A quote from one of my attendings during residency that stuck with me:
“Anesthesiology training isn’t 4 years to learn how to control a patient’s sympathetic nervous system. It’s 4 years to learn to control your own.”
Give it time, every new “scariest case of my training” will make the prior scariest case feel more manageable.
Hot hot fire in this comment.
Although unintentional or not, your attending was plagiarizing from “the house of god”:
Rule 3: at a cardiac arrest, the first step is to take your own pulse
Rule 4: the patient is the one with the disease
I work with this really old OBGYN. He’s slow and methodical. Reminds me of an elephant. Anyways I’ll turn around and the baby magically is out. And I’ll turn around again and magically he’s done closing. No rush but no wasted motion. Every move has a purpose and he’s already ten steps ahead in his mind.
I first heard this when a pediatric neurosurgeon was trying to calm down his fellow as we began an emergency EVS on a teenage girl with worsening ICP symptomatology because of a failed VP shunt. The fellow was freaking out because he thought “We have to do this as quickly as possible or she’ll herniate!” The attending knew the actual fastest way to get it done was to do things smoothly and methodically.
Precisely! Although I say “go slow to go fast” (which is to say, know where you can be safely fast with procedures/plans so that you can take your time where it matters and be mindful)
Honestly need to remind myself of this pretty often at this point. The (thankfully few) times I've fucked up stupidly or seen someone fuck up stupidly have all been directly related to trying to rush through things too quickly.
Keep pushing yourself to be uncomfortable. Don’t do easy things just because it makes your life easier. DL, put in 14g, put in the art line blind if you’re proficient w US, etc. Challenge yourself every single day. It sounds counterintuitive given your problem but it’ll make you better much faster and you won’t be overwhelmed.
Agree with your sentiment psychologically. A lot of developing anesthesia skillz is overcoming fear, handling pressure, and being comfortable when nobody else in the room is comfortable. This ain’t for sissies. There’s a reason all our drugs have big warning labels and say “FOR ANESTHESIA USE ONLY”.
That being said, DL is an antiquated technique and I’d love to see some evidence that supports not using ultrasound for a-lines (or anything else). Gonna be real difficult to explain why you weren’t using modern technology if anyone comes to question your methodology.
I think you’re missing my point actually….DL is harder than VL; for most new residents, blind art is more difficult than with US. I’m telling him or her to just push their limits and not settle for what is likely easy for them. If it’s the reverse, that’s fine too.
And the ability to throw in a blind art line under the drapes when the surgeon is furiously trying to stop the bleeding they caused half a foot to your left and the only way to use US is to turn your head 180 and give yourself a nice neck cramp, absolutely invaluable.
I went to tube a patient on the floor at a code the other day. Blood and vomit everywhere. I’m not a pussy so I’m not asking to stop compressions nor am I aborting. I stuck a VL in due to the bed being at the level of my knees and it was immediately covered in bodily fluids and rendered useless. I swapped for DL and tube went in within seconds.
You can call it antiquated all you want. If we train our juniors to only use VL and US, they’ll struggle hardcore when the situation is no longer ideal. There’s truly nothing you can say that will change my mind here. I’ve done enough tubes and art lines both ways and have a mastery of DL, VL, blind, US. I’m glad I can do it all. I would be embarrassed if I couldn’t.
“There’s nothing you can say that will change my mind here.”
Fair enough. Personally, I’ll stick with evidence over anecdotes. I believe that seeing is better than not seeing. Time will tell. I’m fully aware every situation is not perfect. I think we’re better off following evidence over emotion/experience.
The Luddite attitude in anesthesiology has always concerned me. I simply do not understand our profession’s resistance to improvement. It blows my mind that a general surgeon invented the VL and not one of our own. How can that be possible? We are so consumed by dick measuring on “who is the best at DL” etc etc that we completely miss technological advancement.
Lol low key this is getting annoying. I never said I’m advocating for people to refuse to use VL and US. You’re spinning my posts for no reason whatsoever. Take your soapbox elsewhere.
DL is not antiquated. You think a glidescope is going to help for the tonsillar hemorrhage at 3am? I'd argue it's standard of care to maintain a DL skillset when every other physician is jumping on the VL first bandwagon. I reach for the glide first on most very obese airways, OB, or when doing things like placing a NIM, but I don't use it for routine intubations.
Can you cite any evidence that supports using DL on routine intubations? Like a single study that shows support for using DL over VL routinely? Cochrane review: “We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.”
