How Many Teeth Was That?

There are times in one’s life that certain events become seared into one’s brain.  The first day of my anesthesia residency offered just one of many such opportunities for me.  I had completed several medical student anesthesia rotations during medical school. I had honed some basic medical skills such as IV starting, drawing blood specimens, attaching appropriate heart and blood pressure monitors to patients and had the rudimentary skills needed for performing an intubation.  Intubation, the placing of a breathing tube into a hopefully unconscious patient is the mainstay of providing a modern anesthetic.

 

It was my first day as an anesthesia resident, I had reviewed the histories of the patients I was assigned to do for the day and had even reviewed each case with the attending anesthesiologist I was assigned to on that fateful morning – Felix Fernandez.  Felix was a gentle, always smiling, always pleasant, very competent anesthesiologist from a South American country, the name of which escapes me right now.

 

The morning started as one might expect.  I was so nervous I could hardly keep my nearly frozen hands from shaking.  I had reached a new record high in the number of times a person could go to the bathroom and still be expected to maintain some dignity and forward motion for the day.  I had arrived in the operating room at least an hour earlier than necessary, had set up my room as best I could remember from our brief but terrifying orientation.  The patient was waiting for me in the operating room holding area.

 

I met the patient with my attending.  Did I tell you that although Felix was a very pleasant and competent anesthesiologist he stuttered terribly.  For the whole time I knew him I don’t believe I ever heard him begin or end a sentence without getting held up on some consonant.  Because that type of communication can pattern can be less than comforting to a patient he let me do the bulk of the talk.

 

I am not sure how I managed to get the intravenous line in and started, but I do remember the man commenting on how cold my hands were and then, out of the blue, asking me how long I had been doing anesthesia and how many anesthetics I had given in the past.  I smiled at him and then quickly said I needed to check out the medications I would be using for his case – first land mine side stepped.

 

Felix and I came back to the patient’s side about 10 minutes later and rolled the patient into room 7.  Why do I mention room 7, because that is part of the searing that was soon to take place.  Monitors were placed, an oxygen mask was placed on the patient’s face and my first anesthetic induction was about to begin.  There I was with Felix, my  faculty member and mentor, standing at the head of my patient’s bed in a relative state of ‘unconscious incompetence’ and yet felt totally ready to start my anesthesia residency.

 

I firmly believe that the state of unconscious incompetence is a true state of mind.  To expand on this a bit, I think there are four phases of learning.  To truly be competent as a doer of a set of skills and more importantly as a teacher of a set of skills, one must progress slowly and painfully through each of these four phases.  I believe the phases, in order, are: unconscious incompetence –you have no idea what you don’t know but you think you are completely competent; conscious incompetence – you are now aware of the things you don’t know and you tread very carefully into those unknown areas; conscious competence – you know what you know and are comfortable with most tasks in those areas, and finally unconscious competence – you have no consciousness why you know something but you know it anyway (I probably stole these learning phases from someone years ago, and if so, I apologize for not giving you appropriate attestation).

 

To illustrate what I mean, take the example of medical students.  They are in the unconscious incompetence phase.  They live in a world in which they have little idea how truly incompetent they are.  They have finished 4 rigorous years of schooling, 2 of which have been on the medical wards getting immersed in ‘real medicine’.  Many leave thinking that they truly ‘have it’ and they just need a bit more practice.  Maybe that is why they call what doctors do ‘the practice’ of medicine.  They just practice and practice their whole life trying to get it right most of the time.  I fear I digress.  If these moment of unconscious incompetence overlap with truly life threatening moments, one can only hope there is a seasoned professional around to bail both the student and patient out.

 

Now residents, particularly midway through their residency training, for the most part, appreciate they are in their conscious incompetence phase.  They recognize their areas of competence, but more importantly, recognize those areas where they are still at some level incompetence and must tread those areas carefully. They know what they don’t know.

