Tonight will be my fifth “Team Captain”, or “TC” call. The standard anesthesiology overnight call team at my training program includes an attending, a senior resident (the TC), a junior resident (the assistant TC, or ATC), and two first-year residents. There are also six “short call” people who typically go home somewhere between 1800 and 2230.
This call team is distinct from other call teams, which include a cardiac call team (an attending and a resident or fellow who take home call), an ICU call team (an attending who takes home call, two in-house fellows, and a handful of residents/physician assistants/nurse practitioners), the Pain Management night-float resident, the pediatric call team (an attending and a senior resident or fellow who take home call), and the obstetrical anesthesia call team (an attending, a night-float resident, and a 24-hour resident). There’s also a liver transplant attending who only comes in as needed.
The Team Captain functions as a junior attending. He is the point person for the OR desk when new cases need to be scheduled. He delegates responsibility to the various team members, including setting up operating rooms and assigning cases. He speaks with the surgeons if there are issues that need resolved before a case proceeds. He is the first person the junior residents call if they have intraoperative problems. He manages the PACU (Post-Anesthesia Care Unit). He advocates with the ICU fellow for ICU care for appropriate patients. He resonds to requests for “stat intubations” and medical codes in the hospital wards and sometimes even the emergency department. On occasion, he assists the pediatric team or advises the pain resident. He orders food for the team.
When starting a case, the TC generally aims to have a room set up, the patient’s pre-operative evaluation done, the junior resident briefed, and the patient in the room before the attending is called. This way, the attending can simply swoop in, sit in the corner of the room while the TC induces anesthesia, and then stumble back to bed. Of course, if there are medical or anesthetic concerns, the attending will be called much earlier at the TC’s discretion.
In sum, this is a multifaceted, interesting, and challenging role. I think it’s one of the strengths of my training program, since it prepares us not only to be anesthesiologists, but to be managers of the entire perioperative process. After every one of my team captain calls, I’ve thought, “I should come home and write a post about this.” Unfortunately, in my sleep-deprived state, I usually collapse on my bed for a good four or five hours and awaken in an afternoon haze, when writing is the last thing I want to do.
Some notable parts of my last TC call:
- Reintubating a post-operative patient in respiratory distress within fifteen minutes of my arrival and within thirty minutes of his arrival in the recovery room.
- Getting something on the order of 30 pages between 1600 and 2200. This averages out to only five pages per hour, but when they come in quick succession, it sure feels like a lot!
- Managing multiple ICU level patients in the recovery room (PACU) who were there because the ICU was full. Their problems included mild myocardial infarctions (heart attacks), profound bradycardia (slow heart rate), and hypotension/sepsis (low blood pressure due to a bloodstream infection).
- Putting in a subclavian central line (a large IV just under the collar-bone) all by myself. Regrettably, anesthesiologists at my institution are a little paranoid about subclavian lines because of the increased risk of pneumothorax (accidentally puncturing the lung and developing an air leak around the lung, preventing it from inflating fully and requiring a chest-tube placed between the ribs to help re-inflate the lung). I’d done nearly 40 of them as an intern, but only 1 or 2 as an anesthesiology resident. This PACU patient already had a chest tube from his surgery (and he needed a central line), so I figured it was a good time to put in a subclavian, since the treatment for the potential pneumothorax was already there! It was gratifying to get blood returned from the subclavian vein on the very first try.
- Bread-and-butter PACU problems like post-operative pain in a shoulder surgery patient requiring massive opioid doses when his nerve block wore off (I nearly asked the attending if he would supervise me placing another nerve block for post-operative pain), managing fussy epidural catheters, taking care of routine post-operative respiratory failure, etc.
- Starting two “ASA 5E” cases almost simutaneously at 0630. When I got the calls about these cases within minutes of each other, I paged the entire call team, because I knew I would need everyone’s help. See next few bullet points…
- The first case I was evaluating was a 65 year old woman in the medical ICU (MICU) who appeared to have dead intestines and was looking sicker by the minute (with no invasive blood pressure monitoring). While starting to look at her chart, I got called by the neurosurgery resident…
- “We have a 35 year old with a subdural hemorrhage who’s dying. We need to come down [from the neurological ICU] right now.” When a neurosurgeon says that a patient is dying and they need to come now, I tend to believe him. I told him to come right away, and I had two of my team members meet me there.
- Within minutes we had the neuro case underway, and I returned to the MICU to help transport the general surgery patient. With very little down-time, the patient was intubated and the surgery was underway. The patient’s femoral (groin) central line was difficult to access, besides not being a very “clean” site, so I slipped in a neck line under the drapes. Given her short neck and obesity, this was going to be potentially challenging. I had one of the first-year residents retract the patient’s breast under the drape so as to stay out of my field while I quickly prepped with a sterile cleaning solution, draped, and cannulated the internal jugular vein with only one minor redirection of the needle. By this time, it was 0730, and I turned the case over to the attending and resident who’d come on for the day.
One last side note–because the job of TC is so demanding and because we expect to get no sleep and to be on our feet almost the entire night, the shift begins at 1600 and ends at 0700 the following morning. In comparison to my ICU calls, TC call doesn’t involve the same level of acuity (since most of the patients I’m dealing with are not ICU-level patients) and it’s more in my comfort zone (dealing with intra-op and post-op issues is what I’ve mainly been doing for two years, compared with only two or three months in the ICU). However, there’s no “wall” of an intern or junior resident between the TC and the PACU “nonsense”, so I’m the first up to deal with everything from simple issues like low urine output or a patient missing standard post-op orders, to more complicated problems. Thus, by about midnight, I usually feel a bit like a trampoline which is stretched equally in all directions. But overall, I’ve found the calls to be challenging, interesting, and often rather fun but exhausting.