November 18, 2017 | Rome, Italy | °C

The order


When you begin prescribing, "the" patient is "your" patient.
By Lorien Menhennett
Published: 2017-11-19
I

placed my first medication order yesterday. Nothing exotic. It was a one-time dose of the drug Labetalol for a patient, my patient, whose blood pressures had been elevated. As I typed in my password to sign the order, I took a deep breath.

"By signing this, I thought to myself, I'm telling people that I think my patient needs this exact medication at this exact dose at this exact time."

Suddenly, caring for this patient was no longer abstract or hypothetical. It was as real as the prescription I was about to issue. I wasn't just writing out my daily plan for her care in my morning progress note. I was putting it into action.

As a medical student, any orders I place require a physician cosigner, either my resident or attending. The safety net exists for obvious reasons. Still, learning how to issue orders for my patients — whether it's for laboratory tests or medications or fluids — and then doing so is part of assuming greater clinical responsibility. It's also part of progressing from student to doctor.

But from a logistical perspective, just entering these orders is far from easy. Take the blood pressure medication. It is normally dosed twice a day, morning and night. It was about 1 p.m. at the time. If we ordered it twice a day to begin immediately, the patient would get it at 1 p.m. and 1 a.m. — not ideal if you're the patient. You'd have to be awakened in the middle of the night to take a pill.

So I placed a one-time order for the medication to be given by the nurse immediately. I then placed another order for the same medication, same dose, this time twice a day, but starting that night. Going forward, the patient would be getting her pill at 9 a.m. and 9 p.m.


The first medication order may be the hardest.

Making small things happen in the electronic medical record system is another thing entirely. It requires selecting or unselecting many checkboxes and highlighting the appropriate fields in various drop-down menus. I'm sure once you do it repeatedly it becomes second nature. But as a medication order novice, I needed someone to show me around the system. Thankfully, my kind resident took the time to walk me through the process step by step. Attention is paramount. If you don't click (or unclick) one of the required boxes, you get an error message that reroutes you back to the order screen to fix your mistake. And if you don't click (or unclick) some other box that's important for your particular instructions but not technically required for the order to go through, your order may inadvertently tell the nurse to do something else altogether.

The "how" of these orders is the easy part. It's the "what" and the "why" that require the real thinking. Why is the patient's blood pressure elevated? Does she need a medication? If so, which one? At what dose and frequency? How long will you assess her blood pressure levels to determine if this medication is effective before either increasing its dose or adding another drug? And this is only her blood pressure. We haven't gotten started on her antibiotic regimen.

It's an iterative process that goes on throughout any given day. Sometimes you're doing the investigating. Sometimes it comes in response to changes in vital signs or laboratory results (or urine output or an MRI). This means you're monitoring all these details — vital signs, lab tests, urine output, and imaging, among others — over the course of a day to see if you need to change your handling of the patient.

To a third-year medical student just introduced to the world of inpatient internal medicine, it's dizzying. But it's also deeply exciting for obvious reasons. The more clinical responsibility I assume, the more I learn, and the more tangible the "live" practice of medicine becomes. And the more I am prepared for the time when I'll be the one signing the orders on my own.

Print | Email | | | 1

AREA 51

Christopher P. Winner

On witches, Reds and Spacey

When Satan, communism and sex enter the American picture, the mitigation covered by the word "alleged" beats a hasty retreat.


L'AMERICANA

Kristine Crane

Coming 'home'

For the author, time spent in Lazio's Sabine Hills pops open a treasure chest of Italian memories.


THE ECONOMIST

Mark Bassani

Unthinkable thinking

Donald Trump's economic priorities are overturning old apple carts, but it's unwise to blindly label all the shakeups as bad.


AMERICAN GIRL

Madeline Klosterman

The confession

A man who once wanted to be a lover returns to your life, but what to make of his story?


IN THE STICKS

Elisa Scarton Detti

Be thankful and keep complaining

Complaining is not only necessary, it's an art form, all the more so when you're an expat in a small Tuscan town.


NOTEBOOK

Madeleine Johnson

The colonial report

Eastern reporters still searching for clues to explain the ascent of Donald Trump repeat a condescending error again and again.


PSYCH DEPT.

Elaine Luti

Vantage point

Too many stories that play a critical role in therapy are based entirely on adult perspectives.


BIO-LINGUAL

Lorien Menhennett

The order

A medical student's first medication order represents something of a milestone from many perspectives.


FIRST PERSON

The existential piazza

In many small Italian towns, you still learn about death in one way only, by writing on a wall.


MEMORY LANE

Vermi d'inchiostro

Italo Calvino was a monk, a scribe, a transcriber of Gamma Rays.


FEATURES ARCHIVE


Day and Boarding International High School in the Heart of Rome

Everything you need to know about visiting or moving to Tuscany, Italy.