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Reflections on a Taster Week in Anaesthetics

Welcome back to the second installation of Anaestheasier’s tips and tricks to help you get the most out of your anaesthetic taster sessions, to build your anaesthesia portfolio and give you that all-important edge whenv it comes to those pesky anaesthesia core training interviews.

In our previous article, ”Top Tips for a productive Taster Week in Anaesthesia“, we discussed how to organise your taster week, how it would likely be arranged, and some of the things you might expect to see along the way. In this post, we’ll explore how a taster week will not only inform your career decisions, but how the time spent will pay further dividends when it comes to anaesthesia core training applications and anaesthesia interviews.

The Maltese Foundation Programme write that taster weeks provide a

‘better understanding of what becoming and being an anaesthetist means’.

In other words, it’s all well and good saying that you’ve had a five day taster in anaesthetics. But you should aim to take it to the next level, like the Maltese, and demonstrate that you have reflected on not only the fun stuff and your love for propofol, tubes and coffee, but also the gritty stuff like the specific training requirements, appraisals, exams, and importantly, what life looks like post-completion of training/CCT.

💡 How do we get the most out of a taster week in anaesthetics?


Getting the most from your anaesthetic taster week

When you’ve got your taster session organised, you might want to think about the reasons and factors that are drawing you to anaesthesia in the first place. Your understanding and articulation of these reasons will become more shapely in time, but everyone knows that they need to be top-drawer for your interview and thus every anaesthetics consultant you meet in your sessions will ask…

So, why do you want to become an anaesthetist?

In response, ‘I like coffee, bicycles, I know my VO2max, have a Garmin strapped to every limb and on Sundays I dabble in sudoku’ is a very good start, but this week can provide opportunities to learn more about what the day-to-day really looks like, with all the ins-and-outs and variations of an anaesthetist’s role, rather than compounding various stereotypes. After all, not every anaesthetist likes cycling and coffee (shock, horror!).. we think.

The more you discover about the career itself, from a variety of people at different grades and levels, the more you’ll be able to virtually slot yourself into their shoes that are taking steps in both one and thirty+ years in the future.

Here are some groupings of themes of questions I like to ask, with an overlay from recent experiences and chats that I have had in theatres.


What is life as an anaesthesia trainee really like?

  • What do they do when they sit at the head of the patient on the other side of the ‘blood-brain-barrier’ surgical drape and surgeons? What do all of the beeps mean?
  • What about cool procedures and kit? E.g. I recently saw an interscalene nerve block. Give enough and you numb the arm’s brachial plexus and the patient will thank you. Give too much and you’ll cause Horner’s syndrome and/or a phrenic nerve palsy; the patient definitely won’t thank you!
  • What does this drug do? ‘Apparently, to anaesthetise a big animal like a hippo, vets must use opioids (Carfentanil) so strong and lipid soluble that they need to cannulate themselves and have naloxone ready, because if the drug touches their skin or is accidentally inhaled they will become apnoeic…’
  • What does anaesthesia core training or the ACCS training program look like? What about the experiential side of training? How did they get to where they are? How did they adapt from being a dogsbody house officer to becoming a sanctioned drug dealer?
    • Generally there is universal pride in the time and quality of teaching.
    • There’s a feeling of being in a ‘tribe’ and having a purpose (of dedicated learning and skill acquisition, rather than just passing your exams!)
    • Relief at having no more ward rounds or administration to take up the ‘bandwidth’ of each given day. 100% of time can be spent in a close learning environment with a consultant anaesthesist, with patients, doing procedures or having protected study time.
    • Can you imagine a job where you feel fatigued at the end of a day because of the amount of learning that has been had!?
  • Advice about courses or exam preparation – this is super important for your sanity in the future and also to answer ‘what will the hardest part of this training programme be for you’ when asked during any interviews.

What is life as an anaesthesia consultant really like?

  • What was their path to consultancy?
    • People take many paths until they find the right one. I’ve met anaesthetists with first lives as orthopaedic surgeons, sound engineers, general medics and lawyers, who despite accrual of knowledge, experience and seniority in their fields have found themselves migrating to anaesthetics.
  • Why do they like anaesthesia?
    • Sometimes it’s due to the job plan, PAs per week, or salary.
      • Work as a consultant is mapped onto the week as PAs, with one PA equalling a 5 hour session i.e a morning’s work. Anaesthesia is friendly to people who work part-time, job share, or split work with other specialties and commitments e.g. intensive care. The salary as a consultant, or even as a registrar, can be augmented with private practice work – but the amount of private work taken up varies between persons; thus, I conclude that anaesthetics is a very flexible specialty that can be tailored to fit many individuals.
  • How do they feel about their job roles and responsibilities?
    • Some consultants love the focussed nature of their job – be a friendly and nice person to allay the fears of the patient and do the job safely, effectively and efficiently. Many say that they feel ‘free’ with their names above no beds in the hospital, with no retention of responsibility once they leave in the evening or for the weekend. Some find the anaesthetic part dull after a while, but recognise that a routine anaesthetic tempers high-stress commitments elsewhere.
  • Are they working overtime? Do they feel that they are respected in their jobs? What are the problems facing working as an anaesthesia consultant?
    • It’s highly recommended to explore the opinions of consultants with regards to the past, present and future political states of and working conditions within the NHS.
  • What are the opportunities available to consultants to subspecialise – and why would one choose these subspecialties?
    • Anaesthesia subspecialties include paediatrics, neuro, cardiothoracics etc, while, pain medicine, perioperative assessment, HEMs/retrieval/prehospital/wilderness medicine, intensive care medicine, the military, research and management all combine well with a CCT in anaesthesia.
    • Do you have a greater appreciation of the cerebral side of anaesthesia? Perhaps a parallel career in research is an appealing option. Prefer practical, hands-on RSIs and gung-ho central lines and like helicopters? Maybe consider working in prehospital medicine or a career with the military.
  • Many anaesthetists genuinely love teaching and the company of trainees.
    • One anaesthetist shared with me that having professional discussion with motivated and intelligent juniors is one of his favourite parts of the job. He enjoys teaching because by formulating his answers to complex or unexpected questions he has had to improve his knowledge, and his ability to communicate this knowledge – if this isn’t a sign of a man with a ‘growth mindset’, I don’t know what is!
    • Not many other specialties have as much time to teach, nor as much time of one-on-one senior-junior time.
      • Did you know that if trainees did not join the lists of consultant anaesthetists, the International Crossword Protection group (ICP) estimates that the toll on the worldwide population of crosswords would endanger them to near-extinction by 2030?
  • There appears to be little in-fighting and few unhappy anaesthetic families.
    • ‘There is no other specialty where the staff are so collegiate – we all have fun and banter together, and we all know that we can call for help as soon as anything out of the ordinary happens’. As he finished saying this, a consultant colleague bumped through the door to ask whether he was having fun and had drunk enough tea – the third of such check-ups of the morning.

