The real adventures of Dr Maladict, Intern

Night of the Drunken Idiots

2009-11-23T11:08:22Z

Yes, it's been a while. Since I last posted here, I had four weeks of annual leave, then returned to serve night shifts in a small secondary hospital. And after four weeks of night shifts (we do seven nights in a row followed by seven days off, then repeat) I remained at the secondary hospital to work in the Emergency Department (ED).

ED has three shifts: day (8 a.m. - 5 p.m), evening (2 p.m. - 12 midnight) and night (11 p.m. - 9 a.m.) Generally, we're rostered on for a series of 3-5 of the same kind of shift, then have 2-3 days off before coming on for the next lot of shifts. Everyone has to rotate between the different shifts.

I have now done all the different shift types, and I've decided that nights, while exhausting, are by far the best shifts. There are fewer patients, because people only come to hospital in the middle of the night if there's something really wrong with them. There are far fewer of the "I felt a bit ill and couldn't be bothered making an appointment with my GP" presentations. There are also fewer staff, so there's no battle for computers and people aren't getting in each other's way. The worst possible time to be working is during that three hourse of overlap between the day shift and the evening shift, when you can barely move for doctors, and the waiting room is packed full of people, most of whom don't really need to be there.

Last night I was on the night shift, and it was Night of The Drunken Idiots. Patient after patient showed up in our waiting room fitting the same basic description: young male who did something stupid while drunk. The line up included:

1) A young man who ingested a volatile cocktail of alcohol and various illicit substances at his cousin's wedding and proceeded to act like the world's biggest douchebag before vomiting all over his family. His unfortunate parents, still in their formal wear, brought him to hospital because he freaked out and demanded to be taken there, then sat with him all night while we pumped the idiot full of fluids and waited for him to sober up.

2) An even younger man who punched a solid wall while drunk, then didn't bother to seek medical attention for several days despite the increasing pain and swelling in his hand. He had a fracture in that hand. A great tip for the kids: if you pick a fight with a solid wall, the wall will win. Always.

3) Another young man who decided to race his friends around a swimming pool while intoxicated. He slipped and fell, hitting his head hard enough to knock himself out. His friends brought him to hospital (his saintly and sober girlfriend driving them all in) and laughed like maniacs while I perfiormed a neurological examination. He checked out OK, and his X-ray didn't show any fractures, so we sent him home.

4) The cream of the crop, a young man who drank half a case of beer and decided it would be a really amusing trick to eat a spider which was sitting in its web, quietly minding its own business. He picked the spider off the web, chewed it up and swallowed it, no doubt to the wild amusement of his intoxicated friends. Then he felt sick and decided that maybe he should come to hospital because, hmm, spiders can be kinda poisonous, right? Especially in this country. When we asked him what kind of spider it had been, he assured us that it wasn't a Huntsman. This was small comfort though, as Huntsman spiders, while extremely large and scary-looking, are probably the only spiders in Australia that are actually quite harmless.

As an added bonus, the man with the fractured hand told me a story about a mate of his who, while, drunk, decided to put a light bulb in his mouth. The light bulb then got stuck, resulting in a highly amusing trip to ED. I assurred him that there are worse places one can stick a light bulb (Scrubs fans will appreciate this), but added the story to my growing collection of Retarded Things Young Men Do While Drunk.

The way it ought to be

2009-08-27T11:29:53Z

After my stressful stint in Vascular, I had to come back for a week of Upper GI (gastro-intesitnal), otherwise known as UGIT. My first thought when learning of this placement was "Oh God, not another surgical term!" And then, the following things happened:

1) The reg started the day by explaining what I was expected to do on the team and how best to do it. He stressed the need to document everything in the notes.
2) The registrars actually saw all the patients on the ward round and talked to each of them and answered their questions. They also - gasp! - waited after each patient until I could find the next patient's file, and waited for me to write, occasionally stressing certain things that I needed to include in the notes.
3) After the ward round, they discussed all the patients with the nursing staff, explaining the plan of action for each one.
4) The nursing staff, by the way, made sure that all the patient files were in their rightful spot and all the charts were by the patient's bedside. In Vascular, bedside charts were often missing, which made the ward round even more difficult. And of course, the registrars never waited for us to find stuff, or to write things down.
5) After all this was done, the reg asked me to come an help out in theatre. He then explained everything he was doing as he did it, taught me a bit of anatomy and showed me how to stitch up at the end - and waited patiently while I did so with my clumsy and inexperienced hands. He never, ever showed any signs of frustration, but calmly corrected every mistake and praised everything I did well.
6) When I went back to do the ward work, I found I still had a lot of questions about the patients. I was getting really stressed about it until I had a novel idea: I could ask the reg! I went to theatre and did so. He answered every question clearly and never once made me feel like an idiot for asking.

I think that parhaps my brain, delirious after ten weeks of Vascular, may have simply dreamed up this surgical paradise. I'm actually lying in a coma somewhere with an insanely happy grin on my face. It turns out I actually like surgery. I just never realised it because I've never worked with a nice surgical team before. I'm terribly disappointed that I only got UGIT for a week. If this had been my surgical term instead of Vascular, I might have been filling out applications for surgical training right now, convinced it is my life's ambition to become a UGIT surgeon.

At any rate, I'm going on annual leave as of tomorrow, so I'm sure this brief love affair with surgery will be forgotten by the time I return.

One more brief story before I disappear for a month: I actually had a civil conversation with the Antibiotic Nazi. He answered my questions politely, agreed with everything I said and gave me permission to do exactly what I wanted to do. What changed, you might wonder? Well... I was asking him for permission to stop antibiotics.

Failday, Part 3

2009-08-24T09:49:10Z

With the day drawing to a close, I thought it was time to check on our bleeding patient. I'd promised Scruffy to re-check his bloods.

The patient had kidney failure, and was on dialysis. This was done through a surgically-created "fistula" in his right arm. I won't go into the technical details, but I'll just say this: when a patient has a fistula, you're not allowed to take blood or insert cannulas or even do blood pressures on the fistula arm. So that ruled out his right arm. Now, the surgery he'd had prior to the bleeding was a bypass graft in his left leg. To do this, Scruffy and Dr Fail took a vein out of his left arm and stitched it to the arteries in his left leg, creating a bypass from the groin to the arteries below the knee. The bleeding had been from the edge of this graft.

In effect this meant that he'd just had major surgery on his left arm and left leg. Both were heavily bandaged, and I could not even contemplate taking blood from either limb. That left his right foot. With difficulty, I found a tiny vein and with even greater difficulty obtained a tiny blood sample, barely large enough for the lab to process. I sent this off, and wandered back to the vascular ward to write some discharge summaries.

At a quarter to five, the lab paged me. "His haemoglobin is 57."

Just to put things in perspective: a normal haemoglobin for a healthy adult man, the sort who eats plenty of red meat, is between 130-160. For a woman it's a little lower. Most hospital patients are anaemic, which means they have a low haemoglobin. We generally don't worry about anyone with a haemoglobin over 100. Someone with a haemoglobin of 80 might require a blood transfusion if he's particularly unwell, or about to have surgery. A haemoglobin of 70 is almost definitely grounds for a transfusion.

Our patient's haemolobin was 57 - and this after he'd had two blood transfusions and surgery to fix the bleeding.

I told D. We looked at each other and said, in unison, "Oh, shit."

D marched off to the renal ward, muttering "I hate my job. I hate my job," under his breath. I stayed behind in order to call the blood bank. Our patient most definitely needed a transfusion, and a big one.

But when I asked for the blood, I came across an unexpected problem: his blood group and antibody screen had expired. This is a test required by the blood bank before they can give a patient blood - if you give someone poorly matched blood, they can die. For reasons I don't entirely understand, a group and screen is valid for three days only - after than, if you want to give the patient blood, you first have to repeat the group and screen.

Our patient's group and screen had expired at 10 a.m. that day.

I told the blood bank that the patient had a haemoglobin of 57, that this was very urgent and that he'd already had a MET call that day. But no amount of begging or cajoling would force them to bend the rules: he needed a new group and screen.

I raced to the renal ward, afraid that the patient would crash at any second. When I arrived, the nurses told me his blood pressure was dropping. The patient was still conscious, but he looked bad: pale and sickly, the very appearance of a patient who's about to require a MET call.

I couldn't get a blood sample. I had used his last good vein for the haemoglobin test. Now, no matter how many times I pricked him, no matter how much I slapped his veins, I could not get a single drop of blood out of him. The nurses started saying we should call a MET call.

A renal registrar happened to be around, and she offered to help. However, she couldn't get any blood either. While she was trying, I called theatres to tell our registrars what was going on. But they were scrubbed in mid-surgery, and I was forced - like always - to relay a message via one of the theatre nurses. Then, just as the renal reg told me she couldn't get any blood, a nurse came up to me and said that the patient in the next bed - also, unfortunately, one of ours - had a blood sugar level of 1.5. Again, I must pause to explain: 1.5 is low. Very very low. Patient might be about to go into a coma low. Oh, and he was losing consiousness and he didn't have a cannula.

I was starting to panic. The only reason I didn't call a MET call at that moment - which would've been a perfectly reasonable course of action, by the way - was that I couldn't find the red button. And while I stood there freaking out, D managed to insert a cannula and write up the glucose solution that the patient needed (unbelievably, the nurses wouldn't give it until it was properly documented!) I went back to the bleeding patient, but still couldn't get any blood. Meanwhile, his blood pressure dropped a few more points. I told the nurses to call a MET call.

The piercing alarm brought a crowd in to help us. Suddenly, there were anaesthetists, cardiologists and ICU specialists present to help. I explained what'd happened. The anaesthetists quickly inserted a cannula and took bloods (God only knows how). They gave him fluid to raise the blood pressure. I could take a step back: the patient was in experienced hands. D and I retreated to the nurses' station and called theatres again. Then we waited - there was nothing for us to do but wait.

By the time Scruffy and B turned up, the MET team had dissipated, leaving just the team leader. Oh, and the other patient's blood sugar had come up to a safe 6.3 and he was back to being a conscious and very grumpy old man. Our registrars talked to the team leader, and Scruffy called ICU for a consult. In the mean time, the lastest blood results came back from the lab. The haemoglobin, inexplicably, was 90 - even though we hadn't as yet managed to get any blood for the transfusion.

