When I started in Anaesthetic nursing I was preceptored for one and a half shifts. I was task-oriented, which was good as I had demonstrated I could undertake the tasks expected of the role but had no real idea of how much I did not know.
Donald Rumsfeld, the former US Defense Secretary and ground-breaking educational theorist, defined this as the known unknowns. I knew there had to be more to learn, I didn’t know what, and at that time I didn’t know where to start.
The environment in which I was working was an operating theatre suite in a very busy metropolitan hospital. The theatre and the hospital itself were both going through an organisational “down-swing” of morale. I’m sure we’ve all experienced the type: a kind of a “sink or swim” environment, where the old hands are sick of introducing new staff to policies, procedures or even themselves and where the unspoken rule of sink or swim is “just do it quietly, we’re busy”.
So it was as a junior nurse I learnt to ask questions. Many, many questions. I would introduce myself, informing the Anaesthetic consultant or senior registrar that I would ask them questions while we worked. The junior registrars and residents seemed relieved I was offering myself as the person who knew the least, a role some of them must have thought they would never grow out of.
I discovered about the joys of gas dissolvability, of nitrous oxide as a carrier gas (with caution in bowel surgery and never in cranial neurosurgery), of Mean Alveolar Concentrations and the differences between and induction doses of the non depolarising muscle relaxants, in addition to myriad other details.
I continued asking questions when I changed hospitals, moving to a smaller regional hospital with a large obstetric casemix. I learned about the anatomical and physiological changes wrought by pregnancy, about ergometrine, syntocinon, syndometrine, and successfully diagnosed a Mallory-Weiss oesophageal tear in a patient post-epidural hypotension induced nausea. I worked stupid hours.
Eventually I moved out of the public health system and into private healthcare. I was lucky, as by this time I had a fair grasp of the theory behind practice and there are no junior doctors in private practice to use s cover for my learning. Of course, I had long lost my fear of asking questions.
A regular Anaesthetist was on holiday. An anaesthetist no-one had worked with arrived to cover his list, and although we had never worked with her we had heard of her. She was no nonsense, pragmatic, experienced, and seemed to have skipped all the CRM (Crew Resource Management) and communication and conflict theory. It was obvious that there would be no zen-bubble today.
We had paediatric patients on the list. This was new.
I decided I would continue with my usual strategy. I introduced myself, she told me what she wanted, I informed her I had no experience with children, and I would like to know what the major differences were in order to properly anticipate potential issues.
No dice. “Hurry up, we need to get started.”
I’d met the patient and Mum earlier, when waiting for the anaesthetist to arrive. We led them in, got the child monitored, breathed down via a sevoflourane induction. Mum went out, and the child was intubated for surgery.
It was not unsafe, but nor was the process smooth, cool, calm or as controlled as I would have liked. Good learning, I thought.
The anaesthetist was livid. “Damned incompetent anaesthetic assistants who don’t know what they’re doing…waste of effort…” (Just two of the comments I remember hearing). I felt humiliated and frustrated.
Between cases, I gathered my composure and decided this was a conflict worth having. “I told you of my inexperience and asked you what I needed to know to work with you. If you’d worked with me with an adult patient you’d never have dared to call me incompetent. If you answered my questions, all that would have been much smoother. Is this my issue because I didn’t know or yours because you didn’t teach me when I asked?”
The anaesthetist said nothing, and part of me felt I should stop, but a small part was…exhilarated. If this was going to bite me at least it would be worth it.
I continued “So, let’s try again. I’m not psychic, I can’t read minds and I’ve never pretended to. When working with paediatric patients, how do you think, and what do I need to know?”
More silence, and then she actually smiled (well…grinned?). “In twenty years no-one has ever told me that. Usually they’re scared of me. I guess it’s about time…”
I got to learn a great deal about paediatric anaesthesia that day. And I became her anaesthetic nurse of preference when she worked at that hospital. We ended up having some rather good conversations, and a normal working relationship. I learned a lot more working with her after that.
And one afternoon she thanked me for challenging her, as it was “nice to work with someone who was not scared.”
So here is the point:
Healthcare is difficult at the best of times. Working as part of a team is hard, doubly so without effective communication. There are many impediments to communictation, but by far the silliest and most inexcusable obstacle is to assume that the person you are working with can read your mind, and yet we all have colleagues who seem to do just that.
It’s something we all need to remind ourselves of occaisionally.
You aren’t psychic.
Neither is anyone else.
NB: for the uninitiated, a zen-bubble is a bubble of calm created around an urgent or emergency situation by a experienced heathcare professional. They exude a calmness that is infectious and calmer the closer you get. It remains my aspiration to be known for my zen-bubble. You never see them on medical shows on television.