Events Overnight – Five Days Old

“How are things on Red Team?”

“Everyone’s doing okay so far!” I laugh before adding, “I’m not using the Q word.”

We’re a superstitious bunch in medicine, despite our roots in science and evidence based practice. We knock on wood when we say things are going well, and we never proclaim any shift “quiet,” for fear of invoking the wrath of the Medicine gods. We too, like our patients, have fears that are not easily overcome by data.

I was a sub-intern on the Pediatrics floor team, on my first overnight shift. It was surreal that I was covering an entire team, when just a few years ago I was a pre-med shadowing an overnight team, marveling at the prowess of the residents who could report an admission without glancing at their notes. I was months from being in their shoes, in my fourth year of medical school.

All were now second nature: the electronic medical system, the normalcy of short forms like HDS (hemodynamically stable), CTAB (clear to auscultation bilaterally) and NBNB (non-bloody, non-bilious), the adoption of the medical superstition (don’t jinx the shift), even the instinctive search for free coffee in the resident lounge. It felt incredible to acknowledge that I hadn’t always been this person, part of this “we,” that was the medical world. Medical school, having submitted my applications to residency, has been an amazing journey. It is something I will always cherish, as having furnished me with the skills to face a person in need and be able to think critically about what is wrong and what I may do.

If I could break medical school into four parts, it will be based on something we call SOAP. No, not the disinfecting emulsifier, but Subjective, Objective, Assessment and Plan. It is an acronym that defines how physicians communicate; the first part from the patient, the second through tests, the third an analysis and most likely diagnosis, and the last meaning what should be done. It helps us organize our thoughts, it helps the listener compartmentalize our monologue; like chapter titles in a book, the audience knows what to expect from each part. In the fourth year, and even the latter part of third year in medical school, the expectation is that we begin to tell the patient’s story in this manner, with emphasis on the A/P. We are putting together the details of the S&O and using our preclinical and clinical knowledge to develop a reason for why the patient is in the hospital. As an academic exercise, it calls to mind one of the Analects of Confucius, “Isn’t it a pleasure to study and practice what you have learned.” In reality, and especially in pediatrics, it is sometimes a moment of acute anxiety from the audience, the parents, the kids.

As easy as it may be to type an overnight note about a “five-day old male infant, ex-39 weeker, of GBS negative mom, presenting with fever of unknown origin,” the actual delivery of this presentation is a more frightening endeavor. This child was on my team, the team that I was covering. My senior had volunteered to see the patient with me – it was my first overnight after all – and I met the parents, one of whom was a physician. Some family members were also present, one of whom was introduced as a malpractice attorney. Only imagination would allow me to conceive that this may be a quiet night, regardless of the outcome. The Infectious Disease (ID) service had already been consulted, cultures were pending, and broad coverage antibiotics were being delivered empirically. Some erythema and lower extremity tenderness to palpation had been reported by the day team and imaging was recommended, completed, results pending. I had made the rounds and was reviewing vitals in the resident lounge when my pager went off. I recognized the room number and went first to the nursing station.

The parents wanted to speak to someone about the imaging results, cultures, and any updates from the consulting teams. I sent a message to my senior with this information and got the go ahead to update the parents. There is another acronym for presentations in medicine, I-PASS, which was developed to facilitate complete handoffs from one team to another. I-PASS stood for, Illness Severity, Patient Summary, Action List, Situational Awareness and Synthesis. Under “Situational Awareness,” for the room I was about to walk into, was, “delicate situation, parents stressed.”

The enormous understatement of those four words was clear as soon as I walked in; the tension within the room, seeming to push outward, keeping the nurse who had followed me, hovering at the doorway. I took a breath, introduced myself, checked the baby, followed every correct procedure under the watching eyes of the family, rigidly reminding myself that I must still do my job. Completing this, I turned to the parents for the second part. Before making my journey to the room, I had studied: the patient history, every lab value, every vital sign since admission, new radiology entries, the name of the consulting ID fellow, and the number for Radiology. I waited for each question, and there were many. Cultures had returned, sensitivity to antibiotics pending, ID recommendations had not changed. Imaging results pending, my physical exam had not revealed any new signs of infection, and vitals remained stable. I could feel the sweat gathering on my brow as the questions came flying. The anxious expressions around the room never seemed to waver, until the end, when I concluded that I would return with any new updates. There was a terse nod, from dad, and I exited.

As I updated the nurse, I kept reviewing my performance; had I made any errors? Unlike one of the many tests we take in medical school, going back to change an answer given to the parents of a sick child has larger consequences. There was a reason those adults sat listening to me, a student, while their baby lay sleeping, almost blanketed by wires and tubes: trust. I looked at my sheet of notes, nodding to myself over each value. As frightening an experience as it was for me, to feel watched, judged, questioned, it must be an even more terrifying one to see your child in a hospital. Whether five days or five years, it must remain a daunting experience.

I have learned so many things in medical school, from antibiotic therapies to renal disease to interpreting complete blood counts. The most important thing I have learned, though, is to recognize the incredible privilege we have as doctors, as medical students, to be invited into a room to witness the pain of another human. It is a privilege to bear the trust of a parent of a sick child. It is a privilege to feel the fear with them, that we’re not treating appropriately, that there is something we missed. It is a privilege to check, and check again, so they have the most accurate answers. I have learned that it is a privilege to practice medicine.