Life On The Job

Anaesthetic Registrar - Traudi Almhofer

This "A Day in the Life of an Anaesthetic Registrar" is taken directly from On the Wards.org and published on 15 July 2017.


Day in the Life

Start of Day

"As I stumble into the changeroom at 7.15am on a Tuesday morning, I wonder what the day will have in store for me. Today I am the designated ward registrar for the morning in a busy public hospital. After changing into my scrubs, I head to the office to receive handover from the night registrar. She looks weary, having been up for most of the night operating on a series of urgent cases – a paediatric appendicectomy, an exploratory laparotomy, and an emergency caesarean section. There have been a few calls to follow up on about patients with acute pain, a couple of epidurals for women in the birthing suite, and several cases that have been booked for the emergency list the following day. One of those patients is an older man named Max. With a multitude of cardiac and respiratory comorbidities, he will need a perioperative review prior to his upcoming surgery. My day is starting to take shape…

First Job of Day

My first job for the day will be to accompany the acute pain nurses on their ward round for the morning. There are about 20 patients that will need to be seen. For some patients, the consultation will be mercifully brief and may only require checking that their regional anaesthetic block has worn off, or switching from parenteral to oral analgesia. Inevitably, however, the acute pain team will be consulted to see patients with complex pain histories, and uncontrolled acute or chronic pain. One of these patients happened to be John, a 63 year old man who had recently undergone an above knee amputation for severe peripheral vascular disease. I can see that he is suffering, his face is tense, his brow sweaty. Despite his patient-controlled analgesia (PCA), Ketamine infusion, sciatic nerve infusion, and multitude of oral analgesics, his phantom leg pain is out of control. I feel somewhat helpless – I can’t offer him an epidural because his antiplatelet therapy places him at high risk of bleeding around the spinal cord. An IV lignocaine infusion may help, but this would potentially cause local anaesthetic toxicity in combination with the sciatic nerve block. We realised we were caught between a rock and a hard place. After some discussion, we agree to trial calcitonin – it’s expensive and it may not work, but we have run out of other options.



Traudie Almhofer
Deakin University promotion - PDF p.33
(Source: Deakin University)

Code Blue

Toward the end of our visit with John, a ‘Code Blue’ rings out overhead. I apologise to John and hastily make my way to the medical emergency occurring on the other side of the hospital. As I arrive there are crowds gathered outside the gentleman’s room. He has a small bowel obstruction, and his proximal gut is so distended that he is unable to use his diaphragm effectively to breathe. I introduce myself to the intensivist leading the charge, and gain a quick history of preceding events. The plan is to transfer the patient to the intensive care unit until a surgical theatre becomes available. But we could see the patient is tiring, and with impending respiratory failure evident, we make the decision to intubate the patient prior to transfer. Hands trembling from adrenaline, I gather my equipment together – laryngoscope -‘check!’ – endotracheal tube-‘check!’ – syringe -‘check!’ – bougie-‘check!’ -. With fluid pouring out of his nasogastric tube, he is at high risk of aspiration. I make a quick assessment of his airway, and deliver 100% oxygen via a non-rebreather mask – despite this, his oxygen saturation never makes it past 89%. “Are we ready to go?” I ask. The nurse beside me provides cricoid pressure as the intensivist administers the drugs. ‘Propofol in’. ‘Sux in’. And then we wait. As the drugs take effect, I grasp my laryngoscope, and look into his airway. My heart sinks – all I can see is his epiglottis without any sight of his vocal cords to guide my tube placement. In the background, I can hear the tone of the oximeter changing as the man’s saturations fall. I take the tube and guide it underneath his epiglottis, hoping for the best. I connect the self-inflating bag and thankfully his chest moves as I squeeze the bag. My hands are shaking as I tie the tube into place and breathe a sigh of relief. I can’t help but feel that on this occasion I have made a lucky escape.

