Shawn Jia, MD
Your CA-2 year is divided into several month-long rotations that give you exposure to the various subspecialties within anesthesiology. The basic structure of a day in the OR is still a lot like CA-1 year. It involves reviewing cases with your attending the night before, setting up your room around 6 a.m. (earlier on cardiac), starting your first case at 7:20 a.m., and finishing up at around 4:30 p.m. However as a CA-2, the anesthetic management for the subspecialty surgeries is much more nuanced and complex. You’re also given greater responsibility and independence while taking care of a sicker patient population.
You do two months of cardiac anesthesia and one month of thoracic anesthesia during your CA-2 year. Cardiac anesthesia is one of the most challenging and exciting rotations of residency. The high volume and complexity of cardiothoracic surgeries is a major strength of training at Duke. With one of the busiest heart and lung transplant programs in the country, you get a lot of experience doing these difficult cases. By the end of the cardiac rotation you will have done heart transplants, lung transplants, CABGs, valve replacements, mechanical assist devices, pulmonary endarterectomies, aortic reconstructions, and many others. On your thoracic rotation you learn all about the physiology of lung isolation. This is when you get a lot of practice using double lumen endotracheal tubes, operating the fiberoptic bronchoscope, and placing thoracic epidurals for pain control.
On the chronic pain rotation, your time is split between seeing patients in chronic pain clinic and doing interventional pain procedures at the Ambulatory Surgery Center. Pain clinic patients may have conditions such as fibromyalgia, spine pathology, cancer pain, or CRPS. For these patients you always focus on non-opioid therapies first. You learn when it’s appropriate to use adjuncts like NSAIDS, antidepressants, anticonvulsants, topical agents, biofeedback, or interventional pain techniques. When you go to the Ambulatory Surgery Center you learn to do procedures such as fluoroscopic guided injections, neuroablations, as well as intrathecal pump and nerve stimulator implantations. It’s a definitely a fun role reversal to scrub in for surgery and let someone else pay attention to the anesthesia.
During your neuroanesthesia rotation you learn how to manage patients undergoing a wide range of neurosurgical procedures. These include the treatment of aneurysms, AVMs, brain tumors, occlusive cerebrovascular disease, spine pathology, epilepsy, and spinal cord injury. At Duke you benefit from having an internationally recognized brain tumor research center that brings in patients from all around the world to take part in clinical trials. As a result, you do a lot of craniotomies for brain tumors. The awake craniotomy is an especially interesting case that you’ll typically do at least once a week.
In the Surgical Intensive Care Unit (now a CA-1 rotation), you treat some of the sickest patients requiring extensive multi-system care plans. During the mornings you round with a multi-disciplinary care team consisting of an intensivist (either an anesthesia or surgery attending), a fellow, respiratory therapists, pharmacists, nutritionists, nurse managers, and medical students. The workload is often shared with residents from the department of surgery who bring their own unique perspective and expertise. Because of your knowledge in managing patients on ventilators, vasopressors, and inotropes, you are often granted a great deal of independence in managing patient care.
Vascular surgery is another challenging rotation where you are providing anesthesia for a very sick patient population. Some of the typical cases include endovascular and open aneurysm repairs, carotid endarterectomies, lower extremity arterial bypass, limb amputations, and AV fistula surgeries. Here you get a lot of practice placing difficult arterial lines since you do them for almost every case. This is also a great rotation for regional experience since you commonly do peripheral nerve blocks for limb amputations and dialysis fistula placement.
You also have two months of pediatric anesthesia as a CA-2. You get to do enough “bread and butter” peds ENT, urology, dentistry, ortho, and general cases to become comfortable taking care of healthy pediatric patients of all ages. However, because Duke is a major referral center for the area, it’s not uncommon for you to take care of children with rare syndromes, congenital heart disease physiology, and extreme prematurity.
Lastly, three or four times during CA-2 year you take weekend liver transplant call. Liver transplants are great cases because you have to apply all your knowledge about cardiovascular, respiratory, and hepatic physiology. You do a lot of volume resuscitation and get to use nearly every kind of invasive monitoring, often including TEE and PA catheters. After the transplant is over, it’s especially gratifying to visit the patient in the ICU and seeing them do well. Another added bonus of getting called in to do a liver transplant over the weekend is that you get moonlighting pay.