The following is a letter to myself as a CT1 at this point in the year with all the words I needed to hear - maybe someone else will find it helpful too.
You're currently half way through your introductory training to anaesthesia and are well on your way to completion of IAC and joining the on-call rota.
By now you'll hopefully have given some anaesthetics, put some tubes between - or at least near - some vocal cords and stuck a needle in a few spines with varying success rates. You might have done some more independent inductions with the boss hovering outside, and maybe even been involved in an RSI or two.
You've also probably completely forgotten how to cannulate.
You're supposed to feel like this
If you're feeling something along the lines of
"How the hell am I supposed to do all of this on my own on call!?"
then please be reassured you are right on track. You're meant to feel like that right now - that's the whole point of the novice period - to show you what you don't yet know.
If you were supposed to feel ready to go on call at this point, they would have made the novice period two months long. It's four months for a reason, because it takes that much time to realise two things:
- Just how much you don't know yet
- How to use the knowledge you do have safely
If you're not feeling at least a little anxious and hesitant about the idea of doing anaesthesia by yourself at night time, then you're probably not paying enough attention to just how serious this job is, and the importance of your role.
It feels like a big deal going on call - and it is - but as professional neurotics we often inflate our own sense of responsibility and worry about things that probably don't need all that much concern.
"What if something comes up that I can't manage?"
It's not a question of 'if', but 'when'.
Of course there's going to be a whole bunch of clinical scenarios that crop up that you've not seen or managed before, otherwise anaesthesia would be a very dull career indeed, and one of the most rewarding parts of the job is gettting more comfortable with thinking on your feet and improvising with what you have to hand, and the variety of skills and techniques that you've accrued over your career.
But I realise that's not the priority right now. Right now you'd probably just appreciate feeling comfortable giving a safe, sturdy anaesthetic that you feel confident is going to get the job done - and you will, in a few weeks' time.
There are very few cases that you will be expected to manage truly independently, and they will be the cases that you have probably been given free reign to induce and intubate by yourself already, albeit with the consultant watching like a hawk from outside.
You're never alone
This is true in many senses. Not only are you never doing something for a patient truly by yourself - you'll always have an ODP, anaesthetic nurse or ITU nurse helping you - but you also always have someone else you can call for help, whether that's the registrar, consultant or an ITU doctor.
I vividly remember the first time I gave an anaesthetic independently out of hours.
It went something like this
"Okay - roc's in" I announced to no-one purely out of nervous habit as the plunger sank the muscle relaxant silently into the patient's arm, the beeping monitor gently reminding me that the patient and I were equally stressed about our encounter.
I shakily twisted the syringe back off the cannula (that I was thrilled to have actually managed) and set it back down on the anaesthetic machine before taking hold of the mask with both hands and watching the clock for those breathtaking (literally) forty-five seconds while the paralytic permeated through the thirty-two year old patient I'd met half an hour ago.
Then it hit me like a brick - It's three a.m. and I've just rendered a stranger unconscious and unable to breathe - and now I have to keep them alive by myself.
The following thoughts then arrived neatly in order:
- What if I can't intubate him?
- What if he arrests?
- Who let me have this job?
- How did I even get a medical degree?
My express train to panic-ville was interrupted by the ODP who gently handed me the laryngoscope and held the patient's mouth open, taking care to clear the lower lip from the bottom teeth as I slid the laryngoscope over the tongue.
"You're going to be fine, take your time" she soothed, in a voice that suggested I very much was not her first novice-on-the-rota-for-the-first-time intubation.
"I can see the cords!"
"You sound surprised..."
Fifteen seconds later I had an alive, asleep and intubated patient in front of me, and I was grinning like a moron.
"Maybe some sevo?" she hinted in the manner of a very bored OSCE examiner whose candidate has clearly forgotten the point of the station.
"Ah shit thanks."
Most of the ODPs and anaesthetic nurses can manage an airway just fine, and can talk you through a sensible anaesthetic plan without batting an eyelid, so use them.
I regularly ask my ODP and anaesthetic nurse colleagues for ideas and suggestions about how best to anaesthetise a patient or whether they think I've missed anything, especially if it's 3am and I'm overthinking things more than I need to.
So in the middle of the night, if you're feeling the weight of the world on your shoulders, remember that everyone in the room is on your team and will be able to help you out far more than you realise.
Trust your gut
There will be times when you're asked to do something that makes you feel very uncomfortable.
