From Physio to Propofol: Dr Smith Reflects on His First Six Months in Anaesthesia

GasGasGas.uk Podcast Interview Episode #1

We cover everything: imposter syndrome, paediatric airways, moral injury on call, mastering the ventilator, and finally learning to trust yourself at the end of the syringe.

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From Football Dreams to ITU to Anaesthesia

Before medicine, James was an ITU physiotherapist for five years. He came into medical school with one goal: to become an anaesthetist. Why? The perfect blend of physiology, pharmacology, and critical decision-making. His journey from multidisciplinary teamwork on ICU to wielding the laryngoscope was driven by a desire to work at the cutting edge of acute medicine.

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Starting in Theatres: Confusion, Fatigue, and Facing the Fear

James’ first weeks in theatre were, in his words, “a fog of indecision and anxiety.”

• First lesson? The importance of airway skills over textbook knowledge.
• Strategy? He delayed studying formal pharmacology and focused on watching, doing, and surviving.
• “Every consultant gave a different dose of propofol – I didn’t know who was right. I just knew I was lost.”

A local novice course became a turning point, introducing structure and a chance to catch his breath.

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Key Moments: When It Finally Clicked

About 2.5 months in, James started to feel competent:

• He passed the “college tutor test” with a smooth solo anaesthetic.
• A paediatric list initially crushed his confidence — until someone noticed his “wandering little fingers” were obstructing airways. A tiny change in hand position transformed his technique.
• From that point forward, he was able to consistently manage paediatric face masks and started to feel he belonged.

“It was the first day I held every airway. That felt like a win.”

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Difficult Cases & Difficult People

James shared some powerful stories of being on call without immediate consultant presence.

Case 1: The Septic Amputation  

• Critically acidotic patient with a ph < 7.0
• Consultant declined to attend: “Just do a low-dose spinal.”
• James and the registrar performed the anaesthetic themselves, bolusing adrenaline as needed.

Case 2: Escalating Surgical Pressure  

• An operation converted into a laparotomy under spinal.
• With no senior anaesthetist present, the surgeon became aggressive.
• James: “I was shouted at mid-theatre. I felt small, powerless.”

These moments are not uncommon in anaesthetic training. Stress inoculation is real — but it must be balanced with safety and support.

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How He Manages Decision Fatigue

James keeps it simple: ABCDE, every time.

• Focus on one variable at a time.
• Take extra minutes in the anaesthetic room to get everything right before entering theatre.
• Checklists, preparation, and reflection are his tools of choice.

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Culture in Theatres: What No One Prepares You For

• Recovery nurses and ODAs expect anaesthetic leadership — even when you’re new.
• Surgeons can be helpful allies or deeply frustrating.
• “Civility Saves Lives” isn’t just a slogan. Rudeness degrades team function.

“I learned the hard way that shouting doesn’t speed up a GA — it makes it worse.”

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Coping & Resilience: Running Through It

How does he stay sane?

• Long-distance cycling and running.
• Talking with peers — not just supervisors.
• Honest self-reflection and a healthy sense of humour.

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Looking Ahead: The Primary FRCA, and Beyond

James is just beginning his Primary FRCA preparation.

• “It’s not revision. It’s learning from scratch.”
• He’s pacing himself over months, focusing on core concepts and applying knowledge practically.

He’s also off to India for a month on ITU — adding international perspective to his training.

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Future Interests

• ICU remains a passion, but cardiac and paediatric anaesthesia also appeal.
• Obstetrics? “We’ll see,” he says with a smile. “I’m not convinced yet.”

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Advice for Students & Juniors

James offers this advice to anyone thinking about anaesthesia:

1. Embrace your placements. Reflect on what excites you.
2. Use your taster days wisely. Try cardiac, neuro, paeds, regional if possible.
3. Talk about your experiences. Reflection is a learning tool.
4. Be honest about your limits. But don’t be afraid to push your comfort zone (safely).
5. Anaesthesia is a team sport. Build relationships, stay kind, and ask for help early.

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Key Takeaways

• Anaesthetic training is messy, exhausting, and rewarding.
• Airway skills take time. Don’t expect to be good at them early.
• Speak up when you feel unsafe.
• Learn from failures — they are part of growth.
• You’re never truly alone — but you need to speak up to get support.

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References & Resources

• Civility Saves Lives
• RCoA Training Hub
• e-Learning Anaesthesia Programme
• GasGasGas.uk

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Final Thoughts

James’ story is deeply familiar to anyone who’s ever started in anaesthesia. The path from fear to fluency is never straight — but it’s always worth it. If you’re heading into your novice block, we hope this episode gave you courage, perspective, and a few useful airway tips along the way.

Listen now on Spotify, Apple Podcasts, orwherever you get your podcasts...

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“Thanks for listening guys… Every day you are getting better at this. Take it day by day, don’t overcook yourself, don’t freak out, and keep studying!”

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Transcript

Gas Gas Gas: Interview with James – Early Anaesthetic Training Journey

Introduction and Background

00:00-01:02

So hello everyone, this is James at Gas Gas Gas. Today we have a different variety of episode. It’s not someone getting vivid, it’s not me telling you pharmacological things. It is in fact me interviewing one of my junior colleagues about their choices and life choices about anaesthesia. His name is James, but I’m going to let him introduce himself to you.

So my name’s James. I’m one of the CT2 ACCS anaesthetic trainees. I started two years ago just after COVID. I was previously, before I did any medicine, an intensive care physiotherapist. So that was my steer of why I wanted to do anaesthetic training and ideally wanted to do dual training. Before I was even a physio, I used to play football and thought that was a fantastic career opportunity, but that sadly didn’t take off.

I’ve worked on ITU for a number of years, five years before doing medicine, so have quite a good experience of intensive care, but not purely anaesthetic.

Why Anaesthetics?

