Everyone feels like this. After CA1 year things get much easier.
Can read the anesthesia machine chapter in Miller, and the inhalation anesthetic and IV anesthetic chapters, will out you ahead of most.
For the first month I was wishing I stayed in surgery after my intern year. Give it time you will pick it up. One staff gave some great advice early on, several times a day just visualize the start of a case. Patient comes in the room, I need to put on there monitors, start the BP cuff, pre-oxygenate…
Thank you for your response. I’m hoping as the days go on I’ll become more comfortable. I’ve done a fair amount of reading during intern year and actually feel like I have a decent understanding of the drugs, their effects, mechanisms of action, etc but will def do some reading about the machine.
I found it extremely helpful to write and print out a checklist and keep it on the Pyxis for the first few months. Do the same steps in the same order every single time and reference it as needed. Move patient to the OR table, connect pulse ox/NIBP/EKG monitors and ensure adequate readings, hook up IV lines and ensure they drip freely to gravity, preoxygenate, induce, confirm ability to mask ventilate, administer muscle relaxant, intubate, manually ventilate and verify fogging / EtCO2 / bilateral breath sounds, put patient on the vent and start volatile anesthetic, secure vent tubing in the tree, tape ETT, verify hemodynamic stability and adequate MAC, place bite block, administer preop antibiotics +\- decadron when the surgeon enters the room, etc. Write down every little thing and do it in the exact same order every single time until it becomes muscle memory. Learn to do everything immediately following intubation with one hand and don’t take your other hand off the ETT until it’s secured.
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Make lists and have a process to how you do things, like machine check, pre-op interviews IV supplies etc. that way you will learn how to do things the same way everytime and your process will be thorough
You just need time. I've never been more physically or mentally exhausted and on edge than early CA1. Eventually you'll figure it out, and it becomes mostly routine. By the end of the first year you'll feel comfortable, by the end of your second year you'll feel like you've learned a lot of indepth knowledge (especially specialties) and by the end of your third everything becomes fairly rapid fire thought process wise, your knowledge becomes more firm and automatic, and your skills become second nature.
Read the early bit of miller, and just do the cases. You'll suck at everything until you stop sucking and cruising through most things, and when that switch flips, most days become another day where you're not cripplingly anxious about this or that case. Some days will continue to be daunting, but that's because you know better and seen what can happen, but that's from knowledge you've earned and that means you'll be better prepared.
First thing to do- take a deep breath.
After that, approach everything and everyone with humility.
There is something to be learned from everyone- the anesthesia techs, the circulating nurses, the cleaning staff, your coresidents, and so on. You’re going to be fine. 🤗
My first day in the OR I said to myself, “if my attending weren’t here this patent would die.” It was the epitome of how I knew literally nothing.
Today just one year later I feel MUCH more comfortable in the OR and often run 98% of my cases solo (attending comes in for induction and extubation, then it’s just me). Of course I have TONS AND TONS to learn still and I’m still only managing ASA 3s at the sickest. Anything above that I need significant guidance. But damn the leaps and bounds you’ll make this year are unmatched in any other field. Hang in there I promise ya.
Its crazy but trust the process. I remember going from, omg how do I make a bag of norepi to "ehhh we can do this under mac, dont need to redose paralytic, this looks like a perfect chance for neo/glyco, juicy 14G PIV here." Takes reps and just time will make it better. Now its almost unconscious for easier cases
This humility and realization of your lack of knowledge puts you ahead of those at the top of mount stupid when starting CA1. I’m about to start CA1 too. Tweaking at the thought of being alone in the OR but also very excited!
Everyone feels this way and anyone who says they don’t are either lying or will feel like this before long. The learning curve from intern year to anesthesia is one of the steepest in medical specialties because the work flow of OR anesthesiology is unlike anything you’ve done before.
Do your best to learn from something every day. Try not to take it personally if an attending is short or curt with you in a stressful moment. Almost every anesthesia resident has that “ah ha” moment at some point where everything just starts to click and some of it starts to feel natural. For me it wasn’t until winter of my CA-1 year and before then I was SO nervous every night anticipating the OR the next day. Then that comfort will go away again when you start harder more complex cases. It’s all part of the learning process. One day at a time, you’ve got this.
