As an anesthesiologist with 30 years of practice, I didn’t think I could improve my performance in simple procedures like iv line insertion. I was wrong. I reduced my failure rate 5-fold using the power of intention.
Robin Youngson reflects on a novel strategy to improve healthcare practice
Many of us know the true story of the heroic airline pilot, Captain ‘Sully’ Sullenberger, who landed his aircraft on the Hudson River after catastrophic engine failure caused by bird-strike shortly after take-off. His decisive actions and extraordinary skill saved the lives of every single passenger and crew member. The dramatic story is told in the feature film, ‘Sully’, with Tom Hanks playing the lead role.
Even more interesting to me is the back-story. Shortly after we saw the film, my wife Meredith bought me a copy of Captain Sullenberger’s autobiography, a very inspiring read. I identified strongly with Sully’s story. He was a top-notch military pilot and a pioneer in aviation safety before he began his career in commercial aviation. I grew up in a military family and was an engineer before I was a doctor. For many years I was a leader in patient safety and healthcare quality, taking lessons from aviation and applying them in healthcare.
Aviation is a high-reliability industry with an astonishing safety record, considering the millions of passengers who fly without injury. In contrast, healthcare is a low-reliability industry where we accept high rates of error and failure. International research shows that at least 10% of patients admitted to hospital are accidentally harmed in the course of their care – the true number is probably far higher. Of course, patients are not machines, we can’t engineer out all the modes of failure, and healthcare is infinitely more complex and uncertain than aviation. But, reading Captain Sullenberger’s life story, I was inspired to apply some of his approaches to my own clinical practice.
Sully describes the incredible precision with which he conducts each flight. For instance, he calibrates his final approach and landing to achieve perfection in terms of minimal fuel consumption. For Sully, nothing is routine. Could I emulate his approach and improve the performance on procedures I do with every patient?
As an anesthesiologist, one of the tasks I have to do for every patient is insert an iv line. On average I get the cannula successfully placed in a vein for about 90% of my attempts. The other 10% I miss the vein, cause a haematoma, can’t advance the cannula, or penetrate the back wall of the vein. Usually it’s because the patient has ‘bad veins’ or those constricted by cold or nervousness. By the standard of Sully’s practice, a 10% failure rate is a very poor standard. In medicine we do some of the complex things really well but we’re bad at getting the simple things right 100% of the time.
My first attempt to improve my performance used a technical approach. I wanted to understand exactly how a vein behaves when it’s punctured by the needle and entered by the cannula. What were the risk factors for the cannula accidentally penetrating the back wall of a vein, or rupturing a valve? I spent hours with an ultrasound scanner examining the detailed anatomy of peripheral veins in my forearm and hand and trying to observe the needle penetrating the vein wall. I learnt almost nothing useful except that it’s difficult to visualise superficial veins when they are flattened by the touch of the ultrasound probe! I was also unable to visualise or located valves within the peripheral veins. My technical studies didn’t make any difference to my success rate, I needed a different strategy.
I decided to take a consciously intentional approach to the insertion of iv lines. Rather than trying to improve my performance, I just held a powerful intention that the cannula would be correctly placed in the vein and I visualised the end result as I performed the procedure. This approach yielded impressive results. I missed only two veins in about 100 consecutive patients over a six week period. I had reduced the error rate 5-fold, as shown in this cumulative error chart.
On reflection I noticed something odd: not one of these 100 patients had vaso-constricted or ‘difficult’ veins even though the study period ran into winter weather when patients more commonly have cold hands and hard-to-find veins. My newfound success rate wasn’t just owing to my improved technical skill, the patients and their veins changed too! It’s as if the veins became open and receptive to my intention.
If that sounds fanciful, consider this lovely story told by a colleague and friend in the USA. Julie is a nurse specialist who is often called to do iv lines in patients, when others have failed. As I do for difficult cases, she uses an ultrasound scanner to find bigger veins deeper in the arm and then inserts the iv line under direct vision, steered by the ultrasound image. On this occasion, she was called to help a teenage patient who was very anxious and needle-phobic. The patient’s mother was sitting at the bedside. Julie scanned the forearm and found a vein that was adequate but not very big in cross-section. Keeping the scanner on the arm, she asked the patient what reward she would like, after the iv line was inserted. ‘What’s your favourite food?’ she asked.
The patient said ‘ice cream’ so Julie asked her to describe her favourite ice cream, type of cone, best toppings, and so on. As the girl imagined her treat, Julie kept her eye on the ultrasound image. The vein doubled in diameter as the patient relaxed. Even the patient’s mother saw the change and exclaimed in surprise.
So my belief that my conscious intention influenced my patients and changed their veins, as well as my skill in the procedure, is not so far-fetched. Maybe there is some subtle change in my attitude that is allowing my patients to relax and the veins to become dilated?
When I bring powerful intention and consciousness to my work, extraordinary things happen. Conversely when I try to improve performance by trying harder, my success rate falls rapidly. The day after I began composing this blog, I missed two veins out of four!
We know that emotional and psychological factors powerfully influence the course of an illness or injury and that compassionate care is great medicine, achieving much better clinical outcomes.
Perhaps if we add powerful intention to our care, we can help patients be more open and receptive to our treatments? I’d love to hear if other practitioners have adopted this approach.