for anesthesia would provide amnesia, analgesia, hypnosis and muscle relaxation. However, there are caveats to this which depend on the surgery or procedure. Without going into too much detail, if your goal is to provide general anesthesia then that's what you're aiming for: you want to make sure the patient doesn't feel pain, stays asleep and does not remember they went through surgery.

2. We have a lot of medications that ultimately do the same thing but are used for specific instances. Let's just take the induction medications (meds we use to put someone asleep at the beginning of surgery). There's propofol (the Michael Jackson drug), ketamine, etomidate, barbituates (methohexital for ECTs and pentobarbital which may still be used in other countries but not in US), and even the inhalational anesthetics (usually sevofluorane because it's not irritating to the airway). All of these can put someone asleep but depends on specific instances:
- propofol: most commonly used induction meds but causes hypotension hence you'd want to avoid in people who are hypotensive/bleeding out
- etomidate: much more hemodynamically stable medication but can cause adrenal suppression in patients (avoid in ICU pts), increased risk of nausea/vomiting and precipitates a porphyria attack in pts with porphyira
- ketamine: also hemodynamically more stable but the big thing is that it does not depress the pts respiratory drive and is a good medication when you want to keep the pt spontaneously breathing like when they have tamponade. Also available in IM form so we use it a lot in big autistic pts who don't like needles.
- barbituates: avoid in porphyria pts but methohexital used in ECTs as it doesn't suppress seizure activity like the other meds I mentioned
- sevo: the go to induction agent of choice in pediatrics or adults who don't like needles (i.e. no IV access) because it doesn't irritate the airways (bronchospasm/laryngospasm that is a whole different issue we don't want)

We also often adjust medications depending on renal clearance/hepatic clearance so pts with these diseases we use the meds that's not metabolized by the impaired organ. Again, over simplifying but I'm not trying to make you an expert.

3. This depends on the type of surgery and the patient's comorbidities. And this is why I love Anesthesia. It's like a puzzle. You have all these different techniques available to you and you try to mix and match in order to provide the best care while taking into account what the surgery entails and the patient's other medical problems. Some surgeries you have to just do general anesthesia because there's no other way around it like a gallbladder where they insufflate the abdomen. Other surgeries like knees and hips you can do general or you can do a spinal to numb the lower extremities while running a propofol drip in the background to keep the patient comfortable and asleep throughout the surgery. You can even do some surgeries in high risk patients with a regional technique where you inject local anesthetic near the nerves that supply the surgery region and numb them up for 10-12 hours (usually orthopedic surgeries).

Surgery centers by definition don't do overly complicated surgeries and the patient population that go to them generally are a lot healthier so the goal is to do them as fast as possible without too much anesthesia so the patient wakes up faster and can be sent home faster. Hence why they like regional procedure for the ortho stuff. The major cases or very sick patient still go to the hospital where there's just more hands on deck and equipment available if problems arise. So, basically the answer to your question is that it depends on the surgery type.

Sorry for the long rambling post but hopefully it provided you some clarity.

 

[RNthenDoc]

Were you truly home-educated?

Do you ever play “Dr. Feelgood,” “Enter Sandman” or “Mr. Sandman” when you do your pre-procedure assessments?

How annoying is it when ICU nurses call you to come intubate their crashing patients when you are SWAMPED WITH THE REGULAR SURGERY SCHEDULE?!

 

[HomeSkool]

Are there any tasks you perform that a CRNA cannot perform?

That depends on their training. My experience has been that most of them have little if any training in regional anesthesia techniques. A more appropriate question, though, is whether there's anything unique I bring to the table. The answer to that is yes. Just as FP docs have deeper, broader education and superior training in critical thinking and the analysis of complex presentations relative to the NPs with whom they work, I bring a more advanced skill set to the table than my CRNA colleagues.

If CRNAs obtain independence - like they've tried to seize in the VA - could they directly compete for your job?

In theory, but that would vary significantly depending on the hospital system. As a faculty member in a major academic medical center, I won't be replaced by a CRNA any time soon. And even in states with CRNA autonomy, individual hospital systems may opt to allow or disallow independent APRN practice. Again, this is really a concern everywhere in medicine, not just in anesthesiology. NPs, PAs, and other mid-level providers are pushing for more autonomy across the board, and physicians are lobbying to preserve the physician-led healthcare team.

