Purple Steth - musings of a clueless intern

Inspired

2012-02-21T23:01:00.000-08:00

It's Tuesday evening on my last day off after a run of evening shifts last week that included the weekend. This week I am back on night shifts starting from tomorrow night. This means that I must try to stay awake tonight and sleep for a good portion of tomorrow day so that I can stay awake tomorrow night, etc (you get the drift). Once this week is over, I will be half-way through my first internship rotation (yay!). Onwards and upwards people!

I wanted to post about how restless and unsettled I have been since returning from Fiji. Basically, for reasons I can't quite put my finger on, I just have this overwhelming desire to travel; and in particular, to be out at sea or settled on a little tropical island. It's crazy I know, but that's where I am right now. A few years back, before I had been anywhere (except for Jordan and here), I was desperate to just travel. This feels different though: less arbitrary and random... more focused. In short, I don't want to "just travel" anymore - I want to go to specific places, spend longer periods of time there, and (at the risk of sounding pretensious) somehow be involved or useful.

This time I risk sounding completely ungrateful - for the blessing of a stable income and the opportunity to further myself academically with this great internship program that I am undertaking - but the sad and inescapable truth is that it binds me here to quiet suburban Sydney life, for the next couple of years at least. Regardless, I am young, restless and hate nothing more than feeling powerless... so I map out plans instead. And this is not a bad time for it either. My last life plan ended last year with the completion of med school. I made a hasty one towards the end of the year (that of doing Anaesthetics training) to get me into the new year and starting internship with some degree of focus. Now it's time to go back to the drawing board.

"Why Anaesthetics?" was the first question I had to ask myself. Because it's scientifically interesting, well-paid, flexible and with a relatively low out-of-hours commitment load. These are all traits that make for a good speciality to practice in if you have plans for serious extra-curricular travel.

"Why not Anaesthetics then?" was the obvious second question to pose. The primary and fellowship exams are soul-destroying. I have had a look at the curriculum and at past papers. We're taking about an intimate, biochemical- and molecular-level-depth of understanding of human physiology and pharmacology here. It's important to know this stuff obviously - afterall, if you're going to be manipulating human physiology, you'd like to be well familiar on what you're dealing with. Here's the thing - every speciality has a set of exams that need to completed at some point in the training. Anaesthetics happens to be one of those specialities that has primary and exit exams. I would need to start studying for the primary exams in the next 6 months to stand any chance of passing. At the end of the day, it's been done before; but, personally, I don't think I have it in me to commit to rigorous study of such a dry nature anytime soon. At first, I was making other trivial excuses for wanting to switch to another speciality (like, wanting to leave the hospital system) but the bottom line is - as much as I would still love to actually do Anaesthetics, I just simply cannot commit to the academic requirements.

"So, now what?" Well, fortunately, in Australia, regardless of what medical training program one decides to do - that first year of training (this internship that I'm currently doing) is the same. So the door remains open for a little while yet, to decide on what happens next.

My objectives in life when I decided on Anaesthetics have changed somewhat. Back then, I was still set on the mode of wanting to "just travel". Inspired by my recent travels however, and with the added desire of wanting to be more purposeful and involved wherever I go; I've been considering medical specialities that allow for a broader spectrum in practice, geographically speaking. The founder of the Australian Royal Flying Doctor Service, Dr John Flynn, once asked, "What would it mean, if, wherever a little band of men advanced to try their fortune in the middle of nowhere, a Nursing Home, were it only of canvas, could be floated down among them?". This is a neat little clue as to where I'm heading. It makes perfect sense. I want to practice medicine, I want to travel, and I want to be purposeful in doing so - why not combine these? I live in a country with some of most beautiful and remote places on earth; a country that also happens to have a critical shortage of doctors in these areas. It really does make perfect sense! I'm not saying it's set in concrete or that it won't change (because I'm going through a crazy transition phase right now, so anything's possible) but I'm thinking about becoming... a Rural and Remote General Practitioner!

