Everything I wish I knew before starting Anaesthetics Training

If you're just about to start your anaesthetics training then this post is for you.

Welcome to the greatest career in medicine

We hope you enjoy it as much as we do.

It's hard to appreciate just how much you learn as a new anaesthetic trainee - and how quickly - to the point that we very quickly forget what it is exactly we were worrying about in the weeks and months before we started.

This is why we are so grateful to those of you that have emailed and tweeted us with your queries and concerns, so we can help as many people out as possible in time for their big first day.

Here we're compiling a whole host of responses to the commonly asked questions, so hopefully as many people can benefit from it as possible - and we'll keep adding more.

Please don't hesitate to get in touch and ask us anything you like.

What is expected of me as a Novice?

To be 0% knowledgeable and 100% reliable

It’s a big deal starting anaesthetics training as a novice, regardless of your experience or background.

It’s a huge change from ward medicine, or any other sort of medicine really, to a world of:

• Dangerous instant-onset drugs that you administer yourself
• Highly technical machines that you need to understand inside and out to keep people alive
• Invasive procedures involving large needles near some pretty important body parts

This is not to scare you, but to remind you that every senior you work with has been in exactly the same position and knows just how you feel.

Nobody is expecting you to know much at all, rather they’re looking to see that you have a willingness to learn and that you demonstrate diligence and attention to detail, with the right amount of humility and respect for the game.

I do not have any previous ITU/anaesthetics experience, will that put me at a disadvantage?

No amount of ITU experience prepares you for your first fully independent anaesthetic

Of course it helps if you’ve intubated someone before, you know exactly how propofol works, or you’re confident doing central or arterial lines before you start anaesthetics.

But in reality, you’re going to be doing these frequently, and you’ll pick the skills up quickly enough anyway, so don’t worry.

It’s a steep learning curve regardless of your experience, and the trainees I’ve worked with who have come straight from Foundation training have said it’s a potentially little steeper if you’re completely new to the world of sedation and intubation, but in theatre you’re so well supported by consultants and senior trainees that you’ll be able to pick things up at your own pace, so don’t worry!

How much supervision am I given in the first few months?

They’ll watch you adding milk to your coffee

Consider for a moment just how dangerous anaesthesia can be if done incorrectly, and you’ll appreciate why the novice period exists in the first place.

You won’t be allowed to do anything independently until your supervisors are happy that you can do it safely on your own.

That said, as soon as you have demonstrated that you can, they’ll be very quick to get you flying solo as much as possible, because it’s a much better way to learn and much more rewarding.

To give you an idea, I did my first independent induction and intubation on my own (with the consultant hiding in the next room) during the second week of my novice period, so it’s pretty quick progress. This is one of the best bits in my opinion – you feel like you’re learning loads of new skills really quickly. It’s a very rewarding period of time, so enjoy it as much as you can!

After the IAC am I left unsupervised?

Yes!

I can only speak from personal experience, but the prospect of being on the on-call rota and flying solo after just three months or so of supervised learning terrified me throughout my novice period.

I couldn’t fathom how in such a short space of time I’d acquire the experience necessary to anaesthetise someone on my own in the middle of the night.

But around a week or two before the end of the novice period, everything started to click into place in my head, and by the time sign-off came around, I felt pretty ready to get going. Of course I was nervous, but the abject terror had morphed into excitement and it ended up being really enjoyable.

Bear in mind this is only for the overnight on-calls, where you will only be expected to manage the most simple cases (young healthy people for appendicectomy or testicular torsion etc) by yourself.

Everything else you will be supported for, including most cases during the day when there is a consultant around, and you’ll be able to work with your supervisor to ensure you have the right amount of supervision for your level of confidence and experience, whether that’s the consultant standing by your side, in the anaesthetic room, or in the coffee room down the corridor.

What is something many trainees wish they had been told before starting Anaesthetics training?

