I went to his room because I wanted to watch one of the
other medical students use the ultrasound machine to place an IV. She was an EMS in her previous life and knew
things. I was a mere writer—a manipulator
of words, a translator for feelings.
I had met the patient before on rounds, but never spoken to
him. But, of course—instinctively--I
started to talk to him. It’s a miracle
really that I never got in trouble in elementary school for talking in class,
because chit-chat with strangers? I love it.
While my classmate meticulously gelled, wanded,
tourniqueted, and repeated the process with the ultrasound, I just stood there
and talked.
It was true that I was projecting my own discomfort with
needles onto the patient and trying to distract him from what was going to
happen, but I also found him to be genuinely interesting. I learned where he
had lived, how he ended up in DC, and why he was in politics. He was young and alert, unlike so many of our
other patients, and had a suspected underlying depression that he was
somaticizing.
The IV line finally got placed, his PCA was started, and
when I got back to the team room, I was surprised to hear the interns teasing
me after the resident reported that the two med. students were upstairs—one placing
and IV and the other charming the patient into calmness—a dynamic duo, they
said.
I was pleased that my innocuous chit-chat was interpreted positively, and was happy to go when the chief resident told me to come with her and
the other student when the patient became agitated when the IV infiltrated an
hour later. He was ready to sign out
AMA, the nurse said.
When we walked in, he was fully dressed, with his knapsack
over his shoulder. The resident sat down in a chair across from him, while the
other student and I stood awkwardly nearby.
There were no more chairs to sit in.
Then, it started.
Anger turned to frustration, which turned to tears. He wanted to just disconnect, he said. He begged for an IV line, or at least double
dose of the “mental pills” we had suggested.
Like a river that couldn’t be dammed, it was all rushing out—a lost job,
his mother’s death, his lack of social support in DC. He sat on that hospital bed and cried and
begged us to help him “disconnect.”
I know that feeling of wanting to disconnect well. I wanted to disconnect today too.
It started when we had our annoying morning meeting today,
followed by lunch meeting, where we were promised lunch, but not given lunch,
nor allowed to leave to buy lunch. So
then, I finally got to the team room with lunch circa 1:30 p.m. only to have my
attending want to come and talk to me about a note that I gave her last week
for feedback, which she didn’t read, but wanted to go over anyway. So, I had to stop eating (Have I mentioned
that I’m hypoglycemic, by the way? The
whole not eating thing is kind of a big deal), try to remember the patient
stats from last week without sounding stupid (Spoiler: It did not work!) and
then, resume eating. Then, one of the
interns told me that I don’t get there early enough to present my patient’s
vitals to her. Except, I get to the
hospital 2 ½ hours before we start rounding and only have one patient to
see. Then, when I present to the intern and ask her questions about why things happened or what the plan should be, she answers with, “I don’t really know” and I get
annihilated by the attending during rounds. So OK, I can
start coming 3 hours early if that’s what ass-kissing is involved in this
rotation, but it would be nice to also be taught things too.
The intern lecture was the crowning glory on an already
mediocre day and I wanted to disconnect from this day as soon as she walked
away. Heck, I’ve wanted to disconnect
from this rotation, from this existence that I’ve chosen, from all of the frustration
and regret that I have about the life sacrifices that medical school forces me
to make.
Had I had my makeup bag and glasses at The Lawyer’s, I would
have too. I would have gone to his
condo, slept in his bed, and woken up early up to go kiss this intern’s ass, as
long as I could disconnect from my real life for a night. I just wanted that one figurative PCA line
for 8 hours to help me disconnect. To
help me regain the strength to do it all again tomorrow.
It breaks my heart when patients are ashamed to say that
they feel sad or depressed or hopeless, because feeling those emotions that are
the very definition of being human. None
of us would be normal if we didn’t feel the lows, as distinctly as we feel the
highs. And, it’s OK to admit that sometimes
you’re not OK and need help.
Tomorrow, instead of sitting around the team room doing
nothing for the extra two and a half hours before rounds, I’m going to go sit
with this patient and tell him that.
12 comments:
Don't ask the intern what happened to the patient overnight. Ask the nurse. Ask the person the intern got signout from (if possible). That's where the intern is supposed to be getting her/his info from as well.
Be a better student: pretend that you're the ONLY ONE there to take care of the patient, to collect all the information, to do all the work, to come up with the assessment and plan yourself. What would you do? If you were the resident, what would the medical student do that would make your life easier/better? How would you respond if you were in there shoes?
OMDG- Yeah, I think the problem is that I don't know enough to answer those last questions. I usually don't even speak to the intern in the mornings...I check the vitals in the chart, go talk to the patient, talk to his wife, and then to the nurse. Then, my convos. with the intern goes something like,
Me: "So, the patient had v. tach. overnight. What do we do to treat that?"
