Guts and glory.

I’m doing an outreach rotation at the moment.  It involves venturing into the community, leaving the bubble of the hospital, and assessing people to see if they need to go to hospital.  The idea is that if we can treat them in the community, we can prevent a hospital admission.  Hospital admissions are expensive, and for the group of patients I now work for, usually detrimental too.

Except that when you’re in a hospital you have everything.  You have a lab at your disposal, imaging, on-the-spot specialist opinions if urgently required, you’re surrounded by experts.  Out in the community it’s me.  Me and my stethoscope and doctors bag that has antibiotics, diuretics, and a script pad.  If I’m lucky a nurse will come out with me – the nurses I work with are for more experienced than I, they’ve been doing this gig for decades and before that, working in intensive care or emergency.

When I see my patients, I have to ask myself, what is the best for them?  Is it a hospital admission?  Is it prevention of a hospital admission?  Is that safe?  If I don’t send them to hospital, will they survive their ailment?  If I do send them to hospital, was it the wrong call?  Have I created illness for them, have I wasted thousands of dollars?

Last week I saw an elderly woman* who was delirious.  She’d had some blood tests a couple of weeks back which were helpful for me, but had been well in between.  Delirium is a hard one because my patient can’t tell me what’s wrong.  My patient didn’t have any pain (that much you can more-or-less elicit) and she had a catheter for her urine, the contents of which at a glance, was clear.  I gave her some juice and she vomited it immediately.  I examined her in a limted way – she couldn’t follow a single command and I couldn’t find any signs of infection or much else for that matter.  No medication change.  For all I knew it could be a non-medical reason, sometimes simply a change in staff, a change in bedroom, can cause a delirium in our older patients.  She was dehydrated.  The nurse offered to hang some fluids and I agreed and asked her to collect some bloods and sat down to write my notes.  I wasn’t keen to send her to hospital, surely I could figure this out, institute treatment, and keep her out of hospital.  But something was bugging me.  It was her colour.  People can take on a different tinge depending on what is wrong with them.  There is the yellow of jaundice, the flushed of infection, the mottled of sepsis, the pale of anaemia.  The greyish-yellow of uraemia (from kidney failure).

A million years ago I did a term as a renal (kidney) registrar.  It was easily the hardest term of my life, the level of responsibility given to me, given my junior level.  I wont go into details here.  But while it broke me, it made me, it taught me about guts.  My consultant at the time was a kind genius.  He would walk through the emergency department, and collect patients.  They would be admitted under other services but because he’d worked there for twenty years, he knew the whole community and wanted to look after them.  The other registrars would joke about never letting him go to the emergency department or you’d have the biggest round list in the world!

My genius boss, who knew everything and who loved people, used his gut a lot.  When faced with a problem he didn’t know the answer to, he would stand there for what seemed like an age, hand on his chin, and then eventually say “I think we should try this…” He never got it wrong.  It was wonderful to watch the 40 odd years of experience he had at work.  He never really articulated why he chose that and I’m not sure he could, it was just the weight of that experience influencing his gut.  I’ve always found this hard.  Especially in the exams.  There’s so much noise in your mind as you go through.  If you choose this, what about that?  What would others choose?  If you get it wrong does it prove you are as stupid as you suspect you are?  If you fail, what does it mean?  Does it mean you’re a terrible doctor, does it mean everyone will look down on you?  Isn’t that the right answer as well?  The answer is lost somewhere in all of that.

When the patient is in front of you, it’s even harder.  It’s none one of 5 options anymore, it’s 50.  My patient could have had a stroke.  She was delirious, she couldn’t swallow properly.  If I didn’t send her to hospital, was I missing a stroke?  I didn’t think it was a stroke, but it could be.  How would I know?  I sat there staring at my notes for a really long time.  I had no blood tests.  I had my examination findings, my history.  I had that strange colour.

The nurse returned.  I took a deep breath.
“I’m sending her to hospital.”
The nurse blinked in surprise, a little bemused.
“I think she’s uraemic” I blurt out, “I’m not a hundred percent sure, but if we send the bloods and wait for the results, and I’m right, she’s not getting into the hospital until 9pm and no one senior is going to see her for a while.”
“Your choice doc”.  It may seem a benign statement, but my wonderful, experienced nurse who knows far more than me, isn’t arguing.  And if they’re not arguing, you’re probably right.  But still, if I’m wrong, then I’ve put a lady through a lot of unnecessary and painful intervention, and cost thousands of dollars to a very stretched system.  There are so many points at which I could second guess myself.  So many wrong calls.  This could be a completely wrong call.  It would be so easy to talk myself out of it, go with inertia.

We organise an ambulance.  I ring the emergency department consultant.  They are never pleased to hear from me but we keep it polite because we both get it.  The nurse and I run the bloods back to the hospital ahead of the ambulance to expedite the patient through the department.  I call the patient’s next of kin and explain, they are accepting.  And then I move onto another patient and try to put it out of my mind.

Later in the day when I’ve returned to the office, the nurse claps a hand of my shoulder.
“Nice call doc – good to see you trusted your gut”.  She thrusts a printout of the blood test and brain CT in my hand and there it is.  Severe kidney failure, no (obvious) stroke, right call made, correct treatment and admission commenced on arrival.

When I was more junior, the glory would have been in making the right diagnosis.  There is no glory in this for me now, because it’s a horrible situation for the patient.  I’m glad that things were done correctly, but the glory is in the trust I afforded my own judgment.  It’s easy to make decisions when you have a lot of information available.  Out here, in the far reaches of the medical galaxy, it’s so different, you have so little at your disposal.  So my post tonight is a little bit of a pat on the back for me because you don’t often feel successful in this gig so that when you do, you’ve got to take a moment to enjoy it.

But as always, I have a point to make.  Exam sitters, when you take that exam on Monday, trust your gut.  When you have that moment when you think “I think it’s this but I’m not sure why”, no matter how faint that moment is, and no matter how much your mind tries to convince you it could be the other 4 options for so many other reasons (especially if you have an arts degree), hold that moment.  Trust your gut.  I get that you’re junior, that that muscle is as yet underdeveloped but it’s in there.  Your answer is in there.  The exams are the beginning of you finding your voice as a physician.  Don’t worry about failing.  This is the safest place to fail.  You wont harm anyone.  You wont have to tell anyone their loved one is dying.  You wont have to say to a patient “I made a mistake…”.  Your pride might get wounded if you do, but I don’t need to tell you that is nothing in the face of a medical error.

When you have that moment when your mind freezes, when you panic, when something screams at you “I don’t know!”, you know what?  It’s okay that you don’t know.  Half the time you really don’t.  Answer C, put a star next to it, move on and calm back to it later.  Or take a time out – stop, close your eyes, take 5 really deep breaths in and out, open your eyes, and keep moving, come back to it later.  The answer might come to you in a little while and if it does, wonderful, if it doesn’t, keep your answer at C.

You can’t harm anyone taking this test.  Your family is safe and unharmed, the people you love are okay.  You are okay.  This is all that matters.  This test is not who you are.  It’s a hurdle, sometimes you clear them, sometimes you crash into them and if you crash, you set it back up and you try again.  And the best part is that this is not a patient.  Even if you’re wrong, you’re not wrong, because you can’t hurt anyone doing this test.  On Monday, start trusting your gut.  It’s an ill-defined thing and it’s scary but ultimately, it’s worth it.

Good luck to all the candidates sitting the FRACP Part 1 Written Exam on Monday!

*patient information heavily de-identified and changed for this piece.

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