The 10 most stressful situations in anesthesiology from an anesthesiologist’s perspective

These aren’t my own thought, however, I can easily agree with the list below.  One of the things that was left off this list was pediatric hearts.  I had the chance to do a one month pediatric cardiac anesthesia rotation at a very busy Children’s hospital and it was definitely an eye opening experience.  Teeny tiny babies.  Itty bity tubes and IVs.  The heart plumbing/circuitry was anything but normal.  I have the utmost respect for pediatric cardiac anesthesiologists — and that’s coming from an adult cardiac anesthesiologist.

Taken and shared from The Anesthesia Consultant Blog:

TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB

  1. Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
  1. Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
  1. An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
  1. Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
  1. Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
  1. Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
  1. Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
  1. An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
  1. Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
  1. The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.
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24 hours with an anesthesiologist

A piece I’d like to submit for: CNN Money 24 hours With….an anesthesiologist

About Kris:

I grew up in a small west Texas town called Abilene, TX. My mom was a standard tiger mom in that she encouraged me to pursue multiple activities while nudging me to do my best. After drama lessons, tennis lessons, basketball, volleyball, piano, violin, band, taekwondo, pageants, and just life, I left Abilene and pursued a biomedical science degree at Texas A&M University.  My earliest memory of wanting to be a doctor started when I was in the third grade.  I hadn’t been feeling well and was diagnosed with pneumonia — I had been reading a book called This is the Child.  My family practice physician Dr. Lawson was about to prescribe me prednisone and I immediately got worried because that was the same medication used to help with the child’s leukemia.  Dr. Lawson picked up on my early curiosity and invited me to hang out with him in his medical office observing patients.  After college, med school proved to be a great experience at University of Texas Medical Branch in Galveston and felt like learning on steroids (as compared to college).  My clinical rotations led me to the path of choosing anesthesiology as a career.  Anesthesia is the perfect combination of anatomy, physiology, pharmacology, psychology, and sociology.  I matched into a terrific internship in Austin, TX and continued my anesthesia training at the prestigious Massachussetts General Hospital.  Following 4 grueling years of training, late nights, memorable cases, and lifelong friendships, I chose to pursue a cardiac anesthesia fellowship at University of California San Diego — a world renowned institution for the treatment of right heart failure following pulmonary thrombosis.  14 years after graduating high school, I have the job of my dreams.  Here’s a sample of my day…

My Day:
Today I’m #2 in our call lineup, which means it will be a pretty busy day. Typically, we have 15 call spots in our main operating room (OR) numbered #1 to #15. #1 position gets the first pick of cases. #2 gets the next pick and so on.

5:45a Early heart day wake up. Today, I will be providing anesthesia to a 70-something year old lady who needs a new heart valve.  On heart days, I wake up at 5:45a to be at work by 6:30. And on regular main OR days, I wake up at 6:15a to be at work by 7:00. Ahhhh… To have more beauty sleep!

6:17a Breakfast in the car – it’s either green juice, Shakeology, or banana on the go!

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Breakfast on the go!

6:31a I meet the patient and her family in the pre-operative area.  We go over a detailed plan for her anesthesia as well as answer any questions.  One of the best parts of my job is meeting all different types of people.  It’s an amazing feeling to meet people at one of their most vulnerable moments in their lives and win over their trust and respect.  It is my job to safely manage their physiologic processes.  Oftentimes, patients tell me it is the anesthesiologist who is the most important part of a surgery — they understand how easy it is to bring them close to the brink of death and then revive them back to a wakeful state.  It’s incredible the amount of trust patients place in your hands in such a short time after meeting them.

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7:15am The patient is under anesthesia and all invasive monitoring lines (arterial, central venous pressure, cordis, pulmonary artery lines) have been placed.  The transesophageal echocardiogram is performed and results are relayed to the cardiac surgeon.


7:45am Cardiac surgeon makes incision.  The patient is monitored throughout the case.  Multiple screens show all the physiologic monitoring results.

10:00a Bathroom break! Partners/colleagues break each other out so there is always an anesthesiologist monitoring the patient.  It’s also a good time to grab a snack!

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My work bag with some life saving snacks to avoid hangriness!

11:32a Drop first patient off in Cardiac Care Unit and grab some lunch. The doctor’s lounge keeps us fed with soup and salad. Today, I’m feeling the vegetable soup. Grab a quick bathroom break and then to interview the next patient.

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Lunch on the go!

11:45a Electrophysiology study for atrial fibrillation ablation. The view from this OR is such a delight!

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The view from my little nook.

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14:00 I get a call from our anesthesia czar, one of my partners who runs the schedule. He was wondering if I would make my 15:00 hip replacement. After a quick conversation, we decide that I would call him in 30 minutes for an update.

14:33 We are finishing up with the current case and I call the czar back to find out about my next case. I learned that there is an emergent heart that will be started by another colleague and that I will continue the lineup in EP (so my day went from a 16:30 finish on paper to roughly a 19:00 finish). Anytime I am in the top 5 call positions, I know not to make defined plans because you never know if there will be addons or changes to the schedule. This makes my social life a bit frustrating as my non-medical friends have a tough time understanding and adapting to this “you don’t get out of work at 5p?” concept.


15:20p Drop patient off in the Post Anesthesia Care Unit (PACU). Grab a quick snack and head back to EP for the next patient.

15:25p Speak to the next patient who has arrived for an afib ablation as well. Induce and get started with the case.

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19:22 Drop last patient off in the PACU.  As #2 on the call list, I look at my watch and realize that I am #2 at night.  This means I will be the 2nd person they call tonight if extra rooms in the OR get booked (traumas, heart call, etc.).  As much as I’d love to head home and grab a glass of wine and unwind, I meet up a friend for dinner to catch up and relax.

21:42 Head home. Shower. Brush my teeth and get into bed.  There’s always a risk of being called into work.  Tomorrow will be a shorter day.  After the hectic day, I am still thankful for my wonderful job and colleagues.  Looking back at my journey to get here, I smile because I couldn’t be happier.