Alex Simmonds, VCU School of Medicine
It was very late on a Friday evening as I sat in the trauma bay of our University hospital. I was about halfway done with my trauma-shadowing shift when the infamous blue lights above my head began flashing. I felt the same surge of adrenaline I remember feeling as an EMT when our page tones would startle me awake. It unfortunately meant that someone was very sick or injured, but it also meant that we were getting the very real opportunity of helping someone.
The M3 student that had been so incredible at guiding me around the hospital all evening had a pager that alerted her that it was a delta trauma patient with a gunshot wound we were about to receive. The delta classification is reserved for the most injured patients, so we prepared accordingly. My M3 instructed me to don the full range of personal protective equipment: gloves, gown, face shield, and mask as practice for the future. As just an M1 shadow, I wasn’t expected to actually participate in the case, just watch.
Within the span of just minutes, approximately 40 people descended on the trauma bay. Doctors, nurses, paramedics, radiology technicians, and social workers arrived all prepared to respond to the needs of our critically injured patient. About that time, two paramedics came bursting through the door: one at the helm of the stretcher, the other on top of it actively performing CPR on a patient who was clearly loosing blood quickly.
Following right behind them came the attending trauma surgeon of the evening. She took control of the crowd of healthcare workers as if a conductor leading an orchestra. Each individual knew their role in caring for the patient, but her job became coordinating the combined efforts of the entire team. It became quickly apparent that radical measures had to be taken to give this patient a chance to survive, leading the surgeon to perform a bedside thoracotomy. This is a procedure done to open up the chest, often so that compressions can be done directly on the patient’s heart, which is much more effective than regular CPR. A paramedic student jumped at the opportunity and began pumping the patient’s heart, a procedure known as cardiac massage.
After 3-4 minutes of this process, the paramedic student became fatigued and needed someone to take his place. A trauma nurse at the head of the bed yelled, “We need a sub on cardiac massage!” and it seemed as though all 40 people in the room looked around for anyone who was gowned and ready that could fill the position.
I stood at the head of the bed, still taking in all of the activity I was seeing for the first time when another paramedic grabbed me by the shoulders, shouting “Everybody move, cardiac massage sub coming through!” I had nearly reached the bedside before I realized that I, in fact, had been drafted as the person to begin squeezing the patient’s heart. I looked around as if to say, “Does everyone here realize that I’m an M1? We just finished genetics, I have no idea what I’m doing!” But after an encouraging nod from my M3 chaperone, I approached the patient.
The attending surgeon stood directly opposite of me, and gave me quick instructions to insert my hands into the patient’s opened chest cavity, and to squeeze the patient’s heart fast and hard allowing for complete recoil after each compression. Without thinking, I began doing exactly as she instructed.
Lots of things go through your mind while you’re pumping someone else’s heart for them. “Am I doing this right?”, “I’m actually holding a person’s heart”, and “I wonder if we can actually save this person” just to name a few. I also began to realize that the patient’s heart was attempting to beat in my hands, in between the compressions I was doing. This activity wasn’t organized enough to support the patient’s life, but the feeling of a beating heart in between my fingers was somehow more profound than anything I had ever experienced before. I realized that I was holding the very thing that is most important to life on a minute-to-minute basis.
My attitude instantly changed from that of an observer to that of a man who was personally invested in an underdog that had nearly insurmountable odds stacked against them. After more medications and shocks from the team, the patient’s rhythm changed from disorganized to normal, creating a heart that was beating independent of my intervention. It felt as if the patient had made a full court basket with seconds on the clock to tie the game. I knew we were not out of the woods yet, but we may have a fighting chance.
As rapidly as the newfound pulse came, it left yet again, and it became quite apparent that our efforts were no longer in the best interest of the patient. The attending surgeon made the decision that we would not continue resuscitation efforts, and announced the official time of death.
What does this all mean? In the span of 20 minutes I transitioned from someone who was enthusiastic about science and healthcare to a person who was intimately involved in the last moments of someone’s life. When a case like this happens, my mind instantly jumps to thoughts like “What didn’t go well? What could we have done a little better?”, but the truth is we did everything that could have been done. All 40 people in the room performed their job to the highest level of accuracy, and yet we were unable to make any difference in the outcome. It’s a hard lesson for a first year medical student to learn, but a necessary one nonetheless.
I did learn some insightful things about myself though. I love the process of decision making under pressure, in the face of unknowns. I love the true team effort that occurs with trauma patients. I love the ability to make a real difference in a patient’s life right now as opposed to over weeks or months. I learned that I thrive in these high intensity, make or break situations. I learned that trauma surgery is where I belong in the world.
Andrea Tooley, Resident Ophthalmologist at Mayo Clinic
I’m back status-post finishing my internal medicine rotation, taking my NBME (national board of medical examiners) exam, and taking my school required evidence based medicine exam! Yippee!!!!! I want to take this time to write all the things I learned from this rotation. By doing this after I finish each rotation, I hope to be able to compare how I felt through each specialty and see the different things I learned through different fields of medicine.
1. Continuity of care matters to me
Continuity of care means that you see the same patient over a long period of time; it’s the way you see your family doctor every year for 20+ years (provided you don’t move and you like your doctor :-)) I did not realize how important it is to me to have a long term relationship with patients until I finished this rotation. Some of the outpatient clinics in which I spent time had patients the doctor had seen for 15 years. One of my hematology physicians could literally tell me everything about each patient. “Oh, this patient just had her baby and is probably coming in because of X”. “This patient first came to me 10 years ago after he went on spring break and X happened”. It was incredible to see the interaction between this physician and his patients. They knew him, they trusted him, and they loved him. It really touched me. In the hospital, you tend to see new patients every single day. It is exhausting having to learn each persons past medical history and having to build up trust with a new patient every hour. I never knew that I would place so much importance on having a long term relationship with my patients, but now I know it is definitely something I will look for in a career.
