I’m currently on the Pain Medicine rotation. Today, I’m doing chronic outpatient pain, which basically means pain treatment center and pain procedures. I wake up at 6am (sleep in!), eat breakfast, and get to the hospital around 7:45am. The six residents on Pain and the two Pain Fellows all meet in the Anesthesia Library with one of the Pain attendings for morning lecture. Today, we discuss opioid use in chronic non-cancer pain management. After the session, everyone splits off to their various assignments. I check with the Fellows to see about the treatment center schedule. Two attendings are seeing patients in the morning, and one attending is doing procedures in the afternoon. I go with one of the Fellows to the treatment center.

The Fellow and I try to see the attendings’ new patients. This entails taking a thorough history about their pain and prior treatments for it, and a focused neurological exam. After talking with and seeing a new patient for about 20-30 minutes, I go present to the attending. We talk about the patient’s likely diagnosis, what noninvasive treatments we could try, and if they would benefit from any procedures. The first patient has low back pain and radiculopathy. The second new patient I see has intractable headaches. And the final new patient likely has bursitis of the hip. We discuss each patient, go see them together, make recommendations, and write up the notes. During downtime, we talk about other interesting cases we have seen recently, and about our plans for the weekend.

After getting lunch and eating it outside, I make my way over to the procedure area where the other Fellow is seeing patients with a different attending. I watch the attending help the Fellow perform a cervical epidural steroid injection. Then they walk me through a lumbar epidural steroid injection. Next, I observe an occipital nerve block and a transforaminal steroid injection. After the procedures are done, we all go to the Fellows’ office to finish up paperwork. At around 5pm, all the work is done, and the attending tells me I should go home. On the subway, I read over a review of chronic low back pain. Then I’m done for the day!

A Day in the Life of a CA-2 Resident
By: Minjae Kim, MD

My alarm goes off at 5am and I immediately hit the snooze button for a few more precious minutes of sleep. Five minutes later, I think about snoozing again but manage to get up to face the new day. I make some coffee and get ready to leave for work. I live in the Upper East Side and this morning I’ll be taking the Cornell-Columbia shuttle that operates between the two campuses. On the shuttle ride over, I briefly go over in my mind the day’s assigned cases and the preparations that need to be made.

I arrive at the hospital at 6:35 am and quickly change into scrubs. I check over the final schedule to make sure there have been no changes and head into my OR to check the machine and prepare the equipment that I will need. The first case is a laparoscopic banding procedure which means general anesthesia. I make sure the vaporizers are full and that all of the necessary induction agents are drawn up.

At 7:05, setup is finished at which point I head to the holding area of the PACU to locate my patient and review her chart. I introduce myself to her and her family and discuss the anesthetic plan and allay any fears that she may have. My attending has arrived in the holding area as well so we discuss how we will proceed with this case.

We’re in the OR at 7:30. The patient has an IV from the holding area so we place our monitors and soon the patient is off to sleep. Induction proceeds smoothly and the patient is intubated and ready for surgery. When I have finished charting on the electronic record, I am ready for my morning break. After I return, my attending leaves to see our next patient. Meanwhile, the procedure is almost finished so I prepare for extubation and soon we are on our way to the PACU.

The next case is a distal pancreatectomy/splenectomy, another procedure requiring general anesthesia. While in the PACU, I say hello to the next patient and return to the OR to clean up and prepare for the second case. It is a little after 10am when we arrive in the room. Again, the patient has an IV so we place our monitors and induction proceeds smoothly. This time, however, we will require more invasive monitoring and venous access as there is the potential for a large amount of blood loss. The patient has a great radial pulse and the arterial line placement goes well. After discussing the merits of placing a central venous line, the attending suggests a 7 Fr rapid infusion catheter in the arm. I have never placed this line before and the attending walks me through the procedure. Now that our lines are in place, we are ready for the procedure to begin.

It is just past noon and my attending arrives to give me a lunch break. The day has progressed pretty smoothly so far without any major complications. I am on overnight call which means my day is just beginning. I try not to think about this too much and relax while having lunch and try to focus on the task at hand. My scheduled cases end at 2:30 pm which means I have a bit of a break before having to relieve the non-call residents at 4pm.

