Dear Journal: One Student's Account of the MSARF Experience

MSARF participant Matthew Gertsch spent the summer of 2009 with the University of Utah Department of Anesthesiology. His primary research mentor, Dr. Harriet Hopf, Professor and Director of Resident Research Training, suggested Gertsch keep a log of his activities to ensure he accomplished his goals and received the required 15% clinical experience. His log blossomed into the following journal, which provides an excellent overview of the type of research experience the program provides.

Student Name: Matthew Gertsch
Medical School: University of North Carolina Chapel Hill
Host Department: University of Utah Medical Center
Primary Mentor Name: Harriet W. Hopf, MD
Additional Mentor: Elizabeth Thackeray, MD
Title of Research Project: Does high intraoperative inspired oxygen reduce postoperative arterial oxygen saturation?

Week 1 (May 27-29, 2009)

Day One - I was greeted warmly by Dr. Hopf and many of the other anesthesiologists. It was nice being introduced to most of the faculty within the department. I was given a tour of the facilities and we discussed the details of my project in further detail. All of the administrative stuff was taken care of very quickly and efficiently on my first day, so that I was able to get started by day two.

Day Two - I arrived at the hospital at 6 a.m. and recruited my first patient into the FiO2 study.  Consents were signed and the anesthesiologist was informed of the patient’s participation in the study. Prior to extubation, I arrived in the OR to record necessary data and then followed the patient to the PACU where I gathered more data. The remainder of the day was spent organizing the data, entering it into a database, and validating previously entered data.

Day Three - I collected the 22- to 26-hour post-op data for the patient from the day before. The remainder of the day was again spent organizing the data, entering it into a database, and validating previously entered data.

Week 2 (June 1-5, 2009)

This was a great week for recruiting and enrolling patients in the study. I started Monday, Tuesday, and Thursday at 6 a.m. in the hospital consenting patients and speaking with the anesthesiologists about their roles in the study. I enrolled a total of eight patients by the end of the week, and again recorded data in the OR, PACU, and on the floor the following day.

On Tuesday night, I attended a journal club at an anesthesiologist’s house, where we discussed several research articles about cerebral oximetry and postoperative cognitive dysfunction. Prior to the discussion of the articles, we had a catered dinner where I was able to get to know more people within the department, including many of the residents and other faculty in attendance.

On Wednesday morning, I got set up with the first-year anesthesia residents to practice adverse airway-management techniques on a mannequin in the simulation center. One of the anesthesiologists came in and described a real-life scenario and then had all of the residents weigh in on the situation, as well as discuss what they would and would not want to do. We then went to the simulation center where that given scenario was in play.  We practiced retrograde intubations and also learned how to use endobronchial block sets.

Following the simulation center, I spent the rest of the day at the Orthopedic Hospital with Dr. Swenson who is an anesthesiologist specialized in regional anesthesia. I was able to see a number of different blocks and I was even taught how to use the ultrasound for a femoral nerve block.

My mentor, Dr. Harriet Hopf, had a barbecue at her house one night, welcoming me to the department and saying farewell to those leaving. I have really enjoyed how friendly and social everyone is here.

Week 3 (June 8-12, 2009)

This week was devoted to more recruiting and consenting patients. I had time to read anesthesia-research articles and to study anesthesia-related textbooks (Handbook of Clinical Anesthesia). I also started reading the rocuronium and sugammadex study manual, which is an Organon study currently being done here, as well as at the University of North Carolina.

Week 4 (June 15-19, 2009)

I spent Monday with a CA-3 resident who was in the end of his transesophageal echocardiogram (TEE) rotation. I had never before been exposed to a TEE, so I loved learning about how to use it and why they use it. One of the patients was having a coronary-artery bypass graft, and it was neat to see what things needed to be considered when doing a cardiac case. I also learned today about the benefits and risks of TIVAs (total intravenous anesthesia), and saw cerebral oximetry in action.

On Wednesday, aside from enrolling patients in the study, I spent the day in the OR with my mentor, Dr. Hopf.  I learned the following:

• The differences between isoflurane, desflurane, and sevoflurane. 
• Where all of the oxygen reserves are and how they are connected. 
• How to put in esophageal temperature probes.
• The contraindications to using succinylcholine, as well as when and why you would use other muscle relaxants, such as vecuronium and rocuronium. I learned that succinylcholine is degraded in the bloodstream by pseudocholinesterase, and that some people are deficient of this enzyme, resulting in a longer lasting effect of the drug.
• When to use fentanyl and dilaudid.
• If the patient’s blood pressure is low, and if his HR is normal or low, you can give ephedrine. However, if the patient’s blood pressure is low and if his HR is high (greater than 60 bpm) you should give phenylephrine. It lowers the patient’s HR while increasing his BP.

