Reflections from Intern Year (Part 2)

Emergency Medicine

There were many patient cases I encountered during my Emergency Medicine rotation in April that left an indelible, emotional mark on me, but I will highlight a couple. 

Preserving a Patient's Dignity

I developed quite a few frustrations with the field of Emergency Medicine during my month working in the emergency department (ED), including the lack of continuity of care, the stress of the high acuity of care, and importantly, having minimal time to spend with patients. The latter prevents you from taking a thorough history or performing in-depth physical examinations. It drove me insane. I'd gotten so used to being thorough on the general medicine services; it was such a shock to experience the rush of emergency medicine. I was forced to write brief, concise notes, rather than the thorough narratives and assessments & plans I was used to crafting on the inpatient side. 

It was one 3-11PM shift (that extended until 12:30AM) in the ED that made me realize how much I hated working in emergency medicine. It was the busiest shift I ever had: I didn't get the chance to eat, go to the bathroom the entire time, or even take a minute to myself. It was very stressful, what with trying to get a patient admitted to the general medicine service, discharging about three, dealing with an unstable patient with diabetic ketoacidosis, and seeing new ones. Things got very crazy. I could feel that my cortisol levels were elevated the entire time.

One patient, an 83-year-old African American woman, came in from her nursing facility after she was found to have a hemoglobin of 5.9 (normal hemoglobin for women: about 12-15.5g/dL). I had just come on to the shift when the decision was already made to send her back to the facility after she received a unit of blood. Unfortunately, after a repeat lab draw, her hemoglobin had actually dropped after getting a unit of blood to 5.5. I banged my computer mouse against the desk in frustration. There's no way we could send this poor woman back to the facility without ascertaining why her hemoglobin was dropping. I was simply told in sign-out (information about the patients for whom I assumed care) that she had a history of chronic anemia and intermittently required transfusions. But why? I wanted to push, but unsurprisingly, this is not information that the previous intern had, and it wasn't really their fault. Emergency medicine is not conducive to obtaining a comprehensive understanding of patients' narratives and medical problems. That's what the outpatient (or inpatient) setting is for. Not the ED. (Photo from here).

However, lack of information about why the patient had chronic anemia caused problems during my shift when I took over. I skimmed through the prior intern's incomplete note which stated that the patient had abdominal pain. No imaging was ordered, no rectal exam done, and I did not see any mention of stool history in the HPI (history of present illness). Goodness, I would have to do all of those things in order for the patient to be admitted to the hospital. The General Medicine team would definitely need this information.

Before entering the patient's room, I began to don my PPE (she was COVID+) and while doing so, I couldn't help but stare at her through the glass window of her room in the ED. She was entirely hunched over on her right side in bed, her glasses misaligned as a result of her head pressing into the bedrail. She was eating her chicken Parmesan meal with her left hand. A prior stroke robbed her of dexterity in her right hand to use the knife and fork on her plate, so she had to resort to grabbing the chicken with her left hand and stuffing it into her mouth. She made a complete mess of herself. The tomato sauce trickled down her left arm and was smeared all over her clothes and sheets.  

I wanted to cry when I saw this. I felt a lump in my throat and tears welling up in my eyes. I was astounded. I knew we had so much to do in the emergency room and it would take a few extra moments to don our PPE before entering the patient's room, but I was sure that we could all find 10 seconds to slow down and try to preserve our patients’ dignity by simply adjusting them in bed. Let's not have them make a complete mess of themselves while they are eating their meals. It took me just a couple of minutes to adjust this patient in bed and feed her dessert while at the same time tell her about our plan for her care. Why are we not slowing down to try to help our patients? 

I explained to her that I would need to examine her backside because we were concerned she may have been bleeding there. When I turned her, I saw that she was soaking wet and had dark black stool smeared all over her backside. Again, I wanted to cry. No one had changed this poor lady for the entire day. There was no need for me to do a rectal exam. She was obviously bleeding, and probably had an upper gastrointestinal bleed causing this dark tarry stool. I still could not believe that no one had thought to look at her bottom. I opened the door of the room and asked the nurse to help me clean the patient. The nurse must have been overwhelmed with other patients because she simply replied begrudgingly, "What supplies do you need?" Well, I thought, that wasn't what I was asking for, but okay. 

