Dirty White Coat

So we had to write a reflection for our clerkship – I figured I’d post it here:

As third year medical students we are often told that when we hit the wards, we will know the most about the basic sciences – that will be our niche. While our first two years of education prepare us for discussions of various diseases and syndromes, we are provided with little idea of how to diagnose and treat these diseases. The majority of us can easily regurgitate the content of our First Aid books, but we are lost when it comes to deciding what test to order or which medications are most appropriate. What becomes painfully obvious on the first day is that we are the conspicuous bottom feeders of physician food chain, most easily identified by our one defining feature – a pristine, short white coat.

At the beginning of my medicine rotation, my first rotation of the year, I had no idea what to expect. Would I like my teams? Would I be a terrible medical student? Would I fail out of medical school? Would I learn something? Anything? After only a few days of being “on the job,” all of my fears disappeared. I loved my team. I was not a terrible medical student. I probably would not fail out of medical school, (but maybe I spoke too soon). Most importantly, I learned a lot – not from my typical teachers, the attending, resident and interns, but from the people that I was visiting daily, the patients.

Not all of my patient experiences have been particularly positive. I have had my share of patients unwilling to speak to the lowly medical student, patients too tired to hold a conversation, patients unable to speak English and my favorite, patients with mental status changes, barely able to tell me their names let alone the nature of their disease. While these patients are painful challenges for fresh students, they provide the greatest opportunities for learning. They add the valuable experience needed to transform great clinicians into great doctors. In my first 6 weeks of 3rd year, I have encountered one particularly challenging patient, who was frustrating enough to make me scream into a pillow. Fortunately, following him also provided incredible learning experiences.

Mr. E was an OCD schizophrenic who had spent much of the last decade residing in an inpatient psych ward. During his time there, he had been prescribed over 20 different psychiatric medications in various combinations. He was also noted to be “dangerous” from previous psychiatric reports. He had come to us overnight for evaluation of new onset drooling and ataxia. In the ED, it became clear that he was in acute renal failure and rhabdomyolysis – most likely the result of the medications he had been taking. In retrospect, Mr. E should not have been admitted to any of the ward teams, let alone my team, but when I left the conference room that morning – it was decided. He was my patient.

When I first saw Mr. E, he was pleasant. I wouldn’t call him conversant, but he could answer all of my questions and follow all of my commands. We made a plan to pump him full of fluids until his kidney were back to normal and to stopped all of his medications until this happened. We got Mr. E on a Friday. Saturday was my day off and I was rested on Sunday, ready to revisit my model patient. Overnight, no events were reports – he was the same as he had been when we left for the weekend. When I walked into his room, it was clear; this was not the same Mr. E I had seen on Friday.

On that Sunday morning, I walk into Mr. E’s room to wake him up. He silently rose to his bed, looked at me and headed straight for the door, dragging a bag of urine behind him. I followed him in fear as we slowly approached the hallway. Just outside of the door, Mr. E turned around, scurried into his room and slammed the door in my face. I returned 10 minutes later with the resident to find Mr. E naked smearing urine and feces on the floor. For the rest of the day Mr. E would wander in and out of his room without saying a single word to anyone. Sometimes he would be disrobed, heading toward the patient with C. Diff precautions. He would become aggressive and swing at the staff trying to redirect him. I was horrified – every time Mr. E came out of his room, I found myself frozen, unable to help redirect him. All I could do was wonder how fast he could be sedated with Ativan.

That afternoon, Mr. E was placed on restraints and given a one-to-one sitter. Over the next few days, he spent much of his time silent, thrashing around in his bed. He would chew on the restraints, pull out his IV’s and disconnect the Foley. He would become so restless overnight that he would be given the maximum doses of Ativan. In the mornings, he would be so sedated that he would be unable to open his eyes. On hospital day 8 or so, I entered Mr. E’s room, prepared to hear about his eventful nights. A new sitter named Teddy was there to greet me. I had been in the habit of thanking the overnight nurse for looking after Mr. E, but this was the first time I felt it was fitting to tell the nurse that he was magical. Overnight, the old Mr. E had returned. He was able to talk and take care of himself. He had quickly gone back to being one of my favorite patients.

I turned to Teddy and said, “You are a miracle worker. What’s your secret?” He simply replied back, “All I do is treat him like a human being, with respect and dignity. That is all.” I felt ashamed. I like most of the people, scared by Mr. E’s behavior, felt the best treatment was to pump him full of benzos until his kidney function had improved and he could be restarted on his psychiatric medications. I had almost forgotten that Mr. E was once a proud soldier, serving our country in Vietnam. He had been trapped in his own mind as a result of his experiences abroad. Within 3 days, Mr. E had improved so much that we were able to return him to his former residence, in perfect condition.

I had walked into medical school with the intention to uphold my Hippocratic Oath “to do no harm.” With a sense of nativity and innocence, I started rotations believing that I would be guided by that principle. While good doctors practice medicine with the intention to uphold the Oath that they took their first year of medical school, real medicine rarely conforms to the principles by which they were taught. In what is now a little over 6 weeks, I have learned a tremendous amount about the number of ethical dilemmas that interfere with medical management. Although I am still a conspicuous bottom feeder on the physician food chain, it seems that I have already got a little dirt on my pristine white coat.

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