An ``Off'' Day

Sometimes you just know things are not going to go well. The other day I was getting out of bed after a surprisingly poor night's sleep. I had to perform a complicated biliary procedure on a 10-year-old boy who had a biliary stricture in a revised biliary enteric anastomosis after a liver transplantation. I don't think the lack of sleep was due to nervousness, but nonetheless it was not the best way to start the day. After I had turned the alarm off, I reached for my glasses, which are usually easy to find on my night table. Couldn't find them. Then, as I searched, I knocked them down to the floor. Feeling tired and like garbage, I went to the bathroom to brush my teeth. I couldn't find my toothbrush. After some searching, I found it. Went to the shower, where I couldn't find my razor. It was that kind of day. Nothing was going easily; everything was a struggle. I felt like crap. But, at least, I had seen it before. It is always good to know yourself and ``visualize'' what you are like. This may be hard in your 20s or 30s, but as you get older a little insight is good. I knew from my 6 AM alarm that something minor was out of sorts. Nothing physical, nothing serious, just that things were smooth.

Everybody goes through this. Maybe it was a test you took; maybe it was a speech you gave; maybe it was a committee meeting you were in; maybe it was a sport you participated in. The important thing, I think, is to recognize it in yourself because then you can deal with it. You can't tell me that you haven't experienced days when every chest x-ray, every CT, every procedure seems a struggle. Not that you can't get through them, just that they are harder than they should be. I sort of knew that no matter what, the biliary case was going to be a struggle. And it was. Thirty minutes of multiple manipulations and we hadn't gotten through the obstruction. Then, a 0.018 ``glide'' slid through. All downhill, I was hoping. But no. I couldn't get any catheter to follow the guide wire. C1, Kumpe, H-1, glide, nothing was working. Finally, a breakthrough. We placed another Kumpe near the point of obstruction and slipped a 0.0353 ``stiff'' glide through. Then the Kumpe kinked. Finally, a small 6 French catheter was passed. Then, our 0.035 stiff wire unraveled and we almost lost a piece in the bowel. Frustration dream-here we come. At least I was prepared for it because my day had started that way.

Previsualization is a hot topic. For all I know, it has been around for years. I guess, in a way, I have been thinking this way for a long time, but I have never really thought of it as ``visualization.'' When we have a difficult procedure, for example, drainage of a collection in the left upper quadrant, I have always had the Fellow think about what problems he could get into if he drained it using different routes. I used to think this was just ``negative'' thinking, as I mentioned the possible problems we could encounter. I would say, ``if you go this route and try to angle from below, you have to be aware of where the colon is. If you use this route, you must take into account the spleen. If you use the transpleural, intercostal route, you must think about secondary infection of the pleural space and/or a pneumothorax.'' In a sense, this is really like ``visualizing your golf swing before hitting it over the water.'' In sports you close your eyes and visualize the golf ball splitting the fairway and carrying the water hazard and landing 250 yards out on the fairway. I have done this a lot in sports. I remember playing hockey and being beaten to the puck because the defenseman always went in a certain direction when he got the puck. I thought about this before a shift, and the next time he tried it, I was ready. We got the puck and eventually scored. Was this ``previsualization''? I guess so. In any case, it worked.

I guess my point is that interventional radiologists have been practicing this for years, I hope. It has always seemed to make sense to think ahead about what the implications of certain maneuvers would be so that you could avoid doing them or, if they happened, you would know the consequences.

In sports, it always makes sense to study your opponent. It helps to know their tendencies. Whether you are playing in the premier soccer leagues around the world or in a pickup game, your game is only improved by knowing what your opponent will do when confronted with a certain situation.

In a sense, when you are doing a procedure, you can think of the procedure as an opponent, in a very abstract sense. For example, you are about to embolize a fibroid. Think of the fibroid as your opponent. In a football sense, the fibroid is the quarterback. You're a defensive lineman. The various arterial feeders and their variants are the offensive lineman. Before the ``attack'' on the fibroid, you think about what you will do if a certain vascular variant comes into play. In addition, you know what you are going to do if you dissect the obturator artery trying to place your catheter into the feeding vessel. This preparation or visualization can only make things go easier and better for you and the patient. If you don't do this, the case can be a disaster if something goes wrong.

I started this editorial talking about the ``off'' day that I was having prior to a tough biliary drainage. Understanding yourself can also help. Maybe you, the reader, are always steady, unemotional, and always ``on your game'' when you do a procedure. I doubt it, because if that is the case, you are an automaton. I think it helps to know you are ``off.'' I knew it the morning of that biliary case. I knew that things were not going to go smoothly. It wasn't that I had lost my skills; it wasn't that I didn't care; it wasn't, in this case, that I wasn't concentrating. It was just that I was off. I have seen it in sports. I have seen it in myself in sports. It is silly to think that it doesn't happen in the ``intellectual'' pursuits, whether it is in diagnostic interpretation or balancing portfolios.

My point is that what we should try to do is, at least, recognize that we are ``off our game.'' It won't make things easier, but it might help the patient or you some day.