MiM Mail: The what-ifs

Ever had one of those cases where you look back and just wish you'd done things differently? What's your way of handling this feeling? Might you be willing to share your moving forward strategy?

I'm an anesthesiology resident transitioning back to work from maternity leave. While I love what I do, there have been quite a few days when I definitely feel that the transition back to work is not as fast as I'd like. The days where I feel like I'm relearning things I used to know. Yes it's kind of like riding a bike after you haven't been riding one in a while, but when you're training, sometimes you don't feel like you ever really knew how to ride it that well even. And I have many moments where I am mentally kicking myself because I just remembered something I should have done or handled differently.

[The case below has been changed to protect patient and staff confidentiality]

For instance, recently there was a code blue at the hospital. A man who had been undergoing a line insertion was now having massive hemoptysis. A double lumen tube was inserted to isolate the bleed. Some air seemed to be entering one lung. The PAC balloon is inflated and the hemoptysis seems to have stopped for a while. The patient seems relatively stable with good sats and bp and the patient's main physician consults ICU to take the patient for close observation. At the back of my head is this niggling feeling as I am not quite sure whether this tamponade from the PAC balloon will hold - should we consider if we need a surgeon to sew up whatever's bleeding? But soon, the patient is bleeding again, CPR is started, the surgeon shows up but the patient is too unstable and despite best efforts, the resuscitation is unsuccessful. When I get back home, I read up on this, and more questions fill my thoughts. What if we'd gotten a cardiothoracic surgery consult much earlier on? Or heart-lung bypass? But now it's too late for the what-ifs and should-haves. I just wished I had known more at the time to be more useful.

Shortly after, I was in a simulator session. While I was fast on initial management managing a crashing patient and securing the airway, I got hung up on troubleshooting ventilator equipment that had failed, without moving on to switching my equipment. It was one of those how-stupid-of-course-I-should-have-thought-of-that moments - if something's not working, sometimes the best option is not to try and fix it, but to switch it entirely. I know that! But hadn't done it fast enough. In a simulator, it's not a real patient crashing and that's great. But if this was a real-life situation, that patient may not have been as good.

I find it hard not to mentally kick myself, or to look with envy at other colleagues and wonder how they seem so much more confident and competent. When I look at my flubs, I often feel like a Bridget Jones while others seem like a Grace Kelly or better yet a MacGyver - always there with the best plan in the nick of time, executed with calm and grace.

I hope I'm not the only one out there who has felt this way - trying my best but feeling incompetent or stupid at times. Yes it is a learning opportunity, and yes, I hope it gets better, and yes I feel I know more than I used to - but when does one start to feel confident and competent, and bring-it-on-because-I-can-handle-it rather than I-hope-I'm-seeing-bad-stuff-when-there-is-someone-else-on-who's-better-than-me-there-to-guide-me-through-it? When I was a med student, I looked at the residents with awe for their competence and confidence, and now that I'm the resident, I don't know that I feel that way.

Have you ever felt this way? Have you ever had cases that didn't go as well as you'd liked? How did you handle it?

RLMD