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five minutes would be declared the winner. Each group would have one
commander, three people to run over and grab the Legos, and three peo-
ple remaining at home base to build with the Legos. Who was to com-
mand and who was to obey in the tower-building process was the essen-
tial teaching point. The commander was to be chosen at random; a doctor
did not automatically assume command. The commander would bark
orders to subordinates, telling them, for example, that the group needed
this size Lego, or two of that size, or four of another. If the commander was a nurse or an orderly, he or she would experience the thrill of ordering doctors to fetch Legos, while doctors, in turn, would learn to accept advice and direction from a lower member of the team.
The race began. A few doctors got into the spirit of things and good-
naturedly ran to the Legos bin when a nurse or orderly commanded them
to. But most of the doctors looked self-conscious, perceiving that the
exercise’s purpose was to wound their dignity and take them down a
notch. Several doctors grinned on purpose to keep from sneering as they
ran toward the bin. A few doctors stared blankly into space as they ran,
each of them embarrassed for the other. One elderly doctor was so in-
sulted that he remained seated, frowning fastidiously in his chair, scouring his coat sleeve for dirt, and obviously thinking it beneath him to be treated in such a manner. As a Lego builder rather than a retriever, I was able to conceal my displeasure with slow hand motions that went unno-ticed.
At the end of five minutes, the group with the two doctors who had
given it their all was declared the winner. Its members cheered and re-
turned to their seats.
A second nurse went up to the lectern. She talked about a case in
which a nurse had tried to tell a doctor about a patient’s new symptoms,
only to have the doctor ignore her. The patient died as a result. The nurse dabbed her eye with a tissue, and then she gave two more examples of
patients injured when a doctor had failed to listen to a nurse. “We can do better!” she declared.
What the nurse said was true. We can do better. I know of several
cases when doctors overlooked a nurse’s wise counsel and the patient
suffered as a result. In one case, a nurse anesthetist suggested giving a patient a drying agent before the doctor tried to perform an awake intubation. The doctor ignored the nurse; as a result, the patient had so many
oral secretions that an awake intubation proved impossible. In a second
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case, a nurse anesthetist suspected that a patient had eaten before surgery.
She suggested canceling the case, or at least placing a breathing tube to protect against aspiration. The doctor refused to listen to her; the case was done under mask anesthesia; in the end, the patient did aspirate and ended up in the intensive care unit for two weeks.
But the nurse at the conference was after something different. Her
sadness, her irritation, her enthusiasm—it was all laid bare for us. Everyone in the audience knew what was going on and quietly submitted to the
invisible process. They knew a new belief system, the team system, was
being drummed into their heads. That new system aspired to put doctors
and nurses on the same level.
Ironically, this new belief system is as flawed as the old belief system
that held doctors to be omniscient and unassailable. Both belief systems
substitute a lofty worldview for complicated reality; both see the practice of medicine as something that can be encompassed through a fundamental principle—an excellent idea, but one that is not accurate. Medical
practice is a murky world of egos and personalities, of authority tempered by the natural give-and-take between people, and something best navigat-ed using tact and common sense. A nurse with a fanatical belief in team
medicine, like a doctor with a fanatical belief in his or her supremacy, is like the housekeeper with a fanatical belief in the possibility of a clean house. The housekeeper’s mistake is not in fighting the dirt but in trying to get rid of it altogether, as though such a thing were possible. A house is necessarily a dirty place. Metaphorically speaking, so is medical practice.
Too many human limitations prevent the application of ideology.
Privately, many in the audience resisted what the nurse was saying or
approached the new system with a mixture of doubt and belief. Even
some of the nurses resisted, wondering about the new system’s viability
in practice. They also resented being given high-minded lessons on how
to live. But everyone feared a shake of the head or a warning finger from the nurse on the podium if they dared to express doubt. Indeed, faults that in other fields might have delegitimized the speaker—her strangely false
and high-pitched moral tone, her melodramatic absurdities, and her belief in progress—gave her power. Everyone in the audience knew they would
have to accept the new system if they wanted to continue their profession-al lives in a quiet, tranquil, and unruffled manner.
The nurse then told the story of how her own mother had mistakenly
taken some medicine with bourbon, thinking it was doctor’s orders. Her
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doctor had only been joking when suggesting she take it with alcohol.
Indeed, the doctor’s own nurse had warned the doctor that the patient
might have taken the order seriously. But the doctor ignored the nurse.
The woman ended up drunk.
The audience stared at the nurse with puzzled eyes, uncertain how
they were to react. Should they laugh? Should they continue thinking
serious thoughts? The audience looked at the other three nurses on stage
to see how they were taking it. All of them were grinning. At once all
doubts vanished. We should have known. This was a comedy turn. Soon
we all echoed with obedient laughter.
