Monday, November 18, 2013

The Most Important Thing Not Being Taught To Anesthesia Residents

This month's issue of the ASA Newsletter focuses on a subject that is often overlooked and belittled by academic anesthesiologists as they preside in their ivory towers. The topic of the month is the increasing importance of non O.R. anesthesia in our field. NORA is any anesthesia that is given outside the usual hospital OR's, such as the GI suite, Cath lab, Interventional Radiology, MRI, etc. You name it, somebody wants anesthesia somewhere that doesn't have all the niceties and comforts of a regular operating room.

NORA is now approaching 25% of all anesthetics being given in this country. If you also count anesthetics that are given in ambulatory surgery centers instead of hospital operating rooms, that figure is approaching 50%. In other words, there are thousands of anesthesiologists out there practicing outside the hospital operating rooms and the numbers are likely to increase for years to come. Yet I find that our anesthesiology residents have incredibly little training in how to give anesthesia outside their comfort zones of the environmentally protected OR's.

Yes every anesthesia resident wants to get their hands dirty on the intellectually challenging cases like liver transplants and aortic valve replacements. When there is an awake craniotomy to be performed, everybody wishes he was on the Neuro rotation that day. We all love to be involved in cases that will make for scintillating party conversations. But let's face it, for a large percentage of residents, they will not be doing these kinds of cases ever again once they finish residency. They will be faced with giving anesthetics in a setting where they may not have full control of the airway, where the support system of the facility is minimal or none, and the equipment may be outdated or BYOB (Bring Your Own Blade).

Add to that is the fact that MAC cases in NORA's are perhaps some of the most difficult cases anesthesiologists are likely to face. Sure most anesthesiologists scoff at giving propofol for MAC as being far beneath their abilities. But I submit that MACs will tax the intellects of our most accomplished anesthesiologists. I remember the first day I had to go to the GI suite to give anesthesia after my residency. Frankly, I drew a blank as to what to give. I knew all about how to intubate patients with difficult airways and pass Swans in heart patients, but in my entire residency I never once gave anesthesia in the GI suite.

How hard can giving propofol in the GI be? How about confronting morbidly obese patients with pulmonary hypertension with pressures in the 70's, sleep apnea, diabetes, and severe aortic stenosis who needs an EGD for anemia with a Hct of 23? If this patient was having a prolonged procedure in the OR, it would be a no brainer to intubate the patient, start an arterial line, and maybe have a few drips prepared. But you can't do any of that for an EGD where the procedure could last anywhere from 3 minutes to 30 minutes. You need the ability to give maximal sedation for the endoscopic intubation that will prevent the patient from coughing and bucking without having the patient's BP bottom out or heart rate shoot sky high and it needs to wear off within a few minutes so that the next case can proceed on schedule. An anesthesiologist wouldn't survive long in the GI suite if she intubated every patient who came in with morbid obesity.

Other challenging environments include the Cath lab where the cardiologists demand sedation in patients with ejection fractions of 15% and BP's in the 80's so that they can insert an internal cardiac defibrillator. Will the old standard of propofol sedation really be the best drug to give in this situation? Many anesthesia residents will never know until they are confronted with this scenario in private practice. How about giving sedation to a patient in MRI who is morbidly obese, with severe gastric reflux, orthopnea, sleep apnea, and wants to be asleep for the procedure because she has severe claustrophobia? In my residency, I didn't have any training in any of these locations. We were all so busy learning how to do blocks on shoulder patients and understanding the intricacies of inserting a right sided double lumen endotracheal tube that taking time away to learn how to give MAC sedation felt like a waste of my busy residency hours.

But as more and more procedures are moved to outpatient settings where speedy sedation and recovery are of the essence, anesthesia residents should do themselves a favor and ask for more education on NORA. The fact is that almost all of them will be doing some NORA MAC cases at some point in their careers and many will be doing only NORA MAC cases. They should be familiarizing themselves in sedation techniques while they still are protected by experienced faculty. Don't wait until the first week in practice to realize that you have no idea how to sedate a prone patient for ERCP with a big honking scope in the mouth and is refluxing bile all over the bed. And anesthesia residencies would be wise to prepare our residents for these seemingly simple but extremely demanding anesthetics.


  1. Clearly you don't work at UCLA. I've had more train wrecks in the Gi suite, medical procedure room, and cath lab than I care to remember.

    1. That's why all anesthesiologist should have more training in NORA locations.

    2. Kudos Kudos you make timely relevant observations that are essential for every graduating anesthesiologist to understand. I am a surgery/anesthesia trained proceduralist at a busy ASC, so I may (may) be a little more sympathetic to the anesthesiologist's plight. But not by much. It's a f@#$%^& two-minute case! Let's get ON with it! I have 20 more! That's private practice. Get used to it, everybody.

  2. I think the ABA/ASA/powers that be have some sort of fetish for double lumen tubes and the proper order of panicking during an airway fire and livers and nerve blocks to the lower extremity. I mean, really? In private practice it's MAC for scopes!