Stethoscopes and Poop

There are few places that can make an intern feel as inept as can the neonatal intensive care unit (NICU).   The medical care required by premature and very ill infants is unlike anything in the rest of pediatrics.  But before new residents can even begin to build a knowledge base, they must chisel through layer upon layer of the foreignness that envelops the place.  As the interns who rotated in the NICU before me repeatedly intoned, it’s just different over there.

A special language is spoken in the NICU, one awash with acronyms – GIR, HMF, PPHN – whose meanings are not easily intuited.  There is a distinct – and distinctly unique – format for presentations during rounds.  Add to these challenges the fact that the NICU is located in a separate hospital from the rest of the pediatric services, with a separate electronic medical record system, and it becomes clear why new interns find it so intimidating. Not to mention the fact that the babies there make our usual patients look like giants.

As I progressed through my first days in the NICU, I felt increasingly unmoored, drifting ever farther from the competence I craved.  It seemed that there was no time to learn, only to do, yet each task highlighted my ineptitude more than the last.  I asked question after question of the senior residents, the fellows, the attending physician, the nurses and nurse practitioners – anyone, which is to say, everyone, who had more experience than I did.

The best and worst parts were the deliveries.  The pediatrics team was called to the labor room or operating room each time a baby was being born that might need some extra support or resuscitation.  We were called for premature babies, twins, and triplets; for babies who had already passed meconium (the baby’s first stool) and so were at risk of breathing it into their lungs; for babies born to mothers who showed signs infection during labor.  Interns took turns responding to these calls, and were accompanied early on by a more senior member of the team.  Once we had demonstrated proficiency with the required skills, we responded on our own.

It was exhilarating and terrifying: the initial scramble to find the right room, never knowing just how far along the delivery would be by the time you arrived; the frantic gloving – or, for the OR, scrubbing – while checking the infant warmer to be sure that all the right equipment was available and properly functioning; the mental checklist, running on repeat, of just what equipment to use when.  And, of course, the ever-present possibility of being handed a baby that refused to breathe on its own.

As with everything else NICU-related, I asked questions.  I double-checked the indications for giving oxygen and for intubating to suction out meconium.  I even discussed Apgar scores – just how pink had the baby been at that first minute of life? – before committing them to the medical record.

But it was tiring, pestering people with so many questions.  I felt irritating, was even irritating myself.  And so, for anything that wasn’t directly related to patient care, I shied away from querying and began to make educated guesses.

I had begun to feel the first tinges of proficiency when I was called to the delivery room, accompanied by a nurse practitioner seasoned in deliveries.  We arrived just as the baby was about to, and rushed to check our equipment.  I grabbed the stethoscope dangling from above the warming lights and set it down on the table where we would soon place the infant.  I had seen others lay the instrument with its diaphragm on the table and the ear pieces hanging off, but this seemed arbitrary, more of a style thing, and so I laid it my own way, with the ear pieces curled up next to the diaphragm, right next to where the baby would soon lay.

The nurse brought the baby to the warming table and I dried him vigorously.  As she wrangled a hat onto his tiny head, I used a bulb syringe to suction the secretions from his nose and mouth.  He began to cry and, as many babies do, to poop.  Black, sticky meconium poured onto the table, oozing over everything in its path.  The nurse practitioner rescued the stethoscope just in time.  “That’s why we lay it like this,” she said, grinning as she straightened it to lay in the normal fashion, with the earpieces safely out of the meconium’s reach.

And so I went back to asking questions, not only in the NICU but also in every unit where I work.  I ask questions about medicine, about how things are run, and about whether there are better ways to do things than I have already found.  It’s exhausting.  But it helps me to keep learning.

And it also helps to keep the poop out of my ears.

The New Doctor

As I drove to my first shift of residency, my first shift as a doctor, all I could think about was my friend’s dog.

***

During my last year of medical school, my husband had moved to a different city for reasons related to his work.  One perk of our arrangement was that he shared an apartment with a friend who owned a feisty little terrier named Barney.

Barney understood only Italian, his owner’s native language. He was not neutered, and he peed aggressively somewhere along nearly every block that we passed during the long walks we took together whenever I visited.  He forced his way into our bedroom at inopportune times, wagging his stubby tail insistently and delivering one of the many tennis balls that were always underfoot.  Every time we left the apartment, he fixed us with his studiously sad gaze, and he jumped in circles and barked with glee each time we returned.

One Friday night late in the spring of that last year of school, I arrived in the city early enough for a dinner out with my husband, his roommate, and a few other friends. We lingered over our sushi, and by the time we strolled home it was close to midnight.  Barney greeted us with his usual fervor and then my husband and I headed down the hall to our section of the apartment.

I took the bathroom first, fishing out the toothbrush and soap that I kept stashed in the medicine cabinet.  Over the running water I heard my name called.  At first I ignored it, slightly irritated by the lack of privacy that my husband and his roommate had established.

Then another voice called, one of the others who had accompanied us upstairs.  “Becky?”  Its higher pitch carried clearly through the hallway.  “We need you.  It’s Barney.”

In the living room, they were crouched on the floor around him.  He lay on his back, his legs twitching.

“Is it a seizure?  Or a heart thing?”  His owner spoke without turning away from his dog.