Scruffy asked if there'd been any fluids running into the limb from which I took the blood (a factor which can sometimes give a falsely low haemoglobin reading). I told him with absolute certainty that there hadn't. I had thought of that when I was taking the sample, and had been relieved to find that the leg from which I was taking blood didn't even have a cannula.

On any other day, Scruffy might've looked at me as if he didn't believe me, or said something to suggest the false reading was somehow my fault anyway. But that day, he just said "It must be a lab error."

I agreed. "It would be just our luck. It's been that sort of day."

And Scruffy laughed a joyless sort of laugh and said, "It really has."

He decided that after everything that'd happened, the patient should have a blood transfusion anyway, and he tried to get him transferred to ICU. ICU couldn't take him as they didn't have any beds, but the ICU reg agreed to check on our patient during the night.

It was 6:30. We'd started work at 7 a.m. that day, eleven and a half very long hours ago. The four of us - Scruffy, B, D and myself - sat down at the nurses' desk and talked about the day. It turned out that the reason our registrars never made it to team lunch was that they'd had another MET call (not one of our patients). It was a cardiology patient who was having a routine cardiac procedure, during which somebody nicked a very important artery. The patient lost oodles of blood, and the vascular registrars had just spent several hours in theatre, fixing the bleeding artery.

"And while we're in there," said Scruffy, now laughing for real, "we start getting these messages. 'His haemoglobin is 57!' Then, 'The blood sugar is 1.5!' and 'He's had a MET call!' We were like - 'What the hell is going on up there?!'"

We all laughed. It really was funny, in a horrifying sort of way. And for the first time in ten weeks, there was a real sense of comradery between us - we'd all had a terrible day, and we'd all survived it.

"We should all have a glass of wine when we get home," said Scruffy. "Speaking of which, let's get out of here before something else happens."

We left.

The next day, my last day on the team, everything was back to normal. Scruffy and the others ignored us on the ward round, then disappeared to theatres for the rest of the day. Nobody mentioned Failday - it was as if it never happened. At the end of the day, Skinny came by to tell us that the other two were still in theatres, and to check if there were any major problems on the ward. We talked about a couple of patients and then she said D and I could go home. We never said goodbye to Scruffy or B.

Failday, Part 2

2009-08-23T05:55:46Z

When Scruffy apologised for for going off at me, I immediately responded with "It's okay. It's been a stressful morning," wanting to clear the air and get on with making it a less stressful afternoon. But while Scruffy might have been done yelling at me, he wasn't done being pissed off at the world.

"It's just ridiculous!" he fumed. "Why am I being harassed about discharge planning? That's not my job! My job is to do the surgery! I've got enough on my plate - this guy has to go back to surgery, we might have to redo his entire graft for Christ's sake!" He banged his fist on the table, then grabbed the phone to call theatres, punching in the number with a ferocity that suggested the phone was somehow responsible for all his problems.

In ten weeks of working with him, I had never seen him lose it like this. He'd always struck me as the typical surgeon: arrogant, uncaring and dismissive of the problems of others, be they his patients or his junior staff. Now, in a moment of glorious clarity, I could see that he was just like the rest of us: stressed out by his job and unwilling to have even more responsibility land on his shoulders. And at this moment, he was worried about our patient, unsure how to deal with the problem and perhaps even blaming himself, since he was the one who did the surgery in the first place.

I waited until he organised for the patient to go to theatres, and ordered me to repeat his blood tests later in the afternoon. Then I went back to the vascular ward. Scruffy's mood was so volatile, he might easily turn on me again. I'd had enough confrontation for one day.

After that, things were quiet for a little while. D and I slowly sorted out the mess left by the internless ward round. We discharged one patient and prepared discharge plans for several others. We wrote out a few medication charts, obtained three consults and inserted several cannulas. After that we split up - I had to do some jobs for a patient in the short stay ward, and D went to see somebody in Day Surgery. I was still in the short stay ward when our third registrar, B, caught up with me. Unlike Scruffy and Skinny, who can both be a bit sarcastic and unhelpful, B is a genuinely nice person. She still won't go out of her way to help an intern, but if you ask for her help she'll give it, and she won't make you feel like an idiot for asking. The first thing she said to me was "Are you all right?" Evidently, she'd heard about the blow-up that morning. I assured her that I was fine. She then told me that they'd finished operating on the bleeding patient and that we were going to have team lunch to farewell D and myself. I found the idea a bit strange - for the entire ten weeks we'd worked together, the only thing we'd done as a team was have coffee on one remarkably quiet day. I was sure that Scruffy and Skinny couldn't give a crap about farewelling us, but I was also sure that the team lunch had been B's idea. In my idealistic way, I thought it might be nice - a good way to clear the air and actually end the term on a friendly note.

I told B I'd come down to the cafeteria as soon as I'd finished what I was doing. She said she had something else to do as well, but she'd meet me there in a few minutes.

When I came down to the cafeteria, nobody from my team was there. I paged D, and he said he was still in Day Surgery but he'd come down in a minute. He also said he just saw B, and she was on her way down. At that moment, I saw Scruffy. He offered to buy me lunch, which was nice, but a bit weird. On normal teams where everybody works well together, it 's almost expected that at the end of term, the senior registrar buys lunch for the entire team. Or at least coffee. But we weren't that kind of team. And besides, the rest of the team - D, B and Skinny - weren't there yet. I told Scruffy they were on their way down and we should wait. At that moment, his pager went off. He spent a short time on the phone and then marched off without a word. He didn't come back.

I waited a few more minutes, then decided it was time to cut my losses. I bought some lunch and was looking for a table, when I spotted D sitting with a group of other interns. He told me he didn't know what happened to the registrars, but he'd given up waiting, just like me. Our attempt to have team lunch had turned out to be just as dysfunctional as the rest of the term.

After lunch, I decided to go find Prof T and ask him to fill out my end-of-term assessment form. I'd originally intended to do it after the ward round, but after the Scruffy explosion and the MET call, I couldn't quite face the prospect of an assessment.

I found Prof in his clinic. He is a jolly old surgeon, the sort of doctor who is well past retirement age and therefore only working because he doesn't know what he'd do if he stopped. He is long past the part of his career where stress is a major factor, and so he has the time and energy to indulge his junior staff. During the term, I generally saw Prof twice a week - during the Thursday meeting and ward round; and on one other random day where he'd show up at the hospital and see each of his patients for two minutes.

I was wondering what the registrars had told him about my performance. I was completely unprepared for the first question he asked.

"So, how did you find working with D? You two are such different personalities!"

I couldn't believe my ears. Prof barely saw us all term, and the registrars were nowhere near interested enough to notice that we had personalities. But the truth was, I had found it extremely hard - D and I did not work well together at all. We got along because we went out of our way to be nice to each other, but we were a poorly matched team. We worked very differently, and worried about different things and never quite trusted each other to do a job right. Truth be told, though the workload clearly required there to be two interns on the Vascular team, I had actually found myself feeling less stressed out on the few days when D was away. But was it really that obvious?

I chose my words carefully. "We managed. We couldn't have done the work alone."

"Yes, but it's always interesting to see two very different people paired up. I was wondering how you'd get along."

"Oh, we got along fine!" I said, wanting to make it absolutely clear that I had no problems with D. I didn't want to come across as a bad team player, either. At the same time, the Prof was offering me quite a good excuse for why D and I didn't make a very good team, and I wanted to acknowledge that he'd hit the nail on the head. It was, after all, a pretty remarkable bit of insight, given that he hardly ever actually saw us work. "But yeah, we do work differently. Sometimes we struggled a bit."

"Yes, I find it fascinating, the dynamics you get on a team. For instance, there's a dramatic change in the way the team functions nos that Skinny and B are here instead of our previous registrars."

If I'd been eating or drinking anything, I would've choked. Again, he had hit the nail on the head. I couldn't suppress a laugh. He was so completely and totally spot on.

You see, junior registrars also tend to rotate around, though on a different schedule to interns. Senior ones like Scruffy might stay in the same job for a year or more, but Skinny and B rotate every three months or so. And the two registrars we'd had before them were far, far more competent and easy to work with. Don't get me wrong, B was nice, but the two we had before actually went out of their way to know what was happening with the patients and what D and I needed help with. They could spot problems long before they arose, and they always found the time to answer questions. I had never really spoken to Scruffy before the registrar changeover - the two juniors handled everything. But after Skinny and B replaced them, I found myself naturally going to Scruffy with questions, even though he was less than eager to help and often quite rude. But I got the impression he was more competent to answer, and for the sake of our patients, I always tried to ask him. B was my second preference, and Skinny a last resort.

I missed the old registrars.

But again, I had to choose my words carefully. "They [the old registrars] were excellent to work with, especially T. She was a great. I mean, I don't know how she is as a surgeon, but working with her was really good."

"Oh, I agree!" beamed Prof. "She is an excellent doctor all round. Just goes to show the calibre of doctors that sometimes come to us from overseas."

He went on for a little while about the relative merits of overseas and Australian trained doctors, while I sat there thinking about all the things that weren't being said. For instance, did Prof pick up on the fact that by praising the old registrars I was essentially saying the new ones didn't measure up? Was he thinking the same thing? Did he know about the kerfuffle that morning? Surely he was shrewd enough to realise that our team was a complete mess.

If he was thinking any of those things, he didn't let on. He told me that D and I had both done a good job in a difficult term, that the registrars were pleased with our work (!) and that he wished me luck in my next rotation. He also told me that D and I were both obsessive compulsive, but in different ways, and that we tended to deal with stress differently, though we both got equally stressed out. "Asian people tend to hide things well. Whereas you're Eastern European - they tend to be a lot more vocal." Again, I wondered if he knew about the showdown with Scruffy. But I wasn't about to bring it up.

I left his office feeling a little dazed. It was the strangest end-of-term assessment I'd ever had.

It was four o'clock. I was on the home stretch - just a few more jobs, then hopefully I could go home.

I had no idea what was about to happen.

(To be continued.)

Failday

2009-08-20T11:53:42Z

Today was a fail of epic proportions. It failed so badly that I'm not even sure where to begin. I will start, I suppose, at the beginning.

Thursday is usually the busiest day of our week, but also the most productive. It's the day when all the consultants come into the hospital and do a ward round. Thursday is the day when things get decided. Usually, the day starts with one particular consultant, whom I shall call Dr Fail because of what happened today. He sees all his patients between 7 a.m. and 7:30. We then have a meeting which usually goes until about 9 a.m. and usually involves the senior consultants, Prof L and Prof T, reminiscing about the good old days when you could perform surgery in a patient's bedroom if they happened to be you beloved neighbour's mother-in-law (and yes, that was an actual story shared by Prof L. I'm not kidding.) After the meeting, the other consultats see all their patients. At this point, it's necessary for the juniors on the team to split up so that one of us goes with every consultant and writes in the patient notes.