So, you’ve organised your taster experience in anaesthesia, put some tubes down and some lines in – after reading this blog, we hope that you’ll appreciate the wider aspects of becoming and being an anaesthetist, and are informed to be able to ask your own questions to find your own answers!


Dr Rory Heath

Anaesthetics Core Trainee

Do Not Resuscitate

DNAR forms, or ‘Do not attempt resuscitation’ forms have received a lot of attention in the media recently, particularly as a result of the COVID-19 pandemic, and they have stirred up rather a lot of controversy regarding how they are used, when they are appropriate and who should be making the relevant decisions involved. This is entirely understandable given the extremely emotive issue they discuss, and the potential harm if used incorrectly. In this post we will cover what they actually mean, when and why they are used, and what they are trying to achieve, hopefully clearing a few of these issues up in the process.


Cardiac Arrest

If you are in hospital and your heart stops, for whatever reason, then by definition you are in ‘cardiac arrest’ and in this situation hospital staff are trained to start CPR, or ‘cardio-pulmonary resuscitation’, in order to try and get it started again. The idea is simple – squeeze the heart to pump the blood – but the procedure is brutal – powerful compressions applied to the middle of the chest, squeezing the heart between the breastbone and spine, cracking ribs and bruising lungs in the process. Hospital staff will do this unless there is a valid instruction in place not to do so, (i.e. a DNAR form). The decision to start CPR has to be very quick, automatic almost, because time is of the essence; as soon as your heart stops your vital organs – particularly your brain – are being starved of oxygen and are therefore rapidly becoming irreversibly damaged. Most organs can be transplanted or replaced, but not the brain, and the brain does not cope well with no blood supply. The aim of CPR is to push blood and oxygen around the body to slow down the damage to the vital organs and buy the medical team time to try and fix the cause of the cardiac arrest. Apart from in very exceptional circumstances, sternal compressions are nowhere near as effective at moving blood and oxygen around the body as the hearts own compressions. This is the key, CPR does not actually fix anything, all it does is buy time, and not very much at that.


https://doctorhomeschool.files.wordpress.com/2021/09/cpr.jpg?w=660
Image credit: @unicyclemedic

Reversible Causes

The key here is understanding whether the cause of the cardiac arrest is ‘reversible’ – that is, can you fix it and get the person better again? Sometimes this is obvious – if the heart has stopped because the entire organ has been forcibly removed from the body by an explosion, then most people would agree that this is not a reversible cause, and starting CPR on the poor person’s body would undoubtedly not work. On the other hand, if a fit young person has been struck by lightning, and their (previously) perfectly healthy heart has flipped into a strange rhythm and stopped pumping effectively due to the electric shock, then this is almost certainly reversible with a defibrillator, and CPR is absolutely appropriate and actually quite likely to work.

So how do you know whether the cause is reversible, when somebody has a cardiac arrest in hospital? You can’t know for sure, but it is widely agreed that there are essentially only eight causes that we can treat, and we call them the

‘Four H’s and Four T’s’

So we aim to treat all of these during the resuscitation attempt, and then we know if it doesn’t work, then it likely isn’t a reversible cause.

Hypoxia

Lack of oxygen causes the heart muscle to stop contracting- for example choking or suffocating.

Hypovolaemia

Not enough blood to supply oxygen to the heart – severe bleeding or severe dehydration.

Hypothermia

Heart too cold to pump blood effectively – very rare – not usually seen in hospital.

Hyper or Hypokalaemia

Potassium levels too high or too low – disrupts the electrical signals in the heart and upsets its rhythm. This also covers other electrolytes like calcium and sodium, all of which should be normalised during the resuscitation attempt.

Toxins

Cardiac arrest due to a specific poison or drug overdose.

Tension pneumothorax

This is a rare form of collapsed lung in which pressure builds up outside the lung but inside the chest cavity, compressing the lungs and heart and rendering it unable to refill after contracting, preventing it from effectively pumping blood around the body.

Tamponade

The heart sits in a rigid bag called the pericardial sac. If blood or another fluid rapidly accumulates in this sac, then it compresses the heart itself, preventing the heart from refilling and causing it to stop beating.

