CA-1 thread

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What's up fellow pimps/pimpettes. Thought I'd start a thread for us to share our experiences over the past month. Today was my third day alone in a room and I'm loving it. My days seem to go by so fast in the OR. No more rounding, notes, etc. at least for this month. It feels so damn good to take my patient to the PACU and reassure him/her that they made it safely through surgery and then move on to the next. The only thing that sucks is that I really notice a difference in how I'm treated in the OR. Maybe this changes a little with seniority but I feel like I get ZERO respect. The OR staff, circulator, surgeon and even the surgery residents have been little bitches. I'm playing it cool here for a while, but pretty soon I'm going to snap on soemone. Overall, can't complain though...all has gone really well.

The most challenging thing for me thus far has been timing the emergence. The threat on here helped me a lot though so I woke em up smoothly today. Seems like it takes some of these med students hours to sew the damn skin.
Anyways, lets here some other stories.
 
Amen brother/sister!
Days are flying by, and I'm actually really looking forward to getting to work in the morning.
So, on to the respect thing. I've actually had the exact opposite experience. All the surgeons/staff I've worked with at 3 different sites have been pretty easy to develop a working relationship with. I have to admit that I make an effort to greet everyone, and get things going early w/surgeon by asking if they want abx on board. At that point they typically want to know a few things like if pts on current abx, allergies, labs etc... If you're able to rattle that stuff off then you curry favor w/the surgeons, which pretty much means you gain favor w/the rest of the OR.
So, above stuff becomes important for my pt mgmt (not just OR cameraderie) when you are trying to time pushing your reversal, switching your gas to N2O, which if pt's low risk PONV, works wonders for helping you blow off residual gas, or opening the circuit and blowing off dead space gas. My best one yet was a patient on a lap band meeting easy criteria and being extubated 15-20 seconds after the last stitch was thrown. I'm under the curtain telling the pt "Sx over, you did great, and Dr W is just putting band-aids on, r u in any pain? (no)." Curtain comes down and attending surgeon looks at her, laughs, and says to me "Nice! If I didn't know better, I'd think she was never under!"😎😎
I've had a couple not-so-cool moments, but overall my experience these last few months has vindicated my decision to leave business and become an MD.
 
lvspro said:
Amen brother/sister!
Days are flying by, and I'm actually really looking forward to getting to work in the morning.
So, on to the respect thing. I've actually had the exact opposite experience. All the surgeons/staff I've worked with at 3 different sites have been pretty easy to develop a working relationship with. I have to admit that I make an effort to greet everyone, and get things going early w/surgeon by asking if they want abx on board. At that point they typically want to know a few things like if pts on current abx, allergies, labs etc... If you're able to rattle that stuff off then you curry favor w/the surgeons, which pretty much means you gain favor w/the rest of the OR.
So, above stuff becomes important for my pt mgmt (not just OR cameraderie) when you are trying to time pushing your reversal, switching your gas to N2O, which if pt's low risk PONV, works wonders for helping you blow off residual gas, or opening the circuit and blowing off dead space gas. My best one yet was a patient on a lap band meeting easy criteria and being extubated 15-20 seconds after the last stitch was thrown. I'm under the curtain telling the pt "Sx over, you did great, and Dr W is just putting band-aids on, r u in any pain? (no)." Curtain comes down and attending surgeon looks at her, laughs, and says to me "Nice! If I didn't know better, I'd think she was never under!"😎😎
I've had a couple not-so-cool moments, but overall my experience these last few months has vindicated my decision to leave business and become an MD.
Click to expand...

Great post LVSPRO. Glad to hear you're digging going into work in the a.m. That's huge.

From my VERY limited experience in the OR (many of you know I'm just an MSII), it seems important to introduce yourself to the OR staff. Granted, as a med student this has been pretty much instrumental. But, the fact is, that in the U.S., the surgeons have the most "power" in the OR. And, they also have you on the #'s, w/r/t their surgical staff. So, by gaining "favor" with the surgeon, everyone else follows suit.

