Question to Gas residents/attendings..

[RxBoy]

So many of us are about to start residency with an intern year ahead of us. Some of us have electives, some of us have extra free time...

My question:

Any advice preparing for the subsequent Gas residency?

1) Electives (aside from the standard Gas/pain electives). Any input?

2) Reading prep?

3) Procedure prep? I never got enough experience with the hands on stuff (ivs, abgs, foleys, NGs, central lines, EJs, ect). Whats the best and quickest way to gain experience?

Any input will be appreciated

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[OB1🤙]

1) Electives (aside from the standard Gas/pain electives). Any input?

ICU rotations are the biggest bang for your buck. Cards is hugely valuable, pulm can be too. Don't worry too much about how well things might translate- you'll have plenty of time to learn anesthesia during anesthesia, now is the time to dip your feet into waters you haven't been exposed to.

2) Reading prep?

Don't worry about it. If you're bored on night float you can thumb through Baby Miller or something, but really, you don't need to be reading ahead. Dabble here and there, but don't take it too seriously. It won't stick without clinical reinforcement anyway.

3) Procedure prep? I never got enough experience with the hands on stuff (ivs, abgs, foleys, NGs, central lines, EJs, ect). Whats the best and quickest way to gain experience?

ICU months are good for this, as are overnight calls. Don't worry about foleys and NGs. Opportunities for central lines will be given to you first by your residents, eventually you'll become comfortable enough to do them on your own. IV starts are worth practicing, and the ICU should give you ample opportunity for these, as well as ABGs and a-lines.

Bottom line is, these opportunities will present themselves, and the residency itself will quickly remediate you on anything you might not be as deft at coming out of internship.

Put it this way: on day 1 of your CA-1 year, your attendings will assume you know nothing and can do nothing. So don't sweat it.

Good luck.

 

[cchoukal]

I'll address your questions by point:

1) Agree with Bruin. Spend your intern year learning to be a good physician. ICU, Cards, even general medicine. Do a surgery month if possible. Pay attention to how your residents and attendings think and communicate around critical illness and perioperative care. Use this insight to inform your care and physician-to-physician interactions later.

2) If you're going to read anything anesthesia-related (which I don't necessarily recommend; see point 1 above), read about Total-IntraVenous Anesthesia so that you can stop calling it "Gas." I know it's been covered here, but I still find it a little annoying. I haven't used "gas" (other than oxygen) in about a month and I'm still an anesthesiologist.

3) you will likely be disappointed with the number of opportunities you have to do "procedures" as an intern Be ready for it, particularly if you're doing an IM or transitional year. Unless you're at a busy, aggressive center, you'll likely be deferring central lines to your residents who haven't done enough of them yet. On the plus side, as Bruin pointed out, your attendings will not trust that you know how to do anything anyway, so maybe it's better not to!

 

[panetrain]

The key procedures/knowledge you should pick up during your intern year include: IV's (every nurse will be more than willing to let you start IV's), a-lines (this is an intern job in most institutions), CVC (IJ's, SC's, Femorals), Intubations (become familiar with airway equipment), mechanical ventilation settings and management, IVF management, blood products.

Regarding anesthesia knowledge...the following is a must before you show up in the OR on day 1 of gas: pharmacology of anesthetics (volatiles, intravenous, neuromuscular blockers, reversal agents, narcotics, benzos etc...), pharmacology of vasoactive drugs, beta-blockers etc..., current ACLS and feel comfortable running a code, and attempt to familiarize yourself with the anesthesia machine.

Depending on your program, day 1 of gas can be candy or hell! Some programs will throw you to the wolves and other programs will caudal you. I would be prepared to be thrown to wolves!

If you think you may be interested in pain, do as much surgery as you can. Learn how to suture, and close skin. The current 1 year pain fellowships are lacking in surgical training!

Final thought, don't starting reading gas until you have passed Step 3, If you don't pass step 3 you don't get a license and cannot start gas!

 

[geauxg8rs]

Intern year is supposed to be just reinforcement for why you didn't pick IM as a career. Have fun getting called in the middle of the night for Na of 138 (doc, I just came on shift and thought you might want to change the maint fluid?)

You will feel like a complete idiot during your early time as a gas resident. As one attending told us during the first week:
" New anesthesia residents are the most worthless of all trainees. At least new Interns can admit a patient and take call. You guys can't do anything. Just accept it."

Just don't make a name for yourself during Intern year and that is considered success. Dont bother learning how to place foleys or do any pelvics. You are not a plumber.

 

[geauxg8rs]

Intern year is supposed to be just reinforcement for why you didn't pick IM as a career. Have fun getting called in the middle of the night for Na of 138 (doc, I just came on shift and thought you might want to change the maint fluid?)

You will feel like a complete idiot during your early time as a gas resident. As one attending told us during the first week:
" New anesthesia residents are the most worthless of all trainees. At least new Interns can admit a patient and take call. You guys can't do anything. Just accept it."

Just don't make a name for yourself during Intern year and that is considered success. Dont bother learning how to place foleys or do any pelvics. You are not a plumber.