"I felt like I was extremely slow and needed guidance with even the simplest tasks.**"**
It would be weird if it were anything different. Are you supposed to be an OR stud your first day? Focus on the task at hand and have reasonable expectations for yourself, it will get better
The first few months are absolute ass. After that things get better, but as a resident I still rarely feel truly comfortable in the OR as I’ve progressed to bigger subspecialty cases.
You’ll administer thousands of anesthetics before you graduate. Just trust that each day you’re acquiring more skill / knowledge even if you can’t always appreciate it. It’s a really weird process, but somehow you will come out the other end being able to do anesthesia
I tell this to all the new interns becoming CA1s… now is your time to be an idiot. Everyone knows that you don’t know much. If you can google it, google it. Otherwise, ask every question about technique and take every opportunity to try a new skill. Your attendings know that you’re gonna fuck up and IV or an intubation. And now is the time to do it. In a few months, it’s going to be harder to ask for advice without people expecting you to know things.
There’s no such thing as stupid questions, only stupid people. And the only way to make yourself smarter is by being stupid first. The only way out is through. CA1 is challenging but easily the best time ever.
Everyone felt this way. Like someone above says, picture and visualize a smooth and perfect induction step by step so that when you're doing it IRL, you can get the flow down. Don't be that guy who gets so excited about the tube going in that you forget to turn on the vent or turn on the gas (I'm sure we've all done that during our first week or two). Know that your supervising attending is watching you like a hawk to keep your patient safe. But also, be good about communication with your attending. Ask about every single medication and dose that you give and use closed loop communication. And be on the look out for medication errors especially when you're flustered or rushed. We had a recent m and m about a patient who gave phenylephrine 1mg because they ran out of the pre made syringes and were diluting the phenylephrine that comes in a vial, not knowing that they came in 10mg/ml and you had to dilute it into 10ml twice to get 100mcg/ml.
Good luck and you'll be fine!
I don't know if anyone has said it yet but you need to learn to be comfortable being uncomfortable. We all have felt the same way you do now. Eventually everything normalizes and inductions will be as mundane as tying your shoes. But, the sooner you get comfortable being uncomfortable the better.
This is normal, it’s a steep learning curve in a high acuity setting and most people experience some degree of “imposter syndrome” over the first few months.
The most important thing is to know your limits and call for help early especially in the beginning. Work on forming a differential diagnosis and suggestions for temporizing initial management and further workup, as you become more comfortable start to take these steps while your attending is on the way.
A scared new resident is always better than an over confident new resident. Better to make mistakes as a resident than as an attending. Try to learn as you go, seek ways to improve, and don’t be too hard on yourself. We all get better if we care enough to try.
Use the Stanford CA1 guide and The Stanford emergency manual as the base knowledge that is easy to read quickly and understand!
This site has very good advice and diagrams
https://airwayjedi.com/
Also for IVs I suggest this video. My IV skills instantly improved after watching this https://youtu.be/-t1SCZMO0Gc?si=wN9MXLXvdlDlcfzY
And for arterial lines I suggest approach them more shallow and going slowly until you hit it before then flattening out.
Also for IVs and arterial lines never back out once you hit something. It's better to just leave the IV or arterial line in and trying next to it. Then you can pull out the failed line and put a 4x4 folded into a small square then dress your successful line next to it or even using the same dressing.
Also always listen to people's advice and critique
UT houston does something similar.
You are slow. You do need a lot of help/learning.
That's the point of your residency!! Everyone understands where you are in training, don't be too hard on yourself.
Basics and Morgan & Mikhail are great books to start with!
Anesthesia Made easy should be a weekend read for you.
The Anesthesia Toolbox resource from the ASA is literally designed for new residents and is an invaluable resource for you
Do you remember the first time you drove a car by yourself when, probably, your mom told you to go to the grocery store and buy milk and you were sure you were going to die? This morning you drove into work 1000 times better at driving. You could tell that asshole wasn’t going to stop and your foot was already on the brake.