01:02-01:44

All right, okay. Why anaesthetics then? Why not something else? Why medicine? I went into medicine purely to do anaesthetics. I had no interest in other surgical skills, wielding a scalpel. I was always interested in the fact that anaesthetics and intensive care brought physiology and medicine together, where you make the patient better, you make your diagnosis with a little bit of support from your medical colleagues or surgical colleagues, but you are the one looking after the sickest patient. And you’re essentially the buck stops with you. And I quite liked that. I felt like you were looking after the sickest patients at the pinnacle of cutting-edge medicine.

First Day in Theatre

01:44-03:00

Cool, yeah. So, the idea or the purpose behind this podcast episode is to try and broach the realities of that first introductory wodge of anaesthetic training and what it is like trying to make the ventilator ventilate people and trying to pick a drug and a dose and not stressing too hard about it, which is a journey everyone’s had to take from being clueless and terrified to moderately knowledge-filled and still terrified.

So tell us about your first day in theatre, James. Did it go well?

So my first day in theatre was with a consultant who essentially told me these three months that I had coming up would be the best three months of my life on the grounds that I would spend 40 hours a week at work learning one-to-one, and then could spend the rest of my time doing whatever else I fancied doing – cycling, running, going off climbing, anything I fancied out of work.

So he pushed me to do other things other than learn anaesthetics at that point in time and just embrace it and accept that within those three months I’d become good enough with a bit of work to become safe enough to go on call.

Early Learning Approach

03:00-04:15

And did you do lots of other things or did you go home and study every night? No, I did loads of other things, trying to avoid studying any anaesthetics, any particular stuff that I really should know. I tried to avoid it for the first month because I felt like in my first days in theatre, I had no idea what was going on with patients.

I was giving a dose of a medication in one day, giving a different dose another day. I had no idea why there was a rhyme or reason why I was doing that. Someone would give a different dose of propofol, then someone else would choose a different induction agent. And I had, you know, maybe in hindsight I should have looked that up and thought about it a bit sooner, but I thought I’ll try and embrace those clinical skills to try and actually understand what I’m doing and how to manage the airway first in the first month rather than learning the chemistry or the pharmacology behind it.

Ah, so I would have loved that advice because someone told me, “Well, in these three months you need to go from having no idea to a fair bit of an idea, so you best be studying” and I did all the e-learning for health introductory anaesthetic competence online packages, all of them. And did they help? Oh yeah, look at me now. Anyway, this isn’t about me, it’s about you, James.

Early Challenges

04:15-05:25

So what were the challenges in those first few weeks? Were you really knackered? Everyone says they’re really tired all the time. Well, I was exhausted every day and I don’t know whether that was my lack of competence of holding an airway and gassing myself down with sevoflurane, or whether it was just embracing a skill that I really just couldn’t grasp at all.

So some days I managed to hold an airway and felt, “You know, I can do this and that’s fine.” And then other days I’d be holding an airway and someone would have to take over because I couldn’t hold the airway. They would then occlude or obstruct their airway and I’d be thinking, “Well, if I was doing this by myself, the patient would be dead, and that would be my fault.” Terrifying.

And I think that was, I then, about a month and a half in, got to that fear level that I’d done no work and I’d embraced what that consultant had told me to go and enjoy my tasks and realised I probably didn’t have a good enough understanding of what I was doing so then went and did a bit of learning.

Structured Learning Support

05:25-06:20

We had a lovely course in our area where we essentially got taught the basics of anaesthetics within the first – but that started a month in. So we then got taught all the basics of the gases, we got taught the basics of different intravenous medications, different types of analgesics that you could use post-operatively, intra-operatively and then obviously other more complex things like simple nerve blocks. And that helped.

I think that helped and it made me feel like I wasn’t having to go home every single night when I was exhausted trying to learn all of that, because where do you even start with learning stuff when there’s so much to learn? And e-learning for health is just enormous. There’s so much on that e-learning for health. Some of it is really relevant, some of it’s less relevant and great for the primary, but it becomes so big and you just get weighed down in mud with it basically.

I’m super proud of that certificate that I got. It was digitally produced that says, “Well done, Doctor, you’ve done the packages” and I was like, “Yes,” uploading that to the portfolio.

Decision Fatigue and Learning Curve

06:20-08:01

I was just going to say, I think one of the things that people don’t realise is that the amount of decisions you’re making when you first start – there’s an alarm. Is that something I should act upon? Do I need to change the dose of anaesthetic? Is it not enough oxygen? Too much oxygen? There’s thousands of micro-decisions you’re making every moment that now you already know your tolerance for how much oxygen a patient should have or “oh that’s just the diathermy messing with the ECG.”

But when you start, everything is a long type 1 thinking process: am I happy? What is going on? Why is it going on? Have I experienced this before? What should I do this time? What did I do last time? All those thoughts go through your head for each alarm, each buzz, each wriggle, each “oh, the patient’s moving when they’re not.”

So, there’s a huge amount of decision fatigue as well. I think people don’t notice that. And I think what consultants do so well is they micromanage that and they manage it so perfectly and so well in that moment. But when you’re trying to watch that as their junior, you have no idea what they’re doing and why they’re turning that down and why they’re turning that up and what they’re responding to. And sometimes if they don’t tell you that, you don’t learn it.

Early Coping Strategies

08:01-09:03

And I felt like when I was first on call, I wanted to make sure my patient was just deep, because then I had control and I could give them vasopressors to boost their blood pressure. Now that’s the wrong way. That’s a poor anaesthetic and then they’ll get post-operative nausea and vomiting and all the other nasty complications that come with it. Delirium.

Absolutely. And I think I only started to learn that micromanagement decision making when I actually had to do it all when you’re on the sharp end. When it matters. When the boss stops.

Breakthrough Moments

09:03-10:27

So, in those early months, was there a moment that stands out to you that you thought, “Ah, now I’m succeeding?” And I want you to tell me this truthfully, James, so the listeners who are thinking, “Oh god, I’m going to start anaesthesia, it sounds awful,” know there’s light at the end of the tunnel.

