Big Boy Pants

Intern year is a weird limbo of sorts. In some ways, you're still like a medical student(+). Your activities consist some days mostly of carrying out other peoples orders throughout the day. The things you do handle independently are mostly algorithmic. Manage this patient's pain regimen. Work up this patient's chest pain. Evaluate this patient's shortness of breath. Put in this patient's admission orders. Anything beyond that, you are generally encouraged to page up the food chain to residents above you (or discouraged from handling these things on your own, depending on how you look at it).

But the other day I had to put on my big boy pants.

Due to a combination of the chief resident being out of town, one of our residents being post call, and the last one being in the OR all day, I was gifted with the responsibility of handling the otolaryngology consult pager for the day. The ENT consult pager is an interesting beast. Most of the time, our consults are something very benign and not particularly time-sensitive. The little old lady with an incidental mass found on imaging when she presented with stroke symptoms. The level 3 trauma with the mandible fracture. The cheek laceration in the motor vehicle accident. But the consult pager is also a terrifying thing, because it is also the emergent airway pager. These are very rare, but present. So every time the pager goes off your heart rate jumps a couple clicks.

Luckily, I escaped without an airway emergencies. However, I did pick up an emergency department consult later in the afternoon. It was supposed to be a curbside consult. "We have a patient with sinusitis and I was wondering whats the best imaging test to order." I ask to hear more about the patient, and there was enough concerning bits about the story I say "you know, we should probably formally consult and lay eyes on this patient." Go to evaluate the patient. Run the story by the chief on call, who is already home for the day. Get the imaging ordered. Read through the images with the chief, and decide the patient has to go to the OR. Immediately. Staff with the attending on call. Get the case booked, talk to the ED resident, explain the findings to the patient, answer questions, get the consent.

As the patient is being wheeled into the OR, the chief and attending still have not shown up, and I realize... I'm the only person who has physically seen this patient.

The necessary powers show up. The attending sits at the computer checking email and the chief ends up taking me through the case in its entirety. Whether it was luck or whatever may be, I end up being right, the operation was appropriate, and everything goes smoothly. With the case complete, I put in the admission orders and go and talk to the family.

When I finally get home later that evening, I think back on the whole sequence of events. It was a fairly straightforward consult. But I was the one who decided we needed to formally consult. I was the one who saw the patient, took the history, performed the physical exam, performed the endoscopy, and ordered the imaging. I was the one who talked to the patient about the findings, talked about the implications, obtained consent, booked the operation, performed the surgery, and talked to the family afterwards. From the patient's perspective, and from the family's, I was the only person they had seen and talked to. I was their doctor.

That was a profound feeling.

I know that is the endpoint for residency, to be able to independently evaluate and treat patients who come under you care. And I know that my chief and attending had my back, and if it wasn't something straightforward, they would have been there to see things over in person. But for someone still so green at all of this, it was a refreshing (and, in some ways, terrifying) experience to be the point person for everything.

The patient did great and went home the next day. I saw him on morning rounds, staffed with the attending by phone, and put in his discharge orders. He is scheduled to follow-up with the attending surgeon in two weeks for post-operative care. And part of me wonders what he will think when he shows up for his appointment and my attending, a person he never met, opens the door to the exam room.

I think I'll try to be there.