 

As residents leave their training they enter either fellowship training or into private practice and they have moved yet again to another phase of learning, the conscious competency phase.  They are conscious of their competence and are comfortable with it.  That is not to say there is not more to learn, they are just conscious in their competence.

 

One enters the final phase of learning at a much more indistinct time in their career.  There comes a point where one becomes unconsciously competent.  You know you have entered that phase when you hear yourself saying, when asked why are you directing someone to do a particular task in a certain way, “I don’t know just do it that way please”.  In fact, you do know why you are asking them but it is difficult to justify your wishes in words.  The right answer or way of doing something is simply unconsciously right, the result of many years of experience.

 

Well, back to room 7.  There I stood, totally unaware of my unconscious incompetency for the situation that was about to confront me.  As I recall the patient was a man of about 60 years of age, a bit overweight.  He was a movie producer from Hollywood who had to go out of town for his surgery to keep his surgery somewhat under wraps.  He had come to us for repair of a condition called rhinophyma, in layman’s terms a large red bumpy nose, a description that fell way short of his appearance.  He had chosen Charlie Cummings, a nationally famous Ears, Nose and Throat surgeon to do his surgery – a great choice by the way.  This case was to be the first case I had the pleasure of doing with Dr. Cummings and over the years we became quite good friends.  His sense of humor matched mine perfectly.

 

The case started in the usual fashion. Me, the resident at the head of the bed, Felix, the attending anesthesiologist at the patient’s left side.  The anesthesia machine to my right and the anesthesia cart with a vast array of essential and emergency equipment immediately behind Felix.  I place the anesthesia oxygen mask on the patient’s face to give him extra oxygen to allow us an additional margin of safety if the intubation was particularly difficult.  A moment later, we were off down the runway of the proverbial anesthesia take off sequence.

 

The mask did not fit particularly well both because of the size of the man’s nose and my inexperience at providing mask ventilation.  That should have been my first clue that things might not go as planned.  We injected medications to drift the man off to sleep, and we were nearing the point of ‘wheels off the ground during take-off’ when I made my first attempt at putting the breathing tube in.  During intubation, we use a special flashlight-like device called a laryngoscope to move the tongue out of the way and open the mouth up sufficiently to see the trachea into which we should effortlessly be able to slide the breathing tube.  Unfortunately, I had not been aware that in cases of rhinophyma not only can the nose be extra-large and hard to deal with but the tissues of the mouth and throat can also be excessive and obstruct visualization of the critical structures one needs to see for a successful intubation.  It soon became painfully clear that my first, second, and third attempt were soon going to be proven to be unsuccessful.  In the vernacular, I banged around quite a bit in this guy’s mouth to no avail.  Unfortunate as well, was the fact that I had not recognized how poorly I had applied the oxygen mask so that additional margin of time often provided by our period of pre-oxygenation was totally inadequate.  The patient’s blood oxygen level began to fall as witnessed both by the numbers being reported out on our monitor screen as wells as by the sound of the heart monitor beeping slowly dropping in tone.  I always thought the person who designed the oxygen monitor to have its tone drop as the oxygen level dropped was trying to remind us that our patient was heading down into the grave.  You know, the tone could have just as well been designed to go up in concert with the increasing anal tone and anesthesiologist experiences as thing get worse and worse.  That natural phenomenon of increasing anal tone with increasing impending doom has saved many a pair of anesthesiologist’s underwear.

