It’s midnight on my first Medicine Sub-I call shift. My new admit has longstanding hypertension and diabetes. He is weak, swollen and has had difficulty urinating for the past two weeks. He anticipated needing dialysis in a few months, but a few missed doses of his medications have quickened his progression. We’ll start dialysis via a temporary catheter tomorrow morning and keep him in the hospital until he is stable and has a guaranteed dialysis chair as an outpatient.
Unlike Mr. ESRD, I’m thrilled to be on the Eskenazi wards. This past January I felt my calling. After a month of inpatient Heme at University and a month of joke-cracking veterans at the VA I knew I wanted to go into Internal Medicine. I loved the complexity of the patients, and the multidisciplinary team-based and evidence-based approach to care.
I learned a great deal during those months as an MS3. I honed my communication skills, improving my presentations on rounds and my interactions with patients. I took great satisfaction in getting to know their stories and relieving their concerns with the knowledge I had gained in MS1 and MS2. My patients, in turn, reinforced the clinical-pathological patterns I had learned in the classroom: the healthy 50-something with weight loss and bone pain presenting with AML. The 60-something vasculopath with chest pain coming in with ACS. Towards the end, I even started to feel confident in anticipating their management. ACS? Then: EKG, troponins, statin, beta blocker, aspirin, clopidogrel, heparin, cath lab soon. The residents made it look so easy. I couldn’t wait to have a go at it myself.
My resident pulls me out of my reverie: ‘okay hotshot, what do you want to do?’
Mr. ESRD has diabetes. He tells me he takes 40 units of insulin each evening and another 24 with each meal. I need to decide how much to give him here. Can I trust his story? Can a man with severe kidney disease really take such large doses of insulin? If I give him too little and he’ll get a headache, fatigue, and I’ll look bad on rounds. If I give him too much, he’ll get a headache, fatigue, and I’ll trigger a code.
Of course, my resident is looking over my shoulder; the patient is in no real danger. But the resident and I have an arrangement: so long as I’m not going to harm the patient, the decision is mine. And so the real stakes are this:
Undershoot the insulin and the nurse will wake me at 4am due to hyperglycemia.
Overshoot the insulin and the nurse will wake me at 4am due to hypoglycemia.
And thus begins my training in patient management in Internal Medicine. I get my first inkling how the Sub-I is different from my experience in IM as an MS3. Knowing a patient’s diagnoses is no longer enough. I must learn to anticipate future problems in the face of imperfect knowledge. I must learn to make decisions to forestall those problems. And I will need to accept the consequences of those decisions: be it a stern lesson on rounds or a sleepless night.
And so here I am, beginning my Sub-I by chart-reviewing with a purpose; hoping to confirm the patient’s true insulin dose via old Med Recs. Because when the decision is mine to make I know I’ll need to sweat the small stuff if my patient is to get the best care, and if I am to get the most restful night.