Anesthesiology Resident Reflection and Perspectives

Intern year got off to a great start on my first rotation in the Emergency Department. I have to admit, I was a little nervous beginning intern year in the ED during a pandemic; however, I could not have found a more prepared, supportive and encouraging atmosphere! Each ED shift (which is a very doable 8 hours!) has you working closely with one attending, one to two upper levels and generally another intern (usually from EM). 

Overall, I found the sense of camaraderie in the ED very uplifting and even fun. Although you are an off-service intern, I was always treated with respect and value, just as an EM intern. Also, if I ever needed help, an upper level was never far. I was able to run questions, differentials and plans by the upper level prior to staffing with the attending. Also, I can't forget the fantastic ED nurses who certainly had my back when I needed help! As a quick side note, I had placed IVs before, but I definitely learned some new tips from the ED nurses who let me practice! Now, being a few more rotations into intern year, I am truly glad for the friends I made in the ED as we frequently cross paths.

Some memorable patients that I took care of included a submassive PE (my very first patient of intern year!), radiation-induced pericarditis, ARDS, and GI bleeds. I also got some great procedural practice with lac repairs, I&Ds, a foreign body removal, and a paracentesis in the ED. It was a fantastic way to start intern year, and after I completed my shifts and any outstanding charting, I had ample downtime which allowed me to enjoy exploring Winston by going running at Reynolda Gardens or hiking outside the city. 

I started my intern year on the hematology-oncology service. To be honest, when I got my final schedule I was not looking forward to that first month. This was mostly because as a medical student I had tried to avoid all of the cancer services and their intimidating treatment regimens. So when I was assigned this rotation, I felt very unprepared to care for the patients. Having been through the rotation now, however, I can say without hesitation that it was a great experience!

First off, all of the residents, fellows, nurses, and attendings that I worked with were extremely helpful. We all had a lot of fun getting to know one another, and the attendings provided a lot of opportunities for autonomy when it came to the day-to-day patient care. That being said, it was also very easy to ask questions and get help when it was needed. Secondly, when you are on this service you don't actually have to know all of the details of cancer treatments. Essentially, you are managing the patient's various medical problems - such as PEs/DVTs, diabetes, hypertension, chronic pain, etc. - while the fellows and attendings manage the cancer. Despite this, I also felt like I did gain a lot of important information relating to specific cancer presentations and chemotherapy drugs. I also learned a lot about some of the complications associated with various forms of cancers and their treatments. 

On this rotation you will become very comfortable with managing patient pain and related symptoms. I had only a tentative idea about pain regimens before starting this rotation but quickly learned when to escalate or de-escalate therapy, as well as how to manage some of the side effects of certain pain medications. In addition to pain control, you will also get a lot of exposure to palliative/hospice care and learn how to have difficult conversations with patients and their families. This can be tough at times, but overall it was a very beneficial and rewarding experience to help patients come to terms with their new cancer diagnoses or the progression of an existing cancer. Learning to deal with these types of difficult situations as an intern is going to be extremely valuable as I progress through my residency training. 

Each day kicked off at 6 am with a "sign out" from the night resident about what happened overnight. Then a full day of medical management, patient interaction, procedures, focused teaching and more began. 

The rounding team consists of two to three interns, one Internal Medicine or Emergency Medicine upper level, a Critical Care fellow, and an attending. The camaraderie between residents and staff is fantastic. It's always an added bonus when the attending brings in Krispy Kreme doughnuts, which I found out was founded in Winston-Salem! 

Ultrasound guided IVs and other procedures, like arterial lines, were one of my favorite parts about the month. Learning and becoming more comfortable with vent management was another highlight. The MICU rotation is certainly a pertinent rotation for us as anesthesia interns because we get to learn about procedures, vent management, and other aspects of critical care.

I feel that the Pain Medicine rotation is a perfect example of how Wake strives to continually improve upon its intern year curriculum. This rotation was originally available to only a portion of the class, but because of its popularity and educational value, every intern now has the opportunity to rotate through the pain clinic. I appreciated being exposed to this branch of anesthesiology early on in my career, and look forward to doing a second chronic pain rotation during residency as well.

The entire month is spent at a pain clinic in Winston-Salem, which is a nice escape from the typical hospital routine. I arrived at clinic around 8AM, and the final patient was typically scheduled for 4:30PM. I found excellent day-to-day variety within the clinic. The days consisted of seeing patients for follow-up visits and medication refills, meeting new clinic patients, performing bedside injections, and learning how to do nerve blocks under fluoroscopy. The pain fellows were excellent teachers and were enthusiastic about explaining the anatomy and techniques they utilized for every procedure. As the month progressed, I gained hands-on experience and was able to perform midline and transforaminal epidurals, medial branch blocks, SI joint injections, and hip joint injections under fluoroscopy with the guidance of the pain team. I was given a comprehensive pain medicine textbook, which helped explain different treatment modalities and will become a valuable resource when preparing for the anesthesiology boards. I also learned about the pharmacology of narcotics, membrane stabilizers, and other medications that I will commonly encounter in practice.