It would be an amazing journey just getting there, let alone pursuing it for life. Of course there are many challenges to be considered too - remoteness is not an element to be taken lightly and I will have to think long and hard about the social and family implications of this choice. But I need something to hold onto for now, or else my restless mind will continue to ruminate aimlessly.

I have spent the last few days browsing through the different regional training centres where I could undertake my training. I like the idea of moving to a tropical, coastal area so Tropical North Queensland and the Torres Strait Islands are high on my list. Like I said, lots to think about still, and much ground to cover.

So, what happens next? In April I will need to apply with the training college to register as a GP trainee. Then, later on in the year (not sure when exactly) I will have to select rotations for next year. The first year of training as a GP (after internship) has to be completed at a hospital-level; with compulsory rotations in Paediatrics, Obstetrics and Gynae, General Medicine, General Surgery, Anaesthetics and Emergency Medicine. After that, I can stay on in the hospital system for an extra year doing specific special-skills training (e.g. in Paediatrics, or O&G, etc) to gain some more experience in an area that would useful for someone who is going to practice in remote and rural settings. Or I can just start rural and remote GP training and return to a hospital setting to do the extra year of special-skills training at the end of the training. I'll describe the program in more detail later on because it's a bit confusing, but for now I'm quite happy that I have some direction in life!!

Inspiration, I am coming to learn, can come from all manner of sources around us. I leave you with a picture of one of the beautiful beaches I visited in Fiji. Seemingly a mere photo of a happy me on a pristine beach - lazy indulgence that is far from noble and far from heroeic. Why not post a picture instead of doctor helping out victims in a war zone or refugee camp? This picture means more than that. On that trip, we visited remote Fijian communities and I started to understand the value of a health care worker in these settings. Health care is so much more than about stepping up in the last minute and saving someone's life... I'll leave you to think about that for a bit.

Here, in the real world...

2012-02-09T01:45:00.000-08:00

Thursday morning, 1:30 am. Just returned home from an evening shift. Too awake to go to sleep; to tired to do anything productive... so I reflect.

I've been meaning to post earlier but couldn't get in the right mood at any point before the present time. Week One of internship seems like it was forever ago and I specifically held off going on a blogging rampage under the influence of all the stress and emotion. Afterall, as with revenge, reflection is a dish best served cold. Week Two - the week just gone past - I was reduced to a zombie, working the graveyard night shifts, with little time/energy to do anything but go to work, fall into a deep coma between shifts, wake-up, and return to work on the evening of the same morning that I was just at work! This week I'm on evenings and the dust of novelty is settling; so it seems like a good a time as any other to reflect on the weeks that have been.

So, as I have alluded to, we work on a rotating roster - doing a run of Day (7.30am-6.00pm), Evening (2.00pm-12midnight) or Night (10.30pm-8.30am) shifts. Typically we will do about four of these shifts in a row, then have about three days off before rotating to a different time slot. While it has its advantages (like random days off midweek and the occasional long weekend), I can't say that I'm much a fan of shift work. There is a tendency to become so consumed in your own schedule that making social plans becomes too much of an effort, logistically. Night shift, in particular, is going to take me a while to adjust to. I always considered myself somewhat of a night owl - but I now appreciate the difference between staying up all night watching DVDs or reading a good book; and staying up all night with the expectation that actual work needs to be done and to the same standards/efficiency as if you were working during daylight hours. The fluoro lights help.. a bit.

The Emergency Department (or ED as we call it) at my hospital is a VERY busy place. I did my Emergency Medicine rotation in a small district hospital, with a low admission rate, frequented by the "worried well" who really should have presented to their GP/family doctor instead of coming to the ED. So my preparation for a term in a busy Tertiary Hospital ED was somewhat inadequate. It's growing on me and every shift is less overwhelming than the previous one was. There is a lot of support for the junior doctors of course, at all times, which I am very grateful for. The registrars, consultants, nurses... but mostly from each other. You end up being best buddies with your fellow intern who is on the same run of shifts with you for that week - like you survived war together, or something.

