A CAREER IN ANAESTHESIA

A CAREER IN ANAESTHESIA

Dr. Alisher Agzamov MD PhD

Anaesthetists play a critical part in the running of the hospital. 

As a medical student and houseman I always admired the “gas man.” Seeing them in their scrubs marked them out from the rest of us, and I felt a sense of admiration and awe. Perhaps it’s because when you struggle with a blue cannula, they come along and nonchalantly insert a grey one. Or maybe it’s because the medical answer to the “who ya gonna call?” question in the event of difficult lines, airways, or critically ill patients is “the anaesthetist.”

I am a doctor, really

Anaesthetists have a poor image among the public, many of whom do not even realise that they are doctors. Maybe it’s because the patient is asleep most of the time or because the specialty has developed only in the past 50 years; in fact, anaesthesia used to be delivered by medical students and nurses.

The reality is different. Anaesthetists make up the largest specialty in the hospital and play a critical part in its running. Without them, theatres, the labour ward, pain services, and the intensive care unit (ICU) would almost become defunct.

The anaesthetist leads in coordinating the multidisciplinary team made up of surgeons, operating department assistants, theatre nurses, porters, and recovery staff. Ntima Ntima, a clinical fellow in anaesthetics and ICU, says: “Anaesthetists are the essential oil in the machinery of the Hospital, but their work is often not recognised by patients and sometimes by doctors too.”

It is therefore surprising that anaesthetics takes up barely a week or two at medical school. It can be difficult to know whether the specialty is for you, but the foundation system now allows trainees to take a two week taster in a specialty and this is a good opportunity to try it out.

Anaesthetists have a good understanding not only of medicine and surgery but also of physics and chemistry, because they work with gases and intricate electrical equipment. Anaesthesia brings physiology and pharmacology to life. These topics can be dry and are not always well taught at medical school. However, when you give drugs that can induce hypotension or apnoea, it is imperative to have a good understanding about these subjects.

Theatre work

The working day starts by doing preoperative assessments on the patients scheduled for theatre. This includes making sure they are fit for the operation, explaining the type of anaesthetic to be used, and answering any queries they might have. Once the surgeon and theatre staff are ready, and the anaesthetic machine has been checked, the list can start.

Contrary to popular opinion, the intraoperative period is not about doing crosswords. Rather, a close eye must be kept on the monitoring equipment, the patient, and on what mischief the surgeon is getting up to. Subtle changes in heart rate, blood pressure, and oxygen saturation may be an early sign of something about to go dramatically wrong, and so the anaesthetist must always be alert to potential problems.

Varied work

Most anaesthetists do a number of lists, including orthopaedic, gynaecological, vascular, general surgical, and dental procedures. This keeps things interesting because you may do an epidural on a 75 year old patient having a joint replacement in the morning, and then a fibreoptic intubation on a 35 year old having a hernia repair in the afternoon.

The next day you may have to do a rapid sequence induction on a pregnant woman in labour. Obstetric anaesthesia is a challenging but rewarding field to work in. Knowing that two lives are at stake in addition to the extra technical difficulty in anaesthetising a pregnant woman adds to the pressure.

For major vascular or bowel surgery you might need to insert central lines, arterial lines, nasogastric tubes, and pharyngeal temperature probes in the same patient. Anaesthetics is the only specialty that offers the chance to do all these practical procedures in one go.

Being part of the trauma and cardiac arrest teams is also demanding. No longer are you in the comfort of a theatre with an operating department assistant at your beck and call; instead you have to prepare and check your equipment and drugs alone while intubating in cramped and hectic conditions. Anaesthetists are also involved in hospital transfers, especially if the patient is being ventilated.

Although ICU medicine is becoming a specialty in its own right, most intensivists are anaesthetists because of their knowledge of ventilators, physiology, and pharmacology. The pain service is also anaesthetist led, and chronic pain clinics are a way of developing a long term rapport with patients.

No other specialty offers direct consultant supervision and teaching on a daily basis. Is there any better way to learn than being taught by a senior colleague “on the job”?