Intern: "I don't know. I'm still learning too."
Today, she finally told me that I should ask the residents for help, because she really doesn't know how to add to my assessment, which is probably true.
I will probably just start asking the residents what the plan should be and bypass her.
I am not from the US but spent a few months there rotating so despite my inadequate exposure to the system I want to write to you about what I know because I love you.
A senior team member can make things very easy for you by telling you everything about what the attending 'really wants'. Only and only few seniors will do it voluntarily because they really want you to do well in front of the attending. Others will help you only if you ask. There are some others who like to see you going down each day in front of the attending.
It is really marvelous that you come in 2 hours before everyone else to pre-round. That intern is such a loser.
Your work will involve identifying the correct person to approach in each situation. And you will definitely learn this inquisitiveness by the end of this rotation.
I hope I do not come out sounding like an outsider pouring in opinions about something I should not.
Love you.
Doc V- Your comment is very much appreciated. I had a long venting session to The Lawyer after I wrote this and one of my frustrations behind what I wrote here is that everything on this rotation feels very disorganized and haphazard. Maybe that's just how clinical medicine is and I don't have enough experience to realize it yet, but I feel like I just don't know who to go to get help. Obviously, my clinical knowledge will improve with time and I won't have to hound the intern/residents about what the plan should be. Until then, I guess I need to get better at just hounding the internet to find out how I should be treating these patients. I guess part of me is also upset about that, because as much as I know that I just have to "figure it out," it seems like I could be doing what I do (meaning getting no guidance) as a volunteer or something.
RS -- You can look up what to do for v tach in either your IM pocket guide (Sabatine?) or on Up To Date or MD Consult. If you only have one patient and you're there 2.5 hours early, that should be plenty of time to do that. Then, if you have time, ask your senior if you can go over your presentation with him/her.
Oh also, at this stage, they probably don't really expect you to know what to do, they just want you to know what happened. So, "At 3AM patient had 20 seconds of v tach with was treated with XYZ, after which the night team did blah blah blah...." in the first part of your presentation.
I wrote a long comment and before I could post it I closed the window accidentally. Ah. But I am writing it again because I really like you and I am an 100% sure you would be an awesome doc and if I ever had to choose a doctor I would choose you.
The truth is that unfortunately everything depends on the team and the attending. Your current team just sucks. But, things will not always be the same... thankfully team changes every month.
Another truth is that Self-Learning is what is expected and highly appreciated by everyone. This is too much to ask from a budding MS3 but you will surely get used to it.
UpToDate and Google are the two things you should rely more on than anything else in this situation.
Also know that every attending is different and every attending has a way to approach his/her rounding. The type of questions they ask and what they expect from you while presentation, plan and discussion changes with every attending. Recognize the Attending's need and prepare accordingly.
After you are done pre-rounding ask yourself what Questions will the attending ask (depending on his style... some want a detailed exam findings etc.) and read up accordingly.
This is just a steep learning curve for you and things will be brighter with each passing week.
Best,
V
OMDG- You are totally right. I don't want to diminish the role that I am supposed to play by knowing my patient and knowing how to treat him/her. I just think that for information (including treatment) that is beyond the scope of what I would know or be able to look up, I should be able to get guidance from the intern. I know now that I need to do whatever is necessary to figure things out, even if that means going to the senior resident directly. I guess I was just trying to follow hierarchy, which is obviously not working in this situation!
Since I don't know anything about medicine (all those acronyms, totally over my head), so I'll keep this general. Any work environment should be all about the greater good and working as a team and all that great stuff, but there will always be politics. You could be perfect 99.999% of the time and someone will still manage to find that one flaw. That's a reflection on them, not you. From reading your blog, I know you will be a good doctor because you care. You care. And this may sound a little twisted, but I would much rather have a caring doctor than a perfect one.
Maybe it's different at your hospital, but the interns weren't expected to go over our presentations with us. That was what the more senior residents were supposed to do. The intern does not have the time, and as you've noted, often does not know. The senior is likely to be far more helpful to you. Just gather all the info you can to the best of your abilities (from the nurse, from the chart, from the vitals sheet, from the signout) write a practice soap note, and practice presenting it. Like I said, they don't really expect that you'll know what the plan is. What they want to see is that you can gather info, synthesize it, and present it in a cogent manner. It gets better over time. Obviously the more you know, the easier it is to present the relevant events/findings. As Dr. V said, it's a steep learning curve.
Your intern is a loser. If they don't know the answer, they should say, "I don't know; let's look it up together." The intern and resident are supposed to make you look good in front of the attending. When I was an MS3, one of my interns would have me practice my patient presentations by memory (no notes, including lab values) in front of him everyday before rounds. He said, "When you look good, I look good."
That sounds totally frustrating. Maybe they should have a refresher course already, like what medical assistant training online would do for nurses.
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