Writing in the patient notes is important. It's our best means of communicating with other members of the team, including nurses and allied health*. It's also our means of keeping track of what we're meant to be doing for each of our patients.

Unfortunately, the consultants and registrars don't seem to realise this. Even worse, if don't ask them specifically, they often don't even bother giving us a verbhal handover of what they want done. This becomes problematic when we try to clarify things, as once the ward round is over, the consultants and registrars disappear into theatres, leaving just myself and another intern, D, to sort out all the issues on the ward. Once in theatres, they are almost impossible to contact.

So today, like every Thursday, started with Dr Fail. His round went smoothly, with just one exception: a petient who appeared to be bleeding profusely from his surgical wound. Dr Fail had a look at the wound, and said that it wasn't actual bleeding - it was just blood-stained fluid which was leaking out of the wound due to a haematoma which had formed there post-operatively. He expected this haematoma would now continue to ooze until it was completely drained. He advised the nursing staff to apply pressure to the wound. We went on our merry way, forgetting all about it.

We went to our meeting, where Prof T told us an extremely depressing story about a patient whose surgery was postponed several times until he keeled over and died just three days prior to the operation. We then split up - D went with Prof T, a registrar whom I shall call Scruffy went with Dr L, and I went with Dr G, along with another registrar, whom I shall call Skinny. I was anxious to see all of Dr G's patients, because many of them were supposed to be going home. Our patient list had grown exponentially over the previous week, and D and I - as well as all the nursing and allied health staff - were keen to discharge as many people as possible. Many of the potential discharges were complex patients, and we had gone to a lot of time and trouble to prepare them for discharge, arranging community nursing, rehab, and respite care as needed. Two of the patients had been given highly sought-after beds in private facilities - all we needed was the consultant's OK to send them there.

Skinny was not aware of this.

Two minutes into the round with Dr G, I was paged. The patient with the bleeding wound had had a MET call. It seemed it wasn't just a draining haematoma.

I was forced to rush off to find out how serious the MET call had been. It turned out that it was very serious indeed - I walked in as the patient was being reviewed by the ICU registrar. The wound was bleeding profusely and the patient was unconscious. I called Skinny and told her what had happened. She said she'd come down to review the patient soon.

I waited. It took longer than it should have - theoretically, MET calls should provoke an immediate response from the treating team. But eventually Skinny turned up, along with Scruffy, who is the senior registrar. They reviewed the patient, who was now having a blood transfusion and had woken up. I decided that since they had the situation under control, I should go back to our other ward and re-join Dr G's ward round. I was worried he would see all the patients and disappear from the hospital without writing anything in the notes.

Unfortuately, this is exactly what happened. When I asked Skinny, she told me they'd seen all the patients, and none of them were to be discharged. She wasn't very clear as to why, which would be a problem when I had to explain to the Allied Health staff why all our hard work had been in vain. Similarly, Scruffy hadn't bothered to write in the notes of any of Dr L's patients, whose discharge planning had also come to a standstill after the ward round.

The ward NUM (nurse unit manager), social worker and D were all present when I broke the bad news - none of our patients were going home. The NUM immediately demanded to know why, and I told her I didn't really know. Of course, there was nothing written in the notes to explain these decisions. The NUM began raving about the incompetence of the surgical registrars, who never write in the notes, and leave their interns to deal with all the problems. Her rage was directed particularly at Scruffy, who is the senior registrar and is notorius for these failures in communication. I had been struggling with his attitude for the past ten weeks, and I was also angry and frustrated. I moaned loudly about his failure to leave clear instructions - or to read the notes himself so that he'd at least be aware of all the discharge planning we'd already done. The NUM asked me if she should make a formal complaint.

Now, this is where it gets tricky. On the one hand, the communication problems had been a constant source of frustration for me. On the other hand, I didn't want to make a complaint. I was upset, but not upset enough to warrant making waves like that. There was enough tension in the air already. In addition, if a complaint has to be made about Scruffy, an equally valid complaint could be made about the NUM. Yes, she was on my side, but she has also been a thorn in my side - the sort of person who can triple my workload while contributing nothing useful herself. She is constantly on my back to deal with issues that should be her job, and has little understanding of the concept of prioritising. I might be in the middle of a ward round, jogging after Scruffy trying to document his plans in the patient's notes, when she'll interrupt me to deal with some minor administrative issue. She also has a tendency to be rather rude - every bit as rude as Scruffy - and gets her knickers in a knot about minor details which really aren't worth worrying about. (For example, she once flew into a rage because Skinny left her purse at the nurses' station. Her problem was that she didn't want to be held responsible if the purse went missing. Skinny said that she wasn't asking her to be responsible, at which point the NUM threatened to make a complaint about Skinny for being rude.)

I said no, please don't do that. The NUM pressed me, saying that if we don't complain, nothing will ever change (a good point). She also said that at the end of the day, it wasn't Scruffy who would be signing my end-of-term assessment, it was Prof T, and he would be asking the NUM about the quality of my work.

It was at this point that Scruffy turned up.

Now, most people would see this as the time to stop venting and simply ask Scruffy for the answers we needed, and clarify some of the issues with our patients. Venting and bitching is one thing, but most people will try to avoid direct confrontation.

The NUM chose to go for the throat.

She started with "Scruffy, we were just talking about you..." and it got worse from there. She gave him a good piece of her mind - but unfortunately, she included me in her rant. I tried to deflect things by turning the conversation to the problems with our patients. The situation was salvaged somewhat by one of our senior nurses, who quickly went to the patient in question to clarify some issues, and came up with a viable discharge plan on the spot. I latched onto that plan, but the damage had already been done. I had just started filling out some paperwork for the patient when Scruffy confronted me. He shouted about the inefficiency of a team that stands around bitching instead of working out a solution to the patient's problems, and the incompetence of interns who need to have everything written down even though he would've written the exact same thing he'd already told me. I said, lamely, that it really did help if things were written down, but I had definitely lost this battle. Besides, I was so upset I could barely talk. Guess my skin isn't thick enough yet. Eventually, Scruffy went off to fume elsewhere, leaving me in peace. I finished the paperwork, then hid in the toilets until I could calm down. A part of me realised that Scruffy had exploded at me because I was the easiest target rather than because I was as incompetent as he'd made me feel, but I was still pretty shaken. I kept reminding myself that I had just two days left in vascular surgery, but that didn't realy help. I kept thinking "What a rotten end to the term!"

I returned to the ward, where I found Skinny. Unaware of everything that'd happened, she'd bought coffees for the entire team, only to return to the ward and find out that we'd just performed a hospital drama worthy of Grey's Anatomy. She gave me my coffee, and initially said a few sympathetic things about the difficulties of being an intern - but then ruined all her good work by starting on a gentler version of the same lecture that Scruffy had give me. At this point, I made an excuse to disappear to another ward. I needed to order some tests for the bleeding patient, and had to go through his file. (But most of all, I needed to get away from the madhouse that was the vascular ward).

But the other ward was not the refuge I'd hoped for. I had just found the relevant file when I ran into Scruffy, the person I was most keen to avoid. To my immense surprise, however, Scruffy, grabbed me by the arm and apologised for going off at me just a few minutes earlier. With a few simple words, he dissipated a huge wall of tension between us. Never underestimate the power of a good apology, kids. It made the rest of the day - which continued to be very eventful - a thousand times more bearable than it would otherwise have been. And for all his flaws as a teacher, I have a new-found respect for the guy - it takes a certain amount of guts and insight to admit you've been a jerk.

And on that note, I shall put a "to be continued" on the soap opera that was my day. I need to get some sleep - but rest assured I will finish this story. The point at which I leave off was at about 10 a.m., and the day had a lot more drama in store.

* allied health - refers to the assorted non-medical people involved in treating our patients, including physiotherapists, speech pathologists and social workers.

The Antibiotic Nazi

2009-08-16T02:09:17Z

After eight months of internship, I have come to the conclusion that there is no registrar in the hospital quite as nasty as the Infectious Diseases registrar. Despite all my best attempts to Not Get Yelled At, he is the one person in the hospital who can always be counted on to bite my head off every time I call him. Every. Fucking. Time.

Nothing fills me with a sense of dread and foreboding quite like as order to "Discuss this with Infectious Diseases..."

The trouble is that in an attempt to decrease the spread of antibiotic-resistant organisms, my hospital has instituted a system where you need permission from the infectious diseases team to prescribe some of the more hardcore antibiotics. And the wonderful infectious diseases registrar seems to have taken it upon himself to single-handedly end the spread of antibiotic resistance by not letting anyone prescribe antibiotics, ever. And if you dare to ask him for them, he will use all his considerable talents to make you feel like the smallest, dumbest, most irritating little person in the universe for daring to waste his time with your idiotic and ill-founded request. There will always be some problem with your request, and he will use any excuse to avoid giving you the damn antibiotics. He's like the Soup Nazi from Seinfield - I can just picture him roaring "No antibiotics for you!!!" at a queue of quivering hopefuls.

A typical conversation might go something like this:

Intern: Hi, I need to get some antibiotic approval.
Antibiotic Nazi: (sarcastically) Of course you do.
Intern: Well, the patient has an ulcer on his leg, we've been giving him Cefalothin and Metronidazole, but the swab grew some Pseudomonas so we need some Pseudomonas cover...
Antibiotic Nazi: What makes you think he has an infection?
Intern: Er, he has an ulcer?
Antibiotic Nazi: Yes, but is it infected?
Intern: Well, it's oozing green pus...
Antibiotic Nazi: (irritated) Yes, but is it infected?

