My Clerkship Experience– A Deep Dive

 

By: Carlos Chan (c2021)

It’s my first ER shift as a clerk. I’m not as wide-eyed and mystified as I was when I first started. I’ve seen my first death, I’ve seen my first birth, and I’ve made countless mistakes in between. Of course I have yet to see a fraction of what I will encounter as a physician, but I’m no longer as scared as I used to be. Even when I am, I have since learned to get my game face on because there is no time for emotions when lives are on the line.

First patient, a bounce-back COPD exacerbation who was discharged just yesterday. Nothing interesting. She’s feeling better but still desaturating, so will need another quick admission before she goes home.

 Second patient, a foul-mouthed man who got cut by his roommate. Why did he get cut? I make half an attempt to find out, but lose interest quickly enough. As one of my senior residents have said, every single knife and gunshot wound case starts at a bar called “I-was-just-minding-my-own-business”. The protocol goes: sutures, tetanus, and then bye-bye because you’re so rude to the nurses. 

There’s a lull in the ER now. Not enough space to even practice hallway medicine. In the interim, I go to see a depressed patient who threatened to jump off a bridge. She shares her life story. I figure out that she’s not actively suicidal, document the pertinent positives and negatives, and then struggle to avoid becoming her therapist. 

I wander around the ER looking for my staff. I hear some commotion in a resus bay, but I don’t investigate. The emergency ward is a busy place, and if I were to respond to everything, I would never finish a single task. If it is real trouble, it’ll make itself known soon enough. And sure enough it does. 

My staff barrels through to the resus bay, and I’m hot on her heels. It’s pulseless electrical activity, and the lady looks about as good as her description. I relegate myself into a corner to observe as well as to make sure I’m not in anyone’s way. Standing against the wall, I go through all the drugs that I had studied just yesterday. Pulseless electrical activity would mean we do chest compressions, we monitor for a shockable rhythm, we push epinephrine, and resort to atropine if all else fails. Suddenly, she’s flailing her arms – she’s back! And just as fast, she’s pulseless and we’re back to CPR. It’s now my turn to do chest compressions. As if in a trance, I have somehow found my way from the wall to the bedside. I’m right behind the EMS guy doing compressions. I lock eyes with the nurse standing on the opposite side of the patient, and we telepathically agree that I will take over the next two minutes’ cycle of compressions. 

Now when I went to renew my CPR certificate, the instructor had said that effective CPR includes breaking of the ribs. I don’t know if I’m breaking this poor lady’s ribs or not. All I know is that I need to push hard enough so that this lady doesn’t miss out on two minutes of potentially lifesaving chest compressions because the idiot medical student hasn’t gone to the gym since his internal medicine core rotation started and ended three months ago. Something else that they don’t tell you during the CPR course – two minutes is forever. Right before I went, I had noticed that the EMS guy was slowing down on his compressions, and wasn’t pushing as deep. I now understand why. Two minutes feels like an eternity when your adrenaline is running so high that you’re either thinking too much or about nothing at all, and the chaos of the room is enveloping you. The two minutes are over. I check for a pulse and hope to God that I’m checking the right place. I thank the stars that the nurse on the opposite side is checking as well so that at least one of us might catch an errant pulse. Nothing. Next cycle. 

I find myself back in the CPR line-up. It is an odd feeling. In retrospect, I am reminded of when I used to go to jump off the diving board at the summer camp pool. We’re all lining up. My anxiety builds as I inch my way closer to the board. I am not sure why I am anxious – I have jumped off diving boards before. I have arrived at the board. I climb up the ladder. I am now standing on the board. There is no going back – the only way is to jump off and dive into the water. The sun’s reflection off the pool is too bright, I can hear the camper behind me grumbling because I am taking too long, and I hear faint laughter and chatting in the shallow end of the pool, just outside of the diving zone. I tense myself, jump, and my mind goes blank. I am in the air for an eternity but also no time at all because of Newtonian classical mechanics. Then I’m in the water. No more adrenaline. I pull myself out of the water, get out of the pool. I find myself back in the CPR line-up. 

I am doing my third cycle. I finish, and then we recheck for the lady’s pulse. I find nothing – but fortunately, the nurse on the opposite side has found a femoral pulse. It is weak, but present. I check for myself on her side, and agree with her assessment. We watch the patient for a few minutes, to make sure that she isn’t going to play any tricks on us and suddenly lose her electrical activity again. She has done it to us two times now already. We pause a beat. Two beats. Looks like she’s here to stay with us at least a little longer. I look up, and somewhere along the way, she has been intubated. She most likely has a fat embolism says my staff. Look at her chest. Don’t forget the bruise. You’ll likely never again see such a classic presentation. I look. I try to burn it into my memory. She is wheeled off for a CT-PE. 

We leave the resus bay. The chatter and laughter from the shallow end of the pool is suddenly present and not so distant anymore. There are other patients to see and review. Most of whom will likely go home, some of whom we’ll need to call the specialists about. Labwork to review. We go about the rest of the shift. 

The diving board and the deep end is a memory now. I look upon the memory, and it looks like absurdist art, my recollection of it having mysteriously undergone post-modern alteration. It is surreal. 

 

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