There’s no one ‘right’ way to do an anaesthetic

There are plenty of wrong ways to do it, but there’s certainly no one ‘right’ way to anaesthetise a given patient.

As long as they’re safe, comfortable, and you’re not anaesthetising all of the staff in the room as well, then you can do what you like really.

I found this hard to get to grips with, especially at the start, because I have the sort of personality who likes to be told ‘do it this way every time‘, which in anaesthetics, doesn’t exist.

You’ll be with a different consultant each day who will do things their own way and it will be frustrating and confusing because you’re still just trying to learn the basics and they seem to be contradicting what you’ve been told before.

Go with the flow, and you’ll start to pick up the traits and quirks that you like from different supervisors, and you’ll create your own recipe to build your anaesthetic.

What courses should I ideally be doing in CT1?

Just get the IAC done, and make sure your ALS is in date

I did no courses at all during my CT1 year.

In my opinion you’ve got plenty of time and the focus should be on just building experience anaesthetising lots of different types of people to build your confidence.

Of course if you want to go on courses, then go crazy – PALS, ATLS, MIMMS, PHEC – take your pick, it’s up to you. But don’t feel any pressure if you’d rather focus on keeping things simple for at least the first year.

As with everything in anaesthetics, don’t let other people rush you.

Please refer to rule nine

Will I actually feel like I’m being trained?

Anaesthetics is one of the few specialties where you feel like an actual trainee, and not just part of the work force

Yes – Short answer.

The training in anaesthetics, and the experience of being a CT1 anaesthetist, is absolutely fantastic, almost to the point of feeling guilty. While your contemporaries in other specialties are running around like crazy getting ward round jobs and discharge paperwork done, you're sat having a casual conversation about vaporisers with your consultant.

It’s a good life!

Anaesthetics is also as much of an art form as it is a science, so you feel like you are building and honing your craft in ways that other areas of medicine don’t offer.

Some people find there is almost too much support, especially after a few weeks when you’re starting to feel a bit more confident in your abilities, but the majority of consultants are very good at giving you enough supervision without feeling overbearing.

Do I need to do any reading before my first day of CT1 Anaesthetics?

You don’t need to, but it’s worth having a look

There are three things I tell people before they start when it comes to reading beforehand:

• The learning curve is going to be steep regardless of what you do
• Any reading is going to help at least a little bit
• The most important thing is to start your training refreshed and relaxed

You will have so much time during your training to learn the necessary material that you don't need to do any reading beforehand.

Having said that, if you want to be a little more familiar with some of the drugs, equipment and procedures before you start, then of course, some preparation is only going to help.

I would advise having a look at our induction agents and anaesthetic equipment pages, to get a feel for the basics that you’ll be doing on a daily basis, and have a look through some of our case posts for examples of a typical anaesthetic. Don’t work too hard before you start, and don’t worry, nobody is expecting you to know very much about anaesthetics at all!

• Read the rest of this post, and all the other posts in our Novice section
• Watch YouTube videos to get a feel for what the operating theatre environment and anaesthetic equipment is like - we recommend our channel and ABCs of Anaesthesia in particular, but there are plenty of great channels out there
• Oh and check out our TikTok

I’m nervous about drawing up drugs

Who is in theatre?

As the anaesthetist you are part of a close-knit family of theatre staff, who will regularly work together for months, day and night, on a whole host of different cases.

There will be chilled elective lists, ridiculously overcomplicated logistics and stressful unexpected emergencies, and you'll get through it together.

It's a lovely team to be a part of - so here's who to expect.

Are you normally with a consultant?

Anaesthetics feels like a bit of a cheat code within the world of medicine, because of just how much time you get one-on-one with a consultant, being properly taught cool new stuff.

During the novice period you are never on your own when doing anything related to anaesthesia.

Once you go on to the on-call rota, you'll start doing simple cases by yourself, but often with some help, for example from the obstetric anaesthetist on the same shift.

For anything even remotely complicated or serious, you call the boss and the boss generally comes to help.

