Taking a New Perspective.

Today on my run I not so elegantly tumbled on some moist leaves on the sidewalk, it had rained earlier that morning. “What is with the leaves?” I exclaimed. Much like Newton realizing gravity from an apple falling on his head, I too had realized the answer to my own inane question. It is fall. I regained my composure and stopped and looked around. I was completely surrounded by trees showing off their violent biological display as they prepare to rest for the winter. This realization caught me off guard, not because of the beauty, but that it has been happening and I had not noticed it. I have been so absorbed in study that my brain had simply stopped taking in information unless specifically prompted to do so. I am sad to admit that I have been walking through a tree lined street stepping through leaves and had not noticed the amazing display happening all around me. Essentially I have been walking around with my eyes closed.

I shudder to think about what else I have not been seeing. Have I been neglecting my patients? My friends? My classmates? Myself? It is terrifying to think that I have lost something so intrinsically human. However, ‘lost’ is not the right word because I willing let it go.

A Dream for Some a Nightmare for Others

People believe in The American Dream, that with hard work and dedication anyone can become what ever they want. However this is a double-edged sward. When they see someone that is not as successful as they are they assume that they are lazy and should have worked harder. The notion is, ‘I worked to get mine and they cannot have any of it.’

I hope that you never find yourself in sickness or bad luck my friend. If you do I hope that someone who doesn't share your views has the time to help you.

I think that The American Dream has destroyed America.

(reaction to youth conversations at local coffee shop)

One glance

Four classmates and I were swapping stories at our table in a restaurant, unwinding after taking a major exam. One of us was still in his scrubs, and our waiter, overhearing our conversation, asked if we were medical students. When we responded in the affirmative, he told us that his mother recently had been diagnosed with a brain tumor and had to get it surgically removed. "It was so stressful waiting for the neurosurgeon to come into the waiting room and tell me and my dad how the procedure turned out," he told us.

"Finally, he came out, and his face was a total blank. Absolutely no expression. Couldn't read anything. I guess that's what he has to do, but those fifteen seconds when the surgeon walked over felt like an hour. With each step I kept feeling like something must have gone wrong, my mom must be dead.

"Then he pulled my father aside, and said that everything went great. I was so mad at him that I wanted to punch him, but I was so happy with what he said that I wanted to dance. I can't believe what that guy put me through."

Our once-boisterous table fell silent.

Some weeks back, a professor had told us that practicing medicine is privilege and a burden--you can restore life or take it away, and with one glance or a few words you can alter someone's life, for better or for worse. He told us that people will treat us differently and expect more of us, just because we will be medical students and doctors.

Our waiter just wanted to tell us his story. And without knowing it, he had reminded us that our professor was right.

Walking through the Valley of the Shadow of Death

"Medical student syndrome" is a mainstay of medical training--many students become convinced that they or those around them are experiencing the symptoms of some of the diseases they study. I don't feel like I am suffering from the syndrome, but learning the sheer variety of diseases has made me more frightened of succumbing to one. I had been blissfully ignorant of most of the myriad ways our extraordinarily complex body fails. I now find myself worrying more about aging and about those I love falling ill.

This "walk through the valley of the shadow of death" is part of the burden and privilege of medical training. Soon we will be assuming shared responsibility for our patients' well-being, and we must know their enemies to best protect against them.

Fretting that things might be more serious than they appear can be a mark of a good physician. If a teenage patient breaks his femur while playing football, it's one thing to repair the leg and cast it. It's rather another to step back and wonder if the bone had broken because it was weakened (perhaps by cancer or an endocrine disorder). Seemingly innocuous complaints (muscle twitches in the leg) can have unlikely but serious conditions in their differential diagnosis (Lou Gehrig's disease). This decision of whether to pursue a case further is informed by years of experience, something I currently lack.

I was taught that one needs to feel concern in moderation--too much worry is disabling and too little is reckless. I hope to strike the right balance, for my sake and for my patients'.

Responding to mass-casualty plane crashes

It heartens me to see the medical community's tremendous response to extraordinarily demanding disasters. The recent Reno airshow crash sent 35 patients, many of them grievously wounded from complex trauma, to a particular hospital's emergency department. Reno's main newspaper described the situation inside the ED in a riveting article.

