Tomorrow, I start being a doctor. I’ve had my MD for a couple weeks now - the stamped and signed diploma says so - but it’s not until I see my first patient and introduce myself as Dr. Zac that it will feel real for me.

My first shift is an overnight in the Pediatrics Emergency Department, which is anxiety provoking. I rarely saw pediatric ED cases at my medical school, so it’s pretty foreign to me. On top of which: it’s children. People outside the medical field are scared enough of what it means if their child has a fever. Me? I’m terrified. Because now I’m supposed to know.

I think we don’t give ourselves enough credit when the stakes are high. I’m sure I know more than I think I do - didn’t go to 4 years of medical school for nothing - but the thoughts keep intruding.

What if an unstable asthmatic comes in and I don’t know which drugs to order?

What if a kid comes in, confused and lethargic, and I don’t know if he has meningitis?

What if a 6 year old swallowed a nail?

What if?

We three emergency interns sat there, chuckling to ourselves. We were to be a team, tested on Advanced Cardiac Life Suppport together, and our group was a good one. We knew our algorithms and drug doses backward and forward.

The day had gone well so far; all 14 of us rowdy ER folks had been identified right off the bat by the nurses running the course, who laughed, “You all must be the emergency docs. Every year, we can always spot the emergency docs.” Too loud, having far too much fun for an ACLS course, rambunctious. Fun.

The group before us - 2 OB/GYNs and a GP - shamble out of the testing center. They had failed, and had to repeat the simulation. This was happening to a disturbingly large percentage of the groups leaving the sim labs. Not us. We knew our shit. Too cocky.

The three of us were ushered into the room. The scenario: Mr. Jones, a 56 year old male, presents to the Emergency Department for shortness of breath and chest pain. Cookie cutter ED stuff, but we knew that the simulation was set up so he would rapidly decompensate. Advanced lifesaving measures would be required.

A voice overhead, “The simulation is commencing.”

We looked at each other, suddenly nervous from the utter unfamiliarity of the testing center, a perfectly simulated hospital room down to the sheets on the bed. We hadn’t been tested here before. The realization sinks in that none of us have ever given orders in our lives.

I fool around for 2 minutes trying to figure out how to get the monitor to display blood pressures and the cardiac rhythm. Without these and a few other critical vital signs, we’ll never know how to proceed.

Dr. A goes to introduce himself to the “patient” - a million-dollar state of the art mannekin - and asks what’s wrong. A groan issues from Mr. Jones. This isn’t good. His pulse is weak and rapid. We crowd around the monitor, tapping buttons and fiddling with wires. Precious time is lost.

We stand, each working haphazardly. The patient is in ventricular tachycardia. Algorithms temporarily forgotten, we debate. Do we shock or give drugs? What’s more critical, heart or lungs? More time is lost. The patient, previously ill, is now dying as fast as he can.

The decision is made to put him on a ventilator. Oxygen levels have been dropping and he is unconscious. Dr. E prepares his equipment and we spend another few minutes trying to find the drugs we need to paralyze the patient prior to the procedure.

The procedure is hard, almost impossible. 8 of our 10 minutes have gone by and we have idly sat by doing nothing. Dr. A and I watch Dr. E sweat through the intubation, offering advice.

The horrible “BEEEEEEEEEEEEEEEEEEP” of flatline issues from the cardiac monitor. We’ve killed Mr. Jones.

“Doctors, you may leave the room,” a disembodied voice informs us, “we will perform remedial testing in 30 minutes.”

We shuffle out of the room, heads hung low. Added to the shame of failing at our chosen specialty was the horrible feeling that we just killed someone. It was just a mannekin, sure, but those 10 minutes felt all too real.

===

We spent our 30 minutes figuring out what went wrong. I think I grew up more in that half hour than I have in the past year. I am not comfortable wearing my doctor shoes but like it or not, I’m wearing them now. Why didn’t anything get done in that simulation? Because we all waited to be told what to do.

Who am I to tell a nurse who has been working 20 years that I want things done my way? I only received my medical diploma in the mail a week ago. And yet, if I don’t tell that nurse what to do… it won’t happen. This is, in fact, the career I have chosen. To give orders, not to follow them. I need to get comfortable with that. And I need to be ok with the fact that I am a doctor.

