Historically, the role of the anesthesiologist was limited to the physician who administers anesthesia to suppress pain and consciousness in a patient undergoing surgery. Today, The American Society of Anesthesiologists defines an anesthesiologist as a perioperative physician, the “all-around” physician responsible for providing medical care through all junctures of a patient’s surgical course. In the current health care system, in addition to providing pain control and life support functions during and after surgery, anesthesiologists play important roles in preoperative surgical planning and preparation as well as many other aspects of patient care.
At many teaching institutions around the country you may encounter anesthesia residents in training. Anesthesiology residency is a four-year program after medical school requiring one year of internship and three years of anesthesia-specific training. Quick tip for medical students: if you do not enjoy physiology and pharmacology, anesthesiology may not be the right specialty for you. A resident performs the roles and responsibilities of an anesthesiologist under supervision of a staff (fully trained) anesthesiologist. During the operation many of the OR staff may come and go but an anesthesiologist will be present during induction, emergence, and all critical portions of the operation. Anesthesia residents often spend rotations in specialized areas of anesthesia as part of their training including cardiac, transplant, pediatric, regional, ambulatory, and neuroanesthesia, as well as critical care, acute pain, and chronic pain. Following residency, some anesthesiologists will pursue fellowship training in these specialties.
The anesthesiologist’s job starts prior to surgery with assessment of the patient’s medical and surgical history. This may start weeks before a planned operation to allow time for appropriate testing and medical treatment if a patient has complex medical problems. The aim of this preoperative evaluation is to discover risk factors that must be assessed and managed, including acute and chronic diseases of the heart, lungs, kidneys, and liver, allergies, medications, and difficult access to the circulation or airway. Failure to carefully evaluate and manage the patient preoperatively may result in delay of the operation or increased complications during or after the surgery. The preoperative evaluation and plan may be performed by another anesthesia provider weeks before but will be reviewed by the anesthesiologist on the day of the operation. Intraoperatively the objectives of the anesthesiologist for the patient include loss of awareness, pain control, vital sign monitoring and intervention, airway management and breathing, and appropriate hydration with intravascular fluid administration. The anesthesiologist assumes control of the patient’s general physiology throughout their operative case.
If a general anesthesia is planned, on arrival into the operating room the patient will first be placed on appropriate monitors for the procedure. For every anesthetic, the patient’s oxygenation, breathing, and circulation are continually monitored as well as temperature if changes are anticipated, intended, or suspected. Monitoring is usually accomplished through use of a pulse oximeter, ECG monitor, blood pressure cuff, and temperature probe. In addition to these standard monitors, some procedures might also require more advanced monitoring and interventions such as a depth of anesthesia monitor, intravascular monitors, and real-time imaging of organs such as the heart with the use of ultrasound. These monitors may be placed before or after initiation of anesthesia (Figure 4.1).
Once the appropriate monitoring is in place, the patient is prepared for the start of anesthesia, which is referred to as “induction.” The patient will be asked to breathe 100% oxygen via a plastic mask that is sealed around the mouth and nose. This step is to give the patient an oxygen reserve from the time the patient stops breathing after induction to when the anesthesiologist can safely assist their breathing. Once the patient is pre-oxygenated, anesthesia is initiated, most often with a memory loss medication (induction agent), a fast-acting pain reliever, and a muscle relaxant given through a vein. The patient will lose consciousness and stop breathing very quickly, almost always in less than a minute. At this point, the anesthesiologist may help the patient breathe with the mask used for pre-oxygenation or proceed directly to placing a hollow plastic tube, called an endotracheal tube, into the trachea, the structure connecting the patient’s mouth to the lungs. To place the endotracheal tube, a laryngoscope is used. A laryngoscope is a blunt metal blade with a bright light on the end, used to push the tongue out of the way and light up the opening of the trachea. When endotracheal tube placement is confirmed, the tube is secured in place and breathing is assisted or taken over for the patient. If the anesthesiologist anticipates a difficult airway, the endotracheal tube might be placed with the patient under light sedation with local anesthetic while the patient remains breathing on their own.
During the operation, the anesthesiologist maintains anesthesia and preserves stable heart and lung function. Most commonly, anesthesia is maintained with a vapor inhaled through the lungs, which travels through the bloodstream and acts on the central nervous system. Maintenance of anesthesia may involve the use of a number of different drugs and fluids, especially when the operation is associated with major interruption of blood flow or major blood loss.
After the operation is complete, if it’s possible for the patient to breathe without assistance the anesthesiologist will reverse the effects of muscle relaxants and anesthetics and remove the endotracheal tube. Awakening from anesthesia is referred to as emergence. If the patient requires continued breathing support, the anesthesiologist may decide to leave the endotracheal tube in. In either event, depending upon the intensity of postoperative care required, the anesthesiologist transports the patient to either the postoperative care unit or an intensive care unit. During this recovery period, the post-anesthesia care unit or critical care nurses may administer drugs to relieve pain, control blood pressure, and stabilize organ function.