I don’t think it started to click until about two and a half months in, where there was talk of me going on call. And I’d been with the college tutor on like my first week, and then all of a sudden I was put with her two and a half months in, hadn’t been with her since, and I knew that was a test. So I made sure that what I was doing I’d read up on the patients and had my plan of my anaesthetic that I was gonna give. And it all went perfectly smoothly, and that felt like the test that I was like, “Well, this has worked and this is fine.”

But I also knew there were multiple other complications that could have gone wrong that day. And I think the prime example I have is I think I had a paediatric dental list – sixteen children of varying ages and I did it maybe two months in. I think I managed to hold one paediatric airway that entire day. And I was so demoralised.

Learning from Feedback

10:27-11:21

I kept asking the consultant, the ODP, “What am I doing? What’s going wrong? What do I need to do? I just can’t hold their airway open. They just obstruct their airway after a gas induction.” And I was so demoralised, so upset. I did so much googling at home to try and figure out what my hand position was, despite having a consultant telling me, “I still don’t know what you’re doing wrong,” and you know, it’s tiny little adjustments that he’d take over straight away and the airway would be open. And I couldn’t get grasp of it.

And there was – I then was with a different consultant maybe two weeks later who said “you just have wandering little fingers, they wander onto the soft tissues very subtly, and you, because children are soft and pliable, those little fingers wandering will make your life a misery.” And I then asked to go back with this other consultant and I held every single airway that day.

Oh, that was great. And that was because of my wandering little fingers that someone else picked up, not the consultant who was there. But that was the time that I knew it had clicked and I knew that holding those simple airways, it just felt like it had worked and I felt comfortable enough that he could be out of the room holding paediatric airways.

Technical Note on Gas Inductions

11:21-11:47

I’d like to just jump in and say that if you’re doing a gas induction, there is a phase where they get partial airway obstruction. And you can’t stop it, it just happens. So don’t beat yourself too hard in the foot either about that first adventure, because everyone’s like, “no, no, no, it’s you, you’re wrong,” but they get a hyper-excitable laryngeal liveliness phase as they’re getting off to sleep and everyone just looks at you and says when actually it’s just pharmacological.

Just to be explicit here, guys, still means you have to keep that airway open. It’s just harder at this point in that gas induction. You might worry about putting a Guedel in, because if they’re a bit light, maybe you tip them into laryngospasm. Generally awkward. Just keep their airway open as best you can and see that you’re getting that trace and that chest movement and it’s not seesaw breathing. And you’ve just got a grizzly.

Developing Vigilance and Systematic Approaches

11:47-13:41

And that is exactly how I felt going home that night. I felt like the previous two months I’d learned nothing. And that’s 320 hours of training already. Gosh, I should have been able to hold an airway by then. Well, that’s what I felt. That I clearly couldn’t. Yeah. Well, that’s all learning, isn’t it?

So going back to managing that anaesthetic on your own and the bosses in the coffee room, how did you manage to adjust to trying to make all those little micro decisions and maintaining the vigilance of being able to do your paperwork, read the news on your phone, but also know exactly when to stand up and fiddle with the anaesthetic?

So I’ll tell you, there’ll be no reading news and no doing paperwork on my first couple of months of solo anaesthetics. I was so vigilant towards what I was doing. I probably couldn’t focus on anything else. And that’s explained to a T when my first on call I did alone and did an abscess or something like that. Someone asked me what I’d done the night before on my own call and I said “I’ve no idea what operation they did but the patient survived through my anaesthetic and they woke up at the end” and that was because I was so focused on it.

I guess focusing on the micromanagement stuff, I have checklists just in my head, and I just keep it as simple as the ABCDE that you’ve literally got from medical school that I’ve grown up with, I know it as ABCDE and that’s how I use it.

Systematic Pre-operative Approach

13:41-14:49

So I always have that checklist just to make sure and I take as much time as I fancy in the anaesthetic room to make sure that I’ve got everything ready so that when those doors open from the anaesthetic room and the surgeons want to pounce on the patient and everyone else wants to pounce, that I’ve actually done everything that I wanted to. I’ve given all my medications that I wanted to. I’ve given the antibiotics. I felt like that just, you know, what’s five minutes of my time versus the twenty minutes of the operation that they still want?

You know, ultimately you’re the one keeping the patient alive at the end of the syringe and making sure that they’re stable. So I don’t think taking that time to just manage each individual thing in an ABCDE approach is the way that I do it.

So making sure that I actually check what the tube length is where it’s going into the lip. Making sure that I actually look at the ventilator and check their peak airway pressures when I start because then I know whether my tube’s in too far. Because if it’s really high, is it in too far? Am I doing the right thing? What pressures on my ventilator?

But those are the things that I do. Make sure I’ve got a blood pressure post-induction. Make sure I’ve checked their rhythm on the ECG strip, because I have been caught off by changes in telemetry on ECGs, which you know, we put ECG stickers on and are we just looking at the rate, are we looking at the rhythm?

Building Confidence and Problem-Solving

14:49-15:32

But I now am very fixated on making sure I know what the rhythm is first when they come to the anaesthetic room and then making sure that I’ve prepared enough drugs to keep them asleep. Always have drugs drawn up but also bring the drugs with you. Put them on the patient. The patient is your perfect tray. If they all fall off the tray, it will cause a loud bang and everyone will help you pick them up off the floor when it happens, because it will happen, and it’s happened to me many times.

And I guess I ended up doing a lot of TIVA and was taught a lot on TIVA and felt probably more uncomfortable about doing gas anaesthetics. So I felt like I wanted to do more gas anaesthetics on my own to build my confidence, because I don’t think you build your confidence until you do it by yourself.

And also, I always wanted, if I needed help, at least try and think about what’s going on before calling for help, so that you’ve got help on the way, because it’s not always immediate. But make sure you’ve called for help but then make sure you actually problem solve what’s going on. If I never problem solved, I would never know. If you just call your consultant with a problem but no solutions then you’ve not bothered to think of it.

