Friday, April 18, 2008

How a "Humble" Task Taught a Humbling Lesson

During my residency I had the opportunity to spend several months getting some pediatric anesthesia training at Children's Hospital in Boston. I have many valuable memories from that place. Some are from my clinical experiences, like the time I had to use a fiberoptic scope to place a breathing tube into a young Peruvian boy's trachea while he was awake, for safety reasons, because he had a dangerous anatomical abnormality distorting all the tissues of his oral cavity, making visualization of his vocal chords extremely difficult (and thus dangerous to do with the child totally anesthetized and unable to breathe on his own). I went to visit the kid in his room the next day and he threw his arms around my waist and thanked me. Then there was the time I placed an epidural in a little boy who was having robotic surgery to remove his uterus. And of course there was the time I was on the other side of the curtain, when my son split his eyebrow open and needed sutures in the emergency room. He got stellar care.

My favorite mental picture is that of all the stretchers lining the corridor outside the operating rooms, each with favorite stuffed animals or other fuzzy friends waiting for their respective children to come out of their surgeries. I was always touched to see that row of stretchers with their comforting occupants - and for a second I would become like a child again, believing in their secret animation as loyal companions with invisible hearts full of affection for their owners. Or charges.

One thing I haven't thought of again till recently was a particular task we had to do as residents as part of our equipment preparation, to ensure our patients' safety. Every morning we arrived early to the O.R. to set up the usual - airway instruments, drugs in their syringes, monitoring equipment - but also to connect tubing to I.V. fluid bags and make sure the tubing was "primed" with some of the I.V. solution. At most hospitals the task of filling I.V. tubing with some of the solution is left to support personnel who also come to the O.R.'s early to help with the set-up tasks. At Children's we were required to do this for ourselves so we would learn to be particularly vigilant about air bubbles in the tubing and be sure to eliminate them so as not to cause complications for children undergoing surgery. I didn't mind it too much, but I didn't look forward to it much either, and after my training, I didn't give it another thought.

Till now. This week I was asked to replace an I.V. in a patient prior to surgery. The bag of I.V. solution had been connected to the I.V. tubing by a nurse, as was customary at this hospital and in fact all the hospitals served by my anesthesia group. Most of the I.V.'s, in fact, are placed by the nurses unless they have trouble with them, in which case they call us to help.

I inserted the I.V. fairly easily and hooked up the tubing. Before directing the nurse to open the line and let the fluid start dripping into the patient's vein, I noticed something about the tubing. A subtle difference in the color of it (though it's colorless), or in the way light was being refracted through it (or not), or SOMETHING - I don't know exactly what - made me stop in my tracks. I disconnected the tubing.

"Could you check the line?" I said to one of the nurses. "I don't think it's been primed."

The nurse opened up the tubing at her end to see if it had indeed been primed with fluid by the nurse who had hung the fluid bag there for us. It had not. I was totally shocked. I tried not to show too much displeasure in front of the patient, who was waiting for her I.V. to be hooked up, had this nurse prime the tubing, and finally reconnected it so we could start her fluid.

I felt angry over the near-miss, and a bit shaken. We could have infused an entire air column into this woman's vein and caused some serious complications. What if I had taken the first nurse's preparations for granted and assumed the tubing had been primed properly? What if I hadn't checked before letting the I.V. run, or hadn't noticed the suspicious appearance of the tubing? Anesthesiologists by nature are totally obsessed with safety and check things almost compulsively - labels on every drug vial before pulling the drug into a syringe, times of particular events, eyes constantly roving, checking, checking, checking...but what if I hadn't glanced down this one time? What if I had failed to keep to the habit just this once? It could easily have been at the very least an unpleasant, stressful afternoon for all, and at worst, a catastrophe. And what if I hadn't seen the difference between empty, air-filled tubing and fluid-filled tubing - a very subtle, almost imperceptible difference - a hundred times at Children's? Then it wouldn't have mattered if I had examined the tubing or not before hooking it up.