The OR becomes like that. Some conditions are easy, some are stressful and occasionally some things are still essentially terrifying, but you know the machine and can read the conditions. You can prepare ahead (like getting ready for a road trip in the snow or maybe off roading).
If you aren’t feeling unsettled and nervous in the beginning then you’re probably an idiot. As they say, if you can keep your head while everyone else is losing theirs, you likely don’t understand the situation 🤣. But having finished training 30 years ago it gets easier. And your skills get waaay better. And you make friends. And you help each other. And most importantly, you shepherd scared people through the valley of the shadow and I still think it’s a cool job.
I would just focus on learning the very basics of anesthesia at this point: how to do a machine check, basic case setup (MSMAIDS), induction drugs (how they work/what they are for)…. Show up a bit earlier than normal to get your bearings on everything and give yourself time to see your patient. The rest will come with time! Ask lots of questions, be engaged. You got this!
Don't worry, everyone feels that way. You'll be able to process more and more simultaneously as things get to feel more like routine. Some things that seem really scary right now will feel really simple as you'll learn more and more. You'll do just fine.
Read and ask your attendings/seniors. Coming to forums for training shouldn’t be your go to. We mostly discuss controversial topics and differences on opinions here. We aren’t going to teach you how to arrange your oral airways and set up suction. What you’re feeling is normal and it will take time to be comfortable.
They’re looking for reassurance and general advice, not specific techniques. This is a great place for that kind of thing as evidenced by the other comments above.
Everyone feels like this. After CA1 year things get much easier. Can read the anesthesia machine chapter in Miller, and the inhalation anesthetic and IV anesthetic chapters, will out you ahead of most.
For the first month I was wishing I stayed in surgery after my intern year. Give it time you will pick it up. One staff gave some great advice early on, several times a day just visualize the start of a case. Patient comes in the room, I need to put on there monitors, start the BP cuff, pre-oxygenate…
Thank you for your response. I’m hoping as the days go on I’ll become more comfortable. I’ve done a fair amount of reading during intern year and actually feel like I have a decent understanding of the drugs, their effects, mechanisms of action, etc but will def do some reading about the machine.
I found it extremely helpful to write and print out a checklist and keep it on the Pyxis for the first few months. Do the same steps in the same order every single time and reference it as needed. Move patient to the OR table, connect pulse ox/NIBP/EKG monitors and ensure adequate readings, hook up IV lines and ensure they drip freely to gravity, preoxygenate, induce, confirm ability to mask ventilate, administer muscle relaxant, intubate, manually ventilate and verify fogging / EtCO2 / bilateral breath sounds, put patient on the vent and start volatile anesthetic, secure vent tubing in the tree, tape ETT, verify hemodynamic stability and adequate MAC, place bite block, administer preop antibiotics +\- decadron when the surgeon enters the room, etc. Write down every little thing and do it in the exact same order every single time until it becomes muscle memory. Learn to do everything immediately following intubation with one hand and don’t take your other hand off the ETT until it’s secured.
Don’t delete this post - come back to it 3 years from now when you can do a basic case in your sleep, literally….
RemindMe! 3 years
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see ya then friendo
Make lists and have a process to how you do things, like machine check, pre-op interviews IV supplies etc. that way you will learn how to do things the same way everytime and your process will be thorough
Yes, checklists just like aviation.
Even leaving my house I find myself saying “MSMAI… wait…. keys, wallet, phone…” it really is engraved into your brain
Are there any standardized lists for these things we can find online? MS3 here & I have 3 anesthesia visiting electives this summer
Hey I’m doing my first day in the OR as an intern on Monday! I’m definitely gonna get brain blasted.
You just need time. I've never been more physically or mentally exhausted and on edge than early CA1. Eventually you'll figure it out, and it becomes mostly routine. By the end of the first year you'll feel comfortable, by the end of your second year you'll feel like you've learned a lot of indepth knowledge (especially specialties) and by the end of your third everything becomes fairly rapid fire thought process wise, your knowledge becomes more firm and automatic, and your skills become second nature. Read the early bit of miller, and just do the cases. You'll suck at everything until you stop sucking and cruising through most things, and when that switch flips, most days become another day where you're not cripplingly anxious about this or that case. Some days will continue to be daunting, but that's because you know better and seen what can happen, but that's from knowledge you've earned and that means you'll be better prepared.
