“practicing” medicine

I have to chuckle at how much “being good at my job” in this field involves simple skills. Either muscle memory, fine motor control, or quick reflex. In school, they cram your head with facts and lab demonstrations. They try to get you to show that you can do what they teach you … it’s still not the same as doing it on a person. And then they throw you into practicum, and you have to poke ten (or so) people before you get signed off on the skill. You will miss a bunch. Theoretically, you could pass the course having only poked those ten people. (It never happens that way, of course.)

I don’t think I’ve met one person who freshly graduated who felt like they knew Exactly What They Were Doing. (At least, not anybody who I would let touch me in a medical sense.)  I was probably on the job for months and dozens of shifts before I began to poke people and assume I wouldn’t miss. This isn’t to say I missed a lot prior to that — just that prior to that point, I wasn’t confident in my skill.

It took months and months of practice before I began to feel confident — and months (and months and months and months) after that before I began to truly get “good”. Some of being “good” at it is individual. Experience, steady hands, a particular technique that works well for you, and even just having a good day. I’ve had days where I couldn’t hit the broad side of a barn.

Some of the skills involve where you work. I had never attempted an arterial line until I moved from the (not-so-affectionately-nicknamed) Center of the Universe to a little hospital in the boonies. In the Center of the Universe (University Center for Excellence I think was its formal title in some permutation) we were of the type that tended to believe that those country bumpkins? Those hicks in the boonies? Their experience could in no way ever compare to my experience, here in the land of too-much-money. Now that I am one of those hicks in the boonies, I realize that there is pretty much no way in which I could have been more wrong.

Prior to moving, intubation practice was a theoretical exercise, done in the OR under the supervision of an anaesthetist. You had your choice of: the gruff ex-military guy, who once barked at me that “putting the tube in is a bar trick, I am not signing you off unless you can tape it and throw him on the vent by yourself,” the lady from down east who hated you up until the point where she discovered you were intelligent, and only then could you be friends, the head of anaesthesia who I think was compensating for something, the tiniest skinniest woman I have ever met, whose capacity for niceness and overall cheer definitely outweighed her entire body soaking wet, and the various other anaesthetists who would rotate through all of the hospitals in the health region, a process I once jokingly referred to as “the rock stars going on tour.” You went through the OR and did your six or ten or what-have-you intubations and got signed off and then left, every year, without fail. You pretty much never intubated outside of the OR, because there were always 835 residents or ICU doctors or somebody who wanted to be a hero who wanted to secure the airway. I demured, partly because it was entertaining, and partly because I didn’t much relish, as a young RT, being the object of scorn to miss an intubation (because it was generally understood that even if an RT were to try, if you didn’t get it on the first attempt, you would be quickly elbowed out of the way by someone ‘more experienced.)

I will never forget the moment at the small-town hospital when, during a code blue in the middle of some department completely unfamiliar with code blues, the only doctor in attendance gave me a funny look from the foot of the bed. I, at the head of the bed, bagging my little heart out, had gathered my things and was waiting for him to come up to the head of the bed and assert his heroism. Apparently in the country they don’t believe in being Big Damn Heroes, because he kind of just gave me the eyebrow until it dawned on me: “OH! You want ME to intubate!” He laughed at me and nodded. I intubated. It felt amazing to get to use a skill I’d practiced nine thousand times and never gotten to use before. Without the nine thousand times of practice, however, I doubt I would have been even moderately successful. Those anaesthetists, when not chuckling at my struggle with bagging via the circuit on the anaesthetic gas machine, were a veritable font of tips and tricks. I have used many an anaesthetist’s dirty trick since.

I had never attempted an arterial line prior to coming here. I remember one anaesthetist here, regarded as a bit of a comedian, giving me the eyebrow when I said I didn’t think I was certified to do one. Apparently here, the certification procedure consisted of “show that you know how to do it.” I have since impressed him with my ability to put one in on the patients with blood pressures so low that the textbooks say they shouldn’t have a radial pulse. (Not gonna lie — some of them didn’t and the only reason I got it was because I’ve poked that artery 9000 times before, and know pretty much where it’s gonna be. I’ve also missed my fair share of those, so no hubris here either.) I have somehow earned myself a bit of a reputation as The One Who Never Misses, which is utter hyperbole — I miss occasionally — but the only difference, apparently, is practice.

It’s not just me, even. The residents and their (sometimes sisyphean) struggle with the subclavian line, out here in the middle of nowhere always positioned without the use of an ultrasound device, a device which, I feel, is a bit like a back-up camera on a small family sedan. Can you please learn to parallel park without the camera before you start to rely on the damn thing? Over-reliance on gear seems to me to be a handicap moreso than an asset — those who are excellent at the primary skill are often far better users of the gear anyway. (I will never forget the day I watched our comedian-anaesthetist intubate a lady with a fractured C2 — move her neck too much and you might be able to see, but you will also kill her — with practiced ease and proficiency with a glidescope. I declared myself a member of his fan club. He replied with a grin, saying he loved being African, because “I’m blushing, and you can’t tell!”)

The practice-practice-practice paradigm shows very clearly why the best are often the ones who’ve been around since dust was invented, and how old are you, again? They’re the ones who could get blood from stones, who could put IVs in even the most hardened IV drug user veins, who could intubate the guy you’re terrified to even try on, who can say, with confidence, “I will get it,” and then they do. They’re the ones with the dirty tricks. The ones who make us better, by making us into amorphous collections of piecemeal knowledge and dirty tricks. There’s an old joke about practicing medicine and “maybe someday I’ll get it right” … I don’t know if it’s possible. Much as it’s not like they come out with a new model of the human body every year, they come up with enough new information and new gear that that’s all we’re ever going to be doing … practicing.

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