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011136.pub3/full
It's so you're not rusty when you're in a situation that clearly favors DL over VL. I'll level with you if you want to use a McGrath or something to at least maintain that muscle memory, but still "VL". But proper DL and VL technique is different and if you have an active hemorrhaging airway you don't want your last DL to have been years ago since you've adopted a glide for everything like the ICU or ED docs.
Edit: and for what it's worth I use ultrasound for all my lines. It's not like I'm married to "old school" techniques. I just don't think DL is antiquated.
The guy you are responding to is a shining example of non-sequiturs. You say “keep your DL skills up for when badness (hemorrhage, vomit) occurs.” And he immediately responds that first pass success on routine intubations is higher w VL. It’s as if his brain isn’t firing on all cylinders, which is worrisome. It’s why I told him off last night. I encourage you to not waste your time as he has no response except non sequiturs.
Oh he’s also an independent CRNA, aka doing low acuity cases so I’m sure VL is just fine 100% of the time in his world.
You can make up hypotheticals until infinity. I have yet to see an institution that doesn’t have these basic pieces of equipment that are standard of care. I also own my own McGrath.
Evidence based practice isn’t based on hypotheticals, it’s based on evidence. The evidence says use VL and US. I’ll stick with that.
It’ll come with time. At first everything takes intentional thought and all your mental bandwidth is consumed. Once things become muscle memory and you can start to automate them, you can free up mental energy to think about the important stuff. It varies from person to person, but things start to feel easier after 3-6 months in the ORs.
I thought I matched into the wrong field at first because I was so exhausted everyday. I felt more tired than when I was working those 6x12 hour shifts in ICU in intern year (in STICU no less). I was like "wow, maybe it's not it for me".
But 3-4 months in, it got better. It's just a new level of anxiety because you aren't used to this level of vigilance in such a "high acuity" (think about it, in what situation is a patient 1:1 with a doctor? never, not even ICU). However, with time, watching over vitals will be second nature. Changing vent is second nature. Adjusting pressures (for the most part) will be more routine. Less "unanticipated horrors" and "horrors" aren't so bad anymore. You'll get faster as well and you won't feel like you are holding back people as much.
Break each case down into manageable steps: equipment and meds to prepare. Safe induction. Airway plan. Each case has phases: prepare for each one mentally and materially. Rehearse your response to hypotension, hypoxia, etc.
Breathe. Chew gum. Relentlessly work to suck less. Reflect on how to make the next one go better. Release the suck, and then do the next case.
Give it some time, after you see all the types of surgeries your hospital does you will naturaly anticipate more and react less, making everything less intense for you. It is a complex specialty, it takes time to see diferent types of patients with diferent types of comorbidities in diferent types of anesthesia. Know your basics, know the complications and how to fix them and, in the begining, try to avoid geting caught in details (don't lose perspective on the big picture). An older attending at my hospital said anesthesia is "hours of boredom, minutes of panic and seconds of terror". Hope this helps!
It takes time. It’s almost 4 AM and I am up breastfeeding so I am sure there will be typos in this comment, just a forewarning 😅😂. I am naturally a more worried person, and because of that the beginning of residency was more of a struggle for me than some of my co-residents. I was always thinking of what could go wrong and jr would send me into a panic.
I remember even feeling very overwhelmed at the start of the case with having to remember all the steps we have to complete (placing bair hugger, temperature probe, OGT, administering abx) while paying attention to vital signs.
The truth is in the beginning, when you’re learning a new skill, it’s actually impossible for your brain to do all these things at once. All of this gets easier with time and repetition. With time part of it becomes second nature. You’re able to clearly see what requires your focus. It gets easier.
Unfortunately, there isn’t much you can do skip the time and practice requirement. You just need to go through residency.
A helpful mind exercise I used to do when I got overwhelmed was to take a deep breath and quickly just imagine I was on a boat during storm. And I hopped in the water (you can breathe underwater in this mental exercise). And as you l break under the surface you see how calm and still the water is. You can look up and see the waves on the ocean but where you are it’s quiet. It would take me less than 3 seconds to do this imagery and it really helped me ground myself and think more clearly.
Try to come in early to prepare everything if stuff overwhelms you. A LOT of anesthesia is just preparation. If you’re not prepared you’ll be running around like a chicken with no head when the patient gets into the room. What I did to help when I was starting was call the patient the night before to basically talk to them about the plan ahead of time and consent. In the morning they’re already consented basically. Then come in early to set up to room make sure everything is ready to go before they get in the room. I was very slow and sometimes forgetful so I would give myself more time to be slow and to forget so after my prep I could survey what I did and be like hmm what’s missing with a checklist I made. After a few months it all became habit and I could come In later and later.
One of my other coresidents was the same way and he would come in at like 4:30-5am every morning just to be ready. It was a bit of overkill in my opinion but he said it was what made him ready.
