Medical Student Guide to Anesthesia Sub-I’s and Aways
An away rotation is one that is not done at your home institution. It can be used as an audition for a program that you are interested in attending for residency. It is an opportunity for you to see if you fit in with the residents, the culture and location, and whether you can see yourself long-term at the host institution. Realize that you are signing up for a month long ‘interview’. General tips to succeed - be adaptable, hard-working, and knowledgeable. Although anesthesia is a procedural field, don't forget that as physicians we add the most value with our overall knowledge base. You will need to strike a balance between being present, demonstrating procedural acumen, using the breadth and depth of your knowledge, and reading up on your cases.
Preparation before rotation
Depending on how the clerkship is arranged, you will either be assigned to a room or be offered the opportunity to choose your cases. It can be helpful to familiarize yourself with what the residents and attendings look like, so that you can introduce yourself when you see them. A quick Google search of their name and institution is usually enough. You will want to balance your clerkship with a variety of cases and people you work with. At the same time, try to work with the same attending for at least a few days. This continuity will enable you to build rapport and advance your skills. The more comfortable an attending or resident becomes with you, the more likely they are to trust you to perform procedural skills (e.g. drawing up medications, intubating, helping manage the anesthetic plan). Adapt your techniques as you work with different people, as everyone will have different preferences for how they like things done.
As for knowledge base, there are several items that an MS4 should be familiar with:
- how to perform a preoperative history and physical exam
- how to place IVs
- how to intubate
- rapid sequence induction
- difficult airway management
- all the medications used perioperatively (indications, pros/cons, doses, side effects, etc.), and PACU concerns.
If you’ve never placed an IV or intubated before, there are numerous YouTube videos to familiarize yourself with the process prior to actually doing it. That being said, nothing compares to actually performing the skill, so always be on the lookout for any opportunity to try. The first few times will undoubtedly be nerve wracking, but the more times you practice the more confident you will be.
Once rotation starts
Every day before you head home, check the schedule for the following day. Try to find the attending and/or resident you will be working with to introduce yourself and find out their preferences for when to meet in the morning. Look up the patient cases if you can and develop an anesthetic plan using the Anesthesiologist’s Manual of Surgical Procedures. Try to identify what challenges you may encounter given any patient’s history, comorbidities, past difficulties with anesthesia, etc.
Arrive early, preferably before your resident. Offer to help set up the room, but do not be offended if they decline. They may find it more efficient to do this themselves. That said, observe how the room is setup. This shows enthusiasm and can go a long way. There are various mnemonics such as MSMAIDS (machine, suction, monitors, airway, IV, drugs, and special equipment) to help you remember the steps.
The best ways to stay engaged during the cases are:
- Ask how you can help: Some examples of ways to help include preparing equipment, drawing up drugs, pushing drugs, charting, etc. Each person will have a different level of comfort over what you will be allowed to do, so please ask.
- Ask questions when things are slow. Be careful about asking questions during induction and extubation as these are critical times. But over the duration of the case, there will be downtime, and this is when you can ask pointed questions (ideally not ones that you can easily read up on yourself at home).
It can be helpful to carry a pocket book as a reference guide. I personally liked Pocket Anesthesia as a book you could easily fit in your white coat. Duke’s Anesthesia Secrets is written in an excellent question/answer format like pimp questions.
When to leave
You will want to strike a balance between staying late and not getting in the way.
When told to go home, you should go home - it’s not a test! Usually the resident/attending is also tired and will want some time alone.
Additionally, it will be a better use of your time to prepare for the next day and come ready to work rather than wear yourself out such that you cannot arrive on time or perform the next day. As a student, you are there to learn and the more you read in your spare time, the more knowledgeable you will be, and the more you will get out of each case.
After your rotation, follow up with attendings you have worked with, particularly if you would like a letter of recommendation. Remind them of any salient patient cases that you worked on together that were particularly meaningful to you.
Frequently Asked Questions
Should I be writing progress notes or OR notes?
No progress notes need to be written. Charting is done intra-operatively, and you will need to ask if this is something that you should help with. Do not be offended if the resident says ‘no’. It is not personal; physicians may be particular about how they like things documented. If not learned on an away rotation, you will have more than ample time to learn once residency begins.
Should I go to lectures?
YES! Even if not mandatory, go to grand rounds and resident lectures if you have time. Some topics may be over your head, but the exposure will be helpful. Try to read on the topics on your own time as well. You never know when you’ll be asked about a particular lecture topic and have a time to shine.