On my second day of fourth year, I had to make a decision.

“Mr. K would like Miralax,” read the nurse’s page.


A medical sub-internship, which a student completes in her fourth year, is designed to be an internship with training wheels. The main difference between third and fourth year is that the  third year reports to an intern (who makes a decision) while the fourth year replaces the intern. Last year I filled in the gaps of a pre-built plan, while this year I build the plan from scratch.  My supervising resident then looks over my orders and reins in the ridiculous ones. But the scary thing is how few of my plans are actually ridiculous and how many of them remain unchanged.


How best to evaluate his request for a relatively benign over-the-counter medication? My mind raced with possible consequences.  What if he had such a voluminous bowel movement that he developed an electrolyte imbalance and tipped into a cardiac arrhythmia?  What if he lost so much fluid that he became dehydrated and damaged his previously healthy 70-year-old kidneys?  The possibilities got more creative as I walked into his room.

Mr. K was Spanish-speaking only, and I was Spanish-speaking sort-of.  What I didn’t learn in high school was an incredibly useful word that I learned that day: caca.  It’s exactly what it sounds like.

“Mr. K,” I inquired in broken Spanish, “can you tell me more about your caca?”  He looked confused. I tried again, using more focused questions.  After obtaining a fairly detailed history about his bowel movements and his recent inability to have them, I began my physical exam.  I pushed on his abdomen, unclear about what I was looking for and what to do if I found it.  His belly was soft and non-tender, exactly the way it had been for his entire hospital stay.

“Can I have Miralax?” he asked again.

“I think so,” I told him.


I understand that patients lose a lot of autonomy when they stay in a hospital.  The larger freedoms are obvious: setting any sort of schedule, getting out of bed without setting off an alarm, or existing without an IV jutting into the forearm.  But some losses are more subtle, so much so that until I controlled them I hadn’t realized their extent.

Taking Miralax.  It was probably something he did at home without a second thought.  But here I was, thinking about his bowel regimen from all imaginable angles. Within hospital walls, basic bodily functions become the medical team’s responsibility.  Thirst?  If we don’t think you’re drinking enough, we’ll run saline into your veins.  Hunger?  If you’re going for a procedure, you’re going to have to wait.  Pain?  Up to us if your current dose of ibuprofen will be uptitrated to something stronger.  Urination?  If you don’t pee out the equivalent of a Coke bottle per day, we’ll prescribe more Lasix until you do.  Sleep?  In between checking your blood pressure and temperature every four hours.  Those sorts of decisions--the unglamorous ones, and the ones that don’t make headlines--are often the ones that the patients feel most.  They are also the ones over which the lowest person on the medical totem pole (i.e., me) has almost complete control.


Back in the workroom, I reviewed Mr. K’s labs, his medications, and even his allergies.  Half an hour after his original request, I wrote for a single dose of Miralax.


There are dozens of small decisions to make on a daily basis. What is the difference between running 100 cc’s or 125 cc’s per hour into a person’s veins?  (The immobile patient needs his bedpan changed an extra time.)  Between changing a person’s diet from no food to clear liquids immediately or waiting an hour to do so while we finish rounding?  (The cafeteria stopped taking lunch orders 20 minutes ago.)  Between feeling comfortable with checking labs once per day to monitor high potassium levels or wanting an extra data point?  (The patient is a hard stick and asks for Ativan during lab draws.)  Between remembering or forgetting to add a patient’s home topical cream for his itchy feet?  (He scratches until microtears form between his toes, giving bacteria a direct route into his bloodstream.)

These are all things a resident skims over but trusts that the sub-intern understands and manages.  As I build the plan's foundation, I have to account for all the stones.  The resident helps move pillars, but the small stones are under my guardianship. My limited clinical experience and unlimited imagination have the house crumbling with the misplacement of one.  This is why I spent much of my that day anxiously awaiting Mr. K’s bowel movement to relieve him and not kill him.


Several hours later, Mr. K’s wife came up to me in the hallway.  She was excited, and her Spanish was far too rapid for me to understand its nuance.  Luckily, there was nothing nuanced about her gesticulations, which conveyed to me just how large Mr. K’s bowel movement had been.  His numbers the next morning were fine, and he left that day.


I’ve read that surgeons take such pride in their work that (ethics aside) sometimes they feel ownership over the part of a patient’s body they have altered.  "That’s my Whipple.”  "That’s my spinal fusion.”

As a fourth year, my “work” is somewhat more disposable.  I look forward to when I move pillars.  For now, I have an inflated sense of elation over the small stones.  Mr. K’s caca?  Mine.