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Days in the life of a New Intern

Discussion in 'Postgraduate Forum' started by Benjamin, Jan 23, 2017.

  1. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    The following thread is a thread where I'll be posting things throughout the year and others are welcome to post as well with their intern experiences or questions directly to interns currently working through the year. It's main purpose is to give everyone who isn't currently an intern an idea what it's like from the very first day through until we finally get signed off for general registration.

    I will be trying my best to keep this updated but likely will lapse a few times over the year. Similarly, I will have some trouble with confidentiality (it's not that hard to find out who I am!) but I'd really appreciate it if people didn't actively mention the hospital I'm at/ask me about specific patients etc as I really won't be able to answer and might have to edit your posts.

    Day 1
    Today I started as a fresh intern in the ED. I chose to start with ED as my first term and this morning during my drive to work I certainly questioned that a few times - I've been told that ED is one of the few places in internship where you have a bit of autonomy/can take leadership with your cases a bit more.. of course this means you have to sort of know where your cases are going.

    After 6 years of medical school and a week of boring administration & introduction lectures I felt entirely unprepared to start managing my own patients. This is something that gets brought up a lot by interns, registrars and consultants when they move up the food-chain, that feeling of being an imposter and like you don't know anything. I was always a perhaps slightly over-confident medical student and yet this morning I felt like I was literally about to walk into a 10 hour long OSCE station that I couldn't possibly have prepared enough for.

    I spent my day seeing predominantly chest pains, which is really no surprise to anyone who has been in an ED. My first prescription was for some "more fentanyl" in a middle aged man with 8/10 chest pain who had already had 250microg of Fentanyl and looked like that 250microg had never actually made it into the cannula. Unfortunately that fentanyl had made it through and the extra fentanyl + GTN I charted really didn't do anything either, and so within <10 minutes of starting my shift I found myself standing in front of my consultant saying "I have no idea what to do about this man's pain". Thankfully consultants are pretty good at knowing what to do most of the time and my consultants seem to be particularly happy to help out a struggling intern.

    Most of the chest pains I saw today weren't serious, most were costochondritis/muscular or reflux related. One was very serious and the speed they made it through the system impressed me a lot. Another patient made me quite sad - carer stress/fatigue and the resulting complications (sepsis + rhabdomyolysis) is not something I've figured out how to cope with yet; most of the time I just feel bad for everyone involved.

    Before today I certainly felt like it wasn't my place to talk about acute resuscitation plans with family but that's where I ended up - somewhere between graduating medical school and now that became an appropriate thing for me to be directly involved in. Overall that's how most of the day felt, like somewhere between graduating and now I was suddenly allowed and expected to do a lot of things that I knew about, had seen, had been involved in but had never actually had direct responsibility for.

    It feels a lot different from medical school but I like the team, I like the medicine and I like the work.
     
  2. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    Nights & Research - Two Weeks in

    This last week I've worked entirely night shifts, running from 10pm - 8am. I've always been someone that stays up fairly late and only sleeps for short periods, so I always thought that nights wouldn't be that big of a task. I was wrong. The entire process is completely different, my night shifts follow on from a run of day shifts so I had to completely invert my sleep cycle over the course of 1 day in order to be functional. Similarly, I finished work on Monday morning (after Sunday night) and start again on Wednesday morning - regardless of how you work it you end up losing the Monday and only having 1 day off between weeks.

    I managed to make it through nights with what can only be described as copious amounts of coffee, more food than I thought I could eat, the lighting being perpetually midday in ED & a little bit of fear/excitement. Overnight in the ED there are two registrars, three residents (not including paeds) and me + a tonne of nurses. Sure, every major decision is still run by the Registrar if possible but there's more chance that you won't be able to - i.e. if you've started working up a 85 year old patient with a fractured neck of femur + ?subdural haematoma with fluctating level of consciousness while the Registrars are both busy in a resus dealing with a difficult airway. It also really makes you wonder what would happen if the ?abdominal aortic aneurysm vs ?aortic dissection that you're taking to CT at 4am actually ruptured or dissected - there isn't really anyone else right there in CT other than you, a nurse and the radiographer.

