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Today’s inane image of the day:

Caption: Legit all of the resources I used to study for the BASIC. Admittedly, I didn’t finish all of the things here, but I only advocate/recommend products I’ve purchased and used myself. Introduction

First and foremost, check out my original article on all of the resources for the in-training exam (ITE) and BASIC exam. If you opened that entry and immediately thought, TL;DR… or you only care about how to study for the BASIC exam, this is the entry for you.

Some basics about the BASIC

From the ABA:

The BASIC Examination, the first in the series of exams, will be offered to residents at the end of their CA-1 year. It focuses on the scientific basis of clinical anesthetic practice and will concentrate on content areas such as pharmacology, physiology, anatomy, anesthesia equipment and monitoring.

http://www.theaba.org/Exams/BASIC-(Staged-Exam)/About-BASIC-(Staged-Exam)

There is always a summer [June] and fall [November] administration of the exam. Exact dates can be found on the ABA website. For each administration, there are two days – you have no say in which day you are going to take it [believe me, I tried to request a specific date from the ABA for my ADVANCED exam since I’m running the Medical Women’s International Association Centennial Congress [#MWIA100] during the weekend of my exam… and I got the date I didn’t want, heh].

The exam isn’t cheap – $775-$1275; sign up once they announce that you’re able to register so you don’t have to shell out an extra $500 for waiting. My program reimbursed us for this exam and the ADVANCED, so make sure you save your receipt.

The exam has 200 questions and you have 4 hours to complete it. As you’ll see from the sample questions, they’re pretty short and to the point.

How do you have any credibility to advise me?

Well, I passed my exam [first attempt, June of my CA1 year]. That’s a start, don’t you think?

I’ve also incorporated recommendations from Peter Brown’s book, “Make it Stick: The Science of Successful Learning” into my entry. For example, spaced repetition, active learning approaches, and doing questions in random mode [not doing a set of questions related only to the subject you just reviewed]. I highly recommend reading this book at some point, especially if you’re interested in a career in education.

WAMC [what are my chances] of passing? Show me the data!

Lucky you, the ABA has this useful data to guide your likelihood of success: 2017 ABA Exams Report.

Pass rates based on your ITE score:

I’d like to highlight that the norms table from the 2018 ITE shows that for CA1s, 31-32 translates into 46-55%ile. Using this information with the data presented in the table above, if your ITE score was average, you fall into the 94% BASIC pass rate [*raises hand* that was me!]. And if you are more awesome than average, you’ll most definitely pass.

If you’re curious about overall pass rate for the BASIC exam:

Here’s another table with some vital information — for the 1,696 candidates that took the exam in June 2017 [oh hey, I’m one of those candidates!], they had an 88.4% pass rate! This slightly down from the June 2016 pass rate of 90.7% [a similar document is available for 2016 through the ABA] but are still pretty good odds.

The most important thing to take away from this, is that you probably have good odds of passing, BUT you shouldn’t neglect the exam altogether! After all, it’s not a 100% pass rate.

Pick your adventure…

Anesthesiology residents come in numerous varieties and are enrolled in a diverse range of programs. This means that what works for one resident may not work for another resident. This means that the amount of time that a resident has at one program to study may not align with another resident. This also means that the availability of resources may also differ. I’m writing this entry to try to address a couple of different scenarios, but I’m delineating the different “adventures” [in a somewhat snarky manner] based on time to examination.

Here are your options [these are fancy anchor links, so either read the whole entry with all the options or jump straight down to the one that is applicable to you!]:

Gunner Style [1+ year prior to the exam]

Casual Studier [3-6 months prior to exam]

Procrastinator [1-3 months prior to the exam]

Gunner Style [1+ year prior to the exam]

If you’re seriously an intern looking into studying for the BASIC exam, I applaud your planning and motivation. I also wonder if you could send some of your ambition and drive this way to me?

Anyway, there are a ton of resources out there if you’re really more than a year out from your exam. I’d say the most difficult thing about trying to tackle studying for the BASIC exam before you’ve started clinical anesthesiology training [unless you’re at a categorical program that integrates anesthesiology rotations into your intern year or elected to do an anesthesia elective rotation] is that… well, you don’t have a ton of context or background in the material you’re studying. A lot of the material will be difficult to learn without a patient, experience or person around to explain why a topic actually matters. Either way, you can still start trying to lay the foundation for your anesthesiology practice.