Until you are a senior registrar or specialty doctor, you will always be put on an elective list with a consultant supervisor.

Cannulas

Cannulae?

This is a contentious area among anaesthetists (what isn't?), with half the crew frustrated at being expected to provide the hospital's IV access service, and the other half enjoying helping out the ward teams with a simple skill we're good at and generally like doing.

What if I'm no good at cannulas?

You will be.

I'm good at them now - I was terrible in my first three years.

It's a numbers and technique game - for technique watch these videos, and as for numbers, you just have to crack on and do as many as you can.

I have failed 697 cannulas and counting...

Please can you do an anaesthetic assessment for this patient and tell us if they need an operation?

This bleep happens weirdly frequently, and it's not your decision to make.

Many surgeons will ask the anaesthetist whether the patient is 'fit' for an operation. Sometimes this is clearly a yes or a no, but most of the time, it's a maybe.

Most self-respecting anaesthetists can get most patients through most operations and have them alive on the other side, but that's not the issue here.

The issue is whether the operation is the right thing to do - which is ultimately a surgical decision - based on whether it's likely to provide a meaningful improvement to the patient's quality of life in the near and distant future.

So by all means be helpful and provide your opinion, but don't get dragged into taking responsibility for saying that a patient should or should not have a procedure.

Again - any concerns at all - call the boss.

Making an anaesthetic plan

"Are you expected to come up with your anaesthetic plan - if so how early on? Is this just something you learn how to do?"

On day one you turn up.

This is your only job.

Your supervising consultant will then introduce you to the basics, bit by bit, and maybe you'll have a crack at intubating or doing part of a procedure.

You are not expected to make any plans, independent decisions or instigate any form of patient management by yourself.

Gradually over the next few days, they'll get you seeing the patients for the pre-operative assessment. This is usually made vastly easier by the presence of a proforma with a load of tick-box questions to ask, so you don't forget anything important.

As you see more anaesthetics and operations, it will become clearer which cases need a general anaesthetic and which are usually done under regional.

You'll also see a whole host of variety between different anaesthetists which can be very confusing and frustrating because it can feel like they're contradicting each other - just go with the flow.

Long story short

You won't have to make an anaesthetic plan by yourself until several weeks in, when it will be a simple general anaesthetic for a laparoscopic appendicectomy, a spinal for a hip replacement, or something similar.

And as always - if in any doubt at all - just ask.

Regional Anaesthesia

"When do you get taught blocks for local anaesthetic things?"

This gradually occurs over time as you gain experience on specific elective lists where regional anaesthesia is used, such as orthopaedic shoulder and knee replacement lists.

You aren't expected to be even remotely proficient at regional anaesthesia until your registrar years, so don't fret about learning this stuff yet.

If you're keen to learn more - check out nysora.com

When do I start holding the bleep?

During your novice period, you'll hopefully get some out of hours experience of the on-call rota, and you'll likely be partnered up with someone to show you the ropes.

Usually during this time they'll start getting you to hold the bleep and respond to calls, to build your confidence for when you go on-call yourself.

By all means ask to hold the bleep - they'll usually be delighted to give it to you!

Do I have to do pain reviews?

Yes. But it's not nearly as scary or complex as you might think.

There are two types of pain patients:

• Acute
• Chronic

Well, technically you have the acute-on-chronic pain patients as well, but they tend to fall into the 'acute' category when it comes to your job as the on call anaesthetist.

Pain is unbelievably variable, complex and nuanced, hence it forms a sub-specialty in its own right, so don't for a second think you're going to be expected to manage complex pain regimes by yourself - you won't.

What you will be asked to do is to review patients and essentially answer just one question:

• "Is their current pain control regime enough?"

You usually garner this information by talking to the patient and repeating this same question verbatim.

