Posted by My OB said WHAT?!?.
Dec
6
Posted by My OB said WHAT?!?.
“I’m Sure You Will Be Fine.”
“I’m sure you’ll be fine,” – Anesthesiologist to mother who had concern that the student Anesthesiologist needed repeated attempts to place an epidural.
There are 27 comments to this post.
If the mother is concerned enough to ask that question, then enough trust has been lost that she is already not “fine.”
Define “fine” for me. “Fine” could mean “everything works perfectly” (which it already hasn’t) or “fine” could mean “not enough damage that it would be worthwhile to take it to court, meaning I won’t ever know about it, so I’ll think you were fine.”
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Arzt4Empfaenger Reply:
December 6th, 2011 at 5:49 am (Quote)
In my case, with me being deathly afraid of needles, I would never actually have been fine with a needle anywhere close to my back, hah.
So I’m thinking the anesthesiologist referred to “I understand it may have been a bit uncomfortable, sorry for that, but please hold out just a moment longer – we’re (he’s = student) nearly done and everything will work out fine, and you won’t be in any medical trouble (i.e. no complications). ”
(I also don’t want to be that student who has to try his first epi on a live patient, but everyone has to, if he’s in that sort of field. There is no way around it and it is scary (only not scary for morons who don’t think about the persons they treat at all).)
Fazit: ask the patient beforehand if a student is allowed to do the procedure, and respect it when fear is expressed and accept a decline of such a request. It’s such a simple rule, and I don’t understand why so many medical professionals seem to ignore any normal, personal bedside manner.
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Arzt4Empfaenger had this to say,
Dec 6, 2011 @ 5:41 am (Quote)
To the first two commenters – thats all well and true, and I partially agree, but somehow the assistant docs/students have to learn this skill hands-on. Usual policy, whether refined doc or assistant, is that you try twice and then get someone else to try (instead of trying six times for example) – some patients backs are really just hard to get for several reasons.
Unfortunately, epis are not really something you can practice on a dummy. I’d say there’s a 50:50 chance that the senior anesthesiologist would have needed several sticks, too, or not made it at all. (The other 50% are always the possibility of a clumsy/nervous student, who missed despite knowing the theory perfectly.)
After the mother expressed concern, the senior resident should probably have taken over the next attempt of the epi. I even suspect that he might have tried to both reassure the mother while indirectly reassuring the student, whose nervousness was probably already high. I agree that it would be unacceptable to let someone incompetent try sticking and sticking the needle in, but putting down someone after the first try would not help that person to gain confidence in any procedure. I want to believe that the senior resident actually supervised this well enough to stop if anything looked dangerously wrong. Sticking the needle in is only half the job, and not too dangerous (small bleedings excluded), the other half is giving just the right dose of the right mix of meds (which is much easier to supervise).
So please – and I’m someone with a horrid fear of needles, too – don’t generalize to “never let students do anything” – because if you want to have that “professional care” that we all need so much, someone has to teach the future doctors how to do it. Some things can not be taught by theory alone, or by intervening at the first nervous hesitation, and some things can’t be directly guided – something like placing an epidural needs to be tried out, because it’s a lot about feeling the resistances of the different layers you go through. The senior res can confirm your point of entry, and can supervise the administration of medication, but the stick itself must be felt.
It would help if the OP let’s us know how many tries they were at when this quote was uttered. After all, most posts only reach MOSW after occurring in a situation that was ultimately frustrating and unpleasant for the poster, but from the text itself it could just as well have been okay.
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Jane Reply:
December 6th, 2011 at 8:58 am (Quote)
I shifted to a position of “never let students observe” after a perfectly nice nurse practitioner turned into a raging egomaniac when she had a junior nurse observing her. She became rude and obnoxious and was quite clearly showing off.
I told the other doctors in the practice what had happened and never let her near my children again, and since then, when I’m asked if I will allow a student to observe, I say no.
I understand that people need practice. Sure. But the one doing the supervision needs to act responsibly otherwise no, you’re not going to have people willing to be practiced on. There’s nothing in it for us to get treated badly and turned into guinea pigs and have to pay for the pleasure of being stuck repeatedly or insulted by a previously competent NP. (And in my case, I had to book another appointment with the practice with the doctor because the NP didn’t even address the problem we came for. So the doctor’s time got wasted, too.)
Who benefits when the supervisor of the student doesn’t step in or behaves badly? In my case, the student was just as horrified as I was!
