Category Archives: The Team

when he said thank you

I hugged him, with one arm, afterwards. I hugged him because he was afraid.

He’s a pediatrician. It’s that season, you see. The season of kids with hideous gastroenteritis, the season of dehydrated little tiny people who are justthisclose to having one of those near-death situations we talk about in PALS so much.

This little one, her heart rate was over 200. She met the standard definitions of shock. She needed a lot of fluid, and fast, before her little heart wore itself out from beating so fast. I only got called to do a cap gas really. If the results aren’t that bad, I don’t ordinarily return to the room. This was one of those situations when I returned in person to the treatment room. This child was doing that eyes-rolling-back-in-her-head-breathing-is-optional thing, being stimulated by nurses rubbing her sternum with knuckles to try and get her to wake up and take a breath. This child was close to having a cardiac arrest. These poor nurses were doing everything they could prior to the pediatrician arriving kind of thing. These poor nurses had poked this poor baby 20 times or more.

By the time the pediatrician had arrived, the favored major sites had been poked to try and get an IV. I could hear the echo of my PALS instructor (another pediatrician) in my head: “how many times do we poke and poke and poke with these sick kids, when we could just do an IO then and there, and leave those veins for after they’ve been rehydrated?”

I had nothing respiratory to do, other than prepare. I changed my mask on my bagger. I had my intubation equipment ready. I was planning for the worst, and, at the same time, I was prodding my pediatrician: “just put in an IO, just do an IO, the gun is six feet from where you’re standing, why struggle with trying to put in a fragile IV in the scalp you can’t pound some real fluid in anyway, just put in an IO.” I was naive about his previous experiences with trying to put in these fabled beasts into small children. I was unable to put myself in that picture, of the child who had suffered through multiple attempts. I was that ignorance-is-bliss voice-of-reason, where I had no clue that he had tried this before and it’d gone horribly.

He did it anyway.

After multiple attempts at an IV cannulation in this very small, very dehydrated child, he finally pulled out the IO gun to drill a needle into this tiny person’s leg bone. It’s a very squick-inducing thing. Had it not been the best method of getting some life saving fluid into this baby, I would never have suggested it. How necessary it was became obvious when they drilled into her leg and she didn’t even flinch. In goes the IO. A very large amount of fluid gets pounded into a very tiny person and very quickly does such a baby begin trying to put the ECG lead cables in her mouth rather than her eyes rolling back into her head. Relief.

“Good, her heart rate is slowing down,” I say aloud, (from the 200 earlier, I’m thinking.)

“Great, mine too,” the pediatrician says, and my heart goes out to him.

He, in truly heroic fashion, later thanked me for making him do the scary IO thing he didn’t want to do, later. I replied with a smile and a one-armed hug.

I am so pleased to have these relationships with the doctors I work with. I chafe to think at how I would work with someone who would not be receptive to input. I am extremely pleased that in this case, this child lived, and am perhaps in this case, not so immodestly proud as to think of how I perhaps may have helped to save this baby’s life by being a right royal pain in the ass.

I love my job.

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“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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setting the tone

Tension is contagious. The job is stressful, what’s happening is scary, yes, but it’s sometimes in these situations that the most important thing you can do isn’t anything life-saving — simply put, you have to keep your cool.

Emergency is a department where you think you would meet some of the most resilient people in the world — people who are unflappable and good under pressure. Some, even the majority of them, are. Not everyone can be perfect, however, so it’s important that the unflappable stay calm, with an even tone of voice, without rushing. It’s precisely because tension is contagious that the naturally un-tense among us mustn’t get caught up in the tension.

Respiratory is a tense job, period. I’ve had moments I clearly remember primarily because of that squeeze of adrenaline burning the memory into my brain. The stress response is a strong thing: my hands shake, my speech is fast, pupils dilated, time dilated, memory sometimes not the most reliable. It’s a struggle in these moments sometimes to keep my tone of voice even, to not rush my words into an unintelligible mumble, to not get impatient to the point where I begin taking my stress out on other people.

It only takes one person to destroy the calm. Even when things are hairy and scary, voices don’t have to be raised, team members can ask for things (rather than demanding,) and tempers don’t have to be short. It’s when the one person who’s not in control, who lets tunnel vision take over, who lets their stress spill into their voice and their ability to cope evaporates in the tension. This person can be the most dangerous player on the team, simply because they stress other people out — those who don’t have iron fist control over their emotions — and it’s in this stressful state, with someone barking orders at you, yelling at you, that you begin to rush, and your judgment and decision making skills become impaired.

This is when experience helps — not because experience will tell you what to do, but because experience will make you harder to stress out, generally speaking.  The exception to that rule, of course, are those people that have a tendency to become flustered even with experience. It’s worse, because the less experienced team members pick up on this, and then end up in this situation of “if they’re freaked out, then I should be freaked out!” Things spiral into disorganized chaos from there.

