Saturday, December 1, 2007

Appropriate Apprehension

There is no more sickening feeling then looking down the blade of a laryngoscope and not seeing the airway, repositioning, attempting secondary maneuvers, and still nothing. Except perhaps the sight of the just delivered head of a baby suck back against the perineum in a severe shoulder dystocia. Or maybe a newborn baby, flat and blue and not responding to artificial ventilation. It makes the pit of your stomach drop. The feeling is sickening. These are cases that cause prudent people apprehension to even consider. In the seconds before repositioning the laryngoscope works and the airway slides into view, before the baby's shoulder disimpacts and delivers, or as another baby gasps it's way to a 5 minute APGAR of 9; these are the moments where the specter of that sickening feeling sits on your shoulder and waits to slide it's hand onto the back of your neck.

Medicine here in the north is a proposition that calls for interdependence between doctors, nurses, ambulance crews, flight paramedics, and interpreters. To practice you need to be able to trust that the other people in the team know what they're doing and will make good decisions. Although confidence can be a marker of an experienced person, in some situations it can also be a red flag. As a Family Medicine resident, one of my teachers told me that every grey hair he had was from a delivery (he was an experienced doctor with over 30 years of obstetrical experience, and a head full of steel grey hair, and always walked into a delivery with a deep breath preparing for trouble). If the specter of apprehension doesn't visit you as you walk into the case room to do a delivery, you simply haven't done enough deliveries to know better.

I once took a phone call from a very nervous nurse in a remote community who was taking care of a child who had stopped breathing. I talked her through bag masking the child, putting in an oral airway and an orogastric tube, and ensuring she had a good seal with the face mask. She was well trained and did fine, but even as the situation moved from chaos to control she worried: 'This might end badly'. Indeed. Appropriate apprehension. I arranged for a medevac, and felt that the pediatrician should go along to intubate the child. The flight medic disagreed: 'I can intubate kids, no problem', he told me, 'I've done it lots of times. You don't need to send a pediatrician' The temptation was to take his confidence at face value, to feel relieved that an experienced manipulator of the pediatric airway was on the case, and flying to the rescue, but instead the pit of my stomach dropped. I know people who intubate kids (Dr. H. among them), and it seems that the more children's airways a person looks in, the more cautious they become. Things can go wrong, and there is a marked difference between being able to handle the situation as long as it goes well, and being able to handle the situation.

Perhaps one of the most dangerous things that can happen to a young doctor (or nurse, medic, etc.) is to have everything go right early in their career. It blurs the line between the confident and the cavalier. Complications breed apprehension, but also strategies for coping with future complications. In an isolated place, where things can go wrong quickly, and help is limited, confidence can be misplaced and sometimes apprehension is simply a marker of good experience.


MedStudentGod (MSG) said...

Very true. Nothing like having everything turn up roses for too long to breed unwelcome cockiness in a newer doctor. A complication, as I've seen many times, puts you right back where you're really at.

Dr. J. said...

Luckily every time I get that I'm on fire now! feeling something humbling seems to walk through the door and tear me right back down to earth....
Dr. J.

WRMedic said...

Too true Aaron, sometimes you gotta know what you don't know. A few FUBAR calls is just what the doctor ordered.