Transition to Broader Management

15:32-17:25

Oh, I had another question. At some point you’ve got to make a transition from micromanaging to seeing the big picture and managing more than just your anaesthetic if you’ve got lots of other things happening all at once. How do you feel about making that transition?

So I’m definitely still in that transition phase. You know, I’ve been on call for six months now, maybe a bit less. I’ve not done many, I’ve done as a full-time trainee enough. I still am very focused on my anaesthetic and can probably forget that there’s other things going on like an operation that are important.

When I’ve spent ages in the anaesthetic room and the surgeons decided to go off for a coffee and then the patient comes into theatre and their blood pressure’s in the eighties and you know, all I want is the surgeons to have scrubbed and started poking and prodding and giving them that stimulus so that their blood pressure gets better. I’m already chasing my tail with vasopressors trying to boost their blood pressure and make the numbers look normal. So I don’t feel like I’m there yet.

And I think maybe as I get more slicker with my anaesthetic and doing things where I feel more comfortable to leave the comfort of my anaesthetic room into theatre, maybe that will get better. And it definitely has. I don’t give my drugs anymore, all of them in the anaesthetic room. I give them in theatre when I get in and get settled. So I’ve started that transition, but I’m still very much doing things to make sure that I’m safe.

Challenging Case: The Septic Patient

17:25-19:49

It sounds like you’ve had quite a lot of fun in the last few months establishing yourself on the anaesthetic rota. Are there any particularly memorable moments or cases or things that happened or comedic moments? Tell me about a moment that seemed a bit challenging when you were on call, James.

So this was probably only a few months ago and we had a patient who was critically unwell, acidotic, had an obvious source of sepsis from an ischaemic foot. We don’t even have Vascular on site here. Vascular said, “We’ll drive over to your hospital and you need to anaesthetise this patient to essentially allow us to amputate.”

Now, patient had a pH below seven, profoundly septic, probably not fit enough for any form of general anaesthetic. And I, as what I define as a novice, felt remarkably uncomfortable about anaesthetising anyone like this without support. And we called the on-call consultant who just said, “Well, just put a low-dose spinal in and if he survives, it’ll be good. I don’t have to come in.”

And to be fair, it was myself and the registrar, and I said I just did not feel comfortable dealing with that as a problem and it took all three of us essentially enough courage to stand there with a very low dose 1.5ml spinal, which I’d never put in anyone either. The registrar doing it, me giving small boluses of adrenaline whilst worrying “is this patient going to make it through this operation, let alone my anaesthetic here?”

And I think that just made me feel quite uncomfortable because I didn’t have that consultant support but what I will also say is what could they have done apart from being there and providing that level of support? There were three of us there who were all free and available to help each other and we did it, we did it safely, the patient survived and I think it’s those times that make you challenge yourself and actually improve yourself in a patient who was really sick but we managed to get better through careful thinking and being pushed out of our comfort zone.

Stress Inoculation and Support Systems

19:49-21:46

Because a consultant coming in for that is kind of more just like a liability sponge at that point in time. As opposed to actually – well yeah, ’cause he’d already provided his clinical opinion of a low-dose spinal and what’s to change that? He’s going to put the same amount of spinal in in the same way, apart from tiny micro adjustments and micromanagement as we’ve already talked about. But he’d given us that advice on the phone. But I still felt uncomfortable as a new novice.

Stress inoculation. And that’s the crux of it, isn’t it? All within reason though. Like, you can’t just pass straight in day one and just think “I’m gonna tube this overdose in recovery on my own,” ’cause you just don’t know what you don’t know ultimately.

And I also think what probably isn’t shared about is – and it is talked about when you’re on anaesthetics, but probably what isn’t – is that when you pass IAC and you go on call, you don’t just start anaesthetising anyone willy-nilly by yourself, doing things alone. At 6pm at night there’s normally consultants around, there’s an ITU consultant free, there’s normally a registrar free, there’s someone in Obstetrics.

You know, there are lots of people around, and as long as I have a rule of thumb that I just tell them if I’m anaesthetising someone so that they don’t go and then scrub for a central line that could be done in 20 minutes and wait for me to just make sure the patient is safely off to sleep without complaint and make sure the poor SHO isn’t going to come across a complex, difficult airway that’s then going to need front of neck access.

Almost like so they can plan their time. In your mind you think you’re alone, you’re not. As long as the bleep system doesn’t fail, you’re fine. Have their mobile numbers, have them written on the wall. That is worth having. It makes your life much easier because I have been in a situation in an emergency where the bleep system failed and then I was dealing with a challenging situation and the cavalry were not coming. Not great. Always fine in the end.

Working with Theatre Teams

21:46-22:50

How have you found working in the theatre complex with the recovery nurses, the ODPs, integrating with the surgeons and managing their expectations?

So it’s a totally different environment to the ward. You are very well respected and your opinion is quite highly sought upon. So from your nursing colleagues and other theatre staff, I think, particularly when I obviously had no idea what was going on and people would ask my opinion and I was always quite clear about how junior I was and most departments, they have quite their departments are made quite well aware of who the novice is and who’s a danger to themselves but also others and should be supervised at all times. So I think that’s quite nice.

I think working with surgical teams, it’s great as long as you get them on board with you and you get to do things together. I think it becomes a challenge when you’re dealing with things by yourself in different times.

Difficult Surgeon Encounter

22:50-29:09

I’ve done procedures by myself under a spinal that then a consultant said, “I haven’t had my consultant with me, he’s at home or she’s at home,” and then they have said, “Well, we need to open this patient up a lot bigger” and when they define a lot bigger, I start raising more questions of “are you defining this now as a laparotomy? Should my consultant be there?” but it was going relatively smoothly. The patient had a perfectly good spinal, it was working well. They were on some conscious sedation, so I could speak to them, but they were tolerating it perfectly fine.