Thrombus

A blood clot, either in the lung or one of the major vessels to the heart, causing a blockage to blood flow and a lack of oxygen supply to the heart muscle, resulting in cardiac arrest.


Advanced Life Support

Once someone has been identified as being in cardiac arrest, there is a set algorithm defined by the Resus Council here, which hospital staff will follow, while the medical team try and work out if any of the above are causing the cardiac arrest. If one of the above problems is identified, then treatment is started while CPR is ongoing, to see if by treating the cause it’s possible to get the heart started again. Sometimes it does, but much more often than not there is too much damage done already for the body to recover. This is especially the case for hypoxia (lack of oxygen) as the heart is so resilient that it will keep going, using whatever fuels it can get its hands on, right until the bitter end. So the body has to be profoundly low on oxygen for it to actually give up and stop. By this time many of the other organs, particularly the sensitive brain, have already been severely damaged.


Why not just give it a go?

Surely, if someone’s heart has stopped, they’ve essentially died, so it can’t get any worse right? So why not just do CPR on everyone because it might just work? This is understandably the stance that many people take, however there are several reasons why it is absolutely not appropriate for everyone to receive CPR when their heart stops:

Chest compressions are very physically damaging

They cause broken ribs, punctured lungs, bruising and bleeding around the heart, and potentially damage to organs in the abdomen as well. Not to mention that the force of compressions also causes leakage of faeces, urine and vomit. If someone’s heart has stopped, and for whatever reason it is deemed extremely unlikely that CPR is going to work, then it is a horrible thing to do to someone when they die. If my grandmother reaches the end of her natural life and passes away peacefully in hospital, with her family at her bedside, would I would want the medical team crashing in and doing that to her poor body?

Chest compressions are psychologically damaging

I remember the first time I performed CPR on a young man and he not only survived but recovered back to full health; it was one of the most thrilling and rewarding moments of my career. However I also remember countless occasions where I have had to perform chest compressions on the bodies of over-80 year olds because they were inappropriately ‘still for resuscitation‘. It is a feeling like no other; frail bones cracking beneath your hands as you try to pummel life back into a corpse, the lifeless eyes gazing as their body writhes and jumps with each jolt of the defibrillator. The psychological damage done to medical professionals by inappropriate CPR is widely underappreciated, equally the impact on the relatives and other patients in the ward who may bear witness to at least part of the resuscitative efforts is often forgotten.

It very rarely works

Remember that CPR is a medical treatment. If I were to develop a drug with the success rate that CPR has, and tried presenting it to a pharmaceutical company, I’d be laughed out of the room. It does not work well at all, especially when done inappropriately, and it should only be used upon the people who are likely to benefit from it. A full-blown resuscitation effort in hospital usually involves up to four or five nurses and health care assistants, three or four doctors, resuscitation officers and then porters running to get equipment. Enormous amounts of non-reusable equipment such as defibrillator paddles, invasive airway equipment, blood test needles, and drugs such as adrenaline are also used up in the process, which may last up to an hour and a half in some cases. Not only are the staff all occupied and unable to help other patients during this time when they’re trying to resuscitate someone who has died, they’re then left psychologically bruised in the aftermath.

There is a fate worse than death

Most people view CPR as a binary process – either it works or it doesn’t – and this is the reason why most people think it’s worth ‘giving it a go’ in everyone. But this isn’t the case. There is large and terrifying grey area in the middle that, if people were more aware of it, would almost certainly change the public opinion of DNAR forms. There are a great number of patients in whom CPR would be just effective enough to get the heart started again, but who would in the process suffer such catastrophic damage to their other organs that they would never be the same again. In the mildest cases this could mean requiring dialysis for the rest of their life or a kidney transplant because their kidneys have failed due to the lack of oxygen during the cardiac arrest. In the most severe cases it could represent a living, breathing person who is unable to walk, talk, feed themselves or use the toilet and who may or may not be in constant pain, but can’t communicate that to the outside world. These people need 24 hour care, every day, until they eventually die of something else. Usually this is caused by a painful, distressing infection either from aspirating food or from developing a pressure sore from lying in one position for too long. They become an enormous financial and emotional burden on their family, and friends who are now wracked with guilt for subjecting their loved one to a life they knew they would have never wanted, but with no way out from their suffering other than to wait for them to die of some other ‘natural cause’. This may sound dramatic but it’s true, and it’s something we see all the time on intensive care – patients who have ‘survived’ but not quite enough to live a life they would want. When you go into the medical profession you vow not to do harm, and this feels a lot like doing harm.


So who should have CPR?

Very few people would argue that a heart transplant would be appropriate in a 94 year old man with heart disease, poorly controlled diabetes, kidney failure, emphysema and who can only walk a few paces with a zimmer frame before needing to sit down and catch his breath. The enormity of the operation, the stress on the already very weak and frail body, and the incredibly unlikely success rate of the procedure, let alone the lengthy and exhausting rehabilitation afterwards mean that it would be completely unfair to put that poor man through all the pain and suffering for what is almost certainly a very poor outcome.

Replace heart transplant with CPR, and the same applies.

There’s an elegant phrase which states ‘CPR works if the heart is the first organ to stop, not the last’. If the heart has stopped in an otherwise fairly healthy person due to an unexpected heart attack, a trauma, electrocution, drug overdose, or any of the 4H’s and 4T’s, then with the right treatment it is possible to get things working again (Hence why we have the 4H’s and 4T’s!). However if a person’s heart is not getting enough oxygen due to a chronic lung condition and the blood is being poisoned with waste products because of the patient’s kidney disease, and then they have an infection on top of that causing the heart to finally give out and stop, then the likelihood of fixing all of these things quickly enough (and sufficiently such that the person can enjoy a quality of life they would be happy with) is so low that you’re more likely to do them harm than any good at all.

