This post is a “Dr. Val classic” – first published in early 2007.
Internship, for those of you who may not know, is the first year of residency training. It is the first time
that a doctor, fresh out of medical school, has responsibility for patient care. The intern prescribes medications, performs procedures, writes notes that are part of the medical record, and generally learns the art of medicine under the careful watch of more senior physicians.
Internship is a frightening time for all of us. We’ve studied medicine for 4 years, memorized ungodly amounts of largely irrelevant material, played “doctor” in third and fourth year clerkships, but never before have lives actually been put in our hands. We know the expression, “never get sick in July” because that’s when all the well-intentioned, but generally incompetent new interns start caring for patients. And so, we tremble as we begin the new stage in our careers – applying our medical knowledge to real life situations, and praying that we don’t kill anybody.
I’ll never forget my first day of internship. I must have drawn the short straw, because not only was I assigned to the busiest, sickest ward in my hospital (the HIV and infectious disease unit), but I was on call that day (so I’d be working for 24 hours straight) with the most hated resident in the program (he had a reputation for treating interns poorly and being arrogant to the nurses). As I reviewed my patient list, I noticed that the sign out sheet (the paper “baton” of information handed to you by the last intern who cared for the patients – meant to give you a synopsis of what they needed) was supremely unhelpful. Chicken scratch with diagnoses and little check boxes of “to do’s” for me. I was really nervous.
So I began to round on my patients – introducing myself to each of them, letting them know that I was their new doctor. I figured that even if I couldn’t completely understand the sign out notes, at least by eye-balling them I’d have an idea of whether or not they were in imminent danger of coding or some other awful thing that I figured they’d be trying to do.
My third patient (of 15) was a thin, elderly Hispanic man, Mr. Santos. He smiled at me when I came
in the door – the kind of lecherous smile that a certain type of man gives to all women of child bearing age. I ignored it and introduced myself in a professional manner and began to check his vital signs. I was listening to his heart, and I honestly couldn’t hear much of anything. There was a weird, very distant beat – something I wouldn’t expect for such a thin chest. The man himself looked awful, but I really wasn’t sure why – he just seemed really, really ill.
My pager was going off mercilessly all night. I wondered if this was how the nurses got to know the characters of their new interns – to test them by paging them for anything under the sun, tempting us to tip our hand if we had tendencies to be impatient or disrespectful. But in the midst of all the “we need you to sign this Tylenol order” pages, there came a concerning one: “Hey, Mr. Santos doesn’t look good. Better get up here.”
My heart raced as I rushed to his bedside. Yup, he sure didn’t look too good. He was breathing heavily, and had some kind of fearful expression on his face. I didn’t really know what to do, so I decided to call the resident in charge (much as I was loathe to do so, since I knew he would humiliate me for bothering
The resident appeared in a froth – “Why are you paging me? What’s wrong with the patient? Why do you need me here? This better be good!”
“Um… Mr. Santos doesn’t look too good.” I said, frightened to death.
“What do you mean ‘he doesn’t look too good?’ Can you be a little bit more specific” he said, sarcasm dripping from his tongue.
“Well, I can’t hear his heart and he’s breathing hard.”
“I see,” said the resident, rolling his eyes. He marched off towards the patient’s room, certain to make an example of me and this case.
I trotted along behind him, hoping I hadn’t been wrong in paging him – trying to remember the ACLS
protocol from 2 weeks prior.
The resident drew back the curtain around the man’s bed with one grand sweep of the arm. “Mr. Santos,
how are you doing?” he shouted, as if the man were deaf.
The man was staring at the wall, taking in deep, labored breaths of air. I saw that the resident immediately realized that this was serious, and he placed his stethoscope on the man’s chest.
I approached on the other side of the bed and held his hand. “Mr. Santos, I’m back, remember me?” He smiled and looked me straight in the eye.
He replied, “Angel.” (in Spanish) Then he let out a deep breath and all was silent.
The resident shook the man, “Mr. Santos? Mr. Santos?!” There was no response.
“Should I call a code?” I asked sheepishly.
“Nope, he’s DNR,” said the resident.
I was flabbergasted.
“Yep, you just killed your first patient. Welcome to intern year.”
As I thought about his cruel accusation, I was comforted by the fact that at least, as Mr. Santos released his final breath, he thought he had seen an angel. Maybe my presence with him that night did something good… even though I was only a lowly intern.