At that point in time where obviously I was thinking about what to do, “Do I call someone first? Do I put them off to sleep? What do I do?” And I was thinking, “Well I don’t put anyone off to sleep without telling someone so I’ll tell someone and I’ll ring my consultant.” So I rang my consultant to just explain “this is what’s happening, I’m happy here doing this, but this is turning into a laparotomy now,” and I’d quite like someone – it was handover time, so they said they would call the next consultant.

But in that moment of speaking to my consultant, the surgeon became quite frustrated that I wasn’t making decisions quick enough, which obviously to a novice, you’re not going to make quick decisions and split-second decisions and say, “Yes, I’m just going to put the patient straight off to sleep and I’ve not drawn any drugs up.” It’s not as simple as that. It doesn’t become “I’ll just put them off to sleep straight away.”

And I think at that point in time the surgeon became quite frustrated with me and the situation that possibly they were losing control of their surgical situation and taking it out on me and wanted the patient to be asleep to gain a bit more control quicker.

Now, I was shouted at then in the theatre, which obviously made me feel hugely small and I already felt small enough that I don’t know a huge amount of what I’m doing. I can get someone safely through a simple procedure, but this turning into a laparotomy with bleeding going on, I’m thinking they now need an arterial line. If I’m going to put them off to sleep, I need to really gently put them off to sleep because they’ve got a spinal on board. I don’t want a full general anaesthetic as well on top of that. I wanted to have enough, and I didn’t have senior support with me.

So I called then for a registrar to come, seen the patient before, and they were very supportive, and that was very nice, and took a bit more control of that theatre environment. But we were still being shouted at by the surgeon, and that communication just broke down and it was a real challenge.

Not having your consultant there to support you when you’ve got a consultant surgeon shouting at you became a big challenge and I found that very stressful. I felt I probably had done a bad job when in probably reflection of it, I’d actually done a relatively good job. I thought thoroughly about the patient – that they had a spinal, they should have a gentle GA, they probably should have an arterial line, would they need HDU post-operatively? I started creating those bigger plans, but whilst being shouted at at the same time.

Learning from Difficult Situations

29:09-32:17

That was just a bit of a traumatic experience, and I’ve probably not had that in my novice period where I was protected under a consultant’s umbrella of loveliness and authority, because I didn’t feel I have any authority. I’m just getting someone through an anaesthetic and cobbling it together.

That does sound very unpleasant. If you were in that situation again, is there anything you would do differently? It sounds like I would just get the consultant on the bleep and just demand their presence if I’d have been in your situation.

So I think that’s probably what I would have done is that I needed the consultant to come in straight away rather than be happy to wait for the other one. I think I was too soft and too nice. And you don’t want to rub anyone up the wrong way, particularly when you’re starting. You don’t want to get a reputation for yourself that you are arrogant or that you know hugely what you’re doing. You want to come across that you have a good understanding and a safe grasp of what you’re doing to practise safely, but also enough authority to get people to do things quickly and come and help you. Because if I need help, I need help.

I probably could have called for other senior support in the hospital who was there, that then I’d have – there are in the hospital I work in there are three anaesthetists and having more of you there creates a united front against such confrontational activity. Outnumber the shouty person. Then you divide the shouting amongst multiple people, and someone can deal with the surgeon whilst the anaesthetic is managed.

And putting someone off to sleep is not a two-minute process, especially when they’re on the table and you’re drawing up drugs. They’ve got bleeding to control. You’re trying to support their blood pressure at the same time as prepping everything to make sure you’ve got the right equipment. Your ODP is already running around asking for everything that you already asked for. So it became a challenge.

Coping Strategies and Peer Support

32:17-30:54

That sounds like human factors. And then it becomes a case of having someone orchestrating things and everyone having a task that they can safely focus on. And you don’t manage this by yourself ever during your novice period. Well you don’t – if that happened during your novice period, your consultant’s in the coffee room or in their office they would come down and help and support you. This happens on call. This is the first time you’ve had to deal with a difficult surgeon.

And I think you need to have a bit of resilience, but I wish I had a little bit more authority. But I probably didn’t have that authority because I lacked confidence. Because you’re in an uncertain situation and it’s very human to feel a bit on shaky ground if it’s new.

That sounds like it was educational on reflection, but perhaps quite stressful during. I think so, yeah. You’re still here though, so you’ve not packed it off and become a GP. Anyway, so sounds like that was quite stressful. Did you go home and moan about it to your loved ones? Did you go do some exercise? Did you just think, “Screw this, I’m going to bed and had a hot chocolate?” Did you do anything to sort of balance things out?

My way of always dealing with that is a long cycle, rather than long cycle, something to just basically exert myself to a point where I have to push whatever has happened that day out of my mind. So that’s my way of doing it. That sounds like an excellent coping strategy. And I talk about it. I was never afraid of talking about it and sharing my challenges with people and why it was difficult and why it became a challenge and I think it’s good to talk to your peers about it.

Everyone tells you to talk to your clinical supervisor, your educational supervisor. They are consultants at the end of the day. They’re the ones who are being called in at the end of a telephone. So they’re not the ones who can recall how – they were years ago – and actually talking to your peers about it, your couple of years above SHOs or registrar colleagues who have just come out of core training. I think talking to them about it was really useful because everyone shares similar experiences of how they were made to feel like that because of their lack of confidence as well. And I think your confidence will only improve as you do more and more and more.

Civility and Team Performance

30:54-32:17

I think it’s an appropriate time to plug there’s this campaign called Civility Saves and being pleasant and civil to your colleagues makes the team perform better. I bet you in that environment when that surgeon was throwing their toys out of the pram, the performance of the theatre team as a whole deteriorated. People might have dropped stuff or got the wrong kit.

So, in actual fact, the wording that was used was the surgeon was just shouting at me “GA, GA, GA, GA, GA, G-A,” repetitively. And what the theatre team – they got stuck on a boot loop – the scrub nurse was getting a device to cut the bowel, a GIA stapler. So they went to – they actually got one out and then showed it to the surgeon because they couldn’t grasp that the surgeon was wanting me to give the patient the GA so she could extend the incision.