@HomeSkool
Do you enjoy the supervisor role that it seems like anesthesiology is moving to in many places, i.e., managing multiple CRNAs across multiple rooms while being present mostly for induction/emergence or for really complex stuff? I've heard from a lot of anesthesiologists that they went into the specialty to pass gas and were disappointed with how hands off they are compared to their perception.

I feel like I get the best of both worlds, actually. I get to manage the most exciting parts of the anesthetic care but have the ability to leave when things are slower. I'm on friendly terms with nearly all my CRNAs, and I often split procedures with them ("You do the a-line and I'll intubate", etc.) to keep up my skill set. In addition, I get to teach residents several times each week. And I can leave the room when the surgeons start playing crappy music. That's HUGE.

What specifically got you interested in or like the most about Anesthesiology?

I like the acuity of care, as well as the mix of procedures, medicine, and applied physiology and pharmacology. I enjoy working in the OR, I'm not a fan of clinic except every once in a while, and I hate rounding. I also enjoy shepherding patients through a stressful, vulnerable time so they can continue on the road to healing. And I like being the leader of a team that literally saves lives.

1) Whenever I try to read into anesthesia medications, the actual pharmacology is way over my head, but I've always been curious-- is anesthesia more making people forget the surgery, or keeping them from being aware that surgery is happening in the first place (forming the memories)? Or does it depend on the drugs? Hopefully that makes some kind of sense.
2) Is there a lot of variability in the quantity and type of medications used in anesthesia? I know that patients' metabolisms are obviously different from one another, but are they different enough that meds have to be specifically adjusted?
3) Do you see anesthesia in general increasing the types of cases using regional anesthesia or monitored sedation type anesthesia instead of GA? I've noticed that for some specialties they seem to be moving in that direction, but I can't tell if that's because it's less costly for the facility (usually surgicenters/non-hospital) or because it's better for patients to not get GA if they don't need it.

@getdown gave you a really great answer (thanks for jumping in there to help!) and I don't have a lot to add except this: I went to Honduras on a medical mission during my residency and can confirm: they still use thiopental there and no, it isn't locked up.

What advice do you have for medical students who don't have a home program? Just finishing M1, but want to make sure that I'm preparing for any possible obstacles this will pose come application time.

I recommend they do visiting rotations, preferably at places they'd like to apply for residency. It's also a plus if those places have some well-known faculty who they could approach for high-impact LORs. Also, get involved with the ASA, which provides resources for medical students here. (That link is a gold mine.)

Were you truly home-educated?

Sadly, I'm a product of the public school system. Home-schooled kids are often really advanced; I can barely read.

Do you ever play “Dr. Feelgood,” “Enter Sandman” or “Mr. Sandman” when you do your pre-procedure assessments?

No, but I do like to play "Closing Time" when the surgeons have screwed around for long enough.

How annoying is it when ICU nurses call you to come intubate their crashing patients when you are SWAMPED WITH THE REGULAR SURGERY SCHEDULE?!

It's not so bad at my hospital -- our senior residents manage most emergent airways with indirect supervision. What's far more annoying is when surgeons think my name is "Hey Anesthesia" or threaten to upgrade their case because they don't want to wait in line for an OR (because, you know, I can totally whip another OR team out of my butt).

@Tommy Needs A Mango, your questions are going to require more brain power than I have this late at night. I'll respond to yours tomorrow.

 

[RNthenDoc]

Anesthesiology is probably one of the least competitive fields to match into. I am an MS4 from a mid-tier MD school and almost every one of our applicants (most of them in the bottom half of the class) got into top 15 programs. I know someone with a 212 Step 1 who matched into a top 10 program. The CRNA takeover is real... I do not see Anesthesia surviving past a decade.

Anesthesiology is probably one of the least competitive specialties out there (probably on par with peds, psych). They are actually in danger of not filling up their spots. From my school alone (mid-tier state school MD), applicants with the lowest step scores (210-220), bottom quartiles matched into top 10 programs. You will also see a lot more DOs getting into Harvard/Duke, which was never the case before. Specialty competition is kind of like the stock market where people try to predict the value of the job in 2-3 decades. As of right now and the past 8 years, Anesthesia is taking a HUGE hit by CRNAs. Why would hospitals hire 4 attendings being paid 350-400k for 4 separate ORs when you can hire 4 CRNAs (being paid 150k) and 1 attending 350k... do the math (Hospitals only care about saving money btw, unless patients die, which isn't happening right now). You will hear that anesthesiologists still make good money coming out of residency, but what is the guarantee is 1-1.5 decades? We partially went into medicine for job security, and for anesthesia the security is not there

So I could work for a decade in a fantastic lifestyle specialty, then do a crit fellowship and be an intensivist after that?
Sounds like an awesome career tbqh.

