as the resident in charge of the entire
medical service for the night
my white coats got six peepers three
granola bars and maybe fifty crib sheets
for every possible medical emergency
there’s something both lonely and
terrifying about walking down the
Hospital hallways in the dead of night
knowing that if something bad happens
you’re it one side of my brain is
galloping through every possible
catastrophic scenario while the other
side is working on a kind of cardiac
serenity prayer to every heart in the
entire Hospital may you keep that beat
nice and steady
for the next 12 hours no funny stuff
until my shift is over men the PA system
blares overhead code four one one
cardiac arrest sixteen West the first
code I’m in charge of I have raced
down the hall and burst into the room
breathless throat parched pulse pounding
and then my brain splinters into
complete and utter blackness say
something anything uh chest compressions
keep back in the oxygen well any idiot
knows the basics for keeping someone
alive but what next did you shock first
or give epinephrine all those training
courses had seemed so easy back then so
ridiculously simple on those ever
forgiving mannequins but now there’s
someone real someone alive though
perhaps not for much longer with me at
the helm I can’t remember anything
someone presses an EKG into my hands and
I stare at it for the answer it’s there
and stare and stare zigs and the Zags
seem to melt into a jumble of Sanskrit
think think okay okay the T waves maybe
the T waves looked a little peaked
Pete t-waves on an EKG indicate elevated
potassium hyperkalemia except when they
don’t and except when they look peaked
but aren’t actually peaked these kind of
look peaked I’m thinking but maybe it’s
just repolarization or maybe they’re
just big I could inject the concentrated
IV calcium to treat the hyperkalemia I’m
so scared I’m gonna be wrong and then
really screw things up who’s in charge
here anyway
a cardiology fellow blusters his way
into the crowd clearly seeing the mess
for what it is I give a little nod and
then there’s an embarrassing moment as
we recognize each other we were in the
same med school class same circle of
friends even but I take out some years
to do research so he was now a
cardiology fellow while I was still a
medical resident he bites back his
obvious criticism and looks in at the
EKG peaked t-waves hypokalemia let’s get
some calcium he announces clearly so not
derisive ly an act of humanity I only
really appreciated years later the
patient did alright in the end or at
least survived the code but I was
mortified my first night on call and I
almost killed a patient i slunk off
afterwards hoping to disappear myself in
the sea of white coats I was furious at
myself for getting so paralyzed by fear
that I couldn’t run the code what had
happened to all of my training what made
me the angriest though was that actually
gotten it right it was hyperkalemia
those T waves absolutely had been peaked
I could have called it on the spot and
been the model of a take-charge doctor
but I couldn’t get beyond my gripping
fear of getting it wrong of killing the
patient of looking like an idiot now I
usually give lectures to other doctors
but I’ve sometimes told this story to
lay audiences and I’ll tell you this is
not what patients want to hear they
don’t want to know their doctors are
scared witless
now if this only happen if is perilous
and fear only happened to those two
deadbeats who somehow slips through the
med school application process that
would be one thing but the truth is it
happens to nearly everyone just ask any
nurse or doctor you know and they’ll
tell you perhaps more than you really
want to hear about their moments of fear
there’s a famous case of a woman who had
um brain damage to her amygdala such as
she did not experience fear researchers
brought in snakes they set loose spiders
they made a watch a double feature of
the shining and alien and she was
completely unperturbed as a medical
student I wanted to be her fear is a
primal emotion in medicine it may be
most obvious and neophytes but that’s
just the first link in a chain that
winds its way throughout the lives of
nurses and doctors you may wax and it
may wane but the fear of harming your
patients never goes away
it’s inextricably linked to the practice
of medicine
now sometimes compare notes with friends
in the business world and asked what
their worst fear is it’s usually
something like you know losing a big
sale making a bad trade they could
inadvertently bring down the world
financial system and I have to restrain
myself from saying that’s it that’s all
you’re afraid of I remember when I first
read Ernest Becker’s classic book the
denial of death better posits that
humans are unconsciously terrified of
imminent death and so every action we
take is really just an act of denial and
it’s precisely captured my fears as a
doctor in training except that my fears
were entirely conscious I was actively
and consciously terrified of imminent
death and if I so much as hiccup while
standing on the medical wards I could
unleash a chain of events that would end
up dismembering or fixing an
unsuspecting patient now people who were
fearful like that tend to be a bit
pessimistic in their outlook and they
often overestimate the risk of bad
outcomes as a result their choice of
action
lean toward the risk-averse when I stood
in front of my coding patient my
overwhelming theater was of making a
mistake so I chose what seemed to be the
least risky path not injecting the
potentially dangerous IV calcium but of
course this wasn’t at all the least
risky path had the cardiologists not
come along in time the patient would
have probably died of a cardiac arrest
when her overwhelmed by fear like that
our sympathetic nervous system kicks
into overdrive there’s a welter of
emotions and we often miss Reed
important cues
and I can remember the swell of stimuli
during the code people shouting machines
beeping medications flying and it seemed
to cave in and my thought process making
it impossible to think clearly
interestingly research suggests that
concrete tasks that require selective
attention like putting in an IV for
example these can actually be improved
by modest amounts of stress the
adrenaline seems to help you focus on
specific narrow tasks but things that
require divided attention that require
integrating information from disparate
sources these suffer notably under
stress well what is medicine if not the
integration of information from
disparate sources
I mean patients don’t present with a
single symptom in a single square
centimeter of their body no they have an
itchy pain coming from their armpit plus
a weird rash and elbow spasms plus a mr.
