By Krystal Johnson, M.D.

As a resident, you frequently find yourself in situations you are unfamiliar with, and in places where you would not ordinarily choose to be. Each month begins a new rotation that can vary drastically in tone and tempo. I just completed my required month in the pediatric intensive care unit, where I was rather uncomfortable because I am not, and do not aspire to be, an intensivist.

Late in the month I found myself by the bedside of a toddler who was a near drowning victim with a prolonged resuscitation. For lack of better terminology, he was mostly dead on arrival to us. No one expected him to survive long, despite ventilatory and blood pressure support. This was conveyed to the mother by my attending physician, but it didn't quite sink in past the initial shock of the words. Later on that evening, when the child began to show signs of brain herniation, it was me who was sent to discuss the code status with the distraught mother. I tried to be calm and reassuring for her, when I felt anxious and upset inside. We discussed his overall situation, and that we would be willing to continue the support we were already providing, but did not want to introduce unnecessary trauma to the child. The mother agreed that this was in the child's best interest, and was of course tearful, but was appropriate. That is, until I handed her the pen to sign the "intermediate code" order. I can't find words to describe the intensity and meaning of the sound she made as she took the pen from me. Feeling tired, overworked, sad, and maybe a little disgusted, I began to cry. I thought of my own toddler at home and was angry that I wasn't home with him right then, able to hug him and play. My own life was being interrupted by this dying child, whom I could not help medically. Then came the sharp stab of guilt for thinking such things about my patient. I was able to semi-compose myself and return to the unit, code order in hand. The attending physician happened to be walking past, and seemed utterly surprised to see my reddened eyes and cheeks. "Are you ok?" he asked, incredulously. "Yeah", I responded, as I quickly looked away, ashamed of my own human-ness.

Later that same evening, I examined the child who had been impaled on a metal rod days earlier in an all terrain vehicle accident. Her parents were the most devoutly religious people I had ever met, and despite the child's critical and intermittently unstable condition, they remained eerily positive, playing inspirational music and greeting each nurse and doctor with a smile and a kind word. As I tried to find the patient amidst several loud bedside machines and miles of tubing and wires, I wondered how these people manage their faith. Don't they realize this child is sick? I wander slowly out of the room, realizing that I will never have beliefs as concrete as theirs, as my training has made me skeptical of nearly everything. There are no absolutes in medicine, or in life. At least that is how I am functioning at 3 am.

I go back to the call room, weary and droopy eyed, with the hopes of lying in the dark for an hour or so. I don't expect sleep, since I have two pagers and a bedside phone that are sure to wake me up, but I need to get away from the constant beeps of the monitors and ventilators for just a little while. I remember another patient from earlier in the month, a young man with muscular dystrophy and progressive scoliosis, who spent hours in surgery to repair the curve of his spine. The next day, as he was waking up for the first time, he was confused and working his way toward combative, as he did not remember going to the operating room or coming back to the unit. His mother was nearly in a panic, grabbing my arm and asking, "Why is he doing that?" The truth was, I had absolutely no idea. I said something about the surgery he underwent was a large one, and he received a great deal of medication, fluids, and blood during the procedure. This was the first he had been awake, and it wasn't necessarily surprising that he would be a little confused. I knew the real question was, "Did something happen to his brain during the surgery, and will he be like this forever?", but I'm not a surgeon or an anesthesiologist, so I didn't know how to address those questions. I stood there at the bedside awhile, searching for something to say, and ultimately walked away feeling helpless. His period of confusion was short lived, but I can't explain why it occurred in the first place.

I think before entering medical school, I was under the impression that doctors knew everything. They always seemed to have an answer, and more than anything, I wanted to know the answers. Problem is, the farther I got in the process, and especially when I got through intern year, I realized it's mostly guesswork. It's just that some people are able to stand confidently behind their educated guesses and project that confidence to others. That must be the real trick, or art, of medicine.

Of course, I learned a great deal in the intensive care unit. I learned about ventilators, medication drips, and resuscitation, about myself, and about what is important and what is insignificant in my life. The same is true for residency as a whole. I have a great deal more patience now than ever in the past, and I have a completely new appreciation for life itself. However, I was glad to walk out of the unit on that last day, and it would take a large amount of mental effort to get me to go back. For now, I'm crossing days off the calendar of my residency and looking forward to a future where I have more choice over how and where I spend my days.