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2007-2008
A Day in the Life of a CA-3 Resident
By Michelle Au, MD
4:00pm: I arrive for work on the labor and delivery floor. Tonight I am the "night float" resident on OB, which means that I am the primary resident on call overnight on labor and delivery. There are two residents on call overnight for OB, though as the night float resident, arriving to work late and presumably rested, I wil be the first one called for any anesthetic issues on the floor. Though the nights over on labor and delivery can occasionally be grueling, I am happy to have had the morning off to spend with my two-year old son. This morning, we went to the playground and even got a chance to have lunch together before I had to leave for work. It's a rare treat to be able to spend time with him during the day, and I enjoyed every minute of it. Of course, chasing after a two-year old means that I am probably not as well-rested for the start of my shift as I might like to be, but overall, I'm ready to get to work!
4:10pm: I've just finished getting signout on the all the current laboring patients from the resident who had been running the floor during the day. Currently there are four epidurals running, two patients who have not yet requested epidurals, and four patients sitting in our "high risk" area, who are in various stages of pregnancy and being monitored closely for a variety of health issues. The OB service on Columbia has a significant percentage of high-risk parturients with a strong maternal-fetal medicine program and a busy NICU, and as anethesiologists, we have the benefit of learning from the anesthetic management of these patients as well. Currently sitting on high risk are patients in premature labor, one with severe pre-ecclampsia, and another with triplets gestation and vasa previa. After learning the pertinant information from my co-resident and making sure that the floor is in order, I head back to the ORs to relieve another resident, who has just started a scheduled C-section.
5:30pm: I am wheeling my patient from the OR to the PACU, having just finished up the C-section. There is another emergent C-section that has just been added to the schedule while we were in the other case, a patient that just got admitted to triage with decreased fetal movements and a non-reassuring fetal heart tracing. My co-resident has already pre-opped the patient and is in the process of bringing her into the OR as we're coming out with the other case. I check to make sure that he's doing OK and that the case is starting smoothly, and then check the other ORs to make sure that they are all set up and ready to go from an anesthetic point of view. There are three ORs on the labor and delivery floor, with at least one room always set up and for stat sections. After walking through the other two empty ORs, I make my rounds on the floor, to talk to any new patients that may have been admitted while I was in the OR, and (speaking of stat sections) to say hi to all our high-risk patients, some of whom may be likely candidates for our next emergency case. Luckily, everyone seems to stable and doing well for now.
7:00pm: I get called to Labor Room #7 do an epidural. My co-residents have already gotten the patient's history and consented her for the epidural earlier this afternoon, but I just pop my head in to make sure that there are no unexpected issues before I start to set up. I get my drugs, get the patient positioned and prepped, and call my attending in to supervise. Given that the patient is a young, healthy multip at 5 centimeters on her last exam, I decide to do a combined spinal-epidural, and my attending agrees. Happily, the procedure goes smoothly, and in ten minutes the patient is back in the bed with a smile on her face. "That was great. Thank you so much. It didn't even hurt." I make some jokes about the miracles of modern medicine and stay in her room for fifteen more minutes to set up the pump and make sure that her vitals are stable. The great thing about OB anesthesia is its one of the few fields where patients really understand what the role of the anesthesiologist is, and where patients actually thank us for our work!
8:00pm: Dinnertime! Our attending has treated both of us on call to a delicious meal from a local Chinese take-out. We take the moment of relative calm to sit and chat and watch some "Animal Planet" on the TV in the nurse's lounge.
10:00pm: A few more epidurals and one vacuum-assisted delivery later, things seemed to have calmed down. I tell the other resident, who has been here all day and who is taking 24-hour call, to go to the call room and get some rest. I head on back to the anesthesia workroom and try to get some studying done.
11:30pm: I get called emergently for a stat section. I come running out to see a crying patient being wheeled down the hall towards the OR. "PPROM, footling breech!" the OBs tell me. I jog alongside the stretcher, get the pertinent medical information, do a quick airway exam, and consent her for anesthesia, all while calling my attending. We meet in the OR, and I manage to quickly put in a spinal and lay the patient back as the OBs descend on her in a flurry of Betadine and drapes. A quick skin test to assess the adequacy of our anesthesia, the C-section begins. Shortly thereafter, the baby is delivered, and whisked away to the transitional nursery by the NICU fellow for further support. The mom is doing fine, and finish and wheel out to the recovery room, the dad shows up, having rushing in from home. "You missed everything!" our patient yells.
1:00am: I place an early epidural on a new patient who has just been admitted with severe pre-ecclampsia for induction of labor, and pull a few catheters on patients who have already delivered. Room #8 is apparently requiring a foreceps delivery, so I grab my emergency drugs and stand by in case we have to move back to the OR, giving a small bolus of lidocaine through her epidural to help her along. It must be working well, because--well, have you seen the foreceps? Thankfully, the baby is delivered with a little help, and the mom is doing well. I head back to the work room to do some paperwork and to log the cases that I've done so far today in my resident care log.
