Rules of Intern Year.

10 Rules of Intern Year

1. Show up.

2. Do your best.

3. Listen to the nurses. 

4. Don’t lie.

5. Put the patient first. 

6. Do fun stuff when you’re off.

7. Cry when you need to. 

8. Laugh out loud when you need to.

9. Eat lunch and take the stairs. 

10. Care like it’s yo’ mama.

July 1. One day down, 364 to go. You’ve got this, interns. And we’ve got you. Let’s get it! 👊🏽🏥 #gohardest #bespecial #carelikeitsyomama #youarereadierthanyouthink

We got this.

Emory SOM '15 alumni on July 1, 2015

July 1 equals new interns. Fresh young faces straight out of medical school stampeding teaching hospitals all over the land. Sounds scary, right? But honestly, it isn't like you think.

Nope.

Their faces may look nervous but I've been doing this long enough to know that these young doctors are ready. Ready to step in and save your life. And if it makes you feel better to know that we are standing right beside them with our arms out now that the training wheels are off, know that we are. Our eyes ever watchful and encouraging, our examples offered with even more intention. Which creates this reciprocating engine of growth for us, the teachers, too. Year after year after year.

How cool is that?

Under the weather? Have no fear. We got this. All of us.

Yup.

***
Happy July 1.

Full Circle: Intern Year Check In.

Okay. I am having a bit of writer's block-ito. So here's a lovely check in from my class of 2011 student advisees who are all hard at work in their internships. (Antoinette is missing from this post--she is graduating this year and starts internship next year! Stay tuned for match day -- coming up this week!!)

And away we go. . . .

Sweet Alanna hard at work in San Francisco. That smile on her face? It's because she's doing something she's been waiting a long time to do.

Well. Talk about full circle. Dougie happens to be an intern on my team this month and let me tell you. . .it's an interesting experience. I liken it to having your own son. . or rather nephew. . .on your team for a month. Weird. . .but in a good way.

Man. Remember when I went to his wedding and cried like a baby? Man. Seems like yesterday.

See, I've known Doug since his very first day of medical school. I mean from the very, very first day. Hell, I've known all of them since then. But this month I'm literally his attending. And he is my intern. So this is kind of crazy for me to see.

Crazy, yes.

But also? Majorly pride-inducing. He is a kick-ass intern and you know? I can't even front like I don't feel like I had something to do with that. Ha! Mostly I'm proud to see him growing up. I'm more proud of that than of me for being there for the ride.

Hreemy! Oh, how I miss her! Chicago seems to be treating her well. I'm so glad I will officially have an ophthalmologist in the family. Lord knows with these eyes I need it!

She passed through town a few weeks ago and we had breakfast. I'm so glad that with one day in town she wanted to meet with me. That was really touching to me.

Jin sent this super funny snap this week of her on call. Looks like she was well stocked up on caffeine! I just hope she had a catheter in her bladder, too! :)  Jin is up in D.C. taking care of America's heroes. She's as awesome as she looks in this picture.

Yes. Tony is as funny as he seems on this picture. I wish I could copy and paste some of the hilarious and tearjerking emails and messages he has sent me chronicling his internship so far. It's just too much to put here. But let me tell you-- he calls me and writes me and he shares those moments on my voice and e- mail. And I deeply appreciate it that he does.

And this guy. Sigh. I've always called him Sparky (a nickname he got after a particularly . . .interesting. . .haircut he once arrived at small group with) but the name has stuck. At least for me. He is the most stoic of my group but has always been the one who could make me cry on the drop of a dime.

Case in point:

*clutching chest*

And this is why I have the very best job in the entire world. Yes, I do.

***
Happy Sunday.


Bonus snap:  Me and fellow Grady doctor Danielle J. in a pic taken today-- after working at Grady all weekend! We are pouting but right before this photo we were both talking about how awesome it is to watch our learners grow.

(By the way:  I met Danielle J. on her first day of internship. And. I was her ward attending during her residency. Now here we are as colleagues pseudo-lamenting about working on a cloudless weekend in Atlanta. )

They got next.

image credit

Words to describe my first day of medical internship on June 24, 1996:

Fear.

Nervousness.

Angst.

Doubt.

Excitement.

Anticipation.

Awe.

Funny. Not much different than how I feel about our interns first day today. . . .

. . . or how I still feel almost every day.

***

Happy First Day of Internship.

Four sticks.

*names, details, etc. changed to protect anonymity. . . you know the deal.

image credit

_________________________________________
Middle-of-the-night, Pediatric Ward - Internship 1997.

"I just wanted to go over the procedure before we do it, okay?"

She nodded quickly as she sat in the bedside chair next to the empty bassinet. Her youngish face was pretty, even without makeup. The over sized sweatshirt that she wore clearly belonged to someone else; her tightly folded arms were lost inside of it, barely offering a glimpse of her trembling fingertips. Two moments later, a man came scurrying inside with car keys jingling in his hands.

"Hey. . ." He looked at her first, immediately grazing her cheek with his lips. Then he faced me, fully alert. All business.

"Honey, this is Dr. Draper. She was just about to tell us about the procedure. You know. . .for the fever."

He gingerly sat down next to his wife but kept his eyes focused on me. With a tight-lipped smile he raised his eyebrows and gestured for me to carry on.

I nervously shifted the three pagers clipped onto my lopsided scrub pants and cleared my throat.

"Hi, sir," I extended my hand to introduce myself. My hand is shaking. Why is my hand shaking? Relax. This is a straightforward procedure. We do this all the time. Poke out your chest. Look confident like your resident always looks.

I cleared my throat to fight of my building nerves. "Okay. So the thing, I mean, the procedure that we are going to do on baby Jasmin is called a lumbar puncture. Have you ever heard of that?"

They looked at each other for a moment and then back at me. He spoke first, but more to her than me.

"Kind of like when you had the epidural, I'm thinking?"

"That's what I was going to say," she added.

"Umm, well yeah. . .it's kind of like that. Since she has a fever, we need to get a sample of the fluid that bathes her brain. . ." I realized that this sounded kind of macabre, so decided to revise that statement. "Since she has a fever and she's less than a month old, we like to exclude all kinds of infections. We check the blood, the urine, do a chest x-ray, and then we also look at the spinal fluid. Just to be, you know, safe. We start the antibiotics and send all of these tests to the lab to see if there are any germs that could be causing a serious infection."

"So this is why she needs the . . .what did you call it?"

"Lumbar puncture or spinal tap," I answered the father. "To make sure everything is okay. If no germs grow, we will be a lot less worried."

"So . . . .is it. . .does it hurt her? This test?" the mom queried. "Like, should I be in there with her?"

I internally recoiled at the thought of this worried mother being present as we folded her firstborn child into a fetal position. I saw my wobbly intern hands trying to obtain a sample of spinal fluid and shuddered, hoping they didn't catch it. "Um, well. . .you. . .well, usually we would just have you wait, you know, here in the room."

"How big is the needle they use?" the Dad asked.

I hated these kinds of questions. There was never a right answer or an answer that I felt was authentic. I was thinking, It's a big ass hollow needle with another smaller needle inside of it. But I didn't say that. Instead I simply said, "The spinal needles are special ones for this type of procedure. The ones for grown ups are pretty large, but the one we are using for Jasmin is the smallest one we have available." There. That wasn't so bad. Even if I never answered his question.

Dad rubbed Mom's shoulder and kissed her hard on the side of the forehead. Her nose was red on the edges. She looked like she was going to cry.

"We need to have you sign this consent form before the lumbar puncture, okay?" I slid the sheet over to them on top of the nearby tray table. "There is a very, very tiny risk of infection, uhh, bleeding, and. . yeah. . .mostly those things but it is really, really rare." Based upon my extensive experience. Um, yeah.

