How to succeed on your anaesthesia rotation

I remember the nervous excitement of my first anaesthesia rotation as a medical student. I was assigned a highly sort after 6 weeks at Monash Medical Centre (one of the largest public hospital systems in Australia) and I had little idea what to expect. I just knew that I had learnt very little anaesthesia in my medical student curriculum, and that I needed to perform well to impress my supervisors and hopefully lead to an anaesthesia training position in the future.

I didn’t realise how crucial this first rotation was for several reasons. Unlike medical, surgical and emergency rotations, this was an optional selective. Not every student is given the opportunity, and I found out years later that the first impression I made here probably set the tone of how this anaesthesia department perceived me into my future anaesthesia rotations.

Insider Tip #1: Make a great first impression

The difficulties in making a great first impression

  • Lack of exposure in med school
  • Anaesthesia is different
  • Multiple consultants
  • Newer and more procedures
  • Lack of time

Lack of exposure

I realised that I have little recall of any anaesthesia lectures or assessments at all in my medical school days except for learning about the neuromuscular junction. I needed to find a resource ASAP to at least have an idea about was expected of me.

Resources I found useful as a medical student

How to survive anaesthesia was the first book I was recommended. The large books were far too detailed (Millers Anesthesiology). The Oxford Handbook of Anaesthesia was too brief and point form wasn’t easy to for comprehension.

Since then I’ve realised that Clinical Anesthesiology by Morgan and Mikhail is a great all round resource after learning the basics.

And a little plug for my ABCs of Anaesthesia Foundations course: it is a very practical compilation of everything you need to know, and actions/decisions you need to be able to make in your first anaesthesia rotation.

No matter what resources you have access to, having advice from a helpful mentor a year or two ahead was invaluable to uncover the nuances of that specific hospital and demystify the answers to all those little questions and uncertainties that I had.

Anaesthesia is just different. Every surgical or medical job felt more like an administrative position. I would be running around writing to-do lists, making sure work was completed, and then trying to make sense of complex patient plans, or get to theatre to watch a surgeon operate. Anaesthesia felt like I was in a real apprenticeship. My (supervised) daily tasks were:

  • Check the theatre setup
  • Assessment of each patient (I would take a detailed history lasting about 15 minutes, and my consultant would ask a few brief questions and be done in a minutes)
  • Draw up the medications (not always a medical student role)
  • Insert an IV cannula
  • Transfer the patient
  • Attach monitoring
  • Manage the airway
  • Complete the intraoperative anaesthesia chart
  • Rinse repeat

Insider tip #2: Make a checklist of your daily tasks

Except for IV cannulation, EVERY TASK was novel. I felt great! The work was extremely engaging, I felt productive, and I felt like my learning curve was steep and rapid! I kept a logbook (with detailed notes of my learning points), and this was seen as very impressive by my supervisor. I have been recommending this ever since!

Insider tip #3: Keep a logbook

You might work with 10 different consultants/supervisors in 1 week! This is unheard of in any other specialty, but as anaesthesia is often the largest single medical department in hospital, this is common. While it’s great to have so many specialists to teach you, each of them may instruct you in a different and sometimes contradictory way. I found learning one reasonable approach difficult and frustrating. Again, being aware of this, accepting this and using strategies to mitigate this issue is critical!

I would just be appreciative of any learning at all. It felt like a privilege to have one to one tuition from a busy specialist. This rarely happens in any other field! If something was very different to another consultant’s approach or opinion, I would politely mention this other approach and ask why. This would often lead to an interesting discussion which I believe helped create rapport with my supervisor.

Insider tip #4: Ask consultant to justify their approach.

Anaesthesia has many procedures that you may even be able to help with as a medical student or junior doctor! IV cannulation, airway management – bag mask ventilation, LMA insertions, intubation, video laryngoscopy, setting up fluid lines, rapid infusion devices, high flow oxygen, regional anaesthesia, spinal anaesthesia, arterial lines, and central venous lines. The secret to getting these experiences is to know they are options for the case, be extremely prepared, and politely ask for the opportunity.