    I struggled with a few patients this week and I think over-investigated others. Some I struggled with because they had problems that I didn't know much about, a few because they were Nepali non-english speaking people and no translator was available and others that were patients that we outright couldn't figure out. These last set of patients had been investigated to our limits and really didn't have anything to go on as to why they had pain, why they were septic or in one case why a normally healthy patient suddenly a hypokalemia of 1.8 (still don't know, they're in ICU). A lot of them ended up being bad referrals to the medics or surgeons.. Overall I felt like a lot of things I did this week could have been done better, but I guess that's the point of internship.

    The most important thing I recognised in this last week was that tiredness really, really impacts how well you think and act. It wasn't until I got confused trying to eat my breakfast following my last night shift that I began to wonder how I was suturing up a large hand laceration earlier that night or even how I managed to drive home safely. The latter is something that I think I'm going to reassess, maybe a taxi home on the last night is a better option than driving myself.

    I've also managed to get back involved in a bit of research during my days off and will probably write up a post on it later - we've been using doppler ultrasound to measure diastolic/systolic function of mice following Irukandji & Chironex Fleckeri envenomation (jellyfish in FNQ). It's been a great experience so far and we've got some great data that hasn't ever been recorded before & helps explain a lot of the significant human case studies following envenomation - i.e. heart failure in healthy, young adults stung off the reef. If I get the time I'll write up a post on my thoughts about research during medical school, how I feel about the honours system and how I approached it throughout my time as a student.
     
  3. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    The Whirlwind of Fatigue & Uncertainty - Third Week

    The roster for ED as in intern where I am is generally fairly comfortable, we tend to work four 10hr shifts on & three shifts off. Somewhere in your term you'll be given a 6 day stint off, which is fantastic & most people use it for a mini-holiday. For this last week that comfortable, easy roster was replaced instead by 8 consecutive days of work.

    For most seasoned professionals that's probably not that hard to cope with; I am unfortunately not a seasoned professional. At the start of the week I was happily finishing work at 1730hrs & heading home to enjoy the evening but somewhere amongst that week I failed to get to sleep at 11PM and instead found myself laying awake at 3AM waiting to go to work at 7. It wasn't insomnia or stress or an existential crisis - just a mistimed coffee that I drank out of ritual more than need. That mistake cost me over the remaining 4 days of work.

    At the time I didn't think much of it, I've worked tired before in jobs that were much more physically demanding and managed okay. In hindsight it's pretty clear that while I still got the job done there were things that could have been managed better and I picked a few fights I probably shouldn't have - the nurse that I argued with about taking blood cultures as an initial draw from an IV cannula (NOT OKAY!) probably didn't need to be told that at the bedside while they were doing it, I was going to take two sets myself anyway and as long as I marked their's as from the IVC it's fine; if I'd been less blunt with the nurse that wasn't putting up fluids when I asked maybe it wouldn't have escalated to where it did; if I hadn't been relying on my stress response to get through the day I might have been able to mute my facial expression a bit more after the radiographer said they were going home instead of doing the urgent ultrasound for ?rupturing ectopic and not gotten them slightly offside for the future. Thankfully I don't think I made any clinical errors that significantly impacted patient care, I'm far too supervised by seniors for that to happen unnoticed. Hopefully my social errors in this last week can be forgiven and not carried around, but politics & relationships in hospitals seem to be strange beasts.

    Despite the fatigue and my inability to maintain the calm, collected demeanour that I am expected to have I still had a pretty enjoyable week. A lot of the cases I saw this week were good reminders that being cautious in the emergency department and getting patients to the right place is my main job as an intern. I saw (and got to the right place) a 60 year old completely well man with appendicitis secondary to a carcinoid tumour, I appropriately diagnosed a posterior circulation cerebrovascular event because I'd been studying it (and the HiNTs exam) literally the day before, I also recognised I was completely out of my depth trying to figure out why an old lady was incredibly itchy with some mildly deranged LFT's and got the medical team to come see her despite her being otherwise well (she ended up having lymphoma). I also saw a lot of complications from chemotherapy & palliative stage cancer, most importantly I had more than a few discussions about end-of-life care with these patients and made sure their wishes were completely documented.

