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Introducing Dr Jonathan Ramachenderan

Broome Docs has a new contributing author.  Dr Jonathan Ramachenderan was going to be a Broome doc, unfortunately due to a misalignment in the stars of medical administration he is now on his way to Albany in the far south of WA (if Broome were the eye at the top of WA, Albany would be the….) – a beautiful, if slightly cold part of Australia.

Dr JR is a newly graduated GP-Anaesthetist and hence is going out into the bush as a country doc with a fresh perspective on what we do.  So by way of introduction Jonathan has written a piece on his experience as an Anaesthesia trainee over the past year.

My JCCA year at a glance

Case It’s the 3rd time my MET pager has gone off in the last hour and I am angry, Anaesthetic nights aren’t supposed to be this busy.

I see it’s the Nurse Special Unit and I pick up the pace (still walking). I walk into the room and see chaos. Situational awareness is something you only learn on the job and its invaluable in any critical care specialty. I hear the cardiac monitor dinging and see a resident poorly applying jaw thrust and chin lift to a middle-aged patient who is obviously obstructed and in distress. There are flashes of nurses running around in my periphery doing something and a medical registrar who is reading the patients notes. In a loud voice I ask “What is the MET-Call for?”, Silence…… I make my way to the head of the bed and surveying. Having excused the resident, who is only one who gives me a coherent history, I relieve the obstruction and gently ventilate the patient. I learn he is 55 admitted with a fever and cough, brought to NSU because of a decreased GCS and tachycardia who has suddenly dropped his GCS. I run through my ABC’s out loud so as a team we know what we are dealing with. I recognise his airway is obstructed and count a GCS of 5, he is hypoxic (Sa02 87% and barely breathing, he is in a sinus tachycardia of 120bpm and hypertensive 160/80mmhg, his eyes are closed, he is making sounds and withdrawing to pain. Moments later we’ve made the decision that he needs to be intubated and transferred to ICU for further management. I find myself delegating jobs to the people around me, asking for equipment, drugs and monitoring getting ready for the intubation. I place a pillow under the patient and ensure the optimum intubating position. With it all set and laryngoscope in hand I suddenly realise I am about to intubate this patient with no senior around. I am the most senior airway person here! How did that happen? I quickly call the SR who comes running but stands back and watches me intubate this patient easily and keep him asleep and stable for the transfer to ICU.

I asked myself after this, when did I become comfortable at the head of the bed managing airways?, when did I become competent at managing a team? And when did I get comfortable with the preparation, induction and maintenance of anaesthesia? This case occurred midway through my Anaesthetics year and highlights the steep learning curve and quick uptake of airway and critical care skills that most GP anaesthetic registrars experience.

With a solid grounding in Emergency Medicine and Intensive Care I headed into my Anaesthetics year with the intent of becoming a Rural Generalist. But here is a confession most ED/ICU trainees have…”I am not confident at the head of the bed and I hope we don’t have to intubate anyone tonight,”.

Between the RACGP, ACRRM and ANZCA a committee, the Joint Consultive Committee of Anaesthesia was set up to assess, accredit and administer Anaesthetic Training for Rural GP’s in Australia. It is usually undertaken as part of the Advanced Rural Skills in GP training. In Perth all the GP Anaesthetists in WA since have been trained at Joondalup Health Campus.Here is a snapshot of my year in Anaesthetics.

Airway:

In an emergency, most medical practitioners would be able to use a laryngoscope, damage some teeth and get a view of the larynx eventually and throw down a tube. It wouldn’t be elegant but be more than likely successful. The purpose of this training is to develop good and safe intubation technique on the hundreds of easy elective intubations you encounter and to realise that positioning is everything to your success However the most important part of this training is to be able to manage those with difficult airways (Obese, pregnant, anatomically weird!), to make plans if you don’t succeed and to be able to recognise those who would be a nightmare to electively intubate. I’ve also learnt what tools and techniques I’ll need in GP-land and have played with some cool toys like video laryngocopes and fiber optic scopes. With the easy intubations, I used this as a chance to develop a style of your own and strong intrinsic hand muscles from airway maneuvering.

Breathing

This year has been intensely practical and as a result I have learnt a great deal of respiratory physiology on the job. This is a great way to learn and see those dry pages of “Respiratory Physiology by West”, come to life as you administer an anaesthetic. All my ANZCA bosses are Physiology experts and were kind in their teaching but I reciprocated this by my own self-directed learning which stimulated some great discussions in Theatre. Why does your unwell 130kg patient who smokes and snores, desaturate to 65% whilst you fumble for a minute to find a decent view of the cords and throw down a tube? Its important physiology that will keep you safe in GP land when you are the expert and are in-charge. With mastery of these concepts comes the ability to control your patient’s ventilation under anaesthesia in response to surgery and a patient’s background respiratory issues. This knowledge and experience carries over to your Family Practice and the ED with that sick patient in Acute Pulmonary Oedema whom 10cmH20 of PEEP seems extravagant….just go for it man! They need it!

