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

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

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 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 finding out more about the patient’s 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. 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 a 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 epidural 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 others in emergency scenarios, anaesthetics may just be for you!

Top Tips for a productive Taster week in Anaesthesia

It can be difficult for prospective trainees to fully understand what a career in anaesthetics is like. Unless a trainee has an intensive care medicine job lined up before they apply to Core Training, the chances are that they may have only met the elusive anaesthetists at emergency or trauma calls, before a patient is whisked away to theatre, or after pleading to the vascular access gods. Luckily, taster sessions are at hand.

Taster days are ‘not essential but will be desirable… to demonstrate interest in specialty and [to] also help you decide if it is the correct specialty for you.’

HEE Yorkshire and Humber

How can you organise a taster session, and what might you learn?

How to organise taster sessions.

Firstly, this is off your own back.

Doctors in training, such as in the foundation years, will likely have a quota of salaried days that they may take to gain experience in specialties that interest them. Usually, it is only about 5 days – which co-incidentally appears to be the minimum number of days that will stand up as a sign of ‘commitment to specialty’ in job applications – so spend your taster days wisely and choose anaesthesia.

It will definitely help to bring the topic up with your educational or clinical supervisors who may know the right contacts, so bring it up early at start of placement meetings.

You need to find out who a few people in your Trust are:

  • The RCoA College Tutor at your ‘local education provider’/Trust, who should be able to give some good advice about a career in anaesthesia and to point you in the direction of people to help you organise your taster sessions.
  • The anaesthetic rota coordinator, who will be able to find sessions that have availability for you to join. You shouldn’t turn up at the theatres without being rota-ed in because theatre time is essential learning time for anaesthesia trainees and for other learners, such as student ODPs, paramedics, nurses and medical students.
  • Your rota coordinator for your current specialty, who will need to find a time in your current rota that allows you to be released while the rota remains safe.
  • An additional avenue to pursue would be to become acquainted with your friendly neighbourhood anaesthetists, in theatres whilst on a surgical placement, during debriefs after emergency calls, or during lighter times at mess events. They might be able to point you in the direction of the anaesthetic consultants who really interested in teaching, or the lists that are particularly high-yield for practical skills e.g. the emergency CEPOD list, certain urology lists etc.

What your taster week might look like

  • With the help of the rota-coordinator, you should be able to form a structured schedule that should provide a wide exposure to anaesthesia.
    • Look to attend lists with multiple different consultants
      • Consultants working in anaesthesia often have other commitments, such as in research, ICU, pain medicine etc – so by meeting many consultants, you can gain insight into these additional anaesthesia-related specialties, too.
    • Look to attend lists of different surgeries
      • Different lists offer different opportunities. A relatively ‘simple’ list might have many short cases requiring only a supraglottic airway – useful if you’ve never put in an I-gel before, and useful to see a fast turnover of anaesthetic inductions. A good list for this might be a general surgery emergency list (with abscess drainages etc) or a gynaecological surgery list.
      • Longer operations often require a more complex anaesthetic, while operations in more frail patients likely need more sophisticated invasive monitoring. If you wanted to gain experience in laryngoscopy and intubation, or to see or partake in central venous access or arterial line placement, an elective or emergency colorectal list with big operations might provide a suitable learning environment.
    • Look to meet trainees!
      • It’s very important to learn from trainees – after all, they’re doing the job that you think you want. What’s it like, really?

💡 What should you ask consultants and trainees to really understand what life in anaesthesia is like? Find out more in an upcoming blog post…

