A Day in the life of a trainee anaesthetist on-call

As an anaesthetic trainee you will spend time ‘on-call’ or on ‘CEPOD’ – which stands for Confidential Enquiring into Perioperative Death, a venture set up in 1987 – which basically just means ‘emergency surgery’.

During these shifts, which are usually twelve hours or so in length, there isn’t a set pattern as to what the day will involve, you’re simply on hand to deal with any emergencies that may arise during the shift, which might include:

• A patient needing emergency surgery
• such as a laparotomy for a perforated bowel, or debridement of a severely infected wound that cannot safely wait until the next day
• A medical patient needing respiratory or cardiovascular support
• such as a patient with severe pneumonia or COVID-19 needing to go onto a ventilator to help their breathing
• A patient needing sedation for a procedure
• such as an adult reducing a fracture in the emergency department, or a child needing an MRI scan
• A critically patient needing transfer, between departments or to another hospital
• such as an intubated patient on intensive care needing a CT scan, or a transfer to another hospital for a specific specialist treatment
• A patient in acute severe pain for whom normal pain medications aren’t working
• such as a patient with rib fractures, who may benefit from a local anaesthetic nerve block to numb the specific nerves supplying the broken ribs

08:00 – The Day begins

“How was your night?”

“Not too bad, thanks, we had a laparotomy at 21:00 which we took round to ITU at 01:00 and then I just had a few pain patients to review overnight. There’s no-one in resus or the cardiac catheter suite and no sick kids. There’s an appendix and a hernia on the board to do today, I’ve seen the appendix who looks fine, no medical problems and looks well, she’s not eaten since yesterday and should be an easy intubation”

“Great thanks, I’ll take the bleep – go get some rest!”

The day starts at eight o’clock with a morning handover from the night anaesthetist to the day team. They will discuss any patients that were operated on overnight, and any issues that occurred as a result. They will also mention any pain patients that need reviewing during the day, and any medical patients that are of particular concern, who may need further assistance from the day team.

The night anaesthetist then hands the bleep to their daytime counterpart and heads home for some sleep!

Often at this stage there will be cases already booked on the the CEPOD board.

This is a live list of patients who need urgent operations, but who could safely wait until daytime hours to have their operation.

There is a general rule that only patients at risk of losing ‘life or limb’ should have their operation performed between midnight and 08:00, as it is far safer to operate during the daytime when there are more people around to help if anything goes wrong.

The theatre team, anaesthetist and surgical team decide between them the order in which these patients need to have their operation, based on clinical need and availability of staff and equipment, and then the anaesthetist heads off to do their preoperative assessment.

This involves firstly locating the patient, and then finding out more about their background and medical problems, to help the anaesthetist construct a suitable anaesthetic plan. This is discussed and agreed with the patient, and the patient can then ask any questions they may have before the operation.

A really important part of this discussion is building rapport with the patient, as they are trusting you with rendering them unconscious and breathing for them, having only just met you!

In the case of very unwell patients, the anaesthetist must decide whether the operation should go ahead immediately, or whether they need to instigate further treatment or even admit the patient to intensive care before surgery, in order to stabilise them as much as possible and therefore improve the patient’s chances of surviving the operation.

09:30 – The first operation

*“Hello and welcome to the operating department! We’re your anaesthetic team today who will be looking after you. We just need to check a few details and then we’ll go inside and pop some routine monitoring on, which just lets us know how you’re getting on while you’re asleep…”

”Well done just some nice deep breaths now, I’m giving you a strong painkiller, and then we’re going to drift gently off to sleep. Keep your eyes open as long as you can, and we’ll take very good care of you…”*

“I can see the vocal cords, tube please…. Tube is in, we’re on the ventilator, please can you call the surgeons to let them know we’re ready?”

“Well done! Time to wake up now, operation’s all finished, it all went well… I’m just going to take this breathing tube out and you’ll feel a lot more comfortable”

The patient is brought up to theatre and the theatre staff perform their usual checks to ensure the right patient has arrived, expecting the right operation. They then enter the operating room and specific monitoring is put on, including

• ECG
• An electronic heart trace that gives information about the rhythm and rate of the heart
• Blood pressure cuff
• To monitor blood pressure during the operation, when anaesthetic and surgical factors can dramatically alter a patient’s blood pressure outside of safe levels
• Pulse oximeter
• To monitor the oxygen levels in the blood to inform the anaesthetist of how much oxygen to give the patient through the ventilator

Once the patient is safely set up on the table with the correct monitoring in place, the patient is induced, or ‘drifted off to sleep’. This is usually done by giving the patient oxygen to breathe while injecting powerful sedating drugs such as propofol, along with a strong painkiller like fentanyl and then a muscle relaxant to allow the anaesthetist to pass a breathing tube into the patient’s trachea in a process called intubation. Once they are asleep, they are connected to the anaesthetic machine which keeps the patient asleep, either with a continuous infusion of anaesthetic drug into the vein, or via delivering an anaesthetic gas to the patient’s lungs. At this point the anaesthetist may perform other procedures such as insterting a tube through the nose into the stomach to help drain any excess fluid, or inserting a central venous catheter into the jugular vein to allow more powerful medications to be given in a more unstable patient. The surgeons are then called to begin the operation.