They both just sat there staring at the paper with all of that tiny writing on it. Finally, Mom took a pen from her purse and scrawled her signature across the bottom of the page. I wish I could say I felt anything more than relief. Relief that this would be moving on along and that I didn't have to page my upper level resident. Relief that she had signed the consent and especially relief that she wasn't demanding that she be there while it was taking place.

I know. That's terrible, right? I mean, how could even I admit that? How dare I? But the thing is. . . . it was true. I was more than half way through my combined Internal Medicine and Pediatrics internship at this point and I had spent more than nine months trotting behind an upper level resident and working obscene hours. The senior residents had the added complexity of supervision; backing up every failed procedure and emergency and being the one who told their haggard interns to "go ahead home" long before they could. What that means is that my main role models were often emotionally and physically exhausted, so they taught me to value things like efficiency, persuasiveness, and pseudo-confidence.

So that's why I felt relieved. It meant that I would be able to get into that treatment room quicker. That I would get a chance to "get" the L.P. on this baby. And just maybe, if I was able to do it in "one stick" and if the lab reported that the fluid was free of so much as a trace of red or white blood cells, I'd get a three A.M. high five from my senior resident--and a cold ginger ale from the patient nutrition room in celebration of my "champagne tap."

I peeled myself away from that room with those worried parents and then into a pair of sterile gloves, size six-and-a-half. As my senior sat nearby on a stool while eating a bag of microwave popcorn, I coached away the tremor in my right hand before starting. I made eye contact with the nurse who was helping me by holding baby Jasmin in position.

"You ready, hon?" the nurse asked me while tightening her grip around Jasmin's lower legs and nape of neck.

"Okay. I'm ready," I said.

And then, after numbing Jasmin with anesthetic, I commenced to advance the spinal needle into Jasmin's three week old vertebral space. With my resident coaching me from his perch, I forwarded it until I met resistance.

"Pull it back and go up a little. You have to kind of head for the head a little bit," he smacked. Pulling a grease covered hand from his popcorn bag he demonstrated the "proper" technique in the air for me while squinting his eye for effect.

So I tried again. And again. And again. Until finally, my resident was forced to dust of his salty hands, wash them, and then put on his own pair of sterile gloves. Eventually, he pulled out that inner needle and clear spinal fluid dripped from Jasmin's tiny back. I then took his place, collecting four separate tubes of the water like liquid to send to the lab.

The nurse strategically placed one band-aid over the four tiny puncture wounds just above her gluteal cleft. One bandage for the four "sticks" that Jasmin endured.

I still remember following my resident out of that room and to the nurses' station where he went right on chomping on those kernels while dictating how I should label the specimen. The main thing I felt was disappointment with "not getting it"--that is, needing to have the upper level step in and successfully complete the procedure. Not so much as a thought about the fact that somebody's baby just had just gotten stuck repeatedly in her back. That was my concern--not Jasmin. So much for that high five and that ginger ale toast.

Jasmin was handed back to her parents swaddled tightly; she had fallen fast a sleep after her marathon of high pitched crying from being held into a jackknife position by a nurse vice grip and being prodded with a needle. Four times. Mom and Dad hugged her and kissed her. And later thanked us even. They were none the wiser.

After that, we went to go eat the Chinese food that the medical student had squared up during our jaunt in the procedure room. I'm pretty sure we didn't speak much of Jasmin again. That is, with the exception of a reference to her being unusually chubby for a three-week old, explaining why "maybe you found it tough to feel your landmarks."

Yeah.

Today Zachary was playing "hide and seek" without notifying us that we were supposed to be seeking. He was crouched under a blanket on the bedroom floor, and my two hundred-plus pound husband unknowingly stepped right on top of him causing him to let out a high pitched yelp. As soon as Harry realized what happened, he quickly scooped crying Zachary up rubbing his face and repeatedly kissing the tiny finger that he'd trapped beneath his shoe. I scooted beside them on the couch and joined into the consolation. We both hate seeing either of our children in pain.

That's what got me thinking of Jasmin.

Today I am reflecting on how different my perspective has become on caring for human beings now that I have children. I feel sad when I think of how often during my training we habitually depersonalized ourselves from our patients; especially during procedures. I'm not saying that we didn't care. We did care. But somehow the culture during those days of unmonitored duty hours led many of us to operate outside of ourselves; going through the motions when we were tired and compartmentalizing the people from the procedures. Even children.

I have cried on more than one occasion while watching my kids get immunizations. When I imagine those parents and their worried faces, and then when I recall how easy it was to separate them and Jasmin from that lumbar puncture. . . . I cringe. I cringe even more when I recall the countless other Jasmin's I encountered along the way. I'm ashamed of that to this day.

Oh, and that horrible consent process I subjected them to? Uggh. That's an entirely different and equally disturbing story for another time.

All I can say now is that I am really happy that this part of medical training has evolved. A lot more time is spent humanizing our patients and respecting them as people more than objects. I recently read this reflection written by a current Pediatric resident blogger and knew it for sure.

And thank goodness for that.

Yeah. Zachary's smushed finger ended up being fine. But I still wonder how those parents felt when they took off that band-aid and saw those four needle marks on Jasmin's back.

***

My baby: Puts a lot into perspective.

Culture Club.

"Do you really want to hurt me?

Do you really want to make me cry?

Do you really want to hurt me?

Do you really want to make me cry?"

~ Culture Club

_____________________________________________________

When I was a resident, we weren't always so professional. In fact, oftentimes, we were downright unprofessional. I mean, we cared about our patients and did everything to keep them alive. But back then, pre-duty hours reform, we worked obscenely heinous hours. And on top of that, the whole "professionalism" and "humanism" movement hadn't quite hit yet. Every now and then, I remember some of the things I heard, said, or to which I didn't object--and I cringe. No--first, I shudder, and then I totally cringe.

Today, I am reflecting on knowing better and doing better.

There was a middle school kid who was emergently rushed into our Pediatric Intensive Care Unit during my PICU rotation as a second year Med/Peds resident. My team that month consisted of a third year Pediatrics senior resident, who took call with me. There was one other junior/senior team, and a nurse practitioner there that month, too. Supervising us all was our attending and a Pediatric Intensive Care Fellow.

This particular day, my team was the one on call, so we admitted that seventh grade boy.

What I remember is that he had deliberately drank a few swallows of Liquid Drano because he was mad at his mother. It unfortunately liquified his esophagus, and nearly killed him. It remains one of the most awful things I have ever seen in clinical practice.

My upper level and I cared for that child all month long. And he was so, so sick. Reconstructive surgeries. Setbacks. Total parenteral nutrition. Back to the OR. Infections. Adhesions. Back to the OR. It was terrible.

But now that I am older, I remember some other parts of that month and those times. If I close my eyes, I can even feel the culture we were in back then . . . .sigh. . . .and it wasn't always good. Humor was our pressure release valve, and we released pressure a lot that month.

Me as a second year, but this classmate, Ron C., is NOT the resident in the story!

After seeing and caring for that young man for so many days, we somehow lost our sensitivity chip. Completely. I wish I could say that I was the one who objected and that I could tell this story not as a "we" but as a "they". . . .but I can't.

It started with my senior resident. He had already been asked to be chief resident, and was considered a golden boy. I worshiped this guy, and everyone else on our team, including the attending and the fellow, thought he'd hung the moon. We were rounding one day. . . on like hospital day ten or something. . . and I can hear it like it was yesterday. We stopped in front of his room and my resident said,

"And now, for 'The Gutless Wonder.'"

My real, true recollection? Everyone laughed. Including our attending. Including me.

"No guts, no glory," my attending replied. Then he added, "Literally."

Everyone howled. Me included.