If you’re at an internship that requires the anesthesiology in-training exam, then that is a good launching point for determining where you’re at. When you get your score report, there will be a page titled, “Personal Performance Report.” This page will give you “Your Percent Correct Score for Basic Items” and another one for Advanced items. For the purposes of this exam, you only care about the Basic items. At the bottom, you will have categories laid out and the # Answered Correctly. On the third page, you will get a categorized report of the questions you got wrong, with specific numbers of Basic vs Advanced items. “Clinical Subspecialties” is an Advanced-only category… so you can glance over that [but really, ignore that until 2 years later when you’re in my shoes as a CA-3].

How will this report help you? Well, you have just used this information to identify where you need to focus your attention from the ABA Content Outline. Make sure you review the areas that you got wrong and understand the concepts surrounding those keywords! There are only so many questions that can be generated about “basic” anesthesia topics, so inevitably there will be repeats.

Now, in terms of an active study plan, if I had the patience, organization, and time to study this far in advance for the BASIC exam, here’s how I’d do it:

6 months to 1 year prior to your exam, make a review book/document & flashcards out of the ABA Content Outline – Basic Topics in Anesthesiology and supplement this with questions.

Pages 4-21 include an outline of the specific keywords you will be asked on your exam. Starting a Google Document or creating Anki flashcards [this is a free program that automatically employs the spaced repetition concept for your review; it costs money to get the phone app, but this is well worth the cost] with each of the keywords and pertinent things to memorize would essentially serve as an active way to study and will be useful for ITEs during CA2 and CA3 years.

I would make a schedule [by week] so you have an idea of how long it’ll take you to get through each of the topic areas. This way you can keep yourself accountable and give yourself flexibility each week. You can then also account for your busier rotations; if you’ll be q3-4 call or an ICU rotation with a brutal stretch of nights, studying for this exam should be low on your priority list.

I recommend this approach if you have lots of time because you will be creating a study bank/book on your own schedule/time rather than paying for one later. This also gives you an opportunity to delve into the evidence and original studies related to concepts you’re learning and collect helpful references that you can pull up easily/quickly.

Just keep in mind that you may find that once you start CA1 year, you’ll feel overwhelmed with trying to learn the clinical aspect that this type of studying takes a backseat. That’s okay.

The best resources to use to create this study guide/flashcards:

  1. M&M or Baby Miller By the time you get to your BASIC exam, you should have read most of one of these books. Most institutions have library access to AccessAnesthesiology which provides online access to M&M as well as Longnecker’s Anesthesiology. During “easier” cases, it’s a good idea to read at least one or two chapters in these books to build a foundation for your anesthesia knowledge. Remember, you cannot use review books as your FIRST resource; these come after you’ve gotten an idea of the concept from a primary source.
  2. OpenAnesthesia Some keywords do not have a definition or explanation available, but this is still a great first source to find a summary and a reference to one of the classic residency textbooks [M&M or Baby Miller] so you can open up to that particular chapter and read up.
  3. Faust’s Anesthesiology Review I highly recommend this review book; the chapters are short and manageable, the information is accurate and it covers all the material you’ll need for the ITE, BASIC and ADVANCED. I’ve used this to create Anki flashcards and have annotated the margins with additional notes. I’ve yet to find glaring errors [though the reality is that most books have at least a few errata].
  4. Anesthesiology Core ReviewThis is essentially the ABA Keywords in review book form. It’s available through AccessAnesthesiology. Although I used this book because it made me feel better about focusing on the “basic” topics that’ll be on the exam, it was frustrating to encounter typos or straight up incorrect information. If you feel confident in your knowledge base going into using this resource, you’ll be able to catch the errata, but it does make you second-guess yourself sometimes.

