Anesthesiology is defined by the dictionary as a “branch of medicine dealing with anesthesia and anesthetics.” And of course that requires the definition of anesthesia: “loss of feeling in a person’s body or part of the body through the use of drugs.” Anesthesiology has moved much further than that. The field now means that the anesthesiologist is a perioperative consultant. The practice of anesthesiology is more than just rendering a patient insensible to pain so that the surgeon can operate. Anesthesiologists are leaders in cardiopulmonary resuscitation and provide care in a variety of settings—the operating room (OR), the endoscopy suite, the radiology/imaging suite, the electrophysiology laboratory, places where electroconvulsive therapy is performed, and the intensive care unit, to name a few. Anesthesiologists are also heavily involved in administrative functions in the perioperative setting and with hospital and OR committees and often serve important roles in hospital administration. They may be engaged in schools of medicine in teaching and other roles.

A brief word about anesthesiology training: Anesthesiologists must first complete at least four years of medical school; some do more to get research experience and PhDs or other advanced degrees. After that, they must complete a base year of residency or internship, typically in internal medicine, surgery, or transitional medicine. The core anesthesiology residency is three years long and follows this base year. After that, many anesthesiologists decide to pursue subspecialty fellowship training in a variety of fields—adult cardiothoracic anesthesiology, pediatric anesthesiology, pediatric cardiac anesthesiology, obstetric anesthesiology, pain medicine, critical care medicine, neuroanesthesia, transplant anesthesia, research fellowships, and more. All in all, you would have four years of medical school, four years of residency training, and then one or more years of fellowship training.

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   Prepare to use your hands. This will be some of the most hands-on pharmacology and physiology you will encounter. It will also be very procedurally oriented. This will be one of your best times as a medical student to learn the following:

   
   
   
   
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      Monitor placement (seems simple, but very important!)

      
      
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      Peripheral intravenous (IV) insertion

      
      
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      Ventilator management

      
      
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      Airway management skills such as mask ventilation, intubation, and laryngeal mask airway placement

   
   
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   Prepare to use your brain! Stay engaged, even when the anesthesiology team is too busy to pay attention to you or even if it feels like not much is going on. It is a very cerebral field, on top of being procedurally oriented. Write down questions about what you are observing during busy times (induction, emergence, critical moments in the case), and be ready to ask and listen during maintenance times.

   
   
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   Prepare to practice situational awareness. This is an important skill to learn, not just for this rotation or field but for the field of medicine in general. You will learn a lot about when it is appropriate to ask questions and gain a better understanding of professional behavior.

   
   
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   Be vigilant. Vigilance is the key word for anesthesiology. You will learn to become aware of all things that occur in the operating room, from changes in sounds in the monitors (pitch of pulse oximeter, for example) to other alarms going off in the background to the surgeon letting you know that the patient is bleeding.

   
   
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   Respect your patient. This is one of the most important rules, not only in anesthesiology but in medicine. When done correctly, the anesthesiologist-patient interaction can be one of the most meaningful and effective that the patient has in the hospital. Think about it: the patient and family come to the hospital anxious and nervous about the surgery, about dying, about “being awake during surgery,” about “never waking up,” and other concerns. Anesthesiologists must earn the rapport and trust of their patients in a matter of minutes, and can, in the process, make or break the patient’s surgical experience. Interestingly, in these few minutes before surgery, the anesthesiologist can also affect longer-term health changes. It is a subtle art: watch it, learn it, and please do not underestimate it.

   
   
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   Be an advocate. Regardless of what you decide to eventually go into (we hope it is anesthesiology!), remember that a good number of patients will undergo procedures or surgeries that will require an anesthetic. You may be their primary care physician; you may be a consultant in the hospital. But you might get asked about what happens when one is “put to sleep.” Learn what you can so that you can continue to advocate and be a source of information for your patients.

Anesthesiologists like doing. They multitask. They perform procedures. They think on their feet. You may not be ready to put in lines or administer medications that can easily be deadly; however, you can learn from your anesthesiologists without laying a finger on the patient.

Here is a good list of questions to start the discussion about various important aspects of anesthesiology. Remember to ask when you think it is an appropriate time—not when the patient is being induced (unless specifically directed); not when the patient is hypotensive, for example. Be smart.

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  Can I help with anything? (Ask the OR nurses too!)

