The Exam

I place the corner piece of the puzzle as close to the edge of the table as possible. Sky and part of a cloud. I bite my dry lips as I glance through the rest of the pieces and taste blood. I know I should have remembered to bring chapstick. I twist my dirty blond hair into a tight bun and weave in a hair tie. My scrub bottoms are too big but the tops and bottoms come as a pair. I cinch the waistband tighter.I should be studying for my final exam or updating the signout.

There wasn’t always a final exam for intern year in residency. But the hospital administration realized after the work hour restrictions, we were less prepared, less trained, and less confident as senior residents. So here we are.

Puzzles always help me focus. I suppose this exam is going to be like the standardized exams I’m used to. In that case, I’m screwed. My one strength is that I can always see how small details fit into the bigger picture. Ooh, another corner piece.

Brenda, my senior resident, who oversees everything I do, comes in with a slightly greenish tinge to her face. “Krista, I don’t feel too—“ Her eyes bulge, and she runs to the bathroom connected to our nurses workstation. The sound of retching, then a splash. One of the great things about this floor is that someone always has gastroenteritis. Then we all catch it. I immediately find alcohol foam and start rubbing my hands with it. Julie, the charge nurse, quickly starts cleaning all of the keyboards and desks with disinfectant wipes.

Brenda is phoning in sick to the chief residents. I guess I am going to get a replacement senior tonight. After she hangs up, Brenda looks at me. “Krista, there’s no way I can stick around right now. I’ll just get everyone sick. My replacement is on her way—it’s Joan, and she’s awesome. I haven’t heard of anyone being admitted so do you think you can handle things for half an hour?”

“Sure,” I say. Things are unusually quiet on the floor.

Brenda leaves with well wishes from the rest of the staff. I’ve never been alone on a floor before, but I’ll be a senior resident in a few weeks so I guess I’d better get used to it. I look at all the patient’s vitals on the computer. I almost relax. Maybe I’ll pass this year after all.

My pager goes off. It’s the ER. “I knew it was too good to be true,” I mutter. This general pediatrics floor is notorious for too many admissions.

“Hey sorry, you’re getting an admission,” the ER resident begins. Yeah, I figured.  “We have a 15 year old male with no significant past medical history who presents with two months of fever and 20 pounds of weight loss. He has some really bad ulcers in his mouth. Came in from an outside hospital who thinks he has cancer. I think maybe they are right. But he doesn’t have an elevated white count, and his NP came back positive for paraflu so he can’t go on the Heme/Onc floor.”

I’m flabbergasted. This kid is going to be sent to my floor? He doesn’t even sound that stable. “Are you sure he’s okay for the floor?” I wipe sweaty palms on my scrub pants.

“His vitals have been fine down here,” he says. “Sorry, I know it’s a mess, but we don’t know exactly what’s wrong with him.”

I close my eyes. Sometimes the ER can be so ridiculous. You’d think they could take a history. “Fine,” I say. “Send him up when he’s ready.”

Something doesn’t click with this story.  I sit down again and connect two pieces on the bottom half of the puzzle. So the white count is normal. Doesn’t sound like leukemia. I need to ask the family more questions.

His name is Peter, and he is accompanied by at least four family members, all who look completely freaked out. Guess the ER didn’t do a good job reassuring them. I don a yellow gown and blue gloves and enter the room. He speaks with a hot potato voice, and there are large red lumps swelling on his lower legs. A thought starts in my head, and I run with it. “Peter, have you been having diarrhea?”

He looks surprised. No one has asked him this question before. “Yes,”he says. “Actually, it’s been getting worse over the past month. I think it looked kind of red when I was in the ER earlier.”

He looks at me with scared eyes. Eyes that have a red tinge to the sclera.

It’s like my puzzles. One piece at a time. Fever for 2 months. Twenty pounds of weight loss. Oral ulcers. Uveitis. Chronic diarrhea that is now bloody. Erythema nodosum on his legs. I glance down on my sheet for his blood count. He has an iron deficiency anemia too. I step back and see the whole picture.

“Have you ever heard of Crohn’s disease?” I ask.

From that point on, I gain my momentum. I’m not sure what happened to Joan, but I don’t need her. I call a rapid response on a mottled infant who needs a ventilator, and I get a chest X-ray on a patient that has an increasing oxygen requirement. Peter gets tachycardic from loss of blood, and I order packed red blood cells.

It’s a long night, but I make it through.  I finish updating the signout and pass out on the now sterilized desk.

I feel a tap on my shoulder. It’s Brenda. She doesn’t look sick at all. “Krista, congrats,” she said.

“Huh?” I am dazed.

“Looks like someone finished your puzzle for you.”

I rub bleary eyes and look over at the puzzle. It’s a beach landscape and over the top is written “You Pass.”