Clinical rotations

Third year: The evolution of flashcards

Madi Garlock, OMS IV, reflects on her first experience with a patient’s death during a chaotic yet organized effort to save his life.


“Pupils dilated bilaterally; no change with light; no pulses felt in extremities.”

Four weeks prior, I had held a newborn baby during my pediatric rotation. Now, here I was at the end of a patient’s life.

I looked at the patient’s daughter and felt overwhelmed. I couldn’t help thinking about my own dad, who has been sick for most of my life. I had stayed in Utah for medical school because I wanted to stay close to my family, specifically my dad. I could only imagine what this woman, who had just lost her dad, was going through.

‘Organized chaos’

I flashed back to a few moments before, when I had watched nurses, techs and doctors run what seemed to me like the most organized chaos I had ever experienced. The evidence of prior lifesaving attempts strewn about the room with the intraosseous access still in place.

The doctor gave me a nod as I placed my stethoscope on the patient’s chest, no longer listening for the murmurs I had been tested on numerous times or breath sounds to form a differential diagnosis. I heard nothing.

Four hours earlier I had shuffled into the hospital with heavy eyes. I was dreading the mountain of flashcards I still had to conquer. I plopped into an open chair at the nurses’ station and began reading about how my patients had done overnight. I felt a tap on my shoulder. It was my attending, asking me if I had ever seen a massive transfusion protocol.

“Two large bore IV access. Rapid administration of large amounts of blood products (at least six units of PRBC) in fixed ratios (usually 1:1:1) for the management of hemorrhagic shock,” he said.

I had read it a thousand times by this point, getting that same flashcard over and over again.

Hands-on experience

I wedged myself into a corner of the room, hoping to observe without being a hindrance. Nurses were running in and out while the anesthesiologist pushed pressors and the gastroenterologist searched for a cause of bleeding. All within the same space but having many different tasks. How long does this chaos last?

A few moments went by, then I felt another tap on my shoulder. My attending was holding out a pair of gloves. He told me to put them on and that I was first up if the patient were to need compressions. I could feel my heart jump into overdrive. The only experience I had with doing compressions was on a mannequin. My attending left the room as quickly as he appeared.

“Sympathetic nervous system: Fight or flight response creates a hormone cascade—including adrenaline—that would enable the body to fight a bear or run away as quickly as possible.”

Another flashcard coming to life. I could barely get the gloves over my sweaty hands as I kept my eyes glued on the monitor. The patient’s blood pressure was not improving. That’s when I heard it. The sound that everyone knows from the movies, the one that gives you an immediate sense of dread.

Facing death

“Asystole: A type of cardiac arrest, which is when your heart stops beating entirely. Without immediate CPR or medical care, this condition is deadly within minutes.”

My attending came crashing into the room, blocking the nurse about to start compressions. He informed the team that he had just spoken with the daughter and the patient was a DNR. It felt as if the breath was sucked out of my body.

“A do-not-resuscitate (DNR) order is a legal document that means a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops.” Here it was again. Another flashcard.

I walked out of the room with my attending after completing the first death exam of my medical career. He asked if I was OK and I said, “Yes. I’m trying to be.” I could hear the patient’s daughter crying as I sat at my computer at the nurses’ station. My attempts to document overnight changes in other patients were futile as my mind continued to put myself in the daughter’s position. The feeling of loss she was experiencing had my heart aching.

Heartbeats and heartaches

That night, flashcards were a little bit different for me. I could see the patient’s face as I clicked through them. I didn’t need to go over them; they were with me forever now, it seemed.

As I think back on my second year of medical school, head in the books, trying to remember every cytokine and interleukin—I had no idea what third year was to bring. Textbooks that were once so hard to read now had names, faces and stories attached from previous rotations. I started my third year burned out, tired of tests and even more tired of flashcards.

Now, things were a little different. Now, two large bore IV access isn’t just a transfusion protocol, it was HIS protocol. Now, a DNR was HIS choice.

To all of the first- and second-year students, know that medicine truly comes to life in third year.

To all the patients who have shared their stories with me and helped me learn, thank you. I am enormously grateful for the honor and privilege of being involved in your care.

Related reading:

Compassion in medicine: It’s not just the right thing to do—it also makes the most cents

Listening to our patients: The sounds of an emergency department

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