Jen Gosling: “Difficult” is a difficult word

“They keep saying I’m difficult”, the patient wept. “I feel so guilty; I worry that they think I’m not co-operating”. It was the second time in a week that we had met. Both times, after multiple unsuccessful attempts at cannulation, the patient had been told that the anaesthetist would be along “to have a go”.

Intravenous cannulation is a basic skill, required to facilitate numerous treatments. Yet there are many reasons why cannulation attempts may be difficult and ultimately fail. Operator experience, human factors, patient anatomy, and patient physiology could all be contributing factors.

We recognise that early identification of patients for whom practical procedures are likely to be challenging creates opportunities for advance planning. Thus we have developed concepts of the “difficult back”, the “difficult airway”, “difficult access”, etc.

While we appreciate that communicating these issues between professionals can reduce the likelihood of morbidity and mortality, “difficult” is a…well…difficult word. The word has a moral dimension; a suggestion of volition. It is how we might describe a sullen child.

Without careful and sensitive explanation, and coupled with an aggressive phrase like “have a go,” being labelled as “difficult” can be deeply upsetting to someone already traumatised by the physical pain of repeated needling. Is our preoccupation with this word actually a reflection of our own frustrations when faced with failure of a supposedly simple task?

Access to ultrasound and other vein visualisation aids is increasing and offers sophisticated solutions for managing technical challenges; however, we can still make better use of basic tools, like choice of language. “Difficult” could be replaced by “not straightforward,” or the patient could be told that the procedure “needs some planning.”

There is an opportunity here.  Very simply, by paying more attention to how potentially challenging procedures are discussed, we can enhance the care we give to our patients.

 Jen Gosling is an ST4 in anaesthetics at Northwick Park Hospital, Harrow

Competing interests: none declared