Tips to Excel on an Anesthesia Sub-I

Written by Crystal Joseph, MD, MS

Congratulations! You finished your third year of medical school and have decided to pursue a career in Anesthesiology. You’re getting ready to start your fourth year with your anesthesia sub-I rotation. Most medical schools do not have a robust rotation in anesthesiology during the third year, but do not fret! Many students are in a similar situation with limited exposure to anesthesia before starting their fourth year. However, there is a lot that you can do to prepare and excel these next few months. In this article, I will share some tips and resources that I found helpful to succeed on an anesthesiology rotation. 

Resources for Anesthesia:

There are many resources in anesthesiology that I found to be excellent while on my rotation. Shout out to my attendings, residents, and fellows for recommending these to me when I was beginning my sub-I rotation! Some references are more comprehensive than others, and you can choose which ones you want to use. You do not need all of them. Here are the resources listed below: 

1.   Miller’s Basics of Anesthesia: This is one of the textbooks that anesthesia residents use as a reference and for their boards (Morgan and Mikhail’s Clinical Anesthesiology is another textbook). It is very comprehensive, but it’s lengthy. You may not get through this entire book, but you can read a few sections while on your rotation!

2.   Pocket Anesthesia: This reference guide is great for quickly looking up the most relevant information that you want to briefly refresh on between cases. 

3.   Duke’s Anesthesia Secrets: Another succinct reference for you to refresh on a topic during your downtime. It is written in a question-and-answer format style. 

4.   ACCRAC Podcast: If you enjoy podcasts as I do, this one is for you! The Anesthesia and Critical Care Reviews and Commentary (known by all as ACCRAC) podcast was created by Dr. Jed Wolpaw, program director of the Johns Hopkins Anesthesiology Residency program. The goal of this podcast is for trainees to prepare for their exams and listen to diverse and interesting topics in anesthesia. I would enjoy listening to this podcast during my walk or drive to and from the hospital.

5.   Open Anesthesia: If you’re looking for an online resource, open anesthesia was recommended to me by residents and attendings. They have brief articles for all the ABA keywords, subspecialty curriculums, block of the month reviews, and more. 

6.   Stanford Ether Guide: Senior medical students and residents recommended this resource for understanding basic topics in anesthesia. This guide was created for Stanford’s CA-1 residents to prepare them for the transition to the clinical anesthesia years. The topics range from standard monitors/set up in the OR to malignant hyperthermia. 

7.   AnSo App: A resident recommended this one to me. This app is so useful when you are doing regional anesthesia or any ultrasound-guided procedures! The app provides probe positions, landmark sketches, and ultrasound pictures with labels of structures that you are looking for when doing a specific nerve block. Also, it is helpful to see ultrasound images of vascular access and airways, echo views, and lung signs. ***NYSORA (a prominent and leading organization in regional anesthesia) also has an app for regional nerve blocks!

Anesthesia rotations do not expect you to be an expert in the field, so do not feel obligated to go through all these resources! They know that you are a medical student and understand that this rotation is your introduction to the field. Having some basic knowledge will help you to shine on the rotation. As long as you are interested and enthusiastic about learning, they will enjoy having you!

During your anesthesia rotation, some important points will set you up for success: 

Be prepared

Be familiar with common anesthetic procedures. The rotation will provide you with many opportunities to perform different procedures. Common procedures to be familiar with are intubations, IV insertions, NG or OG tube insertions, and arterial line placements. You should understand the steps involved and watch relevant videos to familiarize yourself with the process. You are not expected to be a pro at these procedures but take advantage of the opportunities to try. The more you practice, the more comfortable you will be. 

Before you start your rotation, try to become familiar with an anesthetic preoperative evaluation and physical exam. Preoperative evaluation is covered in many of the resources I mentioned above. Other topics that you should learn about are the difficult airway algorithm, rapid sequence intubation, basic cardiac and pulmonary physiology, and OR pharmacology (indications, mechanism of action, and side effects of common medications used). 

If you are assigned to an OR room the day before or know your cases beforehand, read up on the patient and case. Understand the indication for the procedure, pertinent history, and anesthetic considerations for their surgery. You will not only be able to answer questions but also ask insightful ones that will help you to learn even more. 

You should also know who your attending and residents are so that you can introduce yourself once you see them. Communicate with them and ask when it is best to meet with them in the morning. 