At this point the intern tends to lose all confidence and start stammering, because for most people "oozing green pus" counts as adequate evidence that the ulcer is well and truly infected. The intern now has to think of other signs of infection. If the intern is lucky, the patient will have a high fever and a raised white cell count, but if so, God help the intern if he hasn't taken blood cultures. The conversation then takes the following turn:

Intern: Well, he also has a fever and a raised white cell count.
Antibiotic Nazi: (snaps) What does the blood culture show?
Intern: Um, the results haven't come back yet? (NB: most interns, after a couple of conversations with the antibiotic Nazi learn to never admit that they haven't done a blood culture.)
Antibiotic Nazi: I can't give you antibiotic approval without an organism.
Intern: But he has Pseudomonas in the ulcer!
Antibiotic Nazi: *rants about colonizing organisms versus infective organisms, making it very obvious that the intern is wasting his precious time - time which could be spent terrorising other interns asking for antibiotic approval*
Intern: *has to go off and explain to their own registrar why they haven't been able to get antibiotic approval. Most registrars don't believe the infectious diseases registrar can be so awful, and think the intern is simply incompetent.*

The Antibiotic Nazi used to really get to me, because he has a way of making you feel small and stupid and incompetent. You always walk away thinking it's your fault you didn't get the antibiotics you needed - or that you were wrong to even ask. Actually, he still gets to me, because it's impossible to become completely immune to the sort of crap he dishes out every time I'm forced to talk to him. But I was somewhat relieved when I realised that it wasn't me - he really is a just horrible, mean-spirited little person.

The proof came a couple of weeks ago, when I was ordered to "Discuss this with Infectious Diseases..." at ten minutes past five p.m., when the Antibiotic Nazi had already gone home for the day. Out of hours, the person to call is the consultant on call - that is, the head of Infectious Diseases, or the Antibiotic Nazi's boss.

You can imagine my dread at this prospect. Every time I called the registrar, he made me feel like I was wasting his time. This time I would have to call the consultant, and waste his time - out of hours, no less. I prepared myself for the worst ear-bashing of my life as I asked Switch to put me through to his mobile. This was the conversation we had:

Me: Er, hi, sorry to bother you out of hours, but I need some antibiotic approval?
Infectious Diseases Boss: Tell me the story.
Me: Well, this patient, he's an 80-year-old man with a chronic ulcer on his leg, we've been treating him with Cefalothin and Metronidazole, but we've just found the wound culture has grown Pseudomonas.
Infectious Diseases Boss: (calmly) Does he have any other signs of infection?
Me: Yes, he has a fever and a raised white cell count.
Infectious Diseases Boss: (pleasantly) Okay, well you'd better start him on Timentin, and take a blood culture if you haven't done so already. I'll review him tomorrow. Good night!
Me: Thank you. *Hang up the phone, and sit in stunned silence for several seconds, wondering if I could somehow postpone all future antibiotic approval phone calls until ten past five.*

Best. Shift. Ever.

2009-07-26T10:59:26Z

Just so you know, my work isn't always scary and stressful. Yesterday, I had one of those shifts that every intern dreams off: the weekend surgical shift.

What's great about the weekend surgical shift, you might ask? Well, for starters, unlike the weeknight surgical shift, where you cover four wards and may occasionally be called to theatres, the weekend shift only covers two wards. And unlike the medical and geriatric shifts, where you generally have to deal with large numbers of frail, elderly, demented and just plain crazy patients, the surgical wards tend to contain people who are at least healthy enough to survive an anaesthetic and sane enough to sign a consent form. So there tends to be a lot less trouble.

Here's what I managed to do in my fourteen hour surgical shift:

8:30 - 9:00 Attend morning handover. Visit my two wards, write one medication chart and one fluid order.

9:00 - 9:30 Drink a cup of unbelievably horrid coffee from the staff cafeteria.

9:30 - 10:00 Visit the vascular ward. (This is not part of my job on the weekend, but since I had nothing to do, I thought I'd catch up on my discharge summaries.) Discover my registrar doing his weekend ward round. Assist registrar in ordering a CT, which he doesn't know how to do since usually an intern does it for him. Write discharge summaries for two patients he has just sent home with no documentation or paperwork whatsoever. Rewarded for my effrots with a Crunchie bar purchased by the registrar from the fundraising box.

10:00 - 10:30 Called to theatres. Informed to "Come now, we're about to start." Arrive to find surgical registrar making tea in the theatre staff room. Spend half an hour drinking tea and listening to gossip. (Turns out the vascular team isn't very popular with the theatre staff. Surgical registrar is mildly horrified when she realises I am the vascular intern - after I've heard all the goss.)

10:30 - 11:30 Assist in laparoscopic appendicectomy. Assisting in surgery is a remarkably easy job, as long as you're wearing comfortable shoes. All you have to do is hold stuff. I got to hold the camera. The most challenging part of my task was moving it occasionally to make sure it was still pointing at the appendix. After forty minutes of looking at the swollen and inflamed thing on the screen, I was shocked to see how small the appendix was once extracted from the patient. Incidentally, the retrieval process involved cutting off the appendix, then leaving it loose inside the patient while the surgical tools were taken out and replaced with the tools necessary to actually pull it out of the tiny hole in the patient's bellybutton. This also involved temporarily taking out the camera. I asked the surgical reg if she'd ever had trouble finding the appendix again once the camera was re-inserted. She said she'd never lost an appendix, but she did once lose an ovary, which had somehow managed to roll behind the liver while the camera was out. She spent a very nervous half hour poking around with the camera until the ovary was finally discovered.

11:30 - 12:00 Return to wards. Still nothing to do.

12:00 - 12:30 Visit the cafeteria. Discover that hot chips, the only edible thing the cafeteria ever had, are no longer being sold on weekends. Opt for unbelievably horrid sausage roll, which is made palatable only by drowning it in tomato sauce. Lament loss of hot chips. Lament lack of other food outlets at my hospital.

12:30 - 1:00 Visit vascular ward. Complain to nursing staff about loss of hot chips. Spread dismay. Write a discharge summary.

1:00 - 1:30 Visit RMO common room. Take a nap.

1:30 - 2:30 Nap interrupted by two residents coming in to the common room and turning on the TV (they were having a quiet shift too.) Spend an hour reading Marley and Me.

2:30 - 4:30 Return to vascular ward. Write two more discharge summaries. Listen to nurses gossiping about surgeons. Turns out certain members of the vascular team aren't very popular with the nurses, either. They don't seem to mind that I'm listening.

4:30 - 5:30 Paged by surgical ward to write a medication dose. Paged by other surgical ward to write a fluid order. Discover that one patient on the urology ward has spiked a fever but isn't on any antibiotics. Take blood culture and urine culture. Call urology registrar and ask if I should start antibiotics. Advised to do so. Insert cannula. Order antibiotics.

5:30 - 6:30 Visit other surgical ward to write the fluid order. Discover a patient who is asking to see a doctor because she's "feeling unwell". Visit patient. Find absolutely nothing wrong with her. Visit another patient who is complaining of constipation. Chart laxatives. Visit third patient who is feeling nauseous. Chart anti-emetics.

6:30 - 7:30 Eat dinner, which thankfully I brought from home. Check Facebook. Check email. Watch stuff on YouTube. Read several more chapters of Marley and Me.

7:30 - 8:30 Re-visit wards. Nothing to do. Return to vascular ward for more gossip with the nursing staff.

8:30 - 9:00 Paged by surgical ward to insert a cannula. Cannula proves difficult and takes three attempts.

9:00 - 10:00 Write discharge summaries on the vascular ward. It will save me a lot of work on Monday.

10:00 - 10:30 Attend evening handover. Go home, wondering why all my overtime shifts can't be this good.

A bane of my existence

2009-07-21T11:30:23Z

I was going to call this post "The bane of my existence", but unfortunately there are far too many contenders for the title. For example, I could say that seven a.m. ward rounds are the bane of my existence, but then, overtime shifts are equally existence-ruining. Or I could say cannulas are the bane of my existence, but they're occasionally out-baned by the hospital's computer system. For today's post, I will focus on just one current bane of my existence: my medical student.

"What??!" I hear you scream. "You're dissing a medical student? When you were one yourself just six months ago? Surely you remember how difficult it was!"

In fact, I generally really like having medical students. They're fun to talk to, occasionally helpful and always grateful for the time I spend teaching them. And I really enjoy teaching, and generally make a point of finding the time to do it, when students are around.

But this time, I have been saddled with Saddam - so called not because of his racial background, but because of the unfortunate shape of his facial hair. And Saddam is... special.

Saddam is several years older than me, and boy does he know it. I've seen plenty of students in their 30's, but this is the first such student to actually talk to me like I'm his younger relative. What's worse, Saddam has an opinion on everything - and I mean everything. The appropriate medical management of our patients? Saddam always has something to say - much of it incorrect. The quality of medical teaching in Australia? Hell yeah. The relative merits of working alongside an ex-fiancee? You'd better believe it.

(The latter arose while I was talking to one of the other interns about a mutual friend who is soon facing the horror of having to work on the same surgical team as an ex who called off their wedding. Upon hearing this tale, and my opinion that it would be better to change hospitals, Saddam said, with absolute confidence, "Working with an ex-fiancee won't be a problem! If it's an ex-boyfriend or girlfriend then yeah, it's messy. But if you were married or engaged and you broke up, then it's okay. It's over."

Apart from the sheer emotional stupidity demonstrated by this statement, one has to wonder about how this guy can have such a firmly-held belief about the personal life of a person he has never met?)

Saddam also routinely criticises the various doctors he has encountered at our hospital. He has been known to say such things as "Dr so-and-so is a terrible doctor. He doesn't look after his patients," or "Professor such-and-such is extremely arrogant! And he's doing [insert procedure] incorrectly."

Now he might even be right, but as a medical student, mouthing off about the doctoring skills of consultants is a bit of a no-no - especially since the medical world is somewhat incestuous, and you never know who might be somebody's uncle.

With such a wealth of opinions, you'd think Saddam would be one of those studious types who attends every meeting and ward round, but this is not the case. Despite me telling him, several times, that the best time for him to come to the ward is early in the morning when we do the ward round, he usually rocks up around midday, by which time all the patients have been examined, all the bloods have been taken and the only jobs left are the discharge summaries and medication charts - which a student isn't allowed to do. A medical student can learn a great deal by coming to pre-admission clinic - and he can help out the intern there, too - but Saddam has never yet showed up in hospital on a pre-admission clinic day. By the time Sadaam arrives, teaching opportunities are thin on the ground, and I'm hard pressed to think of things for him to do. Yet he follows me around while I go about my work, all the while sprouting his never-ending opinions and offering me "helpful" tips on how to do my job. Today he told me that an intern's job is very difficult and of course I will have tough days. This might've been a meaningful and supportive statement coming from a registrar, but from a medical student it's just plain odd.

