10.01.2007

Choosing a Specialty - AAA (All About Anesthesia)

Today, ER doctor asked me to write an entry about anesthesiology. I am an anesthesiologist with a subspecialization in pain management. I work both in the operating room, take trauma call, and in my pain management clinic. I'm a few years out of fellowship...and today, will shed some insight into my professional world.
I decided to become a physician sometime in high-school. There was no magical 'calling', or parental influence. I just had to make a decision. I thought for awhile about my favorite subjects, those I learned with the most ease, and narrowed it down to a few applicable careers. Although nursing crossed my mind, as I learned more about the differences between what nurses did, and what doctors did...I decided I didn't really want to 'nurse' people. I considered PA, but thought to myself...I'll never regret going for the top rung, but I may one day (as a PA) regret not going full-speed to the top, and "settling" for PA. So, physician it was.

With regard to specialty choice, that came later. As a premed (and my first year or two of medical school) I thought family practice was for me. Back in those days there was a big "push" for medical students to pursue careers in primary care. Family practice is "the doctor" I visualized when I thought of "doctor." I liked the idea of treating the entire family, establishing a long-term relationship with my patients, etc.

As I progressed to my clinical years and gained exposure to the 'real practice of medicine.' After having candid discussions with primary care docs...I 'realized' that family practice isn't what many people/students expected it to be. It's very stressful, and doesn't pay well. The physicians didn't seem to enjoy what they were doing...and that bothered me. Haunted me, actually. So I had to consider (for the first time) that family practice wasn't for me.

Anesthesia isn't one of those specialties that students get much exposure to in medical school...unless they actively seek out the experience. So, it's no wonder appreciation for what we do isn't fully realized. For many students, the only exposure they have is via their surgery rotation....or OB with epidurals.

The process of - Passing the Gas
Anesthesiology requires a medical student to complete their degree, their USMLEs, and a preliminary internship (either surgery, medicine, or transitional). After that, you move on to your CA-1 year as a first year anesthesia resident. Training is 3 years after the internship. The first year of training (the CA-1 year), you mostly get acquainted to the anesthesia machine, and do relatively simple cases such as ortho (usually young healthy men), and ophthamologic cases (with sedation). Most cases are short (unless a new surgical resident is learning to do an appy). The CA-2 year consists of more advanced cases, longer cases, and children. OB/epidurals, c-sections, trauma calls. There were more outside rotations for more specialized experience...such as children's hospital, and transplant centers. You do ICU/critical care coverage. CA-2 year is the nitty-gritty of training. The CA-3 year you do advanced cases, such as long transplant cases, long cases in general, complicated cases (like patients undergoing major surgery that are likely to die). Heart transplants, burn cases, brain and spinal cord surgery, etc. The best part is you have more administrative tasks, like running the OR board (deciding if/when the various operative cases go to the OR). You get to choose your electives, and have exposure to those areas that interest you. Subspecialty areas include pain management, hospice/palliative, critical care - officially. There's also areas that aren't "officially" subspecialties but requires experience/training, some offer an exam and may become 'specialty' soon - such as pediatrics, OB, and neuro.

Why I chose anesthesiology.
During my 3rd year of medical school, I was quite convinced that I'd pursue internal medicine, and subsequently subspecialize in....say cardiology. I knew general internal medicine wasn't for me, but with the numerous subspecialty choices in the field, I figured I'd find something I enjoyed. Then, honestly, as a 'easy rotation' to break the monotony I decided to schedule an elective anesthesia rotation near the end of my 3rd year. That is when I learned what anesthesiologists do all day.

I went to medical school, and subsequently trained at a major trauma center. To me, trauma were the most exciting cases. It was during the traumas that 2-4 anesthesiologists were present. One intubating. One doing an a-line. One doing central line. One getting blood/saline and putting it thru the level 1. All working quickly, carrying out their various tasks of stabilization and resuscitation. I fell in love...
Typical OR day. Arrive between 5:30 and 6:00am to pre-op on the day's patients. Introductions. Acquisition of information. Reassurance. Then off to set up the OR. Pulling drugs into syringes. Getting various equipment set up. And above all, checking the anesthesia machine. There's an intimate relationship between the anesthesiologist and the anesthesia machine.

