Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Searching for Bicarb in July


To succeed in clinical practice, be humble and open to learning from all members of your team.

At night, the cardiac intensive care unit was so dimly lit, I could barely recognize anyone. The main source of light emanated from computer monitors, casting a bright gray shade across the skin, like a ghoulish flashlight. Not that it mattered; I was a July intern and each face and identifying name badge was new to me. The air was punctuated by erratic sprints of fingers across keyboards, and piercing alarms of all kinds: a din, a cacophony, an irregular melody that I needed to learn.


On the brink of death

An extremely sick patient arrived from an outside hospital in severe heart failure and on the brink of death. My senior resident, seemingly unfazed and unflappable, came into the room to assess the patient. Experienced nurses positioned themselves around the bed, primed IV tubing, programmed infusion pumps, and documented in a coordinated, rehearsed manner. Respiratory therapists immediately interrogated the ventilator, tinkering with settings. Pharmacists stood with the emergency code cart, ready to deploy therapeutic concoctions. They spoke in a language that I was struggling to learn, an alphabet soup of acronyms and abbreviations: “What’s the levo going at? Do we need an IO? I have your flush here.”


I stood outside the room, not knowing what to do.


“Labs are back. Her pH is 6.8.”


“Do you want to push some bicarb?”






Where do I find bicarb?


I rushed away from the threshold of the room and back into the safety and relative calm of the poorly lit CCU. Determined to be useful, I wanted to be the one to find the bicarb, although I didn’t know where the medication room was, and didn’t realize in my naiveté that such items could only be dispensed by a nurse.


An experienced nurse

A nurse found me fumbling with the code pad used to enter the medication room. She let me inside, allowed me to gaze around at the walls and drawers and touch screens, on my quest to be helpful, assertive, and knowledgeable. She, in her years of experience, recognized my directionless search, handed me the cylindrical, yellow canisters of bicarbonate and gave me the directive:


“Walk into the room and say, ‘we are going to push three amps of bicarb.’ Okay?”


“Okay.” I sprinted back to the action.


I dutifully carried out my instructions. I announced the plan. We gave our patient bicarb. The patient’s pH improved, blood pressure rose, and the patient stabilized. Disaster was temporarily thwarted.


Empowerment, teamwork, and support

The nurse from the med room empowered me, as new physician, to execute a plan for a critically ill patient in a tumultuous moment. She modeled teamwork by supporting me, and helped me rise to the occasion.


She did not overlook, berate, or ridicule me. She found the opportunity for me to learn in a busy and chaotic situation. She embodied the dictum that sometimes, and perhaps often, the nurses know what to do more than the doctors themselves, especially new ones like me.


Summer in an academic medical center is one fraught with juxtapositions: excitement and fear, doubt and confidence, transition and stability. Now in my sixth July, I recognize the tacit assent nurses and all other non-physician providers give to stand guard both for patients and new physicians.


The potential of ALL team members to be teachers

Beginning a new cycle of training this July, and welcoming new interns into our wards, units, and operating rooms, I would gently remind our new colleagues to recognize the potential for all team members to be teachers. If you are the person searching for bicarb: be humble, be open to learning lessons; you never know when they might occur.


If you know where the bicarb is: be patient and kind, everyone is learning, and we all need help at the beginning. Indeed, throughout medical training, we all go through our personal July, our own summer transitioning into a new role, sometimes as the one searching and sometimes as the one finding.