3:00am: Things seem to be quieting down. I head back to the call room to lie down for a few minutes.
5:00am: Or a few hours. Wow, I can't believe I didn't get called up until now! I go to top up a patient's epidural, pull another epidural catheter, and start getting things ready for the day shift.
7:00am: The day team starts to arrive. We have rounded on all the patients on the floor and pre-opped the scheduled C-sections for this morning, so after a detailed sign-out, we have our daily didactic lecture. Today we are with Dr. Smiley, who leads us through an interesting case presentation on a case of regional anesthesia for labor in an achondroplastic dwarf. Some heated discussion follows, which is always fun. No fisticuffs ensue, however.
8:00am: And my night shift is done! I head out of the hospital towards the subway, tired but happy that I had a good night with some exciting cases, and even managed to get a little bit of rest. I have the rest of the day off (I'm taking my son to music class this morning, and hopefully he'll take his afternoon nap, so I can join him) and then I'm back the next day, this time on the day shift, to do it all again!
A Day in the Life of a CA-2 Resident
By Jonathan Hastie, MD
Rolling out of bed and silencing my alarm clock at 0500, I was both excited and nervous to start my cardiac anesthesia rotation. After spending the first couple of months of my second year doing pain management and surgical ICU rotations, it was good to be heading back to the operating rooms. After a quick shower and grabbing an English muffin for the road, I was out the door and trotting to the subway station by 0530.
The evening before I’d reviewed my two patients’ computer records and touched base with my attending to talk about the anesthetic plan. I had one thoracic case and a tricuspid valve replacement. As I quickly checked the anesthesia machine, set up the monitors and arranged the airway equipment I’d need for the day, I also mentally reviewed the plan my attending and I had discussed. A double lumen tube and a bronchoscope were available for the first case, and for the second case I drew up syringes and prepared infusions according to the helpful guidelines sent to me before the rotation started.
By 0700 I’d completed my first patient’s preoperative evaluation and my attending and I were standing behind her, clad in sterile gloves and preparing to lather her back with chlorhexadine. My attending walked me through my first thoracic epidural which went smoothly, and we transported the patient to OR 20.
With one-to-one attending coverage for the cardiac rotation, my attending had ample time to discuss details and guide me through placing the double lumen tube and confirmation of placement with the bronchoscope. We positioned the patient together, checked pressure point padding, and soon enough the case was underway.
A short morning break allowed me to grab a cup of coffee and check e-mail before returning to the case and transporting the patient to the recovery room. As I called the pain management service to notify them of the epidural, I was reminded how I’ve learned how important careful and clear communication between healthcare providers is.
I was able to do most of the set-up for the tricuspid valve case either first thing in the morning or during the second case, so pre-opping the second patient was my next priority. Things were as “routine” as can be for undergoing so unnatural a procedure as cardiopulmonary bypass! Importantly, my attending was present for all key parts of the case, and she walked me through what to expect and what to plan for. At the same time, she balanced this with giving me alone time in the OR, but she made sure I felt comfortable before taking off.
With the help of my attending and the surgical fellow, I transported the patient to the CT-ICU, printed my record, and gave report to the nurse and receiving resident. The day had gone smoothly, and, by 1730, I was ready to check the schedule for tomorrow and go to see any inpatients that might be coming my way.
Even on a busy rotation, I was still able to grab a bite of dinner with a friend and read a few pages before turning in for the night. I wanted to get some rest for whatever the next day would bring!
2006-2007
A Day in the Life of a CA-3 Resident
By John Seitz, M.D
Man! 5:45 comes early. I rub the sleep out of my eyes and hustle to the bodega for a coffee and a banana. Yet again, the deli guy fails to recognize me. I walk to the Spring Street station stop and just catch the uptown A to 168th. Despite the smell of stale urine and the unpredictable nature of public transit, the subway is something I have really come to embrace. It’s a tranquil retreat from the chaos of the New York City, a short break to relax, read a few articles, and visualize my plan for the first case.
I start my case on time at 0730 and by 0900 it’s time for my coffee break. For fifteen minutes I am free to do as I please without the beeping of the pulse-ox monitor or the surgeon asking for the table up for the sixteenth time. Naturally, I gravitate to the lounge for my second coffee. A few of the attendings are sitting in the lounge, so engaged in their discussion that they barely notice that I have walked in. The topics that are discussed in the lounge are always interesting, anything from the size of the prawns in Mozambique to the best place to ski in the Alps. One aspect of our program that I have truly enjoyed is the diverse backgrounds of our faculty. Our attendings hail from South Africa, India, Israel, Germany, England, Armenia, Greece, Lebanon, Hungary, just to name a few. Needless to say, it makes for interesting discussions during your coffee break.
