Gram stains and growing pains.

gram negative rods

gram positive cocci in cluster

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"All I wanna do

is have some fun

I got a feelin'

I'm not the only one. . ."

~ from Sheryl Crow's "All I Wanna Do"

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"Are you enjoying yourself?"

"Am I? I'm loving it, Dr. Manning! This is so much better than the classroom. I am loving every minute."

This was the exchange that took place between Joelle, the newly minted clinical medicine student rotating on my team, and me this morning as we trudged up the stairs to go and see a patient. The entire team had just rounded on all of our new admissions from the night before, and Joelle stuck with me for my rounds on the rest of our  service of patients. I loved her answer to that question. It was so genuinely enthusiastic.

"That's wonderful," I responded.  "It's something to love, Joelle. It really is. Enjoy your patients as people. That way you'll continue to love every minute even when you've been doing it for a while."

She looked at me and smiled a big smile.  She was loving it.

In that moment, I thought about my very first clinical rotation.  Like Joelle, I too started on inpatient Internal Medicine fresh off the M2 truck carrying a stethoscope without any scratches anywhere and a short white coat free of so much as even a trace of ring around the collar.  And just like her, I was thrilled at the idea of finally getting to take care of real, live patients on a daily basis in the hospital.

Those first few days were rocky for me. I started out at the VA hospital, and felt swallowed up by it.  I remember standing on the wards listening to rounds and hearing the words flying over my head and whirring past my ears.

DNR, DNI, AMA.

"Excuse me. . . .uhhh. . what does 'DNI' mean?"

"Do not intubate. So like I was saying, this guy has terrible COPD and smokes like a chimney. He was demanding pain meds and got mad when I said no.  He wants to leave AMA." The resident spoke directly toward the attending with virtually zero interest in us medical students hearing, let alone getting what he was talking about.

"Pardon--what is AMA?"

The resident did little to hide his scowl at yet another question. "I'll go over some stuff with you guys after rounds," he replied.  This was his way of telling me to shut my piehole until they finished rounding.  It was one of the last questions I would ask that month.

We never did get around to that teaching session.

The following month was at another hospital. I remember being the student on a team with one intern and one resident. Back then, the lab closed at eight p.m. so any special things you needed overnight fell on the doctors. In our case, it fell on the medical student.

"Take this sputum upstairs and make a gram stain of it, okay?"

I remember raking through my terrified brain for some kind of remote idea of the steps involved in a gram stain. Gram stains tell critical information about the type of bacteria causing certain infections. The whole thing involves multiple steps which yield either germs that hold on to this particular stain (gram positive) or ones that don't (gram negative.)  The kind of antibiotic regimen, the urgency, and all of the management in many serious infections rides heavily on this piece of information which, for reasons that will forever escape me, the resident deemed me the appropriate person to obtain.

Um, yeah.

I recalled the times in our second year Microbiology lab where we'd done the gram staining process. Every single time I'd performed it, I'd done something wrong which always left a little too much stain on the slide.  And so. With me as the technician, everything was "gram positive."

Gulp.

I decided to come clean with my trusting/lazy resident.  "I'm not sure I am so good at the gram stain. Can someone help me?"

"No because we'll be doing a lumbar puncture on that other guy we just admitted."

I'd never seen a lumbar puncture.  I had read about them, yes. But had never seen one in real life. "Can I watch you guys do the LP first?"

Bubble expanding. . . .

"No because we need that sputum result."

Pop!

The resident didn't even look like he needed to think about it. Clearly my experience as a bright-eyed, bushy-tailed fresh off the boat clinical medical student meant zero, zip and nada to him. This was a done deal.  "Oh yeah," he added without even looking at me, "and take this urine, too. It's for that lady with pyelonephritis we just got. Spin it and gram stain it while you're up there." He held up a capped cup filled with a scarily cloudy appearing tea-colored urine specimen.  Great.

So I remember fumbling around in that lab praying that my very bootleg gram stain technique would not lead to some poor unfortunate soul receiving the wrong antibiotic. I panicked, thinking about how much scarier a gram positive rod is versus a gram negative one, depending upon the specimen. For a split second, I thought about throwing out all of the specimens, getting into my car, and driving west until I reached my Momma and Daddy's doorstep at home. I decided against that, considering there were sick patients involved.

