By Dan Munoz
There are times when you think you're ready for a big step and other times when you're ready but don't know it. When I was 13, mom and dad finally decided that the walls would not tumble, the pipes would not burst and the kitchen would not burn if they left me home alone for the night. I would be fine, they assured me as they walked down the driveway. I returned to my domain and after a delightful dinner of hot dogs, Oreo cookies and chocolate milk, settled onto the couch for a night of television. I was the captain of my own ship. Life was good.
Fast-forward 12 years, a college degree, three years of medical school and a few gray hairs to my first call night as a medicine sub-intern. Providing just enough independence to teach, but enough guidance to ensure that patient care is not compromised, the sub-internship tests the limits of a student's clinical knowledge, mental composure and physical stamina.
Under the supervision of senior residents, tonight, my classmate George and I would be accepting all admissions to the Janeway medical service, a notion that had us both nervously amused. After asking if we had any questions, the residents left for home, encouraging us to contact them with any questions. With us for the night to assuage our general uncertainty was an intern. An attending also was on site.
At 11:22 p.m., my pager sounded. "Admission in ER, Bed 12." Descending to the hospital basement through empty stairwells, I waded through the personal swamp of what ifs. What if I have no idea what is wrong with this guy? What if I don't know what medicines to give, what tests to order, what questions to ask? As my stomach tightened, I wondered what in the world I thought I was doing. Knowing there was an attending nearby was what reassured me.
Mr. W was in his late 30s and evidently terrified. As I approached his bed, he gripped his blanket around his chin and glared at me suspiciously. In as comforting a tone as I could muster, I assured him I was there to help. His grip on the blanket loosened as he recounted the fevers, chills and sweats that had begun days ago in the setting of daily self-injections of heroin and cocaine.
I placed my stethoscope on his chest and was immediately concerned. Mr. W had an loud heart murmur whose nature and timing indicated that endocarditis could be affecting his aortic valve. That is a serious infection requiring hospitalization and intravenous antibiotics. Confident that I understood his condition and could recommend the necessary treatment, I confirmed my diagnosis with my supervising intern and then arranged for Mr. W's transfer to the floor. Finishing the paperwork, I relaxed a little and even managed a self-congratulatory smile, thinking that a short nap in the call room might be within reach.
At 2:17 a.m., I was called to Mr. W's bedside. He wasn't happy to see me. He'd ripped out his IV and was refusing his antibiotics. I tried to impress on him the severity of his condition, but he was determined not to listen. Annoyed and impatient, he ordered me to leave him alone, yelling, "I just want sleep!" -- the only part of his story I could relate to. I decided the wisest strategy would be to return later, after giving him a chance to calm down.
At 5:39 a.m., I was back at his bedside, determined to place a new IV. A few hours' sleep had calmed him enough to cooperate. He received his first dose of antibiotics, and I again felt confident that we were both back on track.
On rounds later that morning, as I told Mr. W's story, I surveyed my considerably better-rested audience, particularly my attending. All agreed Mr. W's case was compelling for endocarditis and that current therapy was appropriate. As the team moved on to the next patient, I felt relief, fatigue and validation. Then at 3:21 p.m., as I was preparing to head home to bed, my pager sounded. Bad news. Hurrying to Mr. W's room, I found him dressed in street clothes, angry at his nurse and at me. Before I could get a word in, he announced that he was leaving, period.
I convinced him to sit with me, but 20 minutes of gentle pleading met a stone wall. My tone became more blunt. "Do you realize the seriousness of your condition? That this can kill you if you don't get the antibiotic treatment you need? Do you realize that you are in a position to save your own life by staying and cooperating? This, right now, is the biggest decision of your life, sir." Each time, his reply was a terse, "Yes," followed by "I don't care! I need to get out of here." At 3:47 p.m., Mr. W signed a form acknowledging his decision to leave against medical advice. He then walked calmly out of the hospital with a heart infection that would likely kill him.
A clinically sound diagnosis and treatment plan did little to quell my sense of failure. Mr. W's decision to leave the hospital rendered science useless. He provided a humbling reminder that communication -- not just diagnosing or prescribing but truly getting through to patients -- is an aspect of medicine that I cannot afford to take for granted. His stay, however brief, had helped me discover both the satisfaction and unpredictable frustration of having primary responsibility for a patient's care, of being the intern on call. In some way, I felt 13 again, home alone. But as I walked to the parking lot, I also felt a little less scared for my next call night. And perhaps for the first time, I felt like a doctor.