Oh yeah, and the other day he asked one of the other interns, who is around 30 years old and currently pregnant, "Aren't you a bit old for an intern?" Which is not a good thing to say to a woman at the best of times, but coming from a 30-something medical student it is just bizarre.

The red button

2009-06-29T08:38:23Z

The easy times are over. I've started my first surgical rotation. This means several things:

1) I do not actually do any surgery.
2) I start work at 7 a.m. every day.
3) I finish any time between 3 p.m. and 7 p.m., unless I have a rostered overtime shift, in which case I finish at 10:30 p.m.
4) My patient load has gone from an average of five to an average of twenty.
5) Since all surgical registrars and consultants spend their entire day scrubbed up in theatres, I have to deal with pretty much all the problems that arise with our patients on the wards, with only another intern to help me.
6) I now have to make a lot of medical decisions by myself. This includes obtaining consults. So much for my theory that that sort of thing was never an intern's call. (Though I must say, I have never yet been yelled at for any of the consults I obtained based on my own judgement.)

About a week ago, I had an incident which made me realise just how easy I've had it up until now. I was called to see a frail and extremely old patient because of her low blood sugar. When I couldn't find any obvious reason for this problem, I called the endocrine registrar for advide, and he suggested a glucose infusion. I ordered the nurse to give the infusion, and then spent a few minutes placating the patient's daughter, who was complaining about the fact that hardly any doctors had seen her mother. (This is the reality of being a surgical patient: your doctor will see you for a minute at seven in the morning, if you're lucky. Next time they see you, you'll be unconscious in theatre. And if you're too sick to have the surgery, you can lie in hospital for days without seeing a doctor, except for the intern who comes in to put in a cannula - or sort out the blood sugar.)

Anyway, while I was trying to placate the daughter, another nurse came in to check the blood pressure, and found that the machine wasn't getting a reading. She asked me to try taking it manually, which I did, only to find that it was remarkably low. Now, low blood pressure is a bad sign, and tends to send alarm bells ringing. It needs to be dealt with, and quickly. Unfortunately, the usual method of raising a patient's blood pressure - by putting in an IV cannula and quickly pouring in a bag of normal saline - wasn't feasible in this case due to the patient's heart failure. (If you pour a large amount of fluid into a patient with heart failure, the heart can't cope and all the fluid gets pushed out into the lungs. And then you're really in trouble.)

In the ten seconds or so that it took me to figure this out, the patient started turning blue around the lips, and became unresposive. Which left me with only one choice: push the red button on the wall to call a MET call. (This might be called an arrest call in the States - or in TV medical drama lingo, "Get the crash cart, STAT!!!")

In real life, a MET call sets off an alarm on the ward, calling all medical personnel to the scene of the crime, and it also sends a message to the pagers of various people who are on the MET team - a rotating roster of residents, registrars anesthetists and ICU docs. There are usually a few nurses on the MET team as well. One of them will quickly fetch the arrest trolley ("crash cart" in American). The arrest trolley has an ECG monitor and defibrillator, an oxygen tank and masks, and all the equipment necessary for inserting cannulas, taking bloods and inserting breathing tubes. And by the way, those big paddles you see on TV - the ones which the heroic doctor puts on the patient's chest, yells "CLEAR!" and then switches on, causing the patient to jump a few feet into the air before miraculously coming back to life - have long ago been replaced by stickers. You stick them on the patient's chest, advise everybody to stand back and then push a button. There is no dramatic patient-jumping-off-the-bed moment - all you get is the machine saying "Delivering shock" in a Stephen Hawking voice. The shock doesn't really make a sound, but after it's done the machine says "Assessing rhythm" and you wait for it to show you an ECG trace, hoping it has come back to normal. Oh, and if it's a flatline, no amount of shocking will help. But that's a subject for another post, perhaps entitled "Medical misinformation propagated by popular TV shows."

Anyway, due to the woman's status as an old and very frail lady, she wasn't a candidate for shocking with stickers, and that wasn't the problem anyway. The MET team arrived, stuck in a few cannulas and took some bloods, but didn't give her fluids because of the aforementioned heart failure. In fact, they did sweet bugger all, but they made me feel better because suddenly there were senior doctors on the scene and I wasn't all alone and out of my depth. And while all this was happening, the patient woke up and her blood pressure came back to normal. Maybe it was the pain of being jabbed with all those needles, or maybe it was because the glucose infusion had kicked in, but she woke up and started talking. I swear to God the MET team didn't actually do anything that might've helped her. But try explaining that to the daughter!

The daughter went from complaining about her mother's terrible care to praising all the doctors in the hospital, and me most of all. I didn't really do anything, but from her point of view, her sick mother wasn't being treated, then I came in, pushed a button and suddenly there were about twenty doctors all fussing over her mother. And the mother got better. So I had saved the day. (Only that day, mind you - the patient was far too old and sick for any of our efforts to make much difference in the long run.)

That was the first time I've had to deal with a critical situation like that. I had to make the call not to give fluids, and I had to make the call to push the red button - in itself a huge responsibility. In the past, I've always had a registrar to make those decisions for me. So surgical term is proving to be a pretty steep learning curve - ironically, for the medical rather than the surgical side of things.

Spreading the love

2009-05-05T12:16:54Z

I've lost track of what week I'm up to. It was bound to happen sooner or later.

I think there was a Scrubs episode about how when people are having a shitty day, they tend to spread it around like herpes (or swine flu, to keep things topical.) In a hospital, of course, many people are having a shitty day, so there's a lot of bad mood to go around, and sadly, it often gets handed to completely undeserving people.

By "undeserving people" I mean, of course, me. I've grown a thick enough skin now that it doesn't really bother me anymore, but I still reserve the right to bitch about it in my LJ.

So - a few days ago, I ran into my registrar from respiratory term, who was seeing a patient on my ward with one of the respiratory consultants. Now, I had a great time in respiratory and never had a bad word to say about any of the doctors I worked with, so what happened on this particular day was rather unexpected.

You see, when I was in respiratory, we had a patient - Mr S - who had pneumonia. He was with respiratory for a while, before being diagnosed with a progressive neurological disorder (which was responsible for the pneumonia). Once the pneumonia was better, he was transferred to the neurology team's care. Around the same time, I had my term changeover, and happened to be put onto the same neurology team which was now looking after Mr S. Unfortunately, there wasn't anything we could do about his illness, and he died a few weeks later. As you can imagine, it was all very sad - I had watched this patient deteriorate through the length of his hospital stay, and had been present at all the difficult family discussions with the neurology team, when decisions were made about withdrawing treatment and making the patient NFR. All of this happened during my time in neurology - the respiratory team had mainly treated his pneumonia, before realising something more serious was going on and handing him over to neuro.

Anyway, when I ran into the respiratory registrar and consultant, the reg asked me what had happened to Mr S. I told him that he'd passed away a couple of weeks ago, and briefly explained what happened after neurology took over care.

At this point, the consultant suddenly spoke up. "It would've been really nice if someone had informed me when he died," she said in a rather forceful tone. Then, just in case I didn't get it: "It would've been really nice. He was my patient."

I had no idea how to react to this. I looked to the registrar for help, but he said nothing. In the end, after a few seconds of uncomfortable silence, I muttered something like "Sorry" and dashed off, hoping it looked like I had something urgent to attend to. In fact, I just wanted to get away.

When a patient is looked after by several teams during their hospital stay, it isn't standard practice to inform every single consultant who's looked after him of the death. Futhermore, if it were to be done out of courtesy - such as if a patient has been known to that doctor for many years, or if the consultant looking after him at the time of death is friends with the consultant who looked after him earlier - it most certainly wouldn't be the intern's responsibility to do so. In fact, as an intern, you almost never approach a consultant directly, unless it is your consultant, or they're the consulant on call and you need to tell them about a really sick patient.

To add to the unfairness of it all, the patient had in fact remained on the respiratory ward right up until his death, and was well known to all the nursing staff there. If the respiratory consultant was that concerned about his fate, she had every opportunity to find out what was going on. After all, she'd have visited his ward at least every week.

Instead, she chose to blame me for not telling her. Well, it is possible that she was blaming the neurology team in general, but they weren't around when she made her comment. It was just me, and I felt like I was being held responsible for not doing something that isn't usually done, and wouldn't be my responsibility even if it was.

I knew it was unfair, but I spent the rest of the day worrying and seething. A few days later, I ran into the registrar on his own, and asked him if I should've informed the consultant about Mr S's death. He told me no, of course not - she was being unreasonable. It was reassuring to hear that, but it made me think of another sad reality about hospital life - nobody ever sticks up for you. The very thought of the registrar telling the consultant that it wasn't my responsibility is almost as absurd as the thought of me saying so myself. You simply don't contradict a consultant. As an intern, you might question a registrar if you're on friendly terms. But you never talk back to a consulatant - not even if you're a few months away from being one yourself, like the registrar was. You just take the crap, and try not to let it get to you.

Weeks 10-12: An unexpected lull

2009-04-16T00:25:54Z

Okay, so I have been neglecting this. Truth be told, not a whole lot has happened on the work front for the last couple of weeks.

I finished my respiratory term and have now changed over to Neurology. The first week of Neuro was rather depressing – two patients died, and another (who is still with us) is waiting to die. The trouble with Neuro is that most of the conditions people come into hospital with are irreversible and often progressive.

But after that rocky start, the term has grumbled into quiet boredom. I know I should not complain, because I will miss this the next time I’m so busy I have no time for toilet breaks… but OMG I AM SO BORED. It’s 10 a.m. and I have nothing to do – even my discharge summaries are up to date. Yet I can’t leave the hospital because something could happen at any moment. So for better or worse, I’m stuck here until 5 p.m., and goddammit there’s only so much you can do on Facebook.

Last week I had my most taxing overtime load so far. I worked the dreaded 14-hour Saturday shift – which was every bit as horrendous as it always is. Afterwards, a friend who lives nearby invited me over, allegedly to hang out with her and a couple of other friends. Thinking a quiet evening with friends would be a nice way to end the stressful day, I went over – only to discover that the quiet evening was actually a party in full swing, celebrating the fact that two of our friends have just bought a house. Anyway, instead of hanging out for a while and then going home to sleep like a sensible girl, I ended up seeing the sunrise from the wrong end of the night. By the time I went to bed, it was past the time I would normally be getting up. And to make things worse, it was Sunday, and I was facing the prospect of going back to work on Monday… and working another overtime shift on Wednesday.

