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


Anonymous said...

In the heat of battle, when things are really tense, stuff sometimes just happens. I think there is a difference between raising your voice during a critical moment vs. routinely yelling at people.

The important thing is that apologies were made, yes?

And I would hope the people who know you and work with you can recognize that you wouldn't raise your voice unless you really meant it or were really pushed to the boiling point.

I hope you also will have a word with your student. From time to time, there are inevitably going to be these moments in the OR and it would probably be good for him to have an understanding that it's not meant to be personal.

But you're right... I always regret losing my temper too, even though it happens pretty rarely.

make mine trauma said...

You are too nice! I didn't think she deserved an apology. As a nurse in the OR she should know the protocol. If anything, she should have apologized to you for barging in loudly during intubation.

T. said...

MMT - I have to admit, I actually totally agree with you. If it had really been a case of lost temper, I think the apology would have been mandatory, but I felt at the time, and still feel right now, that I was barking out an ORDER. Not a request. An ORDER.

What I was apologizing for was that I felt I had to do it without a shred of social decorum. But now that the dust has settled I find myself still thinking that if anything, as you say, the woman I hushed up should have had more respect for, and paid more attention to, what was going on in the O.R.

Sometimes I think the pendulum has swung too wide in terms of "equality" in the workplace. I have always strongly believed anyone should be able to make a valid point or objection or raise a safety concern, and be LISTENED to, but I also think the pecking order exists for a reason, and there will be moments when we can't all be buddy-buddy in there. There are always going to be situations in which a person's expertise makes them the highest "ranking" person in the room, and in those cases people need to PAY ATTENTION and do what needs to be done. It's not a "please, could you" or "would you mind terribly doing X" kind of situation.

That said, I don't typically yell at people at work, so I still felt bad having play General or Admiral or Commander or whatever your favorite military analogy would be.

And Anna - the only apologies that were made were mine. As my boss said when we discussed the incident, "Some people just aren't teachable."

So maybe I'm not so nice. Or maybe you're right, MMT, and I'm often too nice. Or both. I go back and forth. Maybe my husband has it right: he tells me that I'm a good person, but that I also "have an edge." All I know is that I'll be fiercely protective of my patients until the day I retire.

make mine trauma said...

"All I know is that I'll be fiercely protective of my patients until the day I retire."

And how lucky your patients are that you are so dedicated to their well being.
Personally, I think that nice people with an edge are ideal. They are easy to work with yet respected enough to be, well...., respected.

T. said...

Thanks, MMT - I appreciate the support from someone who knows the O.R. so well from the inside!

Anonymous said...

You're right, it was an order. An order is different than a request, it is something that has to be complied with RIGHT NOW, with no option for personal preference or desire or room for hurt feelings. Just a requirement for immediate obedience.

The nurse (btw, what was a front desk (ie, street clothes/unscrubbed) nurse doing in the OR anyway?) was out of place, out of line, and as you said, was interrupting a life-critical task that had to be completed for the patients well-being. Her barging in like that is symptomatic of a lack of understanding what happens in an OR: What if she had barged in as a surgeon was (say) harvesting a heart - one slip and there goes the SA node, or a neurosurgeon working inside the calvarium...your procedure may not have been quite as dramatic but the point holds.

Anything that the nurse had to say that was critical (ie, life-threatening) should have been relayed over a PA system or life-safety warning system (the building is on fire or whatever). Anything else could have waited and should have been preceded with 'Excuse me everyone' AFTER she determined that nobody was talking, better yet after she was recognized by the surgeon or you and asked the problem. Just as she didn't have time later to talk to you, you didn't have time then for her announcement.

As an EM attending, I often will call for quiet just as you did, and for more reasons: Intubating, auscultating, sometimes just to get a moment of quiet to think when a patient is in distress. We understand the necessity of it...and everyone does it, including techs and nurses, it's a privilege that goes with working in the ED - and should in the OR as well.

Finally, if she is so insensitive and yet thin-skinned that being told to be quiet in an OR is distressing to her, she's obviously in the wrong profession, or at least the wrong branch of nursing.

T. said...

Fidel, I so appreciate your conscientious comment and how well you understand these clinical situations. Thank you very much for taking the time to be here.

Doc said...

I agree with other contributors. You didn't need to apologize to the nurse. She should have known what was going on and should have been aware enough to notice. She should have apologized to you for interrupting you during a very critical time. Unfortunately, as you said, those in the room become too cavalier and forget how critical that moment is.

Bongi said...

there must be hierarchy in theater. i think you were totally within your bounds. i too would have apologized afterwards, but if the phone was put down in my ear i would have been fighting mad. well done to you for driving your apology home. maybe the difference between a surgeon and an anesthetist?

T. said...

Bongi, thank you. I WAS fighting mad, believe me. But I also wanted to do right by our profession, and by my own code of conduct. I'm sure you would've done the same! :)