After I’ve gotten through 50% or more of the keywords, I’d start adding in questions. The highest yield questions available are:

  1. Hall’s AnesthesiaThis is a classic Q&A review book. It has stood the test of time and has a lot of the important “basic” questions you’ll encounter throughout your residency. Like any book, it has errata, but after you’ve grasped most of the concepts from your primary sources, you should be able to identify where things just “don’t sound right.” There’s also an app version of this question bank.
  2. M5 I really like this resource for earlier in residency since the answers are very thoughtful and it is split up into Basic and Advanced topics. Plus, you can save 15% off with “M5MGH2019.”
  3. TrueLearn ITE Question BankI highly suggest filtering out the basic subjects [you can select the subjects you’d like to create an exam from] and using random mode [see above about Brown’s book on the science of learning]. If you’re buying this question bank for the ITE, I’d do a longer subscription and use it even after the ITE. I do not recommend getting the TrueLearn BASIC question bank until you’re about 3-6 months to the exam. With my link, you can save $10 off any new subscription of 3-months or greater! [TrueLearn no longer provides a straight percentage discount without specific membership in an organization or during one of their promotions!]
  4. ACE Books – You cannot filter out “basic” questions from the rest of the questions, so I put this toward the end of your resource list. It’s a great resource for ITE and overall studying.
Casual Studier [3-6 months prior to the exam]

I fell into this category – I studied for the ITE then took a long break before realizing that I didn’t have a ton of time to study for the BASIC. Looking back, I wish I had looked at my ITE breakdown of incorrect questions in my report a bit closer so I could make sure to address those obvious weaknesses. So don’t make the same mistakes I did.

The single best resource for the BASIC exam is the TrueLearn BASIC question bank.

I have heard from numerous residents that they passed by just completing the BASIC question bank and reviewing the questions they got wrong [including going back to a primary source and reviewing the concepts missed]. There are under 1000 questions in the bank, so it is manageable to do 10-20 questions a day and finish it. That’s totally doable.

The approach I took to reviewing questions I got wrong was to write down the concept as well as make Anki flashcards with similar types of questions. This ensured there was an active learning component, and also meant that I’d see the question over again to reinforce the concept. I also tried to finish the question bank at least 2-3 weeks prior to my exam date to give me time to review the incorrect questions and do them all again.

Procrastinator [1-3 months prior to the exam]

If you’ve gotten away with approaching all of your exams this way and did at least average on the ITE, you’ll probably pass the BASIC as long as you complete 1 full resource [i.e. question bank, review book, etc] that addresses the ABA BASIC Keywords/Concepts. I want to mention that if you scored less than 20-30%ile on the ITE and you’re scheduled for the June administration, I’d seriously consider talking with your program to determine whether you’ll be adequately prepared to take the exam. There is a later administration date in November — it may make more sense to take more time to prepare.

My advice from the Casual Studier category above applies here — finish TrueLearn’s BASIC question bank, and make sure to review what you got wrong. The biggest mistake people make is picking up a new resource and only getting through part of it; you need to be exposed to all the concepts before you take the exam.

Parting advice

The BASIC exam turned out to be more straightforward than I had originally anticipated. Most people pass. Many questions that you see in TrueLearn you will see on the exam [in some flavor]. Many concepts are repeated on the exam itself. There are curveballs [there always are!], but you have to go into the exam recognizing that this and just take your best guess.

You got this!

As always, feel free to with any questions, concerns or just to get some positive words of affirmation. I love hearing from readers [and colleagues!].

The post How to study for the ABA [American Board of Anesthesiology] BASIC exam appeared first on Amanda Xi.

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Today’s inane image of the day:

As my Transitional Year internship progressed, my anxiety about starting my first year in clinical anesthesia increased exponentially. By June, I was frantically searching the depths of the internet for resources [e.g. how does one DO anesthesia!? what IS anesthesia?] to prepare for the mysteries that lie behind the drapes. At the end of my internship, I felt comfortable entering senna/colace orders, the periodic ABG [arterial blood gas] stick, and pontificating about my differential diagnosis in a SOAP [subjective, objective, assessment, plan] note, but the thought of being able to safely anesthetize a patient for surgery made me nauseous. I also started second-guessing my decision to pursue anesthesiology; during my TY year, I thoroughly enjoyed my inpatient medicine months and was prepared to switch to medicine if I didn’t end up liking anesthesia. Looking back, I can see now that I would have been happy doing a medicine residency, but I’m definitely happier and overall more satisfied in the field of anesthesiology.