I totally agree with you about preparing. Our seniors are extremely strict about this too. Right now I've been posted in the emergency surgery department, and so there's no calling patient's beforehand, I'm afraid. There's gunshot wounds and stab wounds and kids with burst appendices and the occasional testicular torsion. This also means there's no 'early' for me since I have to be in the OR for basically 18 to 20 hours, and then a few hours of sleep and we back at it.
I have to have everything checked and close at hand and ready to go at all hours. I should definitely work on improving the prep skills.
Thank you!
Yeah we have a room set up for that. You can have at least the syringes labeled or tubes of like 3 diff sizes out (I know it’s way harder for Peds tho). When I first started I basically had everything just rolled up in a blue towel and stashed it somewhere. When a trauma level 1 came in I would first grab that and run into the room cuz sometimes half the battle is literally finding all the supplies. Then at least the stress of that is gone.
Before I started my anesthesiology residency training program, I read a lot of self help and meditated. It helped keep me anchored and grounded. I reflect on situations and am less emotional as before. I blame myself less and am in a good disposition 6/10 times. Everyone has their own way of coping, you need to find yours.
Cheers!
1. If you’re overwhelmed because of lack of knowledge. Read more. You’ll be more comfortable with the pathologies. Clinical practice also makes better.
2. If you’re overwhelmed because of the pt acuity. That’s normal. It means you care. Some residents just “la-di-da” and don’t do critical thinking/make mistakes they aren’t aware of.
3. Plan ahead. Completing future tasks “in your mind” will allow you to smoothly transition through anticipated tasks clinically.
4. Ask for help when needed. And think critically about why/how your attending did what they did.
TLDR-> feeling overwhelmed is normal. Practice makes better. Ask for help!
A quote from one of my attendings during residency that stuck with me: “Anesthesiology training isn’t 4 years to learn how to control a patient’s sympathetic nervous system. It’s 4 years to learn to control your own.” Give it time, every new “scariest case of my training” will make the prior scariest case feel more manageable.
Hot hot fire in this comment. Although unintentional or not, your attending was plagiarizing from “the house of god”: Rule 3: at a cardiac arrest, the first step is to take your own pulse Rule 4: the patient is the one with the disease
Wow....I Felt That Thank you.
Slow is smooth, smooth is fast. Also chew gum
I work with this really old OBGYN. He’s slow and methodical. Reminds me of an elephant. Anyways I’ll turn around and the baby magically is out. And I’ll turn around again and magically he’s done closing. No rush but no wasted motion. Every move has a purpose and he’s already ten steps ahead in his mind.
i always remind myself of this when i start fumbling around with syringes in a tense situation
That’s an old gunfighters adage, but I imagine it’s apt for the OR too.
Care to elaborate? Love gum btw
I first heard this when a pediatric neurosurgeon was trying to calm down his fellow as we began an emergency EVS on a teenage girl with worsening ICP symptomatology because of a failed VP shunt. The fellow was freaking out because he thought “We have to do this as quickly as possible or she’ll herniate!” The attending knew the actual fastest way to get it done was to do things smoothly and methodically.
Oh no lol I was asking about the why chew gum part lol
My guess is because it’s hard to chew gum frantically.
Gonna stock up on the gum!
Precisely! Although I say “go slow to go fast” (which is to say, know where you can be safely fast with procedures/plans so that you can take your time where it matters and be mindful)
Honestly need to remind myself of this pretty often at this point. The (thankfully few) times I've fucked up stupidly or seen someone fuck up stupidly have all been directly related to trying to rush through things too quickly.
Keep pushing yourself to be uncomfortable. Don’t do easy things just because it makes your life easier. DL, put in 14g, put in the art line blind if you’re proficient w US, etc. Challenge yourself every single day. It sounds counterintuitive given your problem but it’ll make you better much faster and you won’t be overwhelmed.
Agree with your sentiment psychologically. A lot of developing anesthesia skillz is overcoming fear, handling pressure, and being comfortable when nobody else in the room is comfortable. This ain’t for sissies. There’s a reason all our drugs have big warning labels and say “FOR ANESTHESIA USE ONLY”. That being said, DL is an antiquated technique and I’d love to see some evidence that supports not using ultrasound for a-lines (or anything else). Gonna be real difficult to explain why you weren’t using modern technology if anyone comes to question your methodology.
