Figure 1.1
Key milestones on the road to the match (Figure Courtesy J. Ehrenfeld)
As with most specialties, applicants must use the ERAS system , whether applying for PGY1 or PGY2 positions. All programs formed as of 2008 must have an integrated internship (predominately medicine, surgery, and critical care), and chances are that all programs will move in this direction eventually. Couples matching is supported, and there is no early match system.
Program directors take personal statements, Dean’s letters, class ranking, grades, and letters of recommendation into account as well as considerations such as geography and medical school reputation, but most will use the step-1 score as an initial screening tool. Most have hundreds of applicants to consider, and generally will interview ~10 candidates per position available, making the selection process complicated.
Although there is no official “cut-off” of USMLE score for prospective residents, given the current competitive nature of the anesthesiology match, many programs have set USMLE step-1 score limits for granting interviews, often in the 200–230 range (national average for interview threshold, for those programs having such a threshold, was 208 in 2012, and average step-1 score of successfully matched students was 222). In general, once you’ve made it to the interview stage, step-1 scores become less important.
Programs may sometimes give priority to students from their own hospital system, or at least to students who have rotated with them. As a student, try to get as much “face time” as possible during your 3rd and 4th years with the programs in which you are interested. Having personal experience in a department can be a great way to gain an advantage over competing candidates and can make up for less-than-impressive test scores.
A Typical General Anesthesia Case
Although the anesthesiologist needs to consider various patient and procedure factors when administering anesthesia care for a patient, there are some routine actions that are commonly performed in the pre-op holding area, in the operating room, and in the recovery room (PACU) during a typical general anesthetic. Figure 1.2 outlines the phases of a typical general anesthetic case.
Figure 1.2
Phases of a typical general anesthesia case (Figure Courtesy J. Ehrenfeld)
Now, let us discuss the flow of a routine general anesthetic:
Josh is a 33-year-old man with cholecystitis who needs his gallbladder removed.
Preoperative Evaluation
Unlike the standard internal medicine history and physical, ours is much more focused, with specific attention being paid to the airway and to organ systems that are at a potential risk for anesthetic complications. The type of operation and the type of anesthetic will also help us focus our evaluation. Prior problems with anesthesia are noted, and physical exam should focus on the heart, lung, and airway (to assess ease of intubation). Josh has a history of hypothyroidism, but takes his medications and recent TSH values are normal. He has no drug allergies, has a good mouth opening, excellent neck extension/flexion, and good dentition. He had an appendectomy 10 years ago, and reports no problems other than postoperative nausea.
Sedation
Although many patients appear to be cool, calm, and collected, anxiety about surgery (as well as pain, prognosis, and being naked in front of strangers) is high and understandably common. We frequently sedate patients with midazolam (a benzodiazepine) and/or fentanyl (an opioid) prior to travel to the OR, with the goal of achieving sedation, amnesia (although this is not predictable), while maintaining normal breathing and airway protective reflexes.
Josh seems relaxed, but his palms are sweaty and his resting heart rate is 90 bpm. Administering 2 mg of midazolam has calmed him right down, and he jokingly asks if he can have it for his kids as he giggles his way into the OR.
Monitoring
Standard required intraoperative monitoring (general, regional, or sedation) includes continuous ECG, blood pressure (at least every 5 min), continuous pulse oximetry, and capnography in cases of intubation. Additional monitors may include temperature, invasive blood pressure (arterial line), central venous pressure, pulmonary artery, TEE (transesophageal echocardiography), and processed EEG (electroencephalography) monitoring, all at the discretion of the provider and guided by the patient’s health status and type of procedure. Given Josh’s good health and the minimally invasive nature of his operation, no monitoring beyond the minimal standard is required.
Induction and Intubation
Following preoxygenation, general anesthesia is induced with a variety of hypnotic and paralytic medications. Propofol is the most widely used induction agent today, with rapid and predictable loss of consciousness in about 20 s, amnesia, and depression of airway reflexes. Other agents include thiopental (a barbiturate), ketamine, which is reserved for those needing a sympathetic boost (e.g. trauma patients), and etomidate, which has minimal cardiac depressant properties and is typically reserved for patients with heart failure or shock. Paralytics come in two flavors: depolarizing and nondepolarizing – with succinylcholine being the only available example of the former. Succinylcholine produces the most rapid paralysis (45 s), but can be associated with hyperkalemia, malignant hyperthermia, and muscle pain. The nondepolarizers are slower and longer acting, but are the most predominantly used agents (vecuronium, rocuronium, cisatracurium, and less frequently pancuronium), with each agent having its own unique advantages and disadvantages.
Intubation is performed following preoxygenation, loss of consciousness, and onset of paralysis using a rigid laryngoscope and a plastic endotracheal tube. The actual mechanics of intubation are much better taught on actual patients, and will not be discussed here, but suffice it to say that the more intubations you do, the better you get, and the tube will either make it into the right hole (trachea), or the wrong hole (esophagus). The key to success is rapidly determining which it is, and correcting a mistake quickly. A number of alternate airway techniques are available, including awake fiberoptic techniques, laryngeal masks, indirect visualization devices such as the Glidescope & McGrath video laryngoscopes, and blind techniques such as the Light Wand.
Josh has a normal-appearing airway, is otherwise pretty healthy, and his operation requires approximately 1 h of paralysis to ensure appropriate abdominal relaxation for pneumoperitoneum (gas insufflation of the abdomen). We will perform a typical induction using propofol (2 mg/kg) and rocuronium (0.6 mg/kg) and intubate him using a Macintosh 3 blade and a 7.5-mm endotracheal tube. We will confirm tube placement by visualizing chest rise, “misting of the tube”, checking for end-tidal (exhaled) CO2, and listening for bilateral breath sounds.
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