Anesthesiology Residency and Fellowships

2014-2015 Chief Residents - Story

As chiefs we remember from our own search for the perfect residency how difficult it is to imagine your life and training as a resident at each program. We decided the most useful way to illustrate what your training and life at Penn would be like is to walk you through a day in the life of a resident. Below is a play-by-play description of my most recent call, which happened to be a Thursday before my vacation.

I arrived at work at 6:00 AM to set up for a transcatheter aortic valve replacement (TAVR) in an 82 year-old woman with critical aortic stenosis. Thursdays are our education days, so after setting up my room I headed for breakfast and grand rounds, which was given by our program director, Bob Gaiser, one of the most effective teachers and masterful clinicians you will ever meet. At 8:30 I brought my patient to the room, placed a central line, floated a pulmonary artery catheter, and guided her safely through a fortunately uneventful valvuloplasty and deployment of a new aortic valve.

My next case was a laparoscopic hysterectomy in a 42 year-old with a destination therapy left ventricular assist device, depressed right ventricular function, pulmonary hypertension, morbid obesity, and an INR of 2.1. Her arterial line was challenging given her weak pulse, and large body habitus, but with the coaching of my critical care and cardiothoracic trained attending and cardiac fellow, I had her successfully lined up within 10 minutes.  The attending and fellow took turns discussing the intricacies of managing this complex patient, using my management of her blood loss, fluid shifts, tenuous right ventricular function, coagulopathy, and hemodynamic challenges of increased intra-abdominal pressures as teaching opportunities to hone my critical thinking and review relevant current literature.

At 5pm I finished my case and began my first call responsibilities for the night. My role shifted from that of a senior resident to a pseudo attending.  As first-call you get to supervise your call team, helping them think critically about their cases, and assisting them during the crucial parts of their cases. I chose Penn because I believed that we only train once and should aim to get the best clinical training possible. It wasn’t until I started taking first call and saw how competent my fellow residents were, that I appreciated how fortunate I was to have chosen Penn.

As a call team our first case was an 82 year-old with a humerus and hip fracture, severe pulmonary hypertension, CHF, systolic anterior motion of the mitral valve (SAM), and COPD. This was a perfect case for a new CA2 who had already logged over 60 cardiopulmonary bypass cases and cared for countless orthopedic trauma patients. She managed the patient brilliantly, titrating her anesthetic to protect the patient’s precarious cardiac and pulmonary function.

Shortly after starting this case my other CA2 call resident was ready to extubate her ENT patient.  Her patient was waking up, following commands, and taking large tidal volume breaths on command.  She extubated the trachea and disconnected the patient’s pulse oximeter while we lifted the patient onto his stretcher.  When we reconnected the pulse oximeter on the stretcher it read 89%.  The patient was no longer following commands.  My new CA2 resident quickly attempt to ventilate the patient, recognized that she was fighting a closed glottis, and broke the patient’s laryngospam with positive pressure and a small dose of propofol.   The patient was then transported uneventfully to the PACU.

At 2 AM our team was called to the OR for a stat craniotomy in a patient with a bleeding brain tumor, a case where time is the health of the brain and every second counts. The patient arrived in the OR within minutes giving us little time to prepare.  We worked seamlessly together as though we had rehearsed this scenario several times before.  We had the patient ready for pinning and draping with large IVs, an arterial line, an endotracheal tube, and a total intravenous anesthetic running within 7 minutes.  Watching my two CA2 residents I wondered, “How did they get this good so quickly?”  The answer is that as CA1s, Penn anesthesia residents spend most of the year in the main ORs taking care of a high volume of high acuity patients with world-class attendings and phenomenal intraoperative teaching in addition to a newly implemented didactic series focusing on the CA-1 residents.  It is a hard working year, and the pay off is enormous.  This 2am stat craniotomy showcased the exceptional skills, judgment, and teamwork that were seemingly second nature to these two residents who were only 10 weeks into their second year of anesthesia.

By 6:30 AM my call team was ready for another round of hot coffee and breakfast, this time for a lecture led by our chair, Lee Fleisher, who facilitated a complex case presentation by a senior resident on a patient with non-ischemic cardiomyopathy, intermittent ventricular tachycardia, and tracheal stenosis undergoing a tracheal resection.  This small-group, optional, didactic session, known as “First Fridays with Fleisher,” is a popular, highly interactive conference with teaching points appropriate for residents of all levels.  When I was looking for a residency, one of the unique highlights of Penn was meeting a chair that was as dedicated to resident education as the program director.  He is currently pioneering a leadership training program, recruiting high profile, interdisciplinary experts in leadership development from across the country to help us become the most effective and responsible leaders possible in the rapidly evolving world of medicine.

Come 7 AM, my team and I were finished, and I was off for a week long beach vacation with two best friends that I met during my Penn anesthesia residency, one who was a year ahead of me and the other who is a year behind me. 

The take homes of this play-by-play are as follows:  Learning anesthesia at Penn is like learning how to ski on the steepest slopes with the deepest powder.  It is made possible by the high acuity of our patient population, and the attendings, program director, and chair who dedicate their lives to training the future leaders of our specialty.  Anesthesia can be a singular residency experience, but at Penn it’s a team sport.  We learn from each other, take care of one another, and build life-long friendships.

Are we happy? I have ski patrolled in Colorado, river guided in Nepal and the Grand Canyon, helped start a school in the Himalayan Kingdom of Bhutan, and can still say that my time as a Penn anesthesia resident has been the highest yield and most rewarding experience of my life.  We work hard, we have fun, and we are happy.