The Longest Shortest Time

One of the most complex emotions to embrace as a parent is the simultaneous push and pull of realizing your child doesn’t need your help in some facet of their life.  My son and daughter charging fearlessly out into the world, getting rid of training wheels or that last goodbye hug at school drop off  shows me they’re flourishing.  Yet as happy as I am in those moments, the mother lizard brain wants more time, more chances to nurture.   We are caught in this conflict of days being long but the years being so short.

As an educator, I can easily see comparisons to a parental role – especially when your job description emphasizes the assessments, career counseling and wellness for all of your learners.  The latent feeling of having 50 extra children becomes fairly explicit on occasion.

I worry about them.  I celebrate with them.  I get a bit emotional and take lots of photos at graduation, as any proud parent would.

Of course, I also love teaching them; someone lighting up when a concept gets explained on rounds keeps me going as much as the endless cups of coffee.  I hope to make an impact on the trajectory of their careers, maybe to someday be that voice in their head when they remember to double check that the young female patient with Diabetes on the ACE inhibitor is still on her birth control.

The unique experience of training residents means that you as the educator have to figure out when you’ve become redundant, when you get to check off the “Ready for Independent Practice” box.    That same push-pull.  You have these longest, shortest years to try and get them ready for everything that Medicine can throw at them, always wishing for the chance to pass on one more clinical pearl.

I rarely have that big moment of redundancy in clinic.  Especially one that was already a busy, being understaffed with residents and faculty getting pulled to other commitments.

Mrs. J didn’t get the memo that it was supposed to be a chill day.

She had what sounded like classic menopause symptoms.  Sweating, and florid, possible hormonally driven anxiety (well documented in her chart) – but with some chest discomfort as well.

And because clinic was slammed, my resident already ordered the “Just in case” EKG as I was half listening to the story they were going over with the med student.  It was a reasonable tack, maybe a bit cautious but with all the times I had told them “you’ve got to consider the can’t-miss diagnoses, even if they’re not likely”  I wasn’t going to change the plan.

And so I finally caught up with them, went over the case with the student.  We reviewed expected menopausal symptoms, indicated treatments and discussed whether or not she merited an outpatient stress test “just to be sure”, going over modalities and risks of false positives given her pre-test probability.

They were already triaging the next patient when I decided to just poke my head in the patient’s room, confirm the history and look at the EKG our nurse was finishing up.

The words “So here’s the thing about hormonal therapy for the control of menopause symptoms…” vanished as my eyes fell on the ST elevations, the classic sign of heart muscle in trouble.

Happily “I’m going to go show this to Dr. A and talk about how we’re going to get you feeling better” came out instead of “Oh Holy Shit.”

And so I showed it to Dr. A, the one who made the right call.  The one who listened and thought about the “just in case” when all I had was overheard history.  Who saw the mild hypotension and didn’t write it off  as just volume depletion.  The one whose eyebrows about hit his hairline when he saw the tracing.

And so it was his job to talk to the patient and explain what was going on.  I carried the cup of water and the 4 baby aspirin.

Of course, he may not have been thanking me in the moment – how exactly do you open the conversation of “I’m pretty certain you’re having a heart attack” with your 10:30 clinic patient?

But he did it.

Sometimes, I have to bite my tongue when I stand back and have my residents run the show.  These are still my patients after all; I have to know the point is getting across, that we’ve done everything to ensure a good outcome.

I almost jumped in when the patient started to push back against the need for them to Go Directly To The ER (Do Not pass Go, No $200 for you.)

But then I watched him kneel next to exam table, consciously altering the physical dynamics of the conversation and change the patient’s ability to feel in control of the situation – exactly as I would have done.  Soften his tone and word choice enough that it was the patient making the decision instead of being forced into it.

There was nothing for me to do except pitch the empty cup of water and watch as he crossed the T’s and dotted the I’s of a rapid ER transfer, all while assuring the patient that things were going to be ok.

It’s good to be redundant.  For tying shoes or managing Myocardial infarctions.

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