My buddy Daniel and I at about 4.30am on a night shift, trying to keep our spirits up

The work itself depends on where you're placed within the ED. I have only ever been assigned to the Acute Care area thus far, so I can't comment on other areas yet. Acute Care is where all the seriously ill patients are placed for review, assessment and initial management. Most of the patients in this area end up being admitted to the wards so there is a tendency to spend longer taking a thorough medical history, examining, investigating, and really getting to know these patients in anticipation of what will be required criteria by the admitting team in order for them to accept the patient. It's a bit bureaucratic - but you basically have to prove to another medical or surgical team that your patient in ED is sick or interesting enough for them to want to accept them under their care on the wards, because obviously the ED is not an endpoint in itself (despite how it's portrayed on ER!). This is the part that I have found most challenging. I have dealt with just about the entire spectrum of human personalities on trying to refer patients to other teams. Some teams are exceptionally open and inclusive - basically happy to take anyone whom the ED (at our discretion) think needs to be under their care. Other teams refuse to even talk to interns. So you have to be adaptable to whatever response awaits you at the other end of the telephone line. Thick skin and remembering that it's not personal also helps.. a lot. Enough said.

"So, what's the verdict doc?" I hear you asking.. Do I love it, do I hate it? Hmm.. hard to tell. Certainly, even as a distant memory, I wouldn't recall that first week as the happiest in my life. It's tough being the new kid in a new playground - that much I was sort of expecting. One morning I came home after a particularly harsh night shift and, despite being completely and utterly knackered, started frantically researching different medical specialty training programs that allowed for an early exit from the hospital system. I'm going to leave posting on that for a different day because this musing has gone on for long enough. I will admit though that switching to General Practice/Family Medicine was looking very attractive at one point. On the same account, three weeks in, things seem better than they did on Day One. The other thing, I work with doctors and nurses who have been there for years, decades even. That's something to hold onto for now.

Love and Peace until next time...

Life starts... now!

2012-01-11T00:45:00.000-08:00

Wednesday morning, just past midnight.

I am less than a week away from starting internship so I thought it might be a good time to resume writing. The holidays have slipped away, as often happens, all too quickly :-( I have disposed of my medical school notes in a timely manner; cleaned my room (sort of); and finally unpacked my suitcase and stored it away after practically living out of it since I first packed it for my rural placement in Lithgow in September (!).

There's a sense of change in the air - all too familiar, I've been here before. I'm still adjusting to life as a non-student. It's weird and I don't know what to do when I am at home. What do people do in their free time? I want to take up photography as a hobby and have been meaning to enrol in a community college course. It's only one class a week over eight weeks but you have to attend a set day and owing to the shift-work nature of my first couple of rotations, I will have to put it on hold until my third internship rotation where I will finally (hopefully) have a more predictable working roster. Speaking of rotations, I got very lucky in my allocation and will be doing the following rotations over the course of the year:

1. Emergency medicine
2. Relief/night cover/annual leave (where you cover for other people who are away on their normal rotations; do night-shift cover for the hospital and take annual leave)
3. Cardiology
4. Vascular surgery
5. Emergency medicine (at a different hospital)

I'm a bit freaked out about starting in Emergency Department because, unlike ward duty where you mostly just follow orders made by more senior members of the treating team, in the ED you actually have to make your own decisions. Do I order this test? Do I prescribe this drug? Do I discharge the patient home or admit them? We are supposed to present each patient to a senior supervisor at some point in our clinical work-up; but I don't know how much of that actually happens in reality and I'm actually quite nervous about being assigned a supervisor who will just tell me to pick up my slack and start making my own clinical judgements!! Okay, clearly I have been watching too many episodes or ER :-S Just to be sure I don't get into a pickle, I have ordered a copy of The Oxford Handbook of Emergency Medicine as a safety net in case I run out of ideas on what to do next with a given patient and can't find anyone to help me. There you have it people: seven years of university and I will be flipping frantically through a how-to guide before I do anything. Warning: do not become ill for the first few months of the year as there is a good chance that you will be looked after by a clueless intern if you present to the ED. Don't say I didn't warn you. Maybe they will just assign me all the triage category 4 and 5 patients who really should have gone to their GPs instead and I will be stuck all day writing sick notes for sore throats and blocked noses.