So who makes the decision?

To cut a long story short, it is the medical team’s decision as to whether they feel that performing CPR would be in a patient’s best interests. However it should be a decision that is communicated properly to, and hopefully agreed with, the patient and their family, to ensure that everyone is on the same page should the worst happen. Legally, or ‘technically’ – however you want to phrase it – the family and patient do not have to agree for the form to be valid, however I very strongly believe that if a proper discussion is had, and the points I’ve made above are effectively communicated, then the family and patient are likely to agree with you if you feel CPR truly would be inappropriate.

This is where the infamous DNAR Form comes in. This bright red form sits at the front of a patient’s notes and specifically states that should this person’s heart stop, then it would not be the right thing to start chest compressions. It has to be big and colourful and right at the front so that it can be found in a rush to avoid doing unnecessary harm to the poor patient.

It is easy to see how a DNAR form looks like a big ‘WE’RE GIVING UP ON YOU‘ symbol to those who don’t know exactly what it means, especially if they haven’t had a proper discussion about it. But it absolutely does not mean ‘withdrawal of treatment’ or denial of any sort of therapy. It only answers one question, which is

‘if this patient’s heart stops, should we put them through the horrible procedure of CPR?’

It’s not an easy discussion, especially given you’re usually trying to bring the subject up when a patient is already unwell and their relatives are desperately worried about them already – the last thing they want to think about is what happens if they die. This is why ideally these discussions should be had much earlier on, for example when a patient reaches a certain age or has multiple chronic illnesses that mean they would be unlikely to benefit from CPR, and to be fair to our enormously overworked GPs, many of them are doing this all the time, to protect their patients’ best interests.


*** VERY IMPORTANT CAVEAT ***

Outside of hospital, when you don’t know anything about the person or their medical background, and you do not have a DNAR form in front of you confirming this person is not for resuscitation, then of course the right thing to do is to start CPR. It is widely agreed that it is far worse to deny someone CPR who may benefit from it than it is to perform CPR on someone who won’t.


Hopefully this has given you some idea of what CPR is and what a DNAR form means and when it’s appropriate. The most important message that I’m trying to convey is that as medical professionals we always try to do what’s best for the patient in front of us, and if it seems like we’re being unfair or ‘denying’ a patient an opportunity or treatment – it’s because we’ve seen the horrors on the other side and are trying to protect them from unnecessary harm.

How to nail the MSRA

Almost as dreaded as MRSA, the Multi Specialty Recruitment Assessment (MSRA) has recently become a key part of any application to specialty training in the UK for a variety of choices of specialty. Both James and Will managed to sneak their way into anaesthetic training before it was introduced, however our resident blogmaster Dr Rory Heath has recently sat – (and crucially nailed) – the MSRA, so he has a few helpful tips and tricks to help you on your way.

What is the MSRA?

The MSRA is a standardised, written examination used to assess applicants hoping to enter specialty training in General Practice, Psychiatry (Core and CAMHS), Radiology, Ophthalmology, Obstetrics and Gynaecology, Community and Sexual Reproductive Health, and Neurosurgery – but if you’re here on Anaestheasier, it’s more than likely that you are taking the MSRA to apply for anaesthetics.

Why does an application to anaesthetics require the MSRA?

ANRO, the Anaesthestics National Recruitment Office, have written their own statement to say that the MSRA

‘has been designed to assess some of the essential competences outlined in the Person Specification and is based around clinical scenarios’,

while HEE expands on this by explaining that the MSRA assesses

‘the foundation level of competence’

i.e. those competencies required to complete the Foundation programme.

💡 See the person specification for Anaesthetics Core Training and for Acute Care Common Stem (ACCS).

But why?!

Who knows, but it likely comes down to a combination of the following two factors:

1) Selection

2) Feasability of selection process

Some might argue that the broad medical knowledge base required for a career in General Practice bears little resemblance to the narrow, highly specialised technical abilities required for a career of drugs, tubes and gas. Others may suggest that a broad situational judgement-based assessment serves as a good baseline assessment of suitability to a variety of specialties, so this shouldn’t matter all that much. While many people readily show frustration at yet another set of exams – both are understandable perspectives.

Some people may also hope to expect that the MSRA falls out of use, as we continue to hope that coronavirus precautions may be further reduced, bringing back the hard-earned portfolio and face-to-face interviews. However, until then, the team at Anaestheasier want to make your life easier by creating a guide to help you nail the MSRA, if you end up having to sit it. (Probably).

  • The MSRA forms part of the selection process to interview, where you face-to-facers will shine and your portfolios will be very helpful.
  • The MSRA forms 15% of your application score – a sizeable chunk of your aggregate score that you should aim to optimise for application success!

How is the MSRA structured?

💡 To excel in any challenge, it’s important to know the format of the test and what is expected of you.

The MSRA is structured in two parts; the Professional Dilemmas (PD) section, and the Clinical Problem Solving (CPS) section.

Professional Dilemmas:

Do you remember the Situational Judgement Test at medical school? Well you’re about to experience a whole world of Deja vu! The PD section ‘provides scenarios in the workplace for applicants to demonstrate their judgement about the most appropriate behaviours in that context’ (HEE).

The PD section is 95 minutes long, asking 50 questions, but note that this was the arrangement for me, and may be subject to change over time, so please check that this is the same with your cohort!