 

[MedScat]

How long do CRNA's even go to school for? I understand that they are an integral part of the OR but, could they really replace anesthesiologists?

 

[RNthenDoc]

How long do CRNA's even go to school for? I understand that they are an integral part of the OR but, could they really replace anesthesiologists?

CRNA = a bachelor’s degree in nursing, 2 years of ICU experience, then typically 3 years in-program for a master’s degree.

They *STILL* come out without anywhere near parity to the abilities of a well-trained Anesthesiologist, but many of the ones I’ve worked with have been stellar clinicians.

CRNA/AAs will eat up a lot of the periphery, but we will always need docs managing the teams.

(I’m not OP, just a lowly nurse who’s discussed this topic at length with an OR gentlemen who know works on HCA executive staff.)

 

[Matthew9Thirtyfive]

How long do CRNA's even go to school for? I understand that they are an integral part of the OR but, could they really replace anesthesiologists?

You need a BSN, then 1-3 years of critical care nursing experience (usually must be ICU/ED/CCU) depending on the school, and then 2-3 years of CRNA school.

As for replacing docs, CRNAs already have independent practice rights in at least one state (Texas), but possibly more--I'm not sure. That said, the only places I've seen them practicing independently have been surgery centers and small hospitals where the OR cases are uncomplicated. You will never see anesthesiologists be completely replaced, as CRNAs just aren't equipped to handle anything complex or when the shtf.

 

[SuaveCardigans]

That moment when your AMA devolves into another “midlevels/sky is falling thread”

Sorry @HomeSkool

Whats your top 5 songs for your OR playlist? Whats the breakdown of whos in control if the music between all the peeps on the operating team? Interested in playlist politics...

 

[Matthew9Thirtyfive]

That moment when your AMA devolves into another “midlevels/sky is falling thread”

Pretty sure everyone who responded to that question implied that the sky is not falling.

 

[ekmf27050]

1. All the different medications we have to deal with can be overwhelming at times, even for new residents. But it becomes second nature once you use it everyday and you see the effects directly. Oddly enough, although we know the mechanism of action we still don't truly know how those medications produce their effect. With regards to your question the ideal medication used for anesthesia would provide amnesia, analgesia, hypnosis and muscle relaxation. However, there are caveats to this which depend on the surgery or procedure. Without going into too much detail, if your goal is to provide general anesthesia then that's what you're aiming for: you want to make sure the patient doesn't feel pain, stays asleep and does not remember they went through surgery.

2. We have a lot of medications that ultimately do the same thing but are used for specific instances. Let's just take the induction medications (meds we use to put someone asleep at the beginning of surgery). There's propofol (the Michael Jackson drug), ketamine, etomidate, barbituates (methohexital for ECTs and pentobarbital which may still be used in other countries but not in US), and even the inhalational anesthetics (usually sevofluorane because it's not irritating to the airway). All of these can put someone asleep but depends on specific instances:
- propofol: most commonly used induction meds but causes hypotension hence you'd want to avoid in people who are hypotensive/bleeding out
- etomidate: much more hemodynamically stable medication but can cause adrenal suppression in patients (avoid in ICU pts), increased risk of nausea/vomiting and precipitates a porphyria attack in pts with porphyira
- ketamine: also hemodynamically more stable but the big thing is that it does not depress the pts respiratory drive and is a good medication when you want to keep the pt spontaneously breathing like when they have tamponade. Also available in IM form so we use it a lot in big autistic pts who don't like needles.
- barbituates: avoid in porphyria pts but methohexital used in ECTs as it doesn't suppress seizure activity like the other meds I mentioned
- sevo: the go to induction agent of choice in pediatrics or adults who don't like needles (i.e. no IV access) because it doesn't irritate the airways (bronchospasm/laryngospasm that is a whole different issue we don't want)

We also often adjust medications depending on renal clearance/hepatic clearance so pts with these diseases we use the meds that's not metabolized by the impaired organ. Again, over simplifying but I'm not trying to make you an expert.

