14 DIFFERENCES BETWEEN EXPERIENCED AND INEXPERIENCED ANESTHESIOLOGISTS

THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
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Is your doctor an experienced anesthesia provider or a newbie? The list below chronicles the crescendo of growth of as I’ve witnessed it from a newly-trained anesthesia doctor to an expert practitioner. It’s a development of skills, maturity, and judgment over many years. As a patient, the only signs you’re likely to recognize are #1 and #2 below, but each of these differences are real. In my view, inexperienced anesthesia providers are more likely to:

  1. Be nervous/anxious. This observation is no surprise. Everyone is more nervous at their job when they’re a novice than when they’re experienced. Imagine you’re two months out of anesthesia training, working at a community hospital, and at 2 a.m. you need to induce emergency anesthesia for a 300-pound man who just ate a full meal of pizza and beer two hours earlier. You’re working alone without that anesthesia attending who stood next to you during residency training. Anesthesia emergencies are anxiety-producing for both experienced and inexperienced anesthesiologists, but experienced doctors are more likely to know exactly what to do and what not to do. In this example, it’s a solid idea to get another anesthesiologist, or the emergency room MD if no anesthesiologist is available, to assist in the induction and intubation of this morbidly obese patient with a full stomach.
  2. Pay less attention to a patient’s preoperative medical comorbidities. Anesthesiology can be thought of as a subspecialty of internal medicine or pediatrics. At Stanford we’re the Department of Anesthesiology, Perioperative and Pain Medicine. “Perioperative” means “the time around an operation”—specifically the preoperative, postoperative, and intraoperative times. Inexperienced anesthesiologists may only contemplate a recipe of anesthesia drugs, instead of seeing his or her role as the management of the patient’s medical problems prior to, during, and after surgery. The sophisticated anesthesiologist must understand the patient’s heart disease, lung disease, kidney disease, etc., in the context of what the surgery and the anesthetic medications do to these diseases.
  3. Be prone to panic in emergencies and not follow the ABCs of Airway-Breathing-Circulation. When I review charts regarding medical malpractice during emergencies, too often I see anesthesia providers administering cardiac drugs and worrying about the blood pressure when no one has managed the airway (i.e. intubated the trachea), or no one is ventilating the patient. If your case turns into an unplanned emergency complication, always turn to the ABCs to guide your next moves.
  4. Use multiple intravenous anesthetic infusions for a routine case. When questioning an anesthesia resident, it’s not uncommon to hear an anesthetic plan which includes two intravenous infusions, one of propofol, and one of remifentanil. In my medical-legal work I review anesthesia charts from across the United States, and I can attest that by far the most common general anesthetic is a dose of propofol followed by sevoflurane (inhaled) maintenance. Sevoflurane is easy to use—you turn the vaporizer on at the beginning of the case and off at the end of the case—and we can accurately monitor the amount of sevoflurane going into and coming out of the lungs with our gas monitors. Using two IV infusions requires assembling the two sets of syringes and tubing, inserting two syringes into two syringe pumps, and programming the pumps. Failing to refill the infusions, or failing to turn them on, or any failure of the IV line can cause serious problems. Dual IV infusions defy the wisdom of the KISS Principle, i.e. Keep It Simple Stupid. And there are no data that remifentanil is a superior anesthetic to sevoflurane for most cases.
  5. Use recipes that include excessive narcotics. When administering mock oral exams to anesthesia residents, it’s common to hear that 250 micrograms of fentanyl are administered IV prior to anesthesia induction, to “blunt the hypertension from intubating the trachea.” In private community practice one discovers that as little as 50 micrograms of fentanyl is sufficient prior to anesthesia induction to blunt hypertension, and that by minimizing the total dose of narcotic for the case, one can achieve less post-intubation hypotension, a quicker wake-up at the conclusion of anesthesia, and less nausea that when one administers excessive narcotic. As a rule of thumb, try to administer a dose of narcotic 45 to 60 minutes prior to emergence to cover post-anesthetic pain requirements. Excessive doses prior to that time add to oversedation and excessive nausea without any clear benefit.
  6. Be afraid of surgeon criticism and feel on unequal status with the surgeon. As one of my faculty members told me decades ago, “some surgeons are bullies.” A bullying surgeon can often smell blood in the water when an anesthesia provider doesn’t feel assertive or confident. Your surgical colleague is skilled at surgery, but you are the expert at anesthesiology. It’s a symbiotic relationship. He or she needs you as much as you need the surgeon. Be confident in your decisions and in your conversation. The surgeon is not “the captain of the ship” in the operating room. You are both co-captains. In private practice, surgeons respect anesthesiologists, and vice versa.
  7. Administer multiple doses of paralytic drugs, so that a patient doesn’t ever move, which would upset the surgeon. See #5 above. If you’re afraid of a surgeon’s criticism, then an episode in which the anesthetized patient moves or coughs may seem like a minor catastrophe. It’s not. A reasonable reply when a patient moves is, “I’ll deepen the anesthesia. Everything’s OK. The patient is asleep.” Inexperienced anesthesia providers may attempt to keep patients paralyzed with muscle relaxant drugs such as rocuronium, even if paralysis isn’t necessary for a particular surgery (e.g. a limb surgery or a facelift), so the patient can’t move and the surgeon will have less opportunity to express anger.
