Agraphia Medical Tragicomedy


Pulling The Trigger

One of our nurses just started nurse practitioner school and today was her first day seeing patients in her new role. She came back from her first patient's room and was completely paralyzed by fear.

"I think I want to check some bloodwork on him... but what if I'm wrong? What if he doesn't need it? What if the IV blows? Is it a waste of money? Oh my GOD I had no idea how much harder it is to pull the trigger when you're the one responsible! All the nurses are telling me I'm overreacting and he's fine, but what if I miss something? I've been a nurse for 10 years but I don't know what to do!"

She suddenly understood something that all practitioners realize during their first day - there is a huge difference between making a suggestion (should we check a CT?) and making a decision (we need to check a CT.) I even wrote a whole post back when I was an intern about a freakout I had about giving tylenol.

The weight of that responsibility rests with the physician, and it is both extremely stressful and extremely rewarding. After the fact, decisions are praised if correct, and second-guessed if wrong. It is easy to criticize both from the sidelines and through a retrospect-o-scope. The weight of those decisions - and the guilt when we chose incorrectly - are one of the main reasons we physicians earn our grey hairs.

For just this reason, I learned a long time ago to trust nurses when they are worried, but not to listen when they blow patients off. Just tonight I picked up on rib fractures in a drunk. "He's just an alcoholic," they said, "kick him out the door so he stops wasting everyone's time." He had shattered his entire left ribcage from a fall.

As an intern, I let a seasoned nurse sway me one shift and I didn't order a test I thought I needed. One of the best mentors I've ever had, who sadly passed away last year well before his time, caught the omission. We picked up what could have been a catastrophically disasterous illness.

When I beat myself up over the mistake, he stopped me. "Zac," he said, "all you have in this profession is your gut, your heart and your brain. Do what you think is right, every shift, every time, for every patient and you'll do right by them."

I've taken that to heart, and I to this day it's the best advice I've ever gotten. I passed it on to the NP student today.

"If you think he needs bloodwork, just pull the trigger and do what you think is right. Every shift, every patient."

Turns out, the bloodwork clinched the diagnosis. Having evaluated the guy myself I could have told her something was wrong, but I wanted her to learn to make the call. The glow of satisfaction on her face when the labwork came back abnormal was incredible.

RIP, John. Your passing has been an unbelieveable blow to our field. You are missed by your colleagues and all the young physicians who will never know what they have missed without your tutelage.

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  1. It’s good advice in medicine AND in the rest of life.

  2. Incredible quote from John. That is one I will have to save. Sorry for your loss Dr. Z.

  3. :) I love this blog post and I remember extremely well your blog post on freaking out about Tylenol. I think it was perhaps even the first time I was exposed to the American-versioned-word ‘Tylenol’ before. And I even remember well those initial starting thoughts you wrote on that post about how your parents had called you to ask you if you felt any different. :)

    Perhaps the reason why it has struck such a chord with me is that, I have been a medical student for such a long time (and I still have a year and a half to go YIKES!), that I guess reading your blog post (like you yourself said) is a peek into how the world on the other side feels like… and it must be extremely refreshing (in its own way) to think you have come back full circle only to land exactly where you started, but with more wisdom and more responsibility (didn’t we mention how growing up is a perpetual pain and there is no hope left for the future!? lol.).

    I’ve admired this quality in you of having a willingness to teach for a very long time. He sounded wonderful, and I hope I also meet my ‘John’ one day… hell, maybe if I’m *really* lucky, I can get to *be* that ‘John’ to someone some day. Who knows, maybe to that nurse, you are that ‘John’ to her! (I am sure you are)

    (Oh and unrelated side-note, damn you write well!! … or maybe it’s just my medical-reading-philia that takes over… either way!)

  4. Thank you.

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