Sunday, October 5, 2008

Don't Say the Q Word: Doctors' Superstitions

I was asking some very run-of-the-mill, routine preop questions for what would be considered a fairly small surgical procedure. The patient closed her eyes. The corners of her mouth began to turn downward. She started to cry. I put my hand on her arm.

"I'm going to be right by your side the whole time," I said. "I won't leave you."

"I don't want to die," she said through her sobs, her voice sick with anxiety.

Whenever a patient says that my wariness increases a bit. It's doctor-superstition, I suppose, but it's been said that when patients have a feeling they're going to die, it's because...they're going to die. But I was hoping this was just her extreme nervousness talking rather than an actual sense of impending doom.

"I'll be there to protect you," I said, looking into her eyes with every ounce of my confidence. "I'll protect you," I repeated.

The woman nodded. A tear slid down her cheek. "Promise you won't leave?" she asked.

"Absolutely. I promise. I'll be with you until you wake up, and afterward too."

The actual surgery went fine, but she had medical issues that made her management a little tricky. I visited her later that night to see how she was doing. She was watching House. She was in much brighter spirits and had a warm smile for me as we spoke.

"I want to hug you. Is that ok?"

"Of course," I said, leaning over to hug her back. She thanked me.

But it was I who was thankful. I was thankful that she didn't in fact code and die on the table. I never tell people, "You're going to be fine," or "Everything's going to be all right," because the truth is the most routine procedure can turn deadly without warning. I guard my words with almost superstitious care. I tell people, "I'll be by your side," or, "I'll do everything in my power to keep you safe."

But that morning, for this woman, I had said, "I'll protect you." I had violated my own ritual observance of meticulous attention to language. What if I hadn't been able to protect her? What if some problem or other among all her medical issues had taken a turn toward disaster, and what if I hadn't been able to keep her safe? I never take those possibilities for granted.

Doctors pride themselves on being rational creatures. We act based on empirical evidence. We scoff at non-Cartesian thinking. And yet...

There's so much stress and chaos in the hospital, and lack of control in medicine, that sometimes little rituals and superstitions can be very comforting. I know one surgeon who never books his cases in a particular O.R. that he considers the Room of Doom. Some folks arrange their instruments a particular way without fail. I knew another doc who had a lucky brassiere that she would make sure she wore on her calls so they would be qui - er, not too busy. That's another thing - never admit that a call is quiet, or say the word quiet at all, ever! Then the cases will start pouring in and the beeper will be beeping non-stop! As for me, my superstitions are language-oriented. I try to avoid phrases like "Everything's going to be fine," or "You're gonna do great," and it makes me uncomfortable when the nurses say things like that. I'd rather say things I know will be true no matter what - like, I'll be right by your side, and I'll do everything I can to keep you safe.

In addition to little superstitions, we have little irrational beliefs. Take, for example, the quiet call versus the painfully busy call. There are those among us who would swear there's such a thing as a Black Cloud - the doc who's always horrendously busy on call - and a White Cloud - the doc that's consistently favored with tranquility and sleep while on call. There's another belief, practically urban legend, which I alluded to above - that patients who feel they're about to die are, in fact, about to die. Or that if someone has a bad, bad disease, and he or she is a really, really nice person, the prognosis is probably dismal.

Then there's the one about patients with red hair. There's an idea floating around that patients with red hair are more prone to complications. I personally haven't observed that or seen any evidence to support even a single anecdote. That said, there's actually been a study* done and presented to the American Society of Anesthesiologists that shows that red-haired patients need more anesthesia to get anesthetized or to experience relief of pain than non-redheads - but the study sample was minuscule, so who knows? There may indeed be a relationship between genes for pigmentation and genes for drug receptors but I certainly haven't read that it's proven.

Many docs, whether they'll admit or not, have these little customs and rituals, some of which have no basis in rational thinking at all. But I think this is humanizing, this "lapse" of our hard, scientific practices. It forces us to acknowledge that no matter how hard we try, in this world of ours that exalts total self-reliance, we're never going to be totally in control, and though we try to anchor ourselves with these consoling things, in the end we're going to have to accept some degree of uncertainty and lack of absolute power as we go about our work.

*Liem, E.B., Chun-Ming, L., Suleman, M.I., Doufas, A.G. and Sessler, D.I. Increased Anesthetic Requirement in Subjects with Naturally Red Hair, American Society of Anesthesiologists Meeting Abstracts, 2002.


Beach Bum said...

I love this post. I remember when I first started shadowing one of my aunts in the ER, I came in one night and said to the nurses at the desk, "it looks pretty dead in here tonight." I got a quick lesson in what not to say in a hospital.

gelci72 said...

I found myself saying, "Aaaack!" just reading your comment! Shhh! :)

But joking aside - thanks for stopping by.

Lisa Johnson said...

Wow. My eyes started tearing up reading this post. As such a recent patient, I just remember that feeling of vulnerability and literally placing my life in the hands of other people. Looking in their eyes and faces for signs of kindness and caring. I assumed the skills, but I really did look for the concern.

