"I'm Not Comfortable With That."
Doctors have to face uncertainty
In these difficult times in medicine, many physicians are not comfortable with complex or difficult cases. It’s easy to always assume that the best thing is to transfer someone or consult someone else, or avoid the complexity and medico-legal risk in any way possible. But our resources are stretched ‘wafer-thin’ (for Monty Python fans). And we all have to do things we don’t like or people will just die or be financially wrecked.
Every day that I work I take care of something that makes me uncomfortable. That’s just the gig people.
This was originally published in Emergency Medicine News, April 2019. Cruise over and read the excellent writing there!
Pull Out the Spear, Even if No One Else Will
Leap, Edwin MD
Emergency Medicine News: April 2009 - Volume 31 - Issue 4 - p 19
doi: 10.1097/01.EEM.0000349236.85503.55
How many times in your career have you heard these words: “I'm not comfortable with that?” It's pretty common where I practice. Because we're a small facility, lacking many subspecialties, I hear it a lot.
“I'm not comfortable operating on a child.” (The child may be 16, mind you.)
“I'm not comfortable with a hypertensive cerebral bleed.” (The patient may be telling jokes and eating Jell-O, of course.)
“I'm not comfortable with that trauma or that MI, that facial fracture or that dental injury, this esophageal foreign body or that gunshot wound.” The list goes on and on.
The reasons for “discomfort” are legion. Sometimes the discomfort of consultants is a reflection of genuine concern. They may not have done a procedure since residency, or may know someone in the next town who does it much better. Some physicians simply fear violating the established science, or may fear malpractice litigation over difficult or high-risk patients. (Better the unstable MI should die in transport than die with the physician's hands on the body. Nobody wants to be the last one to touch the corpse, as it were.) And of course, some physicians are uncomfortable because of their fear of negative comments on patient satisfaction scores or increased rates of infection or other complications. (We can't have any “never” events, can we?)
I don't think it's a stretch to say, even in medicine, that there are also those rare doctors who are just lazy. We've all met them. They'll spend four hours arguing to avoid work that would have taken one hour. The avoidance of work or responsibility is a kind of religion to these folks, who ironically are often the first to complain of falling reimbursement. They don't understand that you have to work to be paid.
But beyond and behind all of it, the “I'm not comfortable” mentality reflects a deeper, more disturbing trend in medicine. The thing is, medicine exists because someone, ages ago, did something uncomfortable. They probably did it because someone else was uncomfortable. A friend or family member lay screaming in agony, dying from an injury or infection, from childbirth or beast claw, stone spear or fall from a precipice. In the face of the misery of another human, that proto-physician bent, with heart racing, hands sweating, mouth dry, and others looking on in amazement, and pulled the spear from the chest, helped the infant stuck in the birth canal, dressed the bite, or straightened the leg. At some point, it worked. At some point, the risk of intervening in what seemed like nature or the will of malevolent gods resulted in the good of life saved. The screaming ceased. The mother and child smiled and lived on a while. The hunter returned to the hunt. A physician was born. And he was born because he overcame his discomfort.
Over the ages, we have been uncomfortable in the face of plagues, parasites, warfare, natural disaster, and untold numbers of miseries visited on humanity. Physicians didn't learn because they had libraries full of evidenced-based medicine. They learned because they observed, plowed through their discomfort for the greater good, and took risks. Medicine didn't advance because it was a great science. It became a science because physicians did things that no one had done, took chances, and endured danger, all for a higher good.
What was that good? Let's not lose the point. The good we sought and the good we seek is not the pursuit of perfect science or the error-free path. The good we desire is not flawless records without mistakes or excellent satisfaction scores resulting in promotion and bonuses. The good we seek, as did our ancestral proto-doctor, is the well-being of humans. All of our attempts to avoid error, to be comfortable in the things we do, those are part of the path perhaps. Those are, in a way, tools to the good. But they are not the good.
The good is the return to normality of the injured. The good is the rescue from peril of the dying. The good is to sometimes share in their suffering by being uncomfortable. The good is sometimes to take a chance and do what seems right, even though no one else will try.
