Agraphia Medical Tragicomedy

2Jul/10Off

End Of An Era

And like that, it's finished.  No fanfare, no awards.  Walk out of the hospital one day an intern, return the next a resident.

My parents called to ask if it felt any different.  To my surprise, I answered, "yes... it kind of does."

Countless books have been written about intern year.  Every physician gets a bit misty-eyed when thinking back to the nascent, formative moments of their career.  Medical students peer forward, trying to pierce that impenetrable veil of transition from student to doctor.

The difference between an intern and a fourth year medical student is simply the M.D. behind their name.  But, of course, that's everything.  Someone has accredited an intern to make decisions about patient care.  An order for a CT scan will result in the same scan, no matter whether an intern, resident, or attending authorized it, but no medical student can give that order.

Exactly one year ago, on my first night on call as an intern, I got a call from a nurse for the simplest of things.  "Doctor," she said, "your patient in bed six has a fever of 102.4, and there is no Tylenol ordered.  Can I give him some?"

I panicked. Tylenol is the oldest of drugs.  Parents give it to their kids like candy.  There are elixer, flavor, chew tab, and extra strength variants.   It has countless brand names across the world.  I was a doctor now, and I should know the answer.  Just a simple Tylenol order.  And yet.

In a patient with liver failure, Tylenol can be lethal.  The primary team didn't think there were going to be any problems with this patient overnight, and suddenly I was presented with a fever.  Fevers in the hospital setting are often the harbinger of massive bacterial infections, lethal blood clots, wound infections, sepsis from urinary tract infections, and so on.  A simple order for Tylenol... well, it's not so simple.

I sprung out of bed, hair mussed, wild eyed, heart racing.  The patient was sleeping, but I woke him up and grilled him for 10 minutes to make sure he felt alright.  Gruffly he responded, "well, I was doing just fine until you woke me up!"  I pored over the chart, trying to comprehend his care, his underlying pathology.  He was postoperative from an appendectomy.  Nervously, I reasoned that his fevers were from atelectasis, a common and benign cause of postop fevers, and ordered the tylenol.

What if I was wrong?  What if it was infection?  What if lying in the bed had caused clots to form in his legs, rocketing off and wedging themselves in his lungs?  I went back to my call room and laid awake for hours, exhausted, the dim blue glow of the computer suffusing the room with bits of the electronic medical record.

In the morning, I called the primary team to let them know I had given tylenol to their patient overnight.  "Cool, man, thanks, he probably just had atelectasis," said the resident.  In a single moment, a night of agony validated and dismissed.

I soon learned that with experience, confidence builds.  With every mistake identified, every correct decision confirmed, I grew as a physician.  4,000 hours spent in the hospital, 80 hours a week, 50 weeks a year.  Bathed in the milieu of medicine day in, day out.

And at the end of it, one step up the ladder.  One layer of supervision, peeled away.  One more level of scrubs asking me the questions. One year of training down.

I saw a new intern walking into the hospital on her first day as a doctor this morning, uncomfortable in her starched new white coat, the hospital logo emblazoned proudly on her sleeve.  She kept grabbing at the pockets, adjusting her stethoscope, buttoning and unbuttoning, checking her pens.  Nervous, but deathly afraid to show it.  I remember that feeling well.

"Morning!" I greeted her, cheerfully, "You excited?"

"Yeah..." she allowed.

"It's going to be a fantastic year, " I assured her.  "Come find me if you have any questions."

Comments (9) Trackbacks (3)
  1. Congratulations! I’ve enjoyed following your journey. Just finished my 10th day of internship. 355 more to go. :-)

  2. Congratulations! Your experience makes me excited (for the most part) about future medical prospects!

  3. Wow. I can’t believe it. You are no longer an intern, the fourth years are now MDs, and in one year I will have the tylenol freak out. Scary! Congrats!!!

  4. Congratulations.
    I’ve enjoyed your blog since the beginning – good to know you’ve made it this far still (mostly) intact…

    Thanks and Salutations to you.

  5. stumbled upon your blog, read the whole thing from the beginning! congrats, you’re a fantastic writer and becoming a fantastic MD. I’m a lowly premed now, and I loved reading the good, bad, and ugly of your experiences through med school. Lots of great advice in here, including how to select a cadaver!

  6. Atelectasis does not cause fever. This is one of the most long standing medical myths. Your patient had a fever.

    http://chestjournal.chestpubs.org/content/107/1/81.full.pdf

  7. While I don’t disagree with you, that study is from 1995, consists of 100 patients, only covers two days, and is only postop cardiac. Debunk medical myths with more data next time :)

    Fortunately, I’m no longer on a surgical rotation so this will never affect me again!

  8. Congrats by the way!

  9. Hey there just wanted to give you a quick heads up.
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