Luckily, that week of insanity was followed by a four-day weekend, which allowed me to recuperate, and I now have an entire week and a half with no overtime. I’m still catching up on my sleep though.

Week 10: Murphy's Law in action

2009-03-29T06:14:39Z

This was the last week of my respiratory term. Tomorrow, I start Neurology.

Given that it was the last week for all the interns and residents, the two respiratory teams decided to celebrate by going out for Yum Cha for Friday lunch. The plan was to give all our pagers to the unfortunate sleep registrar, and leave the hospital for just a couple of hours.

Of course, as luck would have it, after three weeks of having between two and four patients on our list, NOW was the time for a patient explosion. And to add to our misery, we also picked up one particularly annoying patient who, despite being considerably younger and more capable of looking after himself than the majority of our other patients, proved to be more work than all the rest of them combined. (Seriously, people. A hospital is not a hotel: if you don't like the food, get your relatives to bring you what you want. Don't accuse your doctors of mismanagement just because you got pasta instead of rice. And if you stay up all might playing on your laptop, then it really isn't the hospital's fault that you're not getting any sleep. Oh, and when you discharge yourself against medical advice, then it's a bit stupid to say that the reason you're not getting better is because the doctors are mismanaging your condition.)

In the end, the other team went to Yum Cha, while we stayed back dealing with our patients. Alas.

Week 9: Heads will roll.

2009-03-23T10:33:09Z

Saturday, March 21
I’m almost afraid to type this lest I jinx it, but I’m having a freakishly quiet Saturday shift. Last time I worked on a Saturday, I was running around like a headless chicken all day with barely a moment to breathe. Today… I have so far been here for three hours and haven’t had to do anything more difficult than a medication chart.

While I do hope it stays quiet, I have to admit that a totally jobless shift like this is kind of painful. A busy shift goes quickly. A shift with nothing to do is fourteen hours in a hospital with… nothing to do. I haven’t even brought a book to read for fear I would be tempting fate (I brought a book last time and ended up not having time for lunch, let alone reading.)

...
I was interrupted from writing the above by my beeping pager. I was about to write that perhaps the difficulty of my earlier overtime shifts was just due to my inexperience, and now that I’ve been working for a few weeks, I’m getting more efficient. As it turns out however, this is not the case.

My day continued to be reasonably quiet until about five o’clock. Then, just when I was about to go and get some dinner (for want of a better word) from the cafeteria, the ward exploded with problems I couldn’t manage.

First, we had a MET call (or an arrest call, for the Americans reading this). Normally when there’s a MET call, by the time I’ve arrived on the scene, a whole lot of senior people are already there and I don’t have to do much. This time, unfortunately, the patient crashed right before my eyes, so I was actually the first person there. Cue deer-in-headlights scenario – I had absolutely no idea what to do. I did have the presence of mind to check the patient’s pulse, which was thankfully beating, and make sure she was breathing, which she was. After that, I didn’t really know what to do, but a clever nurse rushed over and lowered the head of the bed and voila! The patient woke up. By then, every other person carrying an arrest pager had turned up, and I wasn’t asked to do anything else. The patient was carted off to ICU soon afterwards.

Then I had to deal with something an intern covering an unfamiliar ward on a weekend really shouldn’t have to deal with. There was a patient who had apparently been made NFR (not for resuscitation) on the ward. Unfortunately, the meaning of NFR hadn’t been properly explained to the family, and they were demanding to know why her intravenous nutrition had suddenly been stopped. I’d never seen the patient before in my life, so I had no idea – this is the sort of thing the patient’s treating doctor should explain to the family before the weekend. But not only had they not bothered to explain it to the family, they hadn’t even bothered to write it in the patient’s notes! All it said was that the NFR order had been discussed with the patient’s mother and that the patient was not to be intubated or taken to ICU if they were to have a cardiac arrest. There was no mention of the feeding.

After a long and fruitless phone conversation with the on call oncologist, who also didn’t know the patient, I went over to tell the family that unfortunately, the intravenous feeding was not a decision I could make, and that I was unable to contact the treating doctor. I would make sure the patient was getting fluids, and the feeding would have to be reviewed on Monday.

Bad as this was, it was about to get much, much worse. Somewhere in that conversation, I mentioned the acronym “NFR”. Their reaction?

“What do you mean, NFR?”

It turned out that the NFR order had not been discussed with the patient’s mother, as was written in the notes, but with a relative of the patient’s spouse. I can just picture the unconscious assumption being made by the treating doctor:

Observation 1: Patient is Asian.

Observation 2: There is somewhat older woman is also Asian by the bedside.

Observation 3: Older Asian woman visits patient a lot and seems very upset about the patient’s illness.

Conclusion: She must be the mother.

While this relative did indeed care deeply about the patient, she was not the right person to make the NFR decision. She, of course, hadn’t even realised she was making the decision – her understanding was that the NFR thing had just been something they needed to think about and discuss with the rest of the family. Incidentally, the patient herself was quite alert, clever, and perfectly capable of making her own decisions – yet none of this had been discussed with her!

I hope I’ve conveyed the sheer magnitude of the screw-up here. It was huge, huge, HUGE. And by the time I discovered just how big a problem I had, it was nine o’clock on a Saturday evening, making it an even bigger problem.

At this point, I had to bring in the medical officer in charge – the most senior doctor covering the hospital on the weekend. I don’t actually know what he ended up doing, because I had to rush off to deal with some other, smaller catastrophes. He did tell me afterwards that he reversed the NFR order. Come Monday, the treating team are going to have some explaining to do. Luckily, the family seem very reasonable, and they understood before even I did that there’d been a huge misunderstanding. At no point during the evening did they get angry, even though they had every right to be. They just wanted to understand what was going on, and why.

I can really see why they emphasise communication so much during medical school. Screw up communication, and you end up with a huge mess on your hands. Or worse, you leave it for the weekend intern to deal with. Not fair. Not fair at all.

Weeks 7-8: a whole lotta not much

2009-03-15T06:47:39Z

The last two weeks have been freakishly quiet. One by one, we discharged our patients, and no new ones came to take their place. Maybe they heard about my track record with cannulas...

Speaking of which, I have suddenly gone from student to teacher. We now have medical students attached to the team, and they seem to think that I'm good at putting in cannulas. The truth is, I got lucky. The first time they asked me to demonstrate one for them, I had to do it on a slightly overweight lady with extremely difficult veins. When I say "difficult", I mean there were no veins at all visible to the naked eye. With great difficulty, I found one tiny one in the crook of her elbow. Thinking there was no way in hell I would get this cannula in, I nevertheless had to try it (if you ask a senior person to put in a cannula when you haven't even tried, they yell at you and tell you to call them after you've tried. So you have to try.)

Miraculously though, the cannula went in smoothly on my first attempt, with no traumatic poking around for five minutes before I hit the vein, and with virtually no pain for the patient. Seeing this, the students decided I was an expert.

The next cannula was for one of them to try: a fit young man with huge veins who should've been the easiest cannula in the world. The student, however, failed his fist attempt - understandable, give ne'd never done it on a real person before. He wasn't confident to try again, and neither was the other student, so the job was left up to me. The students went off to a lecture while I stayed to put in the cannula - and failed to do it. I tried three times - nada. In the end, I did have to call the resident. But the students didn't see this, and as far as they're concerend, I'm still the expert. I know it's not true, but oddly, the knowledge that somebody thinks I'm good at my job has given me a little boost of confidence which has resulted in me... being better at my job. Maybe it's just the knowledge that I'm no longer the most junior person around.

In other developments, the medical allocations unit seems to have decided that I don't need to have a social life. My last three overtime shifts have been a Friday night, a Saturday (8:30 a.m. - 10:30 p.m.) and another Friday. And I'm on again next Saturday. Saturday shifts are the worst: you can't go out on Friday night because you need to get up early the next day, and you can't go out on Saturday night because you're too buggered after the 14 hour shift. *sigh*

Week 6: The language barrier

2009-03-01T11:52:33Z

Medical lingo sounds like gibberish to most people. As we go through medical school, we quickly get into the habit of talking in acronyms and medical terms, and often forget that this is an acquired skill. Even other doctors might struggle to understand the language of a different specialty. This is a conversation that took place between myself, my consultant (a respiratory physician) and a radiation oncologist:

Consultant: Do you know how long this patient is meant to be having radiotherapy?

Me (flicking through patient’s notes): It doesn’t say. Just says “5 #.” (Pointing to relevant scribble.)

Consultant: Oh. Well, can you call them and find out?

Me (on the phone to radiation oncologist): Hi, I’m the respiratory intern, I’m just wondering how long Mr Patient is meant to be having radiotherapy?

Radiation oncologist (annoyed): What, doesn’t it say in the notes?

Me: No.

Radiation oncologist (really annoyed): Yes it does. I distinctly remember writing “five fractions”.

Me (whispering to consultant): She says “five fractions”.

Consultant: Yeah, but what does that mean?

Me: She didn’t explain.

I was comforted by the fact that the consultant didn’t understand it either! The radiation oncologist, on the other hand, seemed completely oblivious to the fact that someone outside her specialty might not know exactly what is meant by “five fractions”, and more importantly, how long five fractions might take. It turned out to mean five courses of radiotherapy, given over five consecutive days (not counting the weekend). But seriously, how was I supposed to know that?

The rest of my week can only be described as “OMG, AAAARGH!” My team acquired several new patients in addition to a bunch of old ones we hadn’t yet discharged, and suddenly there was so much work I didn’t have time to pee. Tasks piled up one on top of another, and to cap it all off, I had to come in for a fourteen hour shift on Saturday.

The Saturday shift was even more insane than the “OMG, AAARGH!” weekdays. I was only covering two wards – a relatively small patient load for an overtime shift – but those two wards kept me on my feet for pretty much the entire fourteen hours. My two wards were on a different floor to where I usually work, so I didn’t know any of the patients. Plus, my experience so far includes six weeks of respiratory and nothing else, whereas the wards I had were neurology and haematology – two specialties I know very little about. As an example of my incompetence, I freaked out and called the medical registrar because one of the haematology patients had a fever of 39 degrees. It turned out that this was quite normal for someone on chemotherapy. (But then, if it’s normal, why do the nurses keep calling to tell me that all these chemo patients have fevers? What am I supposed to do about it, apart from giving them Panadol, which the nurses were doing already?)