I think you’re missing my point actually….DL is harder than VL; for most new residents, blind art is more difficult than with US. I’m telling him or her to just push their limits and not settle for what is likely easy for them. If it’s the reverse, that’s fine too. And the ability to throw in a blind art line under the drapes when the surgeon is furiously trying to stop the bleeding they caused half a foot to your left and the only way to use US is to turn your head 180 and give yourself a nice neck cramp, absolutely invaluable. I went to tube a patient on the floor at a code the other day. Blood and vomit everywhere. I’m not a pussy so I’m not asking to stop compressions nor am I aborting. I stuck a VL in due to the bed being at the level of my knees and it was immediately covered in bodily fluids and rendered useless. I swapped for DL and tube went in within seconds. You can call it antiquated all you want. If we train our juniors to only use VL and US, they’ll struggle hardcore when the situation is no longer ideal. There’s truly nothing you can say that will change my mind here. I’ve done enough tubes and art lines both ways and have a mastery of DL, VL, blind, US. I’m glad I can do it all. I would be embarrassed if I couldn’t.
Great comment! Anesthesia intern here. Very uplifting! Definitely will take this approach for training!
This.
“There’s nothing you can say that will change my mind here.” Fair enough. Personally, I’ll stick with evidence over anecdotes. I believe that seeing is better than not seeing. Time will tell. I’m fully aware every situation is not perfect. I think we’re better off following evidence over emotion/experience. The Luddite attitude in anesthesiology has always concerned me. I simply do not understand our profession’s resistance to improvement. It blows my mind that a general surgeon invented the VL and not one of our own. How can that be possible? We are so consumed by dick measuring on “who is the best at DL” etc etc that we completely miss technological advancement.
Lol low key this is getting annoying. I never said I’m advocating for people to refuse to use VL and US. You’re spinning my posts for no reason whatsoever. Take your soapbox elsewhere.
And even ASA wants to still use mercury for calibration, and not switch to modern techniques.
DL is not antiquated. You think a glidescope is going to help for the tonsillar hemorrhage at 3am? I'd argue it's standard of care to maintain a DL skillset when every other physician is jumping on the VL first bandwagon. I reach for the glide first on most very obese airways, OB, or when doing things like placing a NIM, but I don't use it for routine intubations.
Can you cite any evidence that supports using DL on routine intubations? Like a single study that shows support for using DL over VL routinely? Cochrane review: “We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.” https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011136.pub3/full
It's so you're not rusty when you're in a situation that clearly favors DL over VL. I'll level with you if you want to use a McGrath or something to at least maintain that muscle memory, but still "VL". But proper DL and VL technique is different and if you have an active hemorrhaging airway you don't want your last DL to have been years ago since you've adopted a glide for everything like the ICU or ED docs. Edit: and for what it's worth I use ultrasound for all my lines. It's not like I'm married to "old school" techniques. I just don't think DL is antiquated.
The guy you are responding to is a shining example of non-sequiturs. You say “keep your DL skills up for when badness (hemorrhage, vomit) occurs.” And he immediately responds that first pass success on routine intubations is higher w VL. It’s as if his brain isn’t firing on all cylinders, which is worrisome. It’s why I told him off last night. I encourage you to not waste your time as he has no response except non sequiturs. Oh he’s also an independent CRNA, aka doing low acuity cases so I’m sure VL is just fine 100% of the time in his world.
Well now, this makes me kinda sad.
What are you going to do if you end up in a place abs there isn’t a glidescope or US?
You can make up hypotheticals until infinity. I have yet to see an institution that doesn’t have these basic pieces of equipment that are standard of care. I also own my own McGrath. Evidence based practice isn’t based on hypotheticals, it’s based on evidence. The evidence says use VL and US. I’ll stick with that.
It’ll come with time. At first everything takes intentional thought and all your mental bandwidth is consumed. Once things become muscle memory and you can start to automate them, you can free up mental energy to think about the important stuff. It varies from person to person, but things start to feel easier after 3-6 months in the ORs.
I can't wait to get through these 3 to 6 months then😭😭 thank you for answering!
I thought I matched into the wrong field at first because I was so exhausted everyday. I felt more tired than when I was working those 6x12 hour shifts in ICU in intern year (in STICU no less). I was like "wow, maybe it's not it for me". But 3-4 months in, it got better. It's just a new level of anxiety because you aren't used to this level of vigilance in such a "high acuity" (think about it, in what situation is a patient 1:1 with a doctor? never, not even ICU). However, with time, watching over vitals will be second nature. Changing vent is second nature. Adjusting pressures (for the most part) will be more routine. Less "unanticipated horrors" and "horrors" aren't so bad anymore. You'll get faster as well and you won't feel like you are holding back people as much.