Non-hospital work

Anaesthetists often work outside the hospital and are concerned with medical education, relief work, and prehospital trauma care. 
 “Anaesthetists gain managerial and leadership skills that are important in these settings as well as the relevant factual knowledge and skills they possess.”

Training

Anaesthetics has been a forerunner in structured, competency based training, and thus Modernising Medical Careers has had little effect on the curriculum itself even though the method of applying for jobs has changed.

With the foundation programme now well established, it is common for trainees to get a taste of anaesthetics during foundation years 1 or 2. After foundation training, you can enter anaesthetics directly on to a two year programme or via the acute care common stem on a three year programme. The acute care common stem includes acute medicine, emergency medicine, anaesthetics, and intensive care. Trainees will then join year two of the main programme. These first two years (three for acute care common stem) will make up what is now known as core training.

Anaesthetics will return to being an uncoupled specialty in 2012, which means entrance to year 3 of specialty training will be through open competition for anyone who has achieved the relevant competencies. This will run through to the certificate of completion of training.

After the first three months of training an initial test of competency takes place. If the trainee passes he or she will be allowed to “fly solo”—that is, give an anaesthetic without direct supervision.

Jessica Hoyle, a year 1 specialist trainee in anaesthetics, likes this aspect of the specialty. She says, “I benefit from consultant supervision and teaching every day but I also enjoy working independently.”

Further workplace assessments include a three month placement on ICU and obstetrics. Successful completion of these and the primary fellowship of the Royal College of Anaesthetists exam is needed to progress to year 3 of specialty training.

Years 3 and 4 comprise intermediate level training and include exposure to tertiary specialties including cardiac, paediatric, and neuroanaesthesia. Completion of the final fellowship of the Royal College of Anaesthetists exam is also expected in this period to progress to year 5.

Years 5 to 7 make up higher level training and prepare you for independent professional life as a consultant. Emphasis is put on teaching, ethics, information technology, and management. You still have general clinical duties but you can also apply for advanced training modules in subspecialties of your choice. Anaesthetics is a specialty in which the option for out of programme training is well established and is becoming increasingly popular. This could range from experience in rural Africa to a specialist centre in America.

A day in the life of an anaesthetist

0715—Arrive in the department. Quick check of emails and look for any changes to the rota

0730—See patients preoperatively for morning gynaecology list. Prepare drugs and check anaesthetic machine

0800—Weekly anaesthetic audit meeting discussing critical incidents and any problems within the department

0845—Knife to skin on first gynaecology patient. We have two laparoscopies and four hysteroscopies. Assess novice year 1 specialist trainee for initial assessment of competencies for general anaesthesia

1230—Lunch break in department, reviewing patient notes for urology list next week. One patient has severe sleep apnoea. Book a bed for him on the high dependency unit

1300—See elective caesarean patients preoperatively

1330—Site a combined spinal epidural for first elective case

1600—Second elective caesarean patient has bled severely. Send her to obstetric high dependency unit overnight for close monitoring

1700-1830—Attend afternoon ICU ward round as on-call tonight. Quick check in theatres to see cases going on. Go home

2000-2300—Called by anaesthetic year 1 specialist trainee about a patient with a potentially difficult airway for emergency laparotomy. Intubate with fibreoptic scope. Patient sent to ICU postoperatively. Head home; no further calls overnight

Advantages and disadvantages of a career in anaesthetics

Advantages

·         As an acute specialty you see effects of intervention immediately

·         Contribute towards a cure rather than keeping symptoms at bay

·         Challenging, practical procedures

·         Varied work

·         Easy to work flexibly or part time

Disadvantages

·         You will lose some general medical skills of history taking and examination

·         Long days, busy on-calls, and sometimes stressful work

·         Increasing competition for consultant posts

·         Possibility of resident on-calls for consultants

Qualities needed by anaesthetists

·         Ability to think quickly and methodically under pressure

·         Good understanding of physiology, pharmacology, and physics

·         Manual dexterity

·         Leadership skills and team player

·         Attention to detail and self motivation.