The neurology ward presented a different set of problems. For some reason, about half their patients seemed to have pulled out the cannulas, so I spent a great part of my day sticking needles into people. Then a neurosurgical patient decided to get sick – well, sicker – and I spent the rest of the day dealing with that. I ended up having to ring the neurology consultant on his mobile. Luckily, he turned out to be very nice, and quickly agreed to come and see the patient. He also helped me out with a couple of the other neuro patients, and ended up staying around for a few hours until, we’d found out what was wrong with the really sick one (it turned out to be quite a serious infection – we had to call infectious diseases and put her on some hardcore antibiotics.)

I feel somewhat more competent than I did after my previous overtime shifts. It probably helps that I managed to do all my cannulas without having to call the resident for help, and that I solved all the basic medical problems on my own. I still get a little nervous when ordering a medication without checking with a superior, but it’s what I’m supposed to do. Every time I do it, though, a little voice in my head whispers, “Are you sure you’re allowed to do this?”.

Week 5: Doom and gloom

2009-02-22T01:13:06Z

Monday morning dawned grey and miserable, and quickly got worse. The first thing that happened was that one of our patients died. He was the really sick one for whom I had to get the infectious diseases consult last Friday. His condition progressively worsened over the weekend until he was made "for comfort measures" sometime on Sunday night. When we went to see him on Monday morning, he had already died. I had to certify the death and fill out all the paperwork, which was difficult as we never did find out exactly why he suddenly went downhill. Certyfying death wasn't much fun either. It's a legal requirement, which involves doing a physical examination to make sure the patient really has died. (Take a moment to consider the circumstances that might've led to this particular law being passed.)

The next patient we saw had presented for investigation of a suspicious mass on his X-Ray. Having run a series of investigations over the weekend, our registrar had to inform the patient and his family that he had metastatic cancer (yes, that's every bit as bad as it sounds.)

Our third patient didn't speak English, so we had to communicate by means of his grandson. We weren't completely sure what he had, but we suspected metatstatic cancer as well.

All this happened in the first hour of our ward round. We had just acquired a German medical student, who looked quite horrified at the misery and despair our team had to face. We explained to her that it wasn't usually this depressing! Still, on a day like that it's hard not to become jaded. By the time we got to patient number three, I could only distantly think "Oh, that's sad." I guess you really do have to distance yourself. If I cried over every sad thing I saw, I would never have finished my medical degree.

Anyway, after that start, the week got better. The rest of our patients had manageable things like pneumonias, and a few of them got better and went home. We picked up a patient whom I remembered from my student days (I used him for a case presentation.) The man has a condition which predisposes him to recurrent pneumonia, and he has taught generations of medical students. In fact, being a school teacher himself, he occasionally even finds his own former students coming to him in order to learn how to take a history or perform a respiratory examination. He was one of those wonderful patients who could tell me which of his veins would be the best for inserting a cannula, and quietly tolarated my failed attempt. (I got it on the second try.)

Overall, I did better this week. I only got yelled at by one registrar (urology), and my success rate with bloods and cannulas has greatly improved. The previous week, I managed to stuff up nearly every single cannula I attempted, with the one exception of a young, healthy man with veins the size of garden hoses. This week, I managed to get a cannula into every single person I was asked to do, though admittedly not always on the first try. Hospital, while never a fun place to be, is particularly unpleasant at the start of the year, when a brand new cohort of interns is unleashed on the unfortuante patients.

Week 4: The tool factor

2009-02-15T02:50:37Z

An inescapable part of life as an intern is getting chewed out or even yelled at for things that are quite obviously not your fault. An example of this happened on Friday, when my consultant asked for one of our patients to be reviewed by another specialist. As the intern, it is my job to arrange such consults, which means that even though the decision to get the consult was made by my boss, I'm the one who has to ring the other team and explain why we want them to see our patient. I'm also the one who has to cop an earful if the other team isn't happy about this. The question I dread when making these phone calls is "So, what do you want us to do about it?" because a lot of the time I don't know. The other thing I dread is being asked to get a consult late in the day, because there's a certain unwritten law in the hospital that if you're going to ask for a consult after two o'clock in the afternoon, there'd better be a damn good reason for it.

So, back to Friday. I rang the infectious diseases registrar and explained the problem. And got hit with a double whammy:

"So, what do you want us to do about it?" he growled in an irate tone of voice. And before I could try to explain, he continued: "And I hope you realise that it's very late on a Friday afternoon to be asking for a consult!"

I didn't bother to point out that it was only 1:30 in the afternoon and therefore not technically all that late, because that sort of thing just pisses people off. Instead, I explained that the patient was extremely unwell - he had deteriorated quite unexpectedly, and we couldn't figure out why. We wanted infectious diseases to see if they could suggest an infective cause for the problem and advise us on antibiotic choice.

"Well, if the patient is so unwell, it would've been good to know about him earlier in the week!" he grumbled. "All right, we'll see him." And he hung up. I wonder if he was listening when I told him the patient had been perfectly well until earlier that day?

I don't think anybody has ever actually refused a consult - perhaps they're not allowed to legally. But a lot of them really seem to go out of their way to make me feel like an idiot who's wasting their valuable time. And that is extremely unfair because if they stopped to think about it for even a moment, they'd realise that an intern is never responsible for demanding a consult. It is quite simply not my fault. If I'm ringing them at 1:30 on a Friday afternoon - or even 4:30 on a Friday afternoon - it's because my boss decided it was necessary. If they really want to tell someone off, they should be yelling at my consultant. But of course that'll never happen.

I whinged about the incident to another intern, and she had an interesting take on it. "Don't take it personally," she said. "My ex used to work for infectious diseases, and they're only pissed off because they're really, really busy. They get so many consults it's impossible to keep up, so they're really stressed out. I think the stress just brings out their inner tool*. Of course, it all depends on how much of a tool they were to begin with - their baseline tool-ness, so to speak - but basically, if they were only a little bit of a tool when they started working, a day in infectious diseases will turn them into a massive tool."

Oddly enough, that made me feel better. Of course I knew it wasn't personal, but it's good to be reminded that just because somebody is yelling at you doesn't mean they think it's your fault. It also made me wonder what my baseline tool level is, and how much of a bitch I might turn into if I start getting harassed all day by interns stammering out consult requests. Something to watch for, anyway...

* Tool: In this context, the word "tool" is used to denote a meaning similar to "wanker" or "dickhead". However, if Urban Dictionary is anything to go by, the correct meaning of the word "tool", when referring to a person (as in, the whole person, not just their manly bits) is "Someone who is easily swayed or derailed from ones own opinion or true feelings by perceived outside influences. " It seems that I have been using it incorrectly all this time. The shame!

Week 3: The sweet face of extra work

2009-02-08T08:18:22Z

The sleep registrar is a sweet, friendly young man who always asks me how my day is going. He's kind and pleasant to talk to. (He's also married, so don't get any ideas.) But he's a nice person to have around, and has the sort of open, friendly face that people tend to instinctively trust.

Unfortunately, he also has an amazing talent for adding to my workload at unexpected moments - and I suspect his all-round niceness has a lot to do with it.

You see, the sleep doctors are part of respiratory medicine, but they don't have an entourage of minions like the respiratory doctors. All they have is the consultant and the oh-so-nice registrar. So when they need an intern to do the gruntwork for them, they borrow one from respiratory. And I seem to have drawn the short straw.

So I'll be sitting on the ward, happily working through my list of jobs, thinking I'm on top if things and just as soon as I've finished this medication chart, I can go and grab a coffee. Suddenly, up pops the lovely sleep reg.

"Oh hi, Maladict! How are you going? Been busy?"

"Not really, just getting things done, how are you?"

"Yeah, great. Listen, if you get a spare moment, do you mind admitting this new sleep patient? She's coming in for a couple of days, I just need someone to do the paperwork..."

Or:

"Hi Maladict! Hey, when you get a moment, can you go and do a cannula for Mrs Smith? And while you're at it, can you also get her a gastro consult? She's been complaining of stomach pains..."

Or:

"Hey, I hope you're not too busy. Do you mind writing a discharge summary for Mr Bloggs? And can you go and chack on Mrs Smith? I need to go to clinic..."

The trouble is, he strats conversations in such a friendly way, that I somehow never expect him to ask me to do something. I think he's just making chit-chat. And before I know it, I have a whole lot of extra tasks on my list - and they're all dull, time-consuming tasks like filling out admission paperwork or writing a discharge summary for a patient I've never met. The joys of being an intern...

Week 2: Whingy McWhingypants

2009-02-01T10:55:11Z

I seem to have developed a certain nervous habit. It’s a sort of manic grin, which has been appearing on my face with increasing frequency over the past week. The grin is wide, but doesn’t touch the eyes, which remain wide open and staring, while the teeth are clenched firmly together. It is a rather scary looking grin, and with good reason. The grin means one of three things:

1) I am about to strangle somebody.

2) I am about to flush my pager down the toilet.

3) The next person who pages me will be force-fed my pager and then strangled.

Murderous impulses are not good traits in a doctor, so you’ll all be relieved to know they are usually directed at inanimate objects (such as my pager) or a people I have no direct personal contact with, such as the creators of the Guardianship Tribunal forms I was forced to fill out in order to get permission to treat a patient with morphine. It probably didn’t help that the patient had already been on morphine for about a week before the forms were procured, or that it would’ve been extremely negligent to withhold the morphine until permission was granted, since the patient was in a great deal of pain even with the morphine, or that the patient’s public guardian then called me back and demanded to know why I hadn’t obtained permission for the dozen or so other medications we were giving the patient, even though he’d been on those long before he had come to hospital and would probably die very quickly if they were stopped.

Only once was my irritation actually directed at a patient, but before anyone thinks I shouldn’t be getting angry at people under my care, you should know that the guy was by no means helpless. In a hospital full of frail elderly, this thirty-something truckie who can probably open beer bottles with his teeth, and had nothing physically wrong with him except a bit of tonsillitis, turned out to be the most high-maintanence patient I have ever had to deal with outside a paediatrics ward. He bitched and complained about everything. To listen to him, you would think he was dying, and we certainly spared no expense in doing investigations to rule out the possibility. Everything came back clear, yet Whingy McWhingypants continued whingeing and moaning every time somebody came at him with a stethoscope. Five minutes before I was due to go home on Wednesday, I got called down to radiology, where apparently my patient was feeling unwell. “Oh, Doc, my chest really hurts! I can’t breathe!”