During your clerkship, you should take opportunities to work with a variety of people and on different cases. While on the rotation, you should try to also work with the same attending and resident for some time. Continuously working with the same attending and resident will help you build a rapport with them. It also gives them the chance to see your skills and help you hone them. Procedural skills such as intubating, putting a nasogastric tube, inserting an arterial line, and inserting an IV are hands-on skills that take time and practice. However, working with an attending for at least a few days will allow them to become comfortable and trust your skills. 

Arrive early

You should find out the OR start time so you can come earlier to help set up the room, introduce yourself and evaluate your patient, and discuss your anesthetic plan with your attending and resident. They don’t expect you to have a comprehensive plan, but they do expect you to introduce yourself, see the patient, and complete a basic preoperative evaluation. 

Before the patient is brought back to the OR, everything should be ready. This means checking the monitors, ventilator, anesthesia cart, and anesthesia machine. You may find this part intimidating since anesthesia equipment is foreign to most medical students. But that’s ok! You will learn this when helping the attending or resident set up the room. Also, the MSMAIDS mnemonic will be most useful for setting up the OR. Here’s a link from UT Health breaking this mnemonic down: https://www.youtube.com/watch?v=oXn0wqGB6So.

Introduce Yourself

It is important to introduce yourself to everyone in the operating room. The anesthesia team, surgical team, circulating nurses, scrub techs, and other medical students. This way, every team member knows who you are and your role. 

Taking Initiative in the OR

It is tough in the beginning to understand perioperative flow and dynamics, especially when it is the first time on the anesthesia side. The best way to be helpful is to be cognizant and understand when and how you can help out, which will take some time as you get used to the flow. Having situational awareness is important so that you do not interrupt when things get stressful and critical. However, there are many ways in which you can be helpful to your anesthesia team! Be proactive, and ask in advance how you can help the team. Over time, you will gain experience and learn how to better assist. Every anesthesia provider will have a different level of comfort in letting you do things, so it is important to ask first. Drawing up medications, priming IV bags, helping to transfer a patient, getting warm blankets, setting up the Bair Hugger if needed, placing the EKG leads and blood pressure cuff, and putting on the temperature probe or pulse oximetry are ways in which you can help. 

Ask questions when you see that everything is situated. Induction and extubation are critical times so be wary of asking questions during these points of the procedure. Eventually, there will be some time when you can speak with the attending or resident. 

Being vigilant is a vital trait in anesthesia. Attentiveness and raising your concerns to your attending or resident show that you are taking initiative in caring for your patient. From the time of induction to extubation, you should monitor the patient. What are their vital signs? Are they making adequate urine output? What is the fluid status? Is their positioning still ok? Share your observations with the anesthesia team and discuss your concerns. 

Be adaptable

This is a wonderful trait to have as a budding anesthesiologist! Things may not go perfectly during a case or for that day, but you need to be flexible. Adapting to rapid changes in the OR and different personalities on the team is an important skill to have. Everyone will also have different techniques and ways to approach the anesthetic management. A great perspective is to adapt to each provider’s approach so that at the end of your rotation, you have a versatile set of skills. 

Take ownership

You should take ownership of each case you are involved in. If you were there at the beginning, be there at the end. Your attending or resident sometimes will give you a break during the case or see other cases during downtime. However, you should return to the room before the case ends so you can be involved with the extubation process and help transfer the patient to the post-anesthesia care unit (PACU). 

Faculty, Residents, and Fellows

These are your future colleagues, and they can be great mentors and teachers! You never know when a resident, fellow, or attending can help and advocate for you. They can help answer questions about the residency program, give great advice as you progress through the cycle, provide leadership, research, or other opportunities for you later on, and if you shine on your rotation, they can write a strong letter of recommendation on your behalf. Take the time to build strong relationships with the people you interact closely with. During your cases, spend your downtime speaking and connecting with them. You may gain potential mentors after you finish your rotation.

Request feedback

If you don’t explicitly ask for feedback, you may not get the chance to identify weaknesses and address them. Ask for feedback regularly to learn where you can improve. If there is something you wish to work on, ask your resident or attending to review examples with you so you can do it better next time. Feedback is the best way for you to gain insight into your progress and improve as a trainee. 

Last but not least, have fun and enjoy the rotation! The goal is to learn the basics of anesthesia and gain exposure to the field. If there is an affiliated residency program, then this is also a great opportunity to see if the program is a good fit. Be yourself. People want to get to know you and your passions. Be kind to everyone you interact with throughout your rotation. It is important to be a good team player in the OR. Anesthesiologists are a great group of people who are friendly and easy to work with, so you will have a blast!