So I think that’s just clear there how the rest of the team’s communication broke down. People weren’t listening to what was actually happening and no one took charge and took control. And in hindsight, I should have been more authoritative and spoken. Told them to calm down. ‘Cause it sounds like their GCS on the voice side of things was two with incomprehensible sounds. Surgeons aren’t meant to have a low GCS.

Surprises in Early Training

32:17-35:08

Oh, we’ve got loads more questions to go, James. How are you doing? Oh, I’m alright. Are you feeling full of joy? Just about – it’s really easy to interview someone with the same name as you ’cause you can’t forget it.

Is there anything that surprised you that you didn’t expect when starting your airway competencies? How difficult it was. You thought it would just be like, “oh, they make it look easy.” They do. Everyone makes it look easy. Every single person makes it look so simple. They don’t look like they’re struggling, they don’t look like they’re finding it hard, they don’t leave imprints on the patient’s face from holding onto the mask too tight. They don’t – everyone makes it look really easy and it’s not.

And I think I didn’t recognise that until a month or so in until I just accepted “yes I could hold some, yes, I couldn’t hold others.” And I think I had a consultant once who essentially, about two months in, picked me up on my airway management skills and this consultant is very blasé, comes across as not paying attention to what you’re doing and having a laugh and a joke and he’s really good to work with.

And it came across that way and then I’d done the GA, the patient got off to sleep absolutely fine, they were safe, the tube was in. Afterwards he then picked me up and said “you hold the mask like this. If you turn your hand by about thirty degrees so that you’re holding the other side of the mask a bit better, and if you hold your laryngoscope in two positions, you hold it in one position, if you change your hand position when you actually go to lift upwards, you will therefore have much better mouth opening, you’ll be able to have a better view.”

No one had picked me up on that the whole time. And because I’ve got big hands and I can combat that – I can fudge an anaesthetic and I can fudge it – but actually after that one month I don’t think I’ve missed, touch wood now, a single airway, and I’ve managed to hold every single face mask since that moment. And I’ve changed my anaesthetic technique to change the exact position of my hand on the mask. And that was only – that was two months in.

That’s coaching, isn’t it? And I think it’s easy for consultants sometimes to let you have a go, and they, in their mind, they probably create this concept of, “well, you need to learn how it works for you because an anaesthetic is different in everyone’s hands.”

I think it’s probably worth asking people, isn’t it, to be like, “I’m struggling with this. Could you watch me do it and coach me through the positives after the patient’s asleep?” And sort of demand what you want from them.

It was always that leak on the left or the right side of the cheek where the ODP’s holding the cheek up into the mask. It was always that. Always. And now I don’t get that. Difficult bigger airways, maybe, when you use a two-handed technique, but the thing that surprised me most is how easy it looks and how difficult it is in my hands. And it’s got easier, definitely got easier. But it’s not something I’ll tell you it’s easy to hold an airway because it’s just not. And that would – a consultant who’s done it for 30 years might say it’s easy, but they’ve just lost insight into their own skills because it’s become so ingrained. And then that actually makes you feel small again, doesn’t it? The buggers.

Next Steps in Training

35:08-38:16

So next steps. What’s next with your training? Have you got any things you’re looking forward to or any highlights?

So I am starting my revision for the primary. I was late into it. Well, not late. I just tried to embrace anaesthetics, embrace the novice period, embrace going on call, and just accept that I wouldn’t have as much clinical pharmacology knowledge, but I could hopefully get the basics right. And I hope to feel like, well, I feel like I’ve managed that, but now I feel like I’m dragging a bit behind in my knowledge of it.

So I’ve started revision for the primary, I’ve started a course. Is it revision or is it learning? It’s learning, because it’s not even revision, it’s like a postgraduate specialty. You’ve not covered pKa at medical school. At least I didn’t. Well no. So it’s learning, it’s not even revision. So you’ve got to give yourself some slack, haven’t you? You can’t beat yourself up.

And I’ve started really early because I don’t want to do this cram for three months and feel like I’ve given myself a miserable life. I’d rather just do a bit consistently and accept it and try and apply it practically and think about it day to day – what I’ve learnt yesterday about PK and drugs, concentrations, etcetera. Try and apply that a bit clinically in my mind while sitting in theatre and learning about that.

And if you just cram it all in three months, you’re helping yourself, but you’re not helping your patients in six months’ time when you’ve forgotten it all. I feel like, and also I won’t be helping myself for my final, I won’t be helping myself with my viva, the oral part. I feel like you can fudge a bit of a paper-based exam, but an oral exam, if you don’t know the basics, you can really be torn apart and be made to look a bit silly. It becomes rapidly obvious if you can’t explain something.

So I think if I have a good understanding of it, then I should progress. Ah, I know there’s great podcasts that might help you out with your practice and your knowledge and learning. Oh, what’s that? I think it might be called Gas Gas Gas. It’s on Spotify, it’s on Apple, it’s everywhere. It’s like a rash.

I’ve also signed up to go to India for a month, essentially like a medical elective out there on ITU, which the study budget will not pay for, but other than that they’ll give me study time off for it and they’ve said it won’t class as part of my training, but it doesn’t matter because it’s study time. So I’m going to ITU in a different country to do something slightly different. Hopefully I’ll have a bit of a grasp and understanding of ITU at this point and that will hopefully help me progress through training having a different perspective. Gosh, buckle up, that’s gonna be wild. I bet, very busy. You’ll be a busy sausage. You’ll need lots of coffee.

Subspecialty Interests

38:16-40:18

Are there any subspecialties in anaesthesia that interest you? I mean I’m guessing ITU, although they might argue that that’s not a subspecialty anymore, they’re their own specialty. Anything else?