The fellow snickered and said, "Guess he won't be swallowing his pride for trying to get even with his mom!"


Bwwwahhhh haaaa!

I actually remember thinking it was cool that our attending could loosen up and poke fun with us. I thought he was the cat's pajamas for being so easygoing that he'd join in all of our (making) fun. Every day it was something new. And even he was in on it.

"How is Mr. Esophagush?" he asked one morning. Yes, the attending.

More laughter.

Every time I think of that month, I want to hang my head. How could we have been talking that way about someone who was literally on the brink of death? How could we stand in front of his mother, the mother who trusted us so much, and still say such things in her absence? How could our leaders have been talking that way?

It was terrible.

All month long, if a patient stayed with us long enough, at some point they became fair game for "witty" team jokes. Another one I continue to feel ashamed of:

"Are you down with hearing about our Downs baby?" my senior would ask each day.

(Insert collective laughter here--especially from the attending which, to a resident physician, is equivalent to high praise from a parent to a child.)

Wow.

Every single day, this is how he preceded his discussion of this sweet, sweet infant girl on our service who was hospitalized with congenital heart disease as a complication of Down Syndrome. And although I can't remember if I LOL'ed as second year in 1997 or simply looked amused--what I know for sure is that I didn't protest. At all. Not even internally I didn't protest. Even as an intern without a big voice, I could have screamed at the top of my lungs on the inside.

But I never did.

Shame on me. Even in 1997, shame on me . . . . . and shame on us all.

But especially our role models. Now that I am allegedly one myself, I bristle every time I imagine myself as that attending.

That was then, yes. But it was still foul. Real, real foul. . . . .even in 1990's pre-duty hours reform, it was foul. And it's foul to this day.

"Give me time. . . . .to realize my crime. . . ."   

~ Culture Club

Today I am reflecting on the power of culture. More than that, I am reflecting on the power of role models as drivers of the culture in our learning climates. I am so happy to be a clinician educator in an era that promotes feeling and acknowledging that being tired and overworked is no excuse for being unprofessional. I'd like to think that our culture has evolved to something more empathic than walking up to the bedside of a twelve year old with a chemically decimated esophagus and who is fighting for his life, closing the door so his mom can't hear and saying, "Gutcheck!" (Bah-dump-bump!)


What about now?

Do tired learners and faculty still lose their manners? I'd say, yes. Call me naive, but I'd say it's not as bad, though. At least now we are practicing in times where you wouldn't seem like a martian for raising a red flag when someone does take a complete detour from professional behavior.

Knowing better. . . . .

Referring to somebody's beloved child or loved one as "a Downs baby" is beyond offensive. It's hurtful and rude. Furthermore, many don't even realize that the proper term is "Down Syndrome" -- named for the late physician John Langdon Down--and even saying "Downs" with an 's' is not cool.

I now know for sure that just referring to the child by their name works just fine, thank you very much.

Sigh. To every single one of those patients. . . . I deeply apologize. I know it's over a decade late, but I do. I really do.

Nowadays, my "fun" references to my patients are things more like "F.P." for favorite patient or something like that. And while I do like having that relaxed camaraderie with my own students and residents just like my PICU attending did with us, now I know enough to not try to achieve it at my patient's expense.

***

"When you know better, you do better."

~ Maya Angelou

Do better, man.

The Internship Chronicles: Cumulus Clouds

*names details changed to protect anonymity. . .yadda yah. . y'all know what's up!

cloudy with a chance

I'm not sure why, but these days, I have internship on the brain. . . .

(squiggly fingers as we go back in time, anyone?)

Black cloud: (n) A doctor or nurse whose very presence near the wards, clinic, ICU or emergency department, by definition, guarantees a.) multiple new hospital admissions b.) a few very, very sick patients that are just sick enough to keep everyone terrified until sunrise, c.) a random catastrophe such as 35 college kids being brought in by ambulance after a backyard deck collapsed during a keg party or 8 people getting wretched food poisoning off of Ain't Jenny's potato salad. . . .or of course d.) all of the above.


White cloud: (n) A doctor or nurse whose very presence near the wards, clinic, ICU, or emergency department, by definition, guarantees a.) virtually no admissions that evening, b.) very few patients with extremely straightforward problems such as a ringworm, a diaper rash, or head lice, c.) or a medication refill for something that is non-narcotic that their (totally privately insured) patient knows the exact dosage, route, and frequency of, or d.) all of the above.

old school beeper (back when "14" was the way to say "hi.") Yeah, baby.

First Year, Med-Peds Internship: Medicine Ward Month, circa January 1997


"Hey, Kim. I'm down in the cafeteria eating dinner. Care to join?" asked Julia, one of my co-interns on call on another floor that January evening.

I looked at my nerdy calculator watch (I used to calculate a mean GFR back then. . . ) and furrowed my brow. "Dude! It's only 6:15! You're already eating dinner?"

"Yeah, man. Mike is covering us and he's a black cloud," I heard Julia saying as I imagined her leaning against the bank of phones that lined the back wall of the cafeteria. "This may be our only chance for chow, dude. Then again. . . .I'm pretty much a white cloud, so maybe my good luck will cancel out his." We both laughed.

I sat there for a moment and pondered that statement. Julia was right. Everyone knew that the senior resident covering us, Mike, was always in the eye of some kind of storm. A future critical care doctor, there was no doubt about it--this maverick of a resident was as fearless as he was smart. I thought about the other two calls I'd had under his watch. The most memorable occurred not even two months into my internship. This man with pneumonia started out coughing up scant streaks of blood in the emergency department. By the time Mike and I got him upstairs and admitted to the floor, he'd begun hocking up big red lougies. A few moments into us taking the admission history with our TB-proof N-95 masks on, the guy looks at Mike and--I kid you not--starts spraying what looked like buckets full of blood up from his chest and out of his mouth. It looked like something out of a horror flick.

If "O.M. (expletive) G!!!" had been a popular thing to say back then, I assure you that's exactly what I would have said. Instead, I alternated between mouthing "wow" repetitively and being a frozen statue of fear, intensely hoping that this Mike character had at least one clue about what to do next so that there'd be at least one clue between the two of us.

"Turn him right side down!" Mike ordered to the nursing staff in the most sure way ever. Two seconds later, the patient had two large bore IV's in place, Mike was holding a 8 fr endotracheal tube in his right hand preparing to intubate him, and a big metal blade in the other. Four seconds after that, he had a developed stat portable chest x-ray in his left hand that helped locate the source of the bleeding and the position of the endotracheal tube, was writing orders with the right and already had a pulmonologist en route to perform an emergent bronchoscopy. You had to be there, man. It remains one of the dopest, raddest reflex responses to a patient catastrophe that I've ever seen in real life. (Kind of like the way people have all the right answers on those hospital dramas, but this was an actual doctor unscripted--not George Clooney or Noah Wylie.)

Yeah, Mike was a black cloud. I took Julia's advice and joined her in the cafeteria for chicken pot pie and tepid coffee in the 6 o' clock hour.

"I don't know what kind of cloud I am," I told Julia as I poked at a strange piece of meat in my pot pie with a plastic fork.

"Weren't you in the hospital with Mike the night that man with TB exsanguinated on 9B?" She was referring to the aforementioned patient who spewed blood from his chest like a fire hydrant.

"Yeah, that was me," I replied.

"Wait. . .and weren't you there that day that woman came in with the platelet count of 1?"

"Uuuuhhh, yeah. . . .I sure was. That night was crazy. But she did okay. That lady was so nice."

"Dude," Julie stated matter-of-factly, "You are totally a black cloud."