    I think it's fairly easy to get overwhelmed in the Emergency Department as an intern if you lose focus on your own work. It's easy to hold onto a case that didn't go so well, easy to misinterpet how people are reacting to what you're asking of them and easy to forget that everyone is there because it's their job and not necessarily their life calling. Things I learned this week: the nurse who hasn't put up the fluids you asked for might be drowning in work, ask how you can help or do it yourself instead of adding more to their plate; the radiographer who is going home on time instead of staying late to do your urgent case is completely right to do so if that's what they want to do, we have on-call for a reason; being cautious and excluding life-threatening diagnoses is just as important as finding the right diagnosis. Thankfully I have a lot of very understanding and very supportive friends, residents, registrars and consultants who always seem happy to talk through anything & everything.

    P.S. In the future these posts will be cross-posted to our wordpress site which means I can add a few pictures and format things a little more nicely. When that happens I might directly post them there and only leave a link here - not sure yet!
    For example, the first of these posts can be found here: Day 1 in the ED |
    And the second here: Nights & Research – Two Weeks in |
     
    Last edited: Feb 16, 2017
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  4. ashy

    ashy Boo. Moderator

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    Great blog Ben - so much nostalgia haha. Remember that nurses can make or break your term so try and be as respectful as possible! Some of the senior nurses in ED and certain subspecialties have clinical instinct far greater than most registrars that only years on the job can bring about. I've found in all of my ED terms so far that my supervisors make a note to speak to the NUMs and senior nurses about all the juniors prior to giving feedback - chances are you'll work a handful of shifts with your term supervisor due to the number of bosses and rostering/etc so they can find out a lot about you from the nursing staff.

    PS - the literature on taking blood cultures from the first draw of a newly inserted IVC vs a peripheral stab is controversial. There was a large study published in the JAMA 10 years ago that seemed to show slightly increased rates of contamination but recent studies have shown conflicting opinions. This paper (Taking blood cultures from a newly established intravenous catheter in the emergency department does not increase the rate of contaminated blood cultures) was done in a large local department and is a decent read. In Paedsland we pretty much only take cultures from the initial draw after cannulation unless we want to see sterilisation of a positive BC or there's suspicion of IE as a diagnosis (even in this case if the IVC being inserted is a new one the blood culture would still be taken from the first draw).
     
  5. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    Great to see you back, @ashy!

    Absolutely agree, the majority of the nurses are absolutely fantastic. Unfortunately there are some situations that I feel are regularly prioritized incorrectly (as per my experience + colleagues) - e.g. writing notes instead of giving the patient with severe abdominal pain the morphine that was charted 5 minutes ago & I'm waiting for so I can adequately examine the patient. It's very difficult to approach these situations tactfully and I haven't really found a good way to deal with it yet. I'm also a big fan of closed-communication loops because I think that's where a lot of errors come about in stressful situations (i.e. asking for something to be done, failing to confirm it was done & making assessments based on the assumption that it was done) which unfortunately can come across like I don't trust people if they're not aware of why I'm asking/confirming. I suspect these are things that I will eventually get better at dealing with as I get more experience or perhaps as I get more insight I'll realise that what I think now was totally incorrect.

    Agreed that the literature overall is controversial and there's no clear overarching opinion that functions for all hospitals. I think it likely relies largely on how good your aspectic technique is rather than the device used; a butterfly without aseptic technique is almost definitely going to be worse than a cannula with aspectic technique. It certainly is possible to get blood cultures with aspectic technique through a cannula but this is in direct contrast to the technique I see used in our ED. I personally find it more technically difficult to stay 100% aseptic with a cannula vs butterfly for cultures.

    Locally our Infectious Diseases department has reported drastically higher contamination rates from cannula initial draws in the ED.. somewhere around the 15-20% mark rather than the accepted <3% standard. It also logically makes sense to me that using a butterfly system carries less contamination risk than a cannula - with a butterfly all I have to do is hit the vein and attach the transfer device to the culture bottles, with a cannula I need to hit the vein, advance the catheter, remove the needle & dispose of the sharp, attach a syringe & withdraw blood, remove the syringe, attach either a transfer device or a needle & then innoculate the culture. There are far more opportunities (in my opinion) for contamination with a cannula than the butterfly. On top of that my goal when I'm putting a cannula in a septic patient isn't to keep things 100% sterile/aseptic so that my cultures are perfect, its to get a line in so I can give them Abx and fluids and if I have to re-palpate the vein during cannulation to achieve that then I'm going to. On that note, I've never seen any data on it but it would be interesting to see whether inexperienced operators with cannulas (i.e. intern vs reg vs nurse) have different contamination rates.