Circulation

My favourite! If you are like me, a highlight of your medical career was when you put in your first arterial line and then even better was when you put in your first central line! Access! Essential in Anaesthesia! Ive done some amazing things this year, gained access on some difficult patients, mainly because that is all you do! Being able to bang in a 16G into a pregnant woman, a 14G in a sick laparotomy and a tiny 24G into a 18month old is rewarding. Anaesthesia also gives you a calm demeanour when approaching the extremes of haemodyamics, like a BP of 70/40mmhg or a HR or 35bpm and best of all more strategies to fix these than you had before. I’ve learnt an unbelievable amount about cardiovascular physiology, valvular heart disease, myocardial ischaemia and how to manipulate a patient’s haemodynamics to safely anaesthetise them. Can you tell that I’m excited?!

Drugs and Pain

Fentanyl, remifentanil, alfentanil, ketofol, sugammadex, esmolol, intrathecal morphine, these are a few of my favourite drugs… that I’d never used until this glorious year. I am in love with drugs! The ritual of drawing them up, giving them and watching them work is amazing. I have gained a great knowledge and added a whole range of drugs to my repertoire (dangerous ones too!). Being in the controlled theatre environment and repeatedly administering different opioids, induction agents, muscle relaxants and vasopressors and has given me great confidence in using them independently. Especially in an emergency situation like the one I previously described, calculating doses and administering an appropriate amount based on a patient’s acute physiology was second nature. Although most called it their “Week of pain” I called my Acute Pain Service week “Ward Aanesthetics” because I realised that these rounds were invaluable to my practice as a GP Anaesthetist. This is because often we never see our patients again after we anaesthetize them and their post operative care is just as important. The difference between a good and great GP anaesthetist is their planning. Each patient needs a decent post-operative plan consisting of analgesia particular to their surgery, care for PONV and specific interventions. Our goal is to keep our patients comfortable and nausea free and I learnt a great deal from all my consultants and saw a common theme emerge that I began to use myself. I also learnt a great deal from our APS CNC with whom I conducted our rounds with.

Obstetrics

Pregnant ladies! I did 4months of my 12month Obstetric job and ran! On the anaesthetic side (above the pelvis) things are much better. The look of relief on a laboring mothers face and a relaxed father are golden moments. The pregnant lady with a working epidural is a beautiful thing. I used to be so scared of doing lumbar punctures in ED, but now in 11months I’ve done 75epidurals and 46 spinals for Caesarians. If you enjoy procedures then putting in an epidural into a swaying back might be the challenge you need! I’ve managed some bleeders, done some Category-A sections and rescued some sick little ones. I am taking away a wealth of experience to Albany where Obstetric Anaesthesia will be my bread and butter. One of the main purposes behind the funding and training of GP Anaesthetists, is to provide Obstetric Anaesthetic services for Rural Australia.

Paediatrics

Paediatric anaesthesia is one area I enjoyed in my Training. Doing gas inductions, using small largyngoscopes and putting in LMA’s were just as fun as endotracheal tubes! As GP anaesthetist we need to elect an age that we feel comfortable anaesthetizing down to. For me this is 5years or 20Kg. I wouldn’t feel comfortable electively anaesthestising kids lower than that and my ANZCA colleagues would agree. Although I may not electively anaesthetise many children regularly, I feel this year has prepared me to confidently manage a child’s airway, induce anaesthesia and manage common complications such as the dreaded and much rehearsed laryngospasm!

Emergencies

Despite the anaesthetic management behind each patient seeming repetitive at times, the process of Airway, Breathing and Circulation became engrained into my subconscious and my clinical practice. I wasn’t comfortable anywhere but the head of the bed and didn’t start anything without monitoring, an assistant, drugs ready to go, the appropriate equipment and a plan B. The rehearsal everyday in theatre in comfort is essential because when are thrown into the chaos of a MET call or the ED when we need our subconscious system to switch on.

Assessment

What do you need to demonstrate by the end of your 12months? Put simply I needed to be competent, safe, knowledgeable behind my practice and know when to ask for help or send away. The level that I was expected to achieve was to safely anaesthetise ASA 1 & 2 patients (basically fit and healthy maybe with a mild systemic disease) in a variety of general surgical, orthopaedic, gyanecological, urological and ENT cases on my own. I also need to provide management to Obstetric patients in the form of labour analgesia and caesarian section anaesthesia. As I write this piece 6 weeks from finishing my training, I am being left alone to “crack on” with cases and am managing lists on my own. This point of taking off, cruising and landing by myself came around the 9th month but is improving each day I am left alone to do my work. Our formal assessment in the form of the Viva wasn’t too overwhelming as I found it was a formal chat about I would manage certain tricky situations in rural GP land. Their only criticism of me was that my jeans, collared shirt and trainers weren’t “formal” enough for the occasion.