The nurse at the lectern previewed a short film clip we were about to
watch: a dramatic reenactment of a true story about an anesthesiologist in Britain who had trouble intubating a patient. Because the nurses and staff in the operating room had been too cowed to advise the doctor, the patient woke up brain-dead.
We watched the clip. Something in it didn’t make sense. The actress
playing the patient was thin and had a normal-looking airway. The drama
skipped time in five-minute intervals, with the actor playing the an-
esthesiologist failing each time to intubate the patient, but also calmly breathing for the patient with bag and mask. Several nurse-actors attended the doctor. They remained silent and played the role of cowed
subordinates, but what they were kept from saying that would have made
a difference was unclear. The clip conveyed no sense of urgency.
Some doctors in the audience grew emboldened during the discussion
that followed. One anesthesiologist queried, “If the patient was so thin
and with normal airway anatomy, why did the anesthesiologist in real life have trouble intubating her?”
“I’m not sure what the problem was exactly,” the nurse at the lectern
replied. “But that’s not the point. The point is—”
Another doctor cut her off. “It is the point,” she said. “If the patient had been morbidly obese, requiring multiple intubation attempts, then
maybe the anesthesiologist shouldn’t have put her to sleep in the first
place. But that was the anesthes
iologist’s decision. Nothing for nursing to say on the matter.”
Sensing pushback and eager to rescue their cause, one of the other
conference leaders walked up to the lectern. “I believe the patient was
slightly above average weight. But for some reason the anesthesiologist
had trouble intubating her,” she explained.
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“But why?” interjected an ENT surgeon, defiantly. “Even a patient
with a difficult airway can usually be ventilated with a bag and mask,
especially a thin one. Something doesn’t sound right. I don’t think nurs-
ing input would have made a difference in this case. Something else was
going on that caused the patient to wake up brain-dead.”
The two nurses stood at the lectern, hesitating. They appeared not to
know how to react. Should they take the doctor seriously? Should they
perceive some level of insult? Should they ignore the doctor? The situa-
tion seemed to be something outside their experience.
BSN, MSN approached the lectern with the third nurse. She looked
angry, as if the doctors in the audience were saying the wrong things,
appalling things. “The nurses were probably too afraid to tell the an-
esthesiologist that the patient’s oxygen level was declining,” BSN, MSN
declared. “That’s what happens when the team is not allowed—”
“But why would a doctor even have to be told?” I interrupted. “An
anesthesiologist’s ear is carefully trained to listen to the sound of the oxygen monitor. It’s almost second nature to him; he practically hears it in his sleep. The one thing that anesthesiologist would have known is the patient’s oxygen level.”
BSN, MSN’s eyes blazed. “Maybe he didn’t! That’s why a team’s
input is most needed in a crisis!” she loudly declared.
The room fell silent for a moment. An elderly African American or-
derly sat two seats from me on my left. I recognized him from my hospi-
tal. His hair was gray; he stooped somewhat; his face was a spiderweb of
furrows; his demeanor deferential. The old system had not only prema-
turely aged him but also taught him that his opinion was both unwanted
and undesirable. But at this moment, years of operating room experience
seemed to stir his conscience. I heard him quietly mutter under his breath,
“I disagree.”
A brassy, middle-aged OB/GYN sitting in front of me was more vo-
cal. In a sneering tone she shouted at BSN, MSN, “When anesthesia is
having a problem, it’s not time to talk. It’s time to shut the fuck up!”
BSN, MSN looked furious. Staring fixedly and authoritatively at the
audience, she declared, “Now let me tell you, people, that so far as the
future is concerned, it’s going to be like this. We’re going to work as a team, got it? The team has rules. If you’ve got sense, follow them, but if you haven’t, clear out.”
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In a stern voice, she went on about what nurses had to offer the team,
both as patient caregivers and as advocates. Never in my life had I seen a more vicious caricature of nursing love. All of it resembled what nurses
do, but at the same time, for some inexplicable reason, it was so unpleasant that the audience did not utter another word. On the faces of all were confusion and concern.
Two weeks later, the patient with the unexplained anemia returned to
the hospital for removal of a tumor in her small intestine. Nurse A, the
nurse anesthetist on the case with me, was a young man in his mid-
thirties, technically adept, confident, sometimes a bit too confident,
knowing what he knew without knowing what he didn’t know. One might
have called him naive. He had the habit of mentally brushing aside advice from his supervising physician, thinking himself quite capable of working independently. He knew this attitude irritated his supervisors, but for him, that irritation was only a sign that the advantage was on his side.
We decided to place an arterial line preoperatively in the holding area.