    Certainly in someone who is a difficult stab and needs cultures I'm going to grab cultures from the initial cannula draw but I'll still go searching afterwards for at least 1 other set from a peripheral venepuncture, if I can get it before the antibiotics start running then that's great and if I can't at least I have the cannula culture. If they aren't a difficult stab there really isn't any good reason not to try to reduce contamination as much as possible unless you're really pressed for time/resources/children that you really don't want to make needle-averse. A positive blood culture creates a lot of work for a lot of people throughout the hospital & generally means the patient gets some serious Abx thrown at them until its proven that its a contaminant.
     
  6. Gabby

    Gabby Member

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    Waiting for the next instalment. Its like waiting for the next season of your favourite tv show.
     
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  7. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    Days in the Life of a New Intern - Week 8? I'm not even sure anymore!

    Firstly, my apologies for not maintaining the week-by-week blog, things got a bit busy my end and this was the first thing to get put to the side!

    A quick run-down of my last 3-4 weeks:
    • I worked mostly evenings - they suck, more on this later.
    • I at least know sort of how to approach situations now, though I still don't know what I'm doing most of the time.
    • I haven't missed a cannula in a while (will update tomorrow after shift.)
    • I've seen some great acute medicine & the system working as it should
    • I've seen some dreadfully monotonous medicine and had entire shifts of "why are you here?!"
    • Having money/a steady income is brilliant and a welcome change from the impoverished years of medical school
    • I found out that my first term has been an absolute breeze compared to some of my colleagues in other hospitals.
    I might not get to addressing all of the above points but I'll try cover the interesting ones. I haven't really had much "free" time these last few weeks - I worked 8 days on, went for a holiday to see my friends on the Coast for 4 days and then worked another 8 days on. Almost all of these shifts have been "evening" shifts - i.e. 1pm-11pm shifts. These sound great in theory: "I've got the whole morning to myself, if I just get up early then everything will be great!" but in practice they suck. Getting to sleep immediately after a shift is impossible, so instead I wake up at ~9am and my entire house/the people I care about are away. I get home at 1130pm and everyone is asleep - I didn't see my partner in daytime hours other than at work for close on 2 weeks. I would prefer to work nights over evening shifts, at least with nights I can get up 'early' for dinner or stay up 'late' for breakfast and actually see people. I've heard very similar complaints from my colleagues who have also struggled with the lack of routine on ED.

    In saying all that I really have it easy compared to some of my friends. While visiting on the Coast I found that one of them was working 13 days on-1 off with around ~10 hours/day. The surgical team he is on deals almost entirely in very sick, old patients and so the ward has ~1-2 MET calls/day. I honestly don't know how this is possible and he looked utterly shattered, his only solace being that at least he's being paid the overtime he's working & that the term ends in 2 weeks. I'm not entirely sure what I'll do if I get a term similar to this.

    On a similar topic from previous posts I still haven't entirely figured out how to manage certain nurses in the ED. There are two in particular that I actively avoid or simply do all the work myself because I know that if I don't it won't happen in a timely manner. This has gotten me a reputation, apparently, for being the intern that "does all their own bloods, observations, ECG's & urgent catheters". I'm not sure if that's a good or bad thing, but it certainly slows my day down when I have to do nursing jobs on top of my own. The term 'urgent catheter' got me in a little trouble the other day when one of the two nurses tried to tell me off for asking it to be prioritised above what they were currently doing for the middle aged man with a firm, tender ++++large mass in his abdomen that didn't move with respiration, was dull to percuss & had arisen in the last 2 days... the catheter I eventually put in myself drained 2.4L of urine from his obstructed bladder. Similarly, the lady who had been discharged from ICU 2 days prior for acute renal failure and was re-attending because she "hadn't urinated in 24 hours" didn't need to wait on her bloods to confirm she was again in renal failure when the catheter didn't drain more than 5mL of very concentrated urine. Sometime's its hard to communicate that things are urgent when normally they are a lot lower down on the priority list.