I have 3-4 scheduled cases that ideally end at 3pm or so. I get a couple of short breaks, either between cases, but usually during cases when a colleague comes in to relieve me. I also get bathroom breaks and lunch break if they are unable to be scheduled in between cases. There are times when I'll break the OR for lunch, depending on our staffing levels. There are intermittent emergency cases that supersede scheduled cases, but we usually have someone available specifically to cover those instances. One of us anesthesiologists runs the OR board, and it is up to us to decide who gets surgery that day, and when - despite what the surgeons believe or say. It is our prerogative to cancel cases, close OR rooms, and manage the operative suite.

When there's an airway emergency anywhere in the hospital (excluding the ED), we respond and assist with airway control. We respond to all code blue arrests. We backup the ED...if they have a problem airway, they call us. We also assist with intravenous access and spinal fluid access (for lumbar punctures, or anesthesia administration). We cover OB, do epidurals, and are available for crash c-sections. There is a pediatric 'fellowship' in which we work at Children's hospitals doing typical anesthesiology tasks.

In addition to airway, and emergencies, we do regional blocks to prevent or treat painful conditions. In pain management, we treat patients with chronic pain syndromes. We deal with end of life care, and palliative pain issues via hospice and ICU. And of course, speaking of ICU, we manage critical patients in the ICU - usually surgical, and usually post-op.

What I don't like. What I like.
The lifestyle isn't always great. 6am is a very early start to your day. And 3pm easily and frequently turns into 4 or 5 pm....which makes for a very long day. There isn't a lot of down time because an empty OR is costing everyone money. Eventhough you only have 1 patient at a time, there's a sense of hurry to get cases started, and to leave patients in the PAR (post anesthesia recovery) even if you're not quite convinced you should leave them just yet. Dealing with some surgeon types makes for a very stressful, or negative atmosphere in the OR. There is little exchange between you and your patients (practically speaking) since they're sleeping the entire time. The OR is the same everyday, and somewhat boring. They say it's 90% boring, and 10% "oh shit!!" I think that's true. The solitude behind the blue curtain is nice, mostly, but it can get lonely.

There are a few specialties in medicine known for their "problems". Stereotypes don't apply to individuals, but rumor has it that anesthesiologist tend to have drug addiction issues. I guess passing all that gas, and administering all those drugs, makes access easy. This is a problem that is made clear on day one of anesthesia training. This is a problem on the radar of every anesthesia department. Not unlike radiologists getting blood cell cancers, psychiatrists committing more suicide, or surgeons having more broken families/marriages.

Also, patients (and people in general) frequently are unappreciative of the work we do. It's difficult keeping a patient comatose, paralyzed, with adequate blood pressure; breathe for them, protect their eyes, monitor the blood loss, and then....wake them up *intact* after hours of a human digging around in their abdominal cavity (or brain, or back...). When things go wrong, they go wrong FAST. You need to be aware of many drug actions, interactions, indications for use, and how to deal with pretty much any foreseeable (and unforeseeable) catastrophe. You have to be exquisitely more familiar with the workings (on a mechanical level) of the anesthesia machine than you ever imagined possible. You have to have a grip of physics, and understand the differences in gas pressure and turbulent flow of air thru tubes depending on the atmospheric pressure, type of tubing material, diameter and length of the tubing, and the viscosity of the gas. You have to be familiar with all the different procedures the surgeons are doing...and read up on the procedure beforehand to be sure you can anticipate/prepare for complications of that procedure, and anticipate when significant changes in vitals signs are expected to occur. Some drugs are so potent, that mere drops of it makes a huge difference. There are reactions to blood products, failure of equipment...and surgical complications that affect the well-being of the patient. And when things go wrong, everyone is very quick to blame the anesthesiologist. These factors result in a very difficult board exam - amoung the most difficult of any specialty, and many of us do not pass them on the first 1 or 2 attempts.

The job's both exciting, and frightening. The compensation is great. By working with residents I'm not tied to an OR all day. I get to be present at the start of a case, and at the end of a case. I am not tied to one room, therefore I don't feel the boredom or loneliness. I work at a trauma center, so that's exciting. I also have a pain management practice...so I have more 'patient contact' and continuity than almost any other type of doctor. And, I get paid to see my patients in pain management -unlike primary care docs.