This involves inserting an intravenous catheter into one of the arteries at the wrist and connecting it to a pressure monitor, yielding instantaneous blood pressure measurements. I tried placing the catheter in the patient’s left radial artery—twice—but failed. Nurse A was eager to try. I gave him the green light after my second failed attempt. He quickly placed the line in the patient’s right radial artery and was barely able to conceal his self-satisfaction in doing so.
But he had gotten the line in.
During the case, the patient’s IV through her vein stopped working,
and because no other peripheral vein was visible, we decided to place a
central line to regain venous access. Nurse A asked if he could perform
the procedure. I agreed. He bent the patient’s wrinkled neck to the left
and swept across its right surface with antiseptic. Then he broke the
patient’s skin with a well-aimed puncture, eliciting a sudden flash of
blood. He passed a flexible wire through the needle, and then passed the
long catheter over the wire toward the right side of the patient’s heart. He did a nice job.
Shortly after, we checked the patient’s blood sugar. It measured 230.
I directed Nurse A to give the patient a small dose of insulin and then left
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C H A P T E R 4
the operating room. When I returned ten minutes later, the patient’s EKG
showed frequent premature beats that risked turning into a dangerous
arrhythmia. When I scanned the monitor that measures the level of carbon
dioxide in a patient’s breath and saw the number 30 on the screen, I
instinctively knew what had happened.
Insulin drives potassium levels down. So does blood alkalosis. The
normal carbon dioxide level in human beings is 40. Breathing slower than
normal raises carbon dioxide and makes blood more acidic, while breath-
ing faster than normal lowers carbon dioxide and makes blood more
alkalotic. Nurse A was ventilating the patient at twelve times a minute
and causing a respiratory alkalosis. The patient’s potassium level, already low to begin with (at 3.5), had declined from insulin, and declined further from alkalosis, causing dangerous ventricular ectopy.
I dropped the ventilator rate from twelve to six, which corrected the
problem. Nurse A said nothing, but I was angry. He had been hyperventi-
lating the patient for no obvious reason. And yet I was more to blame
than he was for the trouble.
Many doctors prefer to do everything themselves, since all orders can
be misunderstood. But that’s not possible today. There aren’t enough
doctors. Instead, doctors must supervise the work of nurses and other
physician extenders. They must know how to use the minds of others. For
this reason they must take into account both the tradition and the custom of the workplace in which they practice. Every nurse anesthetist at my
hospital, and not just Nurse A, moderately hyperventilated their patients as a matter of course. It was their custom. I had observed this, and I
should have foreseen the consequences of treating my patient with insulin in this environment. It is not enough for a doctor give an order. A doctor must see to its execution and, when giving it, anticipate anything that may nullify its effectiveness. Custom has a terrible way of avenging itself
when violated.
I told Nurse A to call me if there were an
y more problems. Then I left
the room to check on another case. I wandered back an hour later. Nurse
A had just turned off the anesthetic gas and was waiting for the patient to wake up. It seemed to take longer than usual. Also, the patient’s blood
pressure was 83/50, lower than expected during a wake-up.
“What’s going on?” I asked.
“I’m not sure,” replied Nurse A. “I turned off the gas and gave the
drugs to reverse the muscle relaxant, but she’s not waking up.”
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“Are you sure you gave her reversal and not something else?” the
surgeon asked with an accusatory tone.
“Yeah, I’m sure,” replied Nurse A, defensively.
We waited a few more minutes. The patient remained unconscious as
her blood pressure continued to sag.
“For God’s sake, what did you give her?” the surgeon shouted angrily
at Nurse A.
“I told you. I gave the reversal,” he replied, but this time with doubt in his voice. “I know it didn’t cause her blood pressure to drop,” he added
with more self-assurance. “That started before I gave the reversal.”
I jumped in. “Why didn’t you call me?” I asked.
“I knew what I was doing,” replied Nurse A proudly. “I checked the
central line pressure. It was 10 mm. I figured the gas was depressing her heart, and that things would get better when I turned it off.”
I pulled down the patient’s lower eyelid. Her conjunctiva was paler,
and less pink, than when we had started.
“What are you doing?” barked the surgeon.
“She looks more anemic than before,” I mused.
“We didn’t lose that much blood,” said the surgeon, defensively.
“I’m just saying she looks more anemic,” I replied.
“It’s probably from the low blood pressure,” insisted Nurse A.
There is something that exists in anesthesiologists beyond the realm of
consciousness, some mysterious clocklike mechanism that suddenly
gives a signal when trouble looms. Call it a weird prescience or instinct; whatever it is, anesthesiologists learn to trust it. I rested my gaze on the empty suction canister where blood would go if lost and felt something
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