I cleaned the patient up as best as I could on my own, apologizing profusely the entire time. "Ma'am, I'm so sorry that no one was able to help you get cleaned up." All the while, this sweet woman continued to say, "It's quite alright, dear. It's alright." I shook my head furiously in silence, holding back tears. No, ma'am, I wanted to tell her, it's not alright. No one should have left you sitting in your own urine and stool for this long. There were multiple critically ill patients in the trauma bays that required more attention, but they were eventually stabilized. This patient was in the ED for several hours and no one at the facility or here in the ED was able (or willing?) to change her. Again, why are we not slowing down to try to help these people? I abhor that the field of Emergency Medicine oftentimes does not allow you to slow down and spend adequate time with a patient to establish rapport and thorough plans of care that they deserve.

 

The Air Mattress

During one overnight shift in the ED (11pm-7am), I saw a 50-year-old man who came in after a terrible bout of abdominal pain. He had just been discharged the day prior after a one-month stay in the hospital for multiple bowel resections and repairment of an inguinal hernia. He came back to the ED that morning because, since the night prior, he didn't have any furniture in his motel room to lie on, which would help facilitate his healing and recovery postop. He said that his father was going to buy him a recliner and deliver it to his motel, but when he got there, there was no recliner.  His bed was taken away due to hygienic concerns, per the motel owner and cleaning staff. All he had was a chair to sit on, but even that was broken. He woke up multiple times throughout the night. He began having sweats, chills, myalgias, and severely worsening abdominal pain. 

Fortunately, his lab work and imaging in the ED did not reveal anything concerning. His labs actually looked great. His physical exam also looked good: his postop scars were clean, there was no erythema, swelling, drainage, nothing. However, we didn't want to send him home if he didn't have anything there to sleep on. I spent a while talking to social work on the phone, but they were unfortunately unable to identify a way to get him an air mattress or any other furniture to hold him over until the arrival of the recliner that his father ordered. Apparently, the misunderstanding was that his father would buy the recliner while he (the patient) was in the hospital and deliver it to the patient's home, but none of that was done. The patient could not afford to purchase an air mattress for himself. 

I offered to give the patient's father a call to ask for assistance with the air mattress, but the patient adamantly refused. "I appreciate what you're trying to do, Doc," he said, "but that's not a good idea. You calling my pops could make things worse for me. He's an extremely stubborn Jehovah's witness, the chief of our family and household. If he says that the recliner won't get to my place until another few days, then that's that. He won't like it if he finds out I've sent some doctor to go meddling in his business." I asked if it might be better to call his mother instead. "Also not a good idea," he said apologetically. "He'll find out that you called her and become angry about me having someone go over his head to talk to her." 

"Okay," I said calmly, "what about your sister, or nieces and nephews who are living with your parents? Do you think one of them could run to Target or Walmart to get a $10-15 air mattress for you?" 

He shook his head no. "None of them have any money. They go to my pops when they need cash! And then he'll find out that I'm asking them for help when he's already told me that I need to just wait for the recliner to arrive."

This was getting ridiculous. I was trying to help this patient but he seemed to knock down every suggestion I had. I began to get angry with this father of his, but I tried to stay calm because I learned that their social situation was really tough. Earlier, the patient explained that his parents were taking care of his sister (who had "disabilities") and her children, who were previously abused by their father. I understood that there was a lot going on in that household, but I still found it frustrating that the patient was scared and insistent that I not call his father or anyone in the household. I simply wanted to ask if they could spare $10 to go to Walmart or Target and buy an air mattress for him. All in the name of his physical health! Family dynamics can get so complicated.

There was apparently no one else who could do this for him either. I explored a lot of other options with him. His family was basically out of the question, and he didn't really have any other family members around who were available to do this. In the motel, he was close to many of his neighbors. I asked if it would be possible to call one of them and ask if they might be willing to get him an air mattress. He shook his head no and said, "They don't have any money either. We're all paying extremely low rates to live in the motel. No one has any money.” I suddenly decided that I would go out to pick up the air mattress myself and bring it back to the ED for him. The patient expressed gratitude for my offering to do so.

