How important is transplant anesthesia exposure in residency?

[Kodene]

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I’m a fourth year medical student working on my rank order list. I am wondering how important it is to have transplant exposure during residency. Ideally, I would love to have the experience but I am wondering how much it really matters in the large scheme of things. I don’t have any specific plans after residency and I am just keeping an open mind.

A few programs in the middle of my list seem to have a trade-off between transplant vs. trauma exposure. I’m just not sure if I would trade off living in a less desirable location in exchange for an overall more “complete” clinical training. I’m just wondering what your thoughts are on the importance of doing transplants in residency and whether it will influence my competence after residency. Thanks!

 

[rsgillmd]

I'm probably biased because I didn't do any transplant. They offered it to us at the end of my last year as an elective at Mount Sinai, but at that point I was more paranoid about preparing for my writtens and had some family issues going on.

Anyway, to answer your question I don't feel it impacted me negatively. I interviewed at one program that did transplant and said to them that I don't have any experience with it but was willing to learn if they would double me up a few times. The response from the chairman was to not worry because they had enough people interested and experienced in doing livers.

I think its more important to understand the general principles of dealing with pre and post-transplant patients than it is to have done the anesthesia for the procedure itself.

If you don't think you'll be happy at a place because of the location, then don't rank it high. You want to be able to have a life outside of residency. What that life is will vary from person to person, but you need to have an outlet. I believe in leaving home at home and work at work, but in practice you can't separate them 100%. I left the northeast because I was not happy there, although I liked my hospital. I knew it would affect my work eventually.

I hope this helps. Good luck with the match process.

 

[Noyac]

Transplants can be exceptional learning experiences. I never got any of that with the exception of kidney xplants. So I'd say they are great but not absolutely necessary. If you do liver xplants then you can do trauma. But trauma trained anesthesiologists can't necessarily do liver xplants. Heart and/or lung transplants are different.

I would choose the program that fits me best and not worry whether which one they had as long as they had one of these. And then again, there are probably programs out there without either that are good.

 

[seinfeld]

the more exposure to a variety of cases you get in residency the better. In other words dont sell for self short because you never know what your future may hold.

Having said that, unless you plan to practice in a major academic center then exposure to transplant is not completely necessary. Kidney transplant can be done by any level of anesthesia from ca-1 to attending. Livers, lungs, hearts will always be done by anesthesiologists at major academic centers who tend to spend a majority of their time doing them.

 

[dhb]

Not very important: if you want to work at a big transplant center all you'll need is a couple of cases to get going.

 

[periopdoc]

After your training, you will never find yourself at community hospital X with a patient crashing through the OR doors at 3am for an emergent transplant because his "friends" dropped him off at the closest ER to their den of iniquity.

You may well find yourself at community hospital X with a patient crashing through the OR doors at 3am for an emergent ex-lap/ thoracotomy/ pick your trauma poison because his "friends" dropped him off at the closest ER to their den of iniquity.

If you end up in a center where transplantation is performed, you will have enough warning before a transplant recipient comes to the OR to phone a friend and set up an anesthetic plan in advance. You will not have the time to phone a friend with any real trauma.

caveat emptor.

That being said, transplants are awesome and worthwhile if you can get a place that has good experience in both transplant and trauma.

- pod

 

[Mman]

Personally I feel I learned a great deal doing liver and lung transplants. Kidney transplants are nothing special and heart transplants are mostly like any other cardiac case with the exception of a little more frequent use of things like nitric oxide. Trauma is trauma, quick thinking and lots of resuscitation. I was in a level 1 trauma center in a large city with plenty of crime, but I still learned more about resuscitation in liver transplants with >100 units of product transfused in the OR.

And if you ever thought a kidney transplant was boring, just wait til they give you the kidney-panc! Three times as long and the only added fun is checking blood sugars frequently.

 

[sevoflurane]

Liver Transpalnts are my absolute favorite cases. I wish I did them now. They are not necessary for B&B PP, but it does add to your overall skills.