The fellows and attending physicians in the pain clinic were approachable and kind, and were willing to be mentors for individuals interested in pursuing a pain fellowship. The pain fellows were impressed that our residency program allowed for such early exposure to this specialized field, and were envious of our opportunities as first year residents. We were a welcomed presence at the pain clinic, since we helped to efficiently manage and treat patients in a high-volume, face-paced setting. We were treated with the same kindness and respect as the fellows, and were considered to be vital members of the care team.

This rotation was definitely a highlight of my intern year, and I look forward to learning more about the field during the remainder of my residency at Wake.

Pain clinic is a relatively new rotation to the intern year and, for good reason, has rapidly become a fan favorite amongst many of my anesthesia colleagues. Our pain clinic provides residents with a significant amount of clinical and procedural learning as well as a great work-life balance.

The Work: pain clinic is a refreshing change of pace from grind of our inpatient services. Clinic starts at 8 am each day, and ends at about 5 pm. Interns work alongside 1-2 fellows. The fellows are great to work with and are always willing to teach and assist with procedures. The typical day is spent doing patient office visits as well as a variety of procedures interspersed throughout the day, including procedures under fluoroscopy.

The Learning: beyond its great schedule, pain clinic is a good month to gain comfort with pain medication strategies, interventions, and coping mechanisms. Attending physicians, Dr. Ajam and Dr. Kapural are eager and enthusiastic teachers. Additionally, Dr. Kapural has many research projects/abstracts for anyone with an interest in pain management as a career path. I got to perform and observe many procedures under supervision. During my month I did multiple lumbar medial branch nerve blocks, SI joint injections, epidural spinal injections, and an assortment of trigger point injections.

The Lifestyle: with its relatively relaxed schedule, clinic month is a good time to get back into hobbies, travel, and spend time with family and friends.

Welcome to Wake Forest Department of Anesthesiology. One of the things that attracted me most to this program was how invested the administration is in our education. One way this is demonstrated is in the organization of our intern year. Each rotation is deliberately chosen for its usefulness to our future careers as anesthesiologists. In this way it feels as though we begin our anesthesia training well before our CA1 year.

For example, recently I completed a rotation in electrophysiology (EP) consults. On this rotation I worked alongside a first year cardiology fellow to see the most interesting arrythmia patients in the hospital. Often this included managing persistent afib/flutter, high degree AV block, ventricular arrhythmias and many undifferentiated patients with mutliple cardiac issues. I had daily one-on-one teaching from EP attendings on advanced EKG and rhythm strip interpretation. I was able to assist in new patient workup and management as well as device interrogations. It was clear that I was respected as a valuable member of the team and by the end of the rotation was looked to for my opinion when deciding course of action. Whether it is working with patients with ICDs, chronic arrythmias, or a new arrhythmia, it is essential that we develop a comfort with diagnosing and managing these patients. Wake Forest has identified the areas of medicine which are crucial to our success and has integrated them into our training program. By doing this, we are not just "getting through intern year," but rather we begin our training as anesthesiologists as soon as we arrive on day 1. I hope you consider Wake Forest for your future training in Anesthesiology.

When you first hear of a rotation in the blood bank, you may be confused about what you could possibly do for two weeks. There are, in fact, many important learning points in the blood bank rotation. Anesthesiologists are in a unique position in the operating room: we place and fulfill our own orders. We're all familiar (or at least becoming so) with administering drugs, but administering blood products is quite different and can be an anxiety provoking process.

Understanding blood product processing, matching, and administration is a foundational skill that benefits us in the OR. The intern rotation in the blood bank is a worthwhile introduction to the tenets of typing and crossmatching blood, transfusion reactions, and risks of blood product administration. Dr. Fadeyi, the medical director of the blood bank at the hospital, sat with me daily during my two week rotation and gave me personal lectures on the basics. The one-on-one conversation was low-key and extremely helpful. We also reviewed each blood product reaction in the hospital to determine if it was truly a reaction to the blood product and if it can be prevented in the future. Importantly, I became more familiar with common (and not so common) transfusion reactions, what causes them, potential sequelae, and tenets of treatment.

The second two weeks of this block are spent doing pulmonary consults. Obviously seeing--often severe--pulmonary pathology is valuable to us as future anesthesiologists; however, we are also able to see a good amount of airway anatomy (some of it quite unique) in the bronchoscopy suite. I was even able to drive the bronchoscope a number of times, and believe me, if you can get a bronchoscope through the vocal cords in a breathing, coughing, sometimes talking patient, a fiberoptic intubation in the OR will be a piece of cake!

While there is a vast wealth of useful clinical information gleaned during this four-week block, another fantastic benefit is the relatively relaxed schedule and weekends off. It's a great time to study for and take USMLE Step 3, spend time doing things you enjoy, or take a weekend getaway. Definitely take advantage of the free time on this rotation!