Unfortunately, after I clearly communicated to the attending and nurse that I was going to go out and buy the air mattress for the patient, I was never told that the patient was being rushed out of the ED after my attending discharged him in the system. I made a plan with the nurse that we would keep him in a waiting or hallway area until I returned with the air mattress. When I learned after sign-out that the patient was gone, I grew annoyed with the nurse for not fighting for him to stay put somewhere nearby until I returned with the air mattress. 

"There's a chance he might still be out in triage or in the waiting area," the nurse said. I ran out to the waiting area but he was nowhere to be found. I tried calling the cell phone we had on file for him, but it turned out not to be his number. Someone else's voice and name were on the voicemail. The motel he mentioned had multiple locations, so I tried the one located closest to the hospital. No one by his name was staying there. I tried calling a couple of the other locations multiple times, but no one ever picked up. Perhaps because it was 12AM? I hung up the phone after trying the third location for the 4th time and sighed in frustration. I felt horrible. I felt like I really let this man down. I made a promise and I wasn't able to fulfill it for him. I worried that he would probably bounce back to the ED in the days he was waiting for the recliner to be delivered to him. 

I tried to make myself feel better by saying, well, I tried. I really did. But I still felt terrible. This poor patient was alone in what I imagined to be a dark, moldy motel room with a broken chair as his only furniture. He would almost certainly develop severe abdominal pain again after another night of immense discomfort. I was very sad that we couldn't solve the simple problem of getting this poor man an air mattress.

Intern Year Rewarding Experiences

Not all of intern year was stressful. In fact, it was mostly rewarding. Dare I say that I favor residency more than medical school? This is because I am deep in the trenches of patient care. This is why I became a doctor! To serve others, provide healing and comfort, and to fulfill God's purpose for my life. 

I'm grateful to have been selected as a recipient of the Duke NIH R38 CARiNG-StARR (Creating Alzheimer’s Disease and Related Dementias Researchers for the Next Generation–Stimulating Access to Research in Residency) grant at the midpoint of my intern year. I am studying the impact of adversity on epigenetic regulation in the development of Alzheimer’s Disease in African Americans.

It's been rewarding in itself to reflect on many other experiences and patient cases. I keep a notebook in my EverNote app that is dedicated to reflections throughout the year on difficult patient encounters, points of major growth in my training, teams that I worked well with (or didn't work well with), my growing passion for Alzheimer's, etc. It is at the end of these 12 months that I recognize more than ever how much I value the doctor-patient relationship. It is truly a privilege to serve patients in this profession.

Reflections from Intern Year (Part 1)

I am at the end of my intern year of residency. I completed a year of Internal Medicine, which is required for Neurology residency training. I will then begin my Neurology focused training in a couple of weeks, which will last for 3 years.

First day of Intern Year (Orientation)
June 25, 2020

This past year was arguably one of the most challenging and rewarding times of my life. I knew that internship would be difficult, but I never imagined that my experiences would leave me feeling all of the following: humbled, beaten down, furious, shocked, depressed, exhausted, laughing so hard I was clutching my stomach, overwhelmed, stressed out beyond belief, and ultimately, even more passionate about becoming a competent, empathetic physician for patients.

It has been a whirlwind. A surge of random memories is sweeping over me (many negative I realize haha, but I have more positives to share later): getting cursed out after my 28-hour call by a frustrated patient at the VA who demanded more information about his upcoming orthopedic surgery. Feeling so exhausted after working a non-stop 12-hour overnight shift in the Emergency Department that I found myself walking around the parking garage for a good while because I'd forgotten where I parked (I made it home safely). Getting swung at by an angry patient during my night shift on the Cardiology service because the day team had forgotten to re-order his pain medications. Witnessing the "n" word get thrown around by a drunk, older white woman in the ED. Also in the ED, caring for an acutely psychotic patient who used to lead a drug trafficking ring. In clinic, seeing an Arabic-speaking woman whose agitated son demanded that I prescribe a 3-month supply of narcotics for his opioid-naive mother without any clear indication for them. 

