March 12, 2007
Student Scene
Ready? Aim and Fire Anyway
Shotgun.
If I had to summarize the first half of my intern year in one word, this would be it. No, it has nothing to do with riding in the front seat of a sports car (although sometimes, I wish it did). What I’m referring to is the rapid-fire, fly-by-the-seat-of-your-pants-but-cover-all-your-bases kind of medicine that I’ve learned to practice while admitting patients, taking overnight call, and handling emergencies. There isn’t much opportunity for pondering.
Photo by Graham Ramsay Nicole Martin |
On occasion, I’ve actually felt jealous of my medical students—they have virtually limitless time to read and think about their new patients’ diagnoses and management. I, on the other hand, invest most of my energy in keeping patients stable and comfortable overnight. These roles might not sound very different, but they are. Case in point: one of my third-year medical students worked up a patient with a very high calcium level. She was lethargic, and her cardiac rhythm strips from the ER had shown evidence of arrhythmia. The student read about her problem for hours and wrote an eloquent treatise of two single-spaced pages on the differential diagnosis for hypercalcemia. I cosigned his note, wrote orders for fluids and diuretics, and rooted for the patient to perk up. Fortunately, she turned around within a few days.
As the foot soldiers of the medical establishment, we interns have to assess and treat patients as efficiently as possible. This means that the classically taught methods of physical exam and differential diagnosis often go out the window. When I admit a patient at 3 a.m., my assessment can be summarized by the answers to three questions: 1) What is most likely wrong with this patient? 2) What could kill this patient overnight? 3) What could my attending criticize in the morning? I’ve become skilled at protecting my patients (and myself) from impending doom. For the lady with hypercalcemia, I didn’t have to figure out why her calcium was high that first night—I just had to know how to lower it.
On some level, it’s a shame that we have to work this way. Every physician has spent years acquiring vast quantities of knowledge and developing skills in complex thought. We all share a love of learning—if we didn’t, we would have had a tough time finishing medical school. It pains me to think how many questions I’ve asked myself this year that have gone unanswered because I didn’t have time to look up the data. In most cases, I forgot to look up the data because I got sidetracked.
When I do have time to sit down and read a journal article, my brain doesn’t work the same way it used to. It can only handle tables and bulleted phrases. At lectures, it’s a similar story. A PowerPoint slide with more than three lines is really pushing the limit. And whenever I hear the phrase “mouse model,” my eyes glaze over. I simply can’t retain information that’s not directly relevant to patient care. It’s hard for me to retain much of anything because I’m always thinking about the work I have to finish. During a busy workweek, I often long for my college days, when I was pagerless and free to read in a café for hours on end.
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For the lady with hypercalcemia, I didn’t have to figure out why her calcium was high that first night—I just had to know how to lower it. |
But as much as I’d like to slow the pace of my job at times, the most memorable moments are those that are punctuated with adrenaline. One morning during rounds a few months ago, a nurse ran into our conference room to deliver an urgent message: “Mr. Thompson is unresponsive.” He was an elderly patient with pneumonia and advanced Alzheimer’s disease. Our junior resident, another intern, and I ran to the patient’s room and found that he wouldn’t wake up, even if we shouted, shook him vigorously, or pinched him. His pulse, blood pressure, and oxygen level were normal. One of our medical students checked his medication book, and he hadn’t had any sedating drugs that morning. Could he have aspirated stomach contents into his lungs or had a massive stroke? We called for a chest X-ray and head CT, placed more IVs, drew blood, and remained generally puzzled while we waited for the results.
I took this opportunity to teach the students about the neurologic exam. “First, you try to rouse him with a loud voice. ‘Mr. Thompson, can you hear me?’” I shouted, several inches from his ear. “Then, you shake him while shouting.” I shook his shoulders, but he still wouldn’t open his eyes. “Now we need to try a painful stimulus. Let’s try pinching all four extremities.” I tried his right hand, then his right shoulder—nothing. The student did the same on the left. “OK, let’s go for the legs.” I grabbed a fold of skin on his right foot and twisted it.
“Aaaaaahhhhh!” he screamed, opening his eyes. The room erupted in peals of nervous laughter.
“Mr. Thompson, do you know where you are?” the resident asked.
“What’d you do that for?” he whined.
We never figured out what caused the episode—our STAT diagnostics were unrevealing. In the end, we thought it was related to the combination of infection and “poor substrate,” a catch phrase for chronic illness and immobility. A part of me will always wonder what really happened. Why did he become unresponsive at that particular time, after he’d already been in the hospital for two weeks? Was he just in a deep sleep? Was it a medication interaction? Did a portion of his lung collapse temporarily, then re-expand?
Regardless, I was happy because he was better. I had no idea what I was “treating” when I pinched him, but it worked. No PubMed search could have been any more satisfying. Even if internship has lowered my IQ a few points, in the end, I can’t complain.
The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
Copyright 2006 by the President and Fellows of Harvard College