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January 22, 2021

'Why to we always have to use the same technique?' — Another selection from 'Think Like An Anesthesiologist'


A number of peeps asked for more after I featured a selection from my never-completed above-titled book.

Your wish is my demand; it follows.


One complaint I frequently heard from residents during my years as an anesthesia attending was that every general anesthetic employed fentanyl, midazolam, propofol, succinylcholine, nitrous oxide, vecuronium, neostigmine, and glycopyrrolate.

Same drugs, same sequence, every single case.

"Can't we try something else?"


"Why not?"

"Because you don't have a clue about giving anesthesia. So the best thing you can do to get better is to use the same drugs the same way in every single patient for a couple months."

"But that's boring."

"Boring? Yes, very boring. Good anesthesia is boring. Nothing happens out of the ordinary."

"But how will I learn how to use other drugs?"

"With all the other attendings who will be more than happy to humor your enterprising, inquisitive nature."

"You're no fun."

"I'm not paid to be fun. I'm paid to be safe. So are you."


It seemed obvious to me then and it still does today [2006] — 11 years after I left academic anesthesia for private practice — that if you use the same drugs the same way thousands of times in that many different patients, over time a pattern of responses develops such that an unusual event instantly appears as if in lights, highlighted against a deep historical backdrop.

If the only variable is the patient, then the patient can tell you everything you need to know to fix something right after you recognize it as an anomaly.

Very sad to me was one resident who, finishing his third and final year in our program and slotted for a fantastically lucrative job upon completion of his residency, returned to the ready room after each day's cases remarking, "An amazing thing happened to me today."

If an amazing thing happened to him during his day's cases every single day after three years of training, he really didn't have a clue about giving anesthesia.

Because no competent resident has any business being amazed more than occasionally after three years of training and thousands of cases.

That amazement heralded an upcoming world of complications and misery for both the resident and his patients in the years to come.

Hey, don't get me wrong: He was a great guy and I liked him a lot — when he wasn't giving anesthesia in one of my rooms.

Some people just don't get it — and they never will.

January 22, 2021 at 02:01 PM | Permalink


When I had surgery to put my leg back together after a bad break, I thought it important to trust the skills of my surgeon, but I thought it vital to know and trust my anesthesiologist.

Posted by: antares | Jan 22, 2021 4:28:44 PM

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