If you haven't already guessed, residency can be quite an entertaining time. The aforementioned experiences taught me the importance of maintaining a calm composure in high-stress situations. The stories certainly don't end there. And they're not all negative either! It has been amazing working with remarkable, selfless co-interns and residents at Duke. I also can't express enough how wonderfully supportive and encouraging the leadership has been (program directors, Chief residents, other faculty). I have been pushed to learn and grow in ways that I truly didn't think were possible. I deeply value the relationships I've been able to build with my patients in both the inpatient and outpatient settings. I am so grateful to one of my senior residents who showered me with affirmation early on in my intern year, generously sharing that I had one of the best bedside manners he had ever seen by any provider. I embraced opportunities to mentor both medical and PA (physician assistant) students, all of whom were valuable additions to the medical team.

I'd like to share a few stories and highlights from my intern year in this entry. For the sake of organization, I will break it up into challenging experiences then I'll end briefly with the rewarding parts of my training thus far. 

To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families.

Intern Year Challenges

Imposter Syndrome: Being at the Bottom of the Trainee Totem Pole

First-year residents (interns) are fledgling physicians who just finished medical school. We are on a steep learning curve throughout the year. Sometimes I found myself wondering: what in the world would I do if I didn't have [insert name of upper level here] around? Fortunately, I gained more confidence and autonomy as the year went on, but I certainly experienced extreme Imposter Syndrome at the beginning. (Photo from here)

First Day of Intern Year                       

I'll never forget my very first day of intern year: I started off on the Stroke service (Internal Medicine residents at Duke complete a few weeks of Neurology every year during their training). Looking back, it's embarrassing to think about how little I knew at the time. I never got paged as a medical student, so when my pager went off for the first time, I didn't even realize that it was mine. 

As a medical student, no one will yell at you for accidentally leaving your pager at home, or for forgetting your stethoscope or other examination supplies one day. As a resident, you wouldn't dare leave anything behind. In the mornings before driving to the hospital, I got into the habit of double-checking to make sure that I had my hospital ID, pager, stethoscope, face shield (when it was still mandated we wear them), alcohol wipes (to clean my stethoscope), and most importantly, my phone, which is always a lifeline at work. 

Anyway, my JAR (junior assistant resident; second-year resident) had to tell me that it was my pager going off. When I silenced it, I didn't even know how to work it to read the entire message. I internally scolded myself for not fiddling with it ahead of time to figure out how to properly navigate its functioning. The page was about my patient who now had low blood pressure and was feeling symptomatic (lightheaded). His other vitals were fine. I stared at the page. It suddenly felt like all knowledge I may have had about hypotension washed out of my brain. I also didn't know this patient very well as it was my first day on the service. I was finally able to move my feet to find the nearest phone to call the nurse back and ask for more information. She sounded so calm. I was so nervous. 

"Hey Dr. Rose, Mr. E's blood pressure is 86/49 after checking it three times. He says he's feeling a little lightheaded but is otherwise stable. His other vitals look fine. Do you want to give him fluids?"

I froze. Wow, she just called me Dr. Rose. That's me. I pinched myself to re-focus. I had to make a decision. But I wasn't sure what to do! I turned around to see that our team was still rounding. The attending was teaching about common stroke etiologies and the medical students, nurse practitioner, and JAR were listening intently. Crap, I didn't want to pull my upper level away to ask for her help with something this simple. I wracked my brain for what to do next. The nurse, sensing my hesitancy through my silence, offered, "We can give him fluids. They gave some when this happened before. How much do you want to give?" 

I wanted to kick myself. I didn't even know what to tell her for how much or what kind of fluid to give.  "Um... how much fluid did he get before?" I finally got some words out. 

"One liter of normal saline," she replied.

"Okay, let's do that," I told her, happy to have resolved this so I could return to rounds with the rest of the group.

"Sounds good. Would you mind putting in an order for the fluid?"

I froze again. I didn't know how to put in that order! Darn, I didn't know how to do anything. I felt so incompetent. Fortunately, my upper level had by now broken away from the team to see if I needed help. She saved me by showing me how to put in the order. The patient remained stable and his blood pressure improved slightly with the fluid bolus, but later that afternoon we explored and aimed to address the reasons why his blood pressure was intermittently dropping.