I don't know if I ever heard these superstitions before, but I'm glad I'm reading them now and not two weeks ago. : )

Anonymous said...

it really is true!
when I was reading your post I found myself thinking about how I really 'need' to put the epidural kit on the table the same way all the time... :)
today I'm tired after a long shift. I thank you because in the caos we live in, the easiest thing to do is to forget to be human, to be real and to be true to our patients. I'm one of those persons who normally says too easily to their patients: 'everything is going to be all right'... and you are totally right, we never know if that is really true.
yesterday everything went allright. the only thing one can hope and pray for, is that tomorrow there also won't be any problem - and if in the meantime our little superstitions do their magic, well, that's allright too! :)

T. said...

Anali - I was so glad to hear your experience went fine, and totally happy you're back blogging, too!

Catarinolas - That's so funny - I put the epidural kit on the table the same way every time too! And I prepare the stuff in the same basic order (though not strictly). Open catheter packet, snap vial tops off, draw up local, lubricate syringe plunger, take cover off epidural needle, lay out in front of me in order of use. I've never observed whether my departing from my "usual" order "makes" the epidural tougher to do... :)

Patty said...

Well, but even God promises to protect us ... but that doesn't mean we live through anything and everything.

I'm just saying' ... (to quote my son when he has nothing more to support what he's "sayin'")

Yet another great post. :-)

There are certain things I do prior to a performance, and if I've played a solo with my feet in a certain position -- sometimes my left heel is up against my oboe bag or something, which is under my chair -- I feel I have to continue playing the solo that way every performance or I won't do well. And of course if I say something unkind about another player I always fear it'll come back to haunt me. I also have to straighten my tray (I attach a tray to my stand when I'm playing a run of opera or musical theater) so that everything is "just so".

I don't really like having those fears and superstitions ... I fear they are limiting ... but I guess it's just being human and all. :-)

Radioactive Tori said...

When I had cancer, I did the same kind of thing with my kids when they asked if I was going to be ok or if I was going to die. I said things that were true (I believe that everything will turn out fine; I do not plan on dying, etc.) but I never said "I will not die", or "it WILL be ok" because I felt like that might be a lie or that saying that might jinx it or soemthing. I completely understand the superstition stuff you are talking about because I did it too.

Anonymous said...

Oh girl, I could go on all day. I'm not superstitious in "real life" but in the OR I definitely was. I would literally find wood to knock on if someone said the Q word. And I often put extra stuff outside the door to "ward off evil spirits"...trach set, MH cart, vascular clamps...whatever. I didn't usually bring the stuff in the room b/c nothing says to the surgeon "I don't trust you" like a set of clamps!! But I certainly had it right outside.

I worked with an ENT who always, always, always did the right ear first. And I certainly appreciated the anesthesiologists who kept the succ (sux? How do you abbreviate that?) out on the blue bell instead of hidden in the drawer.

Thanks for the memories! Ahhh...

T. said...

Radioactive girl - I'm glad I'm not the only one for whom words seem to carry a certain weight! Thank you for stopping by.

Katy - don't you love the way the respiratory rate just bumps up a notch when you wave a vial of Narcan in the general vicinity, or how unexpectedly well an intubation goes when the Fastrach LMA is on top of the cart? :)

Jared At The Doctor Job said...

What an awesome, well-written post. Thanks for sharing!

Map said...

Wonderful post. I, too, am superstitious when it comes to setting up my room or my epidural kit. I also pray every morning for my each of my patients, sometimes again, right before the case starts.

One of my favorite parts of my job is bonding with the patient before the case. I tell him/her that I will be by their side the entire time, watching them, trying to keep them safe and as comfortable as I can. I agree with you, T: never promise anything that you can't deliver.

Regarding the redhaired patients: I experienced it before I knew about the theory. In my limited sample size, it's true -all of it :)

T. said...

Thanks, Jared and Map!

Nice to have you here.

Anonymous said...

as a lifelong non-smoker, non-drinker, non-druggie redhead, i can say with authority that thru several difficult births, some serious illnesses & a couple of surgeries, the medical staff have always looked at me askance when i don't get pain relief.

they always asked me if i was SURE i didn't do drugs!

and i never, ever did get sufficient pain relief from anyone

thus, still a bit traumatized after all these years

my mother even asked me once "does it hurt that bad or do you just have a low pain threshold?"

sounds like that makes sense, doesn't it?


Anonymous said...

I just found your bog through Grand Rounds - and I'm so glad I did. You are a thoughtful and wonderful writer.

This post touched me - in a kind of mythic way. When someone went to the underworld, they had a ferryman, Charon, who carried them across the River Styx and then back again.

When we go into the darkness, however that comes into our life, the greatest comfort is to know that we are accompanied, that the ferryman will help us find our way back.

Lisa G said...

Found you through Grand Rounds. I had all sorts of these little rituals as an ICU/OR nurse--what pen I had to use, never use the Q word, check my pumps in the same exact order, and so on.

What I loved about your post was how you put yourself out there for that patient. Since I'm having a lap chole next week, I thought to myself...I wish SHE were my anesthesiologist. I find that being a nurse just makes me more frightened.

Thanks again. Truly magnificent post.

T. said...

NurseExec - thank YOU very much for coming, and for your kind words. Your blogs are great, btw. I wish you the very best for your lap chole - let me know how it goes!

Anonymous said...

Yeah. I have one too. It's more of a personal superstition, but it'll do: When there's almost nobody in the hospital, NEVER under any circumstances say "There aren't that many people here..." You know what will happen.