Fake It Till You Make It…

April 20, 2012

“Now this is the confidence that we have in Him,
that if we ask anything according to His will, He hears us.” 1 John 5:14 (NKJV)

Hello again! Today I want to talk to you about something that may seem in complete contradiction to what I wrote about last month. Last month, I talked about not being afraid to ask questions in the clinical setting, because not asking, in the worse case scenario, can be fatal. I also spoke about being aware of how much we don’t actually know once we start actually seeing patients.
However, there is an intimate balance between not knowing and asking questions and appearing as if you do know and being confident. The balance is extremely intimate in fact.
Just today, on my last day in my Internal Medicine rotation, I was with the “on call” team for the day and we were called in to see a 25-year old lady who came into Accident & Emergencies (A&E aka ER) hypotensive, tachycardic, and having passed out. On her bloods, it was shown that she was neutrophilic (high neutrophils on her white cell count) and acidotic (increased lactic acid). Basically, she had an infection. On further examination, it was determined to be a urinary tract infection/pyelonephritis.
Because she was acidotic, it was important for us to monitor her acid levels by taking some blood from her arteries, as venous blood can’t accurately tell us what’s going on with someone’s oxygen, carbon dioxide and bicarbonate levels. This is called an Arterial Blood Gas (ABG). Taking blood from an artery is more painful, as it requires us to go deeper into the skin. We usually do an ABG on the radial artery of the arm. Therefore, you must palpate the artery first to feel for a pulse. There are various techniques, and I have found one that has worked for me.
The registrar doctor I was with asked me to take the ABG. As soon as I walked in to take it, the patient was agitated. She didn’t like needles and kept asking if this was absolutely necessary. This wasn’t helped by the fact that her boyfriend was with her and kept asking why I couldn’t take venous blood (he’s a dentist, and had more medical knowledge then the average populace), and wanting the registrar to do it instead.
What do you do in this situation? First, let me tell you that I was seeing out of one eye, as I woke up that morning with a painful, pus-filled right eye, which was later diagnosed to be bacterial conjunctivitis, so contact lens were out. I had a headache as well. And I was hungry. So, what do I do at this point?
I carried on. I reassured the patient and her boyfriend that this was absolutely necessary. I warned her that it will be painful but hopefully it will be quick.
But guess what? I’ve attempted more than several ABG’s and only succeeded in one! At this point, I had to appear confident.
I prepared the ABG kit, cleaned the area, felt for a pulse, inserted the needle…and a loud YELP followed. No flash! Crap! That means I have to go fishing for the artery. I could feel the pulse underneath my finger, but I wasn’t in. I adjusted my needle and a greater YELP followed. At this point, disappointed, I removed my needle, and replaced it with a cotton ball. SIGH! I was not happy. Although I appeared confident, it didn’t work. The boyfriend beseeched me to let the registrar do it instead. I shamefully let the reg know that I couldn’t get it, and she should give it a go, because the patient was in pain.
Well, what do you know? The registrar gave it a go, and the SCREAM that followed was heard throughout the whole A&E. She couldn’t get it either. It’s terrible for me to say this, but I felt a slight twinge of satisfaction that it wasn’t just me. The patient’s fear of needles and low pain threshold combined with her overbearing dentist boyfriend made it impossible to get the ABG.
To the patient’s dismay, this meant that she had to stay in the hospital overnight, whilst getting I.V antibiotics and monitor her acidotic state.
This situation was a stark contrast to my last ABG, in which the older woman was also afraid of needles, and at that point, I hadn’t gotten a successful ABG yet. However, I appeared confident, and proceeded with the same steps. I was rewarded with a flash of beautiful bright red arterial blood – I WAS IN!!!
Moral of the story? Appearing confident is key. I have been called upon to perform several competencies that we are expected to know as physicians. It is very nerve wracking, especially for a shy girl such as myself. One must decide at this point should I carry on or ask for help. I believe asking for help is always the answer if there is a risk of patient injury. However, how can one learn if one doesn’t practice? As you get to the clinical setting, you will run into these scenarios time and time again, and you have to decide what the intimate balance is for appearing confident and asking for help. You may have to do both!
Today, I’m glad I attempted one more ABG in Internal Medicine. Now, on to Surgery!