As the CA-2 on call, I am responsible for any liver transplants and there was one that started in the morning, so I know that will be my assignment for call. When I arrive to relieve the previous resident, I find that they are actually in the process of closing. The patient was relatively healthy for a liver recipient and the case appears to have gone well. When it ends, we transport the patient to the SICU. It is now about 6pm and I have no more assignments! It was an unusually light day and if it were any other day, there would be more residents to relieve.

Since it was a fairly light day, the short call team has gone home and only the overnight team remains (one CA-3, one CA-2, and two CA-1s). Generally, the CA-2 resident will be asked to cover cases with sicker patients (including liver transplants) but we try to do what we can to help out. As we are waiting for our dinner order, the OR desk books a D&C. The team captain (TC, the CA-3 resident) asks me to set up the OR and since the first year residents are in other rooms, I will cover this case, a quick procedure with an LMA.

Around midnight, I am tired and ready to head to the call room. On my way up, I grab the second arrest pager so that I can help out with any stat intubations in the hospital. I quickly fall asleep and the next thing I know, the arrest pager is going off. I look at the time--6am--and realize that I managed to sleep through most of the night! I quickly head down to the MICU and find the TC there as well. We evaluate the patient and determine that there is no need for an emergent intubation. After writing a brief note, we return to the anesthesia lounge.

Soon it is 7am and the next day’s call team has arrived. After spending the night in the hospital, I am eager to go home, take a shower, and recover from my night on call.

I am on the regional anesthesia rotation this month, and we have three “bread and butter” cases scheduled for the day. I typically get up around 5am, perhaps a little earlier than some of my colleagues, so that I can have a civilized cup of joe and a good old-fashioned New York bagel (Absolute bagels are the best in the city, hands down). Anyway, I also get up on the earlier side to take our two goofy little beagles for a walk around the north end of Central Park. People-watching in Central Park is always interesting, even in the early morning. After all of the squirrels are satisfactorily chased up into trees, I drop off the dogs at our apartment and head to the A train. The A train is (usually) a refreshingly quiet morning respite, and I can get my thoughts straight for my cases for the day.

I get to work about 6:40a, change, and set up my room. Setting up the room in the morning is one of my favorite things…everything is quiet and calm, and I can get ready for my day in a systematic manner. Today is Thursday, which means that we have Departmental Grand Rounds. The talk this morning was by a pediatric attending from Loma Linda. She gave us an excellent lecture about research in anesthesia-related cardiac arrest in children. I enjoy our Grand Rounds—I always learn at least a few new things. This morning, though, I had to miss my favorite part, which is questions from the audience (always entertaining), to go see our first patient. She is in the block area, IV in place, ready for us. She is having ankle surgery, and my attending and I had determined the night before that we would do a spinal anesthetic, but that she would benefit also from a preoperative popliteal nerve block for postoperative pain. Dr. Weller, my attending, has to start his other room with a CA-1, so Dr. Panzer offers to do the block with me. They are both German, so as they discuss our patient outside the block area, I smile when I hear the words “spinal” and “popliteal” before I explain to our lady what this entails. She is agreeable to the block. Dr. Panzer gives me tips on how to position the ultrasound probe and how to visualize my needle, and is very encouraging throughout the procedure. We are happy with our block, and soon thereafter head back to our OR. While Dr. Weller fills out his paperwork for the case, I place the spinal, and our case is underway.

Around 9am, Dr. Weller stops in our room to give me a breakfast break. Morning breaks are fun in that I can grab a granola bar and another cup of coffee, but also because I can go socialize in the Ikea lounge, say hi to the ladies in the office, and get caught up on gossip about interesting cases, celebrities, etc. The important things, of course. Our first case is finishing as I get back, so we wheel her out to the PACU and go see our next patient.

Our next case is also another foot surgery, and the patient is a young, healthy guy. Because he’ll need a tourniquet on his upper leg, I get to do another spinal. Dr. Weller is very helpful and supportive, and I place the spinal without any problems. He springs me for a lunch break, and I come back to find the case close to finishing. We wheel another satisfied customer to the PACU.

Our third case is also a foot surgery with a thigh tourniquet, so another spinal for me! This surgery is slightly longer, but the surgeon prefers to do local anesthetic himself for postoperative pain control for this particular procedure. We get underway fairly easily. Dr. Weller gives me an afternoon break, which tends to be a little rare, mostly because the pace of the day picks up in the afternoons. But, his other room is proceeding just as smoothly as ours, and I am on short call tonight. "Short call" means that rather than be relieved at 4pm-ish, I help the call team finish up the days cases and start any remaining elective cases and/or emergencies, i.e. I relieve other residents around 4pm or so. The most fun part about being a CA-2 on short call is that we get to "step up to the plate" and take over some of the bigger cases. Tonight, there happens to be not much going on, so I help finish a room or two and I am sent home around 6pm.

