Empowerment ≠ Responsibility

As I write this, I only have a month and a half left in my year here. I plan on returning to the states for a couple months to maintain my credentialing and earn some money so I can return to Ethiopia in the winter. As it’s becoming clear to me that our work here will become an important element in my life for the rest of my life, I’m beginning to reflect on what we accomplished this year.

Today, I’d like to show how strides towards mastering endoscopic airway management have surfaced a whole new problem in medical education.

Before my arrival about a year ago, the Otolaryngology attendings nor residents were trained in any type of airway management. At the same time, the anesthesia department (remember, staffed by non-physician techs) had no experience with surgeons that understood airway management. Today, specifically talking about pediatric airway foreign bodies, airway management was terrifying to my pediatric otolaryngology trained eyes. Although in the hands of very capable general surgeons, pediatric airway foreign body surgery here in Mekelle was not an intricate dance between anesthesiology and the surgeon, both sharing the airway culminating in a controlled and safe removal of the foreign body. Instead, it was a battle with the patient. How quickly could a foreign body be found and removed with partial or too much anesthesia?

To add to this. Bronchoscopy had been taught without endoscopes. To look down a long metallic tube with a dim light hoping to find an object at its tip. Then to blindly grab this object and hope that it comes out with the bronchoscope. I know this is what people used to do before endoscopes, but it’s outdated and has no place in modern medicine. It’s like performing an amputation with a tourniquet and hand saw. It works most of the time, but there’s no place for it in modern medicine.

I knew that if I were able to teach this skill to the surgeons in Mekelle, then huge gains in airway management would be made.

For those of you who don’t know, Otolaryngologists in the states (ENTs) are supposed to be “airway experts.” Trained to obtain an airway in any patient, no matter the disease. Most of us take great pride in this skill. In fact, during residency and fellowship, I was involved in trying to create emergency airway response teams where Otolaryngologists are utilized in the most dangerous of situations. Some of my scariest situations in medicine have involved airways, including one I spoke of back in October.

My fellowship in pediatric otolaryngology was fixated on endoscopic and open management of airway disease. That year of working with some of the best airway surgeons I’ve ever met empowered me with expert technique and countless experiences. But perhaps more importantly, the immense oversight involved in American pediatric surgery taught me responsibility. The department’s chairperson taught me to be prepared for the worst. Admittedly, I always thought she was over the top, extreme and always feared the worse. But now that I have been through the worst of the worst, I know that the only way to treat unexpected complications is to expect them, put your ego aside, assume you will make mistakes and always have help. That, to me, is what surgical responsibility means.

Teaching a skill is something I know how to do. Its something I love to do. Its what I live to do.

Starting with the basics, I worked with our department on anatomy, instrumentation and technique. Then, in practice, I showed them (and the general surgeons) how peaceful the procedure could be with proper anesthetic and surgical technique. I drilled the residents on every case, as I was in my training. Teaching them to predict and plan for the unthinkable. Within months the ballet of anesthesia and surgical technique played out as it should. When complications occurred, as they always will, we adapted quickly as a team.

To stand behind my residents and watch them perform sound endoscopic bronchoscopies makes me so proud. When they graduate and spread all around Ethiopia, I know that endoscopic management of pediatric airway will be given a whole new standard in this country. These residents and attendings have correctly diagnosed and saved the lives of dozens of unlucky children in and around Mekelle. If this was the only thing I accomplished this year, I’d be happy. Let’s all sit back and watch their success together.

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BUT, as is said in many cliché Marvel comic movies: “With great power comes great responsibility”

Now that the residents feel like they have the skill to manage pediatric airway, they have, on multiple instances, brought a child to the operating room WITHOUT notifying an attending. Our job as attendings is not only to teach the skill required to be a surgeon but also to teach them how to be a responsible doctor.

I’ve spoken about a similar experience back in November, but why do our residents continue to make these dangerous, irresponsible decisions?

The most dangerous thing for a surgeon to acquire is an ego. Our intense, military-like endless training beats in repetition and expertise. Mastering of a skill and knowledge set DOES NOT mean that we can handle everything on our own. Thinking you can is egotistical and not identifying that there are people that can help you is pure ignorance. A talented, confident surgeon performs a technique flawlessly under the supervision of true experts until they become that expert. Even then, asking for help isn’t weak, its compassionate.

I battle this line of confidence and ego EVERYDAY. We are constantly performing procedures never attempted in Mekelle and although I am confident in my skills, I am terrified that I am making the wrong decisions. I ask for help every day and I’m empowered by the fleet of experts that are willing to help me. Does that make me a bad surgeon, one that isn’t confident, knowledgeable or skilled? Maybe in some surgeon’s eyes.

My ego certainly gets in the way of making good decisions, but if I surround myself by like-minded surgeons, they will check me back into place. Yilkal and my residents have done that for me here. Unknowingly, my patients are thankful for their intervention.

So why do I struggle to convey this important lesson to my learners? I think it’s multifactorial.

In US surgical training, if you were to do something dangerous without informing the attendings, the consequences are severe. You could be fired, sued, go to jail. The fear of this prevents the ego of most learners from making bad decisions. To a large extent, those consequences don’t exist here.

Secondly, for whatever the reason, residents are allowed to make those decisions here. They can proceed to surgery without the sign off of an attending. A systems issue. Remembering that the anesthesia staff are not physicians, so they can’t be held responsible for these bad decisions.

Finally, the self-propagating culture that calling for help is a sign of weakness. A generational untaught reflex that all doctors here seem to agree on. To break this trend, we as attendings must encourage closed-loop communication and eventually, I hope the trend will catch on.

What would be a motivating factor, but I don’t think my residents understand, is that if a patient were to have a significant complication (or die) because of their ill-advised decisions, I would have to live with that guilt forever. My learner’s patients are my responsibility. I must own every mistake they make. My job is to create an environment where those mistakes are minimalized. When they make a decision without my input, how can I control that environment?

Life here has been a struggle over the last year for many reasons, but a major reason I am so happy to continue, is because I know my residents will help me the entire time. We will fight through all of these issues together.

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