A DAY IN THE LIFE OF AN ANESTHESIOLOGIST

16 Feb 202116 Feb 2021THE ANESTHESIA CONSULTANT 1 Comment

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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.
emailrjnov@yahoo.com

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One of my readers asked me to describe a day in the life of an anesthesiologist, as he was considering a career in anesthesiology. To aid you in visualizing yourself in the hospital, I’m substituting the pronoun “you” instead of “I” in the narrative below.

Your day is as follows, Doctor:

0530 hours – Your alarm goes off, awakening you and starting your morning. (Anesthesia is not the career for you if you like to sleep late—surgery always begins at 0730 hours). You complete your morning bathroom and breakfast routines, and leave your residence at 0630 hours for the hospital.

0645 hours—You arrive at the hospital, use your ID to open the gate to the parking lot, and walk one hundred yards from the parking lot to the hospital entrance. You take the elevator to the third floor and proceed to the locker room. The scrubs are enclosed in a device not dissimilar to a soda machine, and you need your ID to operate it. The machine opens and you extract a scrub top and scrub bottom in your size. You leave your street clothes in your locker. Because anesthesiologists do not scrub in a sterile fashion, it’s OK to wear your watch and ring., and to bring your cell phone with you.

0655 hours—You don a bouffant hat and a facemask, and enter your operating room. Your hospital contains multiple operating rooms, and today you are in room #10. Your briefcase contains your personal medical equipment and office items you need for the day. Inside the operating room, the scrub tech is already dressed in a sterile gown and gloves, and is preparing the instruments the surgeon will use to operate on the first patient. The first surgery today is a procedure devised to treat obstructive sleep apnea, a procedure called a maxillary-mandibular osteotomy. An ear, nose, and throat (ENT) specialist will saw through the patient’s upper and lower facial bones, extend their bite forward to open the back of the throat further, and then fixate the bones in their new positions. The surgery will take approximately three hours.

Your station in the operating room consists of an anesthesia machine; a bevy of vital signs monitors; a computerized pharmacy cart; a cart full of syringes and equipment; and the computer which handles the hospital’s electronic medical record (EMR).

You log into the EMR system, and then you log into your first patient’s chart. You’ve looked over the patient’s information the night before, and you now review everything in detail, including the history, physical findings, vital signs, height, weight, body-mass index (BMI) from this morning, and any laboratory results.

Next you log into the patient’s file on the computerized pharmacy cart, and extract the controlled substances/drugs (Versed and fentanyl) that you will use for this case. The lower drawers to the computerized pharmacy cart unlock, and you’re able to access the propofol you’ll use to induce anesthesia. You fill a 20-milliliter syringe with 20 ml of propofol, and set it on the countertop. You remove a plastic breathing endotracheal tube (ETT) from its wrapper and set it next to the propofol syringe. You remove a lighted laryngoscope from a drawer and set it next to the ETT. You prepare several empty syringes which you’ll use to inject medications into your patient’s intravenous (IV) line.

Next you turn to the anesthesia machine and run through a checklist to assure it is connected to oxygen, full of the liquid form of the general anesthetic sevoflurane, and that all the hoses and valves are airtight and operational. You check the suction catheter system to document there is negative pressure should you need to suck saliva or vomitus out of the patient’s airway. You reach into your briefcase and pull out the stethoscope and peripheral nerve stimulator you’ll use during the case.

0700 hours—It’s time to meet your first patient. You walk into the pre-operative area, where your patient is wearing a hospital gown and is lying on a gurney. At this point every patient is apprehensive and anxious. You do your best to reassure him as you introduce yourself and sit down at the foot of the bed. Rather than launching immediately into medical questions, you begin by asking him what he would normally be doing on this day if he wasn’t at the hospital. This way you and the patient can connect on a human level before beginning the anesthetic proceedings. The patient will probably already have an IV in their arm, placed by a registered nurse. (To the contrary, in our practice we physician anesthesiologists start the IVs ourselves. We do this because we’re skilled at placing IVs painlessly and successfully, it doesn’t take that much time, and it gives the patient confidence that we’ll continue to take care of them at the highest level.)

You ask the patient questions that are pertinent regarding their medical history. For example, if a patient has a history of asthma you’ll ask him if he has ever had an asthma attack severe enough to require treatment in an emergency room. If the patient was older than 50 years, you’ll ask him if he gets shortness of breath when he climbs two flights of stairs.

Once your questions are answered, you’ll do a pertinent physical exam of the patient’s airway, heart, and lungs. Then you’ll explain the sequence of the anesthetic, as well as the anesthetic alternatives and risks. Your monologue goes as follows: “I’ll begin by giving you a medication in your IV which will make you feel less anxious. Then we’ll roll down the hallway into the operating room. There I’ll give you a medication which makes you lose consciousness. You’ll be asleep for the entire surgery. I’ll be with you that entire time, and you won’t feel any pain, or experience any awareness. During the time you’re asleep, there’s an airway tube in place. I’ll remove the tube when you wake up. You may have a sore throat from the tube. You may have nausea after general anesthesia. You’ll wake up reasonably comfortable, but as the general anesthesia wears off you’ll likely experience the onset of pain. There’ll be a nurse standing right next to you in the Recovery Room, and he or she will administer pain relieving medication to you if and when you need it. Do you have any questions?”

