A Day in the Life of a Duke Anesthesiology Resident

Octav Constantinescu, MD, CA-2 Resident

Pediatric Anesthesia

The first day of the pediatric anesthesia rotation can be as overwhelming as the first day of your anesthesia residency. Some of the patients are incredibly small, their pathophysiology is complex and the surgical procedures are unfamiliar. The pulse oximetry tones that used to communicate “all is well” now race feverishly, almost certainly making your heart race with them. The simplest of interventions, administering a drug intravenously, gives reason to pause, to check the math and only then to proceed with caution.

Previous rules of thumb or instincts become useless as weight-based calculations, gestational age, NICU history, prior sensitivity and specific surgery are all factors that must inform the proper dosage. Learning to tolerate a mean arterial pressure as low as the gestational age in weeks will become as natural as being alarmed when EBL reaches 20ml. You will learn to make the most minute adjustments to place an IV catheter and to hold a laryngoscope ever so gently with the tips of your fingers. Eventually, the Macintosh #2 laryngoscope blade will seem “too large” and the oxygen saturation of 90% “too high” given the single ventricle physiology.

The day begins by setting up the room, checking the anesthesia machine, and preparing an array of diminutive syringes. Once the set-up is complete, you will go to the pediatric preoperative care unit to meet the patient and his or her family. The patient may be shy and anxious, hungry and crying, or perhaps mature beyond his or her years, with more experience in a hospital setting than that which your training has provided. The trust you engender, the relationship that emerges from your interactions in the first few minutes can make the difference between a smooth induction in front of an appreciative parent and an awkward wrestling match with a screaming child. You will gradually learn to make that connection and even to have fun while doing it! The hallways and operating rooms come alive with marine life and you will be tempted to play Finding Nemo with your patient on the way to the OR. The attending will tell cute, corny jokes and perhaps buy smiles with fruit flavored lip balm and Scooby Doo stickers. If the patient is a 4 year old girl whose favorite Disney princess is the Little Mermaid, and if your attending is Dr. Eck , you may even follow his lead and sing "Under the Sea" with the OR staff to keep the patient comfortable while inducing anesthesia. Or, maybe you'll pretend it is a rocket launch! A trip to the Moon? You never know--each day is different!

Pediatric anesthesia at Duke is challenging but also very rewarding and fun. Cases range from “simple” central venous line placement in premature children weighing less than one kilogram to congenital hernia repair or Nissen fundoplication in infants with complicated and very rare syndromes. Neurosurgery cases may be as simple as a shunt revision or as complex as a craniotomy to excise vascular malformations. The plastic surgery department performs cleft palate revisions and craniosynostosis repairs. Duke also has active services in pediatric orthopedics, urology and head and neck surgery. There is a growing pediatric liver transplant program. Duke dedicates two operating rooms and a smaller procedure room to pediatric patients but also cares for children in the main operating rooms, cardiac operating rooms, the Ambulatory Surgery Center, the Eye Center, pediatric catheterization lab and radiology suites. All but the healthiest children are supervised by an attending from the pediatric anesthesia division.

Any of these cases can be intellectually and emotionally challenging. Feelings of anxiety, exhaustion, elation, fear, sadness and contentment may try you throughout the day. Your challenge and reward will be to make a child feel calm and unafraid, to drift her off to sleep uneventfully, to keep her safe despite the risks and then to deliver her back to her parents pain-free and well. With any luck, you will love what you do and look forward to the opportunity to give it your best each day.

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