More and more students are choosing anesthesiology, and the specialty is becoming more competitive. For years students were told anesthesia was oversaturated...and that created a shortage that was subsequently filled with FMGs. As more American students choose the specialty, and competitiveness increases....our profile will elevate, and that's a good thing for gaining respect and prestige for the profession.

11 comments:

Anonymous said...

This is a really informative and great essay. Thank you for a glimpse into your world. I am a primary care doc and when I was an intern I was advised to go into "gas" because I would work 1/2 the time and get paid 5 X as much. I think that is true but I would hate starting at 5:30AM! I have regretted my choice over the years. Thanks for the good, the bad and the ugly.

Anonymous said...

Wow, your posts are all so enlightening...keep on tellin' it up!

travelRN said...

Thanks for the post. I have wanted to pas the gas, but I could not afford med school. My only hope was to be a CRNA, again the cost is a little out of my league.

said...

A片,A片,成人網站,成人漫畫,色情,情色網,情色,AV,AV女優,成人影城,成人,色情A片,日本AV,免費成人影片,成人影片,SEX,免費A片,A片下載,免費A片下載,做愛,情色A片,色情影片,H漫,A漫,18成人

a片,色情影片,情色電影,a片,色情,情色網,情色,av,av女優,成人影城,成人,色情a片,日本av,免費成人影片,成人影片,情色a片,sex,免費a片,a片下載,免費a片下載

情趣用品,情趣用品,情趣,情趣,情趣用品,情趣用品,情趣,情趣,情趣用品,情趣用品,情趣,情趣

A片,A片,A片下載,做愛,成人電影,.18成人,日本A片,情色小說,情色電影,成人影城,自拍,情色論壇,成人論壇,情色貼圖,情色,免費A片,成人,成人網站,成人圖片,AV女優,成人光碟,色情,色情影片,免費A片下載,SEX,AV,色情網站,本土自拍,性愛,成人影片,情色文學,成人文章,成人圖片區,成人貼圖

情色,AV女優,UT聊天室,聊天室,A片,視訊聊天室

清朝美女 said...

(法新社倫敦四日電) 英國情色大亨芮孟a片的公司昨天說,芮孟av日前成人影片av女優世,享壽八十二歲;這位身價上億的房地產日本av開發商,部落格a片經在倫成人av推出第一場脫衣舞表演。

成人網站
芮孟的財產估計av女優達六億五千萬英鎊成人影片(台a片av女優情色近四成人百億),由於他名下事業大多分布在倫敦夜生色情a片色情區蘇活區sex,因此擁有「蘇成人網站情色之王」的稱號。
部落格

他的公司「保羅芮成人影片孟集團」旗下發a片行多種情色雜誌,包括「Raavdvdzzle」、情色電影「男性世界」以及「Mayfair」。色情影片


芮孟本名傑福瑞.安東尼.奎恩,父親色情為搬運承包商。芮孟av成人光碟五歲離開學校,矢言要在表演事業留名,起先表演讀av心術,後來成為巡迴歌舞雜耍表演的製作人。


許多評a片下載論家認為,他把情色情色電影表演帶進主流社會成人電影,一九五九年主成人網站持破情色視訊天荒的脫衣舞表演,後來更靠著在蘇活部落格區與倫敦色情西區開發房地產賺得大筆財富。

a片下載
有人形成人電影容芮孟是英國的海夫納,地位AV片等同美國的「花花公子」創辦人海夫納。

元美女 said...

(法新社a倫敦二B十WE四日電) 「情色二零零七」A片情趣產品大產自成人電影AV女優十三日起在倫敦的肯辛頓奧林匹亞展覽館舉行,倫敦人擺脫對性的保守態度成人網站踴躍參觀,許多成人網站穿皮衣與塑膠緊身衣的好色之徒擠進這項世界規模最大的成人生活展,估計三天展期可吸引八萬多好奇色情影片民眾參觀。
情色電影
A片下載動計畫AV負責人米里根承諾:「要搞浪漫、誘惑人、玩虐待,你渴望的我們都有情色。」

他說:「時髦的設計與華麗女裝,從吊飾到束腹到真人大小的雕塑,是我們由今年展出的數千件產品精選出的一部分,參展產品還包括時尚服飾、貼身女用內在美、鞋子、珠寶、玩具、影片、藝術、情色圖書及成人影片遊戲,更不要說性愛輔具及馬術裝備。」a片下載

