Piscataway, New Jersey, United States
This story, “Following Orders,” by Boris D. Veysman was originally published in Academic Medicine, 2005 Jan; Volume 80 (1): 114 ©2005 Association of American Medical Colleges Publication.
“I got the ABG1!” I proudly announce to my resident. “Need help with anything else?” It’s a Saturday night, and I am a third-year medical student on my medicine rotation.
“Jane and Cindy may need some help in room 304 with their LP,2” he replies. “Wear gloves though; he’s end-stage HIV positive. It will be a good learning experience.” I feel my pulse quicken in the anticipation of danger. I’ll show that I can handle it, I think to myself as I enter the room.
On the bed, a very ill man writhes and screams, his hospital gown riding up his chest. As one resident tries to hold his hands and feet in place, another chases a moving target with a long spinal needle. Seeing me, they smile and ask me for help restraining him. My thoughts are racing. This is my learning experience? Forcing people into submission?
I take a deep breath. Okay, just do what you’re told. Trapping his wrists between his knees, I then push his head towards his chest. Overpowered within seconds, the patient is still. The residents exclaim, “Perfect position!” and start reprepping his skin with iodine. The patient’s eyes focus on my face. I bend down and apologize, “Sorry. We have to do this.” He looks away. Apology not accepted. Is this the right thing to do?
The needle penetrates his skin, resurrecting his will to fight. Cursing and spitting, he screams for us to stop. “Please don’t move,” I say calmly as I silently scream at the residents, C’mon, hurry up!
Five minutes feel like hours as the residents struggle to draw the spinal fluid. I want to object—overpowering this remnant of a man feels wrong. But it is my duty to continue. Or is it? These senior residents lectured on the importance of patient autonomy last week. He must not have capacity to refuse the procedure. Or does he?
I remain silent. Eying the exhausted and frustrated residents, I struggle internally: They evaluate you. If you fail them, they will refuse to teach you.
With another scream, drops of spit hit my face. Surely they must stop now. But they don’t. I know the residents expect me to be enthusiastic, respectful, and obedient; I shouldn’t embarrass the residents in front of the patient. How can I make them think about what they are doing without shaming them? I suddenly realize the solution. You are a student. Ask a naïve question: “What do we expect the analysis of the fluid to show?”
The question drowns in a double sigh of relief. They got the fluid. “Hold steady, Mr. Johnson.” He closes his eyes as his muscles weaken. The procedure is finished. He lies peacefully in the bed, almost smiling, on a brief vacation from hell. “I am sorry it took so long, but the fluid should be very helpful for the diagnosis,” I say to him gently. I am sorry I cared about being a good medical student more than about you, I confess silently. He slowly turns to look at me. “Please let me be, doctor,” he utters.
I walk out, wishing he never said that. What I did today was not the work of a doctor. While contemplating a diplomatic dissent I lost the chance to intervene—a good learning experience, indeed.
This essay is dedicated to all those who taught me to question their orders.
- An arterial blood gas (ABG) test measures blood levels of oxygen and carbon dioxide
- Lumbar puncture
BORIS D. VEYSMAN, MD, wrote this essay as a resident in the Department of Emergency Medicine, Bellevue Hospital Center, New York University School of Medicine, and it was originally published in Academic Medicine. He is now an attending at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson University Hospital Emergency Department.