First Day

On my first day of anesthesia, I showed up a little before 6, changed into scrubs, and found my operating room. Indeed, I was the first to get there; the medication cabinet was locked, the lights were off, the room was silent. I took the machine through my first machine check, oriented myself to my workspace, drew up the drugs I would need, set out emergency medications. I made several trips back and forth from the anesthesia workroom and figured out how to get my narcotics from the secure dispensing machine. The patients then arrived in holding and I struggled a little to put in an IV just as my attending arrived.

The first case was a repair of a finger fracture. The regional anesthesia team placed a brachial plexus block for us. The case was straightforward, and I spent the time learning my bearings, figuring out how to chart, and familiarizing myself with the flow of the operation.

The second case likewise was a simple toe amputation done under local anesthesia and light sedation. However, there were some concerns because the patient was actively using cocaine which can be lethal if we had to convert to general anesthesia. The surgeons determined that the amputation was somewhat emergent and we proceeded without difficulty. Two easy cases under monitored anesthesia care, and I was feeling good about this. It's not too bad, I thought to myself.

My last case of the day was an add-on of an emergent airway, which sobered me up quickly. A gentleman had come into the emergency department with a large neck mass and difficulty breathing. He had a progressively enlarging thyroid that was beginning to compress his trachea (windpipe) so that he couldn't lie flat to sleep. On exam, even without a stethoscope, I could hear the narrowing of his airway when he breathed, called stridor. This was going to be a difficult case. The surgeons wanted to remove the thyroid, but in order to do so, we'd have to secure a way of ventilating him and helping him breathe. The standard fashion of placing a breathing tube involves lying them flat and inducing general anesthesia, but in this case, we would have no guarantee that if we sedated him and paralyzed him that we'd be able to get into the trachea. We'd have to do this awake.

We anesthetized the back of the patient's throat with nebulized (aerosolized) lidocaine; this is the most important part of the preparation as gag and cough reflexes are incredibly powerful and trying to place a breathing tube in an awake patient can be very uncomfortable and technically difficult if adequate local anesthesia is not provided. Then, I went in with a fiberoptic flexible bronchoscope - a thin camera - and identified the vocal cords and passed the scope into the trachea. I slid an endotracheal tube over the scope into the airway. It was quite exciting as this is one of the more advanced airway techniques, and I had a lot of support from two attendings. The case was also complicated as the patient was persistently hypotensive and required a phenylephrine drip, but luckily we got through it without difficulty. The day ended at 6pm when we had a debriefing with my other co-residents. What a first day!