Clinical Problem Solving:

This tests an individual’s application of knowledge to make clinical decisions. HEE say that this knowledge is based upon the Foundation Programme competencies. In other words, Do as a sensible F2 would do.

In our experience, the MSRA is less knowledge heavy than other entry exams (e.g. MRCP part 1), but still requires active learning and revision above and beyond the clinical exposure of working and attending teaching within the foundation programme. Some find luck when winging it – the rest of us might consider taking a proactive approach of systematic learning and revision.


Tips for the MSRA

Tips for PD:

Many people find it difficult to revise for SJT-type exams – after all, the temptation is to think that it tests your intrinsic moral substance (character flaws be damned!)

Your score isn’t all inevitable though, and there are definitely things to do to know the test, and although you don’t know the markscheme, you can know what the markscheme is based upon.

  • Know your time. 70 questions over 95 minutes = 114 seconds per question. Practice mock exams with a clock running.
  • HEE describe three core competencies which their questions aim to test; Professional Integrity, Coping with Pressure, and Empathy and sensitivity. These are outlined on this document here, page 4/9. It’s worth a read to understand what they expect from you, but you are already likely practicing these qualities in your daily life and work.
  • Familiarise yourself with the GMC’s Good Medical Practice.
  • Use a SJT question bank.

Tips for CPS:

  • Know your time. The CPS paper asks 97 questions in 75 minutes = 46 seconds per question.
  • The questions are ‘single best answer’ or ‘extended matching questions’. Read the question to know how best to answer it!
  • The questions test various ‘domains’ of clinical practice:
    • Investigations; Diagnosis; Emergencies; Prescribing; Management.
      • This is a useful frame work for any revision notes you might make about a particular condition e.g. asthma.
  • Question banks are very helpful, especially those with a ‘textbook’ feature – making the above point easy to achieve.

General Tips:

Answer all the questions as there is no negative marking. You miss all the shots you don’t take!

Start revising little and often, early – it will help to consolidate information before the exam and will avoid last minute panic. Furthermore, learning whilst working makes both activities more fun – You will feel rewarded the next time you remember and implement recently learned information into your practice!

That’s it from us – Good luck, and if you have any useful tips of your own, please share them in the comments!


Dr Rory Heath

Anaesthetics Core Trainee

What is a ‘standard anaesthetic?’

If you’re wondering what an anaesthetist actually does to drift a patient off to sleep for an operation, then please join us for a gentle wander through a standard, low-stress elective operation. Remember that anaesthetics is a craft, much like carpentry or cooking, with many different ways of achieving a good result and a happy patient, so the following is just one example of how to anaesthetise someone, rather than an all-encompassing definitive guide.

After the team briefing with the surgeons and theatre staff, in which the patient and their case are discussed and the surgical and anaesthetic plans agreed upon, the patient is ‘sent for’, meaning the ward is informed that the patient can now be brought up to theatres for their operation. The surgeons disappear and the anaesthetic team get their equipment and drugs ready.

Drugs

There are generally two categories of drugs to draw up and get ready for an elective procedure; those for induction of anaesthesia, and emergency drugs, which are kept on hand to deal with any urgent problems during the procedure.

The basic recipe for a general anaesthetic is as follows

An induction agent

Also known as a sedative, this induces a profoundly deep sleep, rendering the patient unaware of their surroundings and the procedure. Typically we will use propofol, or ketamine if we’re concerned about the patient’s blood pressure being too low. I like to give a little bit of lidocaine local anaesthetic into the cannula as well, to numb the vein before the propofol is injected, because propofol can sting as it is very irritant to the inside of the vein.

A strong, fast-acting opioid painkiller

This reduces the body’s stress response to the physical process of intubation, and also provides pain relief for the beginning of the operation. Frequently fentanyl or alfentanil are used as a bolus injection, or remifentanil as an infusion, because it is so short acting that a bolus would wear off too quickly.

A muscle relaxant

Neuromuscular blocking agents, or muscle relaxants, are used to paralyse the vocal cords, and allow the endotracheal (breathing) tube to be inserted into the trachea without the patient coughing and going into laryngospasm. The agent of choice was previously either atracurium or suxamethonium, but now more commonly rocuronium is used.

Antiemetics

These are given to offset the sickness caused by some of the drugs and the effects of the surgery itself. Ondansetron and dexamethasone are classic examples, but others such as cyclizine and droperidol can also be used, depending on the anaesthetist’s preference.

Long acting pain relief

Usually morphine, given at the beginning of the operation as it takes 20-40 mins to have peak effect. Other pain relief options include paracetamol, NSAIDS such as diclofenac, and clonidine and magnesium also can be used.

Antibiotics

Not all operations require antibiotics, but anything involving the intestines or orthopaedic implants such as a hip or knee replacement will need at least one dose of antibiotic, which is usually given just after induction of anaesthesia.

Emergency Drugs

The emergency drugs are essentially rescue therapies for if the unexpected happens during an operation, for example if the patient’s blood pressure or heart rate drop dangerously low as a result of the anaesthetic or the surgery itself.

As with all things anaesthetics, the choice of drugs depends again on personal choice but I usually have ephedrine, metaraminol, atropine and glycopyrrolate at the ready. As well as being useful to have immediately available, they’re also source of psychological comfort to have at your side when venturing into the murky waters of unconsciousness!


