A Day in the Life of an Anesthesiologist
Anesthesiologists are Peri-Operative Specialists
If you haven't had surgery, you probably haven't given much thought to an anesthesiologist's job. If you have had surgery, perhaps you have wondered, "What does an anesthesiologist do besides send me off to sleep?"
Getting the Day Started
Sometimes It's Easy
**All patient encounters are hypothetical and are not based on any specific patient interaction.**
0700 — Seven AM, it's getting late. One more check of my room shows me that I have indeed gotten everything ready for my first patient, who is having a total knee replacement. I have the tray of syringes and medications ready to give the spinal anesthetic, the large syringe of propofol connected to the tubing to be used for sedation during the operation, and the meds and needle ready for the nerve block.
0705 — Go see the patient. Hello, I'm TahoeDoc, your anesthesia doctor. Have you ever had surgery before? Thus starts the conversation that gives me the medical background of the patient that enables me to formulate an anesthesia plan. This gentleman is pretty healthy and fit. At age 62, he has worn out his joints from a lifetime of skiing, mountain biking, and running.
He is pleasant and relaxed as we discuss his anesthesia options. He does indeed opt for a spinal with sedation and a femoral nerve block. He had general anesthesia before and didn't like trying to wake up, so is happy to have a different option.
0715 — Head to the OR. With my patient lightly and happily sedated, we are in the operating room. I attach the EKG monitor, the pulse oximeter to measure oxygen level during surgery, and the blood pressure cuff.
Next, I place the femoral nerve block. I instruct Mr. B to tell me if he feels any pain or electric shock sensations as I'm doing the block. I uncover his entire right leg, and the nurse and I perform a 'time-out' procedure. We confirm with each other, with the written consent form and with the patient, that the right leg is indeed the correct surgical site, just as we had already done in the preop holding room.
The needle for the block is small and Mr. B doesn't even flinch when I insert just below the crease where his leg joins his hip. I tell him again to let me know what he feels and remind him that soon he will feel his leg twitch. The nerve monitor that I use causes involuntary twitching of the leg when we find the 'right' spot. Mr. B is not obese, his femoral artery that we use for a landmark is easy to feel, he does not move or tense up during the procedure so it goes easily.
I have Mr. B turn on his side and curl up pushing his low back out toward me. A check of the monitors and I prep for the spinal. Cleanse with sterilizing soap, numb the skin with a small needle, insert the spinal needle and see the clear cerebrospinal fluid come back in the needle. No blood and no sign of nerve irritation. In goes the medicine.
The next two hours are spent tweaking the sedation so Mr. B isn't bothered by the sound of the saw cutting through his bone or the hammering of the new joint into place. His blood pressure dips from time to time and I give a touch of ephedrine to bump it back up.
All in all, Mr. B was a pleasure to take care of, personally and professionally.
If only the rest of the day would have followed suit. But, it was not to be.
An Anesthesiologist's Job
Sometimes It's Not So Easy
Just when you think the day is over, that's when the worst call comes. The other patients on this day were all pretty straightforward. A few little bumps but nothing that I couldn't handle with ease, really. That's what all that training does for you. Still, I'm pretty tired when I find out about the emergency.
The 'add on' case was different though. An elderly man was found 'down' in his home after neighbors became concerned. His abdomen is distended and blood is found on a rectal exam in the emergency room. An emergency CT scan confirms that there is a hole in his intestine. And worse, there is a large mass there, as well. Colon cancer has weakened his colon and caused it to rupture. His abdomen is full of air, blood, and stool. When they call us, his blood pressure is 84/36. Not good. And wow, his labs are completely messed up — low sodium, high potassium, and everything else is just a mess. All of this will make it dangerous — life threatening — to have an anesthetic, but surgery is his only hope.
Five minutes to prepare the operating room and find out what I can about this man. Except nobody knows anything. Paramedics found a pill bottle on his counter for a diuretic (water pill). Otherwise, we don't know his medical history or what medications he takes.
As expected, he is barely conscious and is unable to communicate at all when we take him directly from the ER. We take him away before the ER even finishes their work up as it's clear that only surgery can save him now. In the OR, I hook up a medicine that will help keep his blood pressure up a bit. It works, but marginally. An oxygen mask is placed while I try to place an arterial line. This special IV goes in an artery instead of a vein. It will give me his blood pressure every time his heart beats. But you need to be able to feel a pulse to get this thing in. No luck. I get it on the 3rd try, luckily without taking up too much precious time. I start giving his fluid and anesthesia medicines slowly to make sure he doesn't 'tank' - drop his blood pressure too fast and end up in cardiac arrest. No one is in the mood to run a code before starting this surgery.
In spite of my careful and slow 'induction' of anesthesia, his blood pressure is now 54/21. Yep, it's possible, but can I get him back? I groan and quickly grab the phenylephrine. It takes several doses and what seems like forever but his pressure creeps back up to 90/41. I'll take it - it's not great, but it's compatible with life, unlike the former measurement. A quick look with the laryngoscope and I slide the breathing tube between the vocal cords. Moving as fast as I possibly can, I alternate between getting the patient ready for surgery and treating changes in heart rate and blood pressure, I put in an extra IV while the surgeon attempts a central line. Much like the arterial line, this is not easy given that our patient is severely dehydrated. We have to be careful not to flood him with fluids too fast, though. Finally ready, and the nurse's prep the abdomen.
The whole case is a frenzy of activity. Everyone is racing to save our mystery patient. I am hanging units of blood, giving boluses of medicine to get and keep his blood pressure up. Nurses are running for surgical supplies. Beads of sweat form on the surgeon's head from working so rapidly under the hot lights.
I've always said that an anesthesiologist's job in these cases is to keep the patients alive while the surgeon fixes what trying to kill them. Sometimes, this is difficult or even impossible.
By the time we finish the surgery and transport him to the ICU, we realize it's 8 pm. My kids will already be in bed before I get home. After passing on all of the important information to the ICU team, I can finally leave. Before I do, I take a quick look at tomorrow's schedule. I'm first call the next day so I'm in the operating room that runs the latest tomorrow and then I'm 'on call' for the rest of the tomorrow night. Nope, doesn't look like I'll see my kids tomorrow either, maybe the next day.
I change out of my dirty scrubs, splash some water on my face and drive home, exhausted and not looking forward to the next day very much. But, I can think of at least one person who had a worse day than I did. He is still alone on a ventilator in the ICU.
This is a very small glimpse into what an anesthesiologist does. For more information, see these articles too.
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