  8. Draw up ten (unused) syringes prior to a routine anesthetic. Prior to the first case of the day, trainees often draw up multiple drugs into syringes, and then label the syringes, for every drug they could possibly use during that day. Syringes of atropine, ephedrine, phenylephrine, lidocaine, Zofran, fentanyl, Dilaudid and succinylcholine are lined up in a beautiful parallel array on the anesthesia machine desktop. Experienced anesthesiologists know that while it’s necessary to draw up two or three syringes of drugs such as propofol, fentanyl, and rocuronium, the other drugs are available in the top drawer of the anesthesia cart as needed. Some cases require no more than three drugs total. Some cases require a dozen drugs or more. Experienced anesthesiologists draw up drugs and narcotics when they are needed, not prophylactically.
  9. Believe every orthopedic patient needs an ultrasound-guided nerve block. Until the 21st Century, non-total-joint orthopedic cases on shoulders, elbows, hands, knees, and feet were routinely done without ultrasound-guided nerve blocks, and patients had few bad outcomes. Acute pain was treated with IV narcotics followed by oral pain relievers, and patients were discharged home in stable condition. Ultrasound-guided nerve blocks have a role in anesthesia care for orthopedic surgery, but they’re not mandatory. There are no data that ultrasound-guided nerve blocks improve long-term outcome, and the use of ultrasound has not decreased the small but non-zero incidence of permanent nerve damage. Experienced anesthesiologists consider nerve blocks as optional adjuncts for certain painful cases in certain patients. The “recipe” for orthopedic anesthesia does not have to include an ultrasound-guided nerve block.
  10. Fail to respect/fear a difficult airway for what it is: a potentially life-changing event for both the patient and you. One of the greatest risks you’ll face as an anesthesia provider is a patient with a difficult airway. If you mismanage or lose the airway, you run the risk of the patient having hypoxic brain damage after as little as five minutes without oxygen. A patient outcome of hypoxic brain damage can change your emotions and your life in painful ways. It’s not enough to learn the American Society of Anesthesiologists Difficult Airway Algorithm.  If you have a difficult airway, get help such as an additional anesthesiologist in the room. Use technology, such as a video laryngoscope and the difficult airway cart. If you lose the airway, be ready to perform a cricothyroidotomy if intubation or an LMA rescue are unsuccessful. A cricothyroidotomy is not that difficult https://theanesthesiaconsultant.com/2018/11/07/front-of-neck-access/ , and it can save a life—a better choice than waiting for a (non-ENT) surgeon to perform anterior neck access such as a tracheostomy.
  11. Treat bradycardia with Robinul instead of atropine. When a significant bradycardia occurs, i.e. a heart rate less than 50, or a heart rate less than 60 along with hypotension, the Advanced Cardiac Life Support (ACLS) treatment is atropine, not Robinul. Robinul, or glycopyrrolate, is an anticholinergic drug used almost exclusively by anesthesiologists. It’s a weaker chronotrope than atropine. When you want to accelerate the heart rate in the operating room or the post anesthesia care unit, use the first drug recommended in the ACLS and American Heart Association bradycardia algorithms—and that drug is atropine. If the patient has an adverse outcome after a symptomatic bradycardia episode and you didn’t administer atropine, you’ll have a difficult time defending your decision.
  12. Fail to write detailed postoperative notes after a complication occurs. Every anesthesia provider will eventually have complications. Your first responsibility is to manage the clinical circumstances as well as possible. Your second responsibility is to transfer the patient to the clinical forum that’s indicated after the complication, which may be an intensive care unit, a cardiology consult, or a transfer from a freestanding ambulatory surgical care unit to a hospital. Your third responsibility is to write a detailed note about what happened. Usually there’s no time to fill out the anesthesia record during an acute complication, but as soon as you have time, write a detailed note that describes the clinical circumstances that occurred, how you treated those circumstances, and what the patient’s response was. Your note should record the timeline, the vital signs the patient had, and what your presumed diagnosis was. Do this while your memory is fresh. This postoperative note is more than a clinical narrative, it’s a medical-legal document. Walking away from the case without writing a detailed postoperative note/summary is a mistake.
  13. Perform slow patient wakeups, and a slow turnover of cases. Private practice surgeons are faster than academic surgeons, because they are already fully trained and they’re not teaching anyone. A list of private cases will flow faster than a similar list in a university setting. Inexperienced anesthesiologists who haven’t learned how to wake patients efficiently will slow down the system. Inexperienced anesthesiologists can cause slow turnovers from one case to the next. In a private practice setting the operating room may be ready to accept the next patient in just 10 – 15 minutes. There’s little time for a trip to the cafeteria or to run errands.
  14. Fail to ask senior anesthesiologists in the group they just joined for advice on how to do a specific case. Faculty members in residency and fellowship are highly trained experts who guide trainees through academic surgical practice. Community private practice is not a training program—everyone is fully trained—and everyone aims for efficient, repeatable medical care. When you enter into this new arena, don’t be afraid to ask senior anesthesiologists for advice. They won’t be annoyed—they want you to succeed. It’s in everyone’s best interest for you to become a safe, efficient anesthesiologist as soon as possible. Before cases, feel free to ask a senior anesthesiologist how he or she does the anesthetic for an acute hip fracture in a 90-year-old. Feel free to ask how he or she does the anesthetic for a 6-hour revision open rhinoplasty. One day in the future you’ll be that senior anesthesiologist, experienced and ready to answer questions yourself.

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