See One, Do One, Teach One
by Mike Litrel, M.D.

It was two hours later when I finally reached the last baby to begin his exam. He was unusually miserable, his face all scrunched up and red as a beet. Nothing I did provided him any relief, and he was making so much noise I couldn't listen for heart murmurs. My clinical instincts told me something was very wrong. No baby should cry this much.

I opened the baby's diaper and saw a dressing covering his penis. He had been circumcised the day before. Perhaps there was an infection or undiagnosed trauma. Eager to make the diagnosis, I carefully pulled off the gauze and peered attentively at the area. There was a puzzling string that followed my lifting the gauze. It was attached to the circumcised penis. But when the "string" touched my face, I realized it was actually a stream of urine. Flustered, my first instinct was to put the small piece of gauze back where I found it. Urine splashed all over. My hand, my sleeve, my lab coat, my glasses - I was wet.

And then an emergency occurred.

"What's wrong, what's wrong?" Helen Philpot cried as she rushed into the nursery. I looked over to see her leaning over Ruby, who was holding her chest, stiffening in her chair. "I... can't... breathe..." Ruby gasped. The other nurses rushed in. "Ruby is a diabetic," one of them said, "she had a heart attack a few years back."

"Are you choking, Ruby?" Helen asked. Ruby shook her head and pointed at me. Her face was blanching from lack of oxygen. I could see that she wanted my help, and I took out a stethoscope to make an examination. But Ruby's airway suddenly cleared. She took in a deep breath, still clutching at her chest. And then it happened.

Ruby began to laugh. Ruby began to laugh the biggest laugh the world has ever seen. Deep guffaws rolled out of her body as she struggled to explain what had happened. Her hand trembled as she pointed at my urine-soaked front and glasses.

"Oh Doctah," Ruby said, gasping for breath. "That was the funniest thing I evah did see." Tears streamed down her face, and everyone else, relieved and delighted, was soon caught up in her contagious delight, laughing uproariously as well.

Everyone but me. I was humiliated. So much for being a great medical student. I wanted to explain what I had done, how I'd thought perhaps the "string" might be the source of the baby's discomfort. But as I looked at the sea of faces all laughing with delight, I suddenly realized it was okay if I wasn't perfect. So I began to laugh too, uncontrollable laughter - and finally groped for a chair as I collapsed in a paroxysm of cathartic laughing.

It took minutes to recover. During that time one of the nurses took off my glasses and rinsed them in the sink. Helen got a washcloth and scrubbed the urine off my coat. And Ruby got out of her chair and gave me a bear hug. "We love you Doctah," she said to me. "You come back any time." The other nurses were smiling and nodding - making fun a little, but friendly too.

The next time I came I brought a box of donuts to share. We all shared another laugh. It turned out to be a pleasant month of call. And I learned much from folks wiser than I.

Dr. Litrel is in practice at Cherokee Women's Health Specialists in Woodstock and Canton, and is a Clinical Assistant Professor at Emory University School of Medicine. He lives in Towne Lake with his wife Ann and their two sons Tyler and Joseph. (mikelitrel@attbi.com)

The responsibilities of a third year medical student on Pediatrics rotation at Grady Memorial Hospital are relatively straightforward. The third year examines the dozen or so babies ready for discharge and makes certain all is well. Pretty simple stuff - except when you don't have a clue what you are doing.

Grady Memorial Hospital is reputed as a teaching hospital. In the years before I entered its hallowed halls, I imagined multitudes of brilliant professors tirelessly demonstrating clinical techniques to medical students, ensuring perfection in the delivery of care at all times.

Reality somewhat differed.

In most cases, the Grady teaching mantra for medical techniques was this: "See one, do one, teach one." First see it done. Then do it. Then teach it. But for my first day on Pediatrics I wouldn't even get to "see one." I'd be skipping right to the second part - "do one." I arrived at the Newborn Nursery with a booklet called How to do a Healthy Newborn Exam. Its fifty pages described what could go wrong if I missed a diagnosis, outlining case after case of terrible outcomes when the newborn was sent home prematurely. I resolved to do a great job. I envisioned making a difficult diagnosis, maybe even recommending an alternative solution to a Pediatrics professor who would nod his head with appreciation - perhaps even admiration.

So I announced my arrival to Mrs. Helen Philpot, the Nursery Charge Nurse, who noted the name badge which marked me as a mere medical student. She rolled her eyes and walked away.

The hardest part of a medical student's job isn't the work - it's working with the nurses. Each month, before any level of competence is achieved, the medical student rotates through a different service, while the nurses work on the same service year after year, deepening their experience and skills. That particular eye roll wasn't the first I'd seen - and wouldn't be the last.

Being incompetent is bad enough. But being treated as incompetent is intolerable. There was only one way I knew to handle the situation.

I took charge. I was authoritative. I dominated. I demanded that Helen get the babies and charts ready for my examinations, and waited expectantly for her compliance.

Helen obeyed, glowering. The other nurses looked at me, their eyes shooting daggers, but I refused to be intimidated. I swaggered into the nursery, exuding self-assurance. This was one third year medical student who knew his stuff.

The babies were all resting in silence; but no sooner had I begun my first exam that my baby began to cry. His voice woke the crowd and pretty soon a chorus of high pitched wails filled the nursery. I wish I could say their voices were like a chorus of angels from heaven, a reminder of the miracle of life. But the truth is they were making a racket.