Examples from my own experience include:
- Please can you sedate this 2 year old child in Majors so we can relocate her elbow?
- Please can you sedate this 96 year old woman with atrial fibrillation for a cardioversion? Her systolic is 63.
- Please can you put a central line in on the ward so that we can give TPN?
- Please can you do a quick GA for this guy with severe aortic stenosis, lung fibrosis and renal failure? It'll be a super quick laparotomy
- This man has a NELA mortality risk score of 56%, can you assess whether he's fit for an operation?
- Is this ECG okay?
- Can we do it under local with, like - a little bit of muscle relaxant?
We're the handy-people of the hospital, called upon for the odd jobs, bits and bobs that other the other specialties need help with, and often the other specialties are rather 'optimistic' about what we're able to achieve with a syringe of hypnotic and some plastic tubes.
Do not start doing something if your gut is telling you it's not safe, and the second you're not comfortable, you call for help - it's what anaesthetists do, no matter how senior. I have seen very senior consultants ask a colleague to simply be in the room with them for higher risk cases, for moral support as much as genuine assistance.
There is no bravado, no cope culture, no 'just get it done' mentality that plagues many of our fellow teams.
If you're not happy - call for help.
There will be many, many times when you call for help in the middle of the night and end up not needing it, and the senior you called in from their bed will just be delighted that everything went okay.
Never be rushed
Anaesthetists are graceful creatures, gliding swiftly and smoothly through the turbulence of resus and the chaos of labour ward, gently fixing and correcting as we go before disappearing into the ether. Or sevoflurane, take your pick.
We do not rush.
At this point I'll refer you to Anaestheasier's ninth rule of anaesthesia - your lack of planning does not constitute my emergency.
There is never a situation in which you need to rush, because rushing ends up being clumsy and disjointed and much slower than just being methodical, calm and smooth.
- You will have theatre coordinators telling you to go and see patients right now
- You will have ED docs requesting analgesia reviews right now
- You will have surgeons demanding you just get on with it
- You will have cardiologists proclaiming that they need to revascularise and the patient should already be intubated by now
And that's fine.
Just breathe, assess, plan, and do your thing. I promise you can take your time, because in reality even if you feel like you're moving slowly, it'll be fast enough.
The art of Swanning
Swanning is the essential skill of appearing serenely calm and unwavering in your control of the situation, even if you're frantically paddling away underwater just to stay afloat.
One of the key roles of the anaesthetist in any situation is to be the sturdy anchor of reassurance for both your team and your patient, even if you're thoroughly bricking it behind the drapes.
If the anaesthetist panics, everyone panics.
Swanning is not a personality trait, rather it is a trainable skill, that will come with time and practice, so long as you pay attention and plan ahead.
I am an anxious wreck
Always have been. I am very open about this, because I feel that a lot of other people are as well but don't feel they can talk about it in a career that prides itself on never showing weakness.
I am and always have been terrified of making mistakes, and as a foundation doctor I would regularly wake up in sweats at three in the morning in a blind panic over something as serious as whether I'd prescribed the correct rate of fluids or missed a mildly raised CRP.
I never thought I could be an anaesthetist.
One of my biggest fears, especially as a novice anaesthetist, was that I'm not a 'chilled enough' person to do anaesthetics, or to be effective in a crisis. Everyone else seemed much more relaxed than I was, more in control and unfazed by the concept that we literally nearly kill people for a job.
It took time to realise that in truth, everyone is swanning and giving off the appearance of being completely unflustered while hiding a heart rate of 130bpm - you just need to practice.
So if everyone else around you seems dead calm while you're stressed out then please be reassured that this is entirely normal, and as you become more confident managing airways, accidents and asystoles, you too will evolve into the chilled out steady hand on the tiller that the team looks to in a crisis.
Talk to us
I hope that at least part of this post has provided a morsel of reassurance or entertainment, and that your training in anaesthetics is as enjoyable as it is challenging.
We're two anaesthetic registrars that love teaching, mentoring and generally helping other trainees out, so please don't hesitate to get in touch if you have any questions or concerns - we'd be delighted to hear from you - and I guarantee that if you ask a question, someone else will be glad you asked it for them!
- Anaestheasier@gmail.com if you'd rather remain anonymous
- Or comment below
And as always, if you have read something that doesn't make sense, that you disagree with or that is plain wrong then please do let us know - we love feedback and discussion about ideas. Equally if you have your own advice for your fellow colleagues then please share in the comments or via email.
Otherwise - happy gassing!