Doctors are often not managers. They didn’t go into medicine because they’re people-persons. They often like solving problems, so when they see a difficult stick, they want to solve the puzzle rather than changing the parameters. Not good for the person on the receiving end, is it?
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Clear case of the doctor forgeting that the patient always comes first and placing too much empasis on training a new doctor. “This is a teaching opportunity lunk head, go speak to your intern and explain that next time he better get it right the first time because it is important to get it right the first time.” Reminds me of college professor who spends too much time on reasearch and not enough on teaching. You do have to respect that they are going to be pulled in two different directions. It is the nature of the job. But they also have to respect that the patient comes first. Even if the patient is a drugged out whore you still need to demonstrate the correct way to treat a patient (bedside manner) and the correct technique (get it right the first time.) The correct answer would have been 1) check to make sure the epidural is working 2) say, “I will speak to him/her about it.”
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Okay, so this one time I was having a baby, and the anesthesiology attending was bullying the resident who was placing the epi. And for the next 20 hours, when I told them I could still feel on my left side,they told me to lay on that side and the fentanyl would drip down? Yeah, c-sections are done when you are laying on your back.
Ask me how much fun that c-section was.
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yeah, I’ve been there. I had a student try on me 3 times before I insisted that a real doctor get it done. Why on earth I didn’t insist before attempt #3 is beyond me.
Needless to say that after that, I don’t let students place epidurals.
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road2vba2c had this to say,
Dec 6, 2011 @ 8:21 am (Quote)
Wow, I think if the anesthesiologist–forget the student–missed the first time I’d say forget it! I’m so sorry OP! That has got to be miserable and scary!
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Jespren had this to say,
Dec 6, 2011 @ 9:52 am (Quote)
Usually I am all for students. I don’t mind repeating an exam so a student can try, and, not being needle shy in the least, I don’t mind multiple pokes. But, all that being said, I *really* feel for this OP and this doc needs to remember that allowing students access needs to be on patient’s comfort level. I don’t think i’d be feeling to confidient with a student poking around my spine!
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Details Reply:
December 6th, 2011 at 12:32 pm (Quote)
You know anethesiologist don’t specialize in birth. There really is no reason why an anethesiology student should be anywhere near a woman who is already in pain. Let them practise on the regular surgery patients who can take a break and come back in 1/2 an hour! Once they have proven they can find the right spot then maybe they can practice on the scheduled repeat c-sections. If it takes 7 times and you are doing this while the woman is having contractions. That is not just fine.
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Arzt4Empfaenger Reply:
December 7th, 2011 at 11:41 am (Quote)
That is not correct. An anesthesiologist can very well specialize in L&D and gyn, just as he can specialize in fields like neonatal anaesthesia or intensive care. If they *want* to do that is a whole different question. The problem is that laboring women are a special sort of patient – often without any major illnesses and healthy, but also often not able to sit still for XY minutes or able to bend over enough to create nice and wide spaces for the epidural to be placed. So yeah, of course no one should do their first, second or even thirtieth (sp?) epidural on a laboring woman, but just practising on general surgery patients will not make them better in treating laboring women.
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This was from my mother’s birth with me. She has a fear of needles and it took the student Anesthesiologist about seven times to place the needle. She ended up with a week long headache from air getting into her spinal column. Two years later when she went to give birth to my brother they almost weren’t able to place the epidural because of the amount of scar tissue.
This and a few other reasons are why I’ve decided I’m having a home birth. For the past two generations the women in my immediate family have had crappy birth experiences (grandma was put into a twilight sleep and doesn’t know what it’s like to give birth) and I plan to change that.
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Jena Reply:
December 6th, 2011 at 4:01 pm (Quote)
My mom had a horrible OB for my birth and I’ve always felt bad about that. Her experience was nothing like this, though. Holy cow. Good for you for believing in a better birth experience. For what it’s worth, I found that I felt completely confident in my birth & dr after reading a couple books–Your Best Birth, Ina May’s Guide to Childbirth, and a Birthing from Within prenatal class. (I’m one of two women in my family–out of 6–to not have a C-section and the only one who had a 3-month birth high.) Best wishes for your own birth experience!
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Mama Wrench had this to say,
Dec 6, 2011 @ 12:51 pm (Quote)
I know I’m one of those rare people who can pee in front of a room full of people without the slightest shame, so I didn’t have a problem with students at my labor. I actually encouraged it, because I wanted them to see a woman labor without a million tubes and procedures and maybe “get to them” early. But when it came down to the wire and I needed an epidural for a c-section, while my body was still involuntarily pushing, I’m very happy they didn’t allow a student to do it. I could NOT stay still and the anesthesiologist had a hard enough time placing it.