    Throughout this blog I've tended to bring up the negative side of things a bit more than the positive side, it's likely because those are the things that stick with me when I'm writing these posts at 2AM. I guess I'm saying maybe I should talk a bit about the good side of things. In the last week I've seen the system in ED work exactly as it should with very good outcomes - I've called the consultant cardiologist about a young gentleman with Wellen's waves who made it from door-to-needle for PCI in <10 minutes, I've picked up a patient from triage with sudden onset, dense left hemiplegia who made it through CT and to a consultant neurologist review in less than 30 minutes, I've put in a femoral block (with assistance) that relieved the pain of a man with a mid-shaft femoral fracture, I've re-assured countless terrified patients that they're in the right place, that we're doing all the right things & that they're going to be okay, & perhaps most importantly I've really enjoyed myself and made a lot of friends. I also can't emphasise just how nice it is to have a regular pay-check every fortnight.

    I finish ED in 2 weeks and follow it with 5 weeks of holidays, 5 weeks of Orthopaedics, 10 weeks of General Surgery, 10 weeks of Medicine & then 12 weeks of Mental Health. It feels like these first 8 weeks have absolutely flown by - I'm only just starting to get comfortable with my expectations and now suddenly I'm preparing to move onto another job in the hospital. I'm not sure how I feel about ED entirely, I think I love it but I really be certain without trying other things out first. Hopefully a few weeks on surgical terms will give me a good idea of what I want to chase next year and where I want to apply - yes, of course they want us to apply for 2018 jobs + rotations before the middle of the year!

    As always, thanks for reading and I'll update again as soon as I can.
     
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  8. Gabby

    Gabby Member

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    Any more installments?
     
  9. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    On holidays in Asia currently, return to work in about a week in Orthopaedics so there'll be more to follow shortly!
     
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  10. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    Holidays and Orthopaedics

    Read the whole post here: Holidays & Orthopaedics |

    Today was a little bit rough - I'm on orthopaedics and our team is essentially 3 trauma consultants who have been on take (i.e. taking all ortho admissions in the hospital) for the last 12 days straight. Our ward round is around 30 patients with around 6-8 discharges a day. Of those 30 patients around 1/3 of them are serious traumas that have needed an ICU stay, another 1/3 are crumbly old patients with neck of femur fractures & multiple medical problems. These patients obviously require a fair bit of attention and the workload has been compounded by a few unfortunate complications in our otherwise 'simple' patients.

    One of those unfortunate complications happened in a young (20-30y.o.) patient who had an infection in their hand. This infection needed a fairly strong antibiotic because of resistance to the standard stuff - they were given a mixture of Piperacillin/Tazocin + Vancomycin and suddenly (without warning!) developed acute renal failure over the course of 24 hours. They went from eGFR >90 w/ normal creatinine to eGFR 11 & creatinine 1100 overnight + vancomycin levels 5 times normal limits and are an otherwise completely healthy patient that hasn't had any medical issues before this... they're now on dialysis because of their acute renal failure + underwent renal biopsies & with are now faced with at the best dialysis for the next week and at the worst non-recovery of their kidneys & permanent dialysis while awaiting a transplant.

    It's fairly tough seeing someone come in for a simple hand infection and having to tell them that their kidneys have stopped working, that they need to be in hospital for the next week at least & that their kidneys might not recover. I still haven't really figured out what to do when someone starts crying in front of me, my standard response is to grab the tissues & try to stay emotionally stable but it's a bit hard when you can imagine yourself being that exact patient.

    My day-to-day job which is shared with 2 other residents is basically as follows:
    - Arrive at 0600hrs, check every patients bloods + XRAYS/imaging + observations + nursing notes + other team reviews. Combine all of this information into a single list by 0700hrs for the team.
    - Registrar arrives at 0700hrs, ward round with all the patients from 0700-0730.
    - Morning meeting w/ all orthopaedic medical staff incl. all consultants + ortho regs to discuss overnight admissions + consults from 0730-0830hrs.
    - Multidisciplinary meeting w/ nursing + physio + occupational therapy + social workers from 0830-0900
    - 0900 - 1500hrs: manage all ward jobs, sort all discharges, get to pre-admission/fracture/consultant clinics/deal with consults/contact other teams/sort radiology on new admissions & post-op XR's/constantly discuss with nursing TL to ensure all jobs are being done
    - 1500-evening: supposed to be heading home, instead sort all the deteriorating patients on the ward and invariably refer a few to ICU for review. Call ward call to let them know about the patients that are going to deteriorate overnight.