I guess as a novice you’re not exposed to any of them. So you’ve got no exposure and you’ve therefore got very little understanding of what you don’t know. I had a few days – I saw some neurosurgery that looked cool, but the operations looked long and I can’t say I love sitting in the anaesthetic room for hours on end waiting for the operation to be done. I prefer that higher turnover of patients.

There’s cardiac. I quite like that. I think you’re really taking people to the absolute edge of life there which was why I liked anaesthetics and ITU in the first place. I think I’d want to learn about almost killing but not killing people, doctor. Oh dear that sounds like a worrying interest – none of that, we’re all very safe here.

So I think that would be something that I’d want to experience a bit more. I’ve obviously got an obstetrics block coming up. That’s something that I know I have to do, can’t say I’m hugely looking forward to it. Yeah, it’s a bit like Marmite, obstetrics. You either love it or you hate it. So I’m not convinced.

And I did like paediatrics. I did an SSC in medical school for – I managed to intubate an oesophagus three times after convincing a consultant that I knew what the vocal cords looked like at the end of the laryngoscope, and that was the oesophagus. So I did like that until I really couldn’t manage a paediatric airway and now I feel like maybe I do like it. But I’m still unsure. And if I feel like I’m not very good at something, why would I want to do it? We will see.

It is unlike – kiddies are just unsettling unless you’re doing it all the time. And I think then the paeds hospital are just like, “well, of course you can,” it’s like you might feel like that, but we might not feel like that.

Advice for Aspiring Anaesthetists

40:18-43:59

So thinking more about future things, I’m sure there’s people listening who are interested in anaesthesia, be that junior doctors and medical students, James. Is there any advice you could give them about getting to where you are sat right now? Living the dream. Living the absolute dream.

So I think advice would be – I was obviously fortunate, I’d had a previous career in ITU, so I probably haven’t had to do the extracurricular things because it was already in my person specification that I handed in. I think as a medical student just embrace your anaesthetics placements that you go on. You’ll get four weeks, probably some on ITU, some in anaesthetics, maybe some in ED. Embrace that. Make sure you have good experiences and reflect on what you’ve learned.

So if you see a difficult case or something going that’s more challenging than just a simple anaesthetic, reflect on that and think about why you like doing that and what’s important to you there because even in your anaesthetic interviews you can still talk about that. Utilise – as a junior doctor utilise your taster days, you get five taster days. I was fortunate enough that someone just gave me a taster programme and basically gave me cardiac, they gave me neuro, they gave me orthopaedics. I said I was disinterested in ITU because I’d already had that experience and wanted to have theatre time.

If they don’t give you – if they say “what do you want to do?” try and just get a breadth of everything because I still haven’t experienced everything at all yet, and I probably won’t for many, many years. Having that experience to talk about in interview about what you learnt and what you saw, why you were so interested in it, and how it’s different to another specialty.

You are very much, in my opinion, one-to-one with your patient. ITU is a bit different, but you’re one-to-one with your patient. They are your sole focus. You might have a couple of other patients in the back of your mind thinking about, but it’s the only specialty where you get that one-to-one care that you can deliver. You can sort their pain out. It’s literally at the end of a syringe you can sort their pain out. You can make them stop vomiting, you’re there to look after and put them at ease.

And you’re basically putting them to sleep and bringing them back from the brink of death. Oh, James, that sounds very cheesy. They’re not on the brink of death, they’re just anaesthetised. But you’re bringing them back from that point and making them better, and yes, you’re not fixing the absolute pathology, but you’re the one there supporting them.

And patients often are more terrified about waking up from the anaesthetic than they are about the surgeon. Which is mad. I think that’s the – I’d be like, “Of course I’m gonna wake up, the drugs wear off, but what if the surgeon fudges something?” That’s my human reaction to that.

So yeah, I think there’s a lot of trust put into anaesthetists by patients that we maybe don’t appreciate fully sometimes. And I think that trust is earned – you earn it by going to see your patient before an operation and spending a bit of time and talking them through an anaesthetic and how it happens.

And I think you forget about that where actually if you haven’t seen them preoperatively, bringing them to the anaesthetic room and they see an unfamiliar face isn’t so nice anymore. They’re not comfortable. And I, even on my own calls, I like to go and see my own patients, even if it’s just to wave at them and say “Here’s my face, this is who you’re going to see.” Because they’ll be far more at ease than someone who “oh my goodness, you’re not the person who saw me this morning at seven o’clock” or “oh, thank goodness, you’re not the person I saw this morning at 7am who’s been here all night.”

Exam Preparation and Personal Qualities

43:59-45:06

Okay, so it sounds like you’re telling people to try and get as much experience and exposure to anaesthesia before applying as they can. I think to mention, the exams are hard, but good things in life are hard to obtain, so don’t worry about that, because you get loads of support. And I haven’t worried about it. I am the prime example that I have not thought about the exam, I’ve got onto a training programme, I’ve got through the novice period.

You don’t need the exam until you start getting through it and you can learn for the exam but the exam is really, really hard. Unless you’re a smart tool in the box, which I’m going to tell you I’m not, and you don’t need to be to get into anaesthetics. You just need to be a normal, nice person who can reflect on their bad things that they’re not very good at and reflect on the good things to try and improve the bad things.

That’s what they want from an anaesthetist, is someone who will reflect with honesty and integrity. So in an interview where they ask you, “what are you bad at? When have you managed a patient’s pain really badly? What have you done wrong?” Make sure you have a good example of that because that just shows that you’re an honest and humble person and genuine person who understands their weaknesses, not gonna be a bull in a china shop around an anaesthetic room and kill someone in their own bravado.

They don’t like bravado, which is fair.

Retrospective Advice

45:06-47:40

I’m going to ask you then, James, if you could go back six months, what advice would you give yourself? It’s gonna be stuff – studying from the off, isn’t it?

I still don’t think it would be start studying from the off. I think I feel like I did it a good way. I would like to have a little bit better understanding. And I think understanding some of those basics of medication dosages, how they work, what is what, how they act. I think would be useful, and I do think a little bit of that rather than what I did was nothing. I think a little bit of that is important.

