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Time, Indeed, Does Fly

It amazes me how fast life marches on. I feel like I was just a medical student not too long ago. But here I am in my final year of residency. I have almost completed two months. Ten months remain after this. I have my first fellowship interview this coming Tuesday.

It is amazing how one changes over time. I remember when I started medical school. Like 90% of medical students, I briefly entertained the idea of pursuing a surgical specialty at some point. As it came time to apply for residencies I chose Internal Medicine with the intention of going into primary care. I wanted the long-term relationship with my patients. I wanted to get to know them. I wanted to work with them for the improvement of their overall health.

Interests change. Goals change. As I have gone through residency I feel very comfortable on the inpatient setting. Maybe that is a by-product of a heavily based inpatient Internal Medicine residency. My program produces some fine internists that make great hospitalists. Or maybe it is the result of working in a continuity clinic based at a county hospital mainly seeing underserved patients. Only a handful of my patients have any actual “continuity.” Sometimes it feels like every patient I see is a brand new patient to the system. And sometimes I wonder what ever happened to Mrs. X or Mr. Z. Some say that private practice is different. The patient population is different. Perhaps. But I may never actually find out.

Along the way I have decided to pursue sub-specialization. That means that after I complete this Internal Medicine Residency, I will hopefully complete my time as a resident and begin my time as a fellow in an Internal Medicine subspecialty. Of course, there is the chance I won’t match. So for the time being, allow me some privacy. Once (or if) I become a fellow, I will talk about it then.

If I don’t become a fellow I will be able to begin practicing medicine as an attending. That is a weird thought. It’s comfortable NOT having the final say. It’s easier when the decisions and responsibilities don’t fall on your shoulders alone.

The rest of the year promises to be challenging. But I should probably enjoy the ride. Because before I know it, this year will be done.

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Overheard In The ED

I remember one time when my team was on-call. It was late at night and the ED was packed. There were beds and chairs lined up in the hallway with makeshift dividers separating patients.

There was one particular patient at the end of the hallway that I had noticed after walking back and forth. He was a scruffy older man who was lying in a gurney, sunglasses in place. He looked like he was resting comfortably enough.

On one of my trips through the hallway, I had just passed him when a nurse walked up to him and asked, “What’s your name, sir?”

Though my back was turned to them I heard him reply in a deep, rough, scratchy voice, “Wolverine.”

“Wolverine?” the nurse asked.

“Yes,” he replied.

I about died with laughter. I never got to meet this character. He wasn’t admitted to our team. But I’m sure it would’ve been fun to treat a superhero.

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Do No Harm

Do no harm. It’s a simple principle often repeated by medical and non-medical personnel alike. I remember one occasion when a friend asked me, “why do no harm?” He asked why the axiom was a statement phrased in the negative rather than in the positive. Why is the phrase not something more positive like, “Do good?”

During the first 3 weeks of the Internal Medicine rotation I had the opportunity to take part in the care of one Mr. S. He was a 65 year-old smoker who was admitted for a COPD exacerbation. By the time we, the medicine team, had seen the patient, the ED doctors had already seen Mr. S. In the ED, he had received breathing treatments and antibiotics; he also had a chest x-ray performed. The ED Physician’s note, though, had a short comment regarding his negative chest x-ray. It noted that the x-ray was suboptimal and this was probably due to the patient being dehydrated at the time.

The team read the note and put an order for Mr. S to have a repeat chest x-ray the following morning after he had the chance to be rehydrated. No one suspected how much this one order would change the course of Mr. S’s hospitalization. The next morning’s x-ray revealed a new suspicious mass. The reading from the follow-up CT scan reported a new 1.5 cm speculated lesion and an enlarging 2 cm lesion.

After a biopsy that would later reveal that Mr. S had lung cancer, he developed a pneumothorax for which a pigtail chest tube was placed. Somehow the tube ended up out of place – at least that is how the thinking goes. Mr. S subsequently developed massive subcutaneous emphysema. On physical exam, crepitus could be felt from his temples to his ankles. When his airways became compromised, he was transferred to the CCU for intubation and sedation.

Prior to the transfer to the CCU, there was about an hour’s worth of time in which Mr. S slowly ballooned up to the point where breathing was difficult. As a student, one often feels helpless. That feeling is compounded when the rest of the team is also unsure of what to do. In this case, everyone was unsure of how to stop the expanding emphysema. After the transfer, he was no longer under our care so I stopped knowing the details of what happened next. But I heard that Mr. S remained intubated and sedated for days as his body was allowed to reabsorb the air. I stopped hearing updates about him, but I kept thinking about it. The events that led to his emphysema and subsequent intubation and sedation were iatrogenic. It was our fault. We did not notice a misplaced pigtail chest tube until it was too late. Had we failed in doing “no harm?” I don’t know. But we certainly would have failed if the goal was to “do good.”

Perhaps it is all semantics, but I began to think that doing “no harm” is a much more attainable goal than to “do good.” Because doing “no harm” is a more passive approach. And there are times when we just don’t have a “good” option to do. We can merely attempt to do things that won’t make a patient worse while we allow the human body to heal itself. Which is exactly what it felt like we were doing for Mr. S. I kept asking anyone who would hear, “why can’t we do something?” It is a tough thought to accept for people who enter medicine with the intention of doing something. But maybe this slight difference in semantics will help those of us who are in medicine keep our sanity, to feel like we accomplished something – or at least that we are not failures at such a lofty goal as “doing good.”