Ask An Ace: Anesthesiologist Edition

Usually when I tell people about anesthesia, they end up falling asleep… (cricket sounds)… Sorry, I had to take the opportunity to get a dorky joke in there. But seriously, I am excited to be a part of Ask An Ace so I can answer some questions about being the person that steals your senses during surgery, and fades into a hazy, blurry memory. So come gentle readers, let’s step behind those big surgical drapes!

Simply put, an anesthesiologist is the doctor that keeps you alive and comfortable during surgery. Anesthesia itself means “lack of sensation”, but as a practice it refers to relief of pain and lack of consciousness/awareness in addition to blocking sensation. We evaluate patients pre-operatively and come up with a plan for their anesthesia based on their medical conditions and the nature of the surgery. We then administer the appropriate type and dose of anesthesia to make the patient comfortable and safe. We stay in the operating the entire time monitoring the patients’ vital signs for their reactions to the anesthesia and the surgery. If anything isn’t perfect, we correct it. Finally we stop the anesthetic, wake the patient up, and take them to recovery room. Surgeries range from minor to major, but patients are always nervous and being a beacon of comfort and confidence is probably the most challenging yet rewarding part of the job.

Time for some questions!

1. How long are your shifts? Are they typically as long as doctors and nurses? Do you ever get to make your own schedule? – Aurora B.

Some groups have shifts, but many groups assign the anesthesia doctor to an OR (operating room) for the day and the day lasts as long as the cases take. Anesthesiologists are some of the hospital’s early birds; surgeries start around 7:15 am and the anesthesiologists arrive well beforehand to set up the OR, talk to the patient and do paperwork. I usually get to the hospital around 6:15 am. Cases then continue throughout the day, some days are short and some are very long. I could be done as early as 1:00 pm, or as late as 11:00 pm depending on what I am doing.

The day has a flow: Set up the OR, pre-op the patient, do the operation, go to recovery room and repeat. There isn’t really time for breaks. Some hospitals have a system to get their anesthesiologists out during cases for food or bathroom breaks… Ours does not. I just keep almonds in my pocket and credit my job for my girlish figure and my future kidney stones. I am partially kidding, but you really do get used to going for long periods without food or drink or bathroom breaks. I am a DREAM on long flights or road trips!

I don’t really make my own schedule, but I can request short days if I have an appointment and I can request vacation dates. It takes a lot of planning in advance; I can’t really do spur of the moment plans. I also can’t do lunch dates, happy hours or late night plans… But usually I can find a couple evenings a week to do something low key.

2. What are the differences between anesthesia options? Is it just gas vs. an IV? – Beatrice L.

Good question! This leads to my husbands favorite dorky joke, “I’ll try the local anesthesia, is it good?” Oof.

Local anesthesia: This is the injection of numbing medicine at the site of the surgery. Think minor procedures on a small area, like having a mole removed or a dental procedure. I even like to give a little injection of local anesthesia in the skin before I place an IV.

IV sedation: This is intravenous administration of pain medicine and/or sedatives. It can run the spectrum from slightly loopy to totally asleep. This often accompanies local anesthesia for procedures like biopsies or small hernia repairs, or is used for invasive tests like colonoscopies or angiograms. Propofol got some press if you recall; it is a wonderful drug that we use all the time for IV sedation. It gives patients a nice nap and they generally feel good and refreshed afterwards. People call it “The Michael Jackson Drug”, but the dangerous part of that equation was actually “The Michael Jackson Doctor”. The phrases “Don’t try this at home” and “For Professional Use Only” come to mind.

Regional anesthesia (peripheral nerve blocks and neuraxial blocks): A peripheral nerve block blocks sensation at the level of the nerve supplying an area. Imagine your leg falling asleep – that is basically regional anesthesia where the nerve supplying your leg with sensation is blocked after sitting with it compressed for a long time. This type of anesthesia is used for orthopedic procedures on the arms and legs quite often. Neuraxial blocks are spinals and epidurals, which are most commonly known for their roles in labor and delivery. They are also useful for lower extremity surgery and epidurals are very useful for pain relief after big abdominal or thoracic surgery.

General anesthesia: This is where you get the breathing tube. General anesthesia is needed for longer, more invasive operations that require a very deep level of anesthesia. With anesthesia of this depth, we need to breathe for the patient with a breathing tube and ventilator. This is the kind of anesthesia you would have for an appendectomy or for larger surgeries. It is a combination of IV agents and inhaled agents (the gases).