The anesthesiology categorical intern year here at Wake Forest is the total package. The experience provides ample opportunity to acquire necessary knowledge that will be the foundation for learning during the clinical anesthesia years, while at the same time being a manageable experience that does not overwhelm. The intern year is composed of two surgical rotations (ENT and Vascular), Cardiology, Arrythmia, MICU, Blood Bank/Pulm Consults, NICU, Pediatrics, Emergency Medicine, OBGYN, General Med C, and Hem-Onc.

Early in the intern year, my suspicions were confirmed, I am not a morning person. At least, I did not start internship as a morning person, but it gradually grew on me. Mornings on ENT began at 5:30. The list was prepared and “Lightning Rounds” began at 6:00 where the other intern and I split up and put the orders in, helped write the morning notes, and wrote down things to be done later in the day. At breakfast, the list was run, discharges were planned, and the day began to slow down significantly. Then, it was back up to the floor to finish up notes and work for the day, which was typically finished by 10:00 or 11:00am.

The advantage of the ENT rotation is the flexibility inherently provided by the daily schedule. As the majority of work is done early in the day, this frees up the time to see a tremendous amount of airway anatomy. For example, on Mondays and Wednesdays, there exists the opportunity of going to clinic in the afternoon to shadow one of our laryngologists who scope almost every one of the fifteen patients they see in a half day. While there is plenty of normal anatomy to be seen, there is also plenty of pathology to be seen, including laryngeal papillomas, vocal cord paralysis, and laryngoceles to name a few. I should also mention that, while never required during the rotation, venturing down to the operating room also provided great learning experiences. I was able to observe and participate in tracheostomies, observe nasal and oral fiberoptic intubations, and again to see both normal and very abnormal airway anatomy.

What was your deciding factor for choosing Wake Forest School of Medicine?

The two aspects of the program that I held in high regard were the post-graduation plans of the residents and the overall culture of the program. Residents consistently match into strong programs within competitive subspecialties of anesthesia, and those who choose private practice secured excellent jobs in their location of choice all across the country. I felt that this spoke both to the quality of training and mentorship received at Wake Forest as well as the fact that Wake graduates are held in high regard both regionally and nationally. Further, it was abundantly clear that the residents got along well and enjoyed spending time with each other, and that attendings knew the residents well and had a vested interest in them not only as anesthesiology trainees but also as individuals. I felt that the culture within the program lent itself to an ideal training environment, and fortunately I have found this to be the case.

What’s unique/or what you like most about living in Winston-Salem?

Winston-Salem and Wake Forest offer a combination that I truly believe cannot be found anywhere else in the country. In Ardmore and West End, Winston offers local neighborhoods that are safe and affordable with good quality homes and apartments - all within minutes of a hospital that is a tertiary care, level 1 trauma center. As a frame of reference, it takes me longer to walk from my OR for the day to the outside of the hospital than it does to actually drive from the hospital back to my house.

For those who prefer more of a city feel, there are a number of very nice apartments and town homes in downtown Winston surrounded by restaurants, bars, breweries, and in close proximity to the UNC School of the Arts. If you prefer to have a little more distance from the hospital, Clemmons and Kernersville are suburbs roughly 15 minutes from Winston that are quite popular among residents and faculty. There are numerous options for outdoor activities such as hiking, rock climbing, fishing, and kayaking both locally and within a short drive. Charlotte, Asheville, and the beach are all within driving distance, making for ideal weekend road trip venues.

Reflections from CA-2 Year 

Why did you choose anesthesiology as a career path?

I chose anesthesiology as I enjoy the immediacy of making a diagnosis and fixing a problem by manipulating a patient's physiology. With my background in mechanical engineering, the practice anesthesia and study of human physiology were areas that were a natural fit.

What was your deciding factor for choosing Wake Forest School of Medicine for your residency?

I chose Wake Forest because I felt that in addition to unparalleled clinical training, the residents and faculty were great people that I would enjoy spending the next 4 years of my life with.

List two aspects that make Anesthesiology at Wake a unique educational experience.

One of the most unique aspects about training here at Wake is our experience with airway management. Not only do we get training in almost every ancillary airway device and technique, but we have faculty that train others nationally on the use of airway blocks and awake intubation. This allows us to routinely perform awake intubations extremely quickly and smoothly.

Another unique aspect of the training here is the approachability of attendings. I am an avid cyclist and race/train with many of my attendings on a regular basis.

What has been the biggest surprise about your residency?

The biggest surprise about residency is how much I love going to work every day. Some days are better than others, but overall I am truly excited to be able to learn and practice anesthesia here on daily basis.

What is unique about living in Winston-Salem?

Winston is a great place to live. It offers everything you need when it comes to outdoor activities. The mountains are only 1.5 hrs away and the beach not much further.

What are your career goals?

I hope to pursue fellowship training and possibly pursue a career in academics.

Do you feel your Wake training is preparing you to meet your career goals?

Yes! Not only are research interests supported but the clinical training is very strong. I think that after finishing here I will be equally prepared to either enter the world of academics or private practice.