As an attending, many may not be as concerned with gaining "favor", but as a resident etc. (and surely a med student) it just makes sense to introduce oneself to the team. Also, it's the professional thing to do as well.

Respect is earned. But, much of what you guys/gals do is never even known to the surgeons. It's not like you're verbalizing your next move etc. I was with a very good resident on my last shadowing experience (at HF). One thing he may have improved on was the introduction thing. With high turn-over and often no Anesthesiologist posted on the surgical board (2 OR sites I've been to have not shown anes docs on the surg. board), it's no surprise that they say "hey, Anesthesia". But, intros would surely mitigate that. Regardless, it's not personal either way.

Also, I've witnessed how in anesthesia, you need to have a lot of SELF confidence. Rarely, it seems, will you get major pats on the back. I think one needs to be cool with that.

Good advice on getting the conversation (clinical) going early in the pre-op, with the surgeon. I've noticed a lack of clinical communication b/t surgeons and anesthesiologists. This doesn't need to be the case.

Anyway, nice post.
 
No major stories to tell, which I guess is good at this point. So far, things have gone fairly well, with no major mishaps. However, I'm still quite puckered, knowing that any moment something can turn south. I do love this field and am so thankful I'm doing it. It will only get better with time, as I gain more knowledge & understanding and feel more comfortable with things. Good luck to all you CA-1s!
 
In an easy room for the day....at least I thought.

First case, easy, chest wall MOHS, skin graft repair. No biggie..mask with Sevo, LMA, never took a breath for him. Pulled it early. Woke up happy.

I thought I had a breast reduction in a healthy 25 year old....NO, a prone sacral decubitus ulcer repair appeared on my schedule in the AM. 55 year old on the Heart transplant list for ischemic cardiomyopathy, LVAD, IDDM, vasculopath, no IV access (had an 18, did not work)..starting crit 22 ohh crazy.

EJ, then, midaz (very little) + fentanyl + Etomidate + roc ..intubated on her bed. Flipped her. Desflurane. No a-line...(crazy, but staffs idea). Pressures stayed pretty good. Needed some neo and ephedrine. No LVAD alarms throughout the case. Two UNITs PRBCs..ending crit 24 (her goal was 23). Woke up happy and the next day was doing awesome!!!!!

End of case, staff said that was not a CA-1 case but I handled it great. He also said we could have put an a-line in.

I love being a CA-1.
Cubs
 
veetz said:
No major stories to tell, which I guess is good at this point. So far, things have gone fairly well, with no major mishaps. However, I'm still quite puckered, knowing that any moment something can turn south. I do love this field and am so thankful I'm doing it. It will only get better with time, as I gain more knowledge & understanding and feel more comfortable with things. Good luck to all you CA-1s!
Click to expand...

I feel the same way. So far nothing specific to tell. OR staff have been wonderful. CRNAs absolutely wonderful at my program too. Surgery side with some attitudes at times (oddly seems to come more from the surgical residents than the surgery attendings), which is bound to happen with varied personalities and with people under pressure. I too feel things will get even better with increase in knowledge and experience.
 
Keep up the posts CA1-3's. These are great reads for us med students interested in the field. I appreciate the activity.

I know you people are busy, but this is valuable day-to-day stuff that is really nice to read (whether good or bad days). If possible, try not to abreviate too too much, cause then we get lost...lol
 
Hello all. My CA1 year is going well. My second block has been on the pain service, so my OR time has been decreased. I would have liked this block later, but I have enjoyed learning about epidural pumps and PCA's. I have to echo lvspro's statement about enjoying coming into work in the morning. I cannot express what a good feeling this is. Not that I was miserable or anything during my internship 😉, but there were many a morning where I just dreaded rounding on my patients.