Casual “what’s propofol?” As opposed to “is this milk?” “What’s this white solution that everyone seems to inject?” So some general definitions of stuff and like “this is what this is” and “this water circuit is a Mapleson C” and just like little bits of – it’s not all completely mad.

Because obviously I just came in, there was a tube attached to an anaesthetic machine that was attached to some gas somewhere that then just fell through my system and put the patient off to sleep, and there was this milky stuff on the side that I knew was propofol and that I knew I should give one to two milligrams. But maybe learning a little bit more than that and about – and then I could apply that knowledge and hopefully it would have made my learning a bit quicker by having an appreciation for that.

Because I think it’s important to have insight into what style of learning you handle. Because some people do learn best by just piling in and having guardrails around them courtesy of a consultant that stops them causing bother. But other people like to study neurotically beforehand so they’ve got all the cards. So when they see something, they’re like, “I’ve read about this, so therefore I feel safer.” I am that person, as you probably can guess.

And other people find themselves in the middle where they want to work in groups or explore and discuss before they do stuff. So you’ve got to find, I think, how you study and leverage that. And hopefully by now most people have a bit of a grip of what style of learning they like.

I think my style of learning is very much I have to see something practically to make sure then I have an understanding of it. And having a little bit of an understanding of the physiology behind it or the pharmacology behind it first is useful because then I can apply that. But sometimes it’s the other way around. I want to see it first, do it, and then I can think about the pharmacology afterwards. Just knowing how you learn as James said.

Overall Experience and Training Programme

47:40-50:23

Okay, so just to close up, was it a positive experience doing IAC? Genuinely, I’m a better doctor now. I feel it’s probably one of the best training programmes, and I’m biased because I’m in it, but one of the best training programmes you could have and go into. You’re so well supported for three months. They do not push you to go on call.

There is this taboo of “you’re going on call and you’re going to be left alone.” You are not left alone. Someone is there to support you. And if you say at six thirty, “Do you mind just coming round for induction of this patient? Just make sure that I can get the tube in. You don’t need to be in the anaesthetic room, but I’d like you to be outside the doors. Is that okay? I’ll wait 20 minutes if you’re busy doing something.” There is no harm in saying that.

And you need to have that ability to speak up because of your lack of confidence at that time because you’re not hugely confident and you shouldn’t be hugely confident. But you should be aware of the risks of it, and if you are aware of that, you can speak up and say what you want. And I think that’s something that is really important to get across: is that you shouldn’t feel like you’re by yourself doing things alone.

It is a great experience, you’re allowed to do whatever you want for your learning. If you want to do the induction, you do it. If you want to deliver the drugs, you deliver the drugs. If you want to do the lines, you do all the lines, the central line. As long as you say what you want and what you want to get out of it, everyone will support you because you’re here to learn and to be trained one to one by a consultant, by a registrar, and it’s a great experience. And I feel a million times better doctor and have a better understanding of things, having done it.

Portfolio Management

50:23-51:35

I’ve actually thought of one more question, which is how did you find the portfolio?

The portfolio is a challenge in itself because you have a certain mythical set of goals to achieve. So you have a certain mythical set of goals to achieve that you must complete by the time you get to your next level. You must have completed an RSI and done all of this. And everyone wants to offer you completing these work-based placement assessments.

And then they kind of just leave it up to you how to write it so just having a bit more structure, getting one to two a week is what I would recommend. One or two simple things, it can be just holding an airway, it can be doing an RSI, delivering the drugs, emergence from anaesthetic, dealing with a complication within the anaesthetic, just different things. And if you discuss things, just say “can I write a case-based discussion on it? Can I send you a ticket?” is my opening line. And you almost sometimes get too many, but then not everyone signs them off, so you kind of gotta do a bit of scattering.

And sometimes you have to keep a track on who’s signing them off. I didn’t ever find it too challenging, but I’m just quite methodical in what I do and make sure that I follow them up if they’re not signed off. You’ve spent twenty minutes writing it up on a portfolio – one email to say, “Do you mind signing this off when you get a chance?”

I actually find it’s worth once you’ve done your anaesthetic and your bits and the patient’s tucked in and the surgeon’s starting to fiddle around is saying, “Right, boss, I’m just going to go write that ticket we said we’d do, and I’ll send it to you now” because otherwise, you’re going to end up getting home, spending all your bloody life writing stuff. And you do end up spending – you get two tickets in a day, they’re 20 minutes, half an hour each. And once you’ve forgotten it at home, it turns into half an hour, 40 minutes.

Then you feel like you’ve spent the whole evening, you’re home at six o’clock, seven o’clock, and you’re doing tickets. So I agree with that sentiment: go to the coffee room, don’t chat to people, write that ticket out. Or just tap it into your portfolio with like the date, time, who you’re sending it to and approximately what you did so that you can then go back and top it up later.

Final Thoughts

51:35-52:38

Alright, well James for putting up with so many questions and being interviewed. Obviously I’ve not asked you any merciless questions about the Nernst equation, but I’m sure that’s to come. Have you got any last thoughts or anything you’d like to mention?

Any ideas, concerns or expectations? I know that’s what you meant to ask at the end of an interview. The idea of doing anaesthetics is something that everyone should have. And you should not have concerns going into it at all. And you should expect to be delighted. You should expect to be delighted, and you should expect that the on-calls will be fun and challenging and push you to your limits of competence in hopefully a safe way. And I’ve found relatively safe ways.

No one’s gonna let you do anything daft because there’s loads of paperwork. That’s my feeling. Anyway, everyone else, thanks for listening. If you enjoyed it, please like and subscribe, tell your mates about it if you’ve got anyone interested in anaesthesia and you think maybe this is the podcast for them. Let them know. Feel free to email me if you want any questions to go to James and I will forward them to him and let you know the answers. Cheers!

And thank you very much, James, for taking the time to get involved. Thank you very much. All right, okay, cheers, James. All right, bye.