Nancy Brock DVM
Diplomate American College of Veterinary Anesthesia and Analgesia
These days, I focus most of my professional time teaching/mentoring doctors and technicians who want to become efficient and skilled (safe) anesthetists. I have tried to pinpoint what makes a skilled anesthetist and how best to develop robust anesthesia skills short of completing residency training in anesthesia. Not everyone wants to undertake such extensive training. Nor do I think it necessary to take that path in order to deliver effective anesthesia.
Are good anesthetists born or made? I believe they are made. So, for those of you who aspire to excellence in anesthesia, here is some food for thought from an anesthesiologist who has spent the last 40 years in the trenches:
Some people describe anesthesia delivery as 99% stifling boredom and 1% sheer unadulterated panic. It has never been that way for me: Anesthesia fascinates me: It is such a dynamic process, never boring (for better or for worse), a blending of applied anatomy, physiology and pharmacology. I marvel at the anesthesia process and how it allows us to help our patients regain quality of life. Not that weird, unwanted or unexpected things don’t happen during anesthesia delivery but they seldom catch me completely by surprise.
Ongoing learning in anesthesia requires seeing every patient as your teacher and honing your powers of observation.
Our patients as teachers
Healthy and compromised patients each have something different to teach us. Patients with underlying disease present the challenge of drug response variability and unpredictability whereas healthy patients can be excellent teachers in what is “normal”. You have to be familiar with “normal” before you can reliably differentiate it from what is slightly abnormal (but still within the realm of the expected) from very abnormal or potentially dangerous.
When you pay close attention to your patients (awake, then premedicated, then asleep, then waking up), you begin to appreciate how animals are unique in terms of their response to drugs in subtle (and sometimes not so subtle) ways. Become familiar with this range of responses. That way, your patients won’t catch you unprepared. This is how I avoid the 1% sheer unadulterated panic.
Surgery can be “routine” but I am careful not to use that term when describing anesthesia. I prefer the term “uneventful," and then only AFTER my patient is fully awake, never in advance.
Honing your powers of observation
As you embrace your patients as your teachers and start to pay close attention to them, be sure to ask questions when you observe anything out of the ordinary. You may need to dig and ask around to get a clear understanding of what you are witnessing but it is worth the effort. We learn most from abnormal situations IMO.
It is also useful to undertake regular team discussions to review any and all adverse per-operative events. Such discussions help you identify patterns in the unwanted events and help you choose the proper corrective measures.
I have found that posting to the VIN community’s anesthesia message board can be extremely helpful as a learning tool. There is never a shortage of opinions and perspectives as well as thoughtful and considerate responses/explanations from the anesthesia experts as well as seasoned practitioners.
A goal of 0% morbidity and mortality in anesthesia
Along with the commitment to learning from each case that does not go as planned, aiming to completely eliminate adverse anesthesia related events is a very worthwhile goal. It is unachievable but striving for it is what’s important.
As you continue your journey, you will find that changing your anesthesia drug protocols is often not the key to eliminating problems or improving anesthesia safety. Anesthesia delivery has many moving parts that all need to function well in order to avoid problems. Drug selection plays a role in anesthesia success but it is not as important as you might think.
Time and cases
Practice, practice, practice. It works miracles. Give yourself time. Find a mentor. Learn from your inevitable mistakes and don’t beat yourself up when they happen. We are all only human. Developing mastery and control in anesthesia is a slow somewhat humbling process that cannot be rushed. The necessary skills are developed one patient at a time.
Also, welcome challenging opportunities to deliver anesthesia under novel conditions. Even after 40 years, I continue to seek out such opportunities and have been fortunate to work in aquarium facilities, MRI centers, in teaching hospitals as well as private facilities. In each environment, I have learned important lessons.
To my DVM colleagues
Your technicians look to you as their resource when cases are not going as planned or when they observe something that they can’t explain. Encourage their curiosity and inquisitiveness. If you don’t know the answer to their questions, find someone who does. Together you will both learn.
Nurture the skills of your budding anesthetists by giving them permission to attend fully to their anesthesia responsibilities without having to multi task, especially while their patient is unconscious. Anesthesia monitoring is an introspective process so that often times the anesthetist looks like they are not doing anything. But they are — they are focussed, paying close attention and learning. This focus is how they avoid missing early signs of a problem.
To my RVT/AHT colleagues:
We veterinarians cannot do our work without your help and skills especially in anesthesia. It is well worth your time and effort to sharpen these skills. Your patients will thank you, not in words but by returning home safely after surgical procedures and thriving. I have learned much from you over the years.