Friday, December 16, 2011

You're Going to Be Just Fine

     When I was in the 5th grade, my little sister and I came home from school every day, filled our cereal bowls full of Kaboom or Count Chocula or Captain Crunch, and plopped down in front of the TV. We lived in Osawatomie, a tiny town in Kansas, and we only received a few channels. There was no such thing as cable back then, so our choices were limited to the major broadcasting networks on VHF, or the Kansas City channels on UHF. Aside from Zoom and Speed Racer, the UHF channels featured a lot of Japanese sci-fi programming, like Ultra Man and Johnny Sokko and His Flying Robot, both of which were dubbed in English. The storyline was predictable, always the same. An evil villain would perpetrate terrible acts upon innocents in the community, spurring a graphically violent antagonist-protagonist battle. In the end, good always triumphed over evil.
     For me, Johnny Sokko was definitely not a good thing. I was a shy, chubby girl with an overly vivid imagination, who insisted upon sleeping with the light on in the room I shared with my little sister. She didn't seem to appreciate that there was a wolf living under my bed, nor did she, at the age of 8, grasp that sleeping with the light on was essential for keeping him contained. My fears were a source of irritation and interrupted sleep for both of us. After watching a particularly scary Johnny Sokko episode where a sinister chemist poisoned the city's water supply, turning everyone who drank the water into vampires, and where the only way the people who hadn't drunk the water could prevent themselves from being bitten was to contort their necks into a torticollis-like position, I had my first encounter with superstition. My sister and I shared a bunk bed, and I slept in the top bunk. In order for me to avoid being attacked by the vampires lurking in the closet, I had to lie with my head dramatically extended to the left, and then, I had to say a special prayer asking God to bless everyone in my family, from oldest to youngest, and if I left anyone out, I had to start the prayer all over again. There were so many people in my family, which made it very easy to inadvertently leave someone out, and there were some nights where I spent what seemed like hours, trying to get the prayer right. The thing was, I had to do it, in order to protect myself from those vampires.
      Fast-forward 38 years, and voila! Plus ça change, plus c'est la même chose.* I am now a physician, yet after spending many years in school studying evidence-based medicine, I am still plagued by superstition on a daily basis. In the operating room, there are certain maxims you just don't violate. For instance, it is absolutely unacceptable to remark aloud, "Wow, it's been a really quiet day!" because then, you've "jinxed" it, and you will then almost certainly receive an emergency transport, screaming down the hall, straight into the OR. I'll be the first to admit that I've performed silly rituals, such as waving a stick of ephedrine during an anesthetic induction, in an attempt to ward off "evil spirits" of hypotension. In anesthesia residency, we all walked around with an emergency needle trach kit in our pockets, just in case there was someone we couldn't intubate, yet I only know of one person who ever had to use hers. In examining these practices more closely, they do seem somewhat guided by anecdotal experience: been there, done that, try to prevent badness. Is our ritualistic behavior purely a function of superstition, or is it preceeded by intuition?"
     During my cardiothoracic rotation as a second year anesthesia resident, I had a patient who presented for a cardiac bypass. He was a middle-aged guy with high blood pressure, but was otherwise healthy.  Before we went back to the operating room, he talked a lot about his wife and daughters, and how much they meant to him. He was eager to get through the operation so they could resume their lives as a family. He was extraordinarily anxious, which is normal for cardiac patients, and although I remember him expressing some fear about not waking up from his anesthesia, nothing really struck me as odd or ominous. He was just nervous. I laughingly reassured him that we had drugs to help him with his nerves, and giving his shoulder a confident squeeze, I said to him, "You're going to be just fine."
     Those were probably the last words he ever heard. During his coronary artery bypass operation, the surgeon discovered that his aortic valve was damaged, necessitating a concomitant valve replacement. After going on bypass, he needed some blood. The available units of blood were cross-checked and administered by the perfusionist, shortly after which the patient went into cardiovascular collapse. Suspecting a transfusion reaction, I frantically administered fluids, epinephrine, corticosteroids, Benadryl, and Pepcid. His kidneys immediately failed. The procedure quickly converted to sheer damage-control, and we took him up to the cardiac ICU. Later that evening, he developed internal bleeding, and I was called back in to operate on him a second time. It was then that my attending and I learned that there'd been a fatal clerical error in the lab: the patient had received an incompatible blood transfusion. He died the next day. It was the first time I'd lost a patient, and I couldn't erase the image of him, talking about his daughters and being so incredibly nervous, from my mind. I now believe he was having a premonition of death, and because I was so green, I wasn't tuned in to it
     After that case, I changed the way I talk to my patients about their anesthesia. I never tell anyone, "You're going to be just fine." Although my job involves a massive amount of foresight and planning, things can and do happen, and sometimes, they are beyond my control. I can't say with certainty that you won't be hit by a bus as you walk out your front door, and the same holds true for giving anesthesia. In most cases, I'm 99.9% sure that the anesthetic will go smoothly. That means there is a 0.1% chance there will be a problem, and I see no reason to not be honest about these odds. The only real guarantee I can honestly give my patient is the reassurance that I am going to take excellent care of him or her.  Perhaps the hallmark of an experienced physician is the transition from superstitious rituals to the intuitive practice of medicine. Superstition develops from an ignorant fear of the unknown, while intuition implies visceral insight, neither being particularly rational. Because intuition depends upon perceptive knowledge of a situation, whereas superstition illogically associates external forces with an outcome or event, it becomes obvious that experience provides the stepping stones from fear-based practice to one that relies more heavily on cognition. I don't see anything wrong with wielding a magic wand of vasopressors in the operating room, because it's always better to be safe than sorry. Being conscientious and cautious, but most importantly, listening to our inner voice, our gut feelings, leaves little room for surprise, and in the world of medicine, that's a very good thing.

*the more things change, the more they stay the same



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