  
  
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  Can you lead me through the preoperative evaluation/consultation (also known as the “pre-op”) on this patient?

  
  
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  How should I approach the pre-op? What do you look for?

  
  
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  Was there anything special that you needed in preparation for this patient? Why?

  
  
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  How does the patient’s condition (or comorbidities) change the anesthesia plan?

  
  
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  Are there particular things that you are monitoring more closely for this patient?

  
  
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  What sorts of things are you concerned about postoperatively for this patient?

  
  
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  Tell me about the medications that you used (to induce, to paralyze, to maintain anesthesia, to treat that blood pressure, to treat pain, etc). Why did you use that medication versus something else?

  
  
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  Can you discuss inhalational anesthesia versus intravenous anesthesia? Why would you do a TIVA (total intravenous anesthesia)?

  
  
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  Can you lead me through fluid management for this patient?

  
  
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  Can you lead me through what happens on induction? On emergence?

  
  
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  Can you discuss intubating and airway management?

  
  
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  What important steps in the surgery do you need to be aware of in this case?

  
  
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  What is your general goal during maintenance? What are you keeping your eye on?

  
  
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  Can you discuss your ventilator settings for this patient? Can you go through different ventilator settings?

  
  
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  What sorts of things could go wrong with this patient? What would you do when if that happened?

  
  
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  Can I help with charting? What is important in an anesthesia record?

  
  
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  How do you do your post-op PACU (post anesthesia care unit) report? Can I try?

  
  
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  Can I try the IV? Airway? Arterial line? Can you teach me how to do it?

  
  
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  Why did you go into anesthesiology?

  
  
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  Where did you do your residency?

This is a very limited list of questions that we hope will get you started on a discussion.

What does it mean to be anesthetized?

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   Loss of consciousness

   
   
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   Amnesia (loss of memory/no recall)

   
   
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   Analgesia (pain control)

   
   
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   Akinesia (no movement)

   
   
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   Blunting of autonomic reflexes—not always included, though often necessary

ASA Physical Status Classification System

These classifications from the American Society of Anesthesiologists (ASA) are assigned to each patient to indicate how sick the patient actually is. Some studies have shown a correlation between ASA class and risk associated with anesthesia and surgery, though this is debatable.

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  ASA 1—A normal healthy patient

  
  
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  ASA 2—A patient with mild systemic disease

  
  
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  ASA 3—A patient with severe systemic disease

  
  
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  ASA 4—A patient with severe systemic disease that is a constant threat to life

  
  
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  ASA 5—A moribund patient who is not expected to survive without the operation

  
  
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  ASA 6—A patient who has been declared brain-dead and whose organs are being harvested for donation

  
  
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  An “E” modifier is added to the number (eg, ASA 1E, 2E, etc) to designate an emergent surgery or procedure

Morning Anesthesia Equipment Check and Setup

MS MAIDEN is a mnemonic to help you remember the setup checklist:

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  Monitors—at least standard ASA monitors: EKG, SpO₂, etCO₂, blood pressure, temperature

  
  
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  Suction—on and ready to use

  
  
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  Machine check—full anesthesia machine check, including checking for leaks and pressure in the circuit

  
  
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  Airway—all airway equipment including but not limited to anesthesia circuit, mask, endotracheal tube, laryngeal mask airways, laryngoscopes, oral airways, nasal airways, bougie/tube changer, tongue depressor, and emergency airway equipment as needed (especially a bag-valve mask)

  
  
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  IV—all IV equipment, multiple gauge catheters, IV tubing, appropriate IV fluids, etc

  
  
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  Drugs—emergency drugs, induction drugs, neuromuscular blocking agents, inhalational agent vaporizers filled, pain medications (narcotics, adjuncts), etc

  
  
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  Emergency—all emergency equipment including but not limited to a bag-valve mask, extra oxygen tank (checked and full), emergency drugs, etc

  
  
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  Narcotics—both short- and long-acting agents as needed

When you intubate, you will be asked to tell your anesthesiologist what type of view you had. Figure 1 illustrates what they are asking for (the Cormack-Lehane view).