3. This depends on the type of surgery and the patient's comorbidities. And this is why I love Anesthesia. It's like a puzzle. You have all these different techniques available to you and you try to mix and match in order to provide the best care while taking into account what the surgery entails and the patient's other medical problems. Some surgeries you have to just do general anesthesia because there's no other way around it like a gallbladder where they insufflate the abdomen. Other surgeries like knees and hips you can do general or you can do a spinal to numb the lower extremities while running a propofol drip in the background to keep the patient comfortable and asleep throughout the surgery. You can even do some surgeries in high risk patients with a regional technique where you inject local anesthetic near the nerves that supply the surgery region and numb them up for 10-12 hours (usually orthopedic surgeries).

Surgery centers by definition don't do overly complicated surgeries and the patient population that go to them generally are a lot healthier so the goal is to do them as fast as possible without too much anesthesia so the patient wakes up faster and can be sent home faster. Hence why they like regional procedure for the ortho stuff. The major cases or very sick patient still go to the hospital where there's just more hands on deck and equipment available if problems arise. So, basically the answer to your question is that it depends on the surgery type.

Sorry for the long rambling post but hopefully it provided you some clarity.

Thanks so much, that's great information!! I can definitely see what you mean about the "puzzle pieces"-- at least from the outside looking in, it seems like it would be an interesting brain exercise to figure out what best suits the patient and procedure. I knew there were different meds in anesthesia, but not to that degree with the specific pros and cons.

Although, I do have to say this parts weirds me out a little bit (okay, a lot):

Oddly enough, although we know the mechanism of action we still don't truly know how those medications produce their effect.

The only time I ever really got grossed out while shadowing in the OR was when a patient started moving their leg during a knee surgery. It was quickly remedied (and may have been reflexive rather than conscious movement??), but something about to what degree people's minds and bodies are aware that they're undergoing surgery gives me the heebie jeebies.

 

[SuaveCardigans]

Pretty sure everyone who responded to that question implied that the sky is not falling.

I understand that, just lamenting the fact it seems this discussion is inevitable in any thread about gas. I appreciate all the responses that offer doses of reality

 

[DubbiDoctor]

I've been told that anesthesia can be very boring, far more so than other specialties. Is that true?

 

[HomeSkool]

That moment when your AMA devolves into another “midlevels/sky is falling thread”

Sorry @HomeSkool

Meh. Trolls will be trolls, and fools will be fools. I provided plenty of statistics up above, our friend provided an anecdote. (By the way, he's an MS-4 but lists himself as a resident on his profile page. I get that he's excited he matched, but listing yourself as a resident months before you graduate med school doesn't make you a resident, just an insufferable douche.)

To answer his fallacious logic (that anesthesiologists will go the way of the dodo because we cost more than mid-levels), I'll point out again that the mid-level vs physician thing isn't unique to anesthesiology. Plenty of PAs work alongside surgeons and intensivists, but that doesn't make the physicians superfluous or unnecessary. NPs work in family medicine clinics, but that doesn't mean we don't need family practitioners. Mid-levels constantly want more autonomy, physicians want to preserve the physician-led care team, and we need to remain engaged to make that happen.

Whats your top 5 songs for your OR playlist? Whats the breakdown of whos in control if the music between all the peeps on the operating team? Interested in playlist politics...

Honestly, I don't have a top five list. I'm much more likely to put on an album and play it through, then switch to another one. Top five albums:

1. AFI - Crash Love
2. Green Day - American Idiot
3. Pearl Jam - Ten
4. U2 - Achtung Baby
5. Weezer - The Blue album

As you can probably tell, I'm a child of the grunge/alternative revolution.

And I used to be pretty aggressive about controlling the OR music, but now that I'm in and out of various rooms all day it doesn't make much sense. Besides, there's evidence out there showing that happy surgeons are faster surgeons, and part of making them happy is letting them control the radio.

The only time I ever really got grossed out while shadowing in the OR was when a patient started moving their leg during a knee surgery. It was quickly remedied (and may have been reflexive rather than conscious movement??), but something about to what degree people's minds and bodies are aware that they're undergoing surgery gives me the heebie jeebies.

It was almost certainly unconscious movement. Remember, our bodies feel pain and discomfort even when we're asleep. That's why we shift our position while we sleep so we don't wake up with DVTs or neuropathies. It's why my wife can elbow me in the ribs and I'll roll over without waking up.

