ASRA Pain Medicine Update

Cite as: Patel S. Impact of COVID-19 on training in the United Kingdom: starting anesthetics amidst a pandemic. ASRA News. 2021;46. https://doi.org/10.52211/asra050121.037.

Just over a year ago, after squeezing into a suit and compulsively checking my portfolio for anything missed, I headed toward the waiting room getting ready for my core trainee interview for anesthetics. I was anticipating the interview questions and the course of my training pathway. Little did I know that I would start my anesthetic rotation during a major pandemic.

The precipitating months had felt like a never-ending wave of tragedy, both in my personal and work life. I had experienced grief on a different scale, and it would take some time to process. 

My route into anesthetics was not typical, although I have yet to find a trainee whose experience has been. I applied to medical school after a serendipitous conversation with a consultant on the train, who explained to me how my passion for mechanics could best be applied in medicine. At medical school, I enjoyed physiology and the practicality of surgery, which prompted me to apply for a research and clinical post in transplant surgery and regenerative medicine.

My interest in perioperative geriatrics grew in my first years of work, as I saw older adults denied surgical opportunities due to poor physiological reserve. I determined to pursue my training in the first perioperative geriatric center at the Guy’s and St Thomas’ university hospital in London, UK. Next, I needed to decide between specializing in internal medicine or anesthesia. I loved the anesthetic culture, the appreciation of human factors, and the balance between practical skills and theoretical knowledge. So, there I was, sitting in the waiting room awaiting for my turn to convince the interview panel that anesthesia was absolutely my career choice.

The year before my anesthetic training was due to start, I studied for a master’s degree in gerontology while working in a hospital to manage complex elderly patients. When COVID-19 overwhelmed London, the heterogeneity of my patients disappeared, and our wards became almost a palliative pathway. When elderly patients who were not suitable for intensive care arrived on our wards, we would optimize them as much as possible using the changing information we had. Management ranged from oxygen, awake proning, and chest physiotherapy, through to steroids and biologics. We formed closer bonds with our patients, partly due to the need for regular and frequent communication with family while they could not visit. It was appreciated how difficult it must be to be sick in solitude without family members close by, and vice versa. In the uncertainty of what was happening, we bound closer together. When patients recovered, we were ecstatic. When they did not, we found ourselves staring blankly at the required paperwork, unable to fathom how to answer the question “Cause of Death?”

After the first surge, I was given the opportunity to return to the study for my master’s degree. The precipitating months had felt like a never-ending wave of tragedy, both in my personal and work life. I had experienced grief on a different scale, and it would take some time to process. Rather than delaying my training, I decided to continue working on my master’s degree in my “spare” time, while also starting a full-time anesthetic job. I was seeking a balance between the proactivity of clinical work and the silent reflection of my master’s degree.

Following my experience of 2020, I decided I needed to truly invest in my well-being. The impact of the pandemic on my mental health had been subtle but tangible. I was emotionally fatigued and was waking up anticipating bad news. I had vivid dreams about patients I felt I had let down due to not knowing enough about coronavirus at the beginning of the pandemic. I would comb through my management of patients who had passed away, willing their death to have a purpose, to teach me how to prevent further tragedy. At this time, I discovered literature on burnout and post-traumatic stress disorder in the military, noting a link between community-belonging and resilience, which we had lost in our lockdown.

I became the well-being trainee representative and was tasked with identifying well-being needs, directing well-being projects such as creating community spirit, and obtaining warm food, shower facilities, and psychological support for those who needed them. Alongside some exceptional colleagues, we are developing further mindfulness and cognitive behavioral empowerment programs to address the systemic and personal issues faced by anesthesiologists. Trying to understand the causes of burnout and fatigue in trainees is akin to my perioperative research, with heterogeneous causes distilling into one tangled outcome. The most important lesson for me was that resilience would need to be multifaceted but centered around a sense of community and belonging.

In the meantime, I began anesthetic training. Amid COVID-19, we were overwhelmed by the sympathy expressed by our senior trainees for starting our training during such uncertain times. Naive as we were, we did not fully appreciate the meaning and reason for such sympathy. As fresh and excited anesthesia trainees, we were just happy to finally be on our dream pathway, learning new skills, and specializing in anesthesia. Little did we comprehend the deeper problems of starting our training with fewer intubation opportunities, modified anesthetic techniques, and missing the standard training in elective surgery for non-complex patients. Due to the shortage of hospital bed capacity, elective surgery was largely reduced and we noted the emergence of sicker patients requiring more complex surgeries. When there was a need to expand the intensive care unit (ICU), the surgical recovery centers were found to be ideal locations. Staff had suitable experience to manage intubated patients with critical care oversight. As trainees, we were included in the mix, and I had my first exposure to ICU. Although this gave me the best opportunities to develop certain skills such as with arterial line and central line insertions or management of medical problems, my already limited experience in anesthesia saw a dip, together with my confidence. Our muscle memory for skills such as bag-mask ventilation and direct laryngoscopy could not develop as we adapted to use video laryngoscopes to maximize the distance between our face to the patient’s airway. I recently returned to anesthesia for elective surgery, only to find that my “recipe” cards for anesthetics had been replaced somewhat with COVID-19 manifestation and treatment of pulmonary inflammation and fibrosis, hematological complications, cardiomyopathy, dermatology, and renal disease. Inevitably, my medical knowledge expanded, as well as my ability to recognize and prevent the complications of long-term ventilation and sedation. The management strategies also were rapidly evolving with new evidence emerging at lightning speed, requiring us to remember COVID-19 treatment options such as doses of dexamethasone or methylprednisolone when convincing evidence was demonstrated, tocilizumab, and anticoagulation specific to COVID-thrombosis. Practically, I quickly acquired basic ultrasound techniques for vascular access and echocardiography. I became more confident with interdepartmental transfers to scans and how to protect an intubated airway during patient maneuvers. Arguably, some of my experiences might translate into preoperative assessment, postoperative management, and basic muscle memory of airway management and ultrasound skills for regional blocks. However, the impact of inconsistent training for our first year of anesthetics also may contribute to a lack of confidence and fatigue as we progress to our next year.

This pandemic has shown the best and the worst of humanity. In fear and vulnerability, hospitals have adapted on a monumental scale to treat a nation in need. I have been awed by the strength of my colleagues, finding the time to implement hospital level changes, step in to cover colleague sickness, send care-packages to those isolating, generate rotas which could compensate for higher rates of sickness, all the while with their own worries for family, friends, and their own health. In particular, members of the consultant body, who had always seemed assured, were suddenly labelled vulnerable. Leading in such uncertain times, when their own risk was so high, gave me a newfound respect for what it means to be a consultant.

Through COVID, the tragedy of high mortality and morbidity will undoubtedly lead to differences in education, health (mental and physical), and finances. Whereas pre-COVID, these differences might have led to conflict, I am hopeful that we have now learned that at the crux of severe illness, we are all very much the same.

Sanya Patel, MD, is a first-year anesthesia resident at Guy’s and St Thomas’s Hospital in London, UK.

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