Intern year is a rite of passage where we build the foundation of becoming a good (hopefully great) physician. And if we are fortunate, we recognize the experiences that will make us into quality anesthesiologists. But before we go any further, what does it take to be a good resident and physician?
I turned to John Brock-Utne, MD, PhD, who serves as professor emeritus at Stanford University, board member of the California Society of Anesthesiologists, and author of Clinical Anesthesia. Near Misses and Lessons Learned scheduled for release in 2018. His wealth of knowledge and experience was built practicing anesthesiology and mentoring more classes for longer than some of us have been alive.
Take a good history
During your intern year, you’ll certainly meet many new patients. Your goal in all circumstances, whether as an intern, a resident, or a practicing anesthesiologist, is the same – to gather important information during the interview, and earning the patient’s trust.
“You have twenty seconds to convince the person you will be able to look after them,” Dr. Brock-Utne says “How you do it is learnt by doing it. Firm handshake. Explain who you are. And always remember to introduce yourself to people at the bedside and acknowledge them. They are there for a reason and important for the patient’s care.”
In my short time as a CA-1 resident, I’ve seen excellent anesthesiologists quickly put patients at ease and earn their trust. Some pull up a chair and sit at eye level. Others bring a warm blanket. Some have a calm demeanor and will joke, “We’ll give you the good stuff and our jokes will become much funnier I promise.” And others ask questions to let the patient know they are more than a disease, “Did you drive in from far away? I’ve actually been there…”
In anesthesiology and in medicine, knowing about a patient’s past medical history, current medications, and allergies are important. These answers will influence the anesthetic plan and help us anticipate any events intra-op and post-op.
Taking a good history is imperative even for the simplest and most straightforward cases.
You are caring for an elderly patient from the ICU, who has been added on at the end of the day for a special central line catheter placement. You provide monitored anesthesia care with a natural airway. During the case, an inadvertent pneumothorax develops and the patient’s pulse oximetry drops. What should you do? Intubate? That makes sense, unless….
What do you need to know before making this decision?
The question you need to know the answer to is her DNR/DNI status. If that patient has a DNR/DNI order, it is imperative to reach a consensus between the patient, family members, surgical, and anesthesia teams regarding care and resuscitation efforts, prior to taking her to the OR.
You go to meet your next patient who is an otherwise healthy patient in the pre-op area. Your eyes glance at the monitor and you notice sinus tachycardia. You ask about illicit drug use which the patient denies. The nursing team has the room ready and the surgery team is eager to begin. What do you do? Is he just nervous? Does he have unrecognized cardiac disease, or is the answer more straightforward?
Simple – order a urine toxicology screening. In a case quoted by Dr. Brock-Utne, the urine toxicology showed amphetamine levels > 1000 ng/ml. The case was cancelled because a good history was taken and the anesthesiologists refused to be rushed.
Examine your patients
“Always examine the patient. You will be thankful you did.” This seems like a simple trope, but sometimes we can be fooled.
Dr. Brock-Utne recalls a vivid case in which he was reminded of this point. He saw a young adult female in the preoperative holding area. She was a patient with chronic pain, who was on a fentanyl patch and was awaiting ureteral re-implantation. On the day of surgery, she was complaining about severe abdominal pain, which she said was worse today. However, the parents at bedside provided reassurance that her pain intensity was no different than other times. No one else seemed particularly concerned.
What would you have done next? Perform a physical exam. Patients with chronic pain can be challenging to manage. Sometimes additional pain medication is indicated, but in this case when Dr. Brock-Utne laid hands on her stomach, he recognized that she had developed an acute abdomen from the combination of the fecal impaction and bowel prep. Thankfully, the surgery was rescheduled.
As a resident or physician in practice, looking for multiple sources of data and gathering a more complete overview of the patient condition and history is vital. This is one place where the electronic medical record can be both a blessing and a curse. Practically speaking, focusing on cardiac and pulmonology exams are of high yield. If you find one thing, keep looking for another related problem.
For example, Dr. Brock-Utne urges trainees to always examine a patient in the trauma bay and to not take anyone’s words for his or her examination. As an example of that, always remember that an alive patient with only one stab wound most likely will have one or more stab wounds somewhere else on his or her body. Keep looking!
A monitor is just a monitor
Imagine a 54-year-old man who is under anesthesia for an above knee amputation of his left leg. He has type 1 diabetes, coronary artery disease, hyperlipidemia, hypertension, and peripheral vascular disease. Suddenly the patient has a cardiac arrest with a straight-line EKG. You start resuscitation and call a code. When your colleagues arrive, they congratulate you on a job well done. You look up and see the EKG perk up showing a sinus rhythm with a rate of 72 beats per minute.
Are you happy?
Unless you have examined the patient, you should not be content. In Dr. Brock-Utne’s case despite having a seemingly reassuring electrical tracing the patient had no pulse or blood pressure. Unfortunately, the patient died with the EKG showing a normal sinus rhythm with a beat of 72 per minute. What happened?
The EKG monitor was a demonstration model, when suddenly not sensing the heart electrical activity went into a demonstration mode yielding the pre-programmed 72 beats per minute.
While it is unlikely that you’ll only have an EKG rhythm monitor, it is very likely you will be reading about patients who have been admitted, checking morning labs, or reviewing vital signs during an overnight call shift. You will have a deluge of information – the labs and monitors are only one part of the patient’s picture. The patient is the patient.
Develop your skill set
Dr. Brock-Utne’s final gem for trainees is simple: develop technical skills, such as placing IV’s, central lines, arterial lines, and spinals/epidurals. While there may not always be many opportunities to place invasive lines, volunteer as much as possible to place IVs. Be proactive in observing these procedures. Ultrasound is a team sport. While only one person manages the needle, everyone in the room can learn the anatomy
Our technical skills reflect something more important – understanding and interpretation.
What are the indications for the lines? When do you decide to place it? How do you interpret the findings? What are the common pitfalls of interpreting it? What intervention will you make? How do you troubleshoot a difficult line? Are there other alternative ways to gather that information? Are there any contraindications to the line? What clinical question is it helping to answer?
Applying these practical points as developed from Dr. Brock-Utne’s experience, should help us become better doctors and perhaps even great anesthesiologists.