Good physiology... Hemodynamics are interesting. These people may be in hepatorenal failure, encephalopathic, with a belly full of ascites and usually have CO that are supranormal. Ricc lines, rapid infusers, MAC/PA catheters, 2 a-lines. Lot's of products. These cases are an opportunity to put on your internal medicine hat. We usually have a board in the room and write down every little thing (critical panels, mag, phos, lactate, products, abg's, coagulation studies, etc...) Real nice at the end of a case. You can glance at the board (5x8 foot) and see exactly where you were and are going. Good cases to become familiar with TEG's. And reperfusion... is frequently dramatic requirering A LOT of norepi boluses.

Heart transplants are not as exciting although again... good to do a couple of times.

Residency is a time to experience everything. I would go to a program that has a good translplant program. Not necessary... but you may regret it later on in life. My 2cents 🙂

 

[sevoflurane]

Heart transplants are not as exciting although again... good to do a couple of times.

RVADs/LVADs/BiVADs are a lot more interesting. The downside to these cases is that as a senior resident you are going to see more than you like... cuz they always bleed 😡.

I agree with the kidney/pancreas comment. Not very complex. But good to see and get familiar with cis-atr.

As mentioned above... pick a residency that has complex cases. It will make you better in the end.

Trauma, transplant, heart, regional and peds is what I focused on when I was searching. I never slept when I was on call during residency... but now... I don't get worked up if the B.P. is in the toilet... been done too many times during residency.

 

[SleepIsGood]

I’m a fourth year medical student working on my rank order list. I am wondering how important it is to have transplant exposure during residency. Ideally, I would love to have the experience but I am wondering how much it really matters in the large scheme of things. I don’t have any specific plans after residency and I am just keeping an open mind.

A few programs in the middle of my list seem to have a trade-off between transplant vs. trauma exposure. I’m just not sure if I would trade off living in a less desirable location in exchange for an overall more “complete” clinical training. I’m just wondering what your thoughts are on the importance of doing transplants in residency and whether it will influence my competence after residency. Thanks!

Probably not important at all. Unless..........you plan on going to a HIGHLY academic center. Even at most academic centers, transplant isnt done.

So overal...cool to see in residency, but probably not all that important.

 

[Kodene]

Thanks for the responses!

 

[jennyboo]

I posted in the trauma thread already, so here goes again:

What I've learned from doing residency at a level one trauma center is how to quickly take a bunch of anesthesia staff (residents, CRNA, anesthesiologists etc) who start out not knowing their heads from their arses and tripping over each other, and organize them effectively into a coordinated resuscitation. In other words, how to run a code in the OR. This may or may not involve massive transfusion.

What I've learned from doing residency at a transplant center is how to manage a plan-ahead case which involves massive transfusion.

Two very different lessons, both of which are valuable.

If you have few real traumas (or ruptured AAAs), you can still learn how to run a code in the OR in other situations. Level 1 trauma (or ruptured AAA) rolling in from the ER simply puts all those lessons into a nice single package for you, so that you have opportunities to practice these skills all at once.

If you have no transplants, you can still learn how to manage large fluid/volume resuscitations and massive transfusions by other means (for instance, OB, general surgery, vascular surgery).

Trauma and transplant round out your skills, but going to a residency with a "strong" trauma background or a "strong" transplant background will not make you stand out from the crowd when you're done with residency and looking for a job.

 

[hoyden]

Liver Transpalnts are my absolute favorite cases. I wish I did them now. They are not necessary for B&B PP, but it does add to your overall skills.

Good physiology... Hemodynamics are interesting. These people may be in hepatorenal failure, encephalopathic, with a belly full of ascites and usually have CO that are supranormal. Ricc lines, rapid infusers, MAC/PA catheters, 2 a-lines. Lot's of products. These cases are an opportunity to put on your internal medicine hat. We usually have a board in the room and write down every little thing (critical panels, mag, phos, lactate, products, abg's, coagulation studies, etc...) Real nice at the end of a case. You can glance at the board (5x8 foot) and see exactly where you were and are going. Good cases to become familiar with TEG's. And reperfusion... is frequently dramatic requirering A LOT of norepi boluses.

Heart transplants are not as exciting although again... good to do a couple of times.