I practice in a small hospital. I have done thoracotomies, though I am not comfortable doing them. I could have not attempted the procedure and said, “Pulseless with stab wound to heart.” I have delivered babies, though I am not comfortable doing so. I have intubated and placed chest tubes in infants who our pediatricians would have insisted on immediately transferring. I have opened abscesses that made me uncomfortable, and observed suicidal overdoses that no one else wanted to admit because they were uncomfortable.
I've been wrong. But mostly, I've been right. Discomfort, you see, is part of what we do in emergency care. It's comfortable to be a museum curator, to sell coffee at a bistro, to mow lawns, and to balance books. Those are wonderful things vital to our happiness.
But if you want to be a physician, then you'll have to learn discomfort. Accept it, embrace it, use it, and feel emboldened and empowered by it. Medicine is full of comfortable physicians whose answer is always consult or transfer. But sometimes, we can't do that. And sometimes someone has to step up to the plate, hands sweating, heart pounding, and do the right thing.
That's our job. And no study on earth can quantify the delight it brings to succeed, or even to fail, in the struggle to help another human. So pull out the spear, ladies and gentlemen, even if no one else will. Discomfort may become the most comfortable thing you've ever felt.
I had to perform many medical procedures in my career that I was not comfortable with. Failure this time might have resulted in my death.
The Shoulder or the Spear
I grabbed the baby’s hand and shoved it back into the mother’s vagina and then into her uterus. All the time, her husband, a warrior from the ferocious Auca tribe, was scrutinizing from inches away. In fact his face was so close that I could hardly see what I was doing. I knew this was the only way to save his wife’s life and perhaps the baby’s as well. I had seen this rare procedure done during my training at Cook County Hospital, but had never done one myself.
The mother was almost in a coma, but let out faint moans as I shoved my hand into her uterus to search for the baby’s feet. The woman kicked and thrashed around. Sharon helped hold her legs open and tried to get the warrior to help as well. I knew how bad this must be hurting, because we had no anesthesia.
As I pushed my hand deep within her tight uterus, my heart was racing. What if this doesn't work? What if his wife dies and the baby too? Will I be the next victim of the warrior’s deadly spear? I knew that Nate Saint and the other 4 missionaries had been speared to death by these same Auca Indians just a few years prior. I prayed out loud, “Please God, help me!”
Instantly, I distinctly felt one little foot and knew the other should be close by. But how could I possibly find them both with my blind fingers. God must have told the baby what to do, because just then the other foot dropped into my outstretched hand. I grabbed both ankles with all my might and slowly pulled. I could not afford to let them slip from my grip. Then, as if in slow motion, I extracted the feet and the baby just slithered out without a struggle.
The baby boy cried and the warrior screamed. He seemed to be happy. I was elated. The mother lay there quiet and limp. I delivered the placenta and increased the IV fluids to rehydrate her. After about 30 minutes she began to stir and within an hour, I knew she would make it too.
My entire career as a non transporting paramedic working out of hospital ERs and responding to situations that met specific criteria either on chief complaint or clinical presentation. Enough times that made it not rare, the transporting EMTs and sometimes my paramedic partner stated they were uncomfortable with a give clinical presentation.
I always had a doc at the other end of the telephone to help me decide treatment priorities on tough calls. It was up to me to let the doc know what, in fact, I was actually dealing with so our discussion on treatments started by both of us seeing the same patient, me at bedside, my doc through my description.
Me being uncomfortable with a presentation was acknowledged by my great ER doc mentors, then we discussed what needed to be done on my way in to the ER in the back of someone’s ambulance. I always learned something from being uncomfortable in a clinical situation. I frequently continued my care with the docs and nurses in the ER once I arrived.
Medicine has changed since the late 70s. Statewide treatment protocols have been instituted here in Massachusetts. Part of those protocols say which hospitals certain subsets of patients need to be transported to. MI’s to facilities with cath labs, traumas to level l centers. This makes sense because it gets the patient where he needs to be. But….. it makes for atrophy of skills that are sometimes very necessary in true emergencies. Your rare thoracotomy Dr. Leap is one such skill if he comes in BLS, hypotensive and blue.
We have all seen those patients we wish had gone somewhere else or called someone else, but it is the nature of the beast and we must do our best in every situation presented to us. Mostly I have, sometimes I could have thought/realized I was missing something earlier than I did. Great docs have showed me how not to miss things in the future, I have passed that on as it was appropriate. Now I have no regrets having done my best and retiring after 40 years of chaos.