To line or not to line?

This month I'm back on the inpatient wards, and for a variety of reasons (not least of which, I flatter myself, is my outward impression of competency) my senior resident has been very hands off in dealing with me. She lets me know if there's a patient in the ER to see, and then swings by about 45 minutes later to see what my plan is. The confidence is good for me, because I'm realizing I actually have learned a lot in the past few years. Pulmonary embolism? I know what to do. Diabetic ketoacidosis? I'm all over that. But only recently have I started standing up for my ideas against those of my seniors.

From my perspective as an intern, desperate for procedures and learning opportunities, it might have been a bad idea. Mrs. Wilkins was a 70-something year old diabetic with renal failure, and the ER was unable to get IV access on her. Normally they would just stick a central line and call us, but we weren't particularly busy and admitted the patient before they had the chance to. Once we got her up to the floor, my senior told me to get consent and then put in a central line. I was fairly excited about the prospect, because I'm getting close to having done enough not to need supervision for this procedure. But I'm trying to be an internist, so I sat back and considered for a minute. Mrs Wilkins didn't need a central line, she needed maybe a little fluid and the occasional lab. Since we hadn't gotten an IV downstairs we didn't have coagulation labs, and for all I knew she had an INR of 4. So instead I grabbed one of the techs from peds and he got a nice peripheral line on the first try. We gave Mrs. Wilkins her fluids, readjusted her insulin regimen, and sent her home two days later.

It's not a particularly moving story, I know. But it stands out to me as one of the first times I went for something less exciting because I was thinking for myself, and for the patient, rather than for a check box in my training. It was a small step on my road from technician to physician. And even if I still need another central line or two, that step was the more important one.