"I did get 14 admissions one night on the Peds wards a few months back," I added, strangely proud of this record. For a fleeting moment, I remembered the three different baby Velasquez-es that I cared for that night--all under one year old and all with brochiolitis. Even though I knew their first names were different, it was scary to imagine mixing them up. That was one rough night.

"Sounds crazy, but consider yourself lucky. Black clouds become bad ass seniors later. Nothing scares you when you're used to all hell breaking loose all around you all the time. You and Magic Mike might just be like one big ol' tornado cloud."We both chuckled again.

Suddenly, a pager going off interrupted us. I looked down at my pager and then back up at Julia with a big smile. She checked her quiet beeper and gave an exaggerated stretch signifying the sleep she'd be sure to get based upon her track record.

"Cumulus clouds, baby!" she chided as we gathered up our trays and prepared to leave.

I shook my head and scurried off to get my first admission from "Magic Mike."

The admissions and the pages came steadily, like clockwork, all night long. We admitted patients under a "firm" system--which meant there were no guarantees for equal distribution of admissions. That night? Five for me, none for Julia. Chest pain. Pneumonia. Altered mental status. Neutropenic fever. And the cross cover calls. . . .they just kept. on. coming. Patient awaiting discharge now has a fever. Sudden need for more oxygen in another. It just didn't stop.

Ugggh.

But that's okay, I had Magic Mike bumping clouds with me. A six foot tower of teaching and supervising power. (Not to mention the fact that he was easy on the ol' eyeballs to boot which made for some very inappropriate commentary on the part of Julia and me at times. . .but I digress. . . ) Yeah, but Magic Mike was dope. The total "Cool Hand Luke" of senior residents, and I was glad to be his underling that night. I secretly hoped that someday an intern would feel the same way about me.

Finally, after the steady barrage of four worrisome admissions and horrid cross cover calls, Mike gave me my final new patient of the call: an early morning yet super basic case of a vaso-occlusive pain crisis in a young patient with sickle cell anemia. Thank goodness! Bread and butter medicine!

"How is your pain on a scale of 1 to 10," I recall asking my terrified young patient.

"A nine. . ." he whimpered quietly.

"Okay. We're going to be getting you some more pain medicine on a pump in the next few minutes. This way you can push a button to get it on demand. How is your breathing?"

"It's okay," he panted back between shallow breaths splinted by pain. His eyes were like brown saucers and his teeth were chattering.

He didn't look okay. He looked sick. And not just sick. He looked sick sick.

I remembered the advice that I'd always been given in such instances: Keep coming back to do serial examinations. I finished my work up and my orders for pain medications, fluids and antibiotics and made a plan to come back to see him in one hour. I stole away to an empty patient room just three doors down for a few moments of shut eye. Exactly thirty minutes later, I received a page.

I sat on the edge of the bed, rubbed my eyes and called the number back--all the while secretly praying that someone needed an emergent stool softener and nothing more. Fat chance for a black cloud like me.

"Kim, it's Lisa. I need you to get over here. Now. Mr. Jackson. . .this kid is just not right. . . "

Lisa, one of our very best nurses, knew a sick patient when she saw one. I knew she was talking about my final patient, Mr. Jackson. I didn't even say good bye --when Lisa said "jump" to an intern, the proper response was "off of what building?"

When I reached Mr. Jackson's bedside, his entire face was covered with a non-rebreather mask pumping 100% oxygen into his mouth and nostrils. He was leaned forward in a tripod position and working with all of his might to breathe.

"Mr. Jackson?" I greeted him. He looked up at me with extremely tired eyes. He had a right to be pooped--he was breathing more than thirty times a minute. I placed my stethoscope to his chest and heard what sounded like someone blowing bubbles into a cup of milk with a straw. Shoot!

"Mr. Jackson!" I addressed him again. But this time he just slunk down toward the pillow and closed his eyes. I grabbed his shoulder and shook him. "Mr. Jackson!"

Before I could even get scared, sirens were going off above my head and people were swarming the bedside. Everyone that arrived seemed to be equally as junior as me, which 100% freaked me out since there was no one to defer to. Julia was placing a femoral line. Another intern was attempting to get an arterial blood gas. And at the head of the bed stood me and my black cloud--this time with the blade in my left hand and an ET tube in my right.

Totally tubular (image credit)

The respiratory therapist clenched and released the ambu bag that forced the breaths into my patient's chest that he couldn't make on his own. I kept straining my neck to see if someone from Anesthesia would come rushing in to save me from intubating this patient, or even better, Magic Mike to appear in the doorway. "You ready, doc?" asked the respiratory therapist in a tone that sounded far more like a statement than a question. Lisa the super nurse locked eyes with me from the med cart and spoke for me:

"She's ready. Let's go."

This would be my very first intubation on a real, live, non- plastic human being. My heart pounded furiously as I stared at the quiet face of this twenty-something year-old young man who was depending upon me to get this right. Lisa sensed my angst and came directly to my right side after pushing Versed to settle him.

"Eyes on the vocal cords. . . . " I coached myself.

"You got this, baby," Lisa whispered.

". . .vocal cords visualized. . . . ET tube please. . . . ." Thump-thump. Thump-thump. I was certain I would have a heart attack. Or wet my pants. Or both. Please don't eff this up, Kimberly. Please don't eff this up. He's only twenty. Oh my gosh. Please don't eff this up. Despite what my mind was saying, I tried my best to look calm--doing my very best impersonation of Magic Mike. ". . .okay, guys. . . I'm in." I stepped back and let the respiratory therapist connect the tube to the ambu bag.

"Good job, sweetie," Lisa kept coaching in my ear.

And right then, after gazing at those pink vocal cords for dear life, I blinked for the first time in two minutes, losing my left contact lens from one of my bone dry eyeballs. Toric ones, too. Damn.

Just as the respiratory therapist connected Mr. Jackson to the carbon dioxide detector, Magic Mike bounded in gasping. "Shit. What happened?" It was obvious that he'd just run up several flights of stairs.

"You're in, doc," confirmed the RT after looking at the carbon dioxide changer, this time a statement--no question about it. I offered her a smile of relief.

"The chest x ray is completely whited out," I told Mike, "I think it's either acute chest syndrome or maybe ARDS from a bad Pneumococcal pneumonia, but it evolved pretty fast. He lost consciousness right in front of me and Lisa."

"Did he lose his pulse?" Mike queried with worry in his eyes. "Gosh, he looked pretty good when I saw him."

"No, he never lost his pulse. It was all respiratory and witnessed. He'd been on a non-rebreather for a bit and just crashed. We ordered blood and called the Hematology fellow. She's coming in." I thought for a moment about my first encounter with Mr. Jackson, and how I struggled with whether or not he was sick. . .or sick sick. Now I knew that answer. He was sho' nuff sick sick.

"Damn, I'm sorry, Kim," Mike apologized. "I was drawing blood cultures in the skilled nursing facility when I heard the code. Dude, I'm so sorry. I'm so glad you guys had it under control."

With my one good eye, I watched the ICU team whisk Mr. Jackson down the hall as the respiratory therapist bagged breaths that sounded like rhythmic sighs. "I hope he's okay. I never should have left him. I was so tired and I wasn't sure what else to do. I guess I should've called you." I said quietly.

"You were right on the floor, Kim. With such a rapid response by everyone, hopefully he'll do okay." Mike began walking backwards to catch the elevator. "You done good, kiddo."

Once things were quiet again, Julia and I stood outside the doorway, sort of in an intern daze. Lisa passed by and patted my shoulder before going to give report to the nurses coming in for the morning shift. "Good job, Kimmy."

"See?" Julia said with an eyebrow raised.

"See what?"

"Told you it was good to be a black cloud. I probably would have given him a foot rub and fluffed up his pillow." She laughed softly, but I could tell she was somewhat serious.