Tutorial [or bootcamp, orientation, introduction]

Anyway, back to the beginning of CA1 [clinical anesthesia] year. It’s standard practice across the country for incoming anesthesia residents to start in a tutorial/bootcamp/orientation/introduction month filled with shadowing, simulation, skills labs, discussion groups and one-on-one training with either a senior resident or attending staff member. I promise you, after your introductory month, you will have the knowledge base and skills to perform a basic general anesthetic. This being said, there’s a reason our residency is 4 years; I believe that crafting an efficient, safe, and elegant anesthetic for individual patients is an art that takes decades of experience to become truly proficient in. At the end of 4 years, you will have enough experience to know that there’s a lot you don’t know and will have to learn while in practice. That’s okay.

Our tutorial is 5 weeks long. The first week involves shadowing, simulation, and discussion groups. This is followed by two weeks one-on-one with an attending [your “tutor”] then another two weeks one-on-one with another attending [often someone who is the polar opposite in anesthetic style, training or personality from your first tutor]. During tutorial, we use a checklist of procedures and anesthetic types to guide our exposure and learning. As tutees, we were given the first pick of cases before any of the other residents, CRNAs or staff members were assigned. This allows us exposure to a broad range of sub-specialty areas; my first tutor was a pediatric anesthesiologist so I requested a pediatric day along with a wide variety of main OR cases.

My year, they hadn’t started tutorial off with shadowing senior residents so I learned my basic OR setup from my first tutor. Now that they’ve revamped tutorial to include time with senior residents, our incoming CA1s have an opportunity to ask any question about a basic OR setup. We literally don’t expect you to know anything, so take this opportunity to familiarize yourself with where important equipment lives in the OR, machine checks and common areas to check on [e.g. is your backup oxygen cylinder full?]. Practice priming IV bags, learn common vasopressor concentrations [e.g. our phenylephrine concentration is typically 80 mcg/mL for infusions, however many institutions use 40 mcg/mL], and figure out where to get missing supplies. Ask about rationale for induction agents and access. Learn tricks for the electronic medical record [but don’t focus on this; there’s always time to chart after patients are in a stable plane of anesthesia]. Determine appropriate ways to participate in patient care without being obtrusive.

Reflecting upon starting my anesthesia training made me recognize that the book knowledge is important, but usually not the area that new residents start with. Yes – you should make an effort to read your favorite anesthesia textbook [see my entry on prepping for ITE/BASIC for examples] to learn important physiologic and pharmacologic concepts that impact your practice and understanding. But how many times have you gotten the feedback, “keep reading”? I thought back to the subjective things I wished someone had told me when coming up with the tips below – hopefully this addresses some of your concerns and assuages some of your fears as you enter anesthesia training! [Warning: this entry contains 2700 words – sorry, I talk a lot!]

Ask questions [even seemingly “stupid” ones]

There really is no such thing as a stupid question, especially as a trainee. It took me a while to recognize the value in asking about everything, but once I did, I found pearls of knowledge hiding in plain sight. Asking questions is especially important when you are learning a new skill [e.g. how to be an awesome anesthesiologist]. Simple things like labeling syringes in a certain fashion [anesthesia often attracts a certain level of Type A personality, but seriously, having all your labels facing the same direction makes grabbing the correct medication much more likely] or propping up the drape to have full view and access to patients can have a big impact on your future practice. Asking about practice patterns [e.g. asking about dexamethasone for PONV] can also lead to learning opportunities [e.g. discussion of the paper showing the efficacy in general anesthetics and other additional benefits such as analgesia]. There’s also value in asking questions of other operating room staff – the circulating nurse and scrub tech often know where the closest tube station and warmest blankets are. When you’re just starting off in anesthesia, most of the staff in the operating room have been there longer than you – take advantage of the opportunity to learn from them by asking questions [but have situational awareness; asking for a warm blanket when the surgeon is frantically trying to clamp a bleeding vessel may not be taken well].

Learn when, who & how to call for help

When to ask for help will evolve as you progress through training. During my first week of tutorial, I felt no shame in asking for help when the oxygen saturation fell to 95% or the blood pressure was trending in the wrong direction. Earlier on, your attending or senior resident will be in the room most of the time. But as you grow more confident and competent, they will lengthen the leash. This also means that you will encounter clinical situations where you have to decide as you’re managing the patient whether it’s prudent to call for an extra set of hands or for clinical support.