There have been some hectic moments. The task of simply getting the patient into the room, hooking up the montiors, pre-oxygenating, and then inducing was an absolute whirlwind the first couple of weeks. It has slowed down a tad, but I look forward when this becomes second nature.

The day (and week) absolutely flies by. I can definately see these 3 years going by in a heartbeat like everyone tells me they do.

Overall I am extremely satisfied and content with my choice of field. I am thrilled to be training at an awesome facility. Good luck to all in the coming months and keep posting.
 
1st epidural--lots of love
2nd-- no love
3rd-- wet tap
4th --love
5th--no love
6th positive test dose
7th love.

I am less than 50% and loving it.

Cubs
 
Hey everyone,
Im a first year srna anf I hope my posting here is okay. I love the posts here and find them helpful and encouraging. Next week I start full time in the OR. Im a bit nervous. I like the idea of introducing myself, when do you all do that before the case?
FL GAS
 
cubs3canes said:
1st epidural--lots of love
2nd-- no love
3rd-- wet tap
4th --love
5th--no love
6th positive test dose
7th love.

I am less than 50% and loving it.

Cubs
Click to expand...

Ha!! Me too:laugh:
How good does it feel to get through the lig flav, feel the pop, and watch your LOR syringe drop it like its hot?
About the wet tap... any HA?
 
No HA.

It was for a hip in a 77 yo. I guess the incidence in the old folks of having a ha is much less.

That was not as scary as the positive test dose. Prima gravid. Push 3cc of lido 1.5% and 1:200K epi. Negative aspiration. no paraesthesia. A contraction starts. HR goes up 30 beats...look at her previous contractions and her HR always goes up.

Wait 20 minutes (no medication). Wait for a contraction to end. give her a second test dose..no increase in HR. Then as I was about to push the bupiv and aspirated again...blood coming up the line. I then pulled it. Threw a second one in...no prob.

Cubs
 
cubs3canes said:
No HA.

It was for a hip in a 77 yo. I guess the incidence in the old folks of having a ha is much less.

That was not as scary as the positive test dose. Prima gravid. Push 3cc of lido 1.5% and 1:200K epi. Negative aspiration. no paraesthesia. A contraction starts. HR goes up 30 beats...look at her previous contractions and her HR always goes up.

Wait 20 minutes (no medication). Wait for a contraction to end. give her a second test dose..no increase in HR. Then as I was about to push the bupiv and aspirated again...blood coming up the line. I then pulled it. Threw a second one in...no prob.

Cubs
Click to expand...

Kewl. Way to play it safe, and double check! Have you done any interesting regional stuff yet?
 
Regardless of how individuals feel about SRNAs/CRNAs posting, there is no excuse for rude responses. This forum represents our specialty (to medical students, to other residents, and to some extent, to the public). It is my opinion that if individuals would like to limit postings on a thread to residents, they should express this thought professionally and courteously.
 
only a bunch CSE for hips and knees. We do all of our hips with depodur. After I caused the wet tap, we could not use depodur becuase of its risk of crossing into the thecal space and causing a high spinal.

I watched a CA2 place an femoral nerve stim with US.
 
cubs3canes said:
only a bunch CSE for hips and knees. We do all of our hips with depodur. After I caused the wet tap, we could not use depodur becuase of its risk of crossing into the thecal space and causing a high spinal.

I watched a CA2 place an femoral nerve stim with US.
Click to expand...

Nice. Last month I was lucky enough to rotate with a progressive anesthesiologist that does a ton of regional. We were doing 3-5 ax blox/day most w/us, some combined w/stim, and a few in my last cuppla days w/only stim b/c our US machine was on the fritz. I got to watch some interscalenes, and did some femorals for post op pain in TKA's. A pretty good # of epidurals/spinals too, but I had a coin flip success rate(see above).We had one complication, but it was a PACU nurse error (dc'd pt early w/a fem block that was still intact, pt falls, open fx ankle, back to the OR, lots of pissed off people). When I got into the OR for general cases this mo, I was a little flustered on my first couple, but I adjusted alright... I think.
 
proclivity said:
oh man, it might be a rough couple of years for you.
Click to expand...