Impression

This certainly has been a year well spent and so far the best in my short 6 years as a doctor. I have walked away with a significantly increased skill set and clinical knowledge base and a qualification recognising my ability to Anaesthetise independently. For the critically care minded doctor with rural intentions, a year in Anaesthesia is a must. This not only increases your confidence as a Generalist, but allows you to contribute Anaesthetic services to the community you will eventually serve.

Key things Before you get in:

Apply!

Here is a link I found listing accredited sites for advanced rural skills training in Australia.

Whilst you are there

Be early, see your patients, make up a plan for them, then go to theatre before each list and check your machine (ask someone to show you after your first few months) and draw up your drugs. If you are going to anaesthetise someone you need to see them beforehand. Its poor form to turn up late to a list and do all the procedures. You’re not that good! Remember that every moment you are rostered on is precious. Don’t give up time in theatre in birth suite because you cant be bothered. You wont get this supervised playtime back! Go home and read about procedures, techniques and drugs you don’t know about so you can further that knowledge when you are in theatre. Consultants love registrars who have done a little reading beforehand. If you don’t know, ask! And if you don’t feel comfortable, say something! Everyone clinically matures at different rates. Before you leave Find a couple people that you have worked with and get along well with and ask them if they can be your “Phone a friend” person Having used a wide array of equipment, write down what you like and are used to and try to get them where you work.

Looking forward to seeing what JR has in stall for us in the coming months.

Casey

Comments

  1. Minh Le Cong says:

    Casey, Jonathan, you guys are cool! What a great summary article of the JCCA year. Joondalup campus is known to me as one of my EMST instructor buddies is Rodney Petersen, the director of OG there! I let him insert an EZIO needle into my leg one year just to show that even a gynaecologist can do it in an emergency! I had to smile when I read you gave up after 4months of your DipObs!
    Look forward to reading more articles from you, JR!

  2. Brilliant Jonathon..it’s great to know that rural proceduralists are coming out of the pipeline.

    And don’t listen to Casey – Albany is a fine place with a good bunch of GPAs!

    Your essay echoes my experience as a JCCA reg – just on the tail end of it now after a successful viva. My experience a little different in that previous life as ED/ICU reg with 6/12 anaesthetics under my belt, then about 7 years as rural doctor on Kangaroo Island managing RSIs “if had to” but increasingly deskilled. So brave move to go back to tertiary hospital for a year to upskill in anaesthesia – thankfully the $40K grant from ACRRM lessened the financial barrier to leaving private practice, but has been a challenge.

    Interested to hear more of Jonathon’s adventures as starts solo lists as a GPA…indeed, there’s probably a bunch of GPAs out there, both established and starting out – personally I’ve found sites like BroomeDocs most useful in terms of continuing medical education and challenging the way we think.

    One criticism of the JCCA is that it is designed predominantly for elective anaesthesia (and I think it achieves this end well). However, as GPAs we are often faced with the true emergent airway – a 130kg unfasted bearded trauma victim, in C collar, with belly full of beer/pizza and blood/vomitus in the mouth. His huge bikey’s beard conceals an absent chin. Options like ‘waking up’ or delaying until senior help arrives aren’t available to us…so getting a good grounding in emergent airway and thinking ahead to what kit you’ll need and how will approach these problems is more a topic for discussion on these sort of blogs (em-crit and resus.me deserve a mention too) than in an elective theatre list.

    Also some great courses and conferences out there – the NSW GPAs conference was well attended and had some interstate fellows (two from Vic, one each from SA and WA) along…keen to get more of this sort of thing happening and to stop working/thinking in silos.

    Keep up good work. And wake up as many as you put to sleep, eh?

  3. Jonathon Ramachenderan says:

    Hey thanks Guys. Im appreciative of the chance to participate in the medical blog world. I am looking forward posting some perspectives of a newly qualified GP anaesthetist and talking about some relevant issues.

    Minh – Dr Peteresen does the high risk obstetrics here in Joondalup and is the man. Yeah I ran like a little girl, I was wondering, “how did I get so lost?” but I ended up spending the majority of my time in the emergency department of the Womens Hospital. This was invaluable and coincidently where the FACEM’s worked.

    TIm – Thanks for the comments. I will definitely share my experiences as I start on my own. I have found a number of great resources this year from my ANZCA buddies and stumbled across a couple myself, all of which I used for the Viva.

    Yes I agree about the lack of emergency training and the case that you are describing is exactly the type of thing I intend to discuss.

    I think the constant rehearsal in theatre is great preparation for the real world but we do need have individual plans B and C if A fails. A great senior registrar said to me that having a clear plan B is as important as your primary intubation plan.

    Thanks guys again and big ups to Casey for sharing the love.

    Jonathan

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