Day in the life of a CT1 Anaesthetics
I arrive about 07:45, and after searching the shelves, change in to blues. On the theatre wall are all of today’s lists, so I pick up my list and head to the surgical admission ward. I start seeing patients, zipping in between the admission nurses, surgeons, specialist nurses and pharmacist.
I take an anaesthetic history; ascertaining if there were any issues with previous anaesthetics, serious co-morbidities and letting them know what to expect in terms of the anaesthetic. A quick “open wide”, getting the patient to nod and jaw thrust gives me an idea of their airway. Lastly, I try to answer any questions, “How long will it take?” Will I wake up during the operation?” and the surprisingly common “Could we film me going to sleep?”.
I bump into my consultant as I’m writing up the charts. “Straightforward patients on the list. Are you happy to just get on with it? I’ll stand in the corner of the anaesthetic room.” I’m about three months into my training. I know my basic doses for simple induction and emergency drugs, but there is a whole world of things that I don’t even know that I don’t know. Still, I nod as “getting on with it” with consultant help nearby is the best way to learn.
After team brief, I check my anaesthetic machine; making sure I can give my patient oxygen, use the suction and ventilate. I chat to my ODP discussing size of laryngeal mask, endotracheal tube, antibiotics indicated as well as drugs needed. I draw up my drugs in readiness.
First patient is fit young man. Of course, I fail to cannulate his rope-like veins that are visible from space despite my time in the Emergency Department competently cannulating all manner of frail, dehydrated ladies and IV drug users whilst sleep deprived. Thankfully the second cannula goes in smoothly. Now we make idle chat to put the patient at ease; “Have you come far today?” “What would you be otherwise doing today?”.
The induction starts with a dose of fentanyl then propofol. A whole syringe of the white drug goes by and he’s still awake. My consultant nods as I reach for another syringe and I’m beginning to wonder if he will ever drift off. Finally, his arm slides off his lap, caught by the theatre assistant. Time for the muscle relaxant. Once it’s in, I hold the mask to his face and lift his chin. I turn on the volatile and squeeze the bag, pushing gas into the apnoeic patient. It’s now a waiting game. I press the alarm pause on the anaesthetic machine, it’s exactly two minutes.
I smell the volatile despite my best attempt at a good seal, there is a reason why they say beware of men with beards. Luckily my friendly neighbourhood ODP is handing me an oropharyngeal airway before I begin yawning. Two minutes are up.
I place the laryngoscope into the patient’s mouth, and try to consciously remember to lift up towards the ceiling and not lever on his teeth. “Grade 1 view.” The endotracheal tube is put into my hand, and so I direct it towards the glottis. I see the tube pass the cords, but the proof is in the pudding. I connect the tube to the circuit, and hold my breath as I squeeze the bag. Chest rising, tube misting and C02 trace. Success. Tube tied in, 22cm at the teeth. First hurdle overcome.
We are ready to head in to theatre.
The patient is brought through into the operating room. I make sure that I have a constant grip on the tube during patient transfer, my nightmare is trying to deal with a misplaced tube. I reattach the tubing, turn on the oxygen and volatile. A test squeeze of the bag, reassures me that the tube is still working and so I switch to the ventilator. I recheck my monitors and settings once the time out checklist is completed.
“Are we ok to start?” asks the surgeon. Glance at the monitor, C02 trace good, blood pressure check, heart rate acceptable, oxygen sats good, MAC high enough. “Please go ahead.”
I watch carefully as the surgeon puts knife to skin. This is the test of my anaesthetic. Is my patient deep enough? My eyes swing to my monitor, looking for any sign of haemodynamic change. There are none. Second challenge met.
The anaesthesia flight has taken off and the analogy holds true. The main part of the operation is cruising from the anaesthetic point of view. Aside from the minor adjustment of volatile, gas flows and administering some IV analgesia, anti-emetic and fluids as required I can relax and complete my chart. My consultant relieves me for a break so I can grab a coffee (the lifeblood of all anaesthetists) but for remainder of the time is happy enough to leave me to it; making sure that both I and the ODP know where they are should we need any assistance.
“How much local can I use?” I’m not quite quick enough to figure this out in my head yet, but after some straight forward maths scribbled on my list I can tell the surgeon a safe dose for local anaesthetic infiltration of the surgical site. This is a signal that things are coming to a close. Time to check whether the muscle relaxant is safe to reverse. Four strong twitches. Good to go, I give the reversal agent.
I look over and they are closing the skin. I turn off the volatile, but keep my flows low. This is the bit I still find tricky, timing emergence. The final challenge. Thankfully he is starting breathe, so I turn off the ventilator.
Once the theatre assistants are starting to pull off the drapes, I take that as my cue to turn up the oxygen to encourage my patient to blow off the volatile. The patient is transferred onto a trolley, and I sit him up, watching his chest movement. All other monitoring comes off, leaving just the pulse oximeter. The rest of the theatre is tidying up, but amidst that chaos I’m watching for signs that my patient can now take over his own breathing fully again.
And it comes. First it’s a silent cough. Then a bucking. I untie the tube and suction his airway. Finally, the sign I’ve been waiting for: he reaches for his tube. “It’s ok, you are just waking up. Stick your tongue out so we can take out the tube.” The ODP deflates the cuff and I pull out the tube. I hold the Hudson mask to my ear to check the oxygen flow and then place it on his face. For the next minute I closely watch his breathing and sats. It’s regular and the sats are normal. Great, time to go to recovery.
After handing over to the recovery nurse, I congratulate myself on a successful and safe anaesthetic. In the early days, it is definitely a victory. Well, now it’s time to psych myself up for the next patient.