3. What’s the best part about your job? – Layla J.

I love my job. It is stressful, but it is always interesting and I love being able to make people feel better. I love the thrill of the operating room, and I love the challenge of big cases and sick patients (I specialize in liver transplantation anesthesia). I guess it’s an adrenaline rush of sorts. But over time, what is continually rewarding is the patient interaction. I enjoy meeting my patients, and figuring out how to best put them at ease and help them to feel comfortable going into surgery. I should also say I love the surgeons and nurses I work with; we have our own language and we go through a lot together. Everyone is so wonderful, smart and interesting in their own way. One of my favorite transplant surgeons listens to dubstep, just started bee keeping and is building an outdoor pizza oven!

4. What’s the most emotionally draining part about your job? – Reid M.

In residency, the most draining parts of the job were the hours and the constant learning. I spent many long days and long nights in the hospital, and then I would have to study when I got home. It was physically very draining, and when you get that tired and sleep deprived, you get emotional. I missed my friends and family, and the cases could be very emotional as well.

In general, doctors learn to compartmentalize emotions very well. Sometimes too well. We see our patients’ very sad, very difficult and very stressful situations every day, but we have to press on and put on a brave face even if we are terribly sad or emotional for them. I think I bottle up the sadness I feel, and then it sneaks up on me and comes pouring out when I watch a sad movie or even at random “off duty” times (like, say, seeing an older person holding a newly adopted shelter puppy). The weight of my responsibility to my patients can also be pretty emotionally draining.

I have to say, seeing how brave and strong my patients are in the face of horrible things is an endless source of inspiration. Honestly, it prevents me from getting too drained emotionally. As corny as it sounds, I see so much triumph of the human spirit that I seldom get too down.

5. Share the funniest moment with a patient. – Sal J.

Oh boy. Believe it or not, there are many! One time I pulled a sticky ECG lead off a particularly hirsute patient, and he yelled “KELLY CLARKSON”! Another time I had a teenage boy LOUDLY recounting the sex dream he had under anesthesia while we were rolling to recovery room. I had to keep him in the hallway so his mother wouldn’t hear him talking about having a three-way! Another good one was when I walked up to overhear a sweet nurse giving a patient pre-op instructions, “No sir, we don’t include vodka as a clear liquid you can consume before surgery.”

There are many more stories, SO many more… But we have to keep our secrets.

6. What did you find was the single most difficult thing about medical school (workload, staying in touch with non-med friends, possible depression, lack of free time, etc) and how did you cope with it? –Yasu H.

Well, you pretty much named all of the difficult things! I guess I just kept my sights on the future and plowed through. I had a couple of great friends in medical school – I lived with one of my (non-medical) best friends, and my other close friends understood I would sort of crawl into a medical training cave for quite a few years. I tried to just take really good care of myself, study my face off, and reach out when I could. It helps that medical training is insanely interesting and fun.

Oh, and have I mentioned how many times I have watched all Buffy The Vampire Slayer episodes? Yes, that helped me, too.

Now I do yoga like a maniac… Or rather, to keep from being a maniac.

7. How many years of school did it take? –Jen S.

4 years of undergraduate, 4 years of medical school, 5 years of residency (I did two years of surgery), and 1 year of fellowship training. 14 years? And lots of debt.

8. Why did you choose to specialize in anesthesiology? -@fahmeddd

I actually switched from surgery to anesthesiology. I found anesthesia fascinating because of the variety. We treat the very sick patients, healthy patients, all ages, all different types of surgery, and we need to know about medicine and surgery. I also love taking care of one patient at a time so I can devote all of my attention and energy to that patient. Finally, I just love being in the OR – I don’t have to make patients wait in clinic.

10. What are the chances of waking up during surgery/while under anesthesia? -@kayla_m23

I am so glad you asked! In a young, healthy patient, the chance of waking up during surgery is extremely small. There are many ways to ensure the patient has an adequate depth of anesthesia throughout the surgery, and in a healthy patient, we are able to give more than enough anesthesia to ensure that depth. As I tell my patients, “Yes I will make sure are asleep… And I will make sure you wake up!”

Trauma patients, cardiac patients and women undergoing emergency C-sections with general anesthesia are at a slightly higher risk of awareness. Trauma patients and cardiac patients are often too unstable or too sick to physiologically tolerate higher levels of anesthesia. The urgent nature of a crash emergency C-section or with trauma patients sometimes doesn’t allow enough time for adequate levels of anesthesia.

Well, it’s bedtime. Thanks for reading if you are still with me… Or are you asleep? Either way, I’ve done my job.