Julia had been scarce that evening. Not because she was lazy or anything. . . she was just. . .a white cloud. I studied her obvious bed head and took note of her throaty voice--all signs of someone who'd gotten some sleep. I glanced at the snow-covered cars now visible in the top deck of the parking garage as the sun rose in the window behind Julia's head. I had officially been up all night. After a much-needed back stretch, I shook my head and yawned.

"Lucky you, man," I teased Julia.

She reached toward me with her right hand and delicately plucked what was my contact lens from my left cheek.

"Here ya' go, three blind mice."

I smiled gratefully as she placed what now looked like a tiny piece of Saran Wrap into my cupped hand. "Thanks for the help with that line placement, chica."

"Ha. It was the least I could do."

I hi-fived her with my free hand and we bid each other adieu. All was finally quiet on the mid-western front.


After a prolonged hospitalization in the ICU and ward, my 5th admission, Mr. Jackson, was discharged home. He had a full recovery and celebrated his 21st birthday a few months later.


Almost fifteen years later, I now know that Julia was right. When you're a trainee--as crazy as it sounds--you probably want to be a black cloud. Because just maybe enough of those stormy nights might set you and your patients up for cloudless skies later.

Just maybe.

When I was an intern. . . .

Today I'm reflecting on my internship. . . 1996. . . .back in the day. . . (insert wiggly fingers here as we go back in time)

When I was an intern. . . . 

• I didn't have an email address.
• Or a working cell phone that wasn't the size of a football or that didn't cost $500 per second. 

When I was an intern. . . . .

• Clinical questions were explored in the big fat textbooks that sat on the shelves of every ward. (Up-to-date? Chile, please.) 
• I read the Washington Manual so many times that I could tell you what page you could find "management of gastrointestinal bleeding" without even opening the book.

When I was an intern. . . . 

• "Duty hours" was this obscure thing you heard of occasionally mentioned with regards to training programs in New York state. They allegedly had some rules about how long one could work (although no one I knew in New York state was following any kind of rules regarding them back then. . . .)
• Post-call (meaning: you've been up all night admitting sick patients) essentially meant very little to anyone besides you.
• Nobody cared if you were speaking in tongues or writing in hieroglyphics at 4:35 p.m. during post-call sign out rounds due to lack of sleep. (Or if you had clinic the following day.)
• "You okay with sticking around a bit longer?" was not an unusual thing to hear at 1pm after being up all night-- when the only alternative to eking out a tiny "o.k." was to swallow hard and blink fast until you no longer wanted to fall to your knees in tearful exhaustion. ('Cause you knew that if you dared protest, you'd hear a soliloquy that starts with "When I was an intern. . . .")

When I was an intern. . . .

• I once (stupidly) took call two nights in a row because my co-intern and I both wanted an entire weekend off during our "one in three" call schedule month.  (Translation: I worked more than 48 hours straight. Not. Smart.) That Sunday morning while rounding with my attending, I recall him saying, "Who's the on-call intern?"  "Me."  "Uh, okay. So where's the post-call intern?" "Also me."  "Uhhh, can you do that?"  "I think so."  "Uh, okay.  Who do we have first on our list?"
• I was so tired on that Sunday that I had to call a friend to come and drive me home.

When I was an intern . . . . 

• I practiced presenting my patients in the car on the way to one of my ICU rotations because I was so intimidated by my take-no-prisoners attending that I felt it was 100% necessary.
• Case in point: That same attending in the ICU held his hand up to his ear in the middle of my patient presentation one day and said, "Ssssshhhhhh! Do you hear that? Listen."  Everyone looked puzzled and tried to listen to whatever he was talking about. He then narrowed his eyes and exclaimed (yes, exclaimed), "It's the sound of your patient yelling around his endotracheal tube, 'Help me! Help me! This intern is trying to kill me!' " This was followed by a laugh that originated from so far in the deepest parts of his belly that I thought it would never end.  Um, yeah, so that's why I was practicing my oral presentations on the way to work. . .
  
• The only comforting thing about that ICU month was that this same take-no-prisoners attending did not discriminate when divvying out the insults. One of my all time favorites remains: "Do you know what this patient would say if she could talk?"  "No, sir."  "She'd say, 'Somebody save me! I'm surrounded by a group of snot-nosed intern assassins!' "  

When I was an intern. . . . .

• On my ER rotation in December of 1996, I was scheduled for twenty-two "twelve hour" shifts. (My four clinic sessions were folded into two full-day sessions--on my OFF days. Nice.)  
• Oh, in the aforementioned month? Nearly all of my shifts were from 2pm to 2am--exactly perfect for making certain that I had no time for any possible meaningful contact with anyone not requiring stitches, IV fluids or a splint.  
• Whoops, I almost forgot. I did get one shift that wasn't from 2pm to 2am--Christmas Day--which was 10am to 10pm. Exactly perfect for guaranteeing that I would have no time to do anything remotely exciting before work or make anybody's celebration after getting off. 

When I was an intern. . . . . 

• I burst into tears on rounds after my attending kept pimping me on obscure pharmacology questions post-call. 
• I cut the back of my hair with a pair of Fiskars from my sewing kit because I didn't have enough time to go to a professional. (And actually had such a distorted view of style that I thought it looked pretty darn good.)
• Blinked out my left contact lens every single time I intubated someone. ("Eyes on the vocal cords. . . steady, steady. . . . and I'm in!" Blink. "Damn.")

When I was an intern. . . . 

• I fell asleep in my car in the parking lot post call. In Cleveland, Ohio. In the winter. (Fortunately, a security officer tapped my window and woke me up before I developed frostbite.)
• I called my chief resident after the first big snow and asked what I should do about coming in. My chief laughed so hard that I was sure he would tear an intercostal muscle somewhere. That was the answer to that question.

When I was an intern. . . .

• I learned so much that I thought my head would explode.
• I was often more terrified than I had ever been in my entire life.
• I made some really, really great friends who sometimes carried me away from the battlefield on those days when I could no longer walk for myself.

When I was an intern. . . .

• I cried so hard when I lost my first patient that I wondered if I was cut out for this profession.
• I sometimes wasn't sure I'd make it. 
• I prayed. A lot.

Funny how much has changed since I was an intern. New rules, new war stories.  . . . but some things remain the same no matter when you trained or how gruesome your personal version is of the "when I was an intern. . . ." saga:


You learn.
You try.
You grow.
You cry.

And if you're lucky. . . this doesn't end when you finish your internship.  :)

Reflection on a Thursday: Seinfeld Reincarnated

One of the medical students told me recently, "Your life should be a reality TV show. Seriously."

I think he was right. My life is this amalgamation of "only Manning" moments that one would have to see to believe. It never fails. I have a "Seinfeld moment" every single day at Grady. Sometimes more than one.

Like today, for example, I was rounding with my team on our post call rounds. We were on the last of our ten new admissions, and the interns and I decided we'd make a pit stop at the Coke machine. Got my usual: a icy cold Diet Coke. Aaaaahhhh.

I tried to open it to take a sip. . . .grrrrrr. . . . .thought maybe my hand was too oily or something. Dried my hand off in my lab coat pocket and tried again . . . .grrrrrrrr. . . . . . dang, this sucker is screwed on tighter than I thought. Kept walking with team to last patient.

Now standing in front of room of last patient. Listening to Marc, one of my interns, tell me about his patient. Periodically. . .grrrrrr. . .struggling to . . .just. . . get . . .this . . .grrrrrr. . . .open. . ."Yes, okay, go on". . . .grrrr. . . .

Finally, Ben, the other intern, can't stand it any more. He steps in to help his damsel attending in Diet Coke distress. Kind of like Harry always does with a jar of unopened salsa, he did the silent hand wave signaling that with a simple pass it will be opened in an airtight-stopping, manly snap. No shame in my game. I hand it over. Marc politely pauses.

"Thanks, Ben. Go ahead, Marc."

Marc keeps presenting. I keep listening and writing on my billing card. . . . and, okay I'll admit it. . . periodically checking Ben's work with the airtight Diet Coke--more because I think it might explode in his face and not so much because I don't think he has the brawn to get it open. (I'm just saying.)

"Clinically, the patient looks much better than she did on yesterday," said Marc with that post-overnight frogginess that gets into one's voice after being awake for too long, "If things keep going in the right direction, we can aim for a discharge early tomorrow morning." In we go. Diet Coke waits on counter until we finish seeing the patient.

Eight minutes, one physical exam, one assessment and plan, and four or five Socratic questions later, Ben is still in the corner struggling with that bottle. Our fourth year med student, Barb, has even joined in on the task. Marc and I stop and just look at them--passing this bottle of Diet Coke back and forth. Ben's face is turning red with hypermasculine struggle. It's a pretty funny sight. Marc offered up a weak, post-call mini-smile (which, in itself, amused me.)

I can't help but start laughing at Ben's crimson face as he worked on getting his attending's thirst quenched. "Dude! What's up with you and this Coke? This will be reflected in your evaluation!"

Deadpan Ben hands the drink back to me and shakes his head slowly. He says to me with the most somber face he can muster, "Bad news, Dr. Manning. Your Coke is broke."

"What?"

"Your Coke. It's sealed shut," chimed in Barb with a snicker.

"Say what? I have an imperforate Coke?" (Recognizing my extremely lame use of medical jargon.) I study the cap incredulously--fused shut into one infinite plastic piece. Wow.

"Yes. It's official, Dr. Manning," Ben confirmed, "Your Coke is indeed broke."



A broke Coke? Seriously? Seriously.


See? This is my life. I just show up and live it, man.

Reflections of a Clinician-educator: Kimberly and the Giant Calipers

Grasshopper: This is an outrage! You are a disgrace to your Phylum, Order, Class, Genus and Species!

Centipede: Say it in English!

Grasshopper: YOU, sir, are an ASS!



from Roald Dahl's childrens' classic "James and the Giant Peach"

___________________________________________________________

I used to love the book "James and the Giant Peach." If you've never read it, it's this wonderfully trippy journey of the imagination written by British author, Roald Dahl (the same guy who came up with the Willy Wonka books and also the recent book-turned-movie "The Fantastic Mr. Fox".) Poor little James had a few traumatic and convoluted experiences, including getting lost inside of a giant cavernous peach. Despite this, he learned some great lessons there and met some great friends along the way (even if they were insects). Although I loved that book, I'm still not sure about Roald Dahl and what could have been going on with him when he came up with this tale but that's another story. . . .

Anyways, I like to think of medical school and residency training that way. Some parts of it can be downright terrifying, and despite this, you encounter a few people and experiences along the way that ultimately help mold you into an even better version of yourself. Sometimes it's intentional, other times it happens by accident. Either way, it's necessary.



Kimberly and the Giant Calipers

When I was in my internship, I was rotating on inpatient Cardiology with this really hard-core Socratic teaching cardiologist. Every morning we started the day at like 6:30 a.m. for a half-hour of teaching. Here's how it went down:

1. Dr. Socrates marches in and carrying a tray of slides holding pictures of what are quite possibly the world's most heinous EKG tracings.
2. Dr. Socrates sets up projector at very back of the room and then switches off lights. Ginormous image of world's most obscure EKG tracing now in wallpaper proportions over the entire wall. (No, not on a screen, but the size of the ENTIRE WALL.)
   
3. Us terrified interns sit at front of the room vacillating between feelings of nausea and near-fainting. At least one will actually vomit or lose some other bodily fluid.
   
4. Dr. Socrates perches glasses on his nose and walks toward our seats. Although he is only 5'4" max, his shadow is projected on the wall which makes him look like a big, scary monster that has just jumped out of a closet.
5. In his hands are these gigantic wooden calipers for EKG tracings that are, literally, the length of my arms.
   
6. Interns begin praying to whatever God they pray to that somehow, someway they don't faint, become incontinent, or make a complete fool out of themselves in some other way, or that if they do, that all of the others also do the same.
7. Some unlucky intern gets handed the giant calipers and told to go to the front of the wall.

the calipers: like these, but wooden and scarier

the projected image: like this, but an EKG and scarier

Early one morning, circa 1996

I'd been standing in front of the ginormous projected EKG, and had just measured every interval, and answered the initial basic line of questioning. It always started with basic questions, followed by a series of harder questions that felt like water torture. I swallowed hard and prayed for sphincter control.

Me: "This appears to be some kind of incomplete bundle branch block, sir. Left, that is." I wanted to be noncommital, yet smarter-sounding. I could feel myself getting woozy and diaphoretic. "Some kind of interventricular conduction defect, sir." Uh oh. Want to take it back immediately.

Dr. Socrates: (Big sigh) "Okay, so Dr. Draper. . . . .tell me, what are YOUR criteria for left anterior fascicular block?"

Okay, let me give you more on Dr. Socrates. He was from somewhere overseas and spoke with an unapologetically thick accent that seemed to emphasize all the things that you were doing wrong. He constantly looked exasperated with us, and still wasn't happy even when there was a budding cardiologist on the team (which there was that month.) He was so intimidating that during the first few sessions, even when you knew the answer, it fell out of your brain into a crack in the ground, never to be seen or heard from again.

Me: "My criteria?" I had no criteria.

Dr. Socrates: "THE criteria." Even worse.

Me: "Umm. . . a left axis deviation and. . . .ummmm"

Dr. Socrates: "and WHAT?" I could feel myself beginning to sweat. The giant calipers slipping out of my hands.

Me: "Is the QRS interval a little bit prolonged but not too prolonged, right?"

Dr. Socrates: "Is it?"

I look over at my other two co-interns like I'm on some kind of game show hoping they will start shouting out answers. Instead they are both quickly thumbing through their pocket notebooks hoping the spotlight wouldn't turn onto them. No help at all.

Me: "Um, yeah, it's . . . uh. . .short. I mean, yes sir, it is prolonged."

Dr. Socrates: "How prolonged?"

Me: "Umm. . .prolonged a little bit but still less than 0.12?"

Dr. Socrates: "And? I'm waiting." Wait, did he just roll his eyes at me?

AND that was the extent of what I knew about THE criteria. That is, that was all I would be able to recall under those circumstances. I mean, all I really knew is that it wasn't a left bundle branch block, which I'd determined after using the giant calipers. I knew that somewhere in there there was some rule about right bundle branch block, but I wouldn't dare utter it while standing in the big shadow box. I shifted from side to side on my feet, hoping this would end. Instead he sat at the back of the room like Michael Douglas on "A Chorus Line" bellowing scary questions out without the least bit of sympathy. I was sure I was going to be sick (or lose sphincter control.)

Like Michael Douglas at the back of that dark theater, but darker and scarier

Dr. Socrates: (sighs in the most exaggerated way ever) "You interns don't know NAAAH-THING. Don't they teach you NAAAAH-THING? How do you not KNOW the criteria for a left anterior hemiblock?"

Me: speechless but thinking, I might partially know, but the chances of me being able to tell a screaming, 5 foot madman with white spit flying from his mouth are slim to none.

Dr. Socrates: "Look at the inferior leads!" He grabs the calipers from me and heads to the front of the room. He stomps his foot. "LOOK! Don't you see those Q waves? You can't call this a left anterior fascicular block in the face of an old inferior myocardial infarction! Come ON! This is KEEEED STOFF!"

But it wasn't kid stuff. It was new stuff. To me and to the other two interns rotating with me that month. I wanted to become more proficient at EKG reading, but this was terrifying. And so, for an entire month, we withstood the giant calipers until eventually something happened. We kept getting challenged. We went home and studied. We tried harder. At some point, we started getting the answers right. And when we did, he just asked harder questions until we somehow got those, too.

By the end of the month, we realized that hearing him say, "Don't you interns know NAAAAH-THING???" was really a term of endearment, and that his other winner--"Help! Help! THAAAT is what this poor man will be saying while you interns try to ASSASSINATE him by not knowing NAAAAH-THING." --was his way of saying, you have to know this not just for tests but for patients. On the last day of the rotation, I gave him a big hug and even wrote him a thank you card. Crazy as it sounds, that rotation turned out to be one of my most favorite months of residency (despite the PTSD it cause me for complex EKG reading.)

13 years later, I can truly say that I remember that attending with warm nostalgia instead of nausea. While I can't say that I personally endorse his colorful method of teaching, what I can say is that now I do appreciate his dedication and passion to our medical education. Now that I'm a clinician-educator, I know what must have gone into gathering all of those EKG tracings and getting them onto kodakchrome slides. I recognize how committed he had to be to meet us every single morning at 6:30 a.m. before rounds, all while still being responsible for the entire service of patients and probably countless other things. I can now see how, deep down, he had high expectations of us and for us, and though he wasn't so touchy-feely about it, he really cared. And in the end, I'm thankful for it.

Kind of like James and the giant peach. He started out lost and surrounded by scary things. With time, those things became more familiar and less daunting, and even downright enjoyable. Though somewhat traumatic along the journey, he was better for it. The struggle was worth it, and yes, necessary. That attending may not have been warm and fuzzy like a peach, but at least he wasn't apathetic. When it's all said and done, I'll take spunk over apathy any day.

So now, I let my learners get lost in the giant peach just a little bit. . . .never at the expense of patient safety, of course--but enough for them to struggle and learn. I take the best of Dr. Socrates, and soften it with my own style. Like him, I expect them to do well, to learn with experience, and to try. And also like him, I do my best to back it up with instruction, time, and passion. Even if their journey into the core of the peach gets a little rough, I know it's necessary, and that they'll be better for it.

***

At the end of "James and the Giant Peach", James makes a home of the peach pit which turns out to be an oasis in the middle of New York's Central Park. Those insects end up being his very best lifelong friends--and they all live happily ever after. :)

The Internship and Residency Chronicles Volume 2: Follow the Yellow Brick Road

*most names and details changed. . . . . .you know what's up.

"You, my friend, are a victim of disorganized thinking.

You are under the unfortunate impression

that just because you run away,

you have no courage.

You're confusing courage with wisdom."


~ The Wizard of Oz in "The Wizard of Oz" 1939

____________________________________________________

I remember looking at the schedule for inpatient ward assignments during the winter of my intern year. I found my name with my index finger and then dragged it across the paper to find who my fearless leaders would be. My resident was this feisty third year woman. . . . . excellent reputation for being smart although tough. I could handle that. I followed the column upward until it landed squarely on a name that I wasn't so sure I could handle: Dr. Olds. Gasp. My attending that month was. . . .eek. . . the Chairman of Medicine? Great.

Here's the thing: I was in a combined training program where every three months I switched from assignments in Pediatrics to Internal Medicine, and then back again. My yellow brick road was convoluted, to say the least, and finding my footing during those early days wasn't always easy. This upcoming ward month would be my "back to Medicine" month after three rigorous months of Pediatrics. I still had NICU, newborn nursery, and pediatric emergencies on the brain. Those first few days after the switch always felt a little shaky; I'd mastered the art of looking confident when deep down inside I was a quivering blob of jello. But this was even more terrifying than usual. In addition to my normal freak-out, I was given the privilege of having a potential meltdown in front of the Wizard himself: the Chairman. Super.

Okay, so I was a PGY (post-graduate-year) 1 back then, but can I say that even now, as a PGY 13, I would find it equally mortifying to be under the microscope of my Chairman? Picture it. Every day, you get to present your patients, what you discerned from your history and physical, and subsequently do your best to field the barrage of Socratic questioning that would surely ensue. From your Chairman. This meant that a screw up or a bad day could have monumental consequences. A category 1 nausea hurricane quickly organized in the pit of my stomach with every ingredient for growth into category 5.

The good news is that despite how intimidated I was by my Chairman-turned-ward attending, he was pretty nice. In fact, he was more than that--he was really, really nice and surprisingly approachable. The other good thing is that my resident was excellent that month, and she cracked a mean whip on us interns. She'd make us present our patients to her first, and would pick our write-ups apart and then reassemble them before rounds every day. In other words, there was never a performance without a dress rehearsal and a sound check. I mean, this was the Chairman of Medicine, which in case you haven't figured out yet, was kind of a big deal.

Follow the yellow brick road. . . . .

One night on call, I was being covered by a different resident. I was no longer under the watchful and protective eye of my trusted PGY3, but instead was the orphan intern of someone less familiar to me. His name was Gary; a second year resident who was smart, but much less confident than the mini-general that I'd become so accustomed to. This resident would ask me what I thought we should do. And not just in that obligatory way that folks often do when talking to medical students or interns. This guy really needed me to co-sign his decisions. Even though I was feeling more and more comfortable with clinical decision making, his anemic leadership was terrifying. And even more so since my attending was--had he gotten the memo? Uhhh, the freakin' Chairman of Medicine.

It came to a head when we stood before a woman we'd just admitted with community-acquired pneumonia. Gary and I had just gone down to the Radiology suite to review her x-rays which, consistent with her lung exam, revealed a moderate sized fluid collection around her left lung. My wobbly leader discussed the next steps with me as we rode the elevator back up to the patient's room.

"She has a pleural effusion, so the next step is to sample the fluid with a thoracentesis, okay?" Gary asked/said. Then he reached in his pocket and thumbed through the Washington Manual under "Management of Pleural Effusions." He looked up at me and added, "I think that sounds like the right thing to do, don't you?"

I didn't like this co-sign thing. I needed him to speak with authority. I wanted him to be so comfortable with this situation that he could quiz me on the Light's criteria for pleural effusions while picking dirt out of his nails with the edge of an index card. Didn't he get it? I wanted to be his intern, not his co-resident. I furrowed my brow and answered him, "Uh, it's my understanding that an effusion that size needs to be tapped. And I guess depending on what it shows, you determine whether or not a chest tube is necessary."

What did I say that for? Gary's face went pale, and he swallowed hard. "Oh my gosh. I really, really hope she doesn't need a chest tube. Oh my gosh . . ." He shook his head and muttered while devouring the tiny paragraphs printed on the pages of the Washington Manual. Now, I somehow felt like a jinx.

But this patient looked good. In fact, the only thing that had prompted her admission was her abnormal x-ray. She'd had this fever for two days associated with a cough, and when it didn't go away, she decided to come to the emergency department. This patient was youngish--in her fifties--and had been in perfect health. Since she didn't usually get sick and made regular visits to her primary care doctor, she grew a bit worried. She didn't smoke, didn't use drugs or alcohol, and was breathing well enough to not require oxygen. During her visits to her PCP, she'd had regular lab work including several negative HIV antibody tests. And so, the truth is that this lady was not sick-sick by any stretch of the word. She just had an ugly x-ray which sometimes can be enough to make even the most bad-ass the Emergency Department doctors uncomfortable.

A third year senior from the ICU supervised me as I did the procedure since Gary wasn't comfortable being the overseer. The patient tolerated the thoracentesis quite well--in fact, what I remember the most about her was just how great she looked overall. In fact, she was so cool that I remember her talking to me about banana pudding during the procedure. So clinically? She looked cool. Clinically cool, yes. But radiographically cool? Uhhh, not so much.