Despite his personality and antics, Barney was not a young dog.  He had a heart condition and a murmur that was clear even to my own newbie ears.  But he took daily medications – buried in a dollop of peanut butter – and other than a ban on swimming in his favorite pond, there had as yet been no tangible effects on his daily life.

 I don’t know what it is, I thought first.  Could it be a seizure? Mere months from graduation, I had never seen a seizure, and certainly had never seen one in a dog.  I had read plenty, had attended lectures about them, even answered exam questions on the topic, but these left me with no visceral experience upon which to draw.  Weren’t seizures big, dramatic affairs?  Surely something more than these low-amplitude shakes?

I asked questions.  How had they found him?  How had it started?  In the background some small part of my mind regained control and murmured louder and louder, It’s a seizure, this must be what a seizure looks like.

“It’s a seizure,” I finally said, trying to keep my voice from trailing up in uncertainty.  “It isn’t his heart, it’s a seizure.”

We were all quiet for a moment.  Barney continued to shake.  Then my friend turned to me.

“What do we do, Doctor?”

I looked up to protest, wondering perversely if he might be joking.  Several months still stood between me and my degree.  But in his eyes I saw deep fear and a plea for help.  To him, a few cushy electives meant nothing. To him, I was a doctor.

I fumbled through more of what I had studied but had yet to truly know.  If we were in a hospital, I would ask for Ativan – I think that’s the first drug to use.  But there’s no Ativan here.  What do you do for a seizure that’s not in a hospital?  Idon’tknowIdon’tknowIdon’tknow.

“Is there an animal hospital with an emergency room nearby?”  I asked.

But he’s a grad student, half of my brain shouted.  A trip to the emergency room will take half the night and cost hundreds.  And the seizure may break on its own.

And what if it doesn’t? screamed the other half.  I recalled that some resolved without medication, but how long did it take?  How long should I wait?

Then, finally, one defining thought: This is Barney.  Don’t make the wrong call.

“Let’s go,” I said.

I rolled to my feet and Barney’s legs stilled.  Gently, his owner eased him onto his side and stroked his head, murmuring softly. I fell back to my knees, stroking Barney’s side, feeling comfort in the smooth rise and fall of his belly beneath my hand.  He remained still, eyes glazed and unfocused for a few more minutes before he became himself once more.

 ***

It had been easy to go along with the big deal that was made about becoming a doctor.   Just days before starting residency, at a wedding of a fellow graduate, the proud parents had invited all of the freshly-minted MDs out onto the dance floor for a group photo. The banquet hall had erupted in applause.

I felt confident as long as things remained abstract, as long as I focused on the already-accomplished in place of the yet-to-come.  Yes, I had studied for four years, rotated with clinical teams throughout the hospital, earned good grades and a residency of my choice. But I had reached the end, and there was still so much I had not seen or heard or touched.

Yet somehow I was a doctor.  And now I would be called upon to do doctorly things, to diagnose and choose treatments and respond in emergencies.  And I was terrified.

Standing on that dance floor, I had let myself feel confident.  Away from my new coat and badge, I had breathed freely in the belief that with time I would learn what I had yet to know.  But as I drove toward the hospital for my first night in my new role, all I could see were Barney’s shaking legs and his owner’s pleading eyes.  I took a deep breath and continued to drive.

Physician Writer

I wrote my first story when I was four.  To be fair, I dictated it.  My mother took down my words, printing them neatly across the squares of white paper that she had stapled together to make a book.  She left plenty of space above for my crayoned illustrations.  When we were done, I was sold: I wanted to be a writer.

Throughout most of my childhood and adolescence, my goal remained the same.  But when someone I loved became gravely ill, I shifted my attention to a career in medicine.  I wanted to heal people, yes, but when healing was no longer an option, I wanted to be there for comfort, for company, and to bear witness.  In my preparations for medical school, writing fell away.  It was something I looked back on as an enjoyable but frivolous pastime.  Besides, I reasoned when the occasional creative itch arose, what would I write even about?  How could I have anything significant to say?

And then I began to feel the void.  Something was missing, something integral to who I was and what I needed in order to feel fulfilled.  At the end of the semester of anatomy lab, my medical school classmates and I were assigned to write essays reflecting on the experience.  As soon as I sat down at my laptop, the words began to pour out of me and didn’t stop.  I wrote stories, essays, poems, little snippets of thoughts and observations that may never find their way into any finished piece but that felt so good to write down.  And I began to feel whole again.

I also discovered that I was not alone in my combined passion for medicine and the written word.  I scoured bookstores and the Internet for works by physician writers, a breed of folks brand new to me but in whom I immediately found idols and, to my amazement, understanding.  In the words of one of my immediate favorites, Richard Selzer, “To take up a word, then lay it down again to choose another; to set this one down on the page as if it were a pebble and what is being made a mosaic, this is the greatest pleasure.”

Over time I have come to believe that writing is an asset to, rather than a distraction from, the practice of medicine.  My attention to narratives helps me to bring thoughtful awareness to my patients’ stories and problems and to the task of solving them.  It enhances my ability to communicate clearly with my patients and colleagues, and is a tool for reflection that allows me to maintain my own wellbeing.

So as I continue my training, I continue to write.  Now I am choosing to share as I reflect on the challenges, frustrations, and joys inherent in the practice of medicine.  And inherent in being human.