A Critical Juncture (Guest blog piece: a medical student comes of age.)

By Allison Greco at MD2B, September 4th, 2012:

During my inpatient sub-I rotation, one of the patients I had been following was transferred to the intensive care unit. As the rotation progressed, my resident would check up on our patient and give us updates like, “oh, they’re on pressure support now,” or “the unit team started weaning pressors today.”

So, um,  that meant my patient was getting better, right?

I knew that I needed to learn what all this mumbo-jumbo really meant before I got set loose on the wards in July  as a “real” doctor.

Fast-forward to my rotation in the Intensive Care Unit. I learned very quickly how to check ventilator settings and why we use pressure support to wean patients from a ventilator. I learned about the different pressors used to keep a patients blood pressure elevated, and put in arterial lines to help monitor those pressures. I learned about Advanced Cardiac Life Support (ACLS) protocol, and stepped in to perform chest compressions in a code blue situation.

While participating in my first code – a critical, life-or-death situation – was certainly a pivotal experience, I found that it was not the most emotionally-challenging aspect of the rotation. While devastating, there was still a tiny voice in my head reminding me, “we did everything we could.”

Perhaps the most overwhelming,  heart-wrenching, and intimidating juncture of the rotation was the busy afternoon where I became an influential part of a family’s discussion about whether or not to withdraw life support.

That afternoon, the hospital had been particularly chaotic. The senior residents and pulmonology fellow were busy managing codes and admissions that were taking place on the regular hospital floors. My interns were busy with critical patients on the unit. When the family of a patient that I had been following asked for someone to talk to, I stepped up without hesitation; after all, I knew both the patient’s case and family well.

I began by giving the family updates on their loved-one’s condition- test results and recommendations from consulting teams. I had been doing this routinely every morning, but today was different. Each and every result had now confirmed that the patient’s condition was irreversible. It was at this time that the family asked whether or not they should opt to withdraw life support.

I had witnessed similar discussions several times in the preceding days on the unit and I remembered previous palliative care meetings on previous rotations. I shoved my personal opinions aside, gathered my composure, and with a limited wealth of medical experience, began a conversation regarding the patient’s best-case prognosis, previous end-of-life wishes, and family’s ethical beliefs. We talked about what steps  – PEG tubes and tracheostomies – would be needed to sustain life in the long term, and we discussed organ donation in the event of care withdrawal. I answered the family’s questions regarding pain control and logistics of a terminal extubation at the facility. It took everything I had to keep my composure – and in the end I still felt like a bumbling idiot – but by the time I stepped out of that room, the entire family had come to a rational decision.

It was this moment – regardless of all the codes, procedures, and ventilatory setting that I had learned during the rotation- that I felt truly like a real doctor.

OnSurg thanks Allison Greco at MD2B for permission to repost. Visit her blog here.


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