Traudi Almhofer at work
Dr. Traudi at work in Barwon Hospital, Geelong, 2019
(Source: Barwon Health)

Max

Having stabilised the patient in the intensive care unit, it was onto the next job of seeing Max who was booked for a laparoscopic cholecystectomy to treat his gallbladder infection. I take a look through his file – cardiac bypass grafts, heart failure, diabetes. Previous anaesthetic charts indicate that he has a “difficult airway” and when I walk into his room, I can see why. Obese, scarred bull neck, no chin. When I ask, Max tells me he has very severe sleep apnoea but hasn’t gotten around to organising a CPAP machine yet. As we talk, an anaesthetic plan starts coming together in my mind. Once done, I explain my plan of attack – because of his heart, we will need to order an echo preoperatively, and use an arterial line to keep a close eye on his blood pressure. Because of his sleep apnoea, he will need to be transferred to ICU postoperatively. I then advise him that because of his difficult airway, we will need to intubate his trachea using only local anaesthetic – while he is awake. Unfortunately, this last recommendation becomes a major sticking point, and after some thought, the patient withdraws his consent for the surgery. I am disappointed with the outcome, but the risk of any other technique for Max was simply too high.

Afternoon List

Finally, it’s time to start my afternoon list – a single case – a laparoscopic left sided hemicolectomy for bowel cancer in an otherwise well woman. As I put in my drips and arterial line we chat about work, kids, holidays, and the excellent safety record of modern anaesthesia. Part of my job is reducing the anxiety that every patient feels when they enter the operating room. The conversation continues as I inject the propofol that renders her unconscious. I intubate the airway, set the ventilator, and position the patient for surgery while taking care of pressure areas. I administer a carefully balanced cocktail of medications to maintain anaesthesia, provide analgesia, prevent nausea, paralyse the muscles, and control her blood pressure. A warming blanket helps to keep her temperature normal. Lastly, I organise a plan for pain-relief and hydration for after the operation before sitting down to write my notes. I will continue to monitor her for the next three hours, making adjustments as necessary to maintain homeostasis until it is time to wake her up. Provided there are no intraoperative complications the remainder of the day should go smoothly, but after a hectic morning I am looking forward to a more predictable afternoon.

My Unique Job

As I sit in my chair, I am reminded of why I love my job. Every day is unique, and every day offers an opportunity to try something different, learn something new, and make a small difference to someone who truly needs it."

 

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The following information is taken directly from Facebook - Inspiring Doctors, February 7, 2019

Profile #38 – Dr. Traudi Almhofer

Specialty:
Anaesthetic Registrar

Current practice:
University Hospital Geelong

Degrees:
Bachelor of Nursing 2005
MBBS 2011
Master of Medicine 2017

Traudi Almhofer
Dr Traudi Almhofer
(Source: Facebook)

Childhood aspirations?
I remember when I was very little wanting to be a range of inanimate objects, in particular a truck, or a power station. As I grew a little older I wanted to be a florist, and then a vet. The vet thing stuck with me for a very long time due to my love of animals, but alas on my year 10 work experience placement I realised how allergic I was to so many of them also.

Pathway to medicine?

My mother always wanted me to be a doctor. Unfortunately, due to a medical error, her cancer was not diagnosed until it had metastasised widely and she passed away when I was 15 years old. I hated the medical profession for taking her away from me, and I vowed I would never become “one of them”. Instead I began studying disability studies, then changed to bachelor of psychology which was just not a good fit for me. I then changed into a Bachelor of nursing degree. I didn’t enjoy the classwork, but I loved the hands on clinical side, and felt very privileged to be caring for patients during a period of vulnerability. Despite this, I never felt particularly challenged by nursing, and I felt uncomfortable with knowing what I was supposed to do, without knowing why I was doing it. Throughout my nursing practice I met doctors who inspired me greatly, and I met others who were, to be honest, not very pleasant to patients and nursing staff alike, and I wondered why they were even in the profession to begin with. By this time some of the wounds had healed and I thought I might have something to more to offer. So I sat the GAMSAT. No-one was more surprised than me when I passed, let alone was offered a place at Deakin University.

Pathway to your specialty?

