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January 25, 2013

BehindTheMedspeak: On overcoming the fear you're killing someone by inducing anesthesia during your first week of residency

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The year was 1977, the month was September.

After two miserable years as a G.P. and family doc in LA, I'd decided to abandon the boredom I experienced every minute of every working day and become a specialist.

I considered every specialty extant and only a couple — anesthesiology, pathology, and radiology, as best I can recall, required (at that time — all of these residencies are now three years long) only two years of training on top of the internship year I'd already completed.

I picked anesthesia because a very good friend of a very good friend happened to be U.C.L.A.'s anesthesiology chairman at the time: one phone call, a 15-minute audience with him, and he asked me "When do you want to start?"

It was that easy.

Things were different then.

Anyway.

I reported for my first day on September 1, 1977, and was assigned to work with a senior resident for my first two weeks, in his presence every minute.

He gradually let me do more and more, always at my shoulder and never ever leaving me alone to have to decide anything on my own.

That was comforting.

But each time I pushed the sodium pentothal (for induction of unconsciousness — propofol hadn't yet been invented) and succinylcholine (total skeletal muscle paralysis — including breathing — within 60 seconds),

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my heart started beating superfast and I became panic-stricken.

Omigod, I remember thinking, what if I can't ventilate? Or intubate? What if the patient arrests? And dies?

The fear was immeasurable and incalculably debilitating.

I was a wreck at the end of every day — drained, exhausted, spent.

It happened with every patient for the first week or so.

Then, sometime during the second week, I decided I'd had enough of that.

I said to myself OK, go ahead and feel afraid, but make every effort not to seem afraid by anything I said or did.

Talk to my senior resident, ask a casual question as if I were not scared to death but just curious about, say, the half-life of pentothal or how long till spontaneous breathing returned after succinylcholine.

It was as if I'd put a psychological heel down really, really hard on my neck and then pressed down with all my weight: my outward manner would not reveal anything about what I was experiencing.

From the first case in which I invoked this thinking, in my head saying to myself you're cool, it's all OK, don't let them see you sweat, etc., things began to turn around.

The transition took about a week to really take hold.

After that, I actually felt less fear with each passing day until after a while, I no longer ever felt that kind of debilitating paralysis of thinking no matter what happened during a case.

Don't get me wrong: I still get frightened when things go south in the O.R., plenty scared, you bet your life — the difference now is that my thinking remains separate from my emotions, such that I can be aware of feeling the bottom is dropping out really fast yet think as clearly and logically as if I were at home watching a training simulation on my computer screen.

Of course, it helps that I've been giving anesthesia now for over 35 years: I won't lie, anesthetizing 40,000 ± 10,000 people over that time has built up a certain degree of familiarity with what can go wrong and how to quickly right a listing ship.

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But the ability to separate emotion from reasoning: that, I believe, I began learning how to do way back during that second week of September, 1977.

January 25, 2013 at 12:01 AM | Permalink


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Comments

And each time I've been put under, I wonder how long it would take until spontaneous breathing returned after I get the succinylcholine (although I admit I didn't know the name of the drug in question) but then ultimately realize it would be too long for me to worry about :) And a strange-but-true fact -- I started a doctorate program at UCLA at that same time and lived in the grad student dorm just a literal hop and skip from the hospital you were overcoming fear at ... and here we are many years later ....

Posted by: Frances | Jan 26, 2013 8:18:08 PM

Impressive.

Reminds me of my own tiny little story. At my job interview for my second job as a technical writer, the guy I would work for asked me to write instructions for how to tie laces on a shoe.

He went on, explaining that he really didn't know how to qualify technical writing talent and at least he was being fair by giving all candidates the same test, etc., etc.

But I had stopped listening. I was thinking. As soon as he paused for breath I asked him, "Do you want instructions for untying as well?"

"No," he said and went on some more but as soon as he stopped again I asked, "Are the laces already threaded through the eyelets?" "Yes," he said. Then he let me get to work.

This is like an old routine I saw on a TV variety show where one guy does exactly--literally--what another guy tells him to do to put on a coat. It's an illustrative exercise. Funny and frustrating.

Anyway, I got the job. It's just that I was amazed by how my mind could work so automatically, efficiently, and effectively, after only 18 months in the business. And with most of my talent at the intuitive end of the scale, with an education in English Lit and Business and Journalism, instead of Engineering.

But I would never want your job!
😄

Posted by: Pt | Jan 25, 2013 4:00:12 PM

Ah, what the hell - blame it on the surgeon.

Posted by: 6.02*10^23 | Jan 25, 2013 2:34:16 PM

Fascinating.

Posted by: Rhea | Jan 25, 2013 1:51:49 PM

Respect.

Posted by: Rattlesnake Jake | Jan 25, 2013 8:29:50 AM

Best read ever Joe.

Posted by: Jesse | Jan 25, 2013 7:10:30 AM

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