After the patient gives verbal consent, you administer 2 ml of Versed (midazolam), a Valium-like benzodiazepine, into the IV. Within a minute or two, the patient feels the relaxing effect of the Versed, and you roll his gurney down the hallway toward the operating room.

Moving a patient from the gurney to the operating room table.

0715 hours—You roll the gurney in to the operating room. The patient moves himself from the gurney to the operating room table. You and the operating room nurse work to connect the patient to the standard vital signs monitors: the pulse oximeter on his fingertip, the three (or five) electrocardiogram stickers across his chest, and a blood pressure cuff on his arm. You turn to the EMR computer, and with a series of clicks you document the start of anesthesia time; begin data collection from the vital signs monitors; and identify which device (anesthesia machine/monitors in which operating room) you are connected to and receiving input from. You inject two prophylactic anti-nausea drugs, Zofran (ondansetron) and Decadron (dexamethasone) into the IV, and inject 2 ml (100 micrograms) of the narcotic fentanyl. You place an oxygen mask over the patient’s face so that the room air (21% oxygen and 78% nitrogen) that he has been breathing is replaced by 100% oxygen prior to going to sleep.

0725 hours—It’s time to begin anesthesia induction. You inject 40 mg of lidocaine, a local anesthetic, into the IV to blunt the burning sensation that propofol can cause. Then you inject 20 ml (200 mg) of propofol into the IV. Propofol is an opaque white liquid which disappears from the IV line as it enters the vein in the patient’s arm. Within 20 – 30 seconds the patient is unconscious. You ventilate the patient with oxygen for two breaths via the facemask to document that the airway is open and patent, and then you inject 4 ml (40 mg) of the paralyzing drug rocuronium into the IV. You continue to ventilate the patient via the facemask as the patient becomes paralyzed and unable to breathe for himself. You monitor the progression toward paralysis with a small battery-powered nerve stimulator device which you hold against the facial nerve area lateral to his eyebrow on the side of his face.

This surgery requires a specialized ETT which enters through the nose, courses through the back of the throat, and then passes between the vocal cords into the trachea (windpipe). You remove the facemask so the surgeon can insert cotton swaths soaked in local anesthetic into each nostril. Once all motor twitch activity is absent on the facial nerve monitor, you insert the nasal breathing tube, coated with a lubricating jelly, into the right nostril. You advance the tube through the nose until the tip appears in the oral cavity. At this point, you insert the lighted laryngoscope into the patient’s mouth, visualize the vocal cords, and push the ETT from outside the nose through the vocal cords into the trachea. You use a syringe to inflate air into the balloon cuff on the distal end of the ETT, and connect the proximal end of the ETT to the hoses on your anesthesia machine. You inflate the lungs via the breathing system, and listen with your stethoscope to document there are appropriate breath sounds in both the left and right lungs. You turn on your anesthetic vaporizer to administer a concentration of 1.5% sevoflurane gas to the patient. You tape the patients eyes closed so that they do not dry out under general anesthesia. Next you unlock the bed so that it can be rotated 180 degrees, so you are near the patient’s feet and the surgeon has the head of the bed to himself.

While the surgeon, the nurse, and the scrub tech prepare the patient for the surgical incisions, you administer the antibiotic Kefzol (cephazolin) into the IV. Then you spend 10 minutes of time on the EMR, documenting every drug you injected and all the procedures you performed.

0800 hours—Surgery begins. You titrate the depth of anesthetic drugs to match the degree of surgical stimulus. You do this by monitoring the blood pressure and heart rate, and use a variety of IV drugs to keep the vital signs from straying too high or too low from their pre-operative values. By 0830 hours you are finally able to sit down. The EMR inputs the vital signs automatically from the patient monitors into the medical record. You are vigilant regarding the surgical procedure, the IV infusing into the patient, the ventilator, and the inhaled and injectable anesthetics administered. At certain times during the case, when the surgeon is sawing into the facial bones, he will ask you to lower the patient’s blood pressure in order to minimize bleeding from the bone. You do this by adding intravenous anti-hypertensive injections, and/or by deepening the level of general anesthetic drugs. As you near the end of this first case, you log into the second case of your anesthetic list on the EMR, and begin information gathering and EMR documentation as you did for your first case.

1130 hours—The surgery ends. You supervise the rotating of the operating room table 180 degrees, so the patient’s head and airway are adjacent to the anesthesia equipment again. You discontinue all anesthetic drugs and wait for the patient to regain consciousness. This can take from 5 to 15 minutes, and is a potentially hazardous time. Like landing an airplane, you need the patient to arrive at consciousness smoothly, without disruption in the vital signs. Most importantly you need him to be breathing safely through his newly remodeled face and airway.