Depending on the type and duration of procedure being performed, the anesthesiologist may choose a technique other than general anesthesia. Other types of anesthetics include monitored anesthesia care, regional anesthesia, neuraxial anesthesia, or a combination of these techniques. Oxygenation, ventilation, and perfusion must still be monitored with alternative anesthetic techniques and there is always a possibility of transitioning to general anesthesia during the procedure.
Monitored anesthesia care (often referred to as MAC) differs from general anesthesia by allowing the patient to continue breathing under their own power and keeping the patient able to respond to touch or verbal stimuli. This is usually accomplished with IV sedative medications or slow, less aggressive infusions of the same medications used to induce general anesthesia. Vapor inhaled anesthetics are rarely used, as they are pungent and unpleasant to breathe spontaneously.
Regional anesthesia involves injection of a local anesthetic around major nerves to block pain from a large region of the body. The nerves are found using anatomic landmark, nerve stimulator, or ultrasound-guided techniques. For example, a supraclavicular block to the brachial plexus will provide anesthesia to the majority of the arm. Nerve blocks are most commonly used for procedures on the hands, arms, legs, or face. The choice to perform regional anesthesia depends on the patient’s ability to tolerate the block, to tolerate the operating room environment, and the length and location of the procedure. Regional anesthesia can also be performed after an operation to provide postoperative pain relief.
Neuraxial anesthesia includes injection or continuous infusions of local anesthetics in close proximity to the spinal cord. A spinal anesthetic is often used for lower abdominal, pelvic, rectal, or lower extremity surgery. This type of anesthetic involves injecting a single dose of local anesthetic agent directly into the spinal cord fluid in the lower back, causing numbness in the lower body.
An epidural or caudal anesthetic is similar to a spinal anesthetic, and is also commonly used for surgery of the lower limbs and during labor and childbirth. This type of anesthesia involves continual infusion of drugs through a thin catheter that has been placed into the space that surrounds the spinal cord in the lower back, causing numbness in the abdomen and lower body. The advantage of an epidural or caudal anesthetic over spinal is that it allows adjustable anesthetic doses for a long duration. However, epidural and caudal anesthetics can be unreliable in their spread and strength of blocking the nerves due to the complexity of the spaces into which the infusions are entering.
The anesthesiologist is a great resource for learning about airway management, pharmacology, and complex physiology while patients are in the operating room. Their role is central to the safety of the surgical patient before, during, and after their operation.
THE NURSE ANESTHETIST
I remember getting a call at 2:00 in the morning from the obstetrician saying that we had to rush to the OR with an emergency postpartum hemorrhage. Just hours before that, I placed a labor epidural in this same patient to help relieve her pain during labor, in anticipation for her first child. I remember the proud look on the new father’s face as they transferred the family to the postpartum unit. Upon hearing the news that we must rush to surgery, I saw the same father anxiously waiting outside the OR, his face much different this time! I assured him that his wife was in good hands. The OR staff were all busily preparing for emergency surgery. I noticed the patient was afraid and in a state of shock. I grabbed her hand and explained that I would have to place her under general anesthesia so the surgeons could control the bleeding, and I would be by her side and help her get through this unexpected event. I continued to reassure her until she was comfortably asleep under anesthesia. This story exemplifies how I unite my experience as a bedside nurse with my expertise in anesthesia—a unique skill set possessed by Certified Registered Nurse Anesthetists (CRNAs).
CRNAs are highly trained providers of anesthesia. We are first and foremost nurses. Our training begins with a bachelor’s degree in nursing, and all CRNAs must have critical care experience prior to their anesthesia training. This bedside care experience helps CRNAs to connect with their patients on a personal level. It has been invaluable to me as I try to ease the (appropriate) anxiety most patients experience before going to surgery. In addition to our critical care experience, all CRNA programs are between 28 and 36 months, leading to a masters or doctoral degree. Following completion of degree requirements, a rigorous board examination must be passed to ensure competence, and for the safety of the public. These are the entry-level requirements to begin the practice of anesthesia as a nurse.
Anesthesia was first practiced by nurses on the battlefields of the Civil War in 1860 and became the first nursing specialty in the United States. Currently, 38 million anesthetics are provided by CRNAs in the United States each year. At many hospitals where CRNAs practice in a team with anesthesiologists (Figure 4.2). This partnership adds a unique quality to the patients we serve, while keeping safety our top priority.