On Thursday I attended a research conference within the Department of Anesthesiology on the topic of adductor canal blocks for knee surgeries. This is a regional block that was discovered here at the University of Utah. 

On Friday I spent the day working in OB anesthesia. I saw at least ten epidurals, five spinals, and five C-sections. The highlight of my day was being taught how to do a spinal. Working under direct supervision of a faculty member, once the introducer needle was placed, I got to insert the needle for the spinal and feel for placement until I got CSF return. The spinal I placed worked great and I learned a ton in the process. I was also able to glove up during a couple of epidurals so that I could see what it feels like when you are going through the various layers and when you are in the right place. In addition, I learned about the different cocktails given for regular epidurals, epidurals used for C-sections, and spinals for C-sections. For a spinal block involved with C-sections the following drugs are used: bupivacaine, fentanyl, and morphine (lasts about 2 hours). An epidural for vaginal delivery uses a 1.5% lidocaine test dose and then it is followed with bupivacaine and fentanyl, while an epidural for a C-section uses 2% lidocaine, epinephrine, and bicarbonate. Bicarbonate is used to make the lidocaine act faster by decreasing the extracellular pH concentration and allowing the drugs to enter the cell more rapidly. Also, a spinal block for a pregnant woman requires less drug because of the woman’s high level of hormones and their interaction. I also learned about pre-eclampsia (BP > 140/90, proteinuria > 300 mg/24 hours, and edema) and its associated risks. (Airway edema, laryngoscopy and intubation may lead to an increase in BP.)

This was a great experience and I look forward to spending more time in labor and delivery.

Week 5 (June 22-26, 2009)

This week was devoted mainly to recruiting. I enrolled a record total of thirteen patients to the study and the end is now in sight. I have really liked spending time in the ORs and PACUs and I have learned a lot about the various drugs, dosages, and reason for why they are being given. 

One morning I attended a CME lecture on professionalism during which we were taught of its importance and ways in which we can better exhibit this quality within the field of anesthesia. It was very insightful and it will definitely influence the way I practice medicine.

Week 6 (June 29 – July 3, 2009)

This week was also dedicated mainly to recruiting. I now only have six patients left to enroll which I hope to complete the beginning of next week. 

On Friday I had the opportunity to be on call with my mentor Dr. Hopf. I was there from 3 p.m. to midnight and I really learned a lot. I got to see another spinal block in labor and delivery for a lady who was getting her tubes tied. I learned that in her spinal she only got bupivacaine and a little fentanyl, in comparison to morphine added as well during a C-section. I also learned that a normal epidural uses 1/12% bupivacaine in comparison to 1/4% bupivacaine in a spinal block. I also saw two patients requesting blood patches following lumbar punctures by neurology with 20 gauge needles. It was interesting to see the symptoms of a person who is really in need of one versus someone who simply thinks she needs one, but clearly does not. A positional headache is a key symptom in a postdural puncture headache. One lady requesting a blood patch stood up several times and was unaffected, while the other one did not budge from lying down.

I also learned what cricoid pressure is used for, although it was explained to me that it may not be as good as people think. Cricoid pressure may aid in achieving a better view of the vocal cords, however it could also shift the larynx to the side making for a more difficult find. It is also sometimes used to prevent aspirations because by applying pressure, the esophagus can become compressed and pinched off. However, there have been studies showing that the esophagus often times becomes displaced to the side and such benefits are lost. 

I also got to see several other surgeries where I learned the importance of remifentanil, etomidate, ketamine, and toradol. Remifentanil is metabolized quickly by an unknown cholinesterase in the blood, which makes it a short-acting drug. It can be used for sedation or it can be synergistically used with drugs like propofol, which actually allows you to decrease the dose of propofol given. Etomidate is another short-acting anesthetic used for sedation in general anesthesia, but can risk side effects of suppression of steroid synthesis and a possible increase in postoperative vomiting. Ketamine may also be used for induction and maintenance of general anesthesia.

I also learned about pressure-controlled ventilation, volume-controlled ventilation, and pressure-assist ventilation. I learned about the advantages and disadvantages to each, and when you would want to use each of them. Also, it is the flow of oxygen that is needed to push the vapor anesthetics through the machine. So it is usually set on at least 1 L/min for the machine to work, but when the patient is waking up it is turned up to as high as 10-15 L/min to clear the anesthetic from the patient.