I’m at the head of the bed most of the time. I have a very clear role to play and a specific job that is, truly, nobody else’s. Nobody in that room barks orders at me for the most part, and I don’t order anyone else around. Once I’m doing what needs to be done, everything else follows. In a sense, it’s tense at the beginning, but once airway is secured and air goes in and out, I am a spectator at the head of the bed. Maybe it’s what makes it easier to be calm.

This feature of the job allows me to fade in the background and observe people. I consider it a point of pride to remain collected and cool. While spectating, I take notes in my head — notes about the people around me and how they’re handling the stress. I think it stands to reason that the people I observe setting the tone, giving orders in even tones of voice, or focusing efficiently on the task at hand, tend to be the people I gravitate towards when the situation isn’t stressful and hairy. I find their resilience enjoyable, and for the most part, they’re also highly intelligent people who are exceptional at their jobs.

A lot of people start out with emergency medicine in mind thinking that they get to be a hero in those dramatized situations they see on television. The truth is that the best people for the job are the opposite — not trying to showboat their heroics, not making the situation into a dramatic cluster of chaos, but those who calmly go about the task at hand with focus and skill. The truth is, the best run codes are the ones where everyone in the room looks like they are just this side of bored. There’s nobody pressed with anxiety that things should be happening faster. The lack of tension means that it’s easier for everyone to take a second to think. And while in those situations speed is crucial, speed is useless if you haven’t had a chance to think.

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the one who doesn’t cry

An unanticipated death; some professional embarrassment in there for good measure. Difficult, due to the fact that the one who died was a child, and a sweet one; that, and the fact that it was likely our fault in some way. (The reader is left to imagine the multitude of ways in which one person in a team of probably hundreds could be possibly at fault. Trust me. We’re all wondering the same thing.)

A debriefing; listening to the vignettes of the family and the child from the circle of chairs in the playroom. Some tall people on some tiny chairs, wilted from night shifts, or the ones fresh from days off, with perfectly applied makeup. They had a long time with this baby, they laid down in his bed and hugged him, patted his tummy to comfort him in that way they had seen his dad do, taking him to the playroom instead of starting his feeds … interviews with mom … years of past history … perhaps wondering why they hadn’t intervened earlier.

If there’s anything I’ve learned through a multitude of shitty situations, a multitude of debriefings, it’s this: no matter what is your fault, it’s over. Learn from it, for it’s the only possible positive outcome of an entirely crappy situation. Beating yourself up about how it could have been better if you had the power to go back in time and fix your fuckups is ultimately a failed exercise in self-loathing, and the self-loathing is an obstacle to learning: what’s happened has happened, so learn for next time, and prevent it from happening again.

A lot of that happened in that debriefing. From the strong and silent among us semi-blaming themselves, knowing what they’d do different, to the ones who have what seem like the easiest jobs in that they are only so tangentially involved, nearly everyone seemed upset nearly to the point of tears.

Except me.

It came to be my turn near the end, and I spoke of equipment malfunctions, problems with sensors, recalibrating X and Y, and of being pissed at myself (not blaming) because I had been so absorbed in the equipment that for that critical minute, I forgot to look at the patient. I wasn’t upset at the death of the kid, I was more pissed at myself that I had immediately jumped to the conclusion that the equipment was messing up on me.

To be fair to myself, the rest of the equipment hadn’t exactly been working as intended, and I’d had problems from the get-go. Things were quiet and stuff that should have been watched wasn’t, but it’s hard to not feel a bit like an uncaring goon when the people who weren’t even there for the arrest seem significantly more shaken up than I am.

It’s remarkable to me because, I think, this is not simply because of respiratory or because of the sheer amount of times I’ve been there when somebody’s died. I don’t think it’s that I’ve become desensitized or somehow heartless regarding the whole incident. Indeed, I was upset about it — I just did all my crying immediately afterwards and not in the debriefing. So it goes.

I think, however, that last paragraph is a bit reflective of how RTs are. We have the face we show to the rest of the team, and then there’s the things we say, the stuff we complain about, the opinions we share, the discussions of what bother us, the planning what to do next, that we all do behind the closed door of the respiratory department. The reason I never cry at organized debriefings, the ones headed by a social worker or someone with training for crying people, is because in order to keep doing what I do, I have to do it every day, by myself, behind a closed door. More often than not, I do it with other RTs. Sometimes, like the particular instance that struck me this time, I end up doing it at 2am with other health professionals, like the nurse who gave me a hug before I cleaned my vent and went home to bed.

I think it’s healthier that way; that I know how to debrief so that I can sleep, that I do it automatically and without needing hand-holding or prompting. I think it’s what means I can do my job without having a nervous breakdown.

Long ago I used to worry that not crying about these things meant I was getting callous and gritty, jaded and bitter, all those things that they usually say about surgeons and cops. I don’t worry about those things anymore: I think I have a better understanding of grief and attachment as a result of having done it more times than I can count. I can survive without losing compassion. Maybe some would call it tough, but I hate that word for this. It’s not some kind of machismo bullshit need to appear all stiff-upper-lippy. It’s just self-preservation. I can sleep without waking up screaming, I can go to work the next morning, and I can still have fun at work. I still love my job. No matter how shitty it gets, I plan to. For a long, long time.

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