 

It was now time to do the attending resident dance – Felix moved to the head of the bed and I took the position at the patients left side.  Now is was Felix’s turn to have a go at intubation.  The unfortunate state of affairs, was, however, as always is the case, after the resident fails, the attending is starting well behind the curve in trying to rescue the situation.  Time was of the essence.  Felix deftly repositioned the patients head, did this and did that and did this again and then finally looked at me and with urgency written all over his face said, “Hand me the ttttt.. ttttt….. tttt…. ttttttttt”, but his request never progressed beyond the ‘t’ stage. At that point, I gleaned there must be something on the top of the anesthesia cart that he desperately wanted so I just began throwing things his way.  Apparently, the right thing appeared in the flash of things flying past his face, and in what seemed like hours but was probably seconds he had the patient intubated and a hush fell over the operating room.  It was now clear that everyone in the room had thought we were in trouble.  In my mind, I knew we had been in trouble.  The nurses had quietly and efficiently gotten the necessary emergency equipment out and ready.  Charlie Cummings had opened an emergency tracheotomy kit and was calmly and professionally waiting for the word from Felix if he needed to take some drastic measures.  But it was also just like Dr. Cummings, in his absolutely confident and competent style to not interfere and only step in if it truly became necessary.

 

The tube was secured in place, Felix smiled at me, and I took my first breath in about 10 minutes.

 

It was now Charlie Cumming’s turn to shine.  He walked over to the patient’s head, looked down and said, “well now, isn’t this interesting”.  Turning to the circulating nurse he said, “could I have a kidney basin (a small metal pan about 8 inches long, 2 inches deep shaped like a kidney) and a set of medium forceps (tweezers).  Reaching down into the patient’s mouth with the forceps  the next thing I heard was, klink, as one of the patient’s front teeth was dropped into the kidney basin.  This was followed in rapid succession 3 more times with Charlie counting out each and every one.  With each klink my heart sank just a little bit more.  When he finished he just smiled and said, “may be an interesting conversation with the patient tomorrow, you think Dr. Ross?”  I smiled meekly, and at that moment was simply grateful that I had been able to control my colon.  The remainder of surgery went off without a hitch.  During the surgery, Felix tried to reassure me that “those kind of things happen”, but only rarely.  He also tried to fill in some of my unconscious incompetence gaps which had been so glaringly demonstrated by me.

 

It is the practice of anesthesiologists to see their patient the day following surgery to see how things went, ask if they remember anything, and allow the patient to ask questions they may have.  Of course, we check on them carefully before they leave the recovery room but it is not until the next day that the patient is fully capable of understanding and remembering conversations.  Needless to say, I was not looking forward to the first post-op visit of my career.

 

The following day I put off the inevitable as long as I could, but the time had come and it was now or never.  Off I went to visit with the patient.  As I entered the room he was sitting up in bed looking quite nonplused by yesterday’s whole adventure.  He gave me his newly fashioned toothless grin and said, “wow wffhat happenthed to my teefth?”, his upper lip flapping unsupported by his teeth.

 

I was about to start into this long and complex explanation that hoped he did not truly understand when the patient broke in.  “I had asked Dr. Cummings to pull those teeth but he wasn’t sure he would be able to.  I’m really glad he got to it and pulled them, they have been rotten and bothering me for years.  Would you mind thanking him for me if you see him?”

 

“What, WHAT !!!, WHAT the HELL!!!!!”, I thought.  Those two dirty double crossing attendings.  I will thank Dr. Cummings, for sure, I thought.

 

Obviously both Felix and Charlie were in on the plan to let me sweat following the incident.  We had been in trouble that morning, and they both had competently and professionally gotten us out of it.  But, in their wisdom, they knew I would learn way more by reliving the episode a few more times (that searing function we talked about at the beginning of this story), critically reflecting on my performance and then constructing a story that would offer full disclosure to the patient.  I must confess, however, I left the patients room unwilling to change the story the patient had put together about the whole affair.  Rarely if ever, after that moment, was I again caught in a moment of unconscious incompetence!  And yes, I did thank Dr. Cummings, but in a very different frame of mind than I had first considered.  For years to come Charlie was always more than willing to share with residents working with me about my first day as an anesthesia resident.  As the years past, the seriousness of the episode progressively worsened, the number of teeth ending up in the kidney basin grew and grew, but the learning points always stayed the same.