The ink on your graduation diploma isn’t even dry yet. It is 6:59 AM on July 1, a minute before 7 AM on the day all shiny, new doctors begin working as real doctors for the first time.
Let me through! I’m a doctor! It’s arrogant, but it’s what you’re thinking as you make your way to the ER. You know everything and there isn’t anything this new internship thing can throw at you that you can’t handle. After all, you have over 20 years of education under your belt, right? There are initials after your name. Good ones, too.
Then, a simple case of Boerhaave’s syndrome humbles you into a pile of self-condemning wreckage at the feet of the almighty, all-knowing staff man who co-signs your work, one eyebrow raised in crow-serving mockery.
What the hell is Boerhaave’s syndrome?
Looked like plain ol’ asthma to you. Who knew, as they whisked the patient off for her emergency thoracotomy? Who knew that the wheezes of asthma and the pneumodissection of the great vessels could sound the same? So, O.K., you don’t know everything, and that’s the first thing you learn on your first hour of your first day of the rest of your doctoring life.
The good news is that if you ever come across another Boerhaave’s syndrome again, you’ll be ready to nail it. The bad news is that you’ll probably never see it again. How is that even fair?
The good with the bad.
While you yearn silently, suffering, for the very next Boerhaave’s syndrome, you sulk as you read the diagnoses of the patients on your assignment roster:
- Fecal impaction.
- Nausea and vomiting.
- Axillary abscess/hidradenitis.
- “My neck makes noise.”
My neck makes noise? Is there really a choice? Slowly you turn..
So, “my neck makes noise” it is!
You realize that the narcotics you ordered for the fecal impaction patient are the very thing that gave her the fecal impaction. The prom queen with nausea and vomiting hasn’t vomited a single time yet, and you’ve both been here a couple of hours now. You can wait her out. The patient with the hidradenitis just folded his arms and inadvertently drained his abscess for you. Just took a squeeze—better his squeeze than yours.
“Tell me about your noisy neck.”
“Sure. Hear that?” The man is strangely unconcerned.
“No.”
“C’mon doc, you’re messin’ with me. You don’t hear that?”
You lean in and cup your right ear. “No.”
“It’s like the tin man,” he says.
“How so?” you ask. For the first time you look him over closely.
“L’il rusty. Need some oil. Know what I mean?” Thin, wiry, gaunt, weak. His breath wafts subtle hints of formaldehyde your way.
“How much do you drink?”
“Oh, well, now that’s the oil I’m talkin’ about.”
“How much?”
“Oh, I drink quite a bit.”
“How much is quite a bit?”
“Plenty,” he says, narrowing it down.
“A pint a day?”
“More than that, ‘fraid.”
“A fifth?” You intend to go back and forth if you need to, to tag him between first and second base.
“A fifth?” he snorts.
“Yea, a fifth,” you repeat. “Wow, a fifth a day.”
“Nah!” he snorts again. “Hell, I spill that much!” You get the picture.
It goes in, it must come out—Teslacles Deviate of Fudd’s Law.
Meanwhile, the fecal impaction patient has jammed her problem even deeper and more firmly in that place you dare not go, thanks to you. You order an enema, but it’s a waste of a good enema. (Is there such a thing as a good enema?) Knowing how funny this might sound when you’re comparing notes with your fellow interns over beer—as if you ever really get a chance to do that—you realize it’s not funny at all.
Suffering never is.
“Please, doctor,” the obese woman pleads. You wish you could take back the narcotics. You wish the enema had worked. You weigh the options and there’s only one way for her in her peristaltic gridlock. You knew a career in medicine would call for bravery like this:
You put on a glove.
Circadian rhythm succumbs to florescent lighting.
You arrived at the ER before the sun rose and you’re leaving it after the sun sets. It’ll be this way for a month, and you realize that you won’t see the sun for 30 days. You put “Get Vitamin D” on your to-do list on your smartphone’s NOTES app and promise to look up rickets.
The ER is a revolving door. Treat ‘em and street ‘em, and hurry, because there’s more whey they came from. Always more. And you wonder about what you’ve gotten into.
You review what you’ve learned: It isn’t nausea until there’s vomiting; there are many ways alcoholism presents—a noisy neck is just one of them; abscesses are designed to automatically explode without your help, but fecal impactions won’t do well without you. And the differential diagnosis for asthma includes Boerhaave’s syndrome—at least for you.
You wonder about the patient with Boerhaave’s syndrome who had died later that day. You wonder about the armpit horror movie. You wonder how much the man with the noisy neck is spilling right at this very moment. You wonder about the obese woman who will go back to her narcotics because of her spine being held together with a cage and how she will be back, firmly log-jammed.
One day down. [INSERT HERE] to go.
Finally, you will wonder about your career—just how long it may go on. You only get so many heartbeats, and today you beat about a hundred thousand of them. You will wonder how many beats are left. Certainly, more than the people you saw today, a long list that didn’t end with just a noisy neck. There was the high fever, the gallbladder, the woman in labor, the schizophrenic, the hypertensive, the malingerer, and on and on.
And then you think about the obese woman with her fecal impaction. How the most disgusting thing you did today was the most beautiful thing you’ve done in a long time. You gave someone comfort. No one else would, and you weren’t at first, either.
Even though it was a story so gross that you couldn’t talk about without snickers and chortles wherever and whenever you finally told it, you realize that it was the thing in your career so far of which you were the most proud, and today was just the first day. You made the difference, because had it been anyone else, she might be suffering still.