Anyway, I don't care what I'm presented with. I have gone into survival mode and I have one aim for this year and that is: to make it out alive.

Wish me luck!

Part I: The End of the Beginning

2011-11-23T02:50:00.000-08:00

Wednesday morning, just past 1:00am.

Presently, I am sitting behind my desk, tying up virtual loose ends - replying to old emails and fb messages, looking up places to have dinner in Nadi (Fiji), deciding what to "do next"...

I'm in the final of my four-week elective in Anaesthetics at Westmead Hospital - officially the last week of uni too (even though I completed and passed the final exams a good six weeks ago!). Absolutely loved the elective - I think I got really lucky in striking the right dose (for me) with regard to setting and content. If you had asked a more starry-eyed me four years ago, at the beginning of med school, what I planned to do for my elective term in my last year of med school - I probably would have sought something a little bit more adventurous than what I have done. Certainly, Trauma Surgery in Johannesburg did cross my mind at one point or another. But I have no regrets. At the end of the day, among other things I have learnt about the "system", I know that there are far less prudent things to do than spending a month with a department of career/academic interest to you, in a hospital you will be based at for (potentially) a fair few years. I'm still a bit unsure as to what the purpose of the elective term is, so I guess as long as each student has their own agenda and outcomes - as with many things in life - what you put it is what you will get out. My objectives were low-key and modest:
1. I wanted to familiarise myself with the route from my house to Westmead by car (and parking!!), as well as the layout of some of the hospital grounds; so that I don't have to stress about it early on next year.
2. Learn some more about Anaesthetics beyond what I learnt during my official Anaesthetics term earlier on in the year (btw - if we haven't spoken in a while, just an update - Anaesthetics wasn't chosen arbitrarily... I am just thinking of heading in that direction as a speciality... but more on that another day).

So, end of story - I haven't put in any chest drains as my colleagues in South Africa have done... but at least I know where I'm supposed to be for my first day of internship next year! Snaps for me :-D Logistics aside, I also did happen to fulfill my second objective and I picked up a lesson or two in Anaesthetic theory and practice during my time with the Department. Because I like making lists, here is an abridged list of what I learnt/practiced (medically) during my elective:

Cannulations +++ (what at least 20% of my work next year will involve, so never a waste of time practicing this one!)
Maintaining an airway and ventilating using a bag-mask system (for non-med people, supporting someone's airway and helping them breathe with some basic equipment. Again, important skill to know, even if it will (hopefully) not be needed that often)
Use/insertion of specific airway support equipment and adjuncts, e.g. intubation (sticking a breathing tube down someone's trachea to deliver air/oxygen straight to their airways. Okay, so this skill I will never have to do as an intern, but still cool to know nonetheless ;-)
Doing the above on morbidly obese/clinically unstable/medically co-morbid patients.
Pharmacology - what and how much/often to prescribe for two common (esp post-operative) complaints: pain and nausea/vomiting (this is an area that I knew very little about in practice, despite it being covered at some point during the course)
Plus other tid-bits of information specific to Anaesthetic practice, which I shan't bore you with.

Now, having argued about how awesome it is to undertake a local elective in your area of choice, I couldn't surpass the opportunity to, ahem, supplement my learning even further with a few weeks in Fiji. I have a bit of a soft spot for Fiji. A tropical island holiday destination for many; for me, it was the first place I ever travelled to on my own. This is where it (sort of) started - back in 2008, at the end of my first year of med school. Surpassing the popular resorts of the West Coast, armed with an older edition of the Lonely Planet Fiji guidebook that I had borrowed from the local library and the name of a hospital in Suva that I, literally, rocked up to. Two weeks later, I couldn't even bear the thought of returning home. There were many "firsts" for me during my placement at CWM Hospital - first cannulation, first spinal block, first stitches, first amputation, first birth, first death.... These are trivial occurances in the everyday life of a doctor - as they will be for me next year. But at the time, every moment was a novel adventure worthy of reflection and celebration. A few days ago, as I was cleaning my room and essentially purging it of all my med