While your attending is often the first person you should ask for help from, sometimes they might be tied up in another room with induction, giving a break, or managing a critically ill patient. If you run into trouble, knowing who else is around that could lend a hand can be helpful. In our institution, it’s often the “floor walker” [the person who manages that specific area’s staffing] or our staff administrator [often known as the “board runner”]. If you encounter an emergency, there is no shame in calling an “anesthesia stat”- especially in code situations, you need all the extra help with chest compressions, securing invasive lines and overall management.

We have public walkie-talkies [Vocera] for communication between all operating room staff [except for the surgeons]. Many places carry phones or require overhead paging to reach staff members. As you progress through your anesthesia training, you may find it helpful to ask your attendings before you work with them when they like to be called/notified. Some of them will want to know about all episodes of hypoxia or hypotension while others are comfortable with just being paged when you’re ready to extubate. Make sure you’ve had this conversation ahead of time to ensure open lines of communication.

Develop a setup checklist

Many of us have a mnemonic that helps us consistently setup the same way every time – mine is SOAP-IM:

S: Suction – This is self-explanatory but often the first thing new residents miss. Make sure that you have a Yankauer/orogastric tube ready and that your suction is on.

O: Oxygen – Check that your oxygen source to the wall is connected and a full backup oxygen tank is hooked up to your anesthesia machine. Try to learn how to exchange the backup oxygen tank yourself. Remember, if for any reason your pipeline oxygen pressure is lost or disconnected, this tank will be your source of oxygen.

A: Airway – Ensure that appropriate airway equipment is setup or available. Even for a MAC, I always have an oral airway, backup endotracheal tube, and laryngoscope ready. Make sure backup equipment for unanticipated difficult airways is also available. I cannot tell you how frustrating it is to be in a situation where you feel confident that you could secure the airway with a Bougie but it isn’t readily available. Also – laryngeal mask airways [LMAs] can seriously save lives in a situation where a patient is difficult to mask. Always make sure your room is adequately stocked with them. Know how you can obtain a video laryngoscope or bronchoscope if necessary.

P: Pharmacy – Consider stopping by the pharmacy or central Omnicell/Pyxis on the way into your OR to obtain medications that are not readily available in the room. I typically make sure that I have emergency medications within arm’s reach [typically that means lots of purple-labeled syringes live on top of my ventilator].

Dr. Henry Jay Przybylo [pediatric anesthesiologist at Northwestern University in Chicago] describes this concept well in his book, “Counting Backwards: A Doctor’s Notes on Anesthesia”:

There’s one last item in my setup: the mother of all drugs, the resuscitator extraordinaire, the last ditch effort to retrieve a life trying to end – epinephrine. It deserves a special place in my anesthesia next – a place I call the “Oh Shit Shelf.” It’s on top of the anesthesia machine, immediately to the right of the flat-screen monitor. Whenever anyone in the room says “Oh shit,” I reflexively reach high and to my right, and grab the only syringe ever placed there, the epinephrine. [If you haven’t checked out this book, you should – while it’s written to be understood by non-medical readers, it has pearls and anecdotes that are worthwhile to consider by practicing anesthesiologists.]

Often, the missing medications in the room are high-level antibiotics [e.g. meropenem, linezolid], non-standard neuromuscular blockade [e.g. cisatracurium, mivacurium], preoperative oral medications [e.g. acetaminophen, gabapentin, celecoxib], and local anesthetics for neuraxial or peripheral nerve blocks [e.g. lidocaine/bupivacaine with epinephrine, ropivacaine, mepivacaine, epidural mixes].

I: IV – Ensure that you have the appropriate IV fluid bag[s] and sizes ready [e.g. normal saline/mannitol for a neuro case, smaller volume dextrose-containing fluids for tiny babies, etc] and IV start materials available [e.g. have a kit with the appropriate sized angiocatheters as well as subcutaneous lidocaine drawn up if you plan to use it]. If you’re on pediatrics, consider whether you need a Buretrol [good rule of thumb is babies < 10 kg] or just a microdripper to deliver the fluid. Ensure you know where the filters are for patients with intra-cardiac defects.

M: Monitors/Machine – At our institution, EKG cables and blood pressure cuffs are often taken to recovery with the patient, so as part of my setup, I make sure I have a set in the room. I double-check on the cables I need [e.g. arterial line, central line, temperature] and the disposable components [e.g. EKG stickers, temperature probe, pressure bag/transducer for invasive lines]. For the machine, I do the full check in the AM then make sure that the leak test was done between cases or anytime a new circuit is attached.

