Training Wheels Part 2

So I am going to continue where I left off a few weeks ago (sorry for the delay- I need to find time to write this every day, especially now that I saw the film Julie and Julia yesterday and I am convinced that blogs can make a difference in this world if written well and with a purpose).

Let me start with intern year. Now here is a secret about the first week of training that is rarely disclosed: Interns are terrified. Let's face it, 3 weeks ago they were medical students. Then, off come the training wheels and on comes one of the most grueling years in our training. It isn't the work hours that make the transition from medical school to internship so difficult, it's the sheer weight and responsibility of actually being responsible for human lives. OK, so there are attendings who ultimately are legally responsible, and fellows and residents who know more and can help- but at 2am, in those tiny rooms, when the blood pressure is rising and you don't know why- or the chest pain is getting worse- or breathing looks more labored- it's just you and the patient, and occasionally a nurse waiting for what to do next (and another secret is that he or she often knows the answer which the smart interns figure out early on). Let me share a few of these tense moments from my first 3 weeks of intern year to set the tone:

One morning in my second week as a doctor I was told that Mr. S was bleeding out his bottom. I ran to the bedside and indeed, there was a small pool of fresh red blood on the bed. I lifted the sheet and found that the catheter in his penis was gushing blood. Knowing that a balloon inflates to hold this catheter (called a Foley) in place, I asked the nurse to deflate the balloon, push the catheter in further and reinflate it. The gushing continued. I asked another nurse to call my resident and to call urology. But then I was stuck with 5 minutes alone with the patient and the nurse to try to make this better. "Do you want a 3 way?" She asked me. I had no idea what this meant other than the obvious bad joke. She must have seen me look perplexed because then she explained that a 3 way catheter had a larger lumen and could be used to flush the urethra and bladder. Within a few minutes she got this in, and with some irrigation we dulled the bleeding and allowed for the Urology team to come and evaluate my poor patient.

A week later I arrived to check on my patients at the usual 6am start time to find that one of my patients had shallow breathing and wasn't responding to me. I asked the nurse to call my resident and then stood petrified for a moment next to my patient. I froze. I did not know what to do next. I did not know where I was. I was panicking. Then, I remembered some basics and started to tell the 3 nurses who had gathered to help what to do. Someone needed to get a blood pressure. Someone needed to get an oxygen level. I needed to do an arterial blood gas which I had only seen done once and now was in the unfortunate position of NEEDING to do immediately. Minutes later, as I slowly poked around for the radial artery with a needle I remember thinking to myself, "You can do this. You HAVE to do this." And I will never forget how it felt to watch the blood fill that syringe, my heart pounding, sweat beading down my forehead.

Then, during my first night call in my second month of being a doctor, I was told that a patient had died and to come declare the patient dead. I had done this in medical school and knew the routine- listen to the heart, check some reflexes and for a pain response. What I did not prepare for what came next. As I entered the room, a woman sat at the end of the bed holding the patient's cold hand. On her lap was a four year old, crying. He had lost his father. She had lost her husband. And just like that I knew for the first time what being a doctor really meant. I chocked up. I fought back tears of my own as I placed my stethoscope delicately on the chest of the dead man. I fought back tears as I said "I'm so sorry for your loss" to this woman and her boy. I did feel sorry for them. I felt vacant, alone, afraid. I felt unworthy to be there. I felt that the world was not a fair place at that moment. And finally I felt privileged to have been a part of comforting them in any way. That was my role. Confirming his death confirmed something. There was no doubt. She knew that the hand she was holding wasn't just cold, it was dead. And that provided something for a woman who had sat by a man's side for 6 months as he died of cancer. He was gone and I was the person who told her so. And as hard as that was to hear, and to deliver, that was the beginning of mourning, and the end of dying, and that was a gift.

The stories go on and on. There was the time my patient peed on his roommate because he thought he was a urinal. We laughed for 15 minutes in the lounge after that. We had to laugh. There was the man who called me to his bedside to thank me before his breathing machine was discontinued. He requested my presence when he died and that was the biggest honor I ever received. There was the woman who claimed that her quadriplegic husband on a breathing machine who could not communicate with anyone could speak with her through his eyes. And no one believed her at first but slowly some of us began to wonder and finally I was convinced that they were having dialogues without words. And no matter what the story, I was learning. I was learning how to administer medications, do procedures, determine who was really sick and who wasn't from the doorway. And I was learning how to handle someone screaming in your face, and lying about prescriptions being lost, and how to comfort someone who was beaten by a person or by an illness. I was finally living up to the MD that came after my name.

Then, in a blink that takes forever, it's June- and the intern class sniffs emotional smelling salts and suddenly realizes that they are about to be residents. Many say that the transition in July after intern year is complete is the scariest moment of training. It was for me. Suddenly we were sitting through training sessions on how to teach, and floods of emails began to circulate on what to do when and how to manage 2 interns at once. Suddenly I needed to know the rules of the hospital as far as how admitting worked. The things I was protected from as an intern made themselves unbearably clear to me on the cusp of the transition and then, in a blur, in came new interns. This time I was the one being called for the scary situations. My backup was often my colleagues. Attendings weren't always on the floors. They weren't always easy to reach even by phone. Now the real challenge began: Did I know enough? Was I competent to keep people alive? Was I teaching the real lessons of being a doctor or just medial minutia?

The first time I saw feedback from my interns was one of the best days of my training. One July intern described being on my service as a "safe place. " That was my goal. That made me smile. But those late night calls made my heart race as I walked into a room. Now not only was nature playing its role in what had transpired, now the intern had something to do with it, too. On good days, good things were done. On bad days, anything was possible. And as many times as the interns heard: Don't act alone, get help- there wasn't always time. Once, in the ICU, an intern of mine let a patient slowly drop his blood pressure all night until he was critically low in the morning. No one had noticed because the incremental drops were so small. It took new eyes to see what had taken place. That was the day I realized my role as resident. I was to see, and to have others act based on what I was seeing. I was to teach based on those experiences. I was to be a guide, but to let interns make mistakes as long as they didn't do harm and learn from them. It was the toughest job I ever had and the most rewarding. To see the look on an intern's face when she made a diagnosis correctly and helped someone- that made my day. To hug an intern after he had to tell a family that their young father was dying- that was hard, and necessary.

Somewhere in there, between those long nights, crazy days, tears of joy and tears of sorrow- I earned my degree, awarded too soon in my opinion, before I knew what being a doctor meant and what being a doctor took. It took, after all, from my life at home and my life outside of home. It took my tan skin and turned it pale. It took good eating habits. It took well controlled acid reflux and made it out of control. It took all of the patience I could muster and then some. It took my happiness on many winter days. It took my positive outlook on everything on some days and squashed it. But what being a doctor gave back made up for all of it. And I knew it even though I suffered through it. And that dichotomy is medical training summed up. And that's what people need to know before signing up for it.