Now, the answer is usually going to be 'no', otherwise they wouldn't have asked you to review the patient, however you now have three options:

• Increase one of the medications they're already on
• Add in a new one
• Think about some sort of procedure involving local anaesthetic and a needle

You don't need to make this decision on your own

Especially early on when you're brand new to making any sort of anaesthetic decisions at all.

The key is simply recognising the issue, gathering data, and then reporting back to your senior, and in the case of the really complicated acute-on-chronic pain, there's often a lot of head-scratching and back and forth discussion with the acute pain lead, the specialist pain nurses and what ever other specialties may be involved.

Do I attend medical emergencies?

In short - yes - and it's my favourite part of the job.

This is usually only when you're on call, or on the CEPOD theatre list, but it varies between trusts.

Pitching up to a crisis, rapidly figuring out what the problem is (and if there actually is a problem) and helping work with other team members to fix what you can as quickly as possible is very rewarding indeed.

Which specific emergencies you attend depends on your trust's individual way of doing things. In some centres, you attend everything that the bleep shouts about, whereas in many places you only attend as the anaesthetist if they specifically request airway assistance or if it's a cardiac arrest.

In my current hospital, the expectation is that ITU will attend cardiac arrests and airway calls, and the CEPOD and obstetric anaesthetists will help out if they can, but at another hospital in the same trust the roles are reversed.

ABC

Take a deep breath, and do the same thing you do every day for every patient ever - airway, breathing, circulation...

Do not expect to be competent or confident doing this at a crash call when you first start out. It should be terrifying because it is. You will most likely be accompanied by another anaesthetist with whom you can work together, but if not, as soon as you identify a problem that you need help with - you guessed it - call the boss.

"Are you happy for anaesthetics to leave?"

You've pitched up, realised that Margaret has flopped out of bed onto the floor and isn't seriously injured, with no airway or breathing problems, and you're not going to need to intubate her - so you ask the medical emergency team if they're happy for you to wander off, and usually they nod and thank you for coming.

Self-extrication is a skill you will build with time.

What makes a good pre-operative assessment?

A thorough one.

The main concern here is cardiovascular and respiratory function, as these are the main variables we're going to be messing with by inducing anaesthesia and giving muscle relaxants.

For elective surgery, this needs to be pretty comprehensive, to ensure that the surgery is as low-risk as possible.

For emergency surgery, a good preoperative assessment is still important, however the urgency of the operation often means you don't have much opportunity to fix stuff that you would usually take time to optimise before an elective procedure.

But it's nice to be aware of what might crop up once the patient is asleep.

Sometimes your history is extremely limited, such as before a category 1 caesarean section where you don't have time to ask much more than allergy status and when they last ate!

On call day vs nights

The role of the on call anaesthetist is much the same whether it's day, night, Christmas or New Year - you respond to the emergencies as they present themselves.

The key difference between days and nights is the presence of senior support.

Generally during the day, particularly during the week, the CEPOD consultant will be in and helping run the list, allowing the junior to respond to emergency calls, cannula requests and reviewing the next patient on the list.

Overnight, it's up to you (and your fellow on call team) to coordinate things.

The following statement is so important, and so underappreciated.

You only operate overnight if the patient's life or a limb is at risk.

We'll write a separate post about this, because it deserves going into in more detail, and you don't need to worry about this for your first three months anyway.

Drug calculations

Many people dread the thought of having to do complex drug calculations, particularly in stressful scenarios, because they're worried about making mistakes.

Which is precisely why we don't do complex drug calculations in stressful scenarios.

You'll very quickly learn that the vast majority of drug doses are relatively standard, and those that need individual adjustment for the patient in front of you usually have a handy app or calculator to do the hard yards for you.

Download a paediatric drug dose calculator app now, and have a look through how it works, but don't stress about learning all of the information yet.

You will need to know the correct doses by weight.

This is something they love to examine in the FRCA, to check that you are weilding your pharmacological weapons safely, but in reality most of the calculations are either from memory or a machine, and your knowledge is simply used to sense check the number that the calculator churns out.

When do you start doing transfers?