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I had an epi placed for surgery after 30+ hours (that’s another story). I had a veteran anesthesiologist. My contractions were double peaking, and I am also terrified of needles. Sitting on the edge of the bed, leaning on my husband, the last thing I wanted to hear from behind me was “oops.” BUT that’s what I heard. I can’t imagine going through that multiple times.
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Arzt4Empfaenger Reply:
December 7th, 2011 at 11:45 am (Quote)
… I just read that as veterinarian anesthesiologist and nearly keeled over. Holy cow Batman!
Honestly, epis *can* be hard to place, and having a needle phobia too, I would probably only agree to an epi if I felt I was wrenched into small bits and pieces. Oops is definitely NOT what you want to hear even once!!
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Hmm… well, all students have to learn. That’s a simple fact. And the way to learn is to observe and practice. Also a simple fact. When I was a midwifery student, I always really appreciated the Mommas that would let me learn skills on them.
All of that having been said, this doctor should have taken over for his student when the mother expressed concern. She was in labor, obviously in pain, and she shouldn’t have been blown off like that. Showing respect for the mother is paramount and this doctor and student surely missed that somewhere down the line.
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You know, when I teach my kids a new skill I don’t just explain it to them and then step back and watch while they do damage to whatever it is that they a practicing the skill on. Like when I taught my son to clean the toilet- I didn’t just sit there and watch while he made a giant mess and got covered in potty germs. Sometimes you have to stop someone when they are learning and show them again.
In the same way, if a student is allowed to poke around long enough, they’re going to make a mess of things. If they don’t get the skill in a reasonable amount of time, they need to be shown the process again before mom gets an epi headache, or some other more serious problem is caused.
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This is similair to what happened with my first birth. I was 16 and didn’t know any better and they gave me an epidural ‘just in case’ I needed a c-section (which I ended up getting .. ) … It took them a good hour and a half the first time they tried and couldnt get it in, he would hit a spot, and my leg would twitch, they’d hit another spot and my head felt like it was going to explode. Then they said they had to wait for the proper anaesthetist to come down as he was helping in a car accident :/ .. Then, when the proper guy came down it took gime about 20 minutes to place it.. I went on to have a all natural vbac with my 2nd 
But i still get back ache
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Yeah, that’s not good enough for me. I don’t let students work on me. I’m paying (out of pocket, in my midwife’s case) for professional care and that’s what I want to get.
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Selia Reply:
December 6th, 2011 at 5:30 am Selia(Quote)
How do you think the anesthesiologist became a professional? Everyone was a student at some point and doing procedures as a student got them to the professional level. If no one allows any students we will run out of professionals as they retire. Of course, if you don’t want a student you shouldn’t have one, and if this mom was concerned the student should have stopped and had the attending take over!
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Aron Reply:
December 6th, 2011 at 6:31 am Aron(Quote)
Every student needs the opportunity to practice. You are right. However, the OP mentions the student had already made “repeated attempts.” Every time the dural matter is punctured it increases the risk of the client ending up with an epidural headache, not to mention the risk of other trauma. The preceptor should have made the student stop after the second try, not blow off the concerns of the client.
Contrast that with the anesthesiologist at one of the births where I was doula: after 4 unsuccessful tries (and he was GOOD at his job, this was just a difficult case), he asked the OB to check the patient’s dilation and see if she was close enough and willing to push without the epidural because he was afraid of the after effects for this client if he continued. She was complete by then, anyway, and pushed out her baby sans-epidural.
Also, contrast that with nursing students who are allowed a maximum of TWO tries to start IVs. Most hospitals have a policy that no staff person may attempt more than two venipunctures on any one patient – if you aren’t successful, you MUST hand off to another person. Accessing a blood vessel is a heck of a lot simpler than accessing the epidural space, so the student in this case ought to have been pulled out and made to watch after two botched attempts.
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Selia Reply:
December 6th, 2011 at 10:32 am Selia(Quote)
I agree!
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Mama Wrench Reply:
December 6th, 2011 at 12:42 pm Mama Wrench(Quote)
Yes, but my poor husband had to get epidural treatments at a teaching hospital and ALWAYS got severe epidural headaches from incompetent students and attendings who would refuse to do it correctly. One time it took the student 45 minutes to get his epidural in and he couldn’t hardly walk afterwards, the slightest movement made him sick. I can only imagine what the attending would have done if this student was instructed to “practice” on a laboring woman.
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