When you are faced with an emergency situation and you have to make tough decisions, how do you approach this?
“We make tough decisions every day, and making tough decisions in the operating room is kind of part of the job for anaesthesiologists,” Dr Younger explains. “I'd say the most common difficult decisions that we're faced with is what kind of anaesthetic plan we want to proceed with for a given operation and a given patient, and that's a calculus that I go through in my head every single time I'm getting ready to do a case that has to do with whether a patient should go all the way to sleep under general anaesthesia or if they would be safer using a different technique like regional or spinal anaesthesia. We also do a lot of risk stratification to make sure that patients are undergoing the right anaesthetic procedure for the right surgery every day and to minimise risk and maximise comfort.”
Can you talk us through the process of what you do when things go wrong?
“Anaesthesiologists try to not work algorithmically, but the more emergent and unexpected a situation is, the more algorithmic our thinking may become so that we can maximise the chances of doing all the right things in a very small amount of time as efficiently and as well as possible.”
“A situation I'm commonly faced with is in the obstetrical anaesthesia suite when a patient has been in labour for quite some time, sometimes with an epidural for labour analgesia,” continued Dr Younger. “When the status of the baby changes, a decision can be made emergently to take that patient for a crash C-section. The patient needs to be brought from the labour room into the operating room urgently and get adequately anaesthetised to get the baby out that might be in distress. It's often felt in those situations that delivering the baby expediently, so that the paediatricians can take care of it, is the right thing to do.”
“We work according to the ABCs of basic and advanced life support: Airway, Breathing, and Circulation,” said Dr Younger, “to make sure that the patient's airway is addressed and safe and taken care of right away. As an anaesthesiologist, in those moments we sometimes act a little bit automatically. Sometimes, I realise retrospectively that I do things without even thinking about it and have gone through a checklist that may be relatively long. When running to the operating room with a patient, I often interface with the obstetrician to ask how bad the situation is. How much time do I have before you need to make a surgical incision? And that's going to inform what kind of anaesthetic technique I decide to employ. If a patient already has an epidural, I might decide to dose it with a fast-acting local anaesthetic and hopefully get an adequate anaesthetic level on the patient's body that she can undergo the operation without a general anaesthetic,” continued Dr Younger. “Or we might decide to do an emergent general anaesthetic with an endotracheal tube that is putting someone to sleep and putting in a breathing tube because that's the safest and fastest thing that we can do to get that baby delivered.”
What are the best ways, in your opinion, to make sure that the patient or their family receiving bad news understands what's going on despite the shock of it, and also that the communication is open so that you're also receiving any concerns and questions they might have?
“This is a very important point; communication should be open and should be two-way,” stressed Dr Younger. “There's a lot of information that needs to be delivered to patients and family members about bad outcomes. They need to be able to process the information and to feel heard about their feelings, reactions, and questions having to do with those bad outcomes. If you look at closed claims data about medical legal actions, I think that a common theme among people who've decided to file a lawsuit based on an unfortunate outcome in the medical setting is a lack of two-way communication,” explained Dr Younger. “Patients and family members may complain that no one ever said they were sorry.”
“I know that when I've been in the operating room and had outcomes that were less than favourable, it's incredibly difficult for me. It's something that I think a lot of anaesthesiologists take very personally; that we wear and we feel that weight. One of the things that can be very helpful is to sit down with patients and family members and tell them how sorry you are about what has happened. And to explain that it might have happened because of a mistake that was made medically, or that it was just the way things went, or because of a trauma case where a patient wasn’t likely to survive.”
There is a particular strain on anaesthesiologists, but other specialisations suffer from the same problem. How do anaesthesiologists and other medical specialists deal with this in these circumstances?
“In the US, there is an anaesthesiologist shortage,” answered Dr Younger. “In the past years, fewer anaesthesiologists graduated from training programmes than in the years prior. Additionally, at the time of the pandemic, in the US we experienced the phenomenon known as the Great Resignation, or the Great Reassessment or Adjustment, where a lot of people left their current employment situations. The medical field was no exception; many physicians changed their employment situations and did not come back to their original employers.”
“We have experienced quite a bit of attrition in our practice over the last several years. “Other practices around the country have experienced the same thing, such that we're very, very short staffed now. Unfortunately, I don't think it's going to get significantly better for a few more years.”
“This has led to a lot of readjustment in the way people see their employment as physicians. For many years, physicians were expected to and expected themselves to work incredibly hard and do the things that no one else could do, wanted to do, was able to do, including working long hours, working overnight, and working many nights in a row. And in the wake of the pandemic, people may have realised that this isn't healthy and safe. And I'm not sure that the culture around my profession supports the idea that we just suck it up and do it.”
“For physicians, this is combat. And as we know from combat theatres around the world, soldiers don't respond well to prolonged periods of combat stress. And I think for physicians, while it's not the same kind of stress, there is an analogous type of situation going on, and we don't respond well to it either. I, personally, have backed off on the amount that I devote to overnight calls now, and it's only been recently that I've been able to do that because we've been able to hire some people to cover that. That decompression has been very important for me.”
What are the take-home messages about this that you would like to share with your peers?
Dr Younger reiterated that it is very important to have a respectful conversation with patients and family members. “I think it is a very important aspect to have an open two-way conversation about how it feels for them and how it felt for us, and especially how sorry we are that the outcome wasn't what everyone was hoping for. This goes a long way toward helping patients and family members deal with bad news and achieve closure around it eventually. And it's an ongoing process too; the day it happens is not going to be the last time you talk about it and it shouldn't be.”
“I think that it's important for doctors, patients, and family members to recognise that no one is perfect and that we are doing our best to solve very difficult situations,” continued Dr Younger. “For physicians, I think it's very important to recognise and empathise with how difficult bad news can be and that you acknowledge you understand what the patient and family members are going through and that you were a part of this whole experience. For the patients and their family, I think it’s very important to recognise that healthcare providers are really trying to do their best in delivering good care.”
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