Pressure

Issue: BCMJ, vol. 55 , No. 1 , January February 2013 , Pages 36-37 MDs To Be

Clinical confidence comes in many forms; sometimes, you need the confidence to second-guess yourself.


Today was the day I had been waiting for since I was 6 years old. Despite the heat, I wore my nicest shirt, tie, and dress pants to my preceptor’s office. All the way there I obsessed over how to enter the clinic. Would I look too eager, with a white coat on and stethoscope slung around my neck? Or would I look unprofessional—naked—without these tools of the trade? After all, this was my first clinical experience; this afternoon, I was an official medical student.

I stood outside the clinic for a moment, took a deep breath, and stepped through the door into the crowded waiting room. A young mother wrestling with her squirming son glanced up at me. From elsewhere inside the clinic, another child wailed behind closed doors. The receptionist, a kind-looking, middle-aged lady, gave me an expectant smile. “You must be the student,” she said. “I’ll call the doctor.” 

When my preceptor strode into the waiting room, I immediately noticed that she wasn’t wearing a white coat. Thoroughly relieved that I was still only carrying mine, I laid it down gently in her office and followed her to the examination rooms. “Since this is your first time, we’ll see each patient together,” she explained. “You can start each interview and practise taking blood pressures. Afterwards, if you have any questions, don’t hesitate to ask. Sound good?”

I nodded and followed her in to see our first patient. Bernice* was a fit, 50-something woman with dark brown hair and sharp eyes. With an encouraging nod, my preceptor motioned for me to start. My clinical skills lecturer’s voice ran through my head: “Never forget to introduce yourself!” 

After explaining who I was, I began. “So, what brings you into the office today?” 

“For the past 6 months, I’ve been having flutters in my chest” she replied. “It’s not too uncomfortable, but I was worried and got a test done, the one with all the wires? I’m here to see the result.”

“Ah, here it is,” my preceptor interjected, pulling up the ECG and scanning the report. “Looks normal to me, but let’s arrange for a Holter monitor to check your heart over 24 hours. But first, let’s get your blood pressure. If you don’t mind, Joshua will take it.”

“Game time!” I excitedly thought to myself. I sprang up from my chair and squared my shoulders, ready to prove that I belonged in medical school. Grabbing the cuff, I mimicked the numerous doctors I had seen on television, commanding, “Bernice, if you wouldn’t mind sitting up here and rolling up your sleeve, I’m going to feel for your pulse.” 

I felt for the brachial artery. Ten seconds passed, and no pulsations. I nervously moved my fingers to a different spot and pressed harder. Another 10 seconds later, I still couldn’t find it. Bernice, though visibly worried about a possible heart condition, waited patiently. Finally, I felt a faint pulse. Eager to make up time, I started to place the wrong side of the cuff on her arm. Fumbling with it just long enough to sneak a glance for the printed arrow marked “Artery,” I turned it the right way up and wrapped it around her arm. 

I got lucky. The Korotkoff sounds arrived clearly and I proudly announced, “122 over 80.” Both Bernice and I turned to my preceptor, wondering if she was going to double-check my first-ever attempt on a real patient. But she was already recording the pressure in her notes. “Aren’t you going to check it too?” I asked, voicing Bernice’s concern. “No, no, I trust you,” she replied. 

Moments later, I was up to bat again. Bob, a man in his sixties, had a colorful medical history of hypertension, lower back pain, and multiple surgeries. Emboldened by my success with Bernice, I pounced to the bedside again. First, I put the cuff on too loosely, and watched it slide pathetically down Bob’s arm. Then, after untangling the pump’s tubing from my stethoscope, I realized that I had worn my stethoscope backwards. 

Muttering several hushed apologies to everyone in the room, I inflated the cuff, promptly released the catch too fast, and watched the needle shoot past the systolic pressure. “Oops,” I mumbled as I pumped the cuff back up. Whoosh. Missed it again. Feeling increasingly anxious and incompetent, I tried once more. I thought I heard the systolic pressure around 130, and I reported 132. “That’s great Bob,” my preceptor said, “one less thing to worry about.” I hesitated, willing myself to just say that I wasn’t sure. I was embarrassed, but didn’t want that to compromise Bob’s health; the dilemma burned in my throat. But before I could say anything, my preceptor was already talking to Bob about his lower back pain. 

I tried in vain to listen to their conversation as all the applications essays I had written about putting patients first and being a responsible, professional person crashed through my mind. I tried my best to rationalize: How much clinical difference does 5 mmHg make in this range anyway? After all, aren’t indirect blood pressure measurements somewhat inaccurate? And what about the “white coat” effect, which artificially elevates office blood pressures? The more I justified, the more I recognized the fear of shame that led me to blurt out any answer.

Dorothy was our last patient of the day. A vibrant older lady, she complimented me on getting into medical school. “I’m going to be faster and more accurate this time,” I silently promised myself. But the third time wasn’t a charm. Again, I had difficulty determining the systolic pressure clearly. After a few attempts, I sheepishly offered an estimate, “I think it was 120 over 80.” 

“Is that good?” asked Dorothy. 

“Very good, especially for someone your age,” my preceptor reassured. An identical wave of guilt and worry washed past my conscience. Pushing away the fear of what my preceptor might think of me, I stood up and asked, “Actually, do you mind if I check again? I wasn’t a hundred percent sure I got it right.”

My preceptor gave me a puzzled look and hesitated before agreeing. I slowly reapplied the cuff and donned my stethoscope. As I gently released the catch, I could hear the muffled sound of my own heart pounding to the beat of Korotkoff’s rhythm. Phase 1, Phase 2, Phase 3, no sound—Phase 4. Finally, a reading of 124/80. I calmly removed my stethoscope and reported the pressure with confidence. 

As I turned back to Dorothy, she was smiling. “Wants to check my blood pressure twice! One day you’re going to be a fine doctor, young man.” I smiled back, hoping she was right.

Acknowledgments
I would like to acknowledge the members of the UBC Medicine Creative Writing Mentorship group for their feedback and support, and would like to give special thanks to Dr Eric Cadesky, our faculty mentor, for inspiring me to share this story.

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Mr Lai is a medical student at the University of British Columbia, in the class of 2014.

Joshua Lai, BSc,. Pressure. BCMJ, Vol. 55, No. 1, January, February, 2013, Page(s) 36-37 - MDs To Be.



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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

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