What you might expect to do and learn during your taster week

  • Practice tricky things
    • Knowledge and skills of vascular access, airway manoeuvres and the use of emergency drugs are useful regardless of your future specialty.
    • Anaesthetic room time is a great opportunity to practice these tricky things in a controlled environment and readily accessible expertise
    • Learn how to cannulate properly.
    • Learn how to draw up drugs properly.
    • Jaw thrust and bag a patient properly.
    • Learn how to use an guedel/oropharygneal airway, an I-Gel/LMA, and direct/video laryngoscope, bougie and ETT properly.
  • See how the anaesthetist does tricky things
    • Textbooks will teach the alveolar gas equation and pharmacokinetics of anaesthetic agents, but watching or experiencing the changing of gears between I.V. and volatile agents, paralysis and reversal and the manipulation of cardiovascular or respiratory physiology is a demonstration of the art of anaesthesia.
  • Meet a variety of people and gain an appreciation of the team-based environment of theatres.
    • The presence of an ODP helps to aid the smoothness, safety and efficiency of an anaesthetic, while they provide an extra pair of eyes, hands and experience when things go awry. In the day to day, ODPs often do much of the essential hard work such as checking the anaesthetic machine and moving patients around the theatre environment, while also being great people to chat to and learn from as a prospective anaesthetic trainee.
    • You will meet some real characters!
  • See how good communication is done!
    • Some people are naturally good communicators, whilst some stumble over words or don’t quite say what they mean. I’m often in the latter category, but working towards being in the former, which means I listen particularly hard to the friendly and gentle babble of an anaesthetic room that effective teams create to comfort and quieten the anxieties and fears of patients.
    • If you want a masterclass in communication techniques, attend a paediatric anaesthesia list.
    • More broadly still, it’s just lovely to be in an environment where the team works together regularly, if not daily. Unlike many other theatres within medicine, my experience is that the anaesthetic room is not the place for big egos or enemies but is one of friendly banter and generally a good way to pass time; this must be all due to the wafts of Sevoflurane released during my poor preoxygenation attempts.
  • Anaesthetics is based on the practical application of knowledge.
    • Anaesthetics is fundamentally rooted in physiology, which although means that much of anaesthetics practice requires a sound understanding of physics, various eponymous constants, and other equations; by applying a stimulus, we can expect and predict a response. Whether it is understanding the pharmacology of a neuromuscular blocker on a neuromuscular junction with an expectation of the subsequent effect, or of the effects of metaraminol on the cardiovascular system, the effects of interventions in anaesthesia is much more tangible than, for example, the effect of a monoclonal antibody in a subtype of rheumatoid arthritis. For many, the rapid responses elicited by practical application of theoretical knowledge makes anaesthesia a very engaging and satisfying career.

To conclude, here’s a checklist for your taster week:

  1. Go in with an open mind and a desire to see, do, and learn everything.
  2. Ask your own questions, find out what you want to know to see if anaesthesia can provide a career with interest and sustainability over the long-run.
  3. Come out with practical skills and the perspectives of juniors, seniors and allied healthcare staff.
  4. Enjoy the time away from the ward rounds, charts and discharge notes; you’ve only got 5 days of paid taster days.
  5. Get feedback from your tutors, or obtain a certificate, and remember to reflect on your experience daily!

Dr Rory Heath

Clinical Fellow in Emergency Medicine

All systems go

Systems. Habits. Ways of doing things, lining things up, preparing vials of drugs or positioning the ultrasound just-so.

Everyone has one.

Everyone is a bit different; all built from advice from different mentors or in response to different previous disaster-pants moments – a product of the necessary learning curve in anaesthestic training.

As a junior trainee, or a prospective doctor on a taster week, or maybe even an experienced doctor making a move to a new department, watching how other established anaesthetists set themselves, their kit, their drugs and their team up before launching into mission mode is an informative experience.

Today I learned about one anaesthetist’s technique of putting opioids into 5ml syringes, muscle relaxants into a 10ml syringe, and propofol into a 20ml syringe – a system learned in the time-critical arena of pre-hospital care, where differing syringe sizes to identify which drug is which provide tactile information in addition to the visual reminder of a coloured drug label sticker – an extra layer of redundancy to ensure safety during an RSI in a dark corner at 3 in the morning, and a great tip for a junior.

Sometimes, however, watching this preparation and comparing it to our own system (or lack of system) can be intimidating; Is my system not good enough? Which system is best? Which to choose? Will this make or break my anaesthesia delivery?

Maybe there is one single anaesthetic preparation set up that will rule them all.

