In the ER if you’re early you’re on time, if you’re on time you’re late, and late is unacceptable. So on a glorious summer morning recently I arrived to relieve the night shift at 06:45, 15 minutes early, feeling virtuous. Of course I did not beat in any of my residents. They were all there already, laughing, joking, looking ready for anything the day could throw at them, even the ones who had been up all night. Uh oh. I knew that all this energy could mean only one thing: Senioritis. Today was the last day of residency for them. After three years of sleepless nights, countless deaths, constant suffering, and endless shortages of medicines, beds, nurses and ER treatment spaces they had mastered Emergency Medicine. God help their patients. God help me getting through this last day with my chiefs in such unbridled fettle. It was sure to infect the interns who were already rambunctious at having survived their first and toughest year.
The day shift doctors relieve the night shift doctors in a ritual called board rounds. We huddle as a group around the electronic patient tracking board and each night resident presents a brief story about each of his or her patients to a corresponding day resident who will continue the care. Stories of car wrecks and assaults, cancer and colds, nursing homes and homelessness. I and the night shift attending listen and interject when further clarity is needed. Due to the fatigue of the night shift it is usually a low emotion, basic and businesslike affair. We have heard the stories many times before.
This summer morning was different. The stories were energetic and detailed, full of funny things drugged patients said, funny nursing responses, odd and baffling behaviors of patients and even more so consulting physicians. There was a lot of laughter, some of it jaded, but there was mostly an overwhelming joy. This group of residents had been through something big together and had supported each other and had come to love each other. After residency graduation they were going on a grand European tour together.
The interns listened raptly to these tales, envying the cool bravado of these seasoned veterans. I was loath to break up this unusual and therapeutic gathering and so I slipped off to see the waiting patients myself and get their care started. The residents could catch up later.
Eventually the night shift left, repairing to a local tavern for a last breakfast together, while my day continued in the fine fashion it had begun. I still had two senior residents left in grand moods, finishing their last-ever residency shifts. Many of our scribes were also finishing up with us after having graduated from UVA, and the last day of school atmosphere infected them too. One scribe declared he was going to write all of his patient charts today as Japanese haikus. I scanned his work so far.
Unsteady, not dizzy
Chronic history of same
Lung cancer with mets
Multiple falls overnight
Face lacs, spine tender
Increased blood pressure
Noncompliant with ACE-I
Please take prescribed meds
Hmm, Interesting concept.
An EM intern wandered down from a slow inpatient rotation, confident enough in her mastery of her service that she could relax and spare some time away from it to socialize in her favorite place in the hospital—the ER.
We were happy to see her. She was a scribe for us for several years before medical school and rotated with us as a medical student, so many of us have known her for years.
The EMS radio interrupted our chatting to warn of a sick incoming patient, unresponsive, with a faint pulse, and not breathing. I glanced at Lizzy, my senior resident and she nodded—got it. Lizzy looked to the visiting intern.
“You want this?”
The intern looked at me. Technically she wasn’t really working in the ER and this was clearly an upper-level case. But this was transition day, the torch was being passed. Besides it was a chance for Lizzy to pay it forward by passing on the hard -won experience her senior residents had instilled in her. I admired the motivation of the intern, wanting to challenge herself and take on extra work solely to become a better doctor.
“ OK, ’tern, you are running this. Lizzy will back you up if you need it. “
Only in Emergency Medicine would this prompt happy grins from both doctors. I may have allowed a small smile myself, but I carefully hid it from those two.
The smiling stopped when the patient arrived desperately sick and decidedly familiar to us. I had cared for him many times, as had Lizzy, and even the intern knew him from his recent ICU stay. He lived with heart failure, kidney failure, and respiratory failure. He underwent dialysis three times a week. He had been hospitalized in the ICU eight times so far this year, nearly dying each time. He was my age.
Pretty much everything that could be wrong with him today was wrong. For example, he did not have a pulse. Also he did not have an IV. Well, thanks, EMS! To be fair, though, we were unable to start an IV either. Too many IVs over the years had ravaged his veins. Under the “direction” of the intern we drilled a needle into the bone of his lower leg and gave him a shot of adrenalin right into his bone marrow. The bone marrow is very vascular and connects immediately into the central circulation.
Now he had a pulse at least.
We continued to work on him for hours. I had never seen him this sick. He lost his pulse several times. I began to feel a tinge of worry. This was not going in the right direction.
Lizzy and I coached the intern through the resuscitation and the multiple invasive procedures he needed. A central line IV was placed through the jugular vein in his neck and threaded forward until it was positioned just above the entry into his heart. Now we could give him powerful medicines to sustain his blood pressure. Another line was placed in the artery in his wrist to closely monitor the results of our blood pressure tinkering. His breathing was supported by a special ventilator. Antibiotics were given. And still we did not know why he was so sick.
Every few minutes I would slip out to run the rest of the department and give Lizzy and the intern the space they needed to own the resuscitation decision-making.
One of the interns presented a patient to me, a young healthy person with a cold who was hoping for a doctor’s note to get off work. The intern was frustrated with this obvious abuse of the ER.
“Andrew, do you know what I call patients like this?”
“People who aren’t going to die. I like people who aren’t going to die. They are easy to take care of.”
“Well should I give him a work note?”
“That’s what you need to decide.”
Now he was frustrated with me as well as the patient.
I returned to the resuscitation to find there was a new complication. Our patient was now intermittently but mostly constantly having seizures. Oh boy. With careful titration of sedatives and blood pressure support we were able to tame the seizures for a while. By now the MICU team was down and ready to take over. He was finally stabilized and not likely to die, at least in the ED. I slipped out to catch up on my other patients.
The visiting intern came to find me at the desk, where I was reviewing Andrew’s chart. He had given the work note. Good man.
“Dr Reiser, Lizzy and I are trying to decide if we should put him on fosphenytoin or Keppra for long-term seizure suppression. What do you think?”
There was no real scientific guidance to answer this question and no real way of knowing whether he needed either medicine. But neither would hurt him.
“I think you and Lizzy need to decide that.”
“But what do you think?” she demanded.
“ I think you and Lizzy need to decide that.”
Her years as scribe observing my oblique teaching method paid off as a sly smile formed on her face. She had solved the riddle.
“So you’re saying it doesn’t matter which one we choose?”
I smiled back at her but did not say anything.
She turned on her heel and marched back into the resuscitation bay, ready to make a decision. She was no longer an intern. The torch had been passed.