Residency is a time to experience everything. I would go to a program that has a good translplant program. Not necessary... but you may regret it later on in life. My 2cents 🙂

I liked livers in residency, however never have had an experience of transfusing 100 units of blood products and overall anything bad happening. At the end we stopped placing PA catheters in them.
But we had an awesome surgeon who could do a liver transplant in a little kid in 2.5 hours. His other livers were 3-5 hours.

 

[urge]

How important is transplant anesthesia exposure in residency?

Let's see... kidneys are joke. Heart and lungs most likely need to be fellowship trained. Livers... who wants to do those once you are done?


I wouldn't sweat it.

 

[MalloryWeiss]

bumping an old thread. i'm interested to hear more opinions on this, especially from the attendings.

also, to my fellow applicants... how much are your prioritizing transplant exposure in making your rank lists?

 

[Mman]

bumping an old thread. i'm interested to hear more opinions on this, especially from the attendings.

also, to my fellow applicants... how much are your prioritizing transplant exposure in making your rank lists?

Liver transplants are essentially a potential blood bath, but you have the bonus of being able to plan it out ahead of time. It's a controlled situation unlike a terrible trauma that just lands in your lap with little to no warning and you have to fly by the seat of your pants.

Kidney transplants are a boring abdominal case on an ESRD patient. Kidney/panc transplants are just longer versions of kidney transplants with the added fun of tight glucose monitoring for hours on end.

Hearts and Lungs are cardiac cases, although off pump double lung transplants are quite hair raising at times trying to keep people alive on 1 lung ventilation that are barely alive with their 2 lungs.

 

[pgg]

I've done very little transplant. Kidneys, no big deal. Never done a heart. Four or five lungs as a resident during a SICU rotation where I also got to take care of them in the ICU afterward, those were tough but great learning opportunities. If I never do another liver again, that'd be OK with me. I think of livers like neonates, if you told me I was doing one tomorrow, OK, sure, but I wouldn't look forward to it or ask for another the next day. Someone else can have it. I've done zero transplant since residency.

I did very, very little significant trauma as a resident. And yet, I went to Afghanistan and I (like all the other anesthesiologists, who also had done very little trauma previously) had little difficulty with the daily horror show of war trauma. I think the truth is that anesthesia for trauma, even horrible trauma, can be the easiest thing in the world if the facility does a lot of it and the system is well oiled. When the right stuff is there, and the right people are there, and the blood bank is fast and efficient, it's usually an easy day. Blood, warmth, coag watching. Thoracic trauma can get interesting but usually the really bad injuries there don't make it to the hospital in the first place. OTOH ... if the facility doesn't do much trauma, every single one will always be an absolute cluster**** and you'll be in a continuous struggle with the lab and blood bank and surgeon and OR nurse and ER and radiology ... but even then, it's management of other people that's the hard part, the anesthesia is still easy.

Bottom line, I don't think the presence of EITHER major trauma or transplant are a critical/indispensable asset to a residency program, beyond being able to do "some" of both for a well rounded education. I wouldn't factor either too much into a rank order list.

 

[norwood]

I think the truth is that anesthesia for trauma, even horrible trauma, can be the easiest thing in the world if the facility does a lot of it and the system is well oiled.
...
Bottom line, I don't think the presence of EITHER major trauma or transplant are a critical/indispensable asset to a residency program, beyond being able to do "some" of both for a well rounded education. I wouldn't factor either too much into a rank order list.

Agree with both.

Unless you plan to do transplants in future (in which case training for things like the 17Fr IJ cannula for hepatic bypass might be handy), I wouldn't sweat it. My residency did plenty of transplants, but I wouldn't list them among the main learning experiences I had as a resident.

 

[Yo GabbaPentin]

I recommend finding a wealthy place to practice after residency. In which case, I would be focusing on the IMPLANT side of things rather than the transplant.

 

[urge]

I don't think the transplants per se are significant. Nowadays if you plan to end up doing transplants other than kidneys, you probably need a fellowship.

However, places that do transplants tend to have sicker patients and better clinical exposure for the residents.

I trained at a place that didn't do much transplants and my attendings were mostly concerned about nausea and post op pain. ie, they did not want to be called to pacu.

I work in a higher acuity hospital now. My concern is whether the patient will wake up or not, and how long will it take. 1 week or maybe 4.

Don't get me wrong. My theory was top notch.