The anaesthetist’s job is then to monitor the patient, making adjustments to the ventilator settings and blood pressure, administering fluids and drugs such as antibiotics, strong painkillers and medications to reduce bleeding, and – most importantly – adjusting the table height! Once the operation is completed, the patient is woken up by switching off the delivery of anaesthetic agent, and once they are safely awake, the breathing tube is removed.

Much like flying a plane, the most interesting bits are the take off (intubation) and landing (extubation) with periods of steady monitoring in between. While it may appear that not very much is happening on the anaesthetist’s side of the drapes, this is a game of vigilance by the anaesthetist and operating department practitioner, making small adjustments when necessary to keep the patient steady without major changes in blood pressure or oxygen levels, and to ensure they stay deeply asleep and comfortable. It’s a good sign if you’re not needing to do much during the operation, because it means the patient is stable and handling the stress of the operation well. If there are problems, such as excessive bleeding or allergic reactions then it’s the anaesthetist’s job to resuscitate the patient and keep them stable through the operation.

10:30 The first emergency

“CARDIAC ARREST ON THE ACUTE MEDICAL WARD, CARDIAC ARREST ON THE ACUTE MEDICAL WARD”

“57 year old male…..admitted with pneumonia and poor urine output…..found unresponsive in bed this morning…..”

“Hello I’m from anaesthetics, would you like me to manage the airway?”

“This is the third round of CPR…giving the next dose of adrenaline now…”

“I can feel a pulse, he’ll need an arterial line, central line and admission to intensive care, I’ll call the consultant, please can you update the family”

At any point during the day, the crash bleep can go off, alerting the anaesthetist to a medical emergency somewhere in the hospital. This could be a patient that has gone into cardiac arrest, or someone who has suddenly become acutely unwell, and it can occur in any department, including the emergency department, paediatrics, maternity or one of the surgical wards. It can even happen in the car park. The anaesthetist’s job is to work as part of the on-call medical team of doctors to rapidly assess the patient and work out what is causing the problem and how to start fixing it, and this can be one of the most rewarding parts of the job, using your knowledge and technical skills to potentially safe someone’s life.

While all doctors are trained to deal with medical emergencies and run a cardiac arrest team, the anaesthetist’s specific role is to determine whether the patient needs any advanced organ support, particularly any help with their breathing or blood pressure, which may require their specific set of skills, such as intubation and inserting central lines to deliver necessary medications. Often this is coordinated with the intensive care unit, who also have an on-call doctor who can assist with medical emergencies. Generally anaesthetics and intensive care are closely allied departments, and it varies between hospitals as to which department attends medical emergencies and cardiac arrest calls.

12:00 The second operation

“I’m just feeling for the right space in your back, and then I’ll inject some local anaesthetic into the skin to numb the area and then I’ll give you the spinal injection”

“That’s all done, you’ll feel your legs going very heavy now which is completely normal”

“I’m just going to pop this oxygen mask on, are you warm enough? Let me know if you need any more pain relief or something to relax you a bit more”

If another anaesthetist is available, then the emergency operating theatre list can continue while the CEPOD anaesthetist is attending an emergency, otherwise the list has to wait until they are available to anaesthetise the next patient.

Not all emergency surgery requires the patient to be unconscious and on a ventilator, and in many cases it is actually safer to allow the patient to stay awake and keep breathing independently, especially if they have multiple significant medical problems. If the operation involves a limb or the lower half of the trunk, such as draining an abscess or a small hernia, then a spinal anaesthetic can provide safe anaesthesia and effective, long-lasting pain relief after the operation. In this situation a single injection of a few millilitres of local anaesthetic is injected into the fluid that surrounds the bottom of the spinal cord, essentially numbing all of the sensory nerves that travel from the lower half of the body, making the patient unaware of the pain. This naturally wears off after a few hours, but provides pain relief for up to 24hours, avoiding the need for other strong painkillers such as morphine, which can have nasty side effects.

14:00 Sedation in the emergency department

“Hello I’m calling from ED, we have an elderly lady with a shoulder dislocation we’d like to reduce, please can you help us with the sedation?”

“Hello, my name is Will, I’m one of the anaesthetists, we need to get your shoulder back into place, so I’d like to give you some strong pain relief and a bit of sedation to make you more comfortable if that’s alright, do you have any allergies?”

