The Night I Became a Doctor

I graduated from medical school in mid-May, so, I have technically been a "Doctor" of medicine for 7 months.  However, when the first day of my internship rolled around, I didn't really feel like a doctor... I felt like a medical student who suddenly had an inordinately large amount of responsibility.  There's a reason we go into residency to be trained after medical school rather than immediately go right into practice:  We are not even close to being ready to treat patients on our own straight out of medical school.  For those of you reading this and wondering how many times a scared, brand new intern has taken care of them, or their family members, do not fear; we do have our hands held until we are ready to be autonomous.  However as internship goes on we are expected to, and we do learn fairly quickly to fly solo.  I want to recount the night that my training wheels truly fell off...

It was just another 30-hour call day in the Cardiac Intensive Care Unit... I strolled in at 6am with all of my patient notes pre-typed, my preliminary morning plan for each patient already thought out on my 5 minute walk to work, caffeinated sumatra running through my tired veins.  At 7am I had been rounding on my patients for about an hour... quickly going through routine checklists in my head in preparation for presenting information to our attending physician (tha boss, think Dr. Cox from Scrubs) by 8am.  The previous night's call team notified me that a new patient had come in that morning and as I was the intern on call I would be the one accepting the patient.  I quickly glanced over their information and recognized that they were the same person I had transferred out of the unit the day prior.  I had done so because I (and our team, head physician, etc.) had thought them to be stable enough to no longer require intensive care.  I was puzzled... and also worried.  Had I done something wrong?  Had I transferred them improperly?  Was their health now in danger because I rushed them out of the ICU before they were ready?  Did I forget to prescribe all of the proper medications on their transfer to the regular floor?  This was the first time I had felt this kind of worry and it churned my stomach.  I quickly dropped my morning routine and looked in their chart, flipping back to make sure I had done all of the transfer orders correctly, that my transfer summary for the accepting team had all of the necessary information for them to continue their care appropriately.  I could find nothing that I had done that would have put them in danger, and I told myself that I made the right decision, and at the time they were appropriate for transfer.  You can't always predict how people will do, especially patients as sick as this particular person.  I continued on with my morning routine, and while I was two rooms away, I glanced up at the huge monitor with everyone's EKG strips running by and theirs was incredibly erratic.  Their heart was in ventricular fibrillation, a heart rhythmn where the two large chambers of the heart that pump blood to the lungs to be oxygenated, and then the oxygenated blood to every organ system in the body, are pumping so quickly that they make virtually no force.  It is 100% fatal if the rhythmn is not fixed and fixed emergently.  Another physician and multiple nurses were already in front of their room and someone yelled, "We need a crash cart!"
I quickly moved to the room where a nurse was already doing chest compressions, and my senior resident was running the "code" (when a patient needs resuscitation of some form).  My body was so jacked up on adrenaline at this point that I felt like I could have lifted a car. I was also now very fearful that perhaps this was my fault.   I relieved the nurse doing compressions and started doing them myself. This was quite a large patient so I hopped up onto the bed on my knees crouched above them in order to get more force on my compressions.  I could feel their rib cage crunching as I pushed down deeply and then subsequently let the chest wall recoil... I had likely broken their ribs, and I knew it;  It felt awful.  All around me people were scurrying around, giving orders, pushing heart-restarting IV medications.  I had done chest compressions before as a medical student, but this was the first time as a physician that I was doing this on my patient that I had been taking care of.  As I was up on the bed, breaking my patient's ribs to keep their circulation going I almost felt like I wasn't in my own body because it all felt so surreal; Just 24 hours earlier I was chatting with this person about their pets, their significant other, how they were so excited just to go home even if they likely would die of heart failure within the year.  I liked this person, and we had built up a rapport.  And now, I was watching them die as we desperately attempted resuscitation.  They went in and out of fatal heart rhythmns for about 90 minutes... requiring multiple shocks, periodic chest compressions, and very high amounts of IV medications designed to keep the heart/circulation going.  I didn't think they would make it.  By the time we finally got them stablized my arms and shoulders were sore from the exhaustion of giving so many chest compressions.  We had to emergently send them for a procedure which would place a balloon pump just outside of the heart which would assist their circulation temporarily. 

While they were at the procedure, I was frantically looking at labs, chest x-rays, notes, etc. fearing that I had somehow made a mistake.  It turns out the patient had gotten an infection that night and it tipped their already very weak heart over the edge.  There was no way to predict this happening... It just... well... happend.  I was relieved after convincing myself I did not harm this person, but the bottom line was that they were now even sicker than before and it was again my job to get them well enough to leave the hospital.  Or was it?  The majority of "codes" do not end well, usually with the patient either expiring while suffering the discomfort of a tube shoved into their lungs, people breaking their ribs with chest compressions, being shocked multiple times (the amount of pain that a single shock creates was once described to me by a patient as "a mule kicking me in the chest"), or surviving only to suffer their last few days/weeks and never make it out of the hospital alive.  Should we do everything medically possible to keep this person alive with such a poor prognosis?  That is a discussion for its own blog post, but I felt it important to at least note the presence of this always existant delimma.  Eventually the family decided to not resuscitate with compressions/shocks if this were to be necessary again.