At the start of residency, I ran through the mnemonic in my head with every setup to ensure that I didn’t forget anything. As you progress through training, your setup becomes routine and you can often do multiple portions of your setup simultaneously [e.g. have the machine check running as you take out airway equipment and monitors].

Explore your surroundings

Anesthetizing locations can vary in their machines, setup, supplies, and tech support. Often, to be an effective anesthesiologist, you must be nimble and fit into tiny spaces; we are usually competing with radiologic equipment, booms [big semi-moveable pillars with built-in computers, equipment, and/or electrical outlets], and cables from all directions. Knowing the best path around the OR [or purposely creating that path around the equipment as it gets brought in] can be helpful if you need an extra set of hands or to get in/out for breaks. When we go to off-site locations [i.e. endoscopy, radiology, etc], our carts have different setups and usually a different ventilator. During away rotations [we also rotate at the VA, Northshore Medical Center, Mass Eye & Ear, Children’s Hospital], you may encounter completely different branded equipment and supplies in your carts. Make it a habit to open every drawer and always take note of where airway equipment, emergency medications and peripheral IV sets can be found.

Introduce yourself & develop a standardized script

Most large academic institutions have a lot of OR staff, sometimes making it difficult to get to know OR personnel. You may be working with a different set of people every single day. As a result, you should start each day with an introduction.

The patient interview is another area where it’s important to build rapport and ensure all important information is gleaned from the patient. Try out different ways to introduce yourself and interview patients. To stay consistent between patients and avoid missing important information, I use the back of our anesthesia consent form as a template to ask questions. This ensures that salient questions are asked [i.e. past problems with anesthesia, NPO status, medication allergies]. At the start, your patient interview will be longer – that’s how it should be! Unless it’s an emergency, it’s better to be thorough in your assessment. As you progress, time limitations may dictate your interviewing priorities and experience will help you hone in on what history you absolutely want to elicit from every patient.

Expect to be exhausted

My first few weeks of tutorial were absolutely exhausting. It felt like there was an unsurmountable amount of information to learn and integrate into my practice. Even when I thought I had a good grasp of a “simple” general anesthetic [e.g. young, healthy patient undergoing an uncomplicated procedure], I would encounter learning points for improving my practice. This process of continuous self-improvement and learning takes a physical and emotional toll. Don’t be surprised if your bedtime suddenly moves up [I am not ashamed of going to bed at 8PM – ha] – you should be well-rested to absorb all the new information involved with learning the practice of anesthesiology!

Identify mentors

At our program, we are asked to select one of our two “tutors” to be our formal mentor. When I realized I wanted to do critical care, I switched my mentor to someone I respected and received sage advice from. While it can be frustrating to work with new attendings daily [i.e. learning different preferences], the flip side is that exposure to different individuals opens opportunities for mentorship and career guidance. We work one-on-one with attendings that have pearls for managing both clinical and life crises; make sure to take advantage of this resource.

Never settle & be flexible/adaptable

After a few months of main OR assignments, sometimes the practice of anesthesiology can feel mundane. As the SDN Anesthesia forum alludes to, “prop, sux/roc, tube” is an appropriate anesthetic for most situations. Don’t let this prevent you from branching out and trying new techniques. Ask your attendings for ideas on new approaches or equipment to try [e.g. the most common area to pick up new techniques lies in securing the airway; often people mention using a Miller blade after becoming comfortable with a Mac, but what about using a bougie, C-Mac, Glidescope or fiberoptic? What about using the Arrow system or through-and-through technique for arterial line placement? How about high-dose remifentanil instead of paralytic? There’s always something new you can introduce into your practice!].

You will quickly learn that no anesthetic plan is carried out exactly as created and that’s where the art of our practice comes into play. You must learn to be flexible in your plan and anticipate where things may not go as expected. If your senior resident or attending suggests another approach, stay open-minded and discuss how you will carry it out. Remember to be responsive to the environment, the surgical field, and overall feeling in the room.

This entry contains a lot of words – kudos to those of you that made it this far! Am I missing anything? What other things do you wish you knew before starting CA1 year?

The post Behind the drape [reflections on starting anesthesia training & tips for success] appeared first on Amanda Xi.

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