Karthik meds for a week plus they’ve got
a cousin who’s a lawyer hovering up here
and a sodium level hovering down there
what are in states of acute stress and
fear
we often overemphasize the unimportant
facts and end up downgrading the
important ones and you can see how in
the real world of clinical medicine fear
can be a direct threat to patient safety
now for me over the years as I gained
confidence with my clinical practice my
overwhelming fears receded in intensity
the moments of utter panic were fewer
but the fear was never completely absent
thing we have to realize that this fear
is not only normal it’s also necessary
and even though I was a med student I
desperately wanted to be that woman who
didn’t experience fear I now feel
differently when you a certain baseline
of fear to keep us grounded in what we
do these are human beings were taking
care of after all not widgets or
spreadsheets you need a certain amount
of fear for example when you approach
someone’s jugular with a 6-inch needle
or you click on IV of a mustard gas
derivative to treat someone’s cancer if
we eradicate our fears completely we
become those cocky cowboy doctors and we
all know how that can play out but we
also can’t live in a state of utter
panic all the time so I’ve had to
negotiate a sort of armistice with my
fears to keep them at a safe operating
distance and I kind of like to think of
my fears as a left lower quadrant
abscess tucked in a corner away from all
the vital organs so I can function in
the day-to-day world of Medicine
but it’s a soft wold abscess not a
necrotic crusted one so there’s a
baseline seepage of fear into my
bloodstream so that I can function in my
day-to-day work but every so often the
abscess ruptures and it’s the dominant
peritonitis of fears when this happens
though we need to remember that fear is
a perfectly human state for a doctor or
a nurse to be in however it’s not
necessarily the most ideal situation for
your patient to be in now the doctors we
learn from they didn’t talk about any of
this the unwritten rule was to hide any
fears or doubts because looking weak was
the worst sin possible what do they
always say an internship
when in doubt pretend right but
ultimately it’s our patients welfare
that comes first being strong is
accepting fear as the everyday cost of
being human and medicine despite all the
sexy technologies you hear about in
these TED talks medicine is still
fundamentally a human endeavor being
strong means turning to your colleague n
asking for help even to take over while
you step out and catch your breath in
1926 that for Francis Peabody gave a
lecture with enough famous phrase he
said the secret of the care of the
patient is in caring for the patient now
take that one step further and say that
the other secret in the care of the
patient is in caring for the caregiver
rather than pretend that we never
experience fear will be better doctors
for our patients better nurses for our
patients if we admit that we do
experience fear and give ourselves the
breathing room to recover owning up and
asking for help it’s awkward it’s
embarrassing but it’s the most honest
ethical and safest thing to do I’ll
always be grateful to that cardiology
fellow who stepped in that day and
helped me with my first coding patient
and I suspect that the patient was
probably pretty grateful too
and my payback to him is to now be on
the lookout for other colleagues when
they experienced their moments of fear
and proactively step in to help out we
can’t always control when that obsessive
fear will rupture but we can control how
we respond we can resist the urge to
look strong and just fake it we can
actually be strong and ask for help and
keep our patients safe and then we can
forgive ourselves for the human foibles
of occasionally being overwhelmed by
fear if we do it honestly and safely I
think that our patients will be able to
forgive us too and that’s something that no one should be afraid of thank you
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