My month on outpatient service went ok. It reinforced what I already knew about myself, I did not have the aptitude to see 40 patients a day in clinic and then go home and finish clinic notes. I did realize, though, how important preventive care was. Its no joke when doctors keep beating the drum about getting that mammogram done to look for breast cancer in women, or annual checkups to make sure there are no signs of prostate cancer or colon cancer in men. Even run-of-the-mill blood pressure and blood sugar checks on a yearly basis are so important, especially in people over 50 years of age.

Despite all that, I was so glad to finally be on my ICU rotation...with Madi, as my senior resident. And I could not have been more impressed by her in our first week together. She was kind and considerate, had the best bedside manners ever, seemed to know everything about everything and it was easy to see that everyone truly adored her.

We had such a large ICU that there were four teams covering the patients. Each team had a senior resident and an intern on it. The other two female senior residents were fine, but the male senior resident, Liam, was the most toxic person I had ever met. He yelled at the nurses and was always curt with the patients' families. Though, my co-intern, Jake, bore the brunt of his toxicity.

One day when Jake had enough of the abuse, he had come up to me and asked if we could switch ICU teams. Of course, I refused. I was living the dream with an awesome senior resident who was willing to teach me everything without blowing up in my face every five minutes.

"Oh come on Omar, I need a freaking break from Liam...", Jake had protested.

"No can do man...Madi is mine!", I had replied.

"She is yours?", Jake immediately replied with a smirk on his face.

"Oh shut up...you know what I mean!!", I knew that he knew what I meant, but for some reason I could still feel my face heat up.

Which was stupid, because I could never go there with her...she was my senior resident after all. Even though I was probably older than her, since after high school I had done 5 years of med school and 6 years of PhD and she had done 4 years of undergrad, 4 years of med school and 2 years of residency. Besides there was the small matter of her being engaged and me still being hung up on Noor. Though I had to admit, I had been thinking about Noor less and less, and the busy ICU schedule had certainly helped.

Well, it was now my second week in the ICU and things with Liam had calmed down, because Jake had made an official complaint to our residency program director. As for me, I was still living the dream, but being on call every third night was catching up with me and last night I had been so exhausted I went to sleep as soon I reached home. And this morning I woke up late, so didn't have time to make lunch...and there was no noon conference today, so no free food.

I was rummaging through the cupboard where the snacks for patients were kept when I heard Madi's voice behind me.

"If you didn't bring lunch, I am going over to the food court. Want to come?"

The food court? Hell no...

"No thanks, I'll be fine with the snacks here"

Of course, she saw right through me, "Is this about Noor? Because I can't imagine that crackers and peanut butter would ever make a good lunch"

"Its not...", I started to say, but she interrupted me.

"I don't usually offer free therapy sessions, but you can talk to me about whatever it is that you are feeling about her. I need my intern to be in a good mental space...especially in the ICU", she said with an almost serious tone.

But then she chuckled and added, "I can't promise I'll be listening, but you can keep talking if it makes you feel better..."

It struck me then how easy it was to have to have a conversation with her. And what a heartwarming sense of humor she had.

If I ever wanted therapy, I would definitely choose her to be my therapist.

She offered to get me something from the food court and then left after giving me instructions to follow up on the blood tests for our patient in Room 1502.

Our 40 year old patient in Room 1502, was suffering from a blood cancer and was admitted with severe bacterial infection. Because of the chemotherapy he had been receiving, all the blood cells in his body were at a low level. But right now his biggest problem was that his platelets, the cells that are critically important for clotting blood, were almost non-existing. So he had been bleeding out from all the intravenous (IV) lines that we had to put in him to give him multiple antibiotics and fluids.

"Dr Khan, your patient's platelet test came back. They are less than 10 right now!", the nurse popped her head into the resident room to update me.

Less than 10,000 per microliter? Oh no...normal should be at least more than 150,000.

"Thanks for letting me know, I am putting in an order for platelet transfusion. Could you make sure he gets it right away...I'll come an evaluate him soon", I replied to the nurse.

Unfortunately, when I went to see the patient multiple IV sites were still oozing blood. I asked the nurse to give a second bag of platelets to the patient, clearly one was not going to be enough. His blood pressure was also dangerously low, and his blood oxygen was was starting to dip below normal, despite him being on maximum Oxygen through the nasal cannula. All signs pointed towards worsening bacterial infection that was probably spreading through out his body.