1140 hours—The patient opens his eyes. You remove the ETT and place the oxygen facemask back over his nose and mouth. Once you’ve confirmed that he’s ventilating himself safely, you call for the gurney again. Together with the orderlies, the nurse, and the surgeon, you slide the patient back over to the gurney, and begin to transport him out of the operating room.

1145 hours—You push the gurney into the Post Anesthesia Care Unit (PACU), and into a parking berth staffed by a different registered nurse and another battery of vital signs monitors. You and the nurse connect the patient to the same monitors you used in the operating room, and document that the vital signs within safe limits. Then you give the nurse a verbal report of the patient’s preoperative medical problems and the pertinent surgical and anesthetic details. You proceed to the charting room, where you log into the EMR again and finish documenting all the data from the anesthetic. Throughout the time the patient is recovering in the PACU, the nurse follows medical orders you’ve written, and you’re responsible for the patient’s safety and well-being. The PACU nurse will call you for any questions or problems.

1155 hours—You find lunch somewhere. At my hospital there is no doctor’s cafeteria, and there is insufficient time to wait in line at the regular cafeteria. You may bring a sandwich from home, or you may subsist on protein bars, a bagel, a banana, or some yogurt you find in the operating room lounge. For anesthesiologists, the interval between surgeries is a time when the surgeons, nurses, and the empty operating room are waiting for you to get things going again. No surgery can proceed without anesthesia, so your between-case time is to be minimized. In some models of anesthesia care, a certified registered nurse anesthetist (CRNA) may break you out during the anesthetic or between cases, but when there is 100% physician anesthesia staffing, everyone is waiting for you between cases to get the next patient asleep.

1225 hours—You meet your second patient and go through the steps outlined beginning at 0700 hours above once again.

Depending on the length of your anesthetic list, you may be finished by 1400 hours (a 7-hour day), or you may be finished at 1700 hours (a 10-hour day), or if you are on-call you may work all night, until 0700 the next morning. The good news is that your pay is proportional to the duration of time and the number and complexity of the cases you do. When you are on overnight call as an anesthesiologist, you will usually have the next day entirely off.

On certain days you may work at an outpatient ambulatory surgery center (ASC) instead of at a hospital. At an ASC the surgical procedures are simpler, and medical problems are screened beforehand so that no sick patients are allowed. Many ASCs have no EMR, and the charting is done by writing on paper with a ballpoint pen, which is less time-consuming than the current sluggish and expensive EMR systems used at hospitals. During an ASC day you may do one 8-hour anesthetic, or you may do eight 1-hour anesthetics. An ASC often provides food for their staff and their doctors, and you will be finished at a reasonable and predictable time, usually between noon and 1700 hours.

How are your emotions during your day as an anesthesiologist? It depends on how experienced you are. Even veteran anesthesiologists are on edge during the induction of anesthesia and the placement of breathing tubes. The maintenance phase of anesthesia, during the middle of the surgery, is predictably stable most of the time. Are you bored during this time period? Not likely, as there is enough going on with the surgical procedure, its effects on the patient’s physiology, and the pharmacology you are commanding. The end of each surgery increases the vigilance and anxiety level of the anesthesiologist once again until the patient is safely transferred to the PACU. Some cases are more stressful than others. Emergency surgeries, patients at the extremes of age (very young or very old), trauma surgeries, cardiac surgeries, lung surgeries, and neurosurgeries are among the most stressful. Anesthesiologists who practice these subspecialties are often adrenaline junkies themselves, and enjoy the challenge of more difficult cases.

After your work day you’ll drive home and enjoy a free evening. You typically won’t have any phone calls regarding the day’s patients. Once a patient leaves the PACU without complications, it’s unlikely there will be ongoing any issues for the anesthesiologist. For these reasons, anesthesiology is often considered a “quality lifestyle” medical specialty. I’d agree. Your evenings and weekends are usually free unless you are on call, which makes anesthesiology appealing.

On each work evening you’ll receive your list for the following day’s cases. In our practice, we telephone each patient the night before to go over essential questions. Hopefully then you can go to sleep when you please. In my career I’ve had quite a few nights where the next day’s difficult cases gave me cause for concern or worry. Concerns and worries can lead to insomnia, a not-uncommon stressor for a practicing anesthesiologist. You might be worrying about a re-do heart valve replacement anesthetic on an 80-year-old woman, a throat surgery on a 340-pound man, or a list of 3-year-olds with obstructive sleep apnea who are having tonsillectomies.

A career in anesthesia is not for the faint at heart. Mistakes or complications in our specialty can lead to bad outcomes in a matter of minutes. That said, a career in anesthesia is a fascinating and complex lifetime passion, during which you can help tens of thousands of patients undergo surgery safely.