===

We draw straws. Dr. E is going to lead the code. Dr. A and I will act as his assistants. The code starts. Dr. E methodically works through the algorithm. A-B-C. IV-Oxygen-Monitor. Ventricular tachycardia.

It runs like clockwork, Dr. E truly acting like a doctor. I’m proud of him. I follow my orders, giving advice when he asks what the next step is. The final decision is his.

We lose a pulse, but we know what to do. Dr. E asks me to commence CPR while he fires up the paddles. The simulation is fake but the defibrillator is real - when he calls “CLEAR” we stand back. A shock is delivered. A few more cycles of CPR and suddenly we feel a pulse.

The voice, from overhead, “Congratulations, Doctors. You are now certified in Advanced Cardiac Life Support.”

It’s 3:30AM and I can’t sleep. I’ve been studying Acute Cardiac Life Support all day, and the reality that I am the doctor now is slowly sinking in.

I’ve been through ACLS training once before, but I was a medical student and I knew there would always be a real doctor to watch my back. There still is, of course - upper level residents and attendings - but when push comes to shove, if a busy night comes, I’ll be on my own.

Tossing and turning in bed, I can’t help but run through the scenario of a decompensating, tachycardic patient. This particular case is the scariest for me, because it takes the most thought under pressure - something I think I’m good at - but amidst the new city, new hospital, new title, new people, it may be overwhelming.

Mentally I call the code, my team members at the bedside. I’m sweating through my sheets but I’m still trying to keep my cool, imaginary eyes on me as I call the shots.

“Paul, Kelley, I need you to establish IV’s please.”
“Eric, on airway, we need to get him oxygenated.”
“Britt, he needs to be on cardiac monitors.”
“Laura, blood pressure is dropping, be ready for defibrillation.”

I know the drill, I hope. But in that nebulous half-dream state, I can’t remember. Do you shock with 120 kJ or 300? Monophasic or biphasic? My team of nurses will have been through this time and time again, will know the steps, the doses, the outcomes by heart. They will be there to have my back. Thank god for that.

My heart is pounding but externally I hope I appear calm and confident. My patient is tachycardic and I don’t know what’s wrong, although it’s my own subconscious that set up the scenario. The thought that this person might actually die is terrifying and I freeze, unwilling to call out an order that I’m unsure of.

I pop up from the bed, sheets drenched. The humidity is stifling, and my fan is doing no good. I trundle off to the kitchen for a glass of water. I sit in front of the computer, typing this post in the eerie glare of my laptop. It’s time for bed. It’ll all be fine.

It’s a bittersweet thing, moving away from your friends and your life of the last 4 years. More bitter than sweet, because it’s easy to reminisce about the good times you’ve lost than the good times you’ll have. I said goodbye to a lot of friends tonight, and it’s hard to avoid the “lasts” that inevitably crop up; the last time I’ll pop down to No Anchovies for a quick slice; the last night I’ll spend in this room; the last time I will hug and laugh with many of my friends.

It’s fitting, I suppose, that scavenging through the fridge for one last beer before I tuck in, the only one left is my favorite local microbrew. Maybe not the last time I’ll have this beer, but certainly the last for a while. I savor the taste as the malt and carbonation slowly wind down my throat.

I’ll truly miss this town. I grew up here - a quick jaunt out to Pennsylvania for college - but I’ve been a local most of my life. I hated it here in high school (who doesn’t?) but medical school has been wonderful. Fantastic friends, easy weather, great food, wonderful teachers, good life.

It’s time to leave, though. Time to spread my wings at least one more time, tear myself out of my comfort zone, and start life anew. This time I’ll be asked to do things that are far beyond my abilities. I’ll make mistakes, struggle, laugh, cry, learn, and still come out the other side better, wiser, and happier - as I am now after 4 years of medical school. I can’t wait for the future, but I will cherish the past.

To all my friends, my family, and my town, I will miss you dearly. Please come visit. You’ll forever be in my heart.

Alright, everyone, the moment you’ve been waiting for…

I’M A DOCTOR!!!

For your viewing pleasure, here’s the video we made for our graduation.

:: Like A Doc ::

It’s a spoof off the original SNL skit Like A Boss, so if you haven’t seen that, watch it first.

- Dr. Zac