After paging Madi and the attending to update them, I asked the nurse to give him more IV fluids to see if we could improve his blood pressure, and we started him on an epinephrine drip (to help his heart).

"Dr Khan, I am running out of IV lines to put all these fluids through...", the nurse let me know. I knew we would have to get another line in him quickly if we were going to get ahead of his rapidly worsening condition.

Thankfully, both Madi and the attending walked in soon after and I appraised them of the patient's condition. We all agreed that we would need more line access to give him the platelets, fluids, antibiotics and heart medications all at the same time. Plus, he was breathing very rapidly now and was not responding to us when we asked him questions.

"Omar, why don't you put a breathing tube in him, so we can put him on the ventilator. And I'll get a femoral line in", Madi said, as she took charge of the situation. (A femoral line is put in to the femoral vein which is a big vein in the groin area. Its a good place to access the blood in emergencies because it is relatively easy to put in...though not always)

I nodded and immediately set about getting the ventilator equipment ready before I put the breathing tube in. Meanwhile, Madi tried to put the femoral line in the patient's right leg but failed. She then switched over to the left side, as the attending looked over shoulder. I could tell that she was starting to get worried.

It wasn't that she didn't know how to do this procedure, I had seen her get these lines in expertly multiple times before. But because this patient had been sick several times before he had required these same lines previously as well, which meant that his veins were probably quite damaged and scarred.

"Its ok Madi...you got this...", the attending encouraged her.

He then turned to me and said, "Omar get the nurse to hang a bag of clotting factors, we really these lines to stop oozing blood"

When Madi still couldn't get the femoral line in, the attending asked her to do one more maneuver and if that failed they would try to put a line directly into the leg bone or the neck. Unfortunately, when she tried that maneuver she went in to the groin too deep and struck the femoral artery instead of the vein. Because the arteries, especially the major ones like the femoral artery, carry blood that is coming straight from the heart the blood flow is rapid and under pressure. So as the IV line struck the femoral artery, blood immediately gushed out splattering all over Madi.

"Oh crap...", she exclaimed, as she tried to stop the bleeding, "Omar, I need extra hands..."

I immediately went over to help her, and placed my hands over hers so together we could put as much pressure on the artery as possible. The patient was already having difficulty clotting his blood and with a cut in a major artery it was obvious that things were not going well.

I looked at Madi as I stood next to her. She had blood on her face and scrubs, yet her facial expression was calm and collected as usual. The distraught look in her eyes, however, was unmistakable.

"Its not your fault Madi...", I whispered to her.

"I could have done better...", she said softly.

If we weren't the kind of people we were, I would have told her that I thought she had done her best under immense pressure and that I was so proud of who she was. But I was an intern and she was my senior resident, and I didn't trust myself to say those words with the objectivity that our relationship demanded. So I remained quiet, holding pressure over our patients groin area till the bleeding eventually stopped.

While we were holding pressure, the attending was able to get a line in to neck of the patient and with all the therapy we had given him, he had stabilized...at least for now.

"Omar, good job with putting the patient on the ventilator. And I am glad you gave him the platelets early on, he would have been much worse off without them", Madi told me as we left the room.

I knew she was doing what she always did, being kind-hearted and generous with her praise; because propping up others was her default nature. But her eyes told a different story. She still blamed herself for causing harm to the patient, even though the attending had reiterated that there was no way to predict what had happened and she did exactly what he would have done.

In that moment, I decided to put aside the hierarchy in our profession temporarily. There was no reason that I could not reciprocate her praise, support and comfort.

"Madi...for the record, you are the most brilliant physician I have ever worked with. I can't even tell you how impressed I am with how you handle everything...seriously, nothing ever seems to faze you. I would consider it a success, if I could be even half of what you are by the time I am in your position" , I hesitated for a second, but then finished saying what had been on my mind, "If you ever need to talk, I am here for you"

She seemed surprised to hear me say that, but the darkness in her eyes had lightened by the time I finished speaking, and that heartening smile of hers was starting to show up again.

"Thanks Omar...", she held my gaze for a few seconds, before I looked away.

Then, for the first time since I had known her, she sounded flustered, "I...uh...have blood all over me, I should shower, I mean...I need to take these scrubs off...and put on new ones"

Her cheeks were flushed when I looked at her again, but she recovered quickly, "Could you update the patient's note and document everything that happened just now...in the patient's room"

"Will do...", and just like that, I was back to being the intern.

Not that I minded being the intern...and I really didn't mean to cross any professional boundaries with her. Won't happen again...

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