I stained the sputum first. Gram positive.

Oh Lawd. 

Next came the urine. I spun it in the centrifuge, nearly catapulting across the room at first when I didn't close the top on the machine. Whoops.  I stood there praying that I would get it right while making the slide. I wasn't grown up praying--I was praying in that eight-year-old way you pray when you release a bowling ball into the lane and it's headed for the gutter.

Please Lord don't be a gutter ball. Please Lord don't be a gutter ball.

I felt like my bootleg gram stain was headed in a similar direction. Please, please, please. . . .gasp. . . is that. . .gram negative?  I am pretty sure I did the happy dance once I confirmed under the microscope that it was indeed gram negative rods---the typical and expected bacteria of a young woman with a urinary tract infection.

Hallelujah.

I made it back just in time to get handed a specimen bag full of spinal fluid. "Go spin this and stain it."

Nice.

This is what they call getting "scutted." I pretty much got scutted for the majority of that month. The good part of it is that me and a few of my classmates got pretty proficient at random laboratory procedures. The bad part is that I missed out on some high yield things, mostly because I was being sent off on scavenger hunts during all of the action. Even still, I can appreciate the experiential learning that I had while doing all of it. I guess.

But.

The worse parts of both of these months were my interactions with my attending physicians. I was pretty much invisible. And seeing as I have never been invisible anywhere, this was a hard pill to swallow. I will never forget the day that, after like ten whole days of being on the service and rounding with the team, my attending said, "Hello, are you going to be one of the student doctors here with us? What's you're name?"

"Kimberly Draper," I answered quietly, "and actually, I've been here for just about two weeks."

You know, the one that's been spinning down pee and staining up your patients' hocked up loogies all night on every call?! You know, the one that manually evacuated the horrifically constipated bowels of that ninety-nine year old woman two days ago-- upon your request?  You know, the one that introduced herself to you four times already this month?!? 

"Oh okay, then. Nice to meet you, Kimberly."  

Jerk.

From that moment forward, I made a vow. When I grow up, I will never, ever ignore the medical students. Ever. I will never not know who I am working with. I will never allow any hardworking human being on my team--be they a medical student, pharmacy student, pharmacy resident, Physican Assistant student, or visiting student--feel as invisible as I felt over those two months.  Ever.

Fortunately, I had some great role models on my other rotations who paid (sometimes too much) attention to us medical students. But I still will never forget that first rotation and how it made me feel about Internal Medicine.  I pretty much decided that I hated Internal Medicine based upon this experience, only to learn from one of my surgical attendings that "liking the patients on the wards but not the OR isn't really consistent with being a surgeon. That's called Internal Medicine, sweetie."

Ah hah.

I suppose being looked through or not important enough to be memorable after four separate introductions had left me feeling as washed out as those gram negative rods. As much as I'd wanted to hold onto some positive aspect of the experience, all I was left with was a faded version of it any time I looked under the microscope. Which sucked.

Yeah.

So for this reason, poor Joelle and countless other medical students on ward teams past and present  have been schlepped all over the hospital and up more flights of stairs with me than can be quantified. . . . .here, there, everywhere. Seeing patients. Listening to heart murmurs. Discussing hard diagnoses. Holding peoples' hands. And a few times, even looking at gram stains in the lab. But without fail, whenever we do that, we talk. About non medical things and fears and feelings. I try my hardest to find out the things I wish my attending had asked me back then. Like. . . .

"Where are you from?"
"What's your favorite food?"
"What are your hobbies?"
"Do you speak any other languages?"
"Where have you traveled?"
"What kind of talents to you have?"
"What are your mom and dad like?"
"Wow! You did a half-iron man?"


And stuff like that.


But I especially ask this one. . . .

"Are you enjoying yourself?"

Because now that I think of it. . . on many days when I'm teaching + learning + caring for patients at Grady. . . .all I wanna do is have some fun. And you know what? I've got a feeling I'm not the only one.

Olivier, a former student at commencement (with his parents) -- More than a gram-stainer, indeed.