My pathway began on my very first day at med school. I remember being surrounded by all of these incredibly intelligent and socially fluent people, and feeling so awkward and out of my league - I felt like a complete fraud and felt like I didn’t really fit the mould. By the end of the first week of biochemistry I was terrified I wouldn’t even make it through the first semester. I threw myself into studying my guts out, and it became a pattern of behaviour to cope with the social anxiety and fear of failure that I was experiencing. Given most of our marks were pass/fail, I had no idea that I was actually doing quite well and at the end of my degree I was shocked to learn that I had achieved a number of awards, including the dux of my year. I think this made me stand out to employers and I was offered my preference of internship and placements. I worked hard through internship and residency and received very positive assessments, which I believe gave me leverage in getting the rotations I wanted, which I geared toward a critical care specialty. I adored my anaesthetic rotations - I loved the procedural aspect of the specialty, the pharmacological manipulation of physiological variables, and the brief, but intense patient relationships that you develop. While teamwork is essential, the team is often quite intimate and it is still fairly independent practice - there is a lot of time where it is just you and the (often unconscious) patient - this suited my social misfit personality to a tee. I felt so comfortable in the theatre environment, anaesthesia was a natural choice for me. I arrived early and left late, saw all my patients, came up with plans, read widely, and asked lots of questions. Thankfully my bosses saw my potential, and I was offered a training position as a PGY4.

Dr Traudi Almhofer examing patient
Dr Traudi gives patient a health check
(Source: The Standard)

What gives you joy in your life?

My two children are the reason I breathe. The smell of their hair, the way their eyes light up when I get home from work, the unconditional love they give, their peaceful faces as they drift off to sleep, and the cuddles….oh the cuddles. They make every shitty thing you’ve experienced that day just melt away…

How do you balance that with a career in medicine?

Not well! Theatre hours are usually quite long, a fair amount of shift work, and there are two exams to study for. Throw in a Masters degree and a few other courses, travel time, and suddenly you rarely see your children. But sometimes you need a reminder to prioritise what is truly important in life, and for me this came in the form of my son’s autism diagnosis. I realised that I needed to be a more focused and deliberate parent going forward. As I was thrown into the world of a ‘therapy mum” it became very clear that advocating for my child would consume a significant portion of my time and mental and emotional reserve. There was no way I could reconcile this with my desire to be a perfect registrar and I’ve had to settle for just being “good enough”. This year I have made the decision to prioritise my children and my health further, and hence have moved to regional Victoria for a more relaxed pace of life, less travel time, and an anaesthetic department that is very supportive of work-life balance.

How do you look after your own well being?

Another work in progress! By PGY5 I had progressively socially isolated myself and training/exams had consumed me. I recognised that I was burned out but chose to ignore those warning signs as I didn’t want to be a burden to the department I worked for, or my family. My burnout deteriorated into major anxiety and depression which affected my confidence at work and my relationships with family and friends. I am ashamed to admit that I used self harm to emotionally regulate myself, and occasionally questioned the point of my existence. Finally it clicked that this was not normal, and I sought help from my GP. I was on an SSRI by the end of the consultation, and I’ve never looked back. I have chosen to be open about my experience with mental illness to raise awareness, and to help address the stigma, but also so those who know me can recognise if I deteriorate again. I try to regularly check in with my brain to see if we’re doing ok, and I keep in regular contact with my GP. It’s still hard to carve out time for myself, but I’m getting much better at saying no to additional tasks. I’ve learned to recognise when I am vulnerable and that reaching out for help is not a sign of failure.

What are you most proud of in your life?

I am proud that I have been able to maintain my humility and compassion in my practice.
I am proud of my husband who was man enough to step up and fill the (many) gaps that my training and illness left.
I am proud of the two amazing humans that I have brought into the world.
But I am most proud of my son - he has had to work so hard for every milestone he has achieved, but he lives each day with such joy, and he is so kind, fair, and just. He is my greatest teacher.

What makes you unique as a doctor?

I have a fair amount of lived experience, which means I often relate well to many of my patients and can help them feel at ease relatively quickly. Also, I understand more about the nursing role and their scope of practice and hence have been able to develop great relationships with many of the fabulous nurses I work with which makes for a great team environment.

If you could send a message back in time, what would you say to yourself ten years ago?

Back yourself, you can do it!
And for goodness sake, put your own oxygen mask on first.

 

 

 

Activities

The Vocabulary of an Anaesthetic Registrar!

PrimaryPrimary MiddleMiddle  High SchoolSecondary

LiteracyAustralian Curriculum General Capability: Literacy

1. As you read through the sections of Dr Traudi's life, you would have come across words you didn't recognise.

Write down as many words as possible in a list. Compare with a partner.

2. Using a Word Cloud, such as WordCloud Generator by MonkeyLearn, create an Anaesthetic Registrar's Wordle.

3. Using Merriam-Webster's Medical Dictionary, look up and write up the meaning of 3 words you thought were interesting!

Medical Dictionary

 

 

 

 

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