Once the patient returned to our unit from the procedure they were still barely hanging onto life, requiring a ventilator to help their lungs exchange oxygen with blood, a balloon pump and numerous medications to keep their heart pumping with enough pressure to circulate blood to the brain and vital organs, as well as many other intensive interventions.  I spent the next 24 hours micromanaging every aspect of this patient's care (while also covering the other 11 patients in the unit); their cardiac medication drip rates, the amount of blood to filter and remove from their body per hour to prevent fluid overload, ventilator settings, etc. I stayed up all night most likely annoying the nurses with my overly-detailed involvement in this particular person's care.  I was not going to let this patient die on my watch.  The nurses in the ICU are very knowledgable and often times make great suggestions for care that I listen to.  But this patient had highly complicated physiology and the nurses were questioning my decisions quite often; a lot of the management was counterintuitive when compared to simpler cases.  Three months prior I would have been swayed by this... I would have doubted myself, I would have called my senior at 3am and woken them up for help.  Not this time.  I never once had to call my senior resident for help.  I had this.  I stuck to my guns because I knew what I was doing, and I educated the nurses as to why we were doing things the way we were.  "Maybe you should call your resident?".  I politely acknowledged their suggestion and asked them to continue with the current plan.  They gave me that *I hope you know what you're doing, intern* look, but as the wee hours passed we all saw the improvement and they gained my trust.  I also began to trust myself.  I knew this patient was likely doomed no matter what we did, but I clung to every small victory as tightly as my patient was clinging to life.

I started to struggle to stay focused at around 4am.  I had been up for almost 24 hours and I still had about 9 to go.  People always ask how we as resident physicians make decisions that affect people's health after having been up for so long.  Honestly, sometimes I don't know how we do it either, but when there is a sick person in front of you, you wake up.  The things you might miss at 4am when sleep deprived are almost always minor and have very little effect on the overall care of the patient.  You don't miss the important things.  You just don't.  I decided to take a nap at 4, hoping to get about an hour or so of sleep before waking up to round on all of my other patients and finish any minor tasks on other patients in the unit before their doctors came in the morning. I laid down in the creaky twin bed, close enough to the ICU that I could still hear the ventilator alarms and cardiac monitors... not the best sleeping environment but I would've been happy with sleeping on the hard floor in the midle of the ICU at that point.  Within 20 minutes I was in twilight sleep and then my pager went off.  I turned to the edge of the bed like a zombie and picked up the phone to call the number back.  I used my fingers to feel the keypad on the phone and dial by feel so I wouldn't have to turn the light on.  "This is Dr. ___" I said sleepily, "Hey doctor... I'm sorry to disturb your sleep but you forgot to sign one of your orders." (Those are the kinds of things you forget to do at 4am).  I got up, put my white coat, shoes, and pagers back on and walked back into the unit to sign my order.  I was awake again.  So much for getting a nap.  The nurse sheepishly apologized for waking me again, likely having been subjected to a few unpleasant encounters with cranky sleep-deprived physicians she had paged at 4am before.  I told her it was fine and joked, "If those damned interns would just sign their orders..."  She laughed.   I wanted to throw my pager in the toilet, but it was my own fault for not signing the order.  I decided to use the extra time to pre-type some of my notes and organize all of the events over the last 24 hours that I would need to summarize with great precision and brevity to the attending physician.  At about 7am my senior resident, who had been sleeping one floor away, came into the workroom yawning and holding two cups of coffee, one he had bought for me, knowing I had been up all night micromanaging the unit while he peacefully slept for about 7 hours.  It was a thoughtful and very welcome gesture.  I updated him on all of the nights activities, most importantly our very sick patient who was not only still alive but had significantly improved clinically overnight.  His eyes lit up with a bit of surprise.  He said he was half-expecting them to pass overnight.  He was proud of me.  I am often quite hard on myself in my academic and professional endeavors, but I was actually quite proud of myself that morning.  I had run the unit and taken care of one of the sickest patients in the hospital all on my own, and I had done it well!  I still have so much to learn and know that I should never get in over my head, but this experience made me realize just how far I had come in the last 6 months.  It was a grueling call night, but I would never give up that experience for some extra sleep.  It made a man out of me and I will be a better clinician for it.  When the other interns/residents came into the ICU that morning, one of the interns asked, "How was your call last night?" I responded semi-sarcastically, "I think I became a doctor last night..."  He laughed knowingly. I savored the thought for a few moments before starting my morning routine again, still 6 hours from going home to sleep...