And you, as a premed, would know? Or, are you a premed? After all, you have offered advice about switching residency, getting an MBA during med school, and apparently submitted AMCAS in 2007.

SHE-NAN-I-GANS
 
fakin' the funk said:
And you, as a premed, would know? Or, are you a premed? After all, you have offered advice about switching residency, getting an MBA during med school, and apparently submitted AMCAS in 2007.

SHE-NAN-I-GANS
Click to expand...
.
 
flgasman said:
Hey everyone,
Im a first year srna anf I hope my posting here is okay. I love the posts here and find them helpful and encouraging. Next week I start full time in the OR. Im a bit nervous. I like the idea of introducing myself, when do you all do that before the case?
FL GAS
Click to expand...

You absolutely need to introduce yourself before the case. You'll do this in the preop area mostly, and if it's the first case then place your IV.

As to what to say...well that's a different matter. I don't think it's right for an MD anesthesia resident to say "Hi, I'll be your anesthesiologist today". And you probably shouldn't say you're a nurse anesthetist yet either. Patients do deserve to know we're trainees. I introduce myself by name, then anesthesia resident, I'm working with Dr. Smith the anesthesia attending. My name badge says MD very clearly. Patients can see that. They told us in med school that saying your first name helps to bring down the wall between the physician and the patient or something so it's stuck with me. I include the last name as well for formality.

We have SRNA's at my program and they mostly introduce themselves by first and last name, nurse anesthesia student. Occasionally I'll hear them say "RN that's part of the anesthesia team" or "nurse with the anesthesia team". I've heard that some places call SRNA's residents. Ours don't, they also don't work weekends and don't take call so they're fine with that I think. We have a good relationship with them and they do good work.
 
Hi, I am Dr. Cubs. My boss doctor is Dr. Attending. This is Steve Medical student (pointing to the med student) working with me today. One of the anesthesia care team with be present and taking care of you the entire case. Any questions about this?

Sometimes they wake up with a CRNA or different member of the team. I just want them to know that I am a member of a team.

I never use words like attending, resident or others.
 
These CA-1 days have been awesome, but I'm seeing more than ever the demands and stresses on Anesthesiologists. When my non-medical friends or family ask what it is I do, it's hard to explain just how much we are responsible for. I'm realizing I play the role of physician/nurse/anesthesia tech/pharmacist/pt advocate while I'm in the OR. Which is cool but something that internship did not prepare us for. So all the doctoring part is coming great (procedures/intraop management/induction/emergence) but how the heck do I make X stop beeping and where do they keep the dang prone-views! Hehe. So that will all take time. Not to mention at times unrealistic expectations from the surgeons, for example, that a case I just found out I'm doing as an add-on isn't already back in the OR because the surgeon is ready to go and has to teach some class this afternoon. No pressure!
 
2ndyear said:
You absolutely need to introduce yourself before the case. You'll do this in the preop area mostly, and if it's the first case then place your IV.

As to what to say...well that's a different matter. I don't think it's right for an MD anesthesia resident to say "Hi, I'll be your anesthesiologist today". And you probably shouldn't say you're a nurse anesthetist yet either. Patients do deserve to know we're trainees. I introduce myself by name, then anesthesia resident, I'm working with Dr. Smith the anesthesia attending. My name badge says MD very clearly. Patients can see that. They told us in med school that saying your first name helps to bring down the wall between the physician and the patient or something so it's stuck with me. I include the last name as well for formality.

We have SRNA's at my program and they mostly introduce themselves by first and last name, nurse anesthesia student. Occasionally I'll hear them say "RN that's part of the anesthesia team" or "nurse with the anesthesia team". I've heard that some places call SRNA's residents. Ours don't, they also don't work weekends and don't take call so they're fine with that I think. We have a good relationship with them and they do good work.
Click to expand...