Today was almost unusually smooth, especially for a day so early in the year. Yesterday, for instance, I was in the pre-anesthesia clinic, and in between cases, I helped one of my classmates with an emergent intubation. He got a call that a gentleman with a neck sarcoma and a previous history of difficult intubations (requiring fiberoptic intubation) was in respiratory distress, and they needed a fiberoptic intubation. Just as we were arriving with the fiberoptic cart and setting up, one of the critical care fellows showed up, perfectly timed. The fellow showed us how he likes to topicalize (numb) the airway, and then my classmate proceeded with the intubation, right there on the medicine floor. The critical care fellow gave him some very helpful tips, and he did a great job. The patient actually appeared to be much more comfortable after he was intubated.

Regardless of how smooth or crazy the day is, we all get home, preop our patients for the next day (luckily, I can do this from home....), and start it all over again!

A Day in the Life of a CA-1 Resident
By: Nitin K Sekhri, MD

5:30am rolls around so quickly, it seems to get earlier as the week goes on. I roll out of bed, fighting the urge to the hit the snooze button, and get ready to leave. By the time I’m done brushing my teeth, the excitement of the day is creeping up on me. However, it was not always excitement that I had in the morning. Instead, I was having a feeling of nervousness. But after spending four weeks “one to one” with an attending, my nervousness slowly turned into confidence and excitement.

Today we’re doing two radical robotic prostatectomies and I can’t wait to start. I leave my house in under 10 minutes and start my 5 minute walk to the bus stop. I cross the George Washington Bridge, then walk 10 blocks to Milstein. I arrive at my locker at around 6:15am, change quickly, and I’m in my room setting well before 6:30. I go over my set up over and over M..S..M..A..I..as the days go on my set up gets quicker and quicker, but I know it can still get better.

Finally, it’s about ten after 7 and I’m seeing my first patient. I place an IV in the holding area, get the meds I need, and check back in the room to see if they’re ready for me to bring the patient in. They say yes, it’s always yes, I don’t know how they do it, but it’s always yes. I touch base with my attending and we speak with the patient together and review our anesthetic plan.

7:30am--we’re in the room, we induce and intubate the patient using a Miller blade--not for any particular reason, just because my attending thought it would be good experience for me. I then place another larger IV, in case there‘s any bleeding even though it‘s not expected. Everything’s going very well, and at around 9:30, my attending comes and gives me a morning break. I race up to the lounge, grab a cup of coffee, check my email and converse a little bit. Around 9:45, I return back to the room, and we discuss what happened in the interim and a topic that we agreed upon the day before. This is not unusual. Most attendings spend time with the resident discussing specific topics or just topics that come up during the case. 11:30am or so, the surgeon is all finished with the case and my attending comes to extubate-which goes as plan. I take the patient to the recovery room and give the PACU nurse report. Then it’s off to see the next patient in the holding area. After a conversation with the patient and my attending, I give the OR a call, and they’re ready, of course unbelievable. I get my meds, bring the patient back to the room and the attending and I induce the patient, intubate using a MAC blade, and then he offers me a lunch break, which I gladly take. A half hour later I return to the case, we review and discuss. 4:30pm rolls around, and since I’m not on call, a fellow resident comes to relieve me. This is not an anomaly, but the norm.

I give signout to the relieving resident and head up to the office to get my assignment for the next day -two parathyroidectomies and a laparoscopic ventral hernia repair- all outpatients. I pre-op the patients gathering information from the computer systems, page my next day’s attending and we discuss the cases for 20 minutes or so. Two MAC’s with a-lines and a general anesthetic with an endotracheal tube.

I then go to the locker room, change, and I’m out to the door by 5:30pm-just in time to hit the gym! After a quick 45minute workout at the hospital gym with some fellow , I catch the bus home just in time for dinner at 6:45pm. 8pm or so, I try to review for the next day’s cases and then by 10pm, I’m in bed, ready to tackle the next day.