So I am grateful for my time at Children's, not only for the big, glamorous, dramatic cases, but also for the so-called smaller tasks related to patient care, work at once menial, tedious, and incalculably important, with as much potential impact on a patient's life as learning the proper use of a medication or a laryngoscope. I started out my anesthesia career claiming I was attracted to it because every task, from the most mundane to the most clinically showy, was meaningful. I learned first-hand this week how true that really is.

Today I had the chance to teach a nursing student to place her first I.V. As I gave her technique pointers beforehand, then walked her through every step of the procedure, I was astounded to realize how many little steps there are that can so easily be missed and that have become so fluid for me now (no pun intended) that I don't even think about them any more. We both felt happy and proud when she got it on the first try. I told her she did a good job. And of course I told her to make sure from now on that she always, always primes the tubing.


Anonymous said...

I liked your story. I am from Boston (born in Newton). I an a graduate of Northeastern Univiersity and have been an RN for over 22 years. Always being down to earth and professional at the same time. Everyone is important and deserves respect. That's what you show me in your articles. I have been on both sides of the fence (double transplant 10 yers ago- kidney/pancreas). I did rotations at many of the hospitals in Boston as an RN and sometimes a patient (mostly Deaconess/ Joslin ). Thanks for your Blog....more people in the medical profession should be a bit more "humble"...Lisa M. Raco. :)

Øystein said...

The stuffed animals waiting on the stretchers often bring me close to tears. Both because of the sick children, and because it reminds me of that simple comfort of childhood, forever lost to us grown-ups.

T. said...

Lisa, thank you very much for stopping by and for your kind support.

Sterileeye - for me too the sight of those stretchers with waiting teddy bears or what-have-you would bring that catch in the throat, the "pre-weeping throat." But I have a confession to make: I haven't allowed the comfort to be quite "forever lost" in my life - I was one of those who brought a favorite stuffed animal (or two) to my college dorm way back when, and recently I just got an adorable stuffed moose supposedly for my daughter but we all know the truth...Capuccino Moose is miiiiiiiiiiine... :)

Anonymous said...

Hi mommy! You were just kidding about the Capuccino Moose thing, right?

T. said...

Um...yeahhh...sure... :)

Unknown said...

Maybe this is something they teach in med school, but a boy can have a uterus?

T. said...

The short answer is, yes, a genetically male (or partially genetically male) human being can have some female sex organs or remnants thereof.

A longer answer:
In another life, when I was going to be a pediatrician and not an anesthesiologist, I had a special interest in medical genetics and in variations in sex development and their psychosocial impact on gender identity. There are several medical conditions that fall into a category of uncommon but known variations in sex development. Different medical terms have been used for these conditions and some of the ones I learned in school - "ambiguous genitalia," "hermaphroditism" and "pseudohermaphroditism," "gonadal dysgenesis," "dosage-sensitive sex reversal,"and "embryonic testicular regression" - may have fallen out of use by now (or not). I haven't kept up with those details of pediatric endocrinology and genetics, unfortunately.

I don't remember exactly, and this speculation is from ancient med school notes gathering dust on my shelves, so please know that the following may be innacurate, but I think the boy I took care of may have had one of the following conditions: dysgenetic male pseudohermaphroditism, in which a person has a male genotype (46 XY) but also has a uterus, a vagina, testes, and incomplete external virilization; or mixed gonadal dysgenesis, in which a person is genetically what would be called an XO/XY mosaic and would also have a uterus, vagina, testes, and incomplete external virilization.

If there are any genetics and endocrinology experts out there who are a little more current on the topic than I am, please feel free to chime in!

MedStudentGod (MSG) said...

One of my away rotations had residents doing all their IV set ups - priming and getting the tubing ready, etc. I understood how easily it was to forget to check if you'd primed the line, or if there was something not hooked up correctly the first time how that could delay induction and add to patient anxiety. I feel it's these things that make a great physician as opposed to just a competent one.