I Ordered A Blood Transfusion Today

I’m not comfortable with the fact that this was, somehow, allowed.

And blood transfusions are really the WORST example, because there’s so many safety checks between the blood bank and the nurses – but even so, the fact remains: I have waaay too much responsibility.

And it’s not the “so many things I have to do!” kind of responsibility – it’s the “so many things for which I am legally and morally culpable!” kind of responsibility. And I am not used to that.

Med school does not prepare you for that.

Today I carried the other intern’s patients, because she had continuity clinic. And I got a page about a patient with, say, pancreatitis. “Still in pain after I gave tylenol dose. Can you put in an order for motrin?”

… Can I?

Sure, I checked up on the patient first. But even after that, it took me at least 5 minutes of research to feel confident that motrin was definitely okay in pancreatitis. (Why wouldn’t it be? Shit, I don’t know. Stomach ulcers? I just had a general feeling of unease about it).

Then it took me 10 more minutes to figure out how to prescribe it, because of finicky things with dosing and formulations. And then I was unsure if I maybe overprescribed it, so I had to call the pharmacy to double-check.

The nurse was not amused by the delay.

So yes, you could say intern year is going great.

I got another page today: “Patient ‘TotallyStable McHomeSoon’ is desatting to high 80s on blow-by, sBPs in 80s. Please come to bedside to assess.”

So I jogged over, assessed, gave a few obvious orders (Nasal canula, 1 L. …. Nasal canula, 2L… albuterol on stand-by…), came up with a reasonable assessment and plan, and left the nurse at the bedside so I could quickly update my senior resident.

I figured she’d probably be okay with my management, but might be deservedly annoyed I didn’t inform her sooner. I mean, this kid was initially unstable.

But she just said “Right, I heard about that patient’s desats,” – and with great restraint and calculated patience, she continued: “They told me first. So I told the nurse to page you.”

Which… what? Excuse me?

WHY WOULD YOU DO THAT.

So I went back in the room, kept managing him – and the patient turned out fine (eventually stable on room air) – but I do not like that kind of pressure.

Even worse, one of the things on my differential was that I had recently reconciled all of his many, many medications – and some weren’t on formulary, so I had to call the pharmacist – and… maybe I made a mistake? Maybe this was pharmacologic respiratory depression? He had just gotten his morning medications, after all.

So for at least 5 minutes, I was seriously considering the fact that I might have made an inadvertent error that could have seriously hurt someone.

I didn’t. Turns out it was something else entirely – but… the bright feeling of “Whew, I didn’t make a mistake!” is being tempered by this inner voice that’s adding “This time” to the end of that sentence.

Why would anyone WANT this kind of pressure? Who the hell decides to be a doctor? Who wants to reconcile outside medications, knowing that there’s a chance you’ll make a minor error, and see a patient in acute respiratory distress?

(Again: I was not the cause. I reconciled perfectly.)

(… this time.)

We had a code today, too. I was ecstatic that – despite being disturbingly close by when the code was called / the alarms went off – I still somehow managed to be too late to be of any use. (YES! The holy grail: responding emergently like a responsible person, and not being needed.)

Still, I stuck around with about 10 other residents / attendings / nurses in case they had to go to chest compressions and needed the extra help.

Chest compressions, I can do.

This day-to-day “ordering potentially life-threatening medications under my god-given name” thing? That’s much harder.

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9 thoughts on “I Ordered A Blood Transfusion Today

  1. All these stories remind me of my 1st month on the inpatient adult service in July of my intern year which was a little over a decade ago.
    What you are feeling is completely normal and near universal. In fact, if you didn’t have these feelings, you should probably be worried.

  2. It took me over 30 minutes and multiple rechecks just to order potassium replacement. Its potassium! It could kill somebody! But it was fine, and appropriate. I totally get where you are coming from!

  3. Yes, the worry is normal. Yes, be careful and study hard. But also, don’t worry too much. A) People are pretty hard to kill, and B) Your seniors and attendings are usually watching you a bit more closely than they let on . . . as you discovered.

    Right now it seems like people will die if you do the wrong thing. But the wonderful and awful truth is, they almost never will (some will do slightly worse than they would otherwise have done — sometimes). If someone is going to die from your mistakes, they will usually need to be multiple mistakes, fairly large and obvious usually, made in spite of multiple signals from multiple places that things are going wrong.

    That happens, if it’s going to happen, not usually because of a knowledge deficit, but a character deficit. That can be a temporary character deficit, brought on by exhaustion, or burnout, or sickness, or hunger, or it can be something more permanent, like a deep-seeded arrogance, or an insecurity that cannot ask for help. But it’s gotta be pretty profound. If you listen to your nurses, ask for help from your seniors, and respond to failure by doing something different instead of doing the wrong thing harder, you’ll be fine.

  4. “But she just said “Right, I heard about that patient’s desats,” – and with great restraint and calculated patience, she continued: “They told me first. So I told the nurse to page you.”

    You have a GREAT teacher right there, a safety net who is allowing you to practice your skills and build your confidence before you have to go it alone. Learn, learn, LEARN!

    • Thanks for this. It’s true, I’m in awe that the senior resident thought I could handle it. But I guess I did? She has a lot of responsibilty too, now that I think of it – deferring stuff like this to a newbie like me… yikes.

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