Don't get any on you

In med school, I tried to get my hands on as many procedures as I could.  I was competing with residents, though, and they outranked me in seniority, knowledge, and ability.  Some procedures were denied me because they were sufficiently complex or risky that no med student should perform them.  Other times, I wasn't allowed to do a procedure because it was uncommon and this or that resident needed to do it to satisfy graduation requirements.  I was typically assigned procedures that were either simple, common, or undesirable, or some combination of the three.  There is never a shortage of subcutaneous abscesses to lance in the ED, for example, and most residents and nurses don't mind giving up a few IV starts.

Smart med students don't complain about being handed the dregs of their team's to-do list (or, as we say in medicine, "doing scut work") for a few simple reasons.  First, behind that "scut work" is a living, breathing patient, one of our brothers or sisters who has come to us for help and deserves compassionate care from an engaged physician.  Even the most disgusting or mundane task is an important part of that patient's care.  Furthermore, as sentient beings, we can (to some degree) manipulate or sublimate our own emotions.  We can choose to hate the scut or we can choose to love it.  Either way, the scut work has to be done; so why not choose to do it with a smile?

Second, medicine has a deeply entrenched system of hierarchy.  The level of abuse to which med students and residents are subjected has lessened considerably, especially in the past few decades, but it's still important for each member of the medical team to know his or her place in the pecking order.  Med students are not supposed to talk back to residents and residents are not supposed to talk back to attendings.  There is always room for junior team members to ask questions so that they may understand and emulate the logical reasoning and medical decision-making skills of their superiors.  Senior residents may even politely disagree with an attending's assessment and care plan.  But when a superior instructs a junior team member to perform a specific task, the only acceptable answer is "Yes, sir."

The third reason med students don't generally complain is selfish in nature (which is OK, in this case).  Interactions with their superiors become impressions.  Impressions become written evaluations.  Written evaluations find their way into dean's letters.  And dean's letters are of paramount importance when residency directors have scores of applications on their desk and need to separate the wheat from the chaff.

So, to any med students reading this: Be respectful of your residents.  And don't complain.  We know it sucks to be the low man on the totem pole.  But when you whine about it, we notice.

But that's enough soapbox preaching for now.

As a med student rotating on the anesthesia service, I usually asked the scheduler for a day or two when I could be out of the OR in order to practice starting IVs in the preop holding area.  In one day, I could easily start (or blow) a few dozen IVs.  Those also tended to be good days to catch up on some studying.

I was enjoying such a day during the last month of my third year of medical school.  It was late in my second anesthesia rotation, and I was getting pretty decent at IV starts.  I was even learning how to do them without getting blood everywhere.

My patient was a thin man in his late 40s.  The hospital gown he wore was, in some ways, a great social equalizer.  Each patient in the hospital wore an identical one, from the millionaire philanthropist to the homeless beggar.  But there were things the gown couldn't hide.  His eyes were sunken, his hair unkempt.  Those teeth he still had were yellowed and cracked.  There was a heavy layer of grime under his fingernails.  He appeared much older than his 48 years.  He bore unmistakable signs of poverty and years of self-neglect.

I wanted to help out the anesthesia resident assigned to this man's case, so I took a preop assessment form with me when I went to start his IV.  As might be expected, the man's medical care was sporadic and discontinuous, and there was little information to be gleaned from his medical record.  The patient didn't make my information-gathering job any easier, avoiding eye contact and answering many of my questions with shoulder shrugs.  About the only useful information I got from him was that he was HIV-positive.  As we spoke (or rather, as I spoke and he shrugged), I realized he was a man who had simply given up.

He held out his hand for me to start his IV.  Despite my burgeoning IV placement skills, I was still very uncomfortable attempting IVs on patients who looked like "hard sticks."  I was grateful to find that my patient had veins roughly the size of the Alaskan pipeline.  I tied the tourniquet, put on my gloves, and selected an 18-gauge IV catheter.  After numbing his skin with some subcutaneous lidocaine (I consider placing IVs without local anesthesia to be cruel and unusual) I placed the IV and took down the tourniquet.  The patient had watched all of this without a word.  He didn't even flinch or look away, as most patients do.  I placed my thumb on his vein upstream of the catheter to prevent it from bleeding back.  With the other hand, I picked up the IV tubing and then withdrew the needle from the IV.

As the needle came out of the catheter, it was followed by a single drop of blood.  My patient and I both watched as that drop rolled across the back of his hand and fell, landing on my knee.  With a completely blank expression, the patient looked me in the eye for the first time and said, "Don't get any on you, doc.  That's death right there."

To my credit, I remained composed as I hooked up the IV tubing, secured the IV, and cleaned my patient's hand.  I wished him an uneventful surgery and a speedy recovery.  As I parted the curtains around his bed to go change my scrubs, he called over to me, "Hey, doc?"  I stopped and turned back.  "Thanks for the numbing medicine.  I didn't even feel the IV."

In the four years since that encounter, I've thought many times about that man.  I wonder if he's still alive, or if AIDS or some other enemy has ended his journey.  I wonder if he managed to find hope.  I hope he at least found peace.