    On the plus side my bosses are incredibly approachable and always happy to be at the other end of the phone. Most of the time they make specific requests to be called if a patient deteriorates & always seem to back up nursing and junior staff if any issues arise. It's nice to have their support but also a massive change from ED - in the emergency department I could get a consultant review immediately if I was concerned, it felt a lot more supported & a lot less like I had to rely on purely my medical decisions. In orthopaedics most of the medical choices are made by myself & the other two residents, it's only distinct issues that get run by registrars/consultants of other teams.

    This is all a fairly abrupt shift compared to previously being on holidays for 5 weeks. I did the standard South-East Asia trip through Thailand, Vietnam & Cambodia. It was a little bit different than I expected but absolutely stunning & I spent the majority of my free time getting underwater to dive & eating as much ridiculous food as possible.

    Weekly posts (at the least!) should start again after this!
     
    Last edited: May 12, 2017
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  11. amirbang

    amirbang UNE BMED III

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    WE NEED MORE PLEASE KEEP GOING!!!
     
  12. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    Re: We need more please keep going!!

    Once again, my apologies for not keeping things updated since the last post. I really tried to but things got far busier than I could manage from my side and this was one of the first things to be put aside in exchange for more sleep. I've also been hesitant to post some things publicly as they were a little 'emotionally-charged' and I wasn't entirely sure how I would write them without potentially digging myself into a very large hole. It's been a bit of time now, however, and I think I can give it a shot.

    I really don't like being someone who complains about things. I much rather being the person that recognises an issue and then works to solve it, I feel complaining about it rarely does anything unless you're complaining to someone who can actually solve said problem/you can't solve it yourself. With that said I'll reluctantly complain about my Orthopaedics rotation simply in the interest of being honest with everyone else reading this: I really, really did not enjoy the remainder of my rotation.

    I found that a lot of the time I was left on my own to solve some pretty difficult situations. I'd been warned about this impending 'responsibility upgrade' before going onto Orthopaedics but I don't think any warning could have actually prepared me for the reality of it - that those above me on my team really did only care about the patient's bones. I faced a lot of issues that I still (in retrospect) have no idea how I should have dealt with; I had a lot of conversations with a lot of patients that really are above my experience/pay grade but fell to me because otherwise they would never have happened. Overall I think I managed things reasonably well but not without finding myself directly in the middle of a nightmare of a Coroner's case. Getting multiple phone calls directly from the Coroner and the Director of Medical Services at your hospital & then subsequently having to go to meetings with said people on your own is not a situation any Intern wants/expects/imagines themselves in.

    Thankfully I learnt a lot of things from the experience, perhaps the most pertinent being that your medical indemnity insurance company will happily arrange a lawyer to sit on the other end of the phone on speaker while you get asked questions about a patient that at the end of the day isn't actually your final responsibility (it's the bosses!). I think the things that came out of those meetings mean that maybe some things will be looked at a little bit closer & hopefully the disaster of a situation I ended up in won't be repeated anytime soon.

    On top of that I also realised that I've made a lot of friends in different parts of the hospital already. Friends who helped me out more than I can possibly describe. The medical registrars that I knew well from my term in ED who outright told me to call them even when they aren't on-call if I have issues and no one is helping, the geriatrics consultant that I knew as a medical student who stopped by the ward each day to answer all the ridiculous questions I had even when we weren't asking for formal consults, the Intensive Care consultant who realised they couldn't send more high acuity patients up to our orthopaedics ward despite bed pressure when I already had 4 multi-trauma high acuity care patients (some with vasopressors running) on the ward, the Palliative Care registrar & consultant that helped me talk through palliative care discussions and understood when I frantically called them at 4pm on a Friday asking for help starting subcut morphine drivers and documenting clear palliative care plans. I think I also really learnt a lot about what I do and don't want to do in medicine & what I need to work on - for one, I absolutely struggle to deal with a patient in a non-complete sense ... when someone comes in with a neck of femur fracture + severe COPD + an active non-STEMI I cannot look at them and simply focus on their fracture, i.e. Orthopaedics is not for me. I realised that what I do pretty well as an Intern is to communicate with people & I also really learnt how to prioritise things on the ward, pre-empt nursing questions & document everything to absolutes.

