A medical student's reflection of "firsts"

It is honorable to fight a battle in the face of an inevitable ending while not knowing when that end may come.

First day of third year — the year most medical students take a sigh of relief as they put their Step 1 book on the shelf and prepare to face the wards:

I happened to draw the short straw by having my surgical rotation first, one that often brings an extra level of anxiety due to the unfamiliarity of the field. Before I knew it, I was fully scrubbed in side by side with my preceptor. All of a sudden, the textbooks turned into reality. Somewhere around the middle of the third day in the OR, we received a call over the intercom for an ER consult about a 52-year-old woman with abdominal pain. My preceptor, clearly busy, told me to un-scrub and get a jump start on seeing the patient.

First ER consult. Pacing down the hallway, I rattled through differentials in my head, trying to prepare for what I was to encounter. As I approached the room, I saw through the door a thin woman lying in the fetal position barely visible under the blankets. As I timidly came to the bedside, I met Ms. D for the first time. In a soft voice, she began to explain an odd history of abdominal pain with months of agony upon eating, reaching an unbearable limit. Before I could finish, my preceptor arrived and stated that the CT revealed some sort of mesenteric mass leading to a bowel obstruction, a presentation that left both the surgeon and ER physician somewhat puzzled. Regardless, her name was added to the OR schedule for that afternoon.

First open case — an exploratory laparotomy at that. Excited at the opportunity, I assisted my preceptor in removing a golf-ball sized mass from her small bowel mesentery, which had subsequently led to a severe stricture, hence the bowel obstruction and pain. The procedure ran smoothly, and we shipped her off to post-op recovery, satisfied that we had likely removed the source of her suffering.

First day of pre-rounding. The following morning I wandered the halls and eventually found my way into Ms. D’s room. I couldn’t believe my eyes when I opened the door to a huge grin and a “Good morning!” Ms. D, the woman whose abdomen I was practically inside of no less than 24 hours prior was beaming with gratitude. We had eliminated her pain. I continued to round on Ms. D, and eventually, the pathology report revealed that her tumor was a rare type of carcinoid mass with a relatively good prognosis. Though she was thrilled, I’m not sure that anything made her more excited than when she was finally eating solid food — pain-free — for the first time in months. Each morning, as I crept into the room no later than 6 a.m., I was greeted with a smile, another thanks and warm conversation. I learned about her oldest son, who was attending graduate school, all of her bizarre allergies that her family made fun of her for, and even about her upcoming vacation to Colorado later that year. She progressed exceptionally well, and we were hopeful that she would be discharged within the next two or three days.

First day of call. I sat in the surgeon’s lounge the next morning eating the powder=egg soup and questionable coffee as my preceptor ran through the patient list. We had our hands full for the day. As we were wrapping up breakfast, over the intercom, we heard: “Code blue, rapid response room 637. Code blue, rapid response, room 637.” Room 637? I knew that room. Before I could say anything, my preceptor had arrived to the same realization. We had to go.

First code. As we walk up to Ms. D’s room, I saw a flurry of scrubs with orders being shouted left and right and a crash cart open with a nurse performing CPR. As my preceptor rapidly discussed the events leading up to her cardiopulmonary arrest with the hospitalist and nurse, I poked my head in to witness the poetic chaos of running a code. I look over to see Ms. D’s body stripped of clothing, pale and limp as chest compressions bounced her off the bed. As I stood in disbelief, I hear my name called. “Take off your coat and help with compressions.”

First time doing CPR. I stare down at the woman who I had come to know as I stepped to the edge of the bed to begin compressions. Two minutes felt like a mere moment, and before I knew it, the nurse tapped me on the shoulder to trade out. Thirty-two total minutes of CPR. After all the medications, pulse checks and orders shouted, we finally stopped.

First time of death. The hospitalist called the time, and the room fell eerily silent. I, with a couple of nurses, stood panting heavily, sweating, after countless rounds of compressions each. Our efforts were futile; it was her time. As everyone began to clean up, I followed my preceptor in silence back to the nurse’s station. We scoured through her chart, discussing and searching for clues as to what could have happened, deep down hoping we didn’t miss something. There were no answers to be found. Likely a postoperative MI my preceptor mumbled. Once done, we logged off the computer, pulled out our rounding sheet, and off to the next room we went. And that was it.

After all of these firsts and new experiences, I felt something unexpected — guilty. Guilty because I did not feel the remorse that I thought would accompany the first loss of a patient. Aside from the obvious sorrow felt from the unexpected death of a woman who I had come to know, I was perplexed by how little I was I phased, especially since my emotions mirrored that of my preceptor. Classmates asked if I was OK after telling them of my week, which further increased my guilt. Should I have been more upset by this?

I ultimately came to a realization that put my worry at ease. We had done all that we could for Ms. D. I know this for I witnessed and took part in her care from the moment she came through the door to the moment her heart stopped beating. We, as physicians both current and future, have poured our entire lives into medical training, to do just that; all that we can do. Training that gives our patients the best fighting chance at overcoming whatever disease process that they may face. Therefore, since it is nearly guaranteed that these firsts will not be my last, it is imperative that I remind myself and my colleagues that we are merely human. That sometimes our efforts might not be enough. Perhaps, more importantly, that is OK.

As long as the efforts for continuous improvement never cease, both in medical knowledge and patient care, medical professionals can take solace in their chosen career. It is honorable to fight a battle in the face of an inevitable ending, meanwhile not knowing when that end may come. With that knowledge, we strive to buy patients time, by doing just that — all that we can do.