Procedural Efficiency

In private practice, efficiency makes a big difference. On one exhausting night in labor and delivery, I ended up putting in four epidurals in the span of an hour. Consenting for, placing, and setting up an epidural in fifteen minutes is not that challenging, but doing it consistently for four epidurals was tough for me. When you're the only anesthesiologist around and there's a queue of procedures, you learn to optimize everything. It reminded me a lot of how I taught procedures to residents when I was a fellow. I think that developing a routine is the most important thing. By doing each procedure the same way, I don't forget details and I avoid wasted movements. I teach this to senior residents placing central lines: each motion matters, plan ahead, anticipate the next step. I learned from doing nerve blocks that positioning makes all the difference; adjusting the height of the bed and helping the patient get into the fetal position can make the impossible epidural easy. And I also learned from having challenging procedures how to recognize when something's not going to be easy. Sometimes the patient is morbidly obese; sometimes she moves with each contraction; sometimes the anatomy just feels off. When this happens, it's important not to simply proceed by rote; this is when clinical judgment is important to recognize the situation and change the routine to accommodate it. Just like anything, even after the initial learning curve to become proficient with a procedure, there's still a lot to improve in order to master it.