I return to my room fully caffeinated and we start our next case. My attending and I discuss the remaining cases for the day, hoping for the best, but planning for the worst. As a CA-3, my focus has shifted to planning an anesthetic as if it were my case alone, and presenting a careful and thorough anesthetic plan to my attending. Most of the attendings assume that I have become proficient in most of the technical aspects of the case. The emphasis as a CA-3 lies in developing a knack for anticipating the critical aspects of the surgery and tailoring the anesthetic to the comorbidities of the patient.
The CA-3 year at Columbia has been particularly gratifying for me, it’s been a sort of homecoming. After a CA-2 year of mostly subspecialty rotations, I am now returning to the attendings that trained me as a CA-1. As a CA-3 team captain, I get the opportunity to manage the board, cover the PACU, and carry the stat intubation pager. My year is also partly comprised of elective months including cardiac, peds, pain, OB and ICU. One of the conveniences that exists at Columbia is that all of the subspecialty rotations are all under one roof, and the transition from one rotation to the next is generally seamless.
Another unique aspect that I have really appreciated is the freedom I was given to make my own schedule. Dr. Wood and the rest of the administrative staff always are encouraging residents to pursue their interests within anesthesia, whatever they may be. I was encouraged to pursue my interest, which was in international anesthesia. As a CA-2, I had the opportunity to join a pediatric surgical mission to Vietnam. In Vietnam I witnessed heath care like I had never seen it, and I was an active member of a highly motivated and efficient surgical team. The degree of cooperation and communication that existed between team members was beautiful to witness. In September of this year I will be attending another surgical mission to India, and relating my experiences to a committee within the ASA. In October I will be attending the ASA in Chicago and sitting on the committee for Overseas Anesthesia Teaching Programs. In planning these extra-curricular activities, I have been delighted with the support and encouragement I have received from the faculty and administrative staff.
Last but not least is New York City. I can’t say enough about it. With the bizarre schedule that the anesthesia lifestyle can throw at you, it’s great to have a city that can support your every whim 24 hours a day. I feel like the island of Manhattan alone has enough restaurants, bars and theatres to keep me busy for the next three or four lifetimes. There exists an incredible sense of energy among the people who live here, and experiencing this has been very meaningful for me.
A Day in the Life of a CA-2 Resident
By Jessica Spellman, M.D
Let’s take one day from last week… I arrive at Columbia around 6:40am, quickly change into scrubs, and am off to my scheduled OR to set up my room. At this point in the morning I’m rushing and trying to figure out why I hit the snooze button 3 times. The anesthesia tech comes in to check my OR and helps me along to keep from being delayed. By 7am I see my patient in the holding area and complete my anesthetic plan with my attending. As a CA2, my cases are more challenging with respect to both the surgical procedure and the patient’s underlying disease processes. Reviewing my anesthetic with my attending has evolved into a discussion as I now have a strong foundation to formulate my plan. I have already rotated through the General Surgery, ENT, Regional, Cardiac, Neurosurgery, and Pediatric ORs, and have spent 4 weeks in both the SICU and CTICU. I have learned how to anticipate problems in the OR, and know how manage critical situations, but still am comforted knowing my attending is always nearby to help out.
My first case of the day is a Radical Cystectomy, expecting over 1L of blood loss, and my patient has an EF of 20%. Just as I finish intubating, inserting an arterial line, and floating the Swan for pulmonary artery pressure monitoring I am offered my morning break. For the next 15 minutes I am in the lounge enjoying a cup of coffee and recounting the morning thus far with 2 or 3 colleagues. One resident, a CA3, had just finished a fiberoptic intubation on a bariatric patient with a known difficult airway who had had two previous unsuccessful attempts at fiberoptic intubation at outside hospitals. He recounted his steps at anesthetizing the airway, and reported that the scope and tube had passed easily and the procedure was now underway! A second resident, a CA1, is preparing for a kidney transplant and reviewing with their attending key points of the anesthetic. I’ve just started chatting with the PACU resident about where they went to dinner last night when she gets called to a stat intubation in the MICU and is off and running. I finish my coffee, check my email, and return to my OR where my attending is eager to review our morning thus far, and further discuss the pathophysiology of our patient.
The case continues and the patient is doing well. My attending gives me feedback about the day and our anesthetic choices. At the end of the case the decision is made to take our patient to the SICU for postoperative monitoring and I arrange for this with the SICU fellows. I am responsible for transferring the patient to the unit which is at times an anxiety invoking task of manipulating the bed, IV poles, lines, monitors and airway, but as I arrive the anxiety is relieved by the familiar faces of anesthesia residents rotating there and the nurses who remember me from my rotation there just a few months ago.
Overall the day was challenging and successful. I return to the anesthesia desk to review my schedule for tomorrow. I decide to take a copy of my schedule home and look up my cases on line over my secure connection that the hospital provides. I can review the patient’s preoperative record and labs from the comfort of my own living room as I make dinner for me and my husband, and can call my attending at home to discuss tomorrow’s cases.
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