Can anaesthetists communicate?

As usual I struggle to think of something to write about and twitter provides! @sassistheword was engaging with some individuals who suggested that of course she couldn’t communicate as a lowly anaesthetist…

Got me to thinking, it’s a common trope after all. Not helped by most of the public not realising that (in Australia and the UK where I trained) anaesthetists are physicians. In Scandinavia and North America and resource poor countries, anaesthetics are often administered by nurse anaesthetists. Either way the assumption is that we are mere technicians and secondary to the surgeons in some way.

Well obviously I have a chip on my shoulder about that. But nonetheless a failure of communication (ironic eh) on our behalf means that the public don’t fully understand what we do.

So can anaesthetists communicate? Can I? Well on a personal level I’ve failed at that job many times. But I have completed courses on debriefing medical simulation – i.e. telling people when they got it wrong in a non judgemental way. I have completed the Harvard “difficult conversations” course. I worked (although not recently) on intensive care and have told many families that their loved ones are going to die. I’ve mentored junior doctors. I’ve told doctors their behaviour is unacceptable. I’ve told doctors their practice is excellent. I’ve taught medical students, nurses and paramedics. I’ve presented at conferences and written business cases, I’ve published medical papers. So I’ve communicated across multiple domains…

But let’s give specifics:

I might meet a patient who has been in labour for 34 hours and is exhausted and in pain and then has been told that their baby has to come out now. They then meet me in the anaesthetic room, I take a history, I check their airway and IV access, I preoxygenate them and induce them within 10-12 minutes. All while talking quietly into their terrified ear “I know you’re scared, I’m here for you and everyone else is here for your baby, I’m going to look after you, these things are happening and this is why, ok off to sleep, I’ll look after you while we get your baby out…”

I meet a patient who needs emergency abdominal surgery because they have a cancer that will kill them in the next few months. But no one has said that to them because they are young. No one has said we’ll do everything for you but this will kill you and you can choose how you die. And now they meet me in the intensive care unit where 3 of their organ systems have failed. And I tell them, you have to make a decision. You can have this operation, and if we do it, we need to do it now. If you decided to go ahead this might be the last conversation you have with your wife – because there’s a high chance that if I send you to sleep you may never wake up. Or you can turn the operation down and you’ll die in the next two or three days and you can have your family around you and you can get some of your affairs in order. And I bring the surgeon and the intensivist to the bedside to see if they agree with my assessment and to explain exactly what faces the patient.

I’m in theatre and the patient starts to bleed briskly – the surgeon is stressed, the scrub nurse is new and doesn’t hand the right instrument over. The surgeon starts to lose their temper with the scrub nurse and shouts at them. I lean over the drapes and say in as even a way as possible as I don’t want to escalate them “I can hear you are stressed, we know the patient is bleeding, the nurse is trying to do their best, shouting at them won’t help them do that.”

I’m the duty anaesthetist – we have one more room running than we have staff for as it’s the weekend. I get a call for an urgent case – they have to go to theatre within the next hour. I walk to all the theatres and ask each surgeon individually how their case is going and whether they can expedite. I speak to the nurse in charge in recovery and then the nurse in charge in theatre. I speak to the booking surgeon and then I go and assess the patient in ED to get a handle on how sick they are. And then I get them their operation against all the competing priorities.

I’m anaesthetising a 13 year old today. They don’t want the operation that they need. They’re too big and have too much autonomy to proceed against their wishes despite their parents’ giving consent. They’re old enough to know they’re scared and an operation might be unpleasant in some ways. But they’re not old enough to reason with entirely. The parent who has come to theatre starts to berate their child and then cajole. Someone else tries to be helpful by putting in their opinion… I succeed in talking them around and successfully getting them off to sleep. Last time I didn’t and the patient had to be sent away from theatre – the parents didn’t appreciate my reasoning.

I’m going to do 18 cases today – 30 min procedures. I’m going to assess and chat to all 18 patients. I’m going to give each one my individual attention and I’m going to pick up on cues when I talk to them that tells me I need to ditch efficiency in favour of directed questioning or active listening.

The patient has arrived from ED – they have bled out most of their circulating blood volume from trauma. There are 20 people in theatre. Surgeons, nursing staff, assistants, anaesthetists- I lead the brief with the surgeon. “ this is what we think is happening, this is what we think is going to happen, this is what we need to prepare for…” I speak to blood bank and haematology, I delegate an arterial line, I ask a nurse to prepare for a central line and ask another to draw up adrenaline, I ask a junior colleague to squeeze on the bag of blood and check the lactate, haemaglobin and the patient’s temperature. I recognise the patient is deteriorating and lean in to the surgeon whilst asking a nurse to ask my colleague to come in and add their eyes and experience to mine…

I made an error today – it’s not life threatening but it could have been. I sit with the patient and explain what I did, how it happened and how I’m sorry. I confess my sins to my colleagues at the next meeting. But that mistake over time becomes a story to be told so that others may learn from me and not repeat that mistake.

I’m in the pre operative assessment clinic. I have a person with many medical conditions who needs major surgery. “Have you ever heard of an advance care directive?” “No doctor, what’s that?” It tells us what happens to you if you start to die because your body couldn’t cope with the surgery. I explain that not all operations go to plan, who did they want to speak for them if they can’t speak for themselves. Have they ever considered that if they got sick they might end up in a nursing home? How does that sit with them? The conversation is longer of course but I’m talking about the thought of death and dying to someone who thought they were going to live forever…

I go home after 14 hours at the office. My 10 year old asks me how my day was “Dad what’s the worst thing you’ve seen at the hospital?”

“I’ve seen horrible things daughter, you don’t need to know about them, you should just know that you should live your life and be free…”

But no us lowly anaesthetists can’t communicate… (and yet somehow we do, even from behind a mask)