Wednesday, July 23, 2008
Not My Best Moment: A Career "First"
Ordinarily I like friendly chatter. That is, at the right time and place. I think it makes the work day more pleasant.
But when total concentration and focus are required, I dislike chatter. I disapprove of chatter. I think chatter in such a scenario is a symptom of one or both of the following: forgetfulness or lack of understanding of the critical nature of a moment, and indifference to, or disrespect of, the critical importance of a moment.
When a surgeon says sternly, "I need quiet in here right now," I shut up.
When I ask the chief of surgery to turn down his iPod so I can hear my monitors, he does.
When I need to concentrate, and have time to ask nicely, I don't hesitate to tell people I need them to stop talking just for a little while.
None of these requests is ever aimed as a personal attack, to rebuke an individual (who may very well be irritating), or to embarrass anyone publicly. Because the truth is, even in the warmest of environments, patient care sometimes means business only, quick and terse phrases, nothing personal. It's a hospital, after all, not an ice cream social.
And sometimes there just isnt' time for social niceties. Really.
Like during induction of anesthesia and intubation, when your student can't get the airway, and he's softspoken and too inexperienced to be able to verbalize what he's seeing or not seeing when he tries the intubation.
Students like me because I am nice to them. I don't raise my voice. I don't mock them for failing. I reassure them, guide them, try to give them helpful feedback, tell them stories, explain what I mean, more than once if necessary. I try to let them do as much as possible and get them to perform their own corrections, based on the information they give me and my subsequent suggestions. Up to a point. But if it looks like it's not gonna happen, I step in and take over.
But today I yelled. Not at the student; at the nurse in charge of the front desk. This is a woman who can be very nice. But she can also be abrasive and frequently gets stressed out in a way that transmits that stress to those around her.
This woman barged in loudly just as I was trying to elicit important information about the airway from my soft-spoken rookie medic. He had already needed help to improve his mask ventilation, and after listening to my suggestions he had corrected his technique nicely. Now he had the laryngoscope in position and he couldn't see vocal cords.
I was asking him to describe what he saw - was the epiglottis in view? Was there just a tunnel of pink mucosa? Often inexperienced laryngoscopists have a tendency to insert the laryngoscope in a little too far, past the epiglottis, so I told him to pull back a little till he could see it. But I was having trouble hearing what he was mumbling behind his mask.
I had a student who couldn't get the airway and couldn't articulate why, and a patient I was responsible for. Everybody in that room needed to be standing at attention and ready to assist if the situation became perilous. And at that moment the woman from the desk burst through the door speaking at the top of her lungs, without bothering to take note of what was going on and what a critical moment it was.
I didn't even turn my head or stop to understand what she was going on about. I yelled.
There was a stunned silence.
"I need quiet in here!" I continued.
I turned to the paramedic student and said, "I'm going to step in and take a look, all right?"
He gave me the laryngoscope. The vital signs were holding. I made a subtle, almost imperceptible adjustment with my wrist and the vocal cords were there, fully visible, plain as day. A "Grade I" view.
"There you are. Wanna put the tube in?"
He started to, but I think I must have scared him, because he changed his mind just as it was touching the arytenoid cartilages and handed the end of it to me. I passed it into the trachea smoothly and secured the tube.
The student thanked me with a little bow and made a quick exit. I didn't even have a chance to debrief with him.
After attending to the last few details of "take-off," I picked up the phone and called the front desk to apologize to the charge nurse for raising my voice.
She hung up on me.
I was frustrated because I knew I had hurt her, without really intending to; perhaps made the student uncomfortable, causing us both to miss out on a chance for a fruitful teaching interaction; and also detected a real lack of respect for what we do at the head of the bed every time we anesthetize a patient. I had the feeling that we make it LOOK easy 99 times out of 100, so people FORGET that it's a LIFE AND DEATH moment up there, getting the airway. It looks easy most of the time, and after a couple of thousand, yes, most of the time it's a comfortable procedure, but there's also nothing more important than that precarious moment right at that moment. As that student found out - and before this, he had been feeling pretty darn good about the few intubations he'd tried - it looks simple until you actually try it yourself.
Anyway, I sought the woman out a second time later in the day, in person, put my hand on her shoulder and said, "I am truly sorry I yelled for quiet like that, but I didn't feel like I had time for more than a word or two right at that moment."
"I know," she said. "And I had to move on to the other O.R.'s right away, and then to the other phone line after you called, because there was a lot going on."
"Understood," I said.
We patched up. But it was a sad career "first" for me. It was the first time I'd raised my voice like that at a co-worker in the O.R.
Photo credit: orangutan by Malene Thyssen