Week 7 (July 6-10)

I enrolled our last six patients into the FiO2 study this week and I began looking at the data and writing the paper.

I also started a new project at the University Orthopedic Center studying the utility of 1/8% bupivacaine in intrascalene brachial plexus blocks. It is a randomized double-blind study, where study patients receive either 1/4% or 1/8% bupivacaine. We record the following measurements before and after surgery: Vital Capacity, SpO2, diaphragmatic excursion, grip strength, and pain scores. I enrolled my first patient into that study this week.

I also began helping another medical student with his research study, which is looking at the effectiveness of hand hygiene amongst anesthesiologists, anesthesia techs, and operating-room nurses. The nature of this study allows me to observe the beginning of about 12 surgeries each day. I collect data during intubation, foley-catheter placement, IV placement, spinal blocks, arterial-line placement, and central line placement (when applicable).

I also learned this week how to turn over a room in between surgeries with the anesthesia techs. I can now do it on my own and I learned a great deal about the anesthesia machines this week.

On Wednesday I attended a lecture with the first-year residents about the anesthesia machines and all of the circuits involved.

I met with my mentor this week for about an hour to discuss the paper in more depth.

I also met briefly with the residency program director this week for advice on things I can do to become a more competitive applicant for residency, as well as to just get to know him better. I was also able to attend an airway workshop this week where a number of vendors came to show off their new gadgets. It was fun learning more about what is out there and practicing intubations on the mannequins.

Week 8 (July 13-17, 2009)

I spent the majority of the week collecting hand-hygiene data in the OR and I did one follow-up for a patient in the interscalene brachial plexus block study. I also worked a lot on my oral research presentation, which I gave in front of the Department of Anesthesiology on Thursday. My mentor was very helpful in my preparation and provided me with several opportunities to practice with her beforehand. She spent a lot of time giving me constructive criticism and feedback, and I now have a lot more confidence in presenting research.

Week 9 (July 20-24, 2009)

Now that the project is complete I have been able to work a ton on the paper, which we are hoping to get published in “Anesthesiology.”  I have learned a lot about the process of getting published and I have actually really enjoyed writing the paper. My mentor spent two hours one-on-one with me this week explaining the whole process and helping me get started. She also showed me some of the projects that she has worked on, mainly dealing with the ability to measure oxygen perfusion in surgical wounds. It was really interesting to learn more about her research interests, and I enjoyed watching her give a research presentation because I noted a lot of excellent presentation skills that I hope to incorporate into my future presentations. 

I also met with our statistician this week and learned a lot about statistics. He was able to answer all of my questions and I got what I needed to be able to work on the paper some more.

I attended another departmental seminar this week, which was titled “Morbidity and Mortality,” in which a number of different anesthesiologists get up and present various cases. Most of the cases presented contained ethical issues, or mistakes that could be prevented in the future. The idea behind the seminar was to note potential (or actual) mistakes, so that we could learn from them and not make the same ones in our practice.  It was very insightful and neat to see everyone working together so well. There is a very unique learning atmosphere at the University of Utah that really fits my learning style and personality well.

Week 10-11 (July 27-August 7, 2009)

I worked hard on the paper this weekend and finished my first draft. I completed the demographics, tables, charts, and all other parts pertaining to the paper. I also finished my first draft of the poster that I will present at the ASA meeting. I have also been assisting in the closing out of our FiO2 study which is a clinicaltrials.gov study.  I have learned quickly what a lengthy process that can be, but I had all of the required information prepared so it went fairly quickly.

At the end of this week I met with Dr. Cahalan, Chair of Utah’s Anesthesiology Department, to get to know him better and to get his advice on what I can do to make myself a more competitive applicant for residency.

I was also able to attend the department’s research conference this week as well as another seminar for the residents on the topic of airway management.  I have read the assigned readings before each resident seminar and it has really enriched my understanding of the material.

I also had three more patients for the Interscalene Brachial Plexus project that I am working on, so I have managed to stay plenty busy. Lastly, I was able to attend one more grand rounds where a number of difficult cases were presented and discussed. Dr. Hopf and I met one last time to discuss future plans and goals, and to discuss how the summer went.

I had a very positive experience here and I have loved every minute of it.  I have learned a tremendous amount about both anesthesia and research, and it is most definitely an experience that I will always remember.