Although most of my medical school classmates have already begun their formal residency rotations, we here at the Necessarily Anonymous Emergency Medicine Residency have yet to officially start. This is, depending on your point of view, either because our residency is warm and fuzzy and wants us to have a high quality of life, or they lack so much confidence in our abilities that they feel it necessary to train us up for an entire month.

I favor the latter. That said, we did have our fifth program-scheduled party in as many weeks last night, so maybe there’s something to the warm and fuzzy thing.

Anyway. Let us continue in the tradition of “I have no idea what I am doing.”

I had a shift yesterday, one of our short introductory stints in the emergency room. The point of these shifts is for us to take it slow, learn the system, understand how patients flow through the emergency department, and to try and make friends with the nurses.

If you remember my old writing, you’ll probably recall that the flow of things in the ER goes “pick up patient –> read about patient –> go see the patient –> present the patient and your plan to the attending physician –> be incorrect–> do what the attending physician tells you.”

This should not be news.

I may or may not have seen a patient yesterday who may or may not have had a complaint related to something. I cannot say more without our privacy officer smiting me with a broadsword.

I would be smited.

The above, inexplicably, is a top Google image result for the search “smited,” and I couldn’t resist putting it in here.

In a completely unrelated vein and in no way linked to any patient, I had ordered morphine for someone in pain. I had to look up, and then ask the nurse for, the dosage of morphine. I blamed this lack of knowledge on the fact that in med school, my home hospital used Dilaudid for everything. Dilaudid (the generic is hydromorphone) is a semisynthetic opioid, which means it is pretty much identical to morphine but is much more potent – so the dosages are different. Thus, I didn’t know how to dose morphine.

This is a little disingenuous, since I don’t know the dosages for hydromorphone either.

Anyway. I had ordered a few things on a previous shift – namely, Tylenol, a chest x-ray, and some blood tests – and am still getting used to the idea of not having a co-signer. In medical school, we were allowed to put in orders – insofar as every single order had to be reviewed and then signed by a real actual resident. Every drug, every test, every nursing order – everything had to get a second pair of (far smarter) eyes on it.

No longer. Yesterday, I clicked a box on a computer to order some morphine and boom, morphine was given. It was like magic. Terrifying, uncomfortable magic.

The thing about any drug is that they have side effects. Strong drugs have strong side effects, and in the case of morphine the  scary ones are respiratory depression and low blood pressure. I maybe checked on the patient eleven times in the subsequent twenty minutes to make sure he was still breathing.

This sh*t is nerve-wracking.

One of the more amusing things about orders is simply that they are called orders. Somehow, by virtue of the Medical Doctor degree conferred upon me by someone who clearly did not know whom they were conferring a degree upon, I am now allowed to demand things of others. I demand the X-ray tech perform a chest X-ray! I demand the nurse draw these labs!

This is all hilarious to me, because the X-ray tech, the nurses, the scribes, the custodians… all of them are far more knowledgeable than I am. After I put in an order, I almost always go to the person who receives the order (usually the nurse) and humbly beg forgiveness for probably putting in the order wrong. I then humbly request Help In Putting In The Order Right, so another less charitable nurse will not smite me.

Intern year appears to be a yearlong exercise in smiting avoidance. I love this word.

The other weird thing about orders: everything is one. That is, while it makes sense that medication orders are orders, so is every directive related to the patient. There are diet orders. There are restraint orders. There is even an order that says, “ok to use central line,” which is not an order at all.

I will never understand this. I’m going to order some knowledge.