2. Your body is your temple
I cannot tell you how many patients put their health absolutely last on their to-do list. I have seen patients come in with blood pressures of 210/140 (that is BAD) and say “I had no idea it was this bad”. I have morbidly obese patients ask why they are short of breath and have no understanding that the reason they can’t breath is because of their weight. When I would happen to have a patient who cared about their health and was proactive about it, it literally MADE MY DAY! As a physician it will be a personal goal to motivate my patients to put their health first. What are we without our health? I say this as a personal reminder to myself as well. Our bodies are our temples and we should treat them right! That way, we can be active with our grandkids, travel with our spouses, enjoy every minute on this earth.
3. Patients lie and that’s okay
The first time I had a patient lie to me I was sooooo upset. I specifically asked a patient if they had used illicit drugs and this patient assured me it had been 15 years since they had used any drugs. When the urine drug screen came back positive for cocaine, I was SHOCKED!!! I couldn’t believe it! But, now I’ve learned that patients will lie about all kinds of things! Fessing up to all the things going on in your body is a tough thing to do! It’s hard to say embarrassing things like you’ve been having diarrhea, or a sore on your foot smells. And it’s hard to admit to drug use when you know it’s bad for you. It’s my goal to understand that my patients may lie and I simply have to build up their trust to treat them as best as I can. Just because a patient isn’t forthcoming does NOT mean I can write them off and for the rest of their treatment roll my eyes when they tell me something. I just have to work harder! I have to open this patient up and get them to trust me. That way, I can treat them to the best of my abilities.
4. How to calculate a complex acid base state
Okay, this is a sciencey thing but it is still in the top 10 things I learned! Your body can be acidic or alkalotic and balancing those two ends of the scale can be done by your lungs or by your kidneys and GI tract. When you are acidic, you can blow off more CO2 by breathing faster. CO2 is acid in the body and so if you breath it off more, you will come back to a normal state. But if you can’t breath and you are holding on to all that CO2 (like someone with COPD and emphysema for example), your kidneys will compensate by helping excrete more acid. If your kidneys or your lungs aren’t functioning properly we call that either a respiratory acidosis/alkalosis or a metabolic acidosis/alkalosis. It gets tricky when you overdose on drugs or you have a metabolic disturbance caused by a disease etc. In this case, you can have multiple problems. For example, someone might have a respiratory acidosis, a metabolic acidosis, and a metabolic alkalosis all at the same time! There are lots of formulas to calculate all those things and I finally got them straightened out!
5. What to do when someone is having chest pain
Lots of specific questions you need to ask to decide if it’s a cardio problem, a stomach problem, a breathing problem, etc. Lots of different things you need to do right away like get an EKG, get cardiac markers, give them aspirin, oxygen, etc. Basically just some big basics that I learned.
6. Preparation is the KEY to staying healthy
Every hospital has a cafeteria and so I could have easily purchased lunch/dinner/snacks every day. But I GUARANTEE that if I had done that, I would feel like a big pile of mush and I wouldn’t be proud of myself. Prepping food every Sunday has been a LIFE SAVER! I feel like I ate well and stayed on a healthy track even though I was busy.
7. I have no will power
In spite of my healthy attempts to pack lunch every day, I still succumb to all the treats in our team call room. Muffins? check. Puppy chow? check. Brownies? check. Donuts? NO- thank goodness I resisted those! Being able to turn down unhealthy treats is a constant battle. When I get it figured out, I will let you know.
8. I would much prefer a job where I start early and get off early
Days that started at 6 and ended at 3 were WAY better than days that started at 9 and ended at 7. I just like having my afternoons :-)
9. It’s easy to lose your motivation
YES! I found myself feeling pretty blah multiple times over the course of this rotation. I would lose faith in patients, lose faith in medicine, lose faith in myself. I didn’t want to study. I wanted to eat candy. I would eat candy and watch the Real Housewives and then feel like a big blimp. So I would jump on my treadmill and study to undo the damage. Repeat x 2 months.
10. How to get your motivation backI
finally feel SUPER motivated! I am LOVING science. I want to buy all these textbooks that I never bought because I only study from review books and I want to sit down and actually read them and love them. I have this crazy desire to be the best physical diagnostician ever. I want to be able to pick up tiny clues from people’s fingernails, the sound of their breathing, the color of their skin. I want to appreciate my patients. Most of all, I want to appreciate myself. I want to treat my body properly so that I can set a good example for my patients. I want to stay away from the candy and couch and spend days outdoors, riding bikes, grilling out.
SO there you have it! Medicine ended on a happy note. I am thrilled to have gotten this huge rotation out of the way. My next rotation is psychiatry which starts on Monday! I think I will have tons and tons of stories from that one! Have a wonderful day! And remember:
Authored by: Andrea Tooley, Resident Ophthalmologist at Mayo Clinic, www.andreatooley.com
Medical school is tough, even tougher is residency. sometimes we need to hear that voice of inspiration and excitement we carried before entering the journey.
The goal of WhiteCoated is to allow medical students and residents to contribute anything ranging from art to articles to podcasts that help others learn more about the field or rediscover their passion with the goals of bettering themselves and thus enhancing the care of their patients.