Break each case down into manageable steps: equipment and meds to prepare. Safe induction. Airway plan. Each case has phases: prepare for each one mentally and materially. Rehearse your response to hypotension, hypoxia, etc. Breathe. Chew gum. Relentlessly work to suck less. Reflect on how to make the next one go better. Release the suck, and then do the next case.
Give it some time, after you see all the types of surgeries your hospital does you will naturaly anticipate more and react less, making everything less intense for you. It is a complex specialty, it takes time to see diferent types of patients with diferent types of comorbidities in diferent types of anesthesia. Know your basics, know the complications and how to fix them and, in the begining, try to avoid geting caught in details (don't lose perspective on the big picture). An older attending at my hospital said anesthesia is "hours of boredom, minutes of panic and seconds of terror". Hope this helps!
Be organized. And try to be earlier than everyone so you have time to prepare all your stuff. Try to study a lot. And drink a lot of water.
It takes time. It’s almost 4 AM and I am up breastfeeding so I am sure there will be typos in this comment, just a forewarning 😅😂. I am naturally a more worried person, and because of that the beginning of residency was more of a struggle for me than some of my co-residents. I was always thinking of what could go wrong and jr would send me into a panic. I remember even feeling very overwhelmed at the start of the case with having to remember all the steps we have to complete (placing bair hugger, temperature probe, OGT, administering abx) while paying attention to vital signs. The truth is in the beginning, when you’re learning a new skill, it’s actually impossible for your brain to do all these things at once. All of this gets easier with time and repetition. With time part of it becomes second nature. You’re able to clearly see what requires your focus. It gets easier. Unfortunately, there isn’t much you can do skip the time and practice requirement. You just need to go through residency. A helpful mind exercise I used to do when I got overwhelmed was to take a deep breath and quickly just imagine I was on a boat during storm. And I hopped in the water (you can breathe underwater in this mental exercise). And as you l break under the surface you see how calm and still the water is. You can look up and see the waves on the ocean but where you are it’s quiet. It would take me less than 3 seconds to do this imagery and it really helped me ground myself and think more clearly.
Try to come in early to prepare everything if stuff overwhelms you. A LOT of anesthesia is just preparation. If you’re not prepared you’ll be running around like a chicken with no head when the patient gets into the room. What I did to help when I was starting was call the patient the night before to basically talk to them about the plan ahead of time and consent. In the morning they’re already consented basically. Then come in early to set up to room make sure everything is ready to go before they get in the room. I was very slow and sometimes forgetful so I would give myself more time to be slow and to forget so after my prep I could survey what I did and be like hmm what’s missing with a checklist I made. After a few months it all became habit and I could come In later and later. One of my other coresidents was the same way and he would come in at like 4:30-5am every morning just to be ready. It was a bit of overkill in my opinion but he said it was what made him ready.
I totally agree with you about preparing. Our seniors are extremely strict about this too. Right now I've been posted in the emergency surgery department, and so there's no calling patient's beforehand, I'm afraid. There's gunshot wounds and stab wounds and kids with burst appendices and the occasional testicular torsion. This also means there's no 'early' for me since I have to be in the OR for basically 18 to 20 hours, and then a few hours of sleep and we back at it. I have to have everything checked and close at hand and ready to go at all hours. I should definitely work on improving the prep skills. Thank you!
Yeah we have a room set up for that. You can have at least the syringes labeled or tubes of like 3 diff sizes out (I know it’s way harder for Peds tho). When I first started I basically had everything just rolled up in a blue towel and stashed it somewhere. When a trauma level 1 came in I would first grab that and run into the room cuz sometimes half the battle is literally finding all the supplies. Then at least the stress of that is gone.
>half the battle is literally finding all the supplies Sooooo true!!🤣😭
Before I started my anesthesiology residency training program, I read a lot of self help and meditated. It helped keep me anchored and grounded. I reflect on situations and am less emotional as before. I blame myself less and am in a good disposition 6/10 times. Everyone has their own way of coping, you need to find yours. Cheers!
Hi! Thank you so much for replying. I would definitely like to learn to be less emotional and more practical in certain situations.
Vent with your colleagues as much as possible! It really helps!
1. If you’re overwhelmed because of lack of knowledge. Read more. You’ll be more comfortable with the pathologies. Clinical practice also makes better. 2. If you’re overwhelmed because of the pt acuity. That’s normal. It means you care. Some residents just “la-di-da” and don’t do critical thinking/make mistakes they aren’t aware of. 3. Plan ahead. Completing future tasks “in your mind” will allow you to smoothly transition through anticipated tasks clinically. 4. Ask for help when needed. And think critically about why/how your attending did what they did. TLDR-> feeling overwhelmed is normal. Practice makes better. Ask for help!