I remember one stressful case of a patient who was septic, and suffering a post partum haemorrhage. After induction of anesthesia, the patient’s blood pressure dropped precipitously requiring large doses of inotropes. She developed a rash and bronchospasm signifying likely anaphylaxis. How could this unlucky patient have so many complications? We stepped into crisis mode running vasopressors, fluid, optimising ventilation and oxygenation and delivering a massive transfusion of blood products. During a rare quiet moment in the chaos, I looked around to see my incredible team in action, seamlessly communicating, actioning complex tasks, moving swiftly between roles and ultimately saving this patient’s life. I feel emotional just thinking how lucky this patient was and how lucky I was to have this incredible team of anesthesia nurses and support staff.
Reflecting on my training years, I considered my job as an anesthesia resident was 2-fold
- To learn
- To care for patients
And they are both intimately linked to each other. No matter how I express care, it would lack efficacy without critical knowledge and skills. There are many ways to learn and develop your skillset – studying journals, textbooks, online videos, your supervising consultant and anesthesia assistant or nurse.
All of these modes of education can be great but, why isn’t your supervising consultant anesthesiologist often the best teacher?
To be clear, they may well be an incredible teacher, however, they may not have the time, interest or insight to teach many of the basics to a resident. Senior anesthesiologists may have practiced in their own specific way for many years and have little insight into changing practice and trends. The theatre list may be incredibly busy, and the sick patient requires extreme vigilance. Or you may have one of the rare anesthesiologists that don’t particularly want to teach.
Of all these resources, the one with among the highest levels of applied knowledge, skills and experience is your anesthesia nurse or assistant!
These assistants will have an impressive skillset, are often university qualified with a post graduate qualification in perioperative or critical care nursing, and best of all, have years and years of experience with
- The hospital
- The environment
- The equipment
- The daily practice, skills and knowledge of numerous anesthesiologists
Anesthesia assistants are often employed by 1 hospital whereas anesthetists will often move between 1-5 (sometimes more) hospitals in a week. As such, anesthetists may not have familiarity with the theatre layout, where to access emergency equipment and medications, or the best way to access assistance, resources and other specialists. The anesthesia assistant will know all these things very well!
One way to become useful to your team when you’re in training and yet to develop the specialist skillset, is to learn how to be a great assistant from your anesthesia assistant!
Useful tip #1
Learn your environment
Actions
Know how to quickly perform a few key tasks
- Organise a blood transfusion/massive transfusion protocol.
- Obtain a blood gas for rapid electrolyte and haemoglobin measurement.
- Call the interpreter service when your patient is unable to understand your language.
- Locate the defibrillator/crash cart, malignant hyperthermia trolley and intralipid container.
- Call the pacemaker technician.
- Refer to the acute pain service/ICU/HDU/Coronary care unit/other specialists.
Every anesthesiologist is assigned one anesthesia assistant. This is often enough support for a routine case, but even the best assistant’s resourcefulness and skills are exhausted in a crisis (massive transfusion, anaphylaxis, cardiac arrest or severe instability). By learning how to be a great assistant, you will go a long way to relieving your overworked teammate/supervisor of many time-consuming tasks that often need to happen immediately and simultaneously – thereby helping your patient survive!
Useful tip #2
Learn your equipment, systems and setup
Actions
Learn how to set up critical devices you may need in a crisis
- Fluid line
- Rapid infusion device (Belmont, Level 1)
- Rapid infusion catheter (RIC)
- Fluid warmer (blood, cold fluid warmer)
- Central venous line
- Arterial line
- Regional anaesthesia
- Defibrillator and pads
- Blood check prior to infusion
- Video laryngoscope
- Fibreoptic scope
- Can’t intubate, can’t oxygenate (CICO) equipment
Every anesthetist will approach the case in slightly different and occasionally contradictory ways. The anaesthesia nurse is well placed to let you know about how different anaesthetists do things and why.
They also need to know the next steps for many complicated procedures. For example, if the anesthesiologist is having difficulty with airway management, the anesthesia nurse will often have BURP or a bougie ready to go. They can often anticipate what is needed before it is asked for. This practice can be lifesaving in highly stressful moments when escalation steps can be difficult to remember. In your next operating list, ask your nurse about these subtle tips to rapidly escalate your learning!
Useful tip #3
Learn the shared mental models to facilitate effective teamwork
Actions
Learn the next steps to anticipate and plan for tricky situations
- Difficult airway management
- Can’t intubate can’t oxygenate
- Difficult intravenous (IV) cannulation
- Treatment resistant hypotension, hypoxaemia, tachycardia, bradycardia to name a few intraoperative problems
Throughout my training, I have found my team to be critical to my learning and the patient’s outcome. As a consultant, even though I will often lead a team, I have found that the success of any crisis is intimately associated with the team’s communication, adaptability, broad skillset and efficient actions.
In summary, learn from everyone around you! The anesthesia assistants and nurses are the obvious examples, but this extends to the surgeons, theatre technicians and orderly staff. They have golden nuggets of knowledge that evolve from being outside the anesthesia hierarchy and years of experience. One day, this extra information may just save your patient’s life.
Please write any comments or questions below
Dr Lahiru
(NOTE: The terms anesthesiology, anaesthesiology, anesthesia and anaesthesia simply reflect regional differences in spelling. In this website, anaesthetist, anesthetist, anesthesiologist and anaesthesiologist all refer to a medical doctor who has undergone specialist training in anaesthesia/anesthesiology)
