Starting Anesthesia rotation.

[RustedFox]

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Howdy, all -

I'm a PGY-1 who is beginning his anesthesia rotation. While we were given a list of "objectives" during our orientation month, what they amount to is really just a list of "glittering generalities"; nothing that says; "Hey, jackass - if nothing else; learn THIS while you're here."

What should I master while I'm in the world of anesthesia ?

Comments and criticism welcome.

 

[dchristismi]

Airway, airway, airway. And more airway.

This is your opportunity to practice in as controlled a setting as there is. They have all the toys - practice with as many as they will let you... the bougie, LMAs, fiberoptics, the whole nine yards. Learn good technique, which is better than brute force. Learn as many tricks as you can, with as many tools as you can get your hands on.

There's plenty of other stuff, but the bottom line is that airway management is an essential part of EM practice. When it's 3am and you have a tongue swollen all-to-hell, botched cric attempt in the field in a hypoxic pre-coding patient, you need to have your ducks in a row.

(The above patient came in 2 nights ago, and my partner had the honor of trying to save this guy. Nightmare airway. This is why we train, and why you should milk your anesthesia month for all it's worth.)

Just my 2c,
now go be an intubating machine!
Danielle

 

[jbar]

put the plastic thingy where the air comes in and out.

 

[Dwindlin]

put the plastic thingy where the air comes in and out.

My favorite "tip" from medic school was dealing with an airway full of blood or other fluid... "just aim for the bubbles.."

 

[RustedFox]

Thanks, everyone.

Keep 'em coming. Even the jokes are helpful when it comes down to gaining perspective.

 

[jbar]

Thanks, everyone.

Keep 'em coming. Even the jokes are helpful when it comes down to gaining perspective.

Seriously, I'd quickly sort out the expectations of the anesthesiologists who you are working with. When I was on my med student rotation I saw the EM resident getting a bit screwed because anesthesia wanted him to have introduced himself to each patient and read the chart before they'd let him tube, and he was bouncing from room to room just trying to get tubes. They didn't like that and stopped him from getting a few tubes. So figure out how to make them happy to get the most tubes.

Also ask if they have a glide scope. Pretty interesting device, let's your preceptor see what you see. They seem to be getting used at more and more EDs so worth getting some time on one if you can.

 

[docB]

If you're not good at or experienced with using a bag valve mask try to work on that. I had some gas attendings who were adament that students/off service residents bag patients all the way through some shorter procedures. The BLS airway using adjuncts like NPA and OPA will always be your starting intervention and your fall back position when things get ugly.

 

[DoctorMedic]

My favorite "tip" from medic school was dealing with an airway full of blood or other fluid... "just aim for the bubbles.."

beat me to it! Remeber good BLS before ALS, need to know how to properly use and apply BVM and good ventilations before knowing how to intubate. Usually when a doctor switches from mac-->miller or vise versa things are going sour. And don't break any teeth, 10k a piece.

 

[jbar]

And don't break any teeth, 10k a piece.

Glad I didn't know that before. On my MSIII rotation they had me intubate an orthodontist. Never been so scared in the hospital. But managed not to break anything. Wew!

 

[Stitch]

If you're not good at or experienced with using a bag valve mask try to work on that. I had some gas attendings who were adament that students/off service residents bag patients all the way through some shorter procedures. The BLS airway using adjuncts like NPA and OPA will always be your starting intervention and your fall back position when things get ugly.

This is very important. Too many approach the rotation as nothing but tube experience. While that's definitely important, remember that airway management means a lot more than just shoving a tube down somebody's throat. Be comfortable with bag valve masking. Learn how to optimize your intubation attempt BEFORE you look, and learn all the tricks they have to buy time when things start getting tough. And also ask about drugs. There are more inducing agents out there than etomidate; learn to think about them.

 

[kungfufishing]

Ditto the above regarding BVM. If you have a separate peds anesthesia area see if you can spend some time over there.

It is harder to hit the bubbles than you might think.

 

[bartleby]

You're not going to be able master all the techniques of intubation in one month. What you can do is become really proficient at mask ventilating patients and using the LMA. If you can do this, you can drastically reduce the chances that you will killl someone by paralyzing them if you are subsequently unable to intubate them using standard means. If you practice long enough (and are unlucky enough), you will find yourself in this situation sooner or later.

 

[Arcan57]

Try to learn everything from anaesthesia except gas management (has no applicability) and the physical skill of intubation. Conscious sedation, LMA placement, blocks, and BVM, BVM, BVM. You'll get your tubes in the ED, but no one's ever going to take you aside and show you proper BVM except anaesthesia.

 

[roja]

Intubation, intubation. (and BVM).

Get facile with both a mac and a miller.


I absolutely concur with what the others say. Find out what will make the attendings' jobs easier. At my residency, this involved pre-oping all the patients. I filled out the paperwork and put in the IV's. (this was great practice as they like hand IV's and as an intern, this can be great practice).

This made a huge difference on my rotation and allowed me to get 60+ intubations. Be nice. Realize you are on thier turf and be respectful.

 

[Jeff698]

While getting the tube in is obviously important, don't overlook opportunity to learn an awful lot about drugs. Not just induction agents, either. Pay attention to their pressor use during cases.

Also, go with them as time allows to pre-op folks. Learn what to look for when assessing the potential difficulties of airway management. I learned this during my intern rotation and still go through that mental checklist for each procedural sedation I do.

Pick their brains on the physiology of their meds. Also, get as much block experience as you can.

Oh, and this goes for any off service rotation. Don't be a putz. Respect the folks you work with and remember they have a lot to teach you. Try to learn as much of it as you can.

Take care,
Jeff