@getdown's answer can be distilled down to the four goals of anesthesia:

1. Hypnosis (i.e., unconsciousness)
2. Analgesia
3. Amnesia
4. Akinesis

The degree to which we satisfy each of those depends on the patient, procedure, and surgeon. For example, if I have a sick old man with a broken hip, I may do a spinal block that will render him insensate and motionless from the waist down, but I might then give him minimal or no sedation during the case if I felt his comorbid diseases made such medications excessively risky. In a healthier patient, I'd probably induce general anesthesia (hypnosis and amnesia), provide pain relief with opioids and some other medications (analgesia), and provide muscle relaxation with both inhalational anesthetic and IV neuromuscular blocker (akinesis). So the choice of anesthetic varies from patient to patient. But back to your comment about movement: I try to teach my residents that surgeons asking for "paralysis" often just need akinesis (i.e., they don't need the patient's muscles to be paralyzed, they just need the patient to not move), and I try to teach my surgeons that...

I've been told that anesthesia can be very boring, far more so than other specialties. Is that true?

It depends entirely on what you find boring. Rounding? Super boring for me. Clinic every single day? Good heavens, just kill me now. Providing perioperative care for a person who's effectively enduring a controlled assault? Now we're talking!

 

[Goro]

Meh. Trolls will be trolls, and fools will be fools. I provided plenty of statistics up above, our friend provided an anecdote. (By the way, he's an MS-4 but lists himself as a resident on his profile page.

My learned colleague is one of the nicest people on SDN, but he does NOT suffer fools lightly!

Where does the screen name come from?

 

[Matthew9Thirtyfive]

I understand that, just lamenting the fact it seems this discussion is inevitable in any thread about gas. I appreciate all the responses that offer doses of reality

Yeah, I agree. It is unfortunate. People on this forum remind me of that homeless guy on the corner with a "The End is Nigh" sign, but it has always seemed to me that out in the real world, things are never as apocalyptic as they make it seem on here. I wish we could just have a thread that talked about how cool gas is without people trying to paint it as a dying field.

 

[Matthew9Thirtyfive]

I gotta say @HomeSkool, you always make anesthesiology sound super badass. I forget--did you do residency in the Army, or did you GMO and GTFO?

 

[HomeSkool]

I gotta say @HomeSkool, you always make anesthesiology sound super badass.

I forget--did you do residency in the Army, or did you GMO and GTFO?

In the Army, then remained on active duty as an attending for a few years.

 

[Matthew9Thirtyfive]

View attachment 230707


In the Army, then remained on active duty as an attending for a few years.

How was it being an anesthesiologist in mil med? I've heard that MDs and CRNAs are kind of treated interchangeably rather than the ACT model I've seen at most of the civilian facilities I've worked at. I've not worked at a hospital in the mil med, just a small buoy ship, so I haven't seen how it works.

 

[Microbug]

I once met a anesthesiologist who maintains a productive wet lab. Would you say anesthesiology is a MD/PHD friendly field?

 

[FlavivirusProtease]

Have you had any really interesting anesthesia cases? Can you tell us about them?

 

[getdown]

Yeah, I agree. It is unfortunate. People on this forum remind me of that homeless guy on the corner with a "The End is Nigh" sign, but it has always seemed to me that out in the real world, things are never as apocalyptic as they make it seem on here. I wish we could just have a thread that talked about how cool gas is without people trying to paint it as a dying field.

I'd also like to point out (again) that people have been screaming about CRNA take over for the past 30 years and ultimately that's not the case. If you talked to most of the CRNAs, they don't want to be independently liable for patients and they prefer to have Anesthesiologists around because they understand, for the most part, their limitations. It's only a vocal few in the AANA that keep harping about independent practice.

Anesthesiology is probably one of the least competitive fields to match into. I am an MS4 from a mid-tier MD school and almost every one of our applicants (most of them in the bottom half of the class) got into top 15 programs. I know someone with a 212 Step 1 who matched into a top 10 program. The CRNA takeover is real... I do not see Anesthesia surviving past a decade.

Anesthesiology is probably one of the least competitive specialties out there (probably on par with peds, psych). They are actually in danger of not filling up their spots. From my school alone (mid-tier state school MD), applicants with the lowest step scores (210-220), bottom quartiles matched into top 10 programs. You will also see a lot more DOs getting into Harvard/Duke, which was never the case before. Specialty competition is kind of like the stock market where people try to predict the value of the job in 2-3 decades. As of right now and the past 8 years, Anesthesia is taking a HUGE hit by CRNAs. Why would hospitals hire 4 attendings being paid 350-400k for 4 separate ORs when you can hire 4 CRNAs (being paid 150k) and 1 attending 350k... do the math (Hospitals only care about saving money btw, unless patients die, which isn't happening right now). You will hear that anesthesiologists still make good money coming out of residency, but what is the guarantee is 1-1.5 decades? We partially went into medicine for job security, and for anesthesia the security is not there