I agree, leaving 'Dr.' so & so out in the introduction may help bring the barrier down between the physician & the patient. HOWEVER, it is important to distinguish ourselves from other healthcare providers. Period! With the ever growing debacle we're facing, its even more important we physicians clearly make that distinction. So, don't hesitate to use the title that you've rightfully earned. ...just my humble opinion and two cents worth🙂
 
veetz said:
I agree, leaving 'Dr.' so & so out in the introduction may help bring the barrier down between the physician & the patient. HOWEVER, it is important to distinguish ourselves from other healthcare providers. Period! With the ever growing debacle we're facing, its even more important we physicians clearly make that distinction. So, don't hesitate to use the title that you've rightfully earned. ...just my humble opinion and two cents worth🙂
Click to expand...

Simple solution...
Hi, I'm <first name last name>. I am the anesthesia doctor that is going to be taking care of you.
 
So, how are y'all wakin'em up?
I've been waiting for the awake extubations b/c I just didn't have the guts for extubating deep until today. I was working w/a really good attending who wanted me to try it (after some reinforcement), and I jumped at the opportunity. WOW! What a difference. It looke like a nice, smooth wake-up from a twilight sleep. She was spitting the OP-airway out b4 leaving the OR, and telling me how she was in no pain or n/v by the time I got done getting her wired up to the PACU monitors.😍
 
T-10 months til CA-1 year. Gotta read this thread to stay sane with all these ward months. Gosh, tell me it gets better.
 
Coastie said:
T-10 months til CA-1 year. Gotta read this thread to stay sane with all these ward months. Gosh, tell me it gets better.
Click to expand...

Amen Coastie! 10 more months of IM is like nails down a chalkboard...I just have to take it one month at a time and try not to think about the crappy year ahead...it gets overwhelming. At least there is a light at the end of the tunnel!! Good Luck everyone!
 
DreamLover said:
Amen Coastie! 10 more months if IM is like nails down a chalkboard...I just have to take it one month at a time and try not to think about the crappy year ahead...it gets overwhelming. At least there is a light at the end of the tunnel!! Good Luck everyone!
Click to expand...

Good God! It hasn't even been 2 months?!?! It feels longer than all of 3rd and 4th year! CA1s, please talk us down from the roof of our internship hospitals.
 
Seriously, this whole internship thing sucks so, so bad. I'm finally almost done with two weeks of night float, which has been pure cross-cover hell.

Case in point, last night at 3AM:

"Hi, this is the night float returning a page."

"Yes doctor! I page you to tell you Mr. X's pressure is 156/86!!"

"Uhhhhh, OK. What have his pressures been like recently?"

"I don't know, let me check..... (1 minute of searching later) Last measurement was 160/90, one before that 166/90."

"I see. And he's asymptomatic?"

"Oh yes doctor, resting comfortably."

In my head: "I KILL YOU MOTHER&^(#ER I KILL YOU TILL YOU DIE."
Out loud: "Well good, sounds like you're fixing him. Have a good night."

Seriously, July can't come soon enough.
 
lvspro said:
SO...
No CA-1 takers on emergence deep vs. awake?
Click to expand...

Extubating deep is fun, but a lot of my attendings don't do it anymore because we have a lot of turnover nursing-wise in our PACU and not all of the newer folks are familiar with dealing with patients that have been extubated deep.
 
VentdependenT said:
How are my CA-3 AZCOMers doing over at UofA?

Tell Rapico I said hello.
Click to expand...

Vent,
There's 5 AZCOMer's representin' (3 in my class) and we're all doin great. Rapiejko is well too, you even came up in conversation one day when we were talking about AZCOM. Told him you were chief and he wasn't surprised!
 
