Sunday, April 29, 2007

Decisions

It is tough to have to be the one who makes decisions.

I've spent a lot of time preparing for this, reading my protocol book and leafing through notes. All of the advice is fairly linear. Problem A gets solution B. I've spent many nights learning about solution B, memorizing dosages and routes, committing medical control orders to memory. I know all about B.

What is harder, I'm finding, is that most of the time the problem is not A. ...It is A and C. Or part of A and a little bit not A. Patients are so often a murky gray, presenting in their own fashion a disease hidden by muddled complaints which lack the clear definition laid out in my textbooks. Solution B doesn't always work if the patient is not quite A.

I knew this of course. It is one of those things they teach you on the first day, the poignant advice that carries no weight until understanding is brought to the surface through experience. "The patient hasn't read the book on how to present." Sure sure, I thought. That is what assessment is for, right? That is what we were there to learn. Problem A is characterized by these listed symptoms: you just need to be on the ball enough to know what to look for.

Even when I think I'm on the ball, though, patients keep managing to throw me curves. An outlaying complaint, something that doesnt fit. The lack of a critical symptom. The right words, the wrong presentation. It is tough to keep confidence high when treatment comes down to a judgment call, the most important information for which must come from experience that I lack. Does this patient look sick? It is often hard for me to make the decision and remain firm.

The patient is on the monitor, O2 flowing and an IV established. I've done the glucose and performed my physical assessment, obtained the history and got the complete story. Still, I'm scratching my head with indecision. I look away from the patient towards my right, where my preceptor sits. A questioning look on my face.

He is there, sunglasses on, smiling.

"These are the decisions you're going to have to make."

2 comments:

Brett said...

Once again... your exactly on track... I felt the same way on my first handful of shifts... I still feel that way some times

Lori said...

Believe me, as a 15 year veteran, they will throw you curveballs on a regular basis. Sometimes it comes down to gut instinct. You can only treat what you are presented with. When you get to the ER the Doc may be thrown the same curve. Just do the very best you can. Be prepared and always give the best of you to your patients. They deserve it. Lori