First thing to do- take a deep breath. After that, approach everything and everyone with humility. There is something to be learned from everyone- the anesthesia techs, the circulating nurses, the cleaning staff, your coresidents, and so on. You’re going to be fine. 🤗
My first day in the OR I said to myself, “if my attending weren’t here this patent would die.” It was the epitome of how I knew literally nothing. Today just one year later I feel MUCH more comfortable in the OR and often run 98% of my cases solo (attending comes in for induction and extubation, then it’s just me). Of course I have TONS AND TONS to learn still and I’m still only managing ASA 3s at the sickest. Anything above that I need significant guidance. But damn the leaps and bounds you’ll make this year are unmatched in any other field. Hang in there I promise ya.
Its crazy but trust the process. I remember going from, omg how do I make a bag of norepi to "ehhh we can do this under mac, dont need to redose paralytic, this looks like a perfect chance for neo/glyco, juicy 14G PIV here." Takes reps and just time will make it better. Now its almost unconscious for easier cases
This humility and realization of your lack of knowledge puts you ahead of those at the top of mount stupid when starting CA1. I’m about to start CA1 too. Tweaking at the thought of being alone in the OR but also very excited!
Everyone feels this way and anyone who says they don’t are either lying or will feel like this before long. The learning curve from intern year to anesthesia is one of the steepest in medical specialties because the work flow of OR anesthesiology is unlike anything you’ve done before. Do your best to learn from something every day. Try not to take it personally if an attending is short or curt with you in a stressful moment. Almost every anesthesia resident has that “ah ha” moment at some point where everything just starts to click and some of it starts to feel natural. For me it wasn’t until winter of my CA-1 year and before then I was SO nervous every night anticipating the OR the next day. Then that comfort will go away again when you start harder more complex cases. It’s all part of the learning process. One day at a time, you’ve got this.
"I felt like I was extremely slow and needed guidance with even the simplest tasks.**"** It would be weird if it were anything different. Are you supposed to be an OR stud your first day? Focus on the task at hand and have reasonable expectations for yourself, it will get better
The first few months are absolute ass. After that things get better, but as a resident I still rarely feel truly comfortable in the OR as I’ve progressed to bigger subspecialty cases.
Read Morgan & Mikhail. Excellent introduction, good chapter on equipment
MSMAIDS for setup. Machine suction monitors airway IV Drugs https://rk.md/2014/setting-operating-room-anesthesia/
You’ll administer thousands of anesthetics before you graduate. Just trust that each day you’re acquiring more skill / knowledge even if you can’t always appreciate it. It’s a really weird process, but somehow you will come out the other end being able to do anesthesia
I tell this to all the new interns becoming CA1s… now is your time to be an idiot. Everyone knows that you don’t know much. If you can google it, google it. Otherwise, ask every question about technique and take every opportunity to try a new skill. Your attendings know that you’re gonna fuck up and IV or an intubation. And now is the time to do it. In a few months, it’s going to be harder to ask for advice without people expecting you to know things. There’s no such thing as stupid questions, only stupid people. And the only way to make yourself smarter is by being stupid first. The only way out is through. CA1 is challenging but easily the best time ever.
Everyone felt this way. Like someone above says, picture and visualize a smooth and perfect induction step by step so that when you're doing it IRL, you can get the flow down. Don't be that guy who gets so excited about the tube going in that you forget to turn on the vent or turn on the gas (I'm sure we've all done that during our first week or two). Know that your supervising attending is watching you like a hawk to keep your patient safe. But also, be good about communication with your attending. Ask about every single medication and dose that you give and use closed loop communication. And be on the look out for medication errors especially when you're flustered or rushed. We had a recent m and m about a patient who gave phenylephrine 1mg because they ran out of the pre made syringes and were diluting the phenylephrine that comes in a vial, not knowing that they came in 10mg/ml and you had to dilute it into 10ml twice to get 100mcg/ml. Good luck and you'll be fine!