On the other hand, we might be liberated by the existence of a wide breadth and individuality of the systems employed by individuals; That there are so many systems, yet many safe and effective anaesthetics given, means that there are no major differences between the outcomes of different systems.

So, maybe there is no ‘optimal’ set up!?

The excellent principles of rigour, organisation and checklists to enable safe practice are seen throughout anaesthetic practice, and there are many circumstances where the consequences of poor systems are so disastrous that it should take much to contemplate whether an off-piste route should be taken e.g. CICO scenarios.

But, with regard to the large and multi-faceted task of delivering an anaesthetic, the smaller, personal details might not matter so much (as in they probably won’t help another practitioner). Whether you protocolise your pre-gas checks by lining everything up, drawing some drugs up and but leaving others in their vials, or use specific syringe sizes to mark out opioid, hypnotic and muscle relaxants is by-the-by; its success for you probably won’t translate into success for another practitioner with different experiences, habits or foibles. Our systems just play around the edges of a greater whole i.e. the principles of anaesthesia.

In summary, take comfort that no system is best, but the best one is the one that you choose and works for you (safely and consistently).

Dr Rory Heath

Clinical Fellow in Emergency Medicine

Bandwidth

Have you heard of the term ‘bandwidth’?

In simple terms,  our ‘bandwidth’ can be thought of as how much capacity we have to deal with X.

In anaesthetics, X is the RSI/nerve block/resuscitation/enter-other-that-you’re-about-to-perform – the task that has its complexities that need mastering to get right, escape plans if it goes wrong, and consequences if it goes really wrong.

For an expert in the field it might not take much bandwidth to deal with a routine case, instead turning on auto-pilot to tackle other problems or tasks. An established consultant that I know comes to mind – breezily keeping one eye on the monitor while delivering engaging teaching to his trainee while simultaneously making jokes with the nurses about the surgeon.

However, when tricky situations start to approach an individual’s level of confidence, they may find that their bandwidth becomes quickly consumed, almost filling at an exponential rate with increasing stress.

Bandwidth can also be taken up by problems that aren’t being dealt with in the immediate present – tirednesshungerstress, a long commute, or worries and difficulties in life such as finances and relationships.

The problem that will occur when bandwidth is exceeded is failure – which, depending on the circumstances, may mean different things.

Often, bandwidth failure presents as shortsharp, or snappy communication – demanding, not asking. Stating, not suggesting. Arrogance versus humility. Words, not sentences. We’ve all been in situations when, in the heat of the moment, we have said something unpleasant or less-than-gracious that we look back on with regret.

Knowing the capacity and status of your bandwidth is one way of predicting and avoiding errors of misjudged communication. We also know that, in a situation that is complex and overwhelming, progress can be made by asking for help and establishing teamwork; something that, ironically, a stressed-out bandwidth and choppy communication may seek to undermine. Treating team members with incivility or impatience when under pressure probably won’t kick start your colleagues into action but will subdue them with a reluctance to act to avoid further harm – a very real example of how stress and incivility may progressively dismantle teamwork to act as a contributor to disaster.

Obviously, this is a disasterpants scenario that we hope to avoid. What about smaller errors, such as failing a cannula because of hungerneeding a wee, but also needing to see that really sick patient at the other side of the hospital?

You already know what the solutions are to avoid bandwidth errors. While communication errors can derive from a saturated bandwidth, good and transparent communication frees them up. We can check in on our own bandwidths and those of our colleagues – a simple check that spreads the load of complex situations, and makes non-complex situations much more enjoyable for everyone involved.

Addressing the easy stuff – are you and your team fed, watered, caffeinated, and happy in their jobs – will keep the complex stuff easy, too.

Finally, if you feel stressed or that your bandwidth is being squeezed or stretched, take the opportunity to call for help or advice early. Asking for help won’t look bad, but will potentially avoid a tricky situation, and will certainly free up your own capacity to focus on what you can do to help, or what you can learn, or what next step in management you could do independently next time.

Dr Rory Heath

Clinical Fellow in Emergency Medicine