I arrive to the hospital at 5:30 a.m., quickly change into scrubs and check the OR board to make sure my case has not changed. I am assigned to do my first coronary artery bypass graft procedure and I am both excited and nervous for the occasion. It is only November of my CA-1 year and I am being trusted to do the anesthetic for a major cardiac procedure! I pull my crumpled pre-op note out of my backpack on which I took notes on the cardiac setup and surgical steps and head to my OR.
I find the OR set up in the morning to be a period of Zen where I methodically review the steps of the case in my head while I organize my room and listen to music. Over the next forty minutes, I complete my machine check, draw up medications, hang my pressor infusions, and prepare the supplies to start my lines in the preop area. On my way to meet my patient, I stop in the anesthesia tech room to discuss the plan for a central line, arterial line and a TEE with the cardiac anesthesia technician.
When I reach the preop holding area, I see that my patient and his wife are already waiting for me, appearing nervous, as they had been when I met them the day before to talk about the case. I greet them with a bright smile and answer their questions. I then enlist my patient’s wife to distract him while I inject a small amount of lidocaine and put in an 18 gauge IV. Fortunately, the patient has large veins and I am able to get it in on the first try. I am slightly more nervous for the arterial line, but fortunately the patient has a great pulse and I am able to thread it in easily as well. I realize that I have forgotten a chlorohexidine dressing to secure the arterial line just as my attending walks into the pre-op bay to lend a hand. He grabs me an extra dressing and I breathe a sigh of relief that he walked in at that moment. We are ready for the OR with time to spare! I give the patient a high five for being such a trouper during the awake line placement and leave him to have some peace and quiet with his wife before we head back.
I wait in the pre-op break room with my attending for the light next to my patient’s name to turn green, signaling that the OR is ready for the patient’s arrival. As we wait, he checks that I remember the plan that we had discussed the day prior. The light finally turns green and we jump up to get our patient and head to the operating room.
After a timeout with the surgical team, my attending hands me the medications for induction. I push the medications slowly, careful to minimize the hemodynamic changes as we had discussed. After I intubate the patient, we move towards central line placement. I hesitate before making the nick of the skin, careful not to cut the wire. After the central line is placed, the TEE probe is placed, the case begins.
Our time at the VA is one of the most invaluable experiences for our learning as CA-1s, where we are exposed not only to complex cases but also to patients with significant comorbidities. We are fortunate to have intelligent and supportive attending physicians that are patient with us as we learn to care for these extremely sick patients. They seem to know just the right balance of autonomy and supervision, which really helped me build my confidence in caring for sicker patients. Further, the OR department at the Houston VA places a strong emphasis on case efficiency, with mandatory 30-minute turnover between cases. This is only possible due to the hard work of the support staff, especially the anesthesia technicians, who work hard to make our jobs easier by preparing supplies like pre-filled lidocaine syringes and arterial line kits so we can shave a few minutes off our room turnovers. Altogether, the VA rotation definitely made me a more resourceful physician as I was forced to hustle to evaluate these complex patients safely. I look forward to going back again for advanced rotations including pain and neuroanesthesia next year where I can sharpen these skills.