Anxiety is your Superpower

Podcast episode

If, like me, you find yourself on the anxiety end of the self-confidence spectrum, then maybe this will serve as some reassurance that it's not all doom and gloom.

Anxiety is a profoundly unpleasant sensation varying from a mild sense of unease to gut-churning spine-tingling dread, and it has evolved with us because it is an extraordinarily beneficial trait to carry around when it comes to survival in the wild.

When it comes to day-to-day functioning in a modern hospital, in a career that requires at least a modicum of confidence in one's decisions, however, a generally heightened sense of anxiety can vary from inconvenient to utterly debilitating.

I'm an anxious person

As a first year doctor I struggled, and that's putting it very mildly indeed.

• I did not prescribe anything without checking with someone else until May
• I did not prescribe antibiotics without checking for an entire year
• The first time I ran fluid through a giving set and connected it to a patient, I checked back on that patient eight times to reassure myself I wasn't somehow running a column of air into their circulation
• I once took out a cannula that I had literally just put in, because it went in 'too' smoothly, and so there must be something wrong with it, like it being in an artery
• I would wake up in sweats at three in the morning panicking over decisions I'd made during the day - decisions for which the dire consequences of getting it wrong would include 'a single missed dose of paracetamol' or 'a litre of fluid over four hours rather than six' - yeah, exactly
• I drove back to the hospital on more than one occasion to check my prescription hours after my shift had finished, because maybe I'd got it wrong, and a patient was definitely going to die as a result

I simply couldn't cope with the possibility that I might have missed something, or made a mistake.

I was struggling so much that I would absolutely dread driving to work in the morning and I'd then sit through the morning board round concentrating so hard on not looking scared that I must have appeared remarkably strange indeed.

I was genuinely wondering whether I'd have to give up the entire medicine gig altogether.

I just couldn't seem to hack it, there was clearly something very wrong with me. All of my FY1 colleagues seemed to be breezing through, prescribing all sorts of medications and doing all manner of procedures like seasoned pros, and here I was quaking in my boots about the prospect of prescribing more than a single dose of co-amoxiclav.

"She wasn't allergic yesterday, but what if she is today?"

Absolutely no way could I even consider the possibility of becoming an anaesthetist, dealing with the catastrophes, emergencies and split-second decisions that fly at them on a daily basis.

I used to watch them drift in to the crash calls, calmly take over airway management and then start helping make really rather important decisions about a patient they'd met less than five minutes ago.

I mean - they were just too damned chilled - no way could I ever be like that.

Anaesthesia scared me

Yes of course I'm a complete nerd for the science, and the pharmacology of hypnosis is pure magic, and the sense of reward from abolishing people's pain is second-to-none.

But I'll be honest, one of the main reasons I applied for anaesthetics training is because it terrified me.

It was the one specialty I was convinced I'd never be able to do, because I was too damned anxious.

So I applied out of sheer stubbornness.

And after a year of gaining experience and boosting my application on intensive care as an FY3 trust grade, I started to realise something.

Anaesthetists aren't chilled

We're professional catastrophisers.

The art of 'swanning' is held in the highest regard among anaesthetists. The skill of appearing entirely at ease with any emergency situation whilst frantically churning away beneath the surface working out what to do next is invaluable in time-critical scenarios where half of the challenge is keeping everyone else calm.

Panic is a terrible premed, so it's our duty as anaesthetists to be the unflappable smiling air hostess, calmly guiding the terrified patient through what we're still trying to convince ourselves is 'just a spot of turbulence'.

We're actually not that chilled if you think about it. Chilled people have an attitude of 'I'm sure it'll all be fine'. Contrast that to what happens when we're called for help in an emergency.

• We've made two plans
• Three back up plans
• And readied two troubleshooting algorithms before we even look at the patient's monitor
• We know the kit in the resus trolley
• We've checked where our boss is to call for help
• We may or may not have grabbed a syringe of ephedrine on the way

We look calm, despite being in a state of heightened awareness, because we have a plan.

Anxiety into Vigilance

Vigilance and anxiety are cousins.

Vigilance is a state of heightened attention and responsiveness in particular to signs of danger or threat.

If you can turn anxiety into vigilance, it becomes a superpower in anaesthesia, and this was the transformative moment in my career, when I realised that just maybe, I could be a half-decent anaesthetist.

Because for every disaster your anxiety shouts at you, vigilance has an answer:

• The patient might drop their blood pressure - my metaraminol syringe is on top of the machine, fluids are running nicely
• What if I can't intubate? - Try an igel, try an LMA, try facemask and OPA, front of neck access is in the draw, the registrar is in the coffee room, the DAS algorithm is on the airway trolley in the corridor
• I might get a paediatric emergency call - I have the paediatric emergency app, the STRS guidelines, I know how to put in an igel, the consultant is only ten minutes away, the paeds registrar can intubate if needed
• The patient might have anaphylaxis - the adrenaline is in the cupboard, top shelf on the right
• This could be malignant hyperthermia - the MH kit with the dantrolene is in the pharmacy cupboard, my consultant is in the coffee room, and the quick reference handbook is on the fridge
• I might inject the wrong drug - I've checked twice and labelled the syringes, and only drawn up drugs I'm intending to give at some point anyway
• What if they regurgitate during induction? - the suction is under the pillow, the table remote is by my right hand and I've aspirated the NG

This is the key difference between vigilance and anxiety - with vigilance there's an answer.

Anxiety doesn't provide answers. It just stands looming in front of you, conjuring up panic-inducing questions about potential future catastrophes that cause you to freeze up, paralysed by the fear of doing something wrong. It makes you second guess your ability, your decisions and whether you should really be here in the first place. It gets in your way.

Vigilance does the opposite. It's your co-pilot sat right beside you, providing solutions, back up plans, escape hatches and airbags to whatever might come flying in your direction.

It protects you, and the patient, and the surgeon that just trocared the IVC.

• You put in another cannula
• You checked the group and save yourself
• You drew up the tranexamic acid
• You called your boss early because 'things just didn't seem right' when the screen looked darker than usual and they were faffing about with the camera settings

This is why anaesthetists are exhausted at the end of a long day and the surgeon often seems fine - it's tiring thinking of all the possible disasters that could erupt at any given moment, for even the most basic and routine of operations. But if you can turn it from an uncomfortable anxiety into a fortress of vigilance, you'll find yourself enjoying the job a whole lot more.

Hey - you were going to catastrophise anyway - might as well get paid for it.