 

[geauxg8rs]

Intern year is supposed to be just reinforcement for why you didn't pick IM as a career. Have fun getting called in the middle of the night for Na of 138 (doc, I just came on shift and thought you might want to change the maint fluid?)

You will feel like a complete idiot during your early time as a gas resident. As one attending told us during the first week:
" New anesthesia residents are the most worthless of all trainees. At least new Interns can admit a patient and take call. You guys can't do anything. Just accept it."

Just don't make a name for yourself during Intern year and that is considered success. Dont bother learning how to place foleys or do any pelvics. You are not a plumber.

 

[panetrain]

Avoid the DRE's!

Intern year is supposed to be just reinforcement for why you didn't pick IM as a career. Have fun getting called in the middle of the night for Na of 138 (doc, I just came on shift and thought you might want to change the maint fluid?)

You will feel like a complete idiot during your early time as a gas resident. As one attending told us during the first week:
" New anesthesia residents are the most worthless of all trainees. At least new Interns can admit a patient and take call. You guys can't do anything. Just accept it."

Just don't make a name for yourself during Intern year and that is considered success. Dont bother learning how to place foleys or do any pelvics. You are not a plumber.

 

[cchoukal]

Final thought, don't starting reading gas until you have passed Step 3, If you don't pass step 3 you don't get a license and cannot start gas!

This is untrue. In some states, including my state of illinois, you are unable to be licensed before completing 24 months of GME (i.e., your intern and CA1 year). You do not need an independent state medical license to start your CA1 year.

 

[Gimlet]

Avoid the DRE's!

I just finished my last day of clinical work as a med student...managed to make it through without ever having done a rectal.

 

[panetrain]

Not in my state, you can obtain a full license after completion of your intern year and the successful passing of step III USMLE. This allows you to start moonlighting your CA 1 year if you choose to do so!

This is untrue. In some states, including my state of illinois, you are unable to be licensed before completing 24 months of GME (i.e., your intern and CA1 year). You do not need an independent state medical license to start your CA1 year.

 

[Jeff05]

don't worry about doing anything your intern year. just concentrate on learning your medicine. much of it will form a base of your ability as a true perioperative physician. if you do a real internship, trust me, you will not have the time or the energy to read anesthesia.

practice as many IVs and blood draws as you can. do as many lines in ICU as you can. on your first day know the following.
1. about how much fluid to give (don't crap your pants after bolusing 250mL to a healthy 20 year old).
2. doses of propofol, vecuronium/rocuronium, midazolam, fentanyl to give for GA or MAC - ballparks. doses of neostigmine and glyco. dose of sux. dose of atropine. doses of phenylephrine and ephedrine.
3. how to mask ventilate (this is not as easy as it sounds). maneuvers for establishing airway patency. mechanics of intubation - what length to secure the tube.
4. what MAC is and MACs for n20, des, sevo, iso
5. basics of mechanical ventilation.
6. basics of monitoring - which ekg leads we use, size of bp cuff to use, how pulse ox works, indications for a line.
7. extubation criteria

 

[RxBoy]

Thanks guys! Lots of helpful advice.

I have this weird internal conflict where I am both enthusiastic and dreadful of the intern year. Either way I'll try to make the best of it. Can't wait to have May and June off.


PS: As for the post about using the word Gas in place of anesthesiology... I only do it cause its a hell of lot easier than writing anesthesiology every time. Cards, rads, IM got short hands.... and no I am not going to be representing the muscular dystrophy association.

 

[OB1🤙]

Some programs will throw you to the wolves and other programs will caudal you.

To be fair, that would reduce any associated pain.

 

[proman]

I just finished my last day of clinical work as a med student...managed to make it through without ever having done a rectal.

Wait, you've never done a rectal? Ever?

 

[NavyFlightDoc]

Wait, you've never done a rectal? Ever?

I'm not gonna call 'BS', because I know it's possible, but IF getting through med school without doing a rectal meant scamming your way out them, you might find out you missed an opportunity to do something fairly basic to medical practice, though not anesthesia specifically.

Plus, you just can't get through internship and residency that way, without people recognizing it. I did a surgery internship, so I suppose I'm biased.

Maybe you just got 'lucky'?

 

[Impromptu]

When I first read it, I thought the OP's question was pertaining to the end of MS4 year rather than intern year, so that's how I'm going to respond.

ICU rotations are the biggest bang for your buck. Cards is hugely valuable, pulm can be too. Don't worry too much about how well things might translate- you'll have plenty of time to learn anesthesia during anesthesia, now is the time to dip your feet into waters you haven't been exposed to.

I'm finishing out my 4th year with another ICU rotation (this time Anesthesia/critical care rather than trauma or PICU). My hopes were that by the end of the year, the anesthesia interns would be tired of doing the procedures and would instead let me practice under their or the resident's supervision. I've been watching those NEJM procedure videos, taking notes, and am feeling more confident recently.

Like others, I feel some trepidation about my intern year. But, I realize that thousands of others have felt the exact same way and have come out fine. This includes not only those who were more prepared than me, but also those who were less prepared than me. If they can do it, so can I.