參觀民眾遊覽兩百五a片十多個攤位,有性感服裝成人電影、玩具及情色食品,迎合各種品味。
av女優
大舞台上表演的是美國野蠻情色電影搖滾歌手瑪莉蓮曼森的前妻─全世界頭牌脫衣舞孃黛塔范提思,這是她今年在英國唯一色情一場表演。

以一九四零年代風格演出的黛塔范提思表演性感的天堂鳥、旋轉木馬及羽扇等舞蹈av

參展攤位有成人影片的推廣情趣用品,有色情的公開展示人a片體藝術和人體雕塑,也有情色藝術家工會成員提供建議。

漢美女 said...

(法新社a倫敦二B十WE四日電) 「情色二零零七」情趣產品大產自二十三日起在倫敦情色的肯辛頓奧林匹亞展覽館舉行,倫敦人擺脫對性的保守態度踴躍參觀,許多穿皮衣與情色電影塑膠緊身衣的好色之徒擠進這項AV世界規模最大的成人生活展,估計A片三天展期可吸引八萬多好奇民眾參觀。

活動計畫情色電影負責av女優成人網站米里根承諾:「要搞浪漫、誘惑人、玩虐待,你渴望成人電影成人影片我們都有。AV女優

他說:「時髦的設計與華成人電影成人網站女裝,從吊飾到束腹到真人大小的雕塑,是我們由今年展出的數千成人影片件產品精選情色出的一部分,參展產品還包括時尚服飾、貼身女用內av在美、鞋子、珠寶、玩具、影片、藝術、圖書及遊戲,更不要說性愛輔具及馬術裝備。」

參觀民眾遊覽兩百五十多個攤位,有性感服裝、玩具及色情情色食品,迎合各種品味。

大舞台上表演的是美國野蠻搖滾歌手瑪莉蓮曼森的前妻─全世界頭牌脫衣舞孃黛a片下載塔范提思,這是她今年在英國唯一一a片場表演。

以一九四零年代風A片下載格演a片出的黛塔范提思表演色情影片性感的天堂鳥、旋轉木馬及羽扇等舞蹈。

參展攤位有的推廣情趣用品,有的公開展色情示人體藝術和人體雕塑,也有情色藝術家工會成員提供建議。

eda said...

101煙火,煙火批發,煙火工廠,製造浪漫煙火小舖,煙火小舖,衣蝶,衣蝶,情趣用品,情趣商品,情趣,情趣,衣蝶情趣精品百貨,衣蝶情趣精品百貨,,煙火批發,情趣禮品,成人用品,情趣內衣,情趣精品,情趣商品,情趣用品,情趣,情趣,真愛密碼情趣用品,真愛密碼,真愛密碼,真愛密碼情趣用品,貓裝,自慰器,性感內褲,角色扮演,丁字褲,,跳蛋,AV,丁字褲,煙火,情趣用品,情趣用品

酒店上班請找艾葳 said...

艾葳酒店經紀提供專業的酒店經紀,酒店上班,酒店打工、兼職、酒店相關知識等酒店相關產業服務,想加入這行業的水水們請找專業又有保障的艾葳酒店經紀公司!
艾葳酒店經紀是合法的公司、我們是不會跟水水簽任何的合約 ( 請放心 ),我們是不會強押水水辛苦工作的薪水,我們絕對不會對任何人公開水水的資料、工作環境高雅時尚,無業績壓力,無脫秀無喝酒壓力,高層次會員制客源,工作輕鬆。
一般的酒店經紀只會在水水們第一次上班和領薪水時出現而已,對水水們的上班安全一點保障都沒有!艾葳酒店經紀公司的水水們上班時全程媽咪作陪,不需擔心!只提供最優質的酒店上班環境、上班條件給水水們。

Anna said...

I know that an anesthesiologist is a very important specialist during a surgery. Clenbuterol

jimmychooshoes said...

|Jimmy Choo Liu nails black boots
|Jimmy Choo Peep-toe boots
|Jimmy Choo Peep-toe boots
Christian Louboutin Circus 120 cutout boots
Christian Louboutin Esoteri 120 ankle boots