Sunday, May 9, 2010

Warm Blue Water, Beaches in France, and Spinal Anesthesia

“You are tentative,” she said.

My patient was a 73-year old women, who spoke with a heavy Russian accent. I met her in the Preoperative area, where I initially caught a glimpse of her limping and approaching the nurses complaining about how she had been waiting over an hour to go to surgery. She looked her age. Her silver hair was thin and her pale skin was streaked with a yellow hue. She was frail. Her face was sullen and wrinkled, covered with dark pigmented freckles. Her teeth were brown and chipped.

She was already annoyed with me when I asked questions relating to her medical history.

“I do not see why I have to tell you. I already gave all that information. It’s in the chart,” she said.

After eliciting as much of a history as I could, I carefully gripped her hand and pulled her paper-thin skin back to better visualize her veins. Even with tourniquet in place, the blue threads that coursed her hand, left little room for error. I knew that I had one shot to pierce the needle.

The tension was palpable in corner of the room occupied by her bed. She was anxious and she made me fully aware of my role as a student. She could sense my anxiety. I could feel her eyes on me, watching every move I made. Later, I was joined by my resident. And I knew the last thing she needed was to hear a resident instructing me how to pierce her veins.

Despite her overt discomfort, I stayed calm, visualizing the steps of placing a peripheral IV in my head. My resident talked me through the steps, giving me confidence and direction; I had done this before and I knew I could do it again. But at the same time, I knew that the more he talked, the more she doubted my ability.
As I made my first move, positioning the needle in my hand, holding it like a pencil at an angle parallel to the vein, I pierced, and before I advanced, my residence instructed me to reposition. Before I could move the needle, my patient interrupted us.

“Can I have someone who knows what they are doing do this,” she screamed.
Her words were stinging, reminding me about my inherent limitations as a student. Without saying a single word, I handed the needle to my resident, who was able to complete the job, which I had meticulously planned out in my mind. I resumed my position as an assistant, handing him the tape and cleaning up the mess—a familiar role I had come to know as a third year student.

Although I was taken aback by her response, I can understand her frustration. She was alone and exposed in a completely sterile and unfamiliar environment. Strangers rushed passed her and she was completely ignored. She wanted general anesthesia, but the surgeons had decided spinal anesthesia was a better option, given the lower risk of blood clots and quicker recovery. She did not want to feel any pain or be aware of the surgery. And from her perspective, she was not being heard.

Although she was keenly aware that our hospital is teaching institution, she had very limited patience. She was simply expressing what we would all want if we were in her situation. She did not want to be pricked like a pin cushion, or be treated as an experimental subject.

At the same time, her case made me think about how to balance learning with deliver high quality patient care. As a student, you are stuck in the middle. Your patient’s needs come first. However, we all need to learn, so that we can take care of our future patients. A part of me always feel guilty when I am performing a procedure for the first time—be it delivering a baby, suturing a wound, performing a LP, or a placing a peripheral IV—knowing that a more trained provider could do the same job in a shorter amount of time (and probably more successfully). But everyone has to learn and we all have a first time.

When we arrived in the operating room, she became visibly anxious.

As the resident began prepping her back for the spinal anesthesia administration, she kept repeating, “Why can’t I have general?”

At first, I was hesitant to go to her side, having just been berated by her. However, I knew she was vulnerable and could really use emotional support. I moved from watching the placement of the spinal and came to her side. I grabbed her hand and attempted to engage her in a conversation.

Using visualization techniques, I worked with her to think pleasant thoughts. She saw herself sitting at a beach in France with rolling mountains in the background. She was sitting next to good friend and her feet were immersed in warm blue water. French music could be overheard.

As the needle pierced her skin, she gripped my hand and I reminded her about her special place, repeating the details of the French beach. And with each detail, she became a bit calmer. And before we knew it, the spinal was in. She looked at me in surprise at the end of procedure.

“That’s it?” she said surprisingly.

“Yes. They are done.” I responded.

In my role at her bedside, I was able to talk her through a procedure that she had deemed impossible. In doing so, I was able to develop rapport with my patient and optimize her care. I was able to salvage our therapeutic alliance. I put her needs first and enabled her to overcome her fears through visualization techniques.

My experience working with her reminds me about the power of mind over matter. In many ways, these types of experience are just as important as learning technical skills. And sometimes it’s this connection that makes all the difference for our patients.