I have noticed that the more I do something, the easier it becomes the next time I have to do it. This is my 3rd ICU rotation and I'm much more confident about what I can do. This whole medical education system might just work afterall.

 

[racerx]

I just finished my last day of clinical work as a med student...managed to make it through without ever having done a rectal.

I'm a bit jealous. I've done more than I can (pun intended) count on all my fingers. Sometimes I think I get to DRE the difficult patients because I wear an XL glove (OBGYN is definitely NOT in my future)!

 

[Gimlet]

Wait, you've never done a rectal? Ever?

Yep, unless you count one rectovaginal on an anesthetized patient, and one cadaver during 1st year.

I'm not gonna call 'BS', because I know it's possible, but IF getting through med school without doing a rectal meant scamming your way out them, you might find out you missed an opportunity to do something fairly basic to medical practice, though not anesthesia specifically.

Plus, you just can't get through internship and residency that way, without people recognizing it. I did a surgery internship, so I suppose I'm biased.

Maybe you just got 'lucky'?

Never scammed my way out...just lucky, as far as I can tell. During my clinic months I somehow never had an older male for an annual exam. On surgery, for the few rectals I witnessed the surgery resident had me defer to them because of pain/comfort issues (hemorrhoids, etc). I wasn't going to put up a fight.

Don't worry, I'm sure I won't make it through my internship unscathed.

 

[lfesiam]

Yep, unless you count one rectovaginal on an anesthetized patient, and one cadaver during 1st year.



Never scammed my way out...just lucky, as far as I can tell. During my clinic months I somehow never had an older male for an annual exam. On surgery, for the few rectals I witnessed the surgery resident had me defer to them because of pain/comfort issues (hemorrhoids, etc). I wasn't going to put up a fight.

Don't worry, I'm sure I won't make it through my internship unscathed.

amazing gimlet!

done a crap load of DRE during URO prostatectomy cases - usually followed by a CODE BROWN.

 

[beavis]

I just finished my last day of clinical work as a med student...managed to make it through without ever having done a rectal.

crazy! I did a medicine sub-i where one of the attending's "must haves" was a rectal exam. Regardless of chief complaint, gender, etc.

In one instance, where a rectal was warranted, I had a patient who did not speak English. Luckily, an intern with me spoke his language and explained the DRE to him. So I did it....and when the patient shifted back over onto his back, a dime fell out of his pocket -- unbeknown to him. So, being the friendly medstudent that I am, I picked up the dime and handed it to him.....he gave me this really awkward look, his face turned red, and the intern started laughing. I think he thought I was recompensing for the DRE.

Just leave the dimes on the floor...

beav

 

[Gimlet]

crazy! I did a medicine sub-i where one of the attending's "must haves" was a rectal exam. Regardless of chief complaint, gender, etc.

In one instance, where a rectal was warranted, I had a patient who did not speak English. Luckily, an intern with me spoke his language and explained the DRE to him. So I did it....and when the patient shifted back over onto his back, a dime fell out of his pocket -- unbeknown to him. So, being the friendly medstudent that I am, I picked up the dime and handed it to him.....he gave me this really awkward look, his face turned red, and the intern started laughing. I think he thought I was recompensing for the DRE.

Just leave the dimes on the floor...

beav

LOL! Hopefully he didn't think you were doing a variation on the "pull a coin from your ear" magic trick!

 

[NUGasStud]

I just finished my last day of clinical work as a med student...managed to make it through without ever having done a rectal.

I was not so lucky. A medicine attending had two rules regarding rectals for hospital admissions. Every patient gets a DRE unless you don't have a finger or they don't have an anus.

 

[asmallchild]

I went through my entire medicine Clerkship without doing a rectal. Then my intern caught me on the last day

 

[Gimlet]

I love how this thread about intern year has been hijacked into a discussion of DREs. Sorry, RxBoy. Actually, I suppose we aren't too far off track, as I have a hunch that intern year will pretty much feel like one big long rectal for the most part.

 

[pjl]

For electives I would recommend doing a cardiology echo rotation if available, or a general cards month. More ICU is also nice, but I think that is limited to 2 months during the year. Research would be alright if you are inclined towards that. Peds something may be marginally useful if you aren't going to see kids otherwise.

For reading I would not worry much. The baby miller book would be an ok thing to flip through if you felt like you needed to, but it will all stick a lot better once you start doing anesthesia. Reading about ICU medicine may be something you can retain better that will also serve you well in the OR.

For procedure prep, you will get it enough over the year to be equally as clueless as everyone else day one of anesthesia. You can always work on your hand-eye coordination by playing video games.

 

[Gimlet]

Somebody on the interview trail this year - I think it was the PD at U-Florida - recommended getting Stoelting's Anesthesia and Coexisting Disease. That way you can read up on your patients' conditions in the context of anesthesiology, and pretend that you're learning medicine at the same time!

 

[CambieMD]

1. Read the first 17 chapters of Morgan and Mikhail.
2. Try to get as much IV experience as possible
3. Learn how to intubate
4. Read the hand book to Anesthesia an Coexisting Diseases(the book is small)

I think that the above will give you a nice foundation upon which to build.

Cambie