The arrival of the patient

As the patient arrives, the anaesthetic team introduce themselves and run through a sign-in checklist to confirm that the correct patient has turned up expecting the right procedure. If they’re having limb surgery, it is confirmed with the patient which side they’re expecting the operation, left or right, and that there is a visible mark on the correct limb, drawn by the surgeon. They’re then brought into theatre. Before anything else happens, three bits of monitoring are applied:

  • Pulse oximeter
  • Blood pressure cuff
  • ECG or electrocardiogram

These three things provide continous essential information throughout the operation about how the patient is feeling, how well their vital organs are working and how deeply asleep they are. One of the skills required of the anaesthetist is being able to interpret what the numbers mean in any given scenario, and what they need to do about it.

Is the blood pressure low because the heart isn’t pumping properly or is it because the anaesthetic drugs have made all of the blood vessels relax?

Is the oxygen level actually low or is it electronic interference from the surgeon’s cauterising forceps?

High airway pressures, low blood pressure, high heart rate and low oxygen suggests anaphylaxis until proven otherwise

Induction of anaesthesia

I like to draw comparisons between anaesthesia and flying a plane. The generally more interesting bits are during take-off and landing (induction and emergence from anaesthesia), and ideally there are only minor adjustments to be made during the surgery in between.

Induction of anaesthesia is like take-off. After inserting a cannula into a vein in the hand or arm, the patient is given pure oxygen to breathe through a mask, to replace all the air (which is mostly nitrogen) in their lungs with oxygen. This acts as a reservoir of oxygen for the body to use throughout the period of time when they are not breathing during the intubation. It is an important safety net in case anything unexpected happens and we are unable to move gas in and out of the patient’s lungs – such as in the case of an unexpectedly difficult intubation.

💡 To give you an idea of the importance of this pre-oxygenation – a patient breathing room air will drop to critically low oxygen levels within a minute and a half, while a patient with lungs full of oxygen can last up to fifteen minutes.

Once the lungs are full of oxygen, the induction drugs are injected into the cannula and the patient goes to sleep. Once asleep, the muscle relaxant is injected and a timer started. The patient rapidly stops breathing, as their muscles become paralysed, and therefore starts using up the reservoir of oxygen sitting in their lungs. After about ninety seconds the patient’s vocal cords will be adequately relaxed to allow intubation, so the mask is removed and the laryngoscope is used to insert an endotracheal tube into the patient’s trachea.

MAC stands for Macintosh, the standard shape of laryngoscope used in adults. This is a size 4, which is generally used for taller patients

This usually takes less than a minute when uncomplicated, but occasionally there are surprises so it’s important that we have a few back up plans up our sleeve!


The operation

The aim of the game for the anaesthetist during the operation is smooth sailing, with a nice steady blood pressure, oxygen level and heart rate. Many surgical operations involve particularly painful or physiologically stressful parts that the body can react to even in the patient isn’t aware of it, which need careful navigation to avoid upsetting the body’s delicate balance and causing unnecessary spikes in blood pressure or heart rate.

The patient needs to be kept adequately asleep with enough pain relief on board to reduce the stress of the surgery itself. In the same way that a person who is asleep might unconsciously move their hand to swat away the fly that just landed on their nose, a patient under general anaesthesia won’t be aware of what is happening, however their body will still show a stress response to a painful stimulus if they’re not given enough pain relief.

For a simple, lower risk operation this often doesn’t involve actively doing much at all, which is how anaesthetists have become famous for their crossword and sudoku habits, however their job is to remain vigilant to change, and to ensure that they spot anything going wrong and to deal with it before it becomes an issue. It’s very rewarding to hear the surgeon exclaim ‘they’re much more stable than I expected’ from the other side of the drape, unaware that it’s because you’ve been quietly correcting every possible physiological derangement before it became clinically apparent.

💡 The blood-brain-barrier strikes again.


Extubation

As the surgeon ties the final few sutures, it’s time to get ready for landing, or extubation. The easy bit is switching off the anaesthesia, because the patient does all the work of waking up by breathing out the anaesthetic gas or metabolising and excreting the anaesthetic drugs, depending on what you’ve been using to keep them asleep. The tricky bit is keeping them safe as they ascend through the planes of anaesthesia, some of which can be rather turbulent to say the least.

💡 The ‘safe zones’ are either wide awake, or deeply asleep, because in each of these situations either you or the patient has complete control over their breathing.

However much like a plane descending through stormy clouds, the patient must rise through a dangerous middle zone of being semi-anaesthetised, where they can become agitated if not managed correctly, and in the worst case can either go into bronchospasm or stop breathing entirely. Clearly, this could be disastrous if the patient’s oxygen level were to drop to a dangerously low level, so we do our best to avoid these problems in the first place.

The key is ensuring you’ve suctioned out any saliva and secretions that might irritate the vocal cords when the tube comes out, reversed the muscle paralysis to ensure they have the muscle power to breathe effectively, and allow them to transition through this bumpy period relatively undisturbed.

💡 Given that extubation carries the same, if not more, risk than intubation, the patient must also be pre-oxygenated with 100% oxygen, to buy time if anything goes wrong.

Then, once they are awake enough to protect their own airway and breathe for themselves, the tube is taken out. Often the patient will still have strong pain relief and residual anaesthetic on board, and are exhausted from the stress of the operation as well, so they frequently will go back into a more normal version of sleep.


Recovery

While the hardest part is now over for the patient and the anaesthetic team, they’re still not safe to go back to the ward just yet, as the powerful drugs given during induction and throughout the operation will still be swilling around in their blood, and can still have dangerously sedating effects if the patient isn’t monitored appropriately. They are therefore looked after by a specialised recovery nurse in the recovery unit, where they are closely observed and their pain controlled with more strong drugs if needed while the last of the anaesthetic agent is excreted from the body. After handing over to the recovery staff, the anaesthetist usually says farewell to the patient at this point, and heads back to theatre to get ready for the next case!


