oh well hello there my name is max feinstein and i'm an anesthesia resident at the mount
sinai hospital in new york city where the days are getting shorter the temperature's getting colder
and that means there can only be one season in the air:
that's right it's application season for residency and fellowship and i thought
this would be the perfect opportunity for me to procrastinate on my own fellowship application
and make a video highlighting all of the sub-specialties of anesthesiology
anesthesia fellowships are all typically one year and are not required to do anesthesia,
but if you want to practice a certain subspecialty of anesthesia can be necessary or at least very
helpful for the job. in this video i'm going to be discussing the most common fellowships
in anesthesiology which include cardiac anesthesia, critical care, obstetric anesthesia,
pain management, pediatrics, and regional anesthesia. at the end of the video i'll also
mention some of the less common but also very interesting fellowships that are available for
anesthesiology graduates. if you find this video interesting or helpful i'd really appreciate it if
you liked it and subscribe to the channel. without further ado, let's dive in. the first subspecialty
i'd like to talk about is cardiac anesthesia and of course in order to talk about that i
have to be sitting in front of a cardiopulmonary bypass machine and put on my heart scrub cap
cardiac anesthesiologists receive special training not only for cardiac surgery but also for thoracic
surgery as well as vascular surgery. there are special types of equipment that are used
commonly in cardiac anesthesia and of course that includes a cardiopulmonary bypass machine that's
operated by a perfusionist, and then from the anesthesia side of things it's very common to
use transesophageal echocardiography, and also to use pulmonary artery catheters which are not
frequently seen in other types of surgeries. it's very common in cardiac anesthesia to be placing
big types of invasive lines for example central lines and arterial lines and it's common to be
using big types of pressers which you can see more about in this video that i made detailing
a cardiac anesthesia setup. some of the aspects of cardiac anesthesia that attract people to the
field include doing the procedures that i just mentioned as well as working with patients who
tend to be very sick. patients undergoing cardiac surgery tend to have pretty severe
cardiac or pulmonary pathophysiology so people who go into cardiac anesthesia
become extremely comfortable working with patients who are quite ill. one of the other
aspects of cardiac anesthesia that's very unique is going on cardiopulmonary bypass
which often entails stopping a patient's heart entirely and rerouting their blood to go through
this machine to get oxygenated and ventilated. that's something that's not frequently seen
outside of cardiac operating rooms. okay i think we can put this away and we'll move right along.
next up is critical care medicine which is a one year fellowship that allows anesthesiologists
to take care of patients in the ICU [intensive care unit] and typically this entails being in
the surgical ICUs or in the cardiothoracic ICU, so these are patients who are either
about to undergo surgery or are being managed in the post-surgical setting. one analogy that
i find interesting is that working in an operating room is actually very similar to working in an ICU
with the difference being that in the operating room you're taking care of one patient at a time
whereas an ICU can commonly have six eight ten or more patients. a lot of the same type of equipment
is used for example ventilators and a lot of the same medications are used for sedation purposes
and a lot of the same procedures are done like arterial lines, central lines, intubations,
and so forth. it's not uncommon for critical care anesthesiologists to split their time between
working in the ICU and also working as an anesthesiologist in the operating room.
one of the aspects of critical care anesthesia that i grappled with that sort of steered me away
from the field is the distinct lack of chairs and places to sit throughout the working day.
i'm just kidding. (kind of.) next up is obstetric anesthesia and as a resident i actually get quite
a bit of exposure to obstetric anesthesia but the reason why someone might want to
pursue a fellowship in it is so they can get specialized training in taking care of the
particularly sick patients who come in when they're pregnant. the types of illnesses that
obstetric anesthesiologists deal with commonly include bleeding disorders, neurologic disorders
or cardiac issues among a host of other types of disorders that can complicate the anesthesia
that's given during pregnancy. obstetric ORs are pretty unique for a number of reasons: the
first is that patients are typically awake during C-sections although that's not always the case,
and the other is that a patient's often accompanied by somebody who wants to be there
during the C-section and so we have a place for that person to sit. one really important aspect
of obstetric anesthesia training is becoming very facile with volume resuscitation in the
event of rapid blood loss, which is rare but can happen either during C-section or after
delivery. in these types of situations we have to be familiar with the medications that we
can safely administer that are going to increase uterine tone to decrease the amount of bleeding,
and the other aspect of it is to be able to deliver a large amount of fluids and
specifically blood products in a short period of time which can be done using a device called a
Belmont rapid infuser, which brings me to my last point about obstetric anesthesia training which is
there's a big focus on blood transfusion medicine because it's particularly important in this field.