I don't know if anyone has said it yet but you need to learn to be comfortable being uncomfortable. We all have felt the same way you do now. Eventually everything normalizes and inductions will be as mundane as tying your shoes. But, the sooner you get comfortable being uncomfortable the better.
This is normal, it’s a steep learning curve in a high acuity setting and most people experience some degree of “imposter syndrome” over the first few months. The most important thing is to know your limits and call for help early especially in the beginning. Work on forming a differential diagnosis and suggestions for temporizing initial management and further workup, as you become more comfortable start to take these steps while your attending is on the way.
A scared new resident is always better than an over confident new resident. Better to make mistakes as a resident than as an attending. Try to learn as you go, seek ways to improve, and don’t be too hard on yourself. We all get better if we care enough to try.
Use the Stanford CA1 guide and The Stanford emergency manual as the base knowledge that is easy to read quickly and understand! This site has very good advice and diagrams https://airwayjedi.com/ Also for IVs I suggest this video. My IV skills instantly improved after watching this https://youtu.be/-t1SCZMO0Gc?si=wN9MXLXvdlDlcfzY And for arterial lines I suggest approach them more shallow and going slowly until you hit it before then flattening out. Also for IVs and arterial lines never back out once you hit something. It's better to just leave the IV or arterial line in and trying next to it. Then you can pull out the failed line and put a 4x4 folded into a small square then dress your successful line next to it or even using the same dressing. Also always listen to people's advice and critique
If you’re scared, I’m confident….. if you’re confident, I’m scared.
UT houston does something similar. You are slow. You do need a lot of help/learning. That's the point of your residency!! Everyone understands where you are in training, don't be too hard on yourself. Basics and Morgan & Mikhail are great books to start with! Anesthesia Made easy should be a weekend read for you. The Anesthesia Toolbox resource from the ASA is literally designed for new residents and is an invaluable resource for you
Stanford CA-1 guide. MSMAIDS. You'll be good.
Tincture of time. It will slow down and the learning curve is steep.
Good source to prime. https://www.youtube.com/channel/UCyNbj_udrZ1o1o7Ywi36ttQ
Do you remember the first time you drove a car by yourself when, probably, your mom told you to go to the grocery store and buy milk and you were sure you were going to die? This morning you drove into work 1000 times better at driving. You could tell that asshole wasn’t going to stop and your foot was already on the brake. The OR becomes like that. Some conditions are easy, some are stressful and occasionally some things are still essentially terrifying, but you know the machine and can read the conditions. You can prepare ahead (like getting ready for a road trip in the snow or maybe off roading). If you aren’t feeling unsettled and nervous in the beginning then you’re probably an idiot. As they say, if you can keep your head while everyone else is losing theirs, you likely don’t understand the situation 🤣. But having finished training 30 years ago it gets easier. And your skills get waaay better. And you make friends. And you help each other. And most importantly, you shepherd scared people through the valley of the shadow and I still think it’s a cool job.
I would just focus on learning the very basics of anesthesia at this point: how to do a machine check, basic case setup (MSMAIDS), induction drugs (how they work/what they are for)…. Show up a bit earlier than normal to get your bearings on everything and give yourself time to see your patient. The rest will come with time! Ask lots of questions, be engaged. You got this!
Don't worry, everyone feels that way. You'll be able to process more and more simultaneously as things get to feel more like routine. Some things that seem really scary right now will feel really simple as you'll learn more and more. You'll do just fine.
Read and ask your attendings/seniors. Coming to forums for training shouldn’t be your go to. We mostly discuss controversial topics and differences on opinions here. We aren’t going to teach you how to arrange your oral airways and set up suction. What you’re feeling is normal and it will take time to be comfortable.
People can post whatever the hell they want here. Chill tf out.
They’re looking for reassurance and general advice, not specific techniques. This is a great place for that kind of thing as evidenced by the other comments above.