We hope you have found this article useful, please fire away with any questions or comments, and check out our TikTok channel and podcasts for more content like this.

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Dr Rory Heath

Anaesthetics Core Trainee

How To Gain Experience In Anaesthesia As A Medical Student

Anaesthetics is a wonderful specialty that ticks all the boxes for an interesting, varied and sustainable career, but it is difficult to work these things out when we’re studying what feels like all of the books at medical school, whilst simultaneously trying to attend clinical rotations as well as attempting to have fun on the side, all at the same time.

Anaesthesia is a notoriously post-graduate specialty, with few students finding themselves receiving much experience at all prior to finishing medical school. Outside of any defined clinical blocks in anaesthesia that your medical school may organise for you, it might be that you complete your entire medical degree without a true taste of the gas life!

While anaesthetics is very physiology-heavy, we don’t count physiology lectures as anaesthesia experience, as while they are certainly useful, they are often befuddling and dry! If you do want some actually useful and engaging learning resources, check out our Anaestheasier shorts on YouTube).

Any additional experiences in anaesthesia that you can obtain during your time at medical school will not only help to inform your future career interests, but can also serve you very well when it comes to applying for competitive jobs in the future.

💡 So, what can you do to get more anaesthesia experience in medical school, make better life choices, and to optimise your chances of getting a CT1 anaesthesia job straight outta FY2?

Our top tips for getting anaesthetic experience:

Anaesthetics Society

Most medical schools have an Anaesthetics society, which is a great first port-of-call for information and contacts, events and opportunities to get involved. They will often organise conferences, poster presentations and essay competitions for you to get involved with, as well as lots of networking opportunities.

Student selected modules

Many medical schools offer anaesthesia-related Student Selected Modules or Components (SSMs/SSCs). Not only are these great fun and provide a useful introduction to anaesthesia, they also look great on applications and add flavour to interviews when it comes to applying for specialty training in the future.

When I was a medical student I signed up for modules in ‘Diving Medicine’ and ‘The Surgical Airway’. I didn’t really know what I was getting myself in to at the time, but these turned out to be of great value and went on to herald an interest in anaesthetics. In the former, I bent the SSC title to focus more specificially on hyperbaric oxygen therapy for traumatic brain injury, whilst simultaneously learning a lot about gas laws, pressure and the bad things that happen after arterial gas embolisms.

In the latter SSC, the Guy’s Hospital Anaesthetics department taught us about every airway device known to man, front of neck access, and finished the course with a full written and practical viva!

Intercalated degrees

This is quite a hard-core commitment to the specialty, but if you know that you’re keen on anaesthesia then an intercalated degree in a related subject can be a goldmine for opportunities, contacts and extra information.

OK, this is likely to be in Physiology, but you could also make other stretch – detailed anatomical knowledge learned in an Anatomy BSc. is useful for nerve blocks, while if you were to do an Imaging/Radiology oriented degree, keep in mind that ultrasound is a ubiquitous tool for placing venous access devices or for performing FAST scans.

I did my BSc. in Physiology at King’s College London and it was great!

The main highlight of the the course at my university was ‘*Extreme Physiology’. It was what it says on the tin, with lectures about hypobaric medicine at altitude, hyperbaric medicine under the sea, microgravity in space, thermal considerations in the Marathon des Sables or on the British Research Survey in the Antarctica. We also got to go into human centrifuges, while my personal highlight was to pedal on an exercise bike in a sauna with a rather intimately placed thermometer…

The dissertation portion of the degree provided an opportunity to gain experience in a research group that studied the effects of different inspiratory volumes upon the breathing of prematurely born infants – big ventilators providing tiny breaths to tiny lungs.

Electives

A 6 week elective (when Covid permits) is a fantastic opportunity to spend time discovering what you might want to do in medicine.

You’ll meet loads of trainee anaesthetists and can ask lots of questions (which is great, read our blog on Taster Weeks) and see lots of stuff (especially if you go to a big hospital or a trauma centre), which after all, is the experience you need to really decide whether Anaesthesia is the career for you.

I did my elective in Australia. Aside from wrestling wallabees, of my favourite parts was when we all went to visit ‘Mrs Brown’, permanently residing on the 5th floor in the staff coffee shop. A flat white, please.

Make sure to get your elective signed off by your supervisor, and remember to keep the documentation!! All of these seemingly trivial crumpled bits of medical school papers will come in useful someday, I promise.

Useful websites to check out:

There we have it! Some tips for getting your anaesthetic career well under way even before you’ve graduated. Check out our other blogs, vlogs, and learning resources on Anaestheasier.com.

Dr Rory Heath

Anaesthetics Core Trainee

Emergency Drugs

Part of the morning ritual of a novice anaesthetist is drawing up a pristine set of emergency drugs for the day’s list. There’s something satisfying about quietly cracking ampoules of deadly drugs open and labelling the syringes ‘just right’. And as with everything in anaesthetics, we’ve already hit a point of controversy.

Some consultants will advise you to draw up a full tray of emergency drugs for each list, while others will insist it is a waste of drugs and plastic and that you shouldn’t need them that quickly if you’re doing your job properly.

My advice? Draw them up. Especially as a novice. Why? For two main reasons:

There’s enough on your plate

The learning curve is steep enough as it is without the added stress of having to find, crack open, draw up and administer drugs that you really need to be giving within a minute or two. Having them sat reassuringly on your anaesthetic machine labelled at the ready was a real confidence booster for me.

