For most medical students, the fourth year is a time of coming into our own. We’ve completed our clinical clerkships, passed our first board exam and begun applying to residencies in our hoped-for specialties.
We also get our first taste of independence as clinicians.
During special rotations called subinternships, we act as patients’ primary-care providers. Under the supervision of an attending physician, we examine patients, write orders for tests and medications and make decisions on treatment plans.
This experience is exhilarating, but it can also spark fear–of failure, of harming a patient or of saying or doing something foolish. For me, the fourth year has been marked both by great hopes and by a hefty dose of fear.
It’s the morning of the last day of my pediatrics subinternship at a large children’s hospital, and I’ve just made a bit of a fool of myself.
At 6:00 am, I saw a new patient–a boy, age six, with severe neurological issues. Admitted overnight after a failed surgery, he’d spiked a fever and was in pain.
I did a quick exam, and one of my findings sent my heart up into my throat–a single, fixed and dilated pupil. Pupils like that are scary. It could mean the brain is being compressed, from trauma or swelling or something else.
I rushed out and grabbed my senior residents. We were just about to call the ICU emergency team when the neurosurgery team informed us that the boy’s pupil is always like that.
Even though I was worried for all the right reasons, it’s hard not to feel stupid. Students have a reputation for panicking unnecessarily; I hope I haven’t just earned that reputation for myself.
Now the boy’s fever has broken, and he looks better. Reassured, I move on to Noelle, my last patient of the morning.
Almost two, she’s been my patient for the past week, so I know her well. I have ten minutes before morning rounds; only time for a quick hello and exam.
Entering Noelle’s room, I say, “Hi, good morning,” just loudly enough to rouse her mother, Allison, who’s dozing in the reclining chair. “Sorry to wake you.”
Noelle is sleeping in her crib. Allison looks tired, but content. They’re waiting for a bed at a rehab facility; she’s hopeful that they’ll be leaving soon.
Noelle has been through a lot. She was born with hydrocephalus, a condition where fluid gathers in the brain, and she had to have a shunt (tube) surgically placed to let the fluid drain into her abdominal cavity. Unfortunately, the shunt got infected and had to be replaced. She was lucky to get through it relatively unscathed; too much fluid around the brain can be deadly. But for the past week she’s been recovering well. All along, we’ve carried out the steps and tests needed to ensure that her shunt is still working.
“I heard you had a rough night,” I tell Allison. The night intern had said that Noelle was restless overnight, with some crying, and episodes of high blood pressure–nothing too unusual for her.
“It’s all right.” Allison smiles tiredly. “She’s better now.”
“I’ll just examine her quickly,” I offer. She nods and rolls over to return to sleep.
It’s then that I notice that Noelle looks off. My heart revs up, as if my body knows something my mind doesn’t yet. She’s lying right up against the bars of the crib, with one arm and one leg hanging out. Odd. I walk over and gently place them back inside.
I stare down at her. She’s very still. Her belly isn’t moving. I reach in and lay my hand on her chest. For a second, I’m almost reassured: I can feel her heart pounding. But it’s fast and irregular, and I don’t feel her chest rise and fall.
For the second time this morning, I leave a patient’s room with my own heart pounding. I beckon to the first person I see. I must look terrified, because three people come immediately.
“What’s going on?” the night intern asks.
“She’s not breathing!” I say, then rush back in.
We surround the crib. I yank down the bars. Three sets of hands rub at Noelle’s chest; three voices call her name, to no response.
“Someone press the code bell!”
I reach over to the wall and slam it. It’s so infrequently pressed on the general pediatrics floor that it’s been covered with tape to prevent wayward hands from generating a false alarm.
I rip open a plastic bag and snatch the mask and oxygen bag from inside. I feel like I’m watching myself from a distance: I can’t quite believe I’m standing here, fully prepared to start manually pushing breaths into a two-year-old. I’ve been taught to do this, of course, in an orientation session that at the time had struck me as overkill.
I’ll never forget Allison’s strangled “What’s going on?” and the feeling of her dead weight in my arms as we struggle to help her out into the hallway. The whole floor is suddenly flooded with nurses, doctors, staff and students.
Noelle is intubated and whisked away to the ICU, leaving a curiously quiet, empty room.
I know that she has survived, at least for now.
Later in the day, I learn that her shunt had been slowly, insidiously failing. Fluid had built up inside her skull until her brain was squeezed down against the brain stem, compressing the areas that control breathing. This last development must have happened right before I walked into the room; she couldn’t have lasted long in that state.
Luckily, the neurosurgeons have drained the excess fluid in time. They’re booking another surgery to replace the shunt.
Everyone congratulates me on being there to discover Noelle’s desperate emergency, on getting help and initiating the process that saved her life.
I’m reluctant to take any credit for this–and I’m simply flabbergasted at the timing. If I’d put more stock in her overnight fussiness and had seen her first thing, could I have prevented the whole episode? Or would I have arrived too early, and would Noelle later have died in the room without anyone noticing?
I still struggle with how much of it was due to chance, but I accept that I was in the right place at the right time, even if accidentally. If I’m proud of anything, it’s that I trusted my clinical judgment. Lack of breathing is, of course, a glaring symptom–but so was the little boy’s fixed and dilated pupil. In his case, I’d tried to downplay my fear. With Noelle, I didn’t allow any maybes.
I fight back tears the whole day. My team–students, residents and attending–are all incredibly supportive. In our debriefing session, I get some of these feelings off my chest: how afraid I’d felt to trust my instincts, for fear of being wrong or looking foolish, and how that was swept aside by my fear for Noelle and her life.
It sometimes feels like the worst thing you can be in medicine is wrong. This field is hierarchical, and it can be incredibly difficult to speak out, even in a patient’s best interests. All too often, students’ opinions are met with nonchalance, condescension or even ridicule.
Now, though, I think there’s plenty worse than being wrong. You could be lazy, neglectful, unobservant or distrustful of your instincts.
Or quiet. You could just be quiet, and let bad things happen.
About the author:
Erin McCoy is a fourth-year medical student at Albert Einstein College of Medicine in the Bronx, planning a career in child neurology. Born and raised in Oklahoma, she lives in New York with her fiancé, Jacob. “I have always enjoyed writing as a creative outlet, from the time I was old enough to scribble silly stories. In the summer of 2016 I interned for Pulse and was introduced to how rewarding writing can be, both as a creative hobby and as a way to chronicle and process stressful events like this one. I was so uncertain of how to feel after this incident happened, but laying it out on paper helped me to sort past the congratulations I felt I didn’t deserve, and my own self-criticism, to simply understand how and why everything unfolded and what I learned from it. Lately I’ve been busy finishing up my medical-school rotations, planning my wedding and waiting for Match Day, which is coming up in a couple of weeks!”