As a CA-1 I felt frantic and overwhelmed, and I made a lot of mistakes. Now, well into my CA-3 year, I’m calm, focused, and much more effective. It’s not because I’ve learned more. It’s because I’ve learned to think differently. By Nabil Othman, MD
A month into my CA-1 year, I was so focused on fixing an arterial line that I allowed my patient to become unparalyzed during laparoscopic surgery. He violently bucked–luckily none of the trocars damaged his abdominal organs. I should have noticed the curare clefts on the EtCO2 tracing. I should have checked his twitches sooner. I was so overwhelmed I fixated on a minor detail rather than prioritize more important tasks.
Months went by, and still I didn’t learn my lesson. I thought I had to learn the technical steps of every surgery, the effects and complications of every anesthetic drug, and how to technically perform procedures like intubation, arterial lines, central lines, and epidurals. I thought I had to keep track of the surgeon, circulating nurse, and scrub tech. The possible combinations of patients, surgeries, and anesthetics was infinite. How was I supposed to know what was important?
I continued to make mistakes as I was exposed to new situations (and people) I had never seen before. I missed arterial lines, gave too much IV fluids, too little IV fluids, and intubated the esophagus–twice. When emergencies occurred, my brain seemed to “turn off.” There was so much going on–I felt frantic, overwhelmed, and tachycardic.
And then something began to change.
Midway through my CA-1 year I started my second trauma case on a patient stabbed in his left chest. The endotracheal tube was quickly advanced into the right mainstem bronchi to isolate the bleeding left chest. After intubation the surgeons immediately explored the wound as my attending watched me place an arterial line under the drapes. I could feel the heat of her gaze. I could hear blood being suctioned from his chest. I could smell the bovie electrocautery. To make matters more intense the patient’s blood pressure was 80/40 and he was on 20 mcg/min of norepinephrine. His artery was barely visible.
But this time I was composed and focused. My heart rate didn’t spike. My hands moved steadily with purpose and precision. Much to my surprise, I placed the line successfully. My environment was the same, but how I perceived it was completely different.
Two Systems, One Operating Room
Nobel Prize-winning cognitive psychologist Daniel Kahneman might suggest my two different states of mind are consistent with what he calls System 1 and System 2.
System 1 is a fast, automatic, and impulsive reaction to external stimuli. It can carry out simple tasks, solve simple math problems, or localize the source of a sound but it cannot plan, reason, or think logically. I was in System 1 when the blood spilled onto the floor and my patient moved during laparoscopic surgery. Residents in System 1 make preventable errors, don’t recognize their patient is unparalyzed, and transfuse blood onto the floor. System 1 is not useful in the operating room because anesthesiology means knowing when to listen, when to focus, and when to act.
System 2 is a slow, logical, and effortful thinking strategy that must be consciously turned on. It can carry out complex tasks, solve complicated math problems, and search your memory for a specific sound. I was in System 2 when I placed the arterial line during the trauma case. At that point in my training my cumulative exposure to random combinations of patients, surgeries, and anesthetic techniques made me more efficient at prioritizing environmental stimuli.
I was able to silence my System 1 so my System 2 could prioritize tasks in a logical order then successfully perform them. I also heard this concept called “situational awareness” or “flow.”
Over time my slow-going System 2 started to speed up. As a CA-2 I placed an epidural on an 8cm dilated pregnant woman in 20 seconds between contractions. As a CA-3 I intubated COVID patients in seconds as their oxygen saturation dropped to zero. Repeated exposure to high acuity scenarios sharpened my thinking, reflexes, and manual dexterity. My System 1 was fast–but my System 2 was faster.
A fast System 2 is necessary to save lives in the operating room. When a problem occurs, anesthesiologists can’t consult other doctors, we can’t order more tests, and we can’t talk to the patient. Unlike other specialties we have seconds to minutes to save the day. In those critical moments System 2 must prevail.
Systems…Processing
Recently in the middle of the night I was called to start an emergency exploratory laparotomy. The patient sustained gunshot wounds to his abdomen, damaging his colon and spleen. Just as we thought we were done with the case the abdomen filled with blood, and the trauma surgeon looked over the curtain and said, “Get ready to transfuse.” The patient had an unrecognized iliac vein injury deep in the pelvis. Despite manual pressure the vessel continued bleeding.
Vascular surgery was called. The attending accessed the femoral vein through the groin. He slowed down the bleeding just enough to ligate the common iliac in the pelvis. We also figured out why we couldn’t control the bleeding: he had injuries to both the external and common iliac veins. I wondered if the vascular surgeon made up that solution in the moment–definitely System 2.
After 20 units of blood products the patient was finally stable. In the midst of the chaos I simultaneously transfused the blood, corrected his acid-base status, prevented electrolyte disturbances, titrated pressers, collected then interpreted laboratory results, and kept him paralyzed. I even placed an arterial line under the drapes.
Meanwhile, I noticed my junior resident in System 1: confused, frustrated, and exhausted. He even spilled blood on the floor just as I did as a CA-1. He lamented over his mistake, multiple times pleading to our attending he did in fact know how to hang blood. Before he could ask, I handed him a package of blue OR towels then gave him some positive encouragement. I realized I was looking at myself just two years ago. His intubation at the start of the case was flawless. I could tell he didn’t realize it, but his thinking was already changing.
Nabil Othman, MD is an anesthesiologist in Los Angeles, California. He earned his bachelor’s degree in Biochemistry from Oakland University in Rochester, Michigan, followed by his medical degree at Wayne State University in Detroit, Michigan. Currently, he is in his final year of anesthesiology residency at Cedars Sinai Medical Center. After residency, he will complete a critical care fellowship at the Texas Heart Institute. When he is not an indentured servant in the hospital, he enjoys CrossFit, telling everyone he knows about CrossFit, and planning dangerous hikes in Hawaii with his college roommates. He blogs at http://www.airwaybagelcoffee.com.
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