You’ll use them if they’re there

If you’ve got a syringe of ephedrine drawn up and ready to go, you’re far more likely to actually use it than if it is sat in the cupboard. Then when you find the patient’s blood pressure just a little lower than you’re comfortable with, with a heart rate in the fifties, then giving 3 – 6mg of ephedrine is not going to do any harm, and it allows you to practice with the tools of your new trade. It’s useful to get experience with seeing how these drugs work, and how much effect you get from a given dose. That way when you actually need them, you’ll be far more comfortable using them. A lot of consultants seem to take pride in not needing emergency drugs, suggesting that if your anaesthetic is good enough, then you’ll avoid having to give them. Personally I disagree, particularly with vasopressors. If you’re giving someone a syringe full of propofol, causing their entire vascular system to relax, to me it makes total sense to counteract that with a little metaraminol or ephedrine just to replace some of that vascular tone – but hey – each to their own.

Standard recipe for an emergency drugs tray

Metaraminol 0.5mg/ml
  • For hypotension with a heart rate above 60bpm
  • Give 1ml and assess response in 30 seconds
  • If you’ve given more than 10ml in divided doses, then you should think about an infusion, and maybe even a central line and noradrenaline
Ephedrine 3mg/ml
  • Usually comes as 30mg in a 1ml vial
  • Draw up 9ml of saline into a 10ml syringe, then add your 1ml ephedrine to make 3mg/ml
  • Give 1 – 3ml boluses and assess response in 30 seconds
  • There’s no point giving more than 10ml in total, because it exhausts the body’s noradrenaline stores – move onto metaraminol or noradrenaline next
Glycopyrrolate
  • Usually comes as 200microgram/ml in either 1 or 3 ml vials
  • Used to treat airway secretions (45 mins before induction ideally)
  • Also used for bradycardia – generally considered more ‘gentle’ than atropine
Atropine
  • Usually 600microgram/ml
  • Used for profound bradycardia, particularly in paediatrics (20microgram/kg)
Propofol
  • Used for rescue sedation, in case patient wakes up agitated, bites the tube or develops laryngospasm
  • 2 – 5ml bolus to re-establish control of the situation
  • Often forgotten until you need it!

A Thread worth Reading

Tap image to see original tweet

Remifentanil is useful but I have never liked it in cases where one is reliant on subsequent IV analgesia. The transition from a carefully titrated anaesthetic to smashing in 10mg morphine, or the like, towards the end has always irked me. You don’t really know where you are!

Most people use small aliquots of Alfentanil for short sedation cases but when given in larger amounts by infusion it can be used entirely differently. Below is a graph of CSHT’s which are relevant in this context.

I use this anaesthetic for cases longer than an hour for which I don’t use regional as the primary analgesia.
IMO one needs this long to infuse adequate Alfentanil and have enough time to get the patient breathing again.

Draw 5mg Alfentanil up to 50mls with normal Saline. (100mcg/ml)

Select the maitre model (freely available to download) on the Alaris PK pump which is generallt ubiquitous in the NHS.

Select a Cpt of 120mcg/ml and wait for it to reach target Ce before starting the propofol.

This will administer a far larger and slower bolus than one would normally deliver at induction and result in a cardio stable therapeutic Ce. For an average man 120mcg/ml will be reached in 3 min and 2mg of drug.

I watch the patient closely at this point as the Ce at which they relax and then go apnoeic is useful in guesstimating at what level they are likely to start breathing again on emergence at the end. More about that later….

I then start the propofol. Marginally off piste, Guedel’s plains of anaesthesia are useful here and although slightly bastardised by modern practice I wait until the patients’ eyes are fixed in the midline before instrumenting the airway.
BIS is also useful.

I generally use this technique for larger cases, and because the patient will de facto be apnoiec at these Alf concentrations I usually intubate. Unless there is an airway issue I do not use muscle relaxant (I will write another thread about that if more than 2 people read this)

As soon as the tube is in I reduce the Cpt to about 90mcg/ml and leave it there for the duration of the case.

The very slight intricacy of this technique is towards the end. Patients will remain apnoeic until a Cpt between 60>x>70mcg/ml, so one has a set a decrement concentration. One does this by pushing the <?> key and entering a number of your choice.

I choose the decrement concentration depending on how the patient went off the sleep and how painful the operation was. Depending on habitus and length of surgery the decrement can be anything from 5 minutes to over an hour which is why using the model is vital.

The decrement time is set to 70mcg/ml in the below and is the lower right figure……14 mins. I have set the target Cpt to overshoot this in this instance.

Whilst the Alfentanil Cpt is decreasing I will decrease the MV to stimulate respiration. An ETCO2 of approx 7 is normally about right to do the latter without completely ruining the acid base balance and waking someone up feeling like they have a neck size of 30 inches!

When the patient resumes respiration I establish a regular pattern on PSVpro. Having done that, and if necessary, I then up titrate the alfentanil to a RR of about 8 to ensure maximal safe analgesia concentration on emergence.

No other analgesia is routinely required in theatre aside from the standard “non anaesthetic” affairs (ie paracetamol, NSAIDS). This can be, and often is, a 2 drug anaesthetic.

Every anaesthetist knows that there are hundreds of ways to safely skin a cat and giving someone else’s anaesthetic is almost impossible. That being said this is the best one I can give, I believe in it and have anaesthetised colleagues who subsequently agree!

Thanks for reading!

Originally tweeted by Luke (@Shr_Nottingham) on August 6, 2022.

Reproduced with Permission by Anaestheasier