12 THINGS TO KNOW AS YOU NEAR THE END OF YOUR ANESTHESIA TRAINING

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

The most difficult challenge for any anesthesiologist is the transition from the end of anesthesia residency into the beginning of your first job. You’re on your at the hospital, sometimes on weekend nights, and sometimes at 3 a.m.

In “Subterranean Homesick Blues” Bob Dylan wrote, Twenty years of schoolin’ and they put you on the day shift. 

For anesthesiologists, it’s more like twenty-five years of training and they put you on the night shift. Alone.

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Every anesthesiologist walks a long road before they finish their education. This includes thirteen years to finish high school, four years of college, four years of medical school, a year of internship, three years of anesthesia residency training, and possibly an extra year of a subspecialty fellowship.

When I finished my training I was naïve about what was around the corner. I had no physicians in my family and no older physicians as close friends. I learned my lessons in real time on the front lines. As you near the end of that twenty-fifth year of education, here’s a list of twelve things you should know before you leave the cocoon of academia and venture out into the job market as an anesthesiologist:

  1. Your professors won’t find you a job. Their role is to teach anesthesia, to take care of patients, and to do research. They are not guidance counselors. Most of them are academics who either enjoy teaching or who enjoy the university faculty lifestyle. If they knew of or coveted a private practice job themselves, they would have taken one themselves long ago. You’ll likely have to find a job yourself. Your professors are of significant value when you are being considered for a specific job, because they can give your prospective employer a positive evaluation of you.
  2. You’ll find job listings on the Internet. Apply for jobs you have interest in. Don’t be surprised if most of these posted jobs have a problem such as low pay, an undesirable location, a dead end career track, or (let me say it again) low pay. The more jobs you look into, the better you’ll understand the marketplace. You’ll learn from every unsuccessful inquiry. Why are jobs posted on Internet sites usually inferior jobs? See #4 below.
  3. The best job opportunities are communicated by word of mouth. For example, imagine that an excellent group needs a new anesthesiologist with an emphasis in regional anesthesia. Members of that group will communicate with acquaintances at local university training programs or with top national university training programs, and ask for the names of recommended candidates. You want people to recommend you. It’s an old boy’s club of sorts (except that it includes men and women). You’ll get called up when the old boys agree that you’re the one they want.
  4. If there’s a hospital location or an anesthesia group you’re particularly interested in, but they are not advertising a job opening. don’t waste your time writing them a letter with your curriculum vitae attached. The letter will be discarded. Instead, make phone calls. Find out who the leader of the group is, and call the operating room or the anesthesia company’s phone number. If they are unavailable, leave a message. Repeat in a week or so until you make contact. If they never call you back, so be it. But if you apply this strategy to multiple different jobs, you will connect with a real human voice, and you’ll have the opportunity to sell yourself over the phone.
  5. Make as many personal contacts as you can with anesthesiologists who are already in private or community practice. Ask them questions when you can, and once you’ve landed a new job, connect with one of your new colleagues so they can serve as your mentor for the early career years. You’ll need to transition from a trainee mentored by professors to a graduated anesthesiologist mentored by a doctor who’s already out there in anesthesia practice.
  6. Retain at least one close contact with a former faculty member, so you can ask questions of them as well after you are out in community practice. The theme here is build bridges with new colleagues, and never burn bridges with your old teachers.
  7. You’ll have to pass your board examinations. My advice is to read every word of Miller’s Anesthesia prior to your oral boards. It’s a terrific book, and this is the one time in your career that you’ll be motivated to have encyclopedic knowledge of your specialty.
  8. Along with book learning, find opportunities to take mock oral exams from faculty at your training program. Stanford conducts twice-yearly mock oral exams, using the identical format that the American Board of Anesthesiology uses. See my column ADVICE FOR PASSING THE ORAL BOARD EXAMS IN ANESTHESIOLOGY. If you read Miller’s Anesthesia and undergo mock oral training, you’ll pass the board exams and you’ll become board-certified in anesthesiology—a requirement for all top shelf jobs.
  9. Think “Airway – Airway – Airway.” Airway –Breathing – Circulation, or A – B – C, describes the core management of critical care situations in the operating room, the emergency room, or the ICU. Of these three, the one that can get a new graduate (or any anesthesiologist) in a heap of trouble in less than five minutes is a botched airway. Be extremely careful and vigilant regarding all issues of airway management, both at times of intubation and extubation. Faulty judgment which leads to three minutes of hypoxia for your patient could severely harm your patient and change your life. Learn the ASA Difficult Airway Algorithm, and read AVOIDING AIRWAY DISASTERS IN ANESTHESIA. Avoid an airway disaster at all costs.
  10. Find a reliable recipe for each common type of anesthetic, hone it, and stick to it. The early career years are not about doing “interesting” anesthetics, they are about doing safe, predictable anesthetics with safe outcomes.
  11. Private practice surgeons are fast. Avoid the high doses of narcotics and muscle relaxants you used on those tediously long university cases. These will be overdoses in private practice, and your patients will be slow to wake up.
  12. Learn how anesthesia billing is done. Learn how money is distributed to new anesthesiologists in a prospective job, and how your income will change over the years at that job. A quality job will have a path to partnership, where you will earn as much as the senior members of the group do at this point in time.