The ED began preparing for patients as soon as they received word of the crash, and an automated telephone system requested that all of the hospital's emergency medicine physicians come in immediately. Physicians from all types of specialties flocked to the hospital unasked so that they could be on-hand. What resulted was remarkably efficient and collaborative care.

I'm reminded also of the 1989 crash of United Flight 232 in Sioux City, IA. 296 people were aboard the DC-10, which due to improper maintenance lost its tail engine and all of its hydraulics. This meant no flight controls (throttle, rudder, elevators, ailerons), no landing gear, and no brakes. The only thing the pilots could control was the amount of fuel going to their two remaining engines. By opening and cutting off the fuel lines, the pilots were able to very crudely control their altitude and somewhat guide the plane, which was constantly turning right. Through a combination of sheer luck, skill, experience, and assistance from air traffic control, the pilots guided the plane over Sioux Falls airport and crash-landed.

Approximately 200 survivors were rushed to Sioux City's hospital. Physicians, in turn, rushed in to help assist. There were so many physicians on hand that the hospital director arranged for a plan: each arriving patient would be met by a team of a doctor, a nurse, and a technician. This team would remain with the patient until they were either discharged from the hospital or admitted. Miraculously, 184 passengers lived.

Sioux City had conducted a mass-casualty simulation a little over a year prior to prepare its emergency response services. The scenario: a passenger aircraft crash-landing at Sioux City airport.

Close call

11:40 PM. I'm on a deserted major road dotted with strip malls in an unfamiliar part of town. I am just about done making a U-turn when a man runs from the side of the road into the right lane, directly in front of my car. I slam on the brakes. The man now is running straight at me. There's something metallic in his hand and he's clasping it to his chest. Is it a pistol? His expression is cold and he says nothing. He is perhaps 30 feet away and closing fast.

What to do? I quickly floor the accelerator and peel out, tires screeching, jerking my steering wheel sharply to the left. I curse loudly. He seems surprised and runs to my right. Everything seems to be in slow motion. I brace myself for the gunfire that I fear is imminent.

I look in the rear-view mirror and see the man returning to the hedges at the side of the road. My car doors are unlocked.

Some experiences make you feel lucky to be alive.

Errors

My heart sank and I swallowed nervously. I had just finished administering a vaccine for the second time, and the syringe's plunger felt strange as I finished pushing it in. It hit me. I had forgotten to check the vaccine for air bubbles, and had almost certainly injected a bit of air into my patient's left deltoid. I pictured him dying overnight of an air embolism, a cruel fate brought on by a vaccine that was supposed to protect from harm.

I tried to look calm and found an attending physician, who assured me that everything was fine. The amount of air in vaccines is miniscule, and in fact, having a bit of air in the syringe often helps an injection. No harm done. But I was still shaken. I had skipped a step that I had believed at the time to be critical.

The experience convinced me of just how easy it is to commit a medical error.

Even a simple procedure like administering a vaccine involves a number of important sequential steps. The sharps disposal container needs to be placed with arm's reach before the needle's cap is removed. The medical chart needs to be double-checked to ensure that the correct vaccination is being given. The injection site needs to be disinfected properly. Inevitably, even the best practitioners mess up a step. And it's a tremendous problem, responsible for 48,000 to 98,000 deaths per year.

There is a growing movement to use checklists when carrying out medical procedures, just as pilots do when they fly. One of my favorite medical writers, Prof. Atul Gawande, wrote a fascinating article in the New Yorker on the subject, which I encourage you to read for free. Yes, individuals commit errors, yet the systems they work in can reduce the likelihood of those errors. For example, anesthesiology equipment wasn't standardized in the past, and turning a knob to the right would release more anesthetic on some machines and release less anesthetic on others. Now the equipment is consistent at every hospital in the country, avoiding needless deaths.

The fruits of prevention efforts are masked. When a hospital implements a labeling system to avoid wrong-side surgeries, a patient whose procedure goes well won't know that it could have ended in catastrophe. It's not very obvious when the system succeeds, only when it fails. But even if prevention isn't sexy, we need to still try. Avoiding medical errors is inexpensive, it saves lives, and it is the right thing to do. For my part, I'm writing up a checklist for myself on how to administer vaccines properly.

Photo reproduced with permission via Creative Commons license. Author: @alviseni