The preoperative evaluation, or pre-op, is a complete but focused history and physical, anesthesiology style. It is important to pre-op planning and is equally important for knowing what to expect intraoperatively. The preoperative evaluation is often done in a pre-op clinic a few days before surgery (to allow for optimization if necessary). In certain cases, it is done directly prior to surgery. If the pre-op evaluation is done in a clinic, the anesthesiologist taking care of the patient on the day of surgery will do another evaluation to make sure that nothing has changed from the original pre-op exam. The pre-op will look at the major organ system and assess how optimized a patient may be for the surgical procedure planned. Oftentimes, depending on what the pre-op finds, the surgical procedure may change or a different approach may be used or it may be canceled.

The first thing on a pre-op is the planned surgical procedure and the reason for the procedure: a brief history of present illness. It follows with a complete review of systems, with a lot of importance given to the cardiopulmonary system. It then looks through prior surgical and anesthetic histories, followed by a focused physical exam. The following is an example of what may be covered.

Date:   Surgery Planned:   Surgeon:

History of Present Illness (reason for surgery)

Review of Systems

Neurologic

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  Current mental status

  
  
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  History of strokes/transient ischemic attacks; residual symptoms

  
  
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  Chronic pain issues—what medications, how much, and how often

Cardiovascular

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  Hypertension—whether it is controlled or uncontrolled; meds being taken

  
  
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  Cardiac disease, coronary artery disease, valvular disease heart failure, history of myocardial infarction, angina, any cardiac surgeries

  
  
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  Any shortness of breath, dyspnea on exertion, orthopnea

  
  
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  Exercise tolerance

Pulmonary

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  Any pulmonary disease (chronic obstructive pulmonary disease, asthma, etc)—how well is it controlled, medications, recent hospitalizations or intubations, recent steroid use

  
  
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  Shortness of breath

  
  
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  Recent upper respiratory infections

  
  
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  Obstructive sleep apnea; snoring history; use of continuous positive airway pressure

Gastrointestinal

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  Liver disease or failure

  
  
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  Gastroesophageal reflux disease or hiatal hernia—controlled, any current symptoms, what medications

Renal

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  History of kidney disease, dialysis, fistulas, or grafts anywhere, etc

  
  
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  Any history of electrolyte issues

Endocrine

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  Diabetes—which medications; last A1C

  
  
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  Thyroid issues—hypo vs hyperthyroid; level of control

  
  
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  Chronic steroid use

Social History

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  Alcohol and drug use

  
  
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  Tobacco history (ever smoked?)

Current Medications

Allergies

Past Surgical and Anesthetic History

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  Any problems with prior anesthesia, including postoperative nausea, vomiting, complications, difficult airway, etc

Family History

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  Any family history of problems with anesthesia

Physical Exam

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  Vital signs

  
  
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  Weight/BMI

  
  
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  Neurologic exam (including mental status)

  
  
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  Cardiovascular exam

  
  
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  Pulmonary exam

  
  
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  Any other necessary exams based on above information

  
  
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  Airway exam—mouth opening, Mallampati score, neck range of motion, thyromental distance, jaw mobility.

  
  
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  Review of pertinent lab work and data—metabolic panel, complete blood count, coagulation studies, blood type and cross, chest x-rays, CT scans, EKGs, TTEs, cardiac stress testing, etc

The pre-op information along with any other information that you have available is used to assign an ASA Physical Status Classification, as discussed earlier.

Also, important to note is that the American Heart Association has guidelines on when more testing is necessary, when it comes to cardiac-related issues such as: When should you get a heart catheterization or a stress test?

Start/Induction/Intubation: This is the beginning. Induction refers to when medications are delivered to the patient (via IV or inhalation). It results in general anesthesia. Intubation refers to placement of an endotracheal tube into the trachea.

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  Preoxygenation with 100% oxygen via face mask. The goal should be an end-tidal oxygen concentration of more than 80%.

  
  
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  IV anesthetic medication (propofol, etomidate, etc) is administered until the patient is unconscious. Inhalational anesthesia can also be used. In this case, anesthetic gases are started while the patient is conscious.

  
  
  
  
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    Check for a loss of lash reflex (brush the eyelashes and look for the eyelid to move).

  
  
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  In most cases, after the patient is unconscious, you will attempt to ventilate the patient with the anesthesia bag (masking).

  
  
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  If you are able to mask the patient, a paralytic is given (such as succinylcholine, rocuronium, etc).

  
  
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  After the paralytic has taken effect, intubation is attempted.