We All Spend Time As A Shadow

I leave my apartment and hop in the car, already feeling a little drowsy. It's 10:30 pm, and I'm heading to work. In order to satisfy a requirement for an internship, I scheduled two ED shadowing shifts back to back, starting at 11pm and going till 7am. I took two shifts previously from 6pm to 2am, but this was different. Going to work in the middle of the night feels unnatural, though the commute is pretty good. I arrive at the hospital, carrying my coffee-filled thermos (essential), ready for the night shift.

So, you want to be a doctor. Fantastic (although if I had a nickel for every time I heard that, I wouldn't be taking out so many loans for med school). What does a doctor do? If you answered "Helps people" you are probably a freshman with good intentions but much naïveté. If you chose "Paperwork" or "Sitting at a computer" you probably have a little more experience. If you said "Inflict pain and interrupt frequently" you are probably a patient. Most people have a general idea of what physicians do, but they lack the important day-to-day details. Medicine is fairly romanticized thanks in large part to shows like ER, House, or Grey's Anatomy, and the many that came before it. Watching people put in orders, review charts, wait for labs, or conduct rounds does not make for very interesting TV (to the general public at least). Thus we arrive at our stereotypical freshman pre-med, gunning for med school without any conception of what physicians actually do. This is where shadowing comes in.

The ED is arranged like a giant horseshoe, the interior being the nurses' and physician's stations and the exterior being the patient rooms. I set my coffee down and put my snack in the mini-fridge (god help you if you fail to bring snacks). I greet Dr. S. and we begin the night. Dr. S. is very mild mannered and speaks calmly (ER docs tend to come from both ends of the spectrum, calm and manic). It is a typical night at the ER; abdominal pain is coming at us from every direction and shows no sign of letting up. Not too far into the shift, an elderly woman arrives by EMS. She was unconscious and had some dried blood on her head, suspicious for a fall. She was weakly responsive to pain, but no spontaneous movement or sounds. She got the usual 'ER Special' consisting of IVs, blood tests, and cardiac monitoring. She would almost certainly be admitted. Neurology would be consulted as soon as possible. Several hours later, her daughter came running out of the room, shouting for help; the patient was having a seizure. After a tense minute or two of not being able to locate any nurses or Dr. S. (he is the only physician on at this point), we stream into the room to assess the situation. The patient has stopped seizing at the moment, but is now not breathing. Her heart rate plummets. Quickly, a nurse starts to bag her, and Dr. S. makes the decision to intubate. Respiratory is paged, and a nurse prepares anti-convulsants. Finally, she's stabilized, and we all go back to work. No rest for the weary.


Shadowing is exactly as it sounds: the student follows the physician like a shadow, in order to observe. However, unlike a shadow, you will constantly be in the way, and you can/might be allowed to ask questions. Medical students are expected to ask questions, even if they end up being forced to answer their very own questions and ultimately being chastised for not knowing the answer (doesn't seem fair does it). It is extremely useful though, because you gain firsthand knowledge of how a typical day/shift goes. For example, I was shadowing an ER doc, and for the first 2-3 hours, we didn't see one patient. Labs were backed up and beds were full, so we just sat on our asses until it cleared out a bit. You do get to see procedures and patients (especially in surgery), but the little things are actually the most important. Adcoms want to see that you know what you're in for; the fairy-tale can be your motivation, but you better be prepared for the reality.

Around 5am or so, Dr. S. are seeing a patient about back pain when the intercom clicks on. "All help to triage stat!" the nurse shouts (first time I heard stat used in a serious context). Dr. S. is not phased, and continues to interview the patient. Seconds later, "Physician to triage!" Dr. S. sighs, apologizing to the patient, and we head down the hall to the waiting room (slowly I might add). Before we get there, two beds complete with patients come flying around the corner, pushed by a couple personnel. Both patients were stabbed at a party and had just walked in the front door. Minutes later, a third patient comes in and is wheeled back to an empty bed. The ED goes into lock-down, police are called, vitals and IVs are started, and ambulances are called to transfer the patients (the hospital is not a trauma facility). Shortly after our three stab victims arrive, a code blue goes out over the intercom. The physician covering the wards, Dr. P., is currently in the ED, and Dr. S. is not sure if she's even ACLS certified. Dr. S. and his scribe take off after her with the code box, and I am tasked with getting vitals from the patients. They all appear to be in discomfort, but one looks very pale and is shaking (effects of epinephrine). Dr. S. and his now disheveled looking scribe (CPR will do that to you) return, and the patients are transferred.