Anesthesia is 50 times safer today than it was in the 1980s. Practicing anesthesia in teams has the added benefit of making anesthesia even safer for our patients. CRNAs communicate closely with our anesthesiologist colleagues, freeing them to identify risks, mitigate those risks, and provide for a smooth recovery from anesthesia in the recovery room. You will always see an anesthesiologist present during the key moments of anesthesia, including induction, emergence, and placement of invasive lines.
In my anesthesia training I was taught to plan for a smooth anesthetic but always be prepared for the worst. In the example of the postpartum hemorrhage, I had previously prepared myself for any emergency. As the OR staff were busy with the tasks of preparing for surgery, I was free to attend to the patient’s fears. My years of bedside nursing experience made me remember that my duty was not only to administer anesthesia, but also to care holistically for patients and their families.
FROM MEDICAL STUDENT TO SURGEON
A surgical team at an academic medical center is composed of individuals at multiple levels in their training and careers. There is a specific surgical hierarchy in the operating room and it is important for everyone to understand this, especially during cases involving critically ill patients (Figure 4.3).
The clinical training to become a general surgeon is five years long, following medical school. Other surgical specialties such as obstetrics and gynecology, neurosurgery, or otolaryngology have training that ranges from four to six years. Choosing what type of physician to become is a lengthy process that usually starts during undergraduate training, where premedical students will follow (or “shadow”) senior physicians to better understand what different specialists do. Premedical students have no formal training in OR etiquette or procedure and will usually need specific instructions from the OR nursing and scrub staff on where to stand and how to avoid contaminating the sterile field. If you are a premedical student, I can’t emphasize enough to you—please ask questions when you are observing in the OR so that you don’t breach etiquette or have a negative impact on the safety of the patient.
In medical school, students typically begin to scrub for cases during their third year. Medical students receive varying amounts of training on how to properly scrub and maintain sterility, so assuming they know proper sterile technique can be dangerous. Medical students rotate through various specialties during their clinical years, so they will have limited time and experience in the operating room. They will usually help the surgical team with retraction during cases and generally focus on learning the operative indications and anatomy. Medical students are commonly tasked with closing the incision at the end of the case. Expect medical students to struggle initially with wound closure, and keep in mind how you appreciated the patience of your senior colleagues early in your training.
When a medical student graduates, they are officially referred to as “doctor,” and enter a residency training program. Residency is when physicians become specialists in different areas of medicine such as a family practice, pediatrics, surgery, or radiology. The clinical training to become a surgeon, as noted above, generally lasts five years. First-year residents, referred to as interns, typically spend most of their time outside the OR learning how to manage patients before and after surgery. When interns do come to the operating room they are closely supervised by more-senior doctors and are focused on learning basic surgical techniques. The nursing and scrub staff in the OR can play a tremendous role in shaping these future surgeons by helping them learn the names of instruments and also the safe handling and passing of instruments. It is critically important for residents to learn early how to guard needles and safely pass sharps so that it becomes habit even (and especially) during stressful OR cases.
After completing their internship, residents in their second and third years of residency are referred to as junior residents. Junior residents will scrub most of the bread-and-butter cases for their specialty and help supervise medical students and interns. Residents in their fourth year of training are typically referred to as senior residents, and residents in their final year of surgical training are called chief residents. Senior and chief residents will typically scrub for the more complex cases in the operating room and are also tasked with overseeing the rest of the resident team. Senior and chief residents are sometimes entrusted to take a junior resident through a case as a teacher, but today, with the emphasis on patient safety, the attending is expected to be present. It is not uncommon for senior and chief residents to have to field multiple pages and phone calls while scrubbed in for surgery. It is helpful to remember that residents are functionally expected to be in multiple places at once—operating, managing floor and ICU patients, as well as seeing and staffing consults. It can be frustrating to the OR staff to help with returning pages, but this generally speeds cases along and allows the team to function more efficiently.
After completing a surgical residency many surgeons choose to subspecialize into a more focused practice. These subspecialty programs are called fellowships. Fellows are focused on learning the complex nuances of their subspecialty and generally practice relatively independently under the direction of a mentoring attending surgeon. Fellows will often complete cases as the attending of record and are responsible for teaching and directly supervising residents in the operating room.
Finally, the most senior member of a surgical team is the surgical attending or consultant. The surgical attending is the individual ultimately responsible for the care of the patient in the operating room and makes the final decisions on all care provided to the patient. Depending on the type of case in the OR, there may be multiple attending surgeons present for a given operation, and ideally the interaction is collegial and allows for a safe and efficient operation for the patient. Cases with multiple attending surgeons present a particular challenge for OR staff in terms of setup and expectations, so extra preparation, extra communication, and extra patience is fundamental during these events.
Surgical training is lengthy and rigorous because of the amount of medical knowledge and technical skill that surgeons must have to care for patients. Surgeons have to be able to operate under both ideal and difficult conditions, and they also must know when offering an operation is unlikely to help a patient (and therefore not offer that operation).