In this specialty, small inconveniences can quickly snowball into serious threats to your patient. Here are some examples, as applied to our case vignette.

After induction, you note that her existing peripheral IV is running less smoothly than you would expect. It is placed in an arm that will be tucked, so you know it will be unrealistic to continuously monitor it. Rather than risk infiltration of a medication with vesicant properties or of large volumes of fluid, you decide to avoid using the IV altogether.

You place a second IV in the arm that is not tucked, but this proves difficult, requiring multiple ultrasound-guided attempts. You think ahead, noting that you will likely encounter significant fluid shifts and a potential need for vasoactive medications. This IV is deep and took multiple attempts, so the vein may not be hardy and you anticipate a struggle. You also note that lateral positioning will make emergent mid-case IV access extremely difficult if something goes awry. As mentioned, you understand the low threshold one should have to avoid complications from infiltrated or blown IVs. As such, you place a central line.

You gave a large dose of muscle relaxant at the start of the case, only to then be notified by the surgeon that they want to monitor muscle function during the case (this may have been avoided by early communication). Twitches are not coming back as quickly as you hoped. Rather than reassure the surgical team that it will “hopefully” wear off soon, you communicate up-front about the issue and decide how to proceed. Open, honest communication shows respect for the patient and the procedure above your ego. Always, always communicate with the team when something is not going as planned. Particularly as a trainee, you don’t know what you don’t know. The need to monitor muscle function in this case could be trivial, but it is likely to significantly impact surgical decision-making and should not be brushed off.

A recurrent theme among adverse events is poor communication. In our field, there are no small issues. It may feel awkward to speak up midway through a craniotomy to point out that the urinary catheter hasn’t produced urine in 2 hours. But it’s far worse to stay silent and let the issue fester for 8 hours—only to discover a dangerously distended bladder on the verge of rupture, all because of a simple, fixable kink in the catheter. Speaking up shows respect for the serious nature of our interventions, and it shows you put the patient first.