So, shadowing is important, an unwritten requirement of medical school. But how do you go about it? I was lucky; I got an internship through the university that handled the initial contact. For those less fortunate, I would suggest asking around the hospital if you volunteer at one. Academic medical centers are probably the best choice because they will be used to having medical students around. Ask your friends too. I came from a completely non-medical family, so I was at a bit of a disadvantage. Many of my friends had physician parents or grandparents, so they became a great source of knowledge. There are lots of guides pertaining to shadowing though, so just search SDN or Google for more in depth advice. You don't have to rack up hours and hours of shadowing, but spend one or two full shifts per specialty. It helps to get some variety as well, but even one experience is better than none. Don't forget to have fun, but make sure you reflect on your experiences too. If you really can't see yourself living that life, it might be time to switch paths. That's what shadowing is for. It wipes away some of the glamour, exposing the realism of clinical practice. It disenchants, leaving only the most dedicated behind to finish the journey to medical school.

In the Hospital: The Good, the Bad, and the Ugly

Ask any healthcare worker if they have interesting stories from their job, and you will be bountifully rewarded. This is especially true if said person works in an emergency department or hospital. The main reason for this effect is relatively simple: the more people you interact with, the crazier the world seems. The ED is a melting pot, with people of all demographics (though predominantly low SES) represented. Bringing such a diverse group together tends to give you interesting results.

The Ugly
ED stands for "Emergency Department," but it could also just as easily stand for "Elected to Display." What I mean by this is, people often have no shame in showing you exactly what ails them. As a volunteer, one of my jobs was to help people fill out a form so they could be triaged. We had several signs pointing to the forms, indicating they should be filled out first, but people often walked up to the window anyways. The conversation usually goes like this:

Me: Can I help you?
Patient: I need to be seen. I have this huge rash (reaches for shirt).
Me: (Quickly) Ok, I need y...
Patient: (Pulls up shirt revealing a large rash, fully in view of everyone in the room.)
Me: (To myself) Thanks for that.
Me: Ok, please fill out that form for me and we'll get you looked at. Sigh...

The probability of me being shown an ailment is proportional to how bad/disgusting it looks. If blood is involved, the chance jumps to 100%. Traumatic wounds need to be checked of course, so I don't fault people for that. It's the absurdity that gets me. You would not say, show your bulging abscess at a dinner party as part of your introduction (if it comes up in conversation, well, that's fair game). But in an ED, you'll walk up, lift your shirt triumphantly, and share with myself and others your pathological achievement.

The other common presentation is the "waited too long" patient. A couple of instances stand out in my mind. One was a woman who was extremely lethargic. She could barely even speak or hold her posture while sitting. A history revealed that she had hypothyroidism and had either run out of medication or just didn't take it for a while. Without treatment, she surely would have fallen into a myxedema coma. I remember the nurse blatantly scolding the woman and her family for not coming in sooner. The other case involved an older man who may well have set a hospital record for highest temperature in a living person. He arrived (astoundingly) by personal vehicle, driven by his daughter. He was a bigger guy, so I called the paramedic to help get him out of the van. He gave me a ribbing for not doing it myself. After a few minutes, he came back in sweating and out of breath with the patient slumped over unconscious in a wheelchair. "He was complete dead weight" the medic said (I should have gone out to help him, which I apologized for afterwards). I don't know how in hell his family got him into the car. The nurse took his temperature, which read 106.7 F (41.5 C). For those of you wondering, this is borderline "incompatible with life." The nurse wasn't even sure if the thermometer would be able to read that high. I'm fairly certain he was septic, although I think he ended up surviving. The ED really alternates between the mundane and the unbelievable.