    Unfortunately all of the above came at the expense of a lot of my free time. In my first 3 weeks I worked ~70hours/week (i.e from 0600-1800 most days + weekend shifts) and honestly didn't see the sun except on my 3 days off out of 21 days. I got paid (fortunately) for that overtime but in reality I think I would happily have traded the money for some sunlight.

    I'm currently on my General Surgery term for the next 9 weeks (1 week in!) and actually thoroughly enjoying it. The case-mix in terms of patient acuity is similar to orthopaedics as once again I'm on the 'trauma'/'difficult' cases team but the difference seems to be that 1) I know how to deal with being left alone & 2) communication between the team is FAR better than it was on my previous term. It's actually pretty good, everyone keeps telling me that we'll get busy, busy, busy but at the moment things are fairly relaxed. I'm getting to see the sun, I'm getting to see my partner, I'm getting back to being able to write & I'm able to actually get back into my teaching/research roles that I threw to the wayside for the previous term.

    I know the above is a bit vague and probably doesn't really capture things as well as I would usually try to, but it's left that way intentionally. Hope everyone has been well!

    P.S. The wordpress site has crashed for the time being & I don't have access to the server back-end to get it up and running again. I'm in the process of making it function but in the meantime it's down.. Sorry!
     
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  13. chinaski

    chinaski Regular Member

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    Anyone who has spent more than five minutes working in a public hospital will understand this post perfectly - it isn't vague at all! We have all had at least one of those terms.
     
  14. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    Unfortunately this is a bit too true. As I said all I can be is thankful that the other teams in the hospital were willing to pick up the work when I couldn't do it myself/teach me how to do it and then let me loose.

    Of an interesting note I realised something I really hadn't thought of when I was in ED - the orthopaedic work-up in ED is almost the LEAST useful part of the ED work-up / sending someone upstairs with a work-up of: 77M #NOF 2' mechanical fall, fascia iliaca block insitu, obs stable, FBC + U/E + LFT's + COAGS + GROUP/HOLD ordered ... or worse yet "Ortho Expect, #NOF interhospital transfer. Bloods + analgesia done as requested. Admit ortho" made me want to tear my hair out. The orthopaedic issues will 100% be managed by the orthopaedic team, but if the other issues aren't brought up there is very little chance the intern/resident seeing them on the ward will know about them! I began to love a thorough past medical history/issues list/social workup because it meant far less work/easier work for me - the ortho issues will get a 100% work-up regardless of what is done in ED so its the other issues that really matter!

    Similarly, people that document "Alert + oriented to time, place & person" or even better: "Time: 20th June 2016 / Place: Correct Hospital / Person: That's Julie, my granddaughter" as responses in the initial ED note are angels. I would regularly see patients at 0700hrs after they were admitted the night before and have absolutely no idea if they had dementia or were acutely delirious .. only to then go back to the notes and not be able to tell from the ED assessment if they were coherent or otherwise at the time of assessment because it wasn't explicitly documented.
     
  15. chinaski

    chinaski Regular Member

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    Same goes for your stock-standard surgical progress note entry:

    "ISQ, BNO.
    Wound clean.

    P
    Continue"

    Really helpful when you are asked to see the patient as a consult (or worse still) to medically bail them out when the poo hits the fan.

    As for ED workups: they are useless as a rule, 9 times out of 10. You're lucky if you get someone who performs more than a cursory glance before calling the team for admission.
     
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  16. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    The final weeks in Surgery

    Rotations through trauma & general surgery are tough. For the last ~14 weeks my life has consisted of essentially 12 hours days at least 5 days a week and as I've brought up in previous posts I have at times struggled witht he workload. Coming towards the end of my rotations through surgery however, I don't think that's actually what I found the hardest to deal with. As a general rule, most patients admitted under a trauma team have had or are in the process of having a catastrophic event ... similarly for general surgery the majority of patients are either having life-changing surgery because of a new diagnosis or are coming to the end of their chance to be conservatively managed. There are the regular/standard cases of lap choles/appendixes/pancreatitis/cellulitises but these are so common & generally have such short times in the hospital that you barely get to know the patients name before they're discharged.

