“I can’t find the fetal heart tones.” The nurse states with a tone of underlying panic as she exits the patient room.
It’s around 7 am, and those of us working the night shift are getting ready for morning sign out before we can head home and get some much needed sleep after a crazy 14 hours shift.
“Tessa, go scan her” the resident nods towards the ultrasound machine and I cheerfully follow his command, rolling the ultrasound into the room of my patient.
She’s a young woman admitted the night before for preterm premature rupture of membranes (PPROM) at 21 weeks gestation. I’d seen her once before, a few weeks before in the L&D triage area right after she had found out she was pregnant. When I saw she was back in triage the night before I recognized her name immediately. I remembered really liking her and feeling an easy connection.
That night I was there when we explained to her the options with a PPROM at 21 weeks – either we induce labor now to terminate the pregnancy (as a 21 week old is not medically viable), or we wait and hope to keep her pregnant and infection free until 23w5d when we can give steroids to try and mature baby’s lungs. We scanned her and saw cardiac activity but minimal fluid, and she made the decision to try and make it to 24 weeks (when the fetus is considered medically viable).
Throughout the night, whenever I had a spare moment I would stop by her room. I chatted with her and her mother about medical school. They asked me about the details on any of the cute residents and if it really was as much like grey’s anatomy as they imagined (I told them it totally is, except for the fact that everyone else is married and I still go home to my cat everyday. But other than that it’s basically the same 😉 ).
So as I haul the ultrasound into the room, waiting for it to turn on, I try and make cheerful smalltalk, seeing the terror in her eyes. I scanned, and I scanned, and I scanned. Again, trying to maintain a poker face as I didn’t want to be that medical student who told the patient their baby was dead when in reality I just don’t know how to use an US machine. But as I continued to scan, I found no cardiac activity.
I kept scanning.
I knew that I couldn’t tell her this, because while I was nearly 100% positive on the outcome, I am a medical student and I needed a resident to confirm the results. So I stood there, continuing to scan, planning how to strategically exit the room and grab a resident without alarming her. Thankfully, at that moment one of the day shift residents came into the room. We looked at each other and she saw on my face that it wasn’t good.
“Are you having some trouble?” she asked carefully.
“Yea I am, would you mind taking a look for me?”
She did, and found the same thing I had.
I remember as they told her the news, how her and her mother both looked repeatedly back to me. As if somehow the way I responded to this would dictate what came next.
I left that morning with a heavy heart. Just an hour before I had scrubbed into a cesarean section where the attending physician had complimented how good my subcuticular suturing looked (although it literally took me like 6 years to do it) and I had felt on top of the world.
That night as I arrived back at the hospital for another night shift, my patient was ready to deliver (they had induced her that morning after I left). I walked into the room before the rest of the doctors came in, wanting to know if it would be alright with them for me to be present in such a delicate situation.
As I walked in, my patient’s mother came and gave me a hug saying “I am so glad to see you.” I was moved at the importance of a familiar face in this devastating situation.
Continuity of care – it’s an aspect of medicine that we like to talk about, especially in the setting of primary care specialties. Basically, what it means is that you get to see the same patients for a long period of time. It literally translates (from medicine talk to english) as continuing to care (both physically and emotionally) for a patient.
As medical students, continuity of care is a phrase that we throw around when discussing why or why not we want to pick a certain specialty. People who require continuity and really enjoy having long relationships with their patients pick fields where this is possible – family medicine, OB/GYN, Pediatrics.
I struggle with continuity of care. Obviously I believe that having stability in your primary care is a good thing for patients – you won’t find a doctor or prospective doctor who disagrees with that. But I struggle with whether having continuity of care is a good thing for me.
By continuing to care you patients, you are not just taking care of them – you are actually getting emotionally invested in their outcome. How wonderful that is when things go awesome! It’s great when you have helped a patient along from conception to birth. But when things go wrong, how do we deal with that?
I think one of my strengths (and my weaknesses) as a medical student is that I have the ability to throw myself 100% into what I do. When I am in the hospital, I am 100% there, all the time. This allows me to be involved and empathetic to my patients, and they feel that they are my whole focus – because in that moment, they are. The problem I face with this is that it requires that I have a career where when I go home, I can 100% go home. I don’t think I have the ability to compartmentalize my life if the specialty I go into doesn’t do it for me.
I am afraid that for the rest of my life I will constantly be “taking patients home with me”.
The story of the patient above is a perfect example of this. I became emotionally invested in her story, and I am glad that I did. I think that becoming connected to your patients is something that makes you more than a doctor – it makes you a human being.
My fear is that if I allow myself to continuously becoming connected, invested, and heart broken when things go wrong – that eventually I will lose my ability to connect and care at all.