Wednesday, March 01, 2006

Clinical Judgement

My friends and I are at about the point in our internship in which we start to have independent thoughts. During medical school you read a lot, you study a lot, and you accept as gospel the assessments and plans of the residents and attendings. At the beginning of your internship you are too mortified with the idea that you actually are allowed to order medications to really think about what you're doing. (Oh my GOD, I just ordered TYLENOL for this man! And I DIDN'T even ASK the ATTENDING!!!) You rotate from place to place and still can't quite get the hang of everything in one month. But by month 8, you're been back to a couple of rotation sites, and you really have seen a lot, and suddenly you start to have thoughts of your own. And sometimes--sometimes--your thoughts are DIFFERENT from what your SENIOR RESIDENT and even your ATTENDING think.

The first time this happens, you are confused. And maybe you want to die, or throw up, or point and laugh at yourself for your sheer impertinence that YOU, a mere INTERN, could POSSIBLY know what is happening with a patient. Ha.

And so you do what the senior resident and the attending tell you to do.

And then it turns out that you were the one who was right.

Sometimes this isn't important. So the senior put the baby on reflux meds, some reglan and some ranitidine, and then the upper GI showed no reflux. And you d/c the order while the attending stands next to you and wonders, "who thought the baby had reflux anyway?" And all is well, and you didn't argue too too much with the senior, and then you don't tell her what the attending said.

Sometimes this is very much important. My friend Michele is a medicine resident and had a patient whose hematocrit was slowly trending downward. The attending and seniors told her, "don't worry, it's dilutional, it's from the IV fluids, no problem." Michele could not shake the suspicion that the patient was bleeding into her lungs. She asked again. Again she was reassured. It took large amounts of pink frothy sputum pouring from the patient's mouth to change the attending's mind. Look! Michele has clinical judgement! Michele has instincts that are right! Unfortunately for the patient, now the pulmonary hemorrhage is worse. Good luck, patient!

I had an entire day like that last Friday. I have a very complicated 7-month-old who I took care of in August and who I also took care of this past month. He had been clinically doing very well after a number of surgeries and post-surgical complications. He was so well that we were starting to do some pretty intensive PT and OT to get him to start doing normal 7-month-old baby stuff. We were moving quickly toward discharge. Then, Wednesday night, he suddenly took a turn for the worse, and started having a lot of stridor. He was breathing so hard that his poor little body was just covered in sweat. Thursday morning we did the full-court-press of evaluation: chest X-ray for pneumonia/fluid overload, soft tissue of the neck x-rays to evaluate for swelling around the larynx or epiglottis, a nasal wash for RSV--nothing. We tried an epinepherine nebulizer treatment--no change. We gave him double doses of steroids, the attending shrugged her shoulders and said maybe it was post-croup changes, and we went about our merry way.

Well, everyone went about their merry way except for the baby, the nurses, and me. I was paged throughout the day to rush to his bedside. Nothing that we could do calmed him down. Nothing comforted him. Nothing eased his breathing. He laid in his little crib and watched us all with terrified eyes. He was so very much not himself. The senior thought he was fine. When I signed him out to the night team, telling them about the kind of day he'd had, the night float senior resident simply wrote, "F*%CK!" next to the child's name. (That's not really a good sign.)

The next day, the kid was still on the floor--not in the PICU--but was getting worse. I paged the senior resident repeatedly through the day. She kept insisting that he was fine. I kept letting her say that, until finally she told the nurses just to page her and bypass me completely. I had too much work to do, and if all I was going to do was page her--for her to tell me that he was fine--I guess she could say that directly to the nurses. After sign-out on Friday, the senior resident on call actually walked with me down to the patient's room to see him. He looked pretty much the same--terrified, breathing fast, working hard. I kept my fingers crossed, and left.

About an hour after I left, he was taken to the treatment room on the floor, where they eventually intubated him and took him down to PICU. Over the weekend in PICU, the ENT docs performed a bronchoscopy, then placed a tracheostomy. Apparently, one of his previous surgeries caused a narrowing in his subglottic space, which somehow had gotten irritated and basically swelled almost completely shut. The poor kid was trying to breathe through a hole the diameter of a pencil. No wonder he was having such a hard time.

So--hurray, I have clinical judgement! I have instincts! I can tell if a patient is really really sick! It's a hollow victory. I love this baby and he's been deeply unlucky. And I've also lost my trust in my senior resident. If I ever work with her again, I don't know if I'll be able to trust her jusgement, or mine. Somehow the hierarchy broke for me, and the all-powerful Oz (in the form of the senior resident) was found to be a person behind a curtain, working desperately at the controls and just . . . being . . . human.

Meanwhile, it is slowly dawning on me that I might actually be turning into a clinican. Someone who looks at a situation, gets all the information that she needs, and then makes an assessment of her own. I could, possibly, maybe a little bit, be developing . . . independent thoughts. Independent thoughts that are not wrong. Or at least, not wrong all of the time.

I might have a medical degree. (OK, I DO have a medical degree. It's hanging on the wall at home and everything.) But it's experiences like this that are turning me into what I have always wanted to be: a real doctor.

2 comments:

yr brother said...

And maybe you want to die, or throw up, or point and laugh at yourself for your sheer impertinence
I now have this odd mental image of you throwing up in front of everyone, then pointing at yourself and maniacally laughing.

Unfortunately for the patient, now the pulmonary hemorrhage is worse. Good luck, patient!
I also have the mental image of Michele just throwing up her arms and yelling "Good luck, Patient!!" and busting a chuckle while walking out the door. (Well, a hypothetical Michele, being that I have never met the real one.)

Anonymous said...

When I signed him out to the night team, telling them about the kind of day he'd had, the night float senior resident simply wrote, "F*%CK!" next to the child's name. (That's not really a good sign.)

This was a great read, I have to say this made me laugh ("F*%CK)........... you are well on your way to being a good clinician. Trust your gut instincts they are usually right.


a nurse