Anyone else feeling like a ****** on a daily basis or is it just me? 🙁

I was pretty good as a medicine intern, and am starting to wonder whether i'm really cut out for anesthesia.
 
As a CA3 I can tell you that just about everyone feels like a ****** on a daily basis as a CA1. As long as you try not to make the same mistakes twice. Ask your faculty as many questions as you can, thats what theyre paid for.
 
My first two months were pretty miserable too. I felt like I didn't have much hand-eye coordination...I blew a lot of IVs, and just organizing the case was so stressful. One day I performed so ineptly that an attending suggested I go into psych! The worst thing was that I really thought it over. Weirdly enough, I had NO trouble c intubations...(~80-90% of my intubations were successful!!!)

Now two months into it, I feel much better about my IV skills, and my organization. It's the knowledge base that I need to accumulate that is daunting. I still mess up though, but not nearly as much.

Hang in there. During the rough past two months, a kind CA2 pulled me aside and told me that it will take about ~3-4 months to get somewhat comfortable with cases....for some people it might take a year.

Anesthesia is cool in that you don't have to round/know tons of patients, and is pretty fast paced. As broad as the knowledge base you have to acquire might seem....it's NOwhere near that of medicine. Also call is not bad compared to medicine....no H and Ps!!!, mostly procedures.

Then again, I do miss walking around the hospital and meeting/talking to my fellow residents. Also, this sounds kinda of weird, but I liked dressing up. I have a closet full of nice clothes that I don't wear anymore.

Although I sometimes feel psych might have been a better match for me, I know I can be pretty good in anesthesia, it may just take me a little longer than other people.

Stay with it for a few more months....if you still hate it, I am sure medicine or whatever you want will be still waiting for you.
 
"Anesthesia is cool in that you don't have to round/know tons of patients, and is pretty fast paced. As broad as the knowledge base you have to acquire might seem....it's NOwhere near that of medicine. Also call is not bad compared to medicine....no H and Ps!!!, mostly procedures"


As you progress you realize that your knowledge base needs to be be as large as that of medicine if in a different way. We may not need to know how to treat cholesterol, but we need to know how all the various medical conditions can and will affect our anesthetics as well as how to interpret different tests that cardiologists, pulmonologists deal with as well as how chemotherapy medications may affect our patients. We should also know something about the nature of surgical diseases as well as the nature of the surgical procedure itself in order to be able to anticipate what is going to happen next in a given case. This is on top of knowing our machine, our medications, etc... I would say our knowledge base may need to be even broader than that of medicine.
 
huktonfonix said:
"Anesthesia is cool in that you don't have to round/know tons of patients, and is pretty fast paced. As broad as the knowledge base you have to acquire might seem....it's NOwhere near that of medicine. Also call is not bad compared to medicine....no H and Ps!!!, mostly procedures"


As you progress you realize that your knowledge base needs to be be as large as that of medicine if in a different way. We may not need to know how to treat cholesterol, but we need to know how all the various medical conditions can and will affect our anesthetics as well as how to interpret different tests that cardiologists, pulmonologists deal with as well as how chemotherapy medications may affect our patients. We should also know something about the nature of surgical diseases as well as the nature of the surgical procedure itself in order to be able to anticipate what is going to happen next in a given case. This is on top of knowing our machine, our medications, etc... I would say our knowledge base may need to be even broader than that of medicine.
Click to expand...

Yep. When I was a CA-1, i didnt think our knowledge base was that broad. But, that was just because I knew so little. The more you know, the more you realize that there is so much more to know.
 
hey... so i assume things are a lot smoother since we are now in our third months... I definitely am happier about doing anesthesiology rather than IMED. But I'm with some other folks- 12 hours of practicing anesthesia is way more intellectually/physically stressful than any 12 hours of practicing medicine last year as an intern- even call and the MICU. Rounding is horrid, but "GI rounds" to grab a dr. pepper and some chocolate with fellow residents is something I miss.😉
 
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