 

Good luck, happy job searching, and may your patients all be safe!

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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AVOIDING AIRWAY DISASTERS IN ANESTHESIA

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Every anesthesia practitioner dreads airway disasters.  Anesthesiologists and nurse anesthetists are airway experts, but anesthesia professionals are often the only person in the operating room capable of keeping a patient alive if the patient’s airway is occluded or lost. Hypoxia from an airway disaster can lead to brain damage within minutes, so there is little time for human error.

A fundamental skill is the ability to assess a patient’s airway prior to anesthesia. One must assess whether the patient will pose: 1) difficult bag-mask ventilation, 2) difficult supraglottic/laryngeal mask airway placement, 3) difficult laryngoscopy, 4) difficult endotracheal intubation, or 5) difficult surgical airway.

Of critical importance is #1) above, that is, recognizing the patient who will present difficult mask ventilation. Conditions that make for difficult bag-mask ventilation are uncommon, and usually can be detected during physical examination. Despite the importance of expertise in endotracheal intubation, I teach residents and trainees that the most important airway skill is bag-mask ventilation. Every year I encounter several patients who present unanticipated difficult intubations. In each of these patients, I’m able to mask ventilate the patient to keep them oxygenated while I try various strategies and techniques to successfully place an endotracheal tube or a laryngeal mask airway.

Most anesthesia airway disasters aren’t merely difficult intubations, but scenarios that are classified as “can’t intubate, can’t ventilate.” In these “can’t intubate, can’t ventilate” situations, the anesthesiology professional has only minutes to restore oxygenation to the patient or else the risk of permanent brain damage is very real.

The American Society of Anesthesiologists Difficult Airway Algorithm is a guide for anesthesia practitioners regarding how proceed in airway management. The algorithm is detailed, complex, comprehensive, and defines the standard of care in any medical-legal battle concerning hypoxic brain damage due difficult airway clinical cases. The algorithm is so detailed, complex, and comprehensive that some would say it’s impossible to remember every step in the acute occurrence of an airway disaster.

A simplified approach has been touted.

Dr. C. Philip Larson, Professor Emeritus, Anesthesia and Neurosurgery, Stanford University, and Professor of Clinical Anesthesiology at UCLA, and previous Chairman of Anesthesiology at Stanford, was one of my teachers and mentors for both endotracheal intubation and fiberoptic intubation. In a Letter to the Editor of the Stanford Gas Pipeline in May, 2013, Dr. Larson wrote, “there is no scientific evidence that anesthesia is safer because of the ASA Difficult Airway Algorithm.  While an interesting educational document, I question the daily clinical value of this algorithm, even in its most recent form (Anesthesiology 2013; 118:251-70). The ASA Difficult Airway Algorithm was developed by committee and has all the problems that result when done that way.  It is complex, diffuse, multi-dimensional, and all-encompassing such that it is not an instrument that one can easily adopt and practice in the clinical setting.”

Dr. Larson recommends a system of Plans A-D, a system he published in Clinical Anesthesiology, editors Morgan GE, Mikhail MS, Murray MJ, Lange Medical publication, 4th edition, 2006, pp 104-5, and in Current Reviews in Clinical Anesthesiology (2009; 30:61-72), and also in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014). An outline of the system is as follows:

A.  Plan A is direct laryngoscopy an intubation using a Miller or MacIntosh blade.

B.  If Plan A is unsuccessful, Plan B includes use of video laryngoscopy with a GlideScope or similar device.

C.  If Plan B is unsuccessful, Plan C is placement of an LMA with intubation through that LMA using a fiberoptic bronchoscope.

D.  “If Plans A-C fail,” Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “one needs Plan D.  The first and perhaps the most prudent option is to cancel the proposed operation, terminate the anesthetic, and wake the patient up. The operation would be rescheduled for another day, and at that time an awake fiberoptic intubation technique would be used.  Alternatively, if the operation cannot be postponed, then the surgeon should be informed that a surgical airway (i.e.: tracheostomy) must be performed before the planned operation can commence.  To date, utilization of Plan D because of failure of Plans A-C has not occurred.”

