This is something that is talked about in medicine but difficult to teach. I mean, how do you explain to a student that it is important to develop and listen to their “gut feelings”? And how do you know who has an accurate “gut” and who doesn’t? And can you “hone the skills” of the gut?
In general, I have found that I have been blessed with a pretty accurate “gut”. If I have that sick feeling in my stomach (I know, very accurate use of medical terms here..), I know that the s— is going to hit the fan. If I don’t have that feeling, things usually go fine, even if the monitors and situation suggest otherwise. I found myself trying to explain this to a resident I was working with last week.
We were doing a list of orthopedic procedures together and our first patient was a teenager with a developmental delay and obesity scheduled for an extensive foot surgery. In most situations, a popliteal nerve block would have been a good option for this patient. And I LOVE getting out the ultrasound machine and performing nerve blocks. LOVE it. And the resident was really keen to do that with me. But something was telling me not to in this patient. And then I heard that he had obstructive sleep apnea, which puts him at greater risk of respiratory side effects from pain medicine like morphine. One more reason to do a nerve block: less morphine use! So I talked to the patient and his family and I learned that the last time he had this surgery (he had his other foot operated on last year) he required oxygen because his breathing wasn’t “good enough”. And I thought, “Well, GUT, I cannot listen to you today, because it is clearly better for the patient to have a block!”. But then, I asked what he had received for pain management last time and they told me acetaminophen! Like no morphine or other opioid for pain! Wow – he is one stoic child.
This was so extraordinary, I had to confirm this for myself, so I went to review the chart again to look at his post operative course. I learned that he did indeed need oxygen and also that he did receive some tiny doses of an opioid pain medication, but not on the day he needed oxygen. And so…what to do…
Trust your gut. Something about this patient just told me that if I did a nerve block I would regret it. And the last time he barely needed any pain medication, as amazing as that is! So I could justify my “no block” decision because I didn’t think that he would be adversely affected by not having it.
The resident with me respected my decision, but couldn’t understand it. He understood the pros and cons and respected that eventually the balanced was tipped by my gut feeling. But he didn’t understand. And we will never know if my concerns were warranted (my main concern was the patient’s ability to communicate his sensations accurately if his cast became too tight and endangered the blood supply to his leg and foot) because we didn’t do the block. But once I had finally made the decision, I felt better. I knew it was the right one. The surgery went well and he woke up comfortable, so I consider the anesthetic a success as well.
Hopefully someday the resident will understand will understand why I made this decision, because my gut feeling has saved me and quite a few patients from a lot of trouble….