Thursday, July 15, 2010

That's Not A Resident. That's Our New Anesthesiologist.

Welcome to your new job, all you freshly graduated, Board Eligible, textbook trained anesthesiologists!  Hundreds of you will descend on hospitals around the country with your Board approved methods of administering anesthesia.  You'll wander around the hospital looking for the operating suite, the scrub lockers, and most important, the bathrooms.  Introductions will be tedious.  After years working in a residency program where everybody knew your name (cue Cheers theme song), you are suddenly the new stranger in the room.  The OR staff will judge you instantly by your appearance, demeanor, humor (or lack of), body odor, and hundreds of other qualities we humans determine if the new person will be accepted into the tribe.  Anesthesia skills will not be one of the factors though.  Remember they think we are all similarly skilled so anesthetic competence is simply assumed, unless of course you knock off your very first patient.  Excellence will only be bestowed on you after about one year of scrutiny.

 Anesthetic decisions that used to come to you without a thought suddenly become onerous, even scary.  Simple determinations like LMA or intubation turn into endless mind exercises.  You will mentally rehearse your rational for everything.  If your training program routinely used morphine but your new hospital uses dilaudid, do you go with the flow or stick to your guns?  And why? And what dose to give a patient with 10/10 pain in PACU but who has morbid obesity and severe sleep apnea?

Actions that you've performed hundreds of times in residency will develop new twists that you never encountered in training.  One of my first spinal anesthetics in private practice developed a complication when the patient complained of paresthesia in one leg hours after the procedure.  I had done innumerable spinals in residency and this had never happened before.  I had already gone home when the PACU nurse paged me about this problem.  I told the patient by phone that the spinal will eventually wear off and she will be fine.  But several hours later the nurse was still calling me.  I finally drove in to examine her.  Her neurologic exam appeared intact but she was still complaining.  I finally called for a Neurology consult and told the attending surgeon that the patient needed to be admitted for observation.  Finally after all this TLC the patient agreed that her leg felt adequate.  She could walk to the bathroom by herself and did not want to come to the hospital.  No neurologic sequela on follow up phone interview.  Never happened before.  Hasn't happened since.  Bizarre, and seems to happen predominantly to new attendings.

The first six months is literally trial by fire.  You come to appreciate the gravity of a job where you literally guide a person towards the path of life or death. There is nobody there to hold your hand, or relieve you for lunch and bathroom breaks.  Your sphincter will feel tight enough to snap a pencil.  There will be days where your pits feel like Niagara Falls.  Then suddenly, the sun will come out.  By around New Year's Day you realize that you are not as nervous about coming to work as you used to be.  Performing anesthesia is actually fun for you again.  You walk into the operating room and can greet everybody by name, and they the same to you.  The surgeon knows your work and is not constantly gazing over the drapes.  You no longer feel the need to stare at the patient monitor every single second. When your case line up is finished, as you walk out of the hospital, leaving your pager and all your worries behind, you remember again why you went into anesthesiology.

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