The Bad
I'll end on good so as not to leave you feeling (too) depressed. Unfortunately, the ED is not generally a happy place. It is visited out of necessity rather than desire, which makes it ripe for unpleasantness. When you add pain/nausea/malaise/uncertainty with long, seemingly arbitrary waiting times, things can get really, really unpleasant. The worst cases occur when someone gets to "cut in line." Triage works like this: the nurse takes your vital signs and a brief history. He/She makes any quick assessments necessary, like a vision test or brief neuro exam, along with a self-reported level of pain. This is all summed up by a triage score 1-5, 1 indicating immediate life-threatening condition (like cardiac arrest) and 5 indicating minor condition with no necessary procedures (like a cold). The severity of the condition dictates who sees the doctor first. Things possibly affecting the heart (chest pain) or lungs (dyspnea) are the more common sources of line-cutting. On certain occasions, it's very obvious someone needs to go back right away (serious laceration, head trauma, altered mental status, etc) for instance, like the man who seized while being triaged. These types of problems draw few objections from the waiting room. Most times it is less obvious why someone goes back first though. One day in particular, I had a women who was fairly sick, with nausea and vomiting (n/v). However, her vitals were essentially normal, with perhaps a mild fever and and tachycardia due to the nausea. Unfortunately for her, several ambulances showed up, and we were already full. Additionally, a few other walk-ins had deviations in vital signs like hypotension, which needed to be worked up. She waited for at least three hours before she had enough. I tried to explain to her why other people went back first, but I wasn't getting through. I think she ended up leaving to go to another hospital (where she will probably wait just as long again).
On my final day, a woman showed up, depressed and on the verge of tears. She was looking for her son, who had gone missing the night before. His car was deserted, and his wallet was left behind, suspicious for foul play. But he wasn't at our hospital, and there was nothing I could do. I told the woman he wasn't at our hospital, but I would look out for the name. She then asked me what she should do. I told her to contact the police (which was her best option). She said okay, and thanked me sadly before leaving. It is a difficult thing in medicine, to want to help others but accept that sometimes, there just isn't anything you can do.

Another part of the ED is that bad news often arrives unexpectedly. People go from alive to dead without any warning or preparation. I've seen a few people coded, and not one of them survived. Listening as the doctors break the bad news is not something you easily forget. I arrived a couple times to deceased children, which is about the worst. I've seen several repeat patients, one of whom always arrives by ambulance, always complains of dyspnea, and then immediately proceeds to go outside and smoke a cigarette. Patients are often obese, some are drug seekers, some malingering for disability or other reasons. And many lack the capacity to understand how medicine and the ED works. They struggle with their own problems, and fail to appreciate the perspectives of the people trying to help them. I've seen people arrive intoxicated or high on drugs, sometimes dangerously so. Patients are combative or abusive to the staff, especially the behavioral or law enforcement ones. And the worst part of all is that so many of these people will return with the same problems, lacking the money or reinforcement they need to change. To see the human condition so exposed, so gritty, it can turn even the most optimistic people cynical.

The Good
Like most jobs that deal with the seedy side of life, you survive for the few good things. Occasionally, you will get a patient who is helpful and courteous, and it makes all the difference. Elderly people tend to be better mannered and more likely to wait patiently, but that's not always the case. The clinical and support staff can also make a big difference. Some people are naturally easy going and funny while others crumple under stress. There was one nurse in particular that I remember, because initially I think she didn't like me. When you start volunteering, you're basically a massive tool because you don't know anyone, you don't know where anything is, and you don't know how things run. As Samuel Shem puts it in the House of God, "Show me a [medical student] that only triples my work and I will kiss his feet." Such was the case with this nurse. But after spending time in triage with her, she eventually considered me a colleague/friend. If you establish yourself as a competent, trustworthy person, you'll make friends easily.
Getting to know the patients also helps. Towards the end of my volunteering career, I started spending more time talking to people. I wish I had done this sooner, because it gives you new perspectives. One man I talked to lived in NYC with his girlfriend until they broke up. He moved to a small town in Arizona, but left because of a drug problem (in the town, not necessarily himself). Another man I talked to was younger than me and had just been released from jail just a few days ago. He suffered from substance abuse and was probably in withdrawal. I chatted with him in the waiting room, and then I checked up on him once he was in a room. He was very grateful that I had spoke with him. The epitome of grateful patients occurred when a woman walked in with questions about medications for a surgery she had a few days ago (yes, she showed me the scar). I didn't want to make her wait in the ED, so I talked to the unit clerk, who managed to contact the surgeon. He said she didn't need any prescriptions for antibiotics or pain pills. I walked back out to the waiting room, expecting to hear objections raised. When I relayed the message however, she smiled and thanked me. She didn't want to take anything in the first place!