“Please can you open your mouth really wide and stick your tongue out for me? That’s great and just tilt your head back as far as you can…okay all done thank you”

Procedural sedation is another core role of the on-call anaesthetist, and can be a very rewarding part of the job. Using exceedingly powerful drugs to help a patient to remain comfortable and safely unaware while undergoing an otherwise painful and distressing produre such as a joint relocation or fracture reduction requires skill, as well as a vigilant anticipation of what to do if things go wrong. Before giving a patient strong sedatives the anaesthetist needs to be prepared for what to do if the patient becomes oversedated and stops breathing, or if their blood pressure drops dangerously low as a result of the medication. The likelyhood of these things happening depends on the individual’s medical background, previous reactions to anaesthetics and clinical examination of the face and neck to see whether they are likely to obstruct their airway when they’re asleep, or whether they would be difficult to intubate in an emergency. It’s a strange and rewarding experience to witness someone’s shoulder clunk sickeningly back into place, only for the patient to sleepily smile and thank you for helping them.

15:30 The third operation

“This man is seriously unwell, and is likely to crash on induction, so we’ll have a vasopressor infusion running and induce with ketamine. I need the surgeons scrubbed and ready to clean and drape as soon as the tube is in”

“Before we go off to sleep sir, I need to put a line into your wrist, and another into the vein in your neck, to allow me to give you strong blood pressure medication before the general anaesthetic”

“We’ll need four units of crossmatched blood, a pool of platelets and five units of fresh frozen plasma. I’ve given tranexamic acid and we’re running the blood pressure as low as he’ll tolerate”

Occasionally a patient will be desperately unwell with a life-threatening condition for which the only solution is to operate immediately, such as injury to a major blood vessel that cannot be compressed from the outside. In this case the most important factors are good teamwork and communication, and optimising speed while keeping it safe. While the surgeon attempts to locate and control the source of bleeding, the anaesthetist is busy trying to ‘fly’ the patient’s physiology without the help of autopilot. By replacing blood products, infusing drugs to help the patient’s blood to clot, and by holding the blood pressure at a low-but-safe level to prevent excessive bleeding, the anaesthetist can help the surgeon by improving the visibility of the surgical field, and ensuring the patient still has enough blood on board once the bleeding stops. This requires clear, concise communication between multiple team members, and often the anaesthetist takes on the role of team leader, allowing the surgeon to focus on the task at hand.

Once the operation is completed, the patient is often too critically unwell to wake up and extubate immediately, their body needing more time to rest and recover, so they are transferred by the anaesthetist to the intensive care unit where they are then monitored closely and kept asleep for another day or two to get over the stresses of the operation.

17:30 Intubation and transfer

“ADULT TRAUMA IN RESUS, ADULT TRAUMA IN RESUS”

“What’s the story?”

“38 year old male pedestrian hit by car, significant head injury with GCS 14 on scene, dropped to 3 with the crew, now has an igel in situ”

“If you’re happy to request the CT, we’ll get drugs and equipment ready for intubation”

“There’s a large extradural haematoma with midline shift, send it to the neurosurgeons and we’ll get packaged for transfer”

“Ambulance is here – ready to go?”

Many smaller hospitals don’t have on-site access to some specialties such as cardiothoracic surgery or neurosurgery, and so if a patient attends hospital with an emergency requiring treatment by that specialty, then they need urgent transfer to a bigger, tertiary centre hospital. A relatively common example is a young person with a head injury who is found to have a bleed inside their skull that compresses the brain. This is very often fatal unless surgically drained within the next few hours, so the priority is getting them safely to a neurosurgeon as soon as possible.

The anaesthetist on call’s role is to assess the patient’s breathing and level of consciousness to determine whether they need to be intubated and have their breathing controlled by a ventilator. A patient who is unconscious following a head injury is not going to protect their lungs from inhaling secretions and vomit, and they may have irregular and ineffective respiratory effort. To fix both of these issues, the anaesthetist will intubate the patient and put them on a ventilator to take over their breathing. They then escort the patient to the CT scanner where the diagnosis can be confirmed, before accompanying the patient in the back of the ambulance to the specialist hospital.

Trying to care for an unstable patient while travelling sideways at seventy miles an hour is an exhilarating experience, and can be hugely rewarding, albeit rather challenging! You just hope that the ambulance is able to bring you home before your shift ends…

20:00 The Day Ends

At the end of the day, the anaesthetist returns to the CEPOD board, and hands over in the same manner to the night team, before heading home to get some rest. One of the nicest things about anaesthetics is knowing that all of your patients have been safely handed over to another clinician or department before you leave, meaning you don’t lose (as much!) sleep worrying about them overnight.

It is an incredibly rewarding and stimulating role to play in the hospital, and so if you’re a bit of a perfectionist who wants to work with their hands, see quick results and lead a team in emergency scenarios, anaesthetics may just be for you!