Tag Archives: professional skill

on being called “a hero”

There’s a hazard to having a friend that’s a sociologist: she forces me to think about why things are the way they are. In this particular case, she’s turned me on to some interesting reading material that seems never to fail me for something to think about.

I am not unaccustomed to risky jobs, and the people who work in them. I work with paramedics, firefighters, prison guards,  the most commonly thought-of “life is on the line, he’s such a hero” sort of stuff. The book they’re talking about is right on the money: for the most part, they don’t think of themselves as anything other than ordinary people in control of an extraordinary situation. Any mishaps that laypeople consider to be risks inherent in the job (a cop getting shot, a firefighter dying in a fire) are not seen as particularly risky to the people engaging in them. I’ve spoken to cops about going into buildings armed against people who have gone totally butternuts and are armed to the teeth — the risks they talk about aren’t that they might get shot at — it’s the fact that butternuts in the shed over there isn’t predictable. They’re trained to predict what the rest of us think are unpredictable.

This, of course, thanks to the grooming of my friend the sociologist, makes me think of the times when I’ve been told I did something “heroic.”

Usually what happened is there was a very sick person in a very bad way, and I was part of a team of people who predicted the unpredictable and then responded. The response is to perform a number of different interventions in order to change the course of their illness or injury. I don’t think what I’m doing is heroic. I don’t think about how people are going to die if I screw up. I don’t feel the pressure, really. What I am is in control.

I can see the signs. I can measure and quantify how bad the situation is using specific parameters which allows me to manipulate those parameters with drugs or pressure or gas. I can control the oxygen or the respiratory rate. Sure, there’s a bit of a scramble trying to get to the point where you’re in control, when you’re on the move from prediction to execution, but you know what to do, so instead of being stressed about how it’s do or die time, you just stop thinking and do.

I find us RTs especially tend to think in “the worst thing that could happen is” sort of parameters. When others are afraid to extubate the patient we’re shrugging our shoulders going, “the worst thing that could happen is she/he gets reintubated.” To us, it’s no big deal. We’re trained to predict what the worst possible scenario could plausibly be, and then be prepared for it. We controlled the airway by putting in a tube, we did it once, we can do it again. If I can’t do it personally, there’s someone close by who can.

I remember a couple of these do-or-die situations happening to me and there was a lot of muscle memory in that st0p-thinking-just-do. A sick neonate thrashes a bit on the overhead warmer and self-extubates, and there’s no pediatrician within a shout’s reach? I’ve been trained for this. They taught me how to intubate precisely so that I could respond to this situation. Paralyzing myself with fear and waiting for the pediatrician to haul his ass into the room is an option, but the worst thing that could happen is I try and I miss. I’m also trained in what to do in that case: the patient would be no worse off for me missing. Besides the fact that I’m qualified and trained and skilled in intubation — the patient needs it right bloody now. If I waited for the pediatrician I’d feel like I had chosen the wrong line of work and would probably quit soon and go become an accountant. What I did was grab the (conveniently located) necessary equipment and make with the intubating. I know what has to be done, and I’m qualified to do it, so I do.

There are those times when despite your best efforts you lose control of the situation. Just like the firefighters do, I find we look for something to blame. Somebody screwed up, somebody didn’t notice the alarm, the monitor was malfunctioning, I gave up too soon and should have kept trying, we didn’t get there in time, they waited too long, and so on, and so on. I failed to predict the outcome. I failed to respond accordingly to the situation in the way in which I was trained. I look for how I could have gained control, therefore, I don’t really fear the loss of life that happens due to variables that are beyond my control.I learned very long ago as an RT that there’s some parts of the clinical situation that you just can’t change.

I’m scared of screwing up or missing something, I’m scared of missing the prediction or failing to respond. I’m also confident that the longer I spend in control and the more I refine my muscle memory, the more I lift the mental weights that allow me to consider more of the situation, the more that muscle memory allows me to automate simple tasks so I can spend more mental energy being observant to other signs, the less likely it will be that my simple screwup results in somebody’s death.

It’s happened in the past: I’ve failed to notice a sign that the patient was in cardiac arrest and then the patient died. That said, so did everyone else in the room fail to notice, and given how sick the patient was prior to going into cardiac arrest, the chances of us being successful even if we’d caught it were pretty slim anyway. No one person killed that patient. The culmination of many factors did, and some of them were beyond our control. Did I learn a hard lesson? Yes, I did. That one’s a notch on my proverbial shield that I’m not ever going to forget — and the next patient will benefit from it.

Therefore, by the same token, no one person involved in saving another’s life is “the hero.” The collective sum of our teamwork and brains and muscle memory and situational awareness and skills are the heroes. We just predicted the unpredictable. We executed our plan for how we were going to gain control. We gained control of the situation quickly and effectively, and then we held on to it. It holds no mystery to us.

We are comfortable.

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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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