This will vary between trusts but in general you'll need your IAC all signed off, and to have completed some form of specific transfer training before they shove you in the back of a van off to a tertiary hospital at the other end of a motorway.

The key here is that they won't let you anywhere near a transfer until they're happy you're capable of doing so safely.

You can check out our top transfer tips post here

How often do you stay late on normal days?

In three years of anaesthetics training I have left on time precisely twice.

Every other day I have been sent home early.

As a consultant anaesthetist you are responsible for the patient's wellbeing right up until the point they're comfortably dropped off in recovery, whereupon you are finally released of your responsibility and you can go home at the end of the day.

If the last patient is on the table, and the operation is taking longer than expected for whatever reason, then you have no option but to stay until it's finished.

As the supranumery trainee, however, you can pretty much go at any time - the patient won't mind.

Clearly you are being paid to work and to learn, and you shouldn't be trying to leave as early as possible and missing valuable learning experiences in the process.

But when the clock is ticking towards 5pm, and the last patient has been anaesthetised, intubated and incised, very frequently the consultant will turn to you and say those blessed words:

"Would you like to go home?"

The answer is yes.

I'm worried about failing intubations

Good. But you don't need to.

There are three things to remember when it comes to intubation:

• Intubation is not the ultimate goal - oxygenation is
• If we could intubate everyone perfectly from the beginning, then anaesthetics training would be very short indeed
• 90% of a successful intubation is the preparation before you pick up the laryngoscope

It's easy to watch someone intubating a patient and assume that all the skill is in the handling of the laryngoscope and tube. The reality is the hard work has already been done:

• Airway assessment
• Equipment planning
• Patient positioning
• Preoxygenation
• Multiple back up plans

If you've done all of these things first, then generally speaking the act of putting the tube between the cords becomes relatively straightforward.

You need to learn to drive the scope.

Technique requires practice, practice and more practice. You will learn the feel of laryngoscopy, the pressure of the blade against the tongue, and the unique arm movement required to safely move the soft tissue out the way to provide that beautiful view of the cords without sending incisors flying.

Don't rush - you're building a craft - it takes time.

How much physics do I need to know?

This is a really common question, because of all the sciences that we use on a daily basis in anaesthesia, physics is probably the scariest, and the least well understood.

Personally, I didn't do physics at A-level, but I am a nerd - I find the physics really interesting - which of course is going to help when it comes to learning it for the exams.

I strongly believe that with the right teacher and the correct approach, the physics you need for the FRCA exams, and a career in anaesthesia, is easy to understand, once it is explained in a way that makes sense to your brain.

It just takes time, and repetition.

I think this is the biggest hurdle for modern students. Life is so fast nowadays that we expect everything to happen instantly, including our own learning. We then assume that if we don't intuitively get something immediately, that it's impossibly difficult and we will never understand it.

The reality is there is no substitution for time and exposure when it comes to learning new concepts - no matter what the TikTok gurus try to tell you.

Our goal here at Anaestheasier is to try and teach all of the physics that you need for the FRCA exams in an approachable, easy-to-digest manner that means you can grasp it, no matter how physics-phobic you are.

Then once you have a handle on the basics, you can see it in action next time you're in theatre, and slowly your confidence will build.

But don't rush - it always takes time.

Other useful posts

• Novice period FAQs
• Emergency Drugs
• What does a normal anaesthetic look like?
• An anaesthetic walkthrough

There are no silly questions

We absolutely love teaching and helping junior trainees, and would be absolutely delighted to hear from you if there's something on your mind about anaesthesia that hasn't been answered by one of our posts.

Ask us anything

If you're a member of Anaestheasier then you can stick a question in the comments below, otherwise if you'd rather email us then go for it - anaestheasier@gmail.com - and we'll get right back to you!

Other useful blog posts for your novice period

• Emergency Drugs
• A Standard Anaesthetic

RCoA Novice FAQs

FAQs

The Royal College of Anaesthetists