next up is pain management... I'm just trying to figure out where to go -I'm
a little out of my element here, there are like carpets and exam rooms and stuff
ah yeah fluoroscopy, we're heading in the right direction. so as you can tell pain management is
very different from OR anesthesia principally because this is an office-based practice,
but there are a lot of procedures that go on which is a big reason why people enjoy
doing pain management, and i just stepped into the fluoroscopy suite which is primarily where
pain management specialists practice. unlike OR anesthesia where technically anesthesiologists are
consultants to the surgeons, the pain management specialist is a primary doctor who sees their own
patients in an outpatient setting and then can go ahead and do procedures here. as you can see
behind me fluoroscopy is used for pain management interventions so that the specialist can see
exactly where they're injecting medication. the types of interventions that are done in pain
management are very specialized and intended to treat longer-term chronic pain issues as opposed
to the types of interventions that are typically learned during anesthesia residency, which are
more focused on the perioperative period meaning immediately before, during, and after surgery.
next up is a subspecialty that's very near and dear to my heart, as well as the application
deadline for fellowship, which is pediatric anesthesia. i think the best way to summarize
pediatric anesthesia is with the old expression that "kids aren't just small adults" and what that
means is that pediatric patients have very unique anatomy and physiology which makes caring for them
pretty different from taking care of adult patients. for that reason there's even a whole
array of pediatric equipment that necessitates its own cart as seen right behind me next to the
adult anesthesia cart. one of the other aspects of pediatric anesthesia that can seem intimidating
is that when problems do arise, they tend to arise very quickly because pediatric patients have a
much lower functional reserve than adult patients on average. while general anesthesiologists
receive training in taking care of pediatric patients, it's not uncommon for hospitals to have
board-certified pediatric anesthesiologists to take care of the very young patients or pediatric
patients who are undergoing particularly complex surgeries. i'll also point out that there's even
more specialized training that one can receive after doing pediatric anesthesia fellowship
which is doing pediatric cardiac anesthesia, which focuses exclusively on cardiac surgery
for pediatric patients. of course one of the prerequisites for doing pediatric anesthesia
is having an affinity for bubble gum. the last of the more common subspecialties i'll cover is
regional anesthesia and acute pain medicine. this subspecialty is focused primarily on
doing nerve blocks which can range from spinals to epidurals to brachial plexus blocks, lumbosacral
plexus blocks, and all different kinds of nerves. pretty much if there's a nerve that you can block,
regional anesthesiologists can block it. one of the principal tools that regional
anesthesiologists use is an ultrasound like this one, which can be used to easily visualize
neurovascular structures so that a needle that's injecting local anesthetic can be
visualized during its entire trajectory, making regional anesthesia quite safe.
among the benefits of doing regional anesthesia include providing less systemic anesthesia which
can be particularly helpful when taking care of patients who have very severe systemic disease
and might not be able to tolerate a deep plane of general anesthesia. another benefit of regional
anesthesia is for longer term pain relief that can last hours or even days after surgery is done.
while performing blocks for regional anesthesia is a part of any general anesthesiologist's training,
the subspecialty training that regional anesthesiologists receive
is second to none. and because i went through the trouble to get an ultrasound to have as
a prop in this video i might as well just show you what my brachial plexus looks like
so for example if i wanted to have surgery on my upper arm right now i could inject local
anesthesia into this nerve bundle right here in what would be called a supraclavicular block
in addition to the fellowships i've already mentioned there are quite a few other options
available for anesthesiologists as well. those include liver transplant anesthesia,
and you can actually check out a video that i made showing the anesthesia setup for a
liver transplant case. there's anesthesia for ENT [ear, nose, and throat] which focuses on
head and neck pathology, for example difficult airways. there's anesthesia for neurosurgery,
and you can actually check out a video that i made where i interviewed the director of the
neuroanesthesia program at mount sinai hospital. there's also international and global health,
perioperative and ambulatory medicine, palliative and hospice care, addiction medicine,
simulation, and clinical informatics. i've included links in the description below if
you want to find out more information about any of these fellowships. well
that wraps up this video and i should probably get back to working on my own application for
pediatric anesthesia fellowship so thanks very much for watching and i'll see you next time