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Recently, an ASA Community member was grappling with their response to an airway emergency. Alone with a patient during the CAA's first experience with a severe bronchospasm, they panicked. Ultimately, the poster called for assistance and worked with their supervising anesthesiologist to help the patient emerge safely.
Concerned about their future in anesthesiology, the post author explained, "I could've told you what to do in that situation if I hadn't been in a panic with my mind blanking." They asked, "Has anyone else gone blank like that? How do you manage your fear in those moments when the patient needs us the most?"
ASA Community members stepped up. Among the many encouraging responses, six themes emerged.
"Remember that smooth waters make for poor sailors," beautifully summed up the perspective of many posters.
One commenter said, "You are reacting this way because you are good at anesthesia." Another expressed that they "work with exquisitely talented anesthesiologists who have a bad outcome and second guess their entire existence," adding that, "not enough resources exist for the 'second victim' of these events."
Another assured, "Every anesthesiologist has probably had a case where he or she at least slightly locked up cognitively in the moment and learned a lot from the situation. We are all human."
The bottom line for one anesthesiologist—"The only people without adverse events are those who aren't in the field."
An early commenter advocated for taking ten minutes to, "self-debrief, as much as possible, before the group debrief...Write what you remember happened and what your thought process was at the time...Ask yourself questions such as: With the information I had at the time, what could I have done better? With the information I have now, what would I change in my approach?"
A second concurred, suggesting that care team members remember to always, "Call for help early. Learn from this case. Do a deep dive into all its details and review as much as you can," so the response becomes muscle memory.
Commenters applauded the poster for engaging with a therapist to work through the trauma of the experience, with some reflecting that they could go even further to get, "not just help with the psychology, but with the mind-body connection," through breathwork, journaling, or meditation.
Other community members urged asking for additional support within the workplace. A more experienced anesthesiologist noted, "The best thing you can do (other than therapy and forgiving yourself) is communicate. Be totally transparent with your attending about the negative clinical experience and that, while you are regaining your confidence, you will need more frequent visits including extended visits during emergence." Similarly, one attending advised, "get a buddy who will chaperone you. After a couple cases, the fear of panic will morph into hyper vigilance, which will become caution and eventually attention to details."
While a commenter acknowledged that "some individuals are just not 'set up' to mentally and physically function well in high-intensity situations," and a respiratory therapy group or similar might be a good fit, the answer may be to find "a stable practice with heavy MD supervision...and a supportive relationship with supervisors and co-workers."
Another reinforced the need to quickly ask for backup—"When things are no longer routine, do NOT hesitate to call immediately for help. A simple, 'get some help in here for me' should never be subject to criticism...I believe that it's when we work completely alone (which may be necessary in some situations) and don't have access to help, outcomes are more likely to be adverse. It's best to avoid a practice where the oversight of the anesthesiologist is perfunctory in any way—calling for help should be regarded positively."
Several respondents pointed out that an early career anesthesiologist or CAA never should have been put in the situation described without support. One respondent mentioned, "Typically, the anesthesiologist is supposed to be there for the induction and emergence part of the anesthetic."
Another maintained, "No one performs their best in a crisis without a supportive environment. It appears your environment was poorly equipped to manage expected reactive airway emergencies...It is easy to blame individuals for bad outcomes especially when the work has not been put in to make the complex systems within which we function safer.
A culture that supports notifying a physician of a patient's impending emergence, easily accessible emergency checklists, clearly established in-servicing and practices, and crisis management training may all represent opportunities for improvement.
Rather than encouraging the poster to pull back from responsibilities and let skills go stale, physicians had several ideas for managing stress. In fact, one noted that, "if you are not regularly using your airway tools and skills...it can be more hazardous," even in what may be perceived as a lower-risk setting.
One commenter suggested that the poster might want to "embrace acuity—take a job where you know you will see difficult cases routinely, and be up front about the supervision you'd like, saying 'I had a recent difficult emergence, would you mind being around when I extubate for a while?'"
A few thought simulator sessions could help instill the poster with a more automatic and calm reaction to stressful situations, explaining that, "Using a simulator will provide a more controlled environment to manage fears and give appropriate feedback without fear of recrimination." At a simulator center, another indicated, they could "put yourself, repeatedly, in stressful situations where no living patient is actually at risk."
"It helps to be a great team player," stated another, "but sometimes you'll have to be knowledgeable, decisive, guiding, and in charge. Simulator training would be invaluable for this." "Using simulators is excellent advice," agreed another. "In a crisis, your working fund of knowledge can be effectively halved by information and alarm overload. Training builds good habituated systematic responses and confidence."
Beyond simulation training, one anesthesiologist says they use personal feelings of stress as a guide, following the adage, "'The first rule of a code is to take your own pulse.' When I notice stress or fear in myself (rapid heart rate or worse, parasympathetic stress like sweating and nausea), I ask myself if it's time for epi for the patient. Supervising anesthesiologists can stay calm for a variety of reasons, but the main one is because they have been in many, many, many potentially life threatening anesthetic situations and have practice getting out of them safely."
One respondent proposed that, "no one should be limited to the contents of their brains alone when bad things happen," citing other professions such as aviation that "require the presence and immediate use of checklists in the cockpit in order to respond to problems."
Several people recommended publications they like to keep on hand, including:
In addition, two offered readings to help gain perspective on stress, decision making, and staying composed.
Ultimately, as one physician put it, "There is a lot to master...we sometimes have situations that are tough to handle. Nobody is expert at everything." The answer? "Confidence doesn't just happen by accident. (It takes) experience and judgment."
What's on your mind? ASA Community members have been there and are happy to share their perspectives. There's even a topic dedicated to conversations among residents, so you can get answers to the issues you're facing right now.
Curated by: Marketing and Communications
Date of last update: January 24, 2023