Now, one year later, I know exactly how I'd approach this situation differently. After getting the page, I'd call the nurse back while reading through the patient's chart to get information more quickly. I would ask for the other vital signs. If they're unremarkable, I'd clarify where and how exactly the blood pressure was measured. Sometimes the read is inaccurate because the blood pressure cuff is not tightened properly or it's placed on the patient's forearm or leg (yes, this has happened before). I would then, in no particular order, and while reviewing information in the chart, inquire about where the patient's blood pressure usually runs (i.e. is the 86/49 reading just slightly lower than a baseline of 90s/50s?), if he was mentating well or experiencing any other symptoms, if there were any concerns about an infection, if he had a history of heart failure, advanced renal disease, or cirrhosis (to determine how much fluid to give him), etc. The nurse would probably be able to answer most if not all of these questions. I would then fill in the gaps with my chart review. It's important to gather and synthesize information quickly to determine the next steps.

If there was any indication that the patient was acutely unstable, such as other concerning vital signs (i.e. needing oxygen to breathe, very fast heart rate) or looking unwell (i.e. pale, perhaps frank bleeding from a clear source such as the rectum), I would not waste time reviewing his chart. I would immediately go to the bedside to evaluate and stabilize the patient. 

I hope to grow in these other important areas as I continue on in my training: 

• Pathophysiologies: My co-interns and I worked our butts off in medical school to solidify our understanding of numerous pathophysiologies that underlie disease processes. As an intern, though my many patient encounters helped hone my knowledge base, I still felt much of this mastery slip away because I wasn't using certain concepts. Lord knows much of the minuscule basic science details we needed to master for Step 1 have dissipated from many residents' minds. I remember more from my Step 2 studying, and perhaps even more from Step 3, but the knowledge I am not using or cases I'm not seeing often (i.e. biostatistics concepts, management of certain cardiologic emergencies such as pericardial tamponade, specific infectious diseases, etc) has inevitably faded. Fortunately, this knowledge is revived and sharpened with more experience and patient encounters.

• RRTs/Codes: (RRT = Rapid Response Team; a patient is unstable, Code = code blue; a patient's heart stops). Throughout the year, I was involved in multiple RRTs and a handful of codes in the inpatient setting, but I led few. I aspire to emulate my senior residents who are confident leaders in emergent situations such as these in the hospital. It takes tremendous skill to calmly, efficiently, and effectively lead a team of clinicians (nurses, respiratory therapists, pharmacists, etc) to achieve optimal quality of care for an unstable patient.

• Goals of Care discussions: Leading conversations with families and patients with terminal illnesses about life-sustaining interventions is such an important skill to hone as a provider. My uneasiness with goals of care discussions stems from a traumatizing experience on the general medicine service: I cared for a patient with terminal bladder cancer who we planned to discharge to home hospice per his wishes. However, the day prior to discharge, he developed major clotting in this bladder that we presumed eroded into a nearby artery, causing massive bleeding. This was completely unexpected. My attending swiftly and gently led a discussion with the daughter about the possibility that the patient could pass away that evening. 

Unfortunately, he died sooner than that evening. After our conversation with the daughter, the attending and I exited the room to place comfort care orders, but not too long after those orders were signed did we hear the daughter scream. A nurse came rushing over to the work station. She tapped me forcefully on the shoulder then waved me over. "We need a doctor, we need a doctor!" She then rushed back into the patient's room. The attending and I were on her heels.

When we entered the room, the daughter was still screaming. Her knees buckled, her head bowed and grazing her father's face, her hands tightly gripping the head of the bed. "Please know that I did all I could!" she cried. The patient looked very pale; he was staring into the distance with lifeless eyes. The nurse looked at me and the attending and shook her head gently before averting our gaze, as if to say, "He's gone."

Another nurse grabbed hold of the daughter before she lost her balance. She was then led out of the room. That was the first time that I pronounced a patient dead. I heard the daughter's screams in my sleep that night. I remember waking up in a panic to those screams, distressed and heartbroken.  

Moving forward, I know that I will lead more goals of care conversations with patients and their families. It is important to be able to do so with deep empathy, candor, and compassion.