Monday, July 8, 2013

We Let Our Residents Grab The Yoke Every Day

As the investigation into the crash of Asiana Airlines on a picture perfect day in San Francisco continues, the focus is now on the pilots running the cockpit. According to the black box voice recorder, a junior pilot with a scant 43 hours of operational time on a Boeing 777 was in the captain's chair at the time of the crash. Though he has thousands of hours of experience with other jumbo jets, this may only have been his third or fourth international flight on that particular model, and the first time he has ever flown into San Francisco. More senior pilots could be heard in the background instructing him on the approach. Unfortunately for them and the passengers, they did not suspect disaster was about to strike until seconds before the plane hit the sea wall at the end of the runway.

I can't help but empathize with the experienced pilots on that flight. With the start of the new academic year this month, our operating rooms are swarming with brand new inexperienced residents, ready to grab the yoke and start taking flight with our patients. This is one of the most stressful and harrowing times of the year for the attendings of every specialty. It is a daily tug of war between allowing the residents to expand their skill sets and reining them in to protect the patient and their medical reputations.

An anesthesiology resident learning direct laryngoscopy can be one of the most trying times for an attending. The only person with a view of the oropharynx is the resident holding the scope. Everybody else can only stand by to assist by giving verbal directions and possibly holding cricoid pressure. We attendings are on pins and needles while the resident seems to take forever and a day to find the epiglottis and the vocal cords hidden underneath. When the resident complains he can't see anything, what does that mean? Is he too deep and thus posterior to the cords? Is he too high and looking at the roof of the mouth? Are the cords extremely anterior and he just needs more cricoid pressure? As the seconds tick by, everybody, including the circulating nurse and maybe even the surgeons start to wonder what's going on. This is where experience counts. One has to know exactly when to step in and rescue the hapless resident. Perhaps the patient does have an unexpected difficult airway that will require more expertise to perform successfully. Or more likely the resident just hasn't intubated enough patients yet to feel comfortable inserting the laryngoscope properly. It's a guessing game with the patient's life on the line.

The same is true for any procedure a resident performs under my watch. A trauma patient comes in and needs an arterial line. How many times do I let him poke around in the wrist, potentially ruining the only site for a good line, before I have to wave him off so I can get it myself. How can I explain to a resident the different sensations she should feel when inserting an epidural needle and catheter? The resident may claim she feels the sandpaper like scratching upon hitting the ligamentum flavum, but how do I know for sure? Maybe she's millimeters away from entering the epidural space and should slow down to prevent a wet tap. Or perhaps she's still in the wrong layer and we could be sitting here all day with a screaming laboring patient demanding pain relief. As attendings, we really don't know. We can only guess, through years of experience, what is happening and take over before any permanent damage is inflicted.

So I feel sorry for the pilots of Asiana Airlines Flight 214. To me, it seemed like they were allowing a junior pilot to take the plane's controls for the first time in San Francisco International Airport because it was a beautiful blue sky, perfect weather ideal kind of day for learning to land a jumbo jet. Anybody who has ever lived in the Bay area know how rare that is with its frequent fog and gusty winds. Cumulatively the pilots had tens of thousands of hours of flying experience to guide them. But one reckless move caused millions of dollars of damages, killed two passengers, injured hundreds of people, and ruined their professional careers. We attendings are on the same tenterhooks every day.


  1. So true great Z. I'm an intern that just started. I'm trying to keep a blog (, and I love the way that you write btw. It's a scary time but necessary too, of course. Everyone starts somewhere.... even though some attendings seems like they've been practicing since the dawn of time with their hearing aids perched in ear, leading rounds and talking about neurosyphilis.

  2. Eh? Eh? What did you say sonny?

  3. This is so true, as a senior registrar (3rd year anaesthetics trainee in Australia), I had to supervise junior registrars just starting out for the 1st time. I found it really difficult to know when is the best time to take over and erred with taking over too early rather than too late, which was probably frustrating to the juniors but I had to do what was within my comfort level.

  4. Dr Great Zee, this is probably one of the best, most concise, and most empathetic descriptions of the conundrum of training in the life-and-death professions that I have read. The crucial insight is that catastrophe might happen under otherwise perfectly safe conditions; indeed, those are precisely the circumstances under which an experienced senior will carefully let a junior "fly solo." People cavalierly assume that well-trained doctors, like pilots, emerge from thin air. Thank you for the insight and sympathy.