Agraphia Medical Tragicomedy

7Sep/11Off

Changing Roles

I'm really enjoying being a senior resident.  This month I'm mentoring our medical students, and it's been loads of fun so far.

Today we had a "simple" laceration that needed closing.  Typically this is the medical student's job, since the residents have traumas and coding patients to take care of.  I sent Medical Student to sew up the lac, but two minutes later he came out of the room, pale-faced and nervous.

"Dr. Zac... I took off this guy's pressure dressing and he's kind of... bleeding out from his wound.  Like, sort of spurting blood. Kind of everywhere. I think I need help."

I'm a pretty laid-back guy, but years of emergency training have instilled a GO switch in me.  I immediately popped in the room.  Sure enough, this guy was hemorrhaging blood from multiple severed arteries in his leg.  I grabbed Med Student's gloved hand and shoved it in the wound.

"You feel where that's pulsing?  I want you to keep your fingers right there and hold pressure.  I'll be right back."

There are varying degrees of emergency; this is one that can be fatal if left unchecked.  I ran out of the room, grabbing the necessary equipment and sutures.  Med Student seemed quite relieved when I returned.  Quickly I tied off the bleeding arteries while explaining what I was doing (throw your stitch under the artery, loop back around again, and tie it off.  This is called a figure-of-eight suture and it will save your ass in a pinch).  Within a minute I had the bleeding stopped.  Med Student appeared impressed.

Suddenly, it was a simple laceration repair again.  I supervised him closing the wound with little teaching points along the way, and to his credit, he did a fantastic job.  It will look great when it heals.

The patient's wife pulled me aside later.  "Doc, you really seem like a fantastic teacher.  We were both so reassured that you were there. Thank you so much for taking such great care of us!"

It was a great day, and it's been a wonderful month so far.  If the rest of my life is like this, I'll be a very happy physician.

30Jun/11Off

Big Fish In A Little Pond

And like that, a year has passed.

I'm officially a senior resident.  It may seem an arbitrary milestone - leave the hospital a second year resident, return as a senior - but the changes are easy to see.

During my shift today, I placed a central line in a matter of seconds; the first one I ever did took an hour and a half.  I casually transfused a trauma victim two pints of blood while on the phone with a consultant.  I coached a family through their mother's catastrophic brain bleed, answering their questions and initiating palliative care.  A man's heart stopped beating - twice - and I restarted it.  Another patient went into flash pulmonary edema and I prevented him from drowning in his own secretions.

It was a good day.  It's been a excellent year.  I'm excited to see what happens next... I love this job.

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."

23Jan/09Off

The Decision

After my interview I head back to the hotel, change into more comfortable clothes, and take a stroll around town. Street jazz bands play while the warm breeze gently caresses the city. People take it slow down here in the South. Today during the interview a woman stopped our group, "Y'all should know I'm the survivor of a pul-mow-nary em-bow-luss. Thanks to God Almighty and to y'all wonderful doctors, I'm still here today to speak with you. God bless". And she continued upon her way, a smile on her face.

An Irish pub with cheap Guinness beckons, and I sit at the bar with a few NASCAR fans. One offers me some chicken tenders, which I politely decline. Eventually the conversation turns round to jobs. The guy next to me, Budweiser in hand, with a flannel shirt and a trucker hat, speaks up.

"So, buddy. What brings you all the way out here from the southwest?"

Slowly, drinking my beer, I reply. "ER residency, actually. Your hospital out here is one of the best in the nation."

"Now, that's a job I can respect. Me, I roof houses." He pauses, catching a quick glance at the cars flying around the track. "You seen people die? And there ain't nothin' you can do about it?"

"Yep," I reply, "it can be pretty rough."

"So what makes it worthwhile? I think I'd up and quit the first time someone died on me."

I pause. This is the most honest question I've gotten on the interview trail, and it isn't from an attending, a resident, or a program director.

"I suppose," I slowly say, "I suppose it's when you can help people that makes it all worthwhile. When you can look someone in the eye and tell them they'll be ok."

He smiles quietly, as though I said just what he expected to hear from a doctor in the making. I smile too. We clink glasses and toast, then sit back and watch the cars race around the track in comfortable silence. This is a good place for me.