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Muscle Memory

  • Maren E. Olson
    Correspondence
    Address correspondence to Maren E. Olson, MD, MPH, MEd, Department of Medical Education, Children's Minnesota, 347 North Smith Ave, Mailstop 70-103, Saint Paul, MN 55102
    Affiliations
    Center for the Art of Medicine, University of Minnesota, Minneapolis, Minnesota

    Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota

    Departments of Medical Education and Hospital Medicine, Children's Minnesota, Saint Paul, Minnesota
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Published:April 07, 2021DOI:https://doi.org/10.1016/j.acap.2021.03.021
      I vividly remember learning to drive. Nothing was automatic. Making a turn required laborious thought: turn on the blinker, check my blind spot, apply the break gently. Right foot, right?
      Hand over hand on the wheel–or was I supposed to keep them at 10 and 2? Carefully center the car in the lane.
      Phew.
      These days, I head down the highway, eyes scanning the road, easing into a different lane and checking my mirrors without ever reminding myself to do it. Meanwhile, I'm discussing snack options with the occupants of the back seat, adding to my mental grocery list, and reminding the dog that he needs to stop barking or I won't toss him any more treats.
      To be on the frontlines in an evolving pandemic in the spring of 2020 was to be back in the driver's seat at 15. I was attending on our busy inpatient pediatric hospital medicine service in March when COVID first hit Minnesota, my hands gripping the wheel while we went careening down an unfamiliar road, the signs impossible to read. All my muscle memory for medicine was suddenly gone.
      I get off the phone with the ER and run the case past my colleague who is busy disentangling herself from an N95:
      • “So, I should test for COVID with that clinical history, right?”
      • “Actually, that's not true anymore. The guideline changed. Again.”
      • “That's the second time in three days! How are we supposed to keep up with everything?”
      I do an unofficial consult during rounds. My patient's mom is panic-stricken, convinced her other son has COVID and has exposed my patient, who is a medically complex child. The depth of her worry catches my attention, so I sit down on the bed, starting to take a history. He is a healthy 5-year-old, she explains, and has had a runny nose and a slight cough for a couple days. Oh. That's all? My shoulders relax. This is familiar territory to a pediatrician and I am not at all worried. I start to reassure her and then stop mid-sentence. Wait, maybe a runny nose is a big deal now? Could he have COVID? Suddenly, I realize that I can't trust what I think symptoms mean. I have to toss out those nuanced illness scripts I know by heart.
      I continue to reassure anxious families, I talk with terrified nurses, I listen to panicked residents, and I sit in my office and cry. I cry and cry and cry. I am scared and exhausted and lost. Do I even know how to practice medicine anymore? I feel like I've lost my north star—my clinical instinct that I've developed over the past 15 years—that gut sense of who I should worry about and who is just fine.
      I watch my colleague—the one who tracks how many times we order tests we shouldn't—standing in front of our group and saying, “I can't believe I'm saying this, but throw the usual guidelines out the window. Test everything. And start antibiotics.” She shakes her head, not believing her own words.
      Walking out of a room in a face shield and N95 for the first time, I am again 15. I have no experience with this. My resident and I look at each other. “Gloves off first? Then the N95? Or is it the face shield first?” We finally burst out laughing. “Someone help us! We're stuck! We don't know how to get out of this PPE!” The charge nurse comes over, shaking her head. She searches around on the CDC webpage, and together, we eventually figure out how to escape.
      A couple months later, I'm rounding with my team on a patient we think might have multisystem inflammatory syndrome in children (MIS-C). Or, more accurately, that's what someone in the ER suspected. As the intern begins her presentation, “Subjective, Objective, Assessment: This previously healthy 8-year-old female with recent COVID infection has been admitted because of possible MIS-C….” I flip through my mental file of illness scripts and realize, my stomach sinking, that the one for MIS-C is completely blank. I hadn't even heard about MIS-C until last week, and that was in a story I caught on National Public Radio—certainly not my usual source for medical information. How do I diagnose something I've never seen, something I don't really understand? I desperately hope that my masks and face shield hide my rising panic from my team. How on earth am I supposed to make a plan of care for this patient? Who left me in charge?
      Suddenly, I'm back in my short white coat, summoning my courage. It's my second day of my first clinical rotation and my senior resident just told me to go pre-round on a patient, apparently believing I am up to the task. Buoyed by her encouragement, I strike out to see my patient whose room is the last one on that hallway that stretched across two city blocks. When I enter, my patient is huddled on her bed, blanket drawn tight across her thin shoulders, losing her battle with oropharyngeal cancer. She gives half-hearted answers to a few of my timid questions, the pain etching her face, then excuses herself to go out for a smoke. Standing outside her room, paper chart before me, I slowly pull together a few lines for each category: S, O, A. Then I get to P. I have no plan. I have no idea where to start or what one might consider putting in a plan. I stand there, hemorrhaging the little confidence I had. I stick the note in my pocket and turn to walk the two-block hallway back to our team room to confess that I do not belong, that I do not know what to do. I have no plan.
      Thankfully, my senior resident is kind and quickly teaches me to think about my plan by systems, giving me a framework to use–the beginnings of a practice I still use today even though I long-ago transitioned to using a problem list in my notes. When a patient's case confounds me, I go back to that: FEN, CV, RESP, GI, ID…. When I don't have a plan, I use that routine to begin to build one.
      Back on rounds, my intern gracefully finishes her presentation on the child with MIS-C and looks expectantly to me for a response. That's right. I know how to do this. I do have a plan: I can model for my team what to do when we have no idea what to do. We begin to work through the systems: FEN, CV….. We sift through the handful of case reports that have been published, read what we can find posted online that seems reputable, and text some colleagues. We muddle through, and our patient, a cheery 3rd grader whose enthusiasm is matched only by her body's energetic immune response, quickly improves and goes home.
      Looking back, it's hard to remember just how little we knew at the beginning. If there is anything I'm grateful for in this pandemic, it has been the powerful reminder of what it feels like to be a beginner in medicine–the constant fear of not knowing, of missing something, of having no plan. For that reason, I'm a better attending than I was a year ago. I had almost forgotten what it felt like to stand at the end of that long hallway and tuck the unfinished note in my pocket. Now I'm awash in empathy for the beginners I encounter every day. This morning, the mom in me wants to hug the brand-new med student on our team who stares at her shoes as she presents in a half-whisper, apologetically offering that it is her first day of her first rotation. Instead, I nod encouragingly when she glances up in panic when she gets to Plan, her voice trailing off. The senior jumps in, “Great! What should we do for FEN?” A smile unfolds under my mask as the student stands a little straighter and begins to build a plan.
      A year into this pandemic, I have new muscle memories. I hate them. Massaging my aching jaw muscles, I stretch the bands of my N95 into place, topping it off with my surgical mask. I adjust my face shield, feeling the usual annoyance at the streaks left from wiping it off after leaving the last room. Hand sanitizer (yet again), then I add a gown and gloves, and knock on the door. Opening it, I call, “Hi, it's Dr. Olson.”
      No one answers. I walk into the room and discover that my 6-month-old patient is alone at the moment. I lower the side of the crib and peek in at her. “Well, hello!” Her bright eyes study me cautiously, then she reaches a verdict and grabs my gloved fingers.
      I grin. And, even though my face is buried beneath two masks and a cloudy face shield, she lights up instantly and smiles back at me.
      Sometimes, muscle memory reminds me that there is hope in these dark days.

      Acknowledgments

      Many thanks to Bernard E. Trappey, MD and Trisha B. Elliott, MD for their thoughtful editing.