Most of my memories from the hospital are snapshots, brief clips that struck me as poignant or odd. Most are relatively neutral, but several fall under the Bad category and even fewer into Good. I learned a lot from my two and a half years at the hospital. Most importantly, I learned that communication is everything. It can mean the difference between making friends or creating enemies; the difference between gaining patient's trust or losing all credibility. What you say can make just as big an impact as what you do, medical or otherwise. When you understand a patient's perspective, it allows you to better help him or her. Medicine is all about the good, the bad, and the ugly. You just never know what your next patient is going to show you.

In the Hospital, Day 1

One hot summer afternoon, I walked into the emergency department (ED) at a local hospital for the first time. I was nervous about my new position because at no point did I receive any substantial training. I was shown places where important items were present and should be, as well as places where important items weren't but should have been. My function was to remedy the situation so that all the places fell under the first category (this was very rarely achieved in full). I was also more or less in charge of the waiting room, which meant I would be the first person patients and visitors would address with their questions and comments. At first this seemed problematic, given the absence of training and a lack of knowledge on hospital procedures. But it quickly became clear that only a few phrases would be necessary, most of which include the words "wait" and "soon" in some configuration.

It was a small waiting room, with enough chairs for approximately twenty-five people. The triage area, nicknamed The Fishbowl, overlooked the room from the corner. The Fishbowl owed its nickname to the plexiglass windows that closed it off from the waiting room (more importantly, the people in the waiting room). Thankfully, it was not too busy, which I considered a good omen. I swiped my badge, and proceeded through the double doors that led to the rest of the hospital and the ED. There I met Roger (not his real name), the volunteer who offered to lend for my first day. His first two pieces of advice immediately contradicted the little training I was given. First, he recommended that I avoid doing "Rounds" on the people waiting. This tended to disturb the fragile equilibrium between people asking me questions and people becoming frustrated with my "wait" and "soon" responses. Once a patient views you as a foe, your job becomes infinitely more difficult and miserable, and so we decided it was best to let sleeping dogs lie (especially the people actually sleeping). Second, he recommended that I stay inside the Fishbowl. This allowed me to watch over the room and get to know the triage nurse while further discouraging questions. And so we set off, thwarting attempts to bother the nurse, helping family members find a relative, and keeping individuals contently (quietly) waiting.

Before my volunteer savior left me to manage alone, a patient arrived by EMS suffering from seizures (unknown to Roger and I). One woman was particularly hysterical, pacing back and forth, barely able to form complete sentences. She pleaded with us to let us see the patient, but he wasn't settled in yet (IVs, meds, exam, etc). At first we didn't even know who she was talking about, and before we could get any information from her, she hurried outside to make a phone call. Roger shrugged, and we went back to work. Later, I recall walking by his bed as he began seizing again. Had it not been my first day, I would have paused briefly to see how they were managing him. Eventually, the woman was let back to see him, although she was somewhat of a thorn in the side of the staff.

The rest of the evening was less eventful, but busier (which tends to be both a good thing and a bad thing). As I was leaving (an hour after my shift was supposed to end), the triage nurse, recognizing that it was my first day, gave me some advice (which I would not heed nor fully appreciate until much later). He told me, "don't forget to have fun." It's easy to spend all your time volunteering or studying or focusing so much on your goals that you forget to take a breather. I left that night tired but excited. This was my first step into the world of medicine, and it was sure to be interesting.