Five milliliters from disaster
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FIVE MILLILITERS FROM DISASTER
The patient was screaming.
Not the controlled breathing of early labour. Not the managed
discomfort of someone working through contractions.
Full, desperate screaming. The kind that fills a labour room and
makes everyone tense.
She needed an epidural. Urgently.
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Everyone in the room wanted the same thing: get the epidural placed.
Stop the pain. Fast.
The obstetric team wanted it.
The patient's family wanted it.
I wanted it.
That urgency—that pressure to move quickly—is when mistakes happen.
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I was preparing my equipment.
For an epidural, I use two bowls:
Bowl 1: Povidone iodine—the brown antiseptic for cleaning the
patient's back.
Bowl 2: Saline—clear fluid I use to flush the epidural catheter
and identify the epidural space.
Standard setup. I've done this thousands of times.
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My assistant that day was new. Junior. This was one of her first
epidurals.
While I painted the patient's back with the brown antiseptic, she
was preparing the second bowl.
I finished the skin prep. Ready to place the epidural.
I reached for the second bowl—the one that should contain saline—
and drew up 5 milliliters into my syringe.
This syringe is critical. I use it to identify the epidural space—
a potential space around the spinal cord. The fluid I inject helps
me find that space. Once I'm in, any drug given there spreads to
all the nerve roots emerging from the spinal cord.
That's what provides pain relief.
That's also why injecting the wrong substance would be catastrophic.
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I loaded the syringe. Five milliliters of clear fluid.
I was about to insert the epidural needle.
And then my assistant said something:
"Doctor Shankar, that's spirit. I filled the bowl with spirit not saline. I thought you'd use it to clean her back again."
I stopped.
I looked at the syringe in my hand.
The second bowl didn't contain saline. It contained surgical spirit—
alcohol used for skin preparation. In my practice I never would have done that, but my assistant was new and well meaning.
If I'd injected 5 milliliters of alcohol into the epidural space,
the damage would have been devastating. Nerve injury. Permanent
neurological damage. Possibly paralysis.
All from 5 milliliters of the wrong fluid.
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I disposed of the syringe. Got a new one. Filled it with actual
saline from a sealed bottle.
Placed the epidural without incident.
The patient's pain stopped. She delivered safely.
She never knew how close we came.
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Here's what saved her:
My assistant was junior. New. Uncertain.
In that moment, she had every reason to stay silent:
→ I'm the senior doctor with decades of experience
→ She'd been working with me for weeks, not years
→ I seemed confident, ready to proceed
→ Everyone in the room wanted speed
→ Questioning me might make her look incompetent
→ Maybe I knew something she didn't
But she spoke up anyway. And she was honest.
Not because she was brave (though she was).
Because weeks earlier, I'd told her—and the entire team—something
specific:
"If you see anything that doesn't look right, speak up immediately.
I don't care how junior you are. I don't care if you think I already
know. Your job is to question. My job is to listen. No exceptions."
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That's the only reason she spoke up.
Not courage. Permission.
I'd explicitly told her that speaking up wasn't optional. It was
her responsibility.
And that made all the difference.
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This isn't just about operating rooms or labor wards.
It's about every environment where:
→ Junior people see problems senior people miss
→ Hierarchy creates silence
→ Speed creates pressure to skip verification
→ "Don't question the expert" is the unspoken rule
That's where disasters happen.
Not because people lack skill. Because they lack permission to
speak up.
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After that case, I changed how I brief new team members.
Now, on their first day, I don't just explain procedures.
I say this:
"You will see me about to make a mistake. Maybe not today. Maybe
not this month. But it will happen. And when it does, you have two
choices:
Stay silent because I'm senior and you're junior.
Or speak up because patient safety matters more than hierarchy.
If you stay silent and something goes wrong, we both failed. If
you speak up and I'm actually right, I'll thank you for double-
checking.
Your job isn't to assume I'm always right. Your job is to catch
errors—mine included."
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I also do something else:
I explicitly ask the most junior person in the room: "Do you
understand that this applies to you? If you see something wrong,
you speak up. That's not optional. That's your job."
Because if I don't say it directly to them, they assume hierarchy
means silence.
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We are always closer to disaster than we think.
The margin between "everything went fine" and "catastrophic error"
can be five milliliters of the wrong fluid.
One moment of distraction. One assumption. One person staying silent
when they should have spoken.
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The best teams aren't the ones where senior people never make
mistakes.
They're the ones where junior people feel not just empowered, but obligated
to speak up when they see something wrong.
Where "that doesn't look right" is met with "thank you for
noticing," not "don't question me."
Where psychological safety isn't a nice-to-have. It's the system.
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That junior assistant saved my patient from permanent neurological
damage.
Not because she was exceptional. Because the environment not just allowed, but required her to speak up.
And that's the system every team needs.
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Question for you:
Think about your team—your workplace, your projects, your
organization.
Does the most junior person feel safe pointing out when something
looks wrong?
Or do they assume "the senior person must know what they're doing"?
If you're not sure, that's your answer.
Hit reply and tell me: What would need to change for true
psychological safety to exist in your team?
I read every response.
—Dr. Anand Shankar
P.S. I'm working on something about communication under pressure—
stories and frameworks from 27 years in operating rooms. More on
that soon. For now, these weekly newsletters are where I share the
lessons.