What are you afraid of?

Those critical care procedures you could / should / would do, but don’t.

It’s been a long shift in the Emergency Department, topped off with resuscitating a young patient in severe sepsis. With no infection source found, you know he needs a lumbar puncture to look for central nervous system infection. But hey, it’s been a long shift, he’s had antibiotics, the staff are busy — he can wait to have the LP upstairs in ICU, right?

At the end of a long shift in ICU, you review the patient in Bed 9 again. An old lady with urinary tract sepsis, she’s needed increasing doses of intravenous fluids and now metaraminol as a vasopressor to keep her blood pressure up. She’s probably going to need an arterial line to monitor BP and a central line to give some stronger noradrenaline. But then again, the antibiotics might kick in soon, and those procedures are a bit rough for the patient, right?

A quick one to finish the night in theatre. Just a 12 year old kid who needs a manipulation and plaster of his fractured forearm — 5 minutes, tops. You know what the old grey-hair anaesthetists would say: potential full stomach, aspiration risk, needs a rapid sequence induction and tube to protect his airway. But he looks well, a quick GA with a laryngeal mask would save a lot of hassle for all concerned, right?

We all know them, the justifications for that slightly less active approach in terms of critical care procedures:

  • Patient comfort — “it’s pretty invasive, I wouldn’t want to cause unnecessary pain.”
  • Time and resources — “we’re a bit busy down here tonight, can’t you do it upstairs?”
  • Other priorities — “let’s just get the scan done, he can have the LP later…”
  • Other ways of obtaining the information — “let’s just check his sats rather than an arterial blood gas”

There are myriad reasons why avoiding, postponing or modifying a procedure might be the right thing to do. But is it possible there is sometimes a reason a little closer to home?

Do we ever avoid these tasks because we’re afraid what the outcome might be? That we’ll fail, look incompetent, cause harm, take too long, make the wrong choices…

Ergasiophobia literally means “irrational fear of being able to work properly”, but usually refers to a surgeon’s fear, or pathological avoidance, of operating. But anxiety in performing critical care procedures isn’t necessarily irrational or pathological. Fear reminds us that what we’re doing is important, that there are consequences to our actions.

Fear, anxiety and stress strikes us at different times as we learn and master procedures. Of course, there’s our anxiety as we first learn a given procedure, but that’s normal.

After that, we enter a purple patch- “We can do this new procedure!” Things seem great. We’ve had success a few times now, including performing the job unsupervised.

Then the more pernicious type of procedural anxiety creeps in… “The Hump” — the difficult period when we are no longer a beginner, we can’t claim to be on the steep learning curve- but we haven’t yet mastered the procedure. The hump starts soon after we’ve become ‘independent’ performing a procedure (and the supervision and aid has ceased) but as we start to hit snags: the tricky procedure, the difficult patient, or our first major complication. It’s now that we feel alone. We can’t claim we don’t know how to do the procedure, but it’s by no means yet straightforward.

Procedural Anxiety

So what can we do?

A few years ago I felt fairly comfortable with my ability to perform an awake fibre-optic intubation, using a flexible camera to guide a tube into a patient’s (usually with abnormal face, mouth or throat anatomy) lungs. I’d done quite a few, and had no major problems. But if I was being honest with myself, I wasn’t hugely convinced that I had this job mastered. Though I could accomplish the procedure satisfactorily in a pinch, I felt clunky, rough, and on the edge of failure every time. And what did I do?

I avoided the fibre-optic intubation whenever possible.

Was this to the detriment of my patients? Possibly. Certainly if I kept it up, one day it would be.

The answer? — I found a friend. A colleague who by anyone’s measure was an absolute gun at awake fibre-optic intubation. I felt miles away from my colleagues skill level. So I asked. Could I watch him do a few? Could he watch me do a few?

With just a few more exposures I realised it was just a tweak here, a little trick there, and some reassurance that I was doing the right thing that changed everything. Suddenly I was over the hump. Need an AFOI now? No problem.

Hopefully now we travel along that green portion of the graph, the smooth level of mastery, until the next challenge comes — that of fading competence and imminent change or retirement.

But until then, it behooves us all to have the insight to recognise our own fear. A subtle fear that masks itself with seemingly reasonable justifications and excuses. Justifications that let us off the hook of doing the right thing. When we recognise the fear, the stress, the anxiety, we can do something about it. Ignore it, the problem gets worse — until our patients suffer the consequences.

So here’s the challenge: When we hit The Hump, we won’t let fear stop us there, but we’ll use the fear, stress and anxiety to motivate us forward toward mastery.

Dr Craig Mitchell

MBBS, FANZCA, PGDipEcho

craig@agb.com.au

www.agb.com.au

www.anzca.edu.au

About me:

I’m an anaesthetist in Ballarat, the main referral city for Western Victoria. I work in both the public and private health systems, and have a very varied workload across most surgical specialties, including a fair percentage of time working as an intensive care consultant. I graduated from medicine in 1997, and undertook specialty training in Victoria, New South Wales and Scotland. After becoming a specialist anaesthetist in 2006 I moved to Ballarat, where in addition to my anaesthetic practice, I have a busy winery, and a very active family.

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