I’ll write a system for this in more detail in a future article.

Insider tip #5: Preparation leads to opportunity

Anaesthesia has multiple time critical incidents that makes learning a challenge. Every theatre list is busy, airway management = risk of desaturation, hypotension needs rapid meds. There’s just less time to think, ponder options, guide the trainee through a technique, wait for the trainee to act when things could rapidly go disastrously wrong!

So how do we manage to learn all the skills and techniques?

Time and creating opportunities.

Over 5 years of training, with diligent effort, and 2 big exams, most anaesthetists will have the experiences and incidents to be an effective and competent anaesthetist.

But how do you increase ‘time’ when doing a 1 to 6 week rotation? I think it can be achieved by taking a systematic approach.

  • Arrive early to the theatre. You’ll need time to orientate, do all the tasks, and assess your patient.
  • During the case, check the patient notes for the next case, and even go to see the next patient/have them called to theatre early to give you more time to assess.
  • If you are going to do an IV or another procedure, set up your equipment in preparation. Again, request the patient to theatre earlier.
  • Plan and know your steps with procedures and verbalise this as you perform the task (more on this in a future blog)

For example

    • Know to escalate bag mask ventilation attempts with 2 hands, manoeuvres like a jaw thrust, adjuncts like a Guedel airway,
    • Verbalise this plan -so your supervisor knows all your next steps and doesn’t intervene too early. You want to get as far as you can with your management before they intervene! The more confidence the boss has in you, the more time they will give you and the more opportunities you’ll have to learn

Insider tip #6: Plan, perform and project (verbalise) your procedures

  • When intraoperative problems (hypoxaemia, hypotension) occur, engage in the 4 phase approach to resolution. Again plan, perform and project.

As a supervisor now, I realise that the process of learning is mutual exchange of thoughts. The rate of learning is much slower if the exchange of thoughts happens slowly. The simplest way to each this is verbalisation of ideas and plans as I am performing them, whether it’s airway management or managing a crisis. If the reasons for my actions are glaringly obvious, learning can occur without incorrect assumptions. Conversely, the verbalisation of my trainees’ thoughts means I can either agree or give feedback to why I would have used a different approach.

A few extra ways to make a good impression.

  • Anticipate
  • Read an article, ask a question with an opinion
  • What next

If you can anticipate what your team needs, even at a junior level you can be extremely helpful and less of a hindrance (I’m sure we all felt this going through medical training, when we were high in enthusiasm and low in execution).

For example:

  • Your supervisor is placing an urgent IV cannula, bring the sharps bin close to them…
  • The patient has a complication, offer to make the referral to ICU
  • Everyone’s busy running a difficult case, offer to complete the anaesthesia record to free up time

It is absolutely the role of trainees to ask questions and learn. This is encouraged! But I also know that much of what my teachers tell me, I may forget, and consultants get asked the same questions on repeat. To keep things interesting, why not read a recent or controversial article, form an opinion and quiz your consultant.

You’ve now had to work for your knowledge, formed more stable memory, and potentially sparked your consultant’s interest in something they may have not considered in a while! Check out more of my articles and also directly from journals like the BJA, BJA education, Anesthesia and Analgesia, The ANZCA Blue Book and any anaesthesia journal really.

If you find that you’re not doing much, try to think “what next?”.

  • Ask if you can help with anything
  • See the next patient
  • Complete the anaesthesia chart
  • Read an article
  • Practice setting up equipment -Optiflow, fluid lines, fibreoptic scopes
  • Explore the difficult intubation trolley, MH trolley, Anaphylaxis box, massive transfusion protocol…

I really hope that was useful and provided you with my insights from my experience teaching, medical student supervisor, critical care resident supervisor and as a specialist anaesthetist.

For my information for junior anaesthetists, check out my ABCs Foundations Course, it has everything you need to know in your first 12 months of anaesthesia practice.

Please ask any questions or comment below and share with anyone about to embark on a rotation in anaesthesia!

Good luck in your career!

Dr Lahiru