Dr. Larson wrote that the airway skills in Plan A – C should be practiced regularly on patients with normal airways. I agree with Dr. Larson that in managing difficult airways, a practitioner needs a short list of procedural skills that he or she is expert at rather that a large array of procedures that they rarely use (such as the alternative intubation techniques using light wands or blind nasal techniques, or invasive airway procedures such as retrograde wires passed through the cricothyroid membrane or transtracheal jet ventilation through a catheter). It’s wise for anesthesiologists to regularly hone their techniques of video laryngoscopy (Plan B) and fiberoptic intubation via an LMA (Plan C) on patients with normal airways, to remain expert with these skills.

Regarding Plan B, an important advance is the availability of portable, disposable video laryngoscopes such as the Airtraq, a guided video intubation device. In my career I sometimes work in solo operating room suites distant from hospitals. In these settings, the operating room is usually not be stocked with an expensive video scope such as the GlideScope, the C-MAC, or the McGrath 5. I carry an Airtraq in my briefcase, and if the need for Plan B arises I am prepared to utilize video laryngoscopy at any anesthetizing location. I suggest the practice of carrying an Airtraq to any anesthesiologist who gives general anesthetics in remote locations.

Regarding emergency surgical rescue airway management, Dr. Larson recently published a Letter to the Editor in the American Society of Anesthesiologists Newsletter, February 2014, entitled, Ditch the Needle – Teach the Knife. In this letter, Dr. Larson wrote:

“in life-threatening airway obstruction, … an emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. It should be deleted from the ASA Difficult Airway Algorithm. I have participated in seven cricothyrotomies in emergency airway situations, and all of the patients left the hospital without any neurological injury or complications from the cricothyrotomy. The risk-benefit ratio is markedly in favor the knife technique…. With a knife, or scissors, one cuts quickly either vertically or horizontally below the thyroid cartilage and there is the cricothyroid membrane or tracheal rings. The knife is inserted into the trachea and turned 90 degrees, and an airway is established. At that point, a small tube of any type can be inserted next to the knife. The knife technique is much safer because there is virtually nothing that one can harm by making an incision within two inches or less in the midline of the neck, and it can be performed in less than 30 seconds. In contrast, the needle is fraught with complications, including identifying the trachea, making certain that the needle is entirely in the trachea and does not move ( to avoid subcutaneous emphysema when an oxygen source is established), establishing a pressurized oxygen delivery system (which will take more than five minutes even in the most experienced circumstances), and avoiding causing a tension pneumothorax… I know of multiple cases of acute airway obstruction where the needle technique was attempted, and in all cases the patients died. I know of no such cases when a cricothyrotomy was used as the primary treatment of acute airway obstruction.”

A final note on the awake intubation of patients with a difficult airway: In hindsight in any difficult airway case, one often wishes they had secured an endotracheal tube prior to the induction of general anesthesia. The difficult problem is deciding prior to a case which patient has such a difficult airway that the induction of general anesthesia should be delayed until after intubation. In anesthesia oral board examinations it may be wise to say you would perform an awake intubation on a difficult airway patient rather than risk the “can’t intubate, can’t ventilate” scenario the examiner is probably poised to skewer you with. In medical malpractice lawsuits, plaintiff expert witnesses in anesthesia airway disaster cases often testify that a brain-dead patient’s life would have been saved if only the anesthesiologist had performed awake intubation rather than inducing general anesthesia first and then losing the airway. The key question is: how does one decide which patient needs an awake intubation? As an anesthesia practitioner, if you performed awake intubations on one out of 50 cases because you were worried about a difficult airway, you would delay operating rooms and surgeons multiple times per year because of your caution. You will not be popular if you do this. In my clinical practice and in the practice of the excellent Stanford anesthesiologists I work with, the prevalence of awake intubation is very low. I estimate most anesthesiologists perform between zero and two awake intubations per year. The most common indications include patients with severe ankylosing spondylitis of the cervical spine, congenital airway anomalies, and severe morbid obesity. Dr. Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “I do anesthesia for most of the patients with complex head and neck tumors, and I find fewer and fewer indications for awake fiberoptic intubation. As long as the lungs can be ventilated by bag-mask or LMA, which is true for almost all sedated patients, Plan C is easier, quicker and safer than awake fiberoptic intubation both for the patient and the anesthesia provider.  In experienced hands, Plan C can be completed in less than 5 minutes, and one can become proficient by practicing in normal patients. I have done hundreds of Plan C’s, many under difficult circumstances, without a single failure or complication.  Obviously, no technique will encompass every conceivable airway problem, but mastering Plans A-D and awake oral and nasal fiberoptic intubation will meet the needs of anesthesia providers in almost all circumstances.”

May you never experience the  emotional trauma of an airway disaster. Become an expert in bag-mask ventilation, always have access to a video laryngoscope or an Airtraq, and consider  Dr. Larson’s  Plan A-D system, described in detail in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014).

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited