My First Rotation as an Intern

Christine A. Garcia, MD, MPH

Disclosures

August 16, 2012

I tremble. They're gonna eat me alive.
If I stumble, they're gonna eat me alive.
Help, I'm alive my heart keeps beating like a hammer.
Hard to be soft, tough to be tender.
Come take my pulse, the pace is on a runaway train.

-- "Help I'm Alive," Metric, 2008

I began my intern year with anxious excitement, combined with fear of making mistakes and not knowing what to do in emergent situations. My first rotation was the Cardiac Acute Care Unit (CACU) night float, one of the most dreaded rotations among interns because of the horror stories passed on by our predecessors. I still wonder who I irritated at orientation to be blessed with this specific rotation as my first.

On day 1, I arrived to the unit coming off the high of being a newly minted doctor. My white coat was blindingly white, clean and crisp, reflective of the naïveté of its bearer. Undoubtedly, every intern has a solid knowledge base: You've passed the boards, graduated from medical school, seen and examined patients before. But on this first day as a doctor, you are tossed to the wolves -- whether those are patients, families, nurses, fellows, or attending physicians.

As the words to a song by the band Metric reverberated in my head, I felt like I knew nothing and that the wolves might eat me alive. As an intern on CACU night float, you are flying solo. You have a senior resident, fellow, and the formal chain of command, but you are first in line to the patients and nurses, and the nonstop pages come to you. It's no longer practice, and decisions are real. The "What would a doctor do?" mentality quickly becomes "What will I do next?"

I've been through the gamut of what I thought were worst-case scenarios, from code blue responses to frightening arrhythmias that had me reviewing advanced cardiovascular life support (ACLS) protocols on every shift as contingency plans.

At the beginning, I thought every case of chest pain in the CACU was a myocardial infarction. I encountered patients whose hearts were like hammers in atrial fibrillation, or patients whose frightening V-tach runs felt like runaway trains. I was constantly on edge, preparing myself to make sure no one died or seriously worsened under my watch. (Before I started night float, someone told me I would be merely babysitting the day-team's patients. That person was mistaken.)

Don't get me wrong: Intern year so far has been gratifying and enlightening. It's exciting to see years of learning slowly but surely come into practice. Each day, I've become less freaked out by middle-of-the-night complaints of chest pain. I've learned to run through algorithms in my head quickly and efficiently to figure out what the real emergencies are. I relieved my own palpitations to arrive at a reasonable level of stress.

Finally, on the 10th day, time slowed. I was admitting another patient when I received the page, "Your patient passed. Family at bedside. Please return to CACU." It wasn't a drawn-out struggle, with codes and shocks. My patient died with family at her bedside, without drama and hopefully without pain. After numerous family meetings, the decision had been made to provide comfort care. No heroic measures; just time for good-byes.

Medical school does not teach you how to deal with death -- just all the measures to keep people living. There was no chapter to read and memorize, no evidence-based algorithm to run through. All that was left was checking the patient for signs of life, officially pronouncing death, making the appropriate calls, and filling out the paperwork. At least that's what I was told.

Entering the room, I felt this calmness after a storm, as family members sobbed around me. I examined my patient for breathing sounds, pulses, reflexes, response to painful stimuli. She looked so relaxed compared with the state she had been in, struggling with her IVs, surrounded by wires and tubes, fighting for life. I felt reassured that my patient was no longer suffering, and I felt peace that her family will no longer see her suffer.

Pronouncing death for the first time has been the most difficult responsibility in this new role. Wrapped up in the crazy nights and worried that I'd miss something or make a mistake, I forgot that death happens. I didn't prepare myself for that option.

These first 10 days have been mind-blowingly busy. But in the middle of all the frantic pages and running to rapid responses, the time seemed to stop in the stillness of that room, with family around me waiting for news they already knew. And while I'm sure it gets easier, I hope I don't lose that part of me that retains the softness of humanity.

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