Narrative reflective practice in medical education for residents: composing shifting identities

Figures & data

Table 1 Leslie’s final parallel chart – March 20, 2008

First time I was ever on call as a resident the shit hit the fan. I looked calm on the outside but my heart was racing and I was full of doubt about what to do. I had learned the theory about what to do in case of various emergencies but I’d never been, never before had been the one to be relied upon. After a while I got accustomed to being on call and dealing with ward issues. That was until I started Cardiology and I had to carry the code pager. From the minute my first Cardiology call started, my stomach was in my throat. Every time the overhead speaker buzzed on, I crossed my fingers it wasn’t a MET call or a code blue. My first night on call my colleague handed me the code pager at 4:50 and at 4:57 it went off. I stared at it in disbelief. It means that I was holding that stupid thing and it went off and I was off and running. I arrived at the code at the same time as the monitor. They asked who was running it and I said I was. Thankfully my senior was still in house and so was in the room. The nurses attached the monitor and I went through the initial steps of ACLS protocol … oxygen and asking what had happened. And then my senior kind of nudged me and suggested I might want to look at the monitor. I was flushed and my pulse was probably about 120 and the sweat was rolling down my forehead. I was so rattled by the fear of trying to run a code that I had totally forgotten to even look at the monitor. The monitor showed a heart rate of 35. The first thing I thought was “Oh my god. What am I going to do now?” And then I ordered the appropriate medications. However it didn’t take very long for a pushy nurse to actually physically push me out of the way, totally minimizing me and adding to my anxiety. And I let her push me out of the way. I felt insignificant and incompetent.

So fast forward 6 months, I’m now at another hospital where there are no seniors in house and only your staff is your backup. I get called about a man having severe chest pain and a low blood pressure. I tell them I’ll be right there to assess him. I walk quickly but I don’t run. I’m not thinking about what I will do for this guy. I’m thinking about how I was hoping to have a short break on this really busy call, and how I was eating dinner and watching something on 60 Minutes about sleep deprivation and the bad things it does to a person’s body, and how I’ve already worked 18 hours and will still be working for at least another 10.

In any event I arrive in his room and very calmly ask the nurse to get a bunch of tests going. He’s 97% sats so this kind of ruled out one of the things I was thinking for causing his pain. I questioned him about his pain, asked him the details very calmly, ordered a bunch of things like aspirin and a Pink Lady. I glanced at the portable vitals machine and notice his heart rate is 30. “Interesting”, I think. “What’s up with that?” I wonder. So I ask, I hear myself say, “Can you get some atropine please?” If I took my own pulse now it would probably still be in the 60s just as it normally is. And, as I’m waiting for the atropine, his heart rate jumps to 100. I get the ECG during this time. He’s bradycardic and then I leave to read it. I can’t read it. It’s the craziest ECG I’ve ever seen. I decide to go down to the ER to see if one of the ER doctors can help me read it so I can then call the staff to tell her that her patient dropped his pressure. Before I leave I check on the patient and his chest pain’s gone. I have no idea what made it go away, if it was the Pink Lady or time or coincidence. One of the ER physicians doesn’t mind looking at the ECG with me but it’s so abnormal he really doesn’t have a good diagnosis either. And neither do my other colleagues. “Oh well”, I think “I guess I’ll call the staff without an ECG diagnosis”. A little while later he drops his pressure again so I go to see him and he feels fine. I check his heart rate and one minute it’s 90 and the next minute it’s in the 20s. He ends up in CCU that night and is going to need a pacemaker. He doesn’t code before being transferred as I anticipate he will.

When I’m finally finished admitting patients and I have a second to think I marvel at the calmness I’ve achieved in my last 6 months of residency. I can now deal with a pre-code without adrenaline coursing through my body causing me to sweat and have palpitations. The answers just automatically come to me about what to do. I trust myself more. I listen less to the criticism of the nurses or the RTs when they don’t think what I’m doing is right. I still have doubts but, if nothing else, residency has given me a gentle calm in place of profound stress. I might have the worst karma among my colleagues. No one else had four codes in one night on Cardiology and yet that was fairly normal for all of my calls, in fact some people never even had a single code during their rotation. But with each day that passes, and with each time my pager goes off, I find myself more and more equipped to deal with issues that are at the other end of the phone. Residency has taken a lot away from me including sleep and free time but the confidence and calm it has instilled in me has proven to be a good thing.

Abbreviations: ACLS, advanced cardiac life support; CCU, Cardiac Care Unit; ECG, electrocardiogram; ER, emergency room; MET, medical emergency team.