Saturday was equally wonderful. I went back around six pm, and stayed till the end of the shift, at ten. The ER was crowded. Just to complicate the evaluation of the usual “rule out heart attack” cases, the troponin machine had apparently broken down. (Troponin is an enzyme found only in cardiac tissue, which is released into the blood during a heart attack. It is a very precise way of identifyin who has and hasn’t had a heart attack.) So the doctor had several patients stuck on her hands, who she was pretty sure were not in trouble, and they and their families were ready to leave, but they all had to wait for the lab to come up with reassuring results.

Most of the patients that I saw had some variation on the following string of problems: abdominal pain, nausea, vomiting, diarrhea, and dehydration. Although not as exciting as the evening with kidney stone patients, I now realize in a way I obviously wasn’t getting from textbooks that viral gastroenteritis can present in multiple different ways, almost none of which are lifethreatening. Once again, the doctor let me see several patients myself. This time I went even faster, being more confident of how little detail she wanted to know. And by the end of the evening I could rattle off “CBC, BMP, normal saline wide open, iv phenergan” as fast as she. (Complete blood count to check for serious infection, basic metabolic panel to check on electrolyte status, salt water in a concentration normal for the body so as to replace lost fluid, and an anti-emetic medicine.) Most of the patients promptly dropped off to sleep upon receiving this treatment.

I also figured out that the doctor was leaving less to chance, or to my inexperience, than I was afraid of. The triage nurse came back to report to her regularly, so she already had the basic story on everybody. And usually she lets the nurses get most of the history, and prescribes things just from the general storyline. She can tell just by the fact that it’s December and the person has had nausea and vomiting for 12 hours that they probably have the flu. I still would like to check for symptoms of esophageal rupture, cholecystitis, pancreatitis, ulcerative colitis, and pyelonephritis, before treating for the flu. (That’s overkill, you understand; that’s what experience is for, so I can tell the difference; and this is why you go to a doctor, instead of reading about it for yourself. This is what medical school is supposed to do, teach you what drastic possibilities can be ignored.)

She also chose some cases to see herself, like the poor old man with Parkinson’s whose daughter was concerned about changes in his functioning, or the nine-day-old baby with a rash, or the young woman two months pregnant with bleeding. That last one we were afraid was having a miscarriage, but after a little bit of investigation it looked more probably to be a little implantation bleeding, and not anything serious.

Last night everyone was commenting on how I look barely old enough to be out of high school. So it’s not like there’s any chance of me being taken for a knowledgeable or authoritative character, even in nice clothes, white jacket, hair back, stethoscope, and official name tag. Although I always conscientiously introduce myself as a medical student (I cringe when the doctors introduce me as “Dr. Alice, my student”) I think most people took me for a nurse, or a student nurse at that, except the nice grandmother with kidney failure who wanted to know all about where I was going to school, and how much longer I had, and all that. Even the nurses, who are nice and friendly in this small ER, watching me write orders with the doctor, didn’t really know how I fit into the pecking order. I’m always amazed by how little everyday people know about where doctors come from; like we appear full-grown from the head of Aesculapius, or something. But then I didn’t realize all that went into medical school until my last year of college.

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