Having ruled out a heart attack, asthma attack, pneumothorax, pulmonary embolism and broken ribs, I was just talking to him while we waited for a porter to wheel his bed back up to the ward. After five minutes, however (five minutes during which he completely failed to stop breathing, and talked quite comfortably in fairly long sentences), he decided he was tired of waiting, jumped out of bed, and proceeded to push his own bed back to the ward. Once back on the ward, he again said he couldn’t breathe. I refused to give him the oxygen mask until I’d measured his oxygen saturation, which, lo and behold, turned out to be 97% (about as good as any of us can expect after pushing a bed around). I told him he could breathe perfectly well on his own and sat down to record the incident in his notes. I also called the evening intern and let her know what had happened – just in case there really was something seriously wrong with the guy and I was just too dumb to figure out what it was.

When I finally left the hospital, I saw Whingy McWhingypants standing outside and smoking a cigarette.

Unsurprisingly, nothing happened to him overnight. Yet he kept whingeing, forcing us to send him for more and more scans. By Friday, he seemed completely well, yet the whingeing continued, leaving us absolutely no choice: we called in a psych consult. I’ll be curious to see the outcome of that tomorrow. (The best possible outcome being that he's been discharged and the weekend staff wrote his dicharge summary. I suspect that's just wishful thinking though.)

Week 1

2009-01-26T01:43:18Z

About ten minutes into my first shift as an intern, I received my first insult. A patient’s wife caught up with the team at the nurse’s station. “Are you the doctors looking after my husband?” she demanded. “He said you looked about fifteen.”

That first day was… messy. My medical knowledge – what little of it there is – never came into play. Instead, I was kept busy trying to figure out how to order bloods or X-rays, how to request a consultation, how to write out a medication chart. Everything has a correct procedure or protocol, but nobody really teaches you that stuff (and it’s different at every hospital, anyway.)

The second day was better. It still took me over an hour to collect a single tube of blood from one of our patients, but that was the only difficult procedure I had to do that day. And I did the procedure just fine – my first set of bloods as an intern came good on the first stab – but it had taken me half an hour beforehand to find all the necessary equipment. You’d think they would keep it all in the one cupboard, but that’s just far too simple for a teaching hospital. And then, once I had the tube in my hand, it took me another half hour to figure out just what the hell I was supposed to do with it. I won’t bore you with the details of all the admin involved in sending off a set of bloods outside of regular blood collection times, but I will say this: the software that you’re supposed to use for the task was clearly designed by the Antichrist. Or a blind IT professional with Asperger’s Syndrome, you choose. Either way, I have never seen a pile of megabytes that is quite so likely to reduce calm, rational human beings to gibbering, monitor-hurling lunatics. In fact, I’m going to go with the Antichrist theory and suggest that Satan also had a hand in making sure that the doctor’s offices at my hospital are small, windowless spaces that always seem to have fewer chairs than doctors, and fewer computers than chairs. And ever fewer phones that computers – a very annoying feature in an institution that relies on a paging system.

Nevertheless, by Wednesday, we had settled into a routine. First thing in the morning, we do a ward round and see all our patients. As we see each patient, the registrar – or the consultant, if he or she happens to be present – comes up with a list of things that need to be done for that patient. These may be things like “Change their medication from such and such to such and such”, “Do investigation X” or, hopefully for the patient, “Discharge them”. After the ward round, the minions – that’s interns and residents – sit down in the small, windowless doctor’s office with not enough chairs, and divide up the tasks. We generally don’t do investigations ourselves – an X-ray, for example, will be done by a radiographer, but we do need to order it using that Satan-designed software. Blood tests which aren’t urgent can be ordered for the next morning, in which case they will be taken by special blood-collecting nurses. However, the vampire brigade only comes once a day, so if we want the bloods urgently, we have to take them ourselves and send them to the lab via a prehistoric chute mechanism.

Perhaps the unusually small number of patients lulled us into a false sense of security, or perhaps this sort of thing always happens on Fridays, but on the last day of my first week everything just seemed to fall apart. A patient we’d been hoping to discharge suddenly went downhill. Two new patients were admitted, both requiring complex investigations we didn’t know how to order. Another patient did get discharged, but he required a dreadfully complicated discharge summary and instructions outlining the changes that had been made to his twenty or so medications. Since I had absolutely nothing to do with any of those medication changes, I was left to decipher the correct instructions from his notes – most of which had been written in the illegible scripts of various busy doctors. To make things even more difficult, the patient didn’t understand why we were discharging him when he was still so short of breath, and I had to try and explain to him that due to his chronic emphysema, his breathing would not be getting any better than it already was. I’m not sure how much he understood, since he didn’t really speak English. I have a sneaking suspicion that we’ll see him again before the next week is out. In fact, I won’t be surprised if he’s back on our list when I come back after the weekend.

Neverthless, I have survived my first week, and now have a long weekend to enjoy. I hope next week runs more smoothly. I also hope I'll be more useful on overtime shifts (my single evening shift this last week involved me repeatedly paging the resident to tell him I had yet again failed to get a set of bloods from a patient.)

Also, only three days until my first pay day!

Week 0

2009-01-18T01:02:58Z

The first week of internship was clearly designed to lull us into a false sense of security. In fact, it felt just like med school, where every new term requires at least one day of tedious lectures on waste management and fire safety. Only in this case, it was four days, and we couldn’t leave when we got bored because we were getting paid. Don’t get me wrong, getting paid is a huge bonus which I’ve been looking forward to for seven years. But I won’t see the money for another two weeks, while the orientation lectures were at the same time mind-numbingly boring, and hideously uncomfortable due to the heat (punctuated by occasional periods of extreme cold when the air conditioning kicked in.)

On Thursday, we had to do the Myers-Briggs personality test. Well, they try to call it a “type indicator” instead of “personality test”, but we all know it’s just their way of weeding out potential serial killers. My type turned out to be “ENFP”, which is described as follows:

Warmly enthusiastic and imaginative. See life as full of possibilities. Make connections between events and information very quickly, and confidently proceed based on the patterns they see. Want a lot of affirmation from others, and readily give appreciation and support. Spontaneous and flexible, often rely on their ability to improvise and their verbal fluency.

All of which is a nice way of saying I’m a chatterbox who needs a lot of attention and tends to jump to conclusions. It was a fun exercise though – a sort of higher class of Cosmo quiz. After we’d all worked out our types, we were split up into groups according to certain characteristics and did a few exercises to demonstrate the differences. When they split us up according to whether we were “introverts” or “extroverts” (the “E” in my four-letter code), we were asked to come up with some questions to ask the other group, which might help us to work with people of a different personality style to our own. One of the girls in the Extrovert group asked, “Why do Introverts hesitate to speak up in group situations?”

Before any of the Introverts could formulate an answer, a boy on the Extrovert side yelled out, “Because we jump in!”

Friday was a day to get acquainted with the team we’ll be working on for the next ten weeks. My first term is respiratory medicine, which is a good one to have in summer since there won’t be that many people with pneumonia. The ward is on the eighth floor of the hospital, so I’ll be getting plenty of exercise this term (the lifts at my hospital are too slow to even consider using unless you have a bed or wheelchair in tow.) I find it vaguely amusing that the second-highest floor of the hospital houses the respiratory ward (for people who can’t breathe) and the orthopedic ward (for people who can’t walk).

My team only had four patients, two of whom were only in hospital because they were waiting for bed in a rehab* unit. As a result, I spent the afternoon watching tennis in the RMO* lounge.

The week ended with a loud and very alcoholic RMO party in the city. Unfortunately, as usually happens at these events, the only thing anyone seemed to want to talk about is work. After two hours of “So, how was your first day on the wards?” conversations, I started openly asking people to tell me something about themselves that had nothing to do with medicine. I was just getting into a discussion of the relative merits of live versus recorded music with a tall intern I had just met, when a UNSW* intern, less tall but much more drunk, decided to join us. When I asked him what he was into outside of Medicine, he said “Ummm… Learning a lot about Medicine.” At this point, Tall Intern excused himself so he could go get a drink, leaving me alone with Drunk Intern. Drunk Intern turned out to have very limited understanding of the concept of “personal space”, though I suppose if I were being charitable I could attribute his behaviour to the level of noise in the bar. At any rate, as we talked, he kept moving uncomfortably close to me. I kept moving back to keep a bit of space between us. We’d only just met, after all, and we’ll have to work together for the next two years. Unfortunately, Tall Intern and I had struck up our conversation while standing next to a me-sized gap between two tables, so as I moved away from Drunk Intern, I found myself getting wedged deeper and deeper into the gap, until I came up against a wall behind me. At this point, with tables on either side, wall behind and Drunk Intern in front of me, I decided I needed to get a drink as well. I’m sure Drunk Intern is a very nice person (and he certainly seems to know a lot of medicine), but next time I talk to him I’ll make sure I’m somewhere less noisy.

I caught the bus home, after walking what seemed like several miles in my new high heels (ow, ow, ow!!!) When I got off the bus, I realized I had probably had a few too many drinks to be driving home from the bus stop. Luckily, I’d left a pair of sneakers in my car just in case this happened, so I gladly removed the heels, locked the car and walked home. It was a forty-minute walk, and I kept hoping against hope that I’d see a taxi come past. And they did, three times, but none of them stopped. It was a well-lit road, so I’m sure they must’ve seen me, but perhaps they decided that a girl walking by herself in the middle of the night, wearing a nice dress and Converse sneakers was trouble waiting to happen. So I walked all the way home.

To my great misfortune, when I got there, my parents turned out to be awake, and when I explained why I’d come home without the car, they lectured me on excessive drinking. Honestly, you’d think they’d be relieved that I had the good sense not to get behind the wheel.

I really need to move out..

* For a list of acronyms, abbreviations and other potentially confusing terms, see my profile.

It begins

2009-01-09T04:51:46Z

...Well, not quite yet. I have just one weekend left as a student. I suppose I should be terrified, but actually I'm just a little bit bored. After seven years of uni, it's hard not to think about the prospect of finally earning an income. The fact that I'll be earning that income by being a doctor seems a lot more interesting to friends and family members than it does to me. That's because friends and family members don't know the sad truth: the job of an intern is actually glorified admin. And no matter how often I try to tell them that actually, most of what I'll be doing will be paperwork, they insist on giving me the incredulous "Oh, as if you expect us to believe that!" look. TV has a lot to answer for.