Resident Thoughts

“There are some things you learn best in calm, and some in storm.”

– Willa Cather

Over the past several years, I’ve thought a lot about what to say during the immediate moments after a failed cardiac arrest or traumatic resuscitation. When the rush of adrenaline comes to a screeching halt and all that is left is a deafening silence, words often fail me. Ashamedly, I tend to look to my attending for guidance in these moments.

After a particularly busy Bellevue overnight, one that included a cricothyroidotomy, a thoracotomy, and multiple chest tubes and central lines, I walked home that morning reflecting over the past three years of training and how things have changed. When I matched three years ago, I had dreams of doing it all – reducing joints, intubating GI bleeds, reversing life threatening DKA. And residency has given me all of that.
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There is a man living in New York City who once suffered a traumatic brain injury and is now frequently brought into our ED by EMS with a chief complaint of “seizure.” Often providers order labs, imaging and medications, prescriptions he doesn’t fill and make clinic appointments he never attends. He appears disheveled so many assume he is addicted to alcohol and has seizures due to withdrawal.

“Seizure” is the one of the few English words this man knows. He is Polish, as am I, and in speaking with him in Polish, I’ve come to understand the circumstances that have rendered him one of our “frequent fliers.” He is street homeless and often sleeps on sidewalks or park benches. Concerned passersby call EMS to help, but they cannot understand him so he says some of the only English he knows – “seizure” – and they bring him to our ED where miscommunication leads to the usual algorithm.
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“Take one more look. Surgery will prep the neck in the meantime.”

Emergency medicine is a cruel field. The more I learn, the more I realize my deficiencies, my weaknesses, my fears. As I uncover the intricacies and nuances of this specialty, questions continue to arise. The scope of practice is ever growing and self-doubt seems to only grow with experience.

If I’m being brutally honest, some things haven’t changed since intern year. I still get nervous before every shift. My heart skips a beat whenever the trauma phone rings and my hands get a little shaky every time a critical patient is wheeled into the resuscitation bay. In many ways, I feel like an imposter as I head into my last year of training.

Why? Because there is so much that I don’t know. And in a year’s time when I graduate, there will still be so much to learn.
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“What’s your airway plan, Michelle?”

To be quite frank, I don’t think I actually listened to what my junior said in response. Without much thought, I promptly replied (in my big boy voice), “Awesome, I’m going to help you set up.”

Since July, I’ve been told that I’m a “senior resident.” I’ve also been told (by Uncle Ben), with great power comes great responsibility. Now that my co-residents and I have been tasked with supervising our juniors and running a team, I’ve encountered a new dimension to clinical medicine – the art of precepting. Suffice it to say, I have never been more tired as a resident. For ten to twelve hours, I am obsessively reviewing labs, looking at imaging, verifying that urine and cultures has been sent, leading resuscitations, and constantly running the triage board. It’s difficult evaluating critically ill patients; it’s even more challenging delegating responsibility and making sure things don’t fall through the cracks in a hectic ED setting when you aren’t always the primary provider.
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The Paradox

“Go take a break.” “Let me quickly pick up these two patients.” “Go grab some food and come back.” “I’m fine, I’ll just…” “Sanjay, get the hell out and don’t come back for fifteen minutes.”

It was my sixth overnight in a row. After having struggled for over 15 minutes with trying to place an ultrasound guided IV in a sickle cell patient, my senior resident felt my exasperation. She had also probably seen me almost engage in a yelling match with a middle-aged man who was demanding a plain film for chronic muscular lower back pain and witnessed my frustration when dealing with several patients requesting medication refills for their metformin and insulin.

As second years in a four-year training program, my co-residents and I are now expected to master triage, volume, and efficiency – we are the workhorse of the program;
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“Just cut. He’s dead”, my senior resident calmly whispered behind me. I had walked through the crash chest tube hundreds of times in my head. I knew the steps like the back of my hand – fourth or fifth intercostal space, mid-to-anterior axillary line, cut above the rib, bluntly dissect with the Kellys, pop through the pleura, and keep your finger in the pleural space. In fact, my senior (who I shall now refer to as the Chest Tube Whisperer for the remainder of my time as a resident) talked me through the procedure just before our patient arrived to the trauma bay. I was ready – I was gowned, scalpel in hand, heart racing. But in that moment, all I could think was, “BUT WHERE IS THE BETADINE?!”

Truthfully, I might have blacked out for the next 10-15 seconds – for the next thing I remember was having my finger in this patient’s thoracic cavity.
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Dear Sanjay,

Hope you’re doing well. You’ve probably just settled into your first adult-sized Manhattan apartment. It may take a while, but you’ll eventually manage to find your stethoscope – it’s been gathering quite a bit of dust since Match Day. Your scrubs are free of bodily fluids – at least for now. And that shiny new badge with the letters M.D. probably feels a little heavy at the moment.

I write to you as your future self – almost a year older, hopefully a year wiser, and ever more confident that I made the right choice in devoting my life to this craft. I write to you in hopes that you heed at least some of my words, for the next twelve months will be some of the most challenging of your life thus far – physically, emotionally, and spiritually.

Much of intern year will be spent outside the walls of the emergency department. 
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I often joke about the first time I ran Side1 as the sole resident. It’s a rite of passage here in our program. During our adult Emergency Medicine months, every so often, one of the interns is responsible for holding down the fort on Side1 in the Bellevue ED during the weekend. To those who are unfamiliar, Side1 is a cozy little corner of our Emergency Department that has 6 patient slots and should hold 12 patients. Of course, on most days, it holds over 20.

A few hours into that first shift, after I began carrying eight patients (four of whom I had yet to write notes for and needed IVs placed and labs drawn), I half-jokingly told my attending that we should probably overhead page, “Side 1 is now on diversion.” Needless to say, she was not particularly pleased. Somehow, twelve hours came and went and I eventually made it back to my apartment beaten and downtrodden.
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