    The 17 year old boy in a car accident who now is a double amputee, the 22 year old female who fell off her balcony and ruptured her spleen, the 88 year old lady with a rectal prolapse that turned out to be an obstructing caecal cancer requiring extensive open abdominal surgery, the 46 year old man with metastatic prostate cancer admitted for cauda equina because of metastatic spinal cord compression, the 56 year old female with locally invasive pancreatic cancer that got a palliative Roux-en-y bypass ... these are just a sample of cases that as a junior doctor you have to reconcile every single day. These patients are not going to come into hospital for 1-2 days and then get sent home with a clean bill of health, back to their independence & dignity. They will have questions, lots of questions & they will be worried. Do you try to be emotionally available to all of them? You don't have time, you don't have the experience, you don't have the knowledge & you certainly rarely have any concrete answers during their acute phase of illness.

    Even if you aren't the one physically telling the patient that their prognosis is grim or that they require extensive surgery, or (sometimes even worse) that there isn't any surgery to offer you still have to deal with the aftermath. Your registrar will be going to theatre shortly after the round, shortly after the conversation & when the patient has questions or needs to be reviewed that's your job. It's your job to try and answer questions & recognise when you're out of your depth.

    I bring this up because today instead of struggling through ... we celebrated. A long term teenage patient that I have gotten to know well had nothing short of a miraculous result. We got to tell him that not only were we going to get him out of hospital in the next week but that his cancer was curable, that the response to treatment had been so drastic we no longer gave him a 5 year survival rate of 30% but rather of 90-95%. That there was a very real chance he would die of a heart attack at 70 rather than his cancer before turning 20. I don't really know how to describe the feeling of being able to tell someone that, I don't think its something that I can ever explain to anyone who hasn't gotten the chance to do it before ... and I don't think its something that you get the chance to do without having to deal with all the other, not-so-positive cases.

    I think too often the stress of working as a junior doctor is considered driven by 'decision making/decision fatigue' / long working hours / hospital politics / job stress ... for me that isn't the case, a lot of my work-stress comes from the fear of not being able to do right by my patients. This fear is compounded when my workload grows, a Monday morning after my team was admitting for Friday, Saturday, Sunday is a nightmare - we usually have ~50 patients of which I have never met a single one. I've gotten better at managing that as my trauma & general surgery terms have progressed but as I became more efficient I only seem to have picked up more jobs to fill the time.

    My time in surgery will come to an end on Sunday next week. I'll switch over to the medical field & spend some time in thoracics/respiratory. I think I might miss surgery a little bit, I like the idea of getting rapid results and I like the pace of the work. I feel like I have things I can add to a surgical team - being thorough & going above expectations is relatively easy, putting some effort into solving medical problems on your own is satisfying & there is a lot of opportunities to be available for your patients if you make it a priority. I'm not sure it will be the same on medicine, I'm slightly scared that I will be little more than a typist/secretary but I honestly have no idea what working on a medical team is like.
     
    Last edited: Aug 9, 2017
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  17. chinaski

    chinaski Regular Member

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    I get that you may be fictionalising for anonymity - because it sounds like you did a trauma-ortho-gen surg-UGI-neurosurg rotation with that casemix!

    Hope this conversation was had after consulting with the oncology team first. Unfortunately sometimes surgical teams tell patients medical things that are not entirely correct. It's not uncommon as a physician to have to come along and ruin someone's day because the surgeons have offered their medical opinion about something that is outside of their expertise, thus establishing expectations that in reality are over optimistic or unattainable.
     
  18. Benjamin

    Benjamin Intern (JCU MBBS) Administrator

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    These were all cases (ages are different) that I have had over the last 15 weeks (ortho + surg rotations). My hospital does not have specific upper GI or neurosurg bosses. The closest we get is a general surgeon with 45 years of experience from South Africa & a young orthopaedic back + trauma surgeon.

    Absolutely was 100% in consultation with the paediatric oncology team - we were in the midst of organising transfer to their hospital for what was expected to be a very difficult process when the paediatric onocology boss called me (my number is on all the forms) to tell me the good news (histopath/immunophenotyping had come back different to expected). I obviously put them onto my boss directly & we told the patient following that discussion. I agree with your sentiment however that often people are given unrealistic opinions by surgical teams on specialist medical conditions ... often as a result of a lack of time & understanding.
     
  19. chinaski

    chinaski Regular Member

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    *makes mental note to avoid having a complex surgical issue in said hospital!*
     

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