And to address our MS4 resident friend above, what most hospital administrators never thought about was the fact that CRNAs fall under nursing therefore they get all the perks of the nursing union. They not only make 6 figures but are paid overtime any time they stay over or additional coverage is needed. So those 4 ORs that are running over their normal 12 hour or whatever contract ... guess what? You're paying more for that. Or you're paying another CRNA to take over the job of the first CRNA ... essentially paying 2 people to do the job of 1 person. A lot of CRNAs also don't take call in the hospital (varies on contractual obligations) but MDs do. So if you look at it in terms of time, labor power and better patient care paying the MD anesthesiologist comes out cheaper. And to your first point of your unimpressive classmates from the bottom half of the class matching into good Anesthesia programs. More and more programs are increasing their class size because residents are cheap labor in the OR and with the monetary crunch most hospitals are feeling this is the best way to offset cost. Ultimately, will this saturate the market? Maybe. But so far it seems to be doing well despite the doom and gloom. But hey, don't take our word for it we're just in the field right now. I'm sure that big brain of yours that got you into Optho is chalk full of groundbreaking information.

 

[HomeSkool]

How was it being an anesthesiologist in mil med? I've heard that MDs and CRNAs are kind of treated interchangeably rather than the ACT model I've seen at most of the civilian facilities I've worked at.

The Army uses an adapted ACT model. The CRNAs are trained to work very independently since they may deploy to areas without anesthesiologist support. So the way that plays out stateside is that I would manage multiple ORs with CRNAs in each. For ASA 3 and 4 patients, I steered the ship -- I had to sign the charts and I was directly involved in the patients' care. On ASA 1 and 2 patients, however, the CRNAs were allowed to function much more independently -- I didn't sign charts, and they determined their own anesthetic plan with me functioning more as a consultant. The caveat to that is that I was empowered to relieve a CRNA from duty if I felt his/her anesthetic plan was unsafe.

I once met a anesthesiologist who maintains a productive wet lab. Would you say anesthesiology is a MD/PHD friendly field?

I honestly don't know a whole lot of MD/PhD anesthesiologists, but my department skews toward the clinical side of things. I know that some institutions' anesthesiology departments maintain divisions for both basic science and clinical research, and I imagine those are very MD/PhD-friendly.

Have you had any really interesting anesthesia cases? Can you tell us about them?

I've had numerous exciting and/or interesting cases, though the majority of my cases are very routine. (Also, interventions most people consider "heroic" actually become very routine after you've done them enough.) I blog some of my noteworthy cases here: Gas Words.

Hey! Thanks for doing this thread!

1) How are surgery and anasthesiology related? I read this saying here on SDN (not sure if it goes exactly like this): Choose surgery, if theres no other place on earth you'd rather be than in the OR. Choose anesthesiology, if theres no other place in the hospital you'd rather be than the OR. I'm not sure what the point there was, but did you ever consider surgery? If you did, why did you change to anesthesiology?
2) What are the pros and cons of your career as an anesthesiologist?
3) Is there anything you think people interested in your field should know of?

Hmmm.. I had so many other questions but forgot them already! I'll check back later if I recall them!

Thanks!

1. That's an interesting way to put it, I don't think I've ever heard it expressed quite like that. I did plan to become a surgeon, but halfway through my MS3 year an anesthesiology resident convinced me to do an elective rotation and see if it was something I liked. I found that it was very much to my liking for several reasons, including that I love acute care; I like the interplay of physiology, pharmacology, and procedures; I enjoy spending my days in the OR; I get to provide care for all sorts of patients and procedures; and my lifestyle is much better than that of most of my surgical colleagues.
2. Pros: pretty much the things I've listed. I love what I do and I get paid very well to do it. I don't have to round and I rarely do clinic (really just the preanesthesia clinic, which I enjoy as long as it's not every day). I handle diverse cases in diverse settings, which helps keep things fresh for me. Cons: The OR is full of big egos that can be...challenging. Many patients don't know the difference between anesthesiologists and CRNAs.
3. This is an exciting field that involves much more than simply rendering patients unconscious and playing sudoku. We work hard and are trained to be the calmest people in the room when emergencies arise. The field is growing and changing, but the sky is not falling.