A Day in the Life of a PGY-1
By: Meredith Wagner, MD

“BZZZ! BZZZ! BZZZ . . .” Oh god, is it 5 am already. As I opened my eyes and my vision came into focus, the bright red numbers of my alarm clock confirmed it: 5AM. I stumbled out of bed in the dark, taking a look outside to see that it wasn’t even dawn yet and mulled over what the day would bring. I quickly got ready, drank my usual morning cup of coffee and was waiting for the uptown A to Columbia by 5:45. I remember that day like it was yesterday. There was nothing usual about it. I was starting my first rotation as an intern in the SICU

I put on my long white coat for the very first time and entered the SICU doors at 6:30AM. The silence and monotony of my early commute gave way to the hustle and bustle of nurses giving overnight signout and the loud beeps and alarms of the ventilators producing an almost melodic tune that would eventually become the music of the SICU.

The first couple of weeks had felt like I’d been caught in a tornado of foreign drips, unforgiving computer systems, and disease processes brought out of textbooks into living, chronically ill patients. However, feeling lost and unprepared soon developed into a sense of routine and familiarity.

As an intern in the SICU we have the responsibility of caring for 2-3 patients at a time depending on the number of interns rotating through the 16-bed unit. Generally, there are interns from general surgery, ENT, urology and even CA2’s who divvy up the patient load. Having so many helping hands, and interns willing to help each other; granted we were all in the same boat, was a true breath of fresh air and helped to make the days go much smoother.

There was a lot to accomplish every morning before 8:30 morning rounds with the attending anesthesiologist and critical care fellows. The 100m dash to the nearest available computer started as soon as we entered the SICU doors, and this definitely set the face pace for the rest of the day. After checking labs, vitals and I/O’s, we would line up next to the overnight intern, like a conveyer belt, eagerly waiting to take signout and find out how our patients fared overnight.

I had been assigned to 2 very chronically ill patients, one who was s/p liver transplant secondary to complications from alpha-1 anti-trypsin deficiency, the other patient who was waging a war against sepsis due to multi drug resistant klebsiella and complications from a bowel perf.

I take a sigh of relief. They did ok. One remained stable overnight, but the other required more attention to address the game of fluid balance; all night the intern was either giving lasix to pull out fluid from the patient’s lungs or giving fluid boluses from the resulting hypotension. Guess I’ll have to see that patient first.

The patient right now has stable vitals, lungs sound clear, maybe the slightest crackle at the bases. Good! Onto the next patient, the nurse informs me that he tolerated trach collar for one hour last night. Hopefully today he will tolerate 2 hours, possibly even stay on trach collar.

8:30 am rounds are about to begin and so I quickly take off my gown and gloves and join the group of interns gathering in-front of the new admission in bed 16. The overnight intern presents any new admissions that hit the ICU doors overnight first so they can be out the door by 10 am. For the rest of us, the attending leads us, like a shepherd leading his flock, through all the patients in the SICU for three to four hours, showing us various physical exam skills, discussing key principles of ICU care like antibiotics or vent settings, and finally modifying our plans for the patients.

A quick post-rounds lunch followed by some order entries and nursing updates on our patient’s status leads right into our afternoon lecture that promptly begins at 1:30 in the afternoon. Today the attending leads a discussion about ventilator settings, and I learn some key information that I could apply to my patients this afternoon.

With afternoon lecture completed, it’s time to finish placing order entries and continue taking care of my patients before sign out rounds. A phone call from the nurse informs me that my septic patient is ready for a CT of the head, chest, abdomen and pelvis. We are trying to find a possible source, such as an abdominal fluid collection, that may explain her spiking fevers and hypotension. The nurse and I wheel the patient to the 3^rd floor CT, picking up emergency meds at the pharmacy on the way. In a flash we are on our way back to the SICU. Thankfully, the patient remained stable during transport. The fellow and I view the results. We soon find out that the CT is not going to give us an answer. The search will have to continue.

Afternoon labs are back and we quickly check to make sure all patients are stable before signout rounds that take place at 4:30 pm. Bedside rounds with the daytime attending the overnight attending and fellow takes us once again full circle around the SICU, however, this time with only a quick blurb of who are the sickest and what to look out for with the patients overnight. As we go through each of the patients, I can taste the closure of my day getting sweeter and sweeter.

After signing out to the overnight intern, I walk out of the SICU doors, feeling a great sense of accomplishment. I know that I gave a full effort in helping my patients on their long road to recovery. I’m exhausted, and because I will be the intern on call tomorrow, I need to get some quality rest tonight.