Musings on my first subinternship

So at times I use HoP as a place to dispose of some emotional/intellectual vomit. Stand back, everyone because I'm feeling some emotional/intellectual nausea. ubblol

I just finished my first subinternship. A subinternship is a rotation that all U.S. 4th year medical students do to prepare them for their first year as a resident (their "intern" year). This is the first time that students are responsible for managing their own inpatients. We are to independently evaluate our patients, formulate a therapeutic plan, and then present this plan to our senior resident and attending. Other than the fact that all our orders need to be co-signed, we function as first-year residents.

As I will be going into pediatrics, I am choosing to do my two subinternships in this field: this last one was a general inpatient pediatrics month and next month will be spent in the Pediatric Intensive Care Unit (PICU).

1) Organization: I think that every 4th year medical student that starts a subinternship goes into it with a large amount of sheer terror riding on his/her back. I'd probably be concerned about a student who was too confident. For me, it wasn't an issue of whether I had enough medical knowledge; I can always look stuff up if I don't know it. For me, it was whether I'd be able to simultaneously juggle 5-6 complicated patients at once.

My senior resident started me off with a very sick little girl...you guys heard about her about 3 weeks ago when I lost her (more about that later). She had a lot of issues. I had to learn all about her, but once I did, I felt very confident in taking care of her...but, oh boy, did she have a lesson in store for me.

You learn how to organize patients on pieces of paper. Each piece of paper has the patient's name, registration number, weight (important for drug dosing in pediatrics), gender, and principal diagnosis. Then I blocked off sections for each day. Each day had a space for vitals, labs, and plan. You make little check-boxes that outline things you need to do each day for each patient. And that's how you remember to get everything done.

I now feel like I will be prepared to manage multiple patients next year. I'm terrified about a great many things next year, and that's normal and healthy, but I, while I still have stuff to iron out, I know I can organize myself. And I think that's the first time in my life that I've been able to say that with confidence. I do have ADHD, after all. cool

I got my final feedback for the rotation from my attending and senior resident yesterday. Basically, per my attending:
"You did a fantastic job this month. It was great working with you. Not only that, but your patients loved you. I heard many of them talk about 'Dr. Mike.' It's really too bad you won't be staying here next year."
Per my senior resident:
"You've been an amazing team player. You always helped the interns out, and you also took just as many patients as they did. It's been great having you on the team. I think you really improved on the stuff we said you needed to work on at your mid-term feedback. Some program is going to be really lucky to have you next year!"

I was expecting many things during the feedback session, but that caught me completely off-guard. redface

2) Responsibility: I think the strongest statement an adult can say about claiming responsibility for a child is "This is my child." Second to that, I think it's "This is my patient." It is truly awesome (in the literal sense of the word) to be told that you will be responsible for evaluating a patient and formulating the therapeutic plan. For every child, I had to ask myself "what would I want done if this was my child?" Which means I had a LOT of kids this last month.

When that happens, you get to know about A LOT about kids. You can spot a sick baby a mile away. You can practically predict the future. And parents looked to me to tell them about it. It's an awesome feeling (there's that word "awesome" again), but more than a little bit intimidating. It's one thing to have an encyclopedic amount of knowledge stuffed in your head. Accessing it properly is a different prospect entirely! ubblol

3) Love and Joy: I remember A.J. (I can't use her real name). She was the first kid I fell in love with. I met her when she was about 30 hours old. She was transferred down from way up north because she had a congenital heart defect where the veins from her lungs were hooked up to the wrong part of her heart ("Total Anomalous Pulmonary Venous Return"). Other than that, she was a perfectly healthy baby. And oh my god was she cute!.

One night, while I was on call, I went into check on her. Her parents weren't there and so after I listened to her, I just watched her sleep. If you haven't had the chance to watch a newborn sleep, it's one of the most powerful experiences a human can experience. I believe that we are genetically programmed to fall in love with babies. You just have to stare at one for a few minutes. Nature has designed them with certain visual cues that touch off centers in our brains. After all, if they were ugly, would we put up with them? Probably not.

The proof is in the pudding: animals that care for their young have young with "baby" features. Foreshortened crania, softened features, big eyes, etc. And the features don't even stick within mammals. Not only do humans find kittens and piglets cute, but also baby birds! And the Animals who don't care for their young have young that look more or less like little adults. Well, either that or larvae. And as the baby animal grows and becomes more independent, it becomes less cute and more adult-looking.

In fact, I think that on some level, I loved almost all of my patients. They always teach you you're not supposed to do that, but that's like ordering someone not to breathe. You can't do it. Perhaps that's why I chose to be a pediatrician. I had doubted it at first, but there is, in fact, room in my heart for all the children I care for. ubblove

The best pediatricians I know: Dr. Pituch, Dr. Nassr (the "matriarch" of pulmonary pediatrics at Michigan), Dr. Fleigel, Dr. Murphy, Dr. D'Andrea, Dr. Mitchell, Dr. Schmidt, etc... They won't admit it (except maybe Dr. Nassr), but I'm convinced they love their patients. I know because I see it in their faces, their actions, and their reactions to...

4) Grief: It was my second night on call when I got a page at 5:40 AM that one of my patients was breathing too fast. This was a previously apparently healthy infant who, at 26 days of life, decided to just stop breathing without warning. They did CPR on her for almost an hour and managed to stabilize her, but the aftermath was horrible: she was neurologically devastated. She would never walk, never laugh, never smile, never speak. She would be a vegetable for the rest of her life. Her parents understood this, but they wanted her kept alive at all costs, and so we did.

Ever since I had known her, her respiratory rate had been in the 80's (normal for her age =30-50) and her heart rate had been in the 170's-200's. Well, after examining her, I saw that, indeed she was breathing at 120 breaths per second. So I went away to brush my teeth and round on my patients. And when I came back she had returned to her normal baseline of 80 breaths per second.

She was on oxygen, but a very low dose, and she was supposed to have gone off it 3 days before, so I decided right then and there, in spite of the fact that I had just witnessed something unusual, to stop the oxygen. After all, she looked like she always did.

But 5 minutes later her respiratory rate was in the 60's. And her heart rate was in the 140's. Normal for an infant, but NOT normal for this girl. And that was when I ordered her back on oxygen at a good, strong dose, and paged my senior resident. But by the time we got the oxygen back on her, her heart rate was now in the 100's and her respiratory rate was in the 30's. And it sank lower, and lower...

We called a Code Blue: a cardiorespiratory arrest. In 30 seconds 20 people came running at full speed into the room. They got a breathing tube into her, spanked her full of more adrenaline than it would take to kill a small pony, paced her heart electrically, and after 25 minutes, they got her stabilized enough to transfer to the PICU.

...where she promptly coded again. And this time, they couldn't get her back. And because I'd just dicked around with her oxygen, I was convinced it was my fault.

In pediatrics, children rarely die. When they do, we normally see it coming a mile away and get them to the PICU, and it happens there. I didn't love this chid; there wasn't much of a child to love. But I had gotten to know and like her parents. And now I had to go and face them, the man who they had trusted to care for their daughter, and say "I am so sorry."

And then I wept.

But on that day, I was dealt the highest praise that exists in medicine by my attending physician. She said "I agree with everything that was done and I don't think that there was anything that could have been done differently that would have changed the outcome." In the final moments; I had done my job: I had known to page my senior resident before the code was called.

I grew a lot that day. I experienced a major rite of passage for all physicians: I lost my first patient.

What did I learn? I learned a thing or two about trusting nurses. I also learned a thing or two about complacency. And I got a major attitude adjustment. I wanted this girl off my service. That had been my main goal, and I had to wonder if it had supeceded my desire to see to this girl's well-being. After all, I wanted her off my service...and I learned to be careful for what I wish for. frown

5) Triumph and Faith: Remember A.J.? The girl I mentioned way back in point 3? She had her operation, she did great, and she's been discharged home. In all likelihood, she will now live a normal life with nothing more than the scar on her chest to remind her of what happened when she was born. Before the age of medicine, that baby would have died before a year of age. I expect her to live a long and happy life...and she'll even be able to play sports.

My loss this month did not overshadow the many triumphs that we made. We can't save every kid, but we can save a lot of them. I saw smiles of happy children who had come in to the hospital practically on death's door and were now better. As a lowly subintern, I sometimes felt like I was just the grunt carrying out others' plans, but many times the plan was my own and I truly felt like I had done something great.

There are tough cases with debilitated, vegetative kids (we call them "train wrecks") where I wonder who, if anyone, we're helping by keeping them alive.

But, perhaps more than ever after this month, I can say on a fundamental level that I believe in what we do in medicine and I could not be more proud to be one of the next generation in the tradition of Hippocrates.

I can't wait! ubbtickled

-Mike

Certified Mad Doctor and HoP High Priest of Nutella

A buckuht n a hooze! -Valura

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