After carefully removing a sample of fluid from the space around her lungs, I confirmed that we hadn't introduced air or caused any complications by checking on both her follow up x-rays and how she was doing. Just like when I'd seen her in the Emergency Department earlier that night, she looked great. My nervous upper level stood beside me as I led the conversation.

"How are you feeling, Mrs. Elmore?"

"I'm actually feeling a lot better. The cough seems to be loosening up some more, and now I'm bringing up more phlegm. I still have a little pain on my left side, but it seems a touch better since you guys took some of the fluid off of my lung." She really did look like she felt better. Even better than she looked before the thoracentesis. "I think my fever broke, too."

"Are you breathing alright?"

"Yeah, I'm okay. My nurse says I am still breathing a little faster than normal, but like I said, I was surprised when they wanted to keep me. I guess I'm glad you guys did since I had the fluid around my lung--what did you call that again?"

"A pleural effusion," I answered with careful annunciation of the technical terms.

"That's right, the pleural effusion. Yeah, but I am feeling a little better. I think I'm going to try to get me some rest," she said with a smile, "I hope you all get some, too." I glanced up at the clock on the wall beside us. 1:36 a.m. I smiled back at Mrs. Elmore and raised my eyebrows. Sleep? Yeah, right.

"You do the resting," I laughed. "I'll be checking on the results of your fluid, and will let you know what it says. The fluid looked pretty clear, so I won't wake you if it isn't too exciting. Right now, I'm anticipating that we won't see anything alarming." I did my best to speak with the authority that I knew my supervisor that night had not quite grown into yet. We both bid Mrs. Elmore adieu as she nodded and rolled over in her bed.

2:21 a.m.

I had my head down for a catnap at the nurses station when my pager startled me awake. It was the "Stat Lab"--I recognized the number. I whipped out my pen and a piece of paper in preparation of Mrs. Elmore's unexciting pleural fluid values.

"I have a critical lab value for you on patient Elmore," spoke the lab technician. He didn't waste any time. "I've got a pH on a pleural fluid specimen of 6.9."

I thought I'd heard him wrong. "Excuse me?"

"The pH on your pleural fluid sample. It's 6.9," he repeated firmly.

"6.9? On patient Elmore?" Again, he affirmed that this was indeed the patient, and no, he didn't stutter: 6.9 was indeed the value. I felt the hurricane swirling in the pit of my stomach again. A pH of less than 7.2 meant the fluid was likely pus, or what we refer to as an empyema. And one of the first things you learn in medical school is that "pus must pass." Uggh. Mrs. Elmore needed a chest tube--the only way for pus to pass out of the pleural space.

"Shoot!" I said aloud thinking about how peaceful she'd looked when we'd left her bedside. I imagined us rustling her awake only to have some baby-faced surgical intern consent her for a hollow tube the size of her pinkie finger to be inserted into her chest. "Shoot!" I repeated. This stunk.

as heinous as it looks: a simulated-model patient with a chest tube

Before I could even fully process it all, Gary was flitting about me like some sort of anxious hummingbird. "You saw that the pH is 6.9!" he exclaimed, "I already called surgery for a chest tube. They're coming. You think she needs a chest tube? I mean, less than 7.2 then she does, right? This is awful. This is so, so awful." He looked like he was going to be sick, which made me feel the same. I longed for my drill sergeant day resident, who likely would have smacked Gary and told him to get a grip. He was making me anxious. I gathered my cards up and prepared myself to go and speak to Mrs. Elmore.

Gary shuffled beside me as I reached the foot of her bed. I could hear her breathing; peacefully sleeping without oxygen or any respiratory distress whatsoever. I whispered to Gary, "Don't you think she looks too good for that pH and way too good to need a chest tube?"

He gave me a puzzled look. "But the pH is 6.9," he spoke more firmly than he had all evening. He paused for a moment to make sure we didn't wake her before adding, "Despite how good she looks, she needs a chest tube!"

"Could it maybe be a lab error? I'm just worried because a chest tube is like a really big deal." We both stared at her quietly for a few moments. I turned and faced Gary before saying the unthinkable. "I think you should call the attending."

It was like my mouth moved in slow motion. I just suggested to my nervous upper-level that he call not just the attending, but the Chairman of Medicine--oh, at 2:40 in the morning to boot. Good luck with that.

"But it is clearly less than 7.2. It's even under 7.0, Kim. This is clear cut. She needs the chest tube."

Great. We've been on this yellow brick road all night, and now the lion finds his courage on the first decision of our call that I actually wanted him to get my input on. I decided to challenge him. "This doesn't make sense, Gary. Dr. Olds always tells us to pay attention when things don't make sense. I think we should call him. If you won't, I'm willing to."

"Call Olds?" he gasped. "You will not call our Chairman at 3 a.m. to ask him an obvious question. Absolutely not." He scowled and walked out of Mrs. Elmore's room to punctuate his position. Great. Now he'd found some heart, too.

I wouldn't give up. I finally convinced Gary to let me call Dr. Olds, but he made it clear that I should tell him I did so without his blessing. In other words, "If you have the audacity to kick open the gates of Emerald City and smack the Wizard on the back of his head in the middle of the night, you'll be doing it on your own." That was fine with me. I just didn't want to see this healthy woman be subjected to a chest tube that she surely wouldn't want and that possibly she didn't need.

And so I called the Wizard a.k.a. Dr. Olds at 3-something in the morning -- without a lion, the tin man or the scarecrow to back me up. Just PGY1 me, waking up first, the Chairman's wife who (as I sat there mortified) let me hear her calling my Chairman "honey" until he was wakeful enough to grab the receiver. Lawd.

Fortunately, just like he had been all month long, the Chairman was wonderfully patient when I got him on the phone. Once I got past my fear, I methodically ran down all that had happened--including her low grade temperature, bright smile/not-sick appearance, normal oxygenation, and then peaceful slumber I'd witnessed a moment before. "Could she look this good with a rip-roaring 6.9 pH empyema in her chest?"

"Call the lab and ask them to repeat it," spoke Dr. Olds decisively. "It sounds like a lab error. If she looks that good and it's still low, I'd retap her. It's possible that the specimen sat too long. Definitely don't put a thoracostomy tube in her without having them run it again."

"Okay," I eeked out while looking at Gary. He held his hands out to say, What? I wrote in all caps on an index card what Dr. Olds had just told me:

REPEAT IT. NO CHEST TUBE YET. And that's exactly what we did.

3:39 a.m.

Page from the Stat Lab.

"Repeat pleural fluid pH: 7.38." (normal.)


***

Today I'm reflecting on the importance of making sense of things in clinical medicine, but also the value of being an approachable leader and supervisor. Although I often point out the differences between my pre-duty hours reform training and the current regimented and humane training, I can proudly say that even then we always had invested faculty supervising us along the yellow brick road. Having a good fund of knowledge helps, but sometimes it takes experience to become a sho' nuf and bonified voice of reason. For this reason, I try hard to channel my inner Dr. Olds when called by residents in the middle of the night or other inopportune times. I make an effort to work through their thought processes, and when necessary, I use my PGY 13-ness to provide that 3 a.m. decisiveness that maybe they've yet to acquire.

***

Later that morning before rounds, I stood at the foot of Mrs. Elmore's bed as she continued to sleep. I looked at my pinkie finger, then back at her and sighed a breath of relief. She was discharged early the following day--without an extended hospitalization, complications, or a chest tube.

me with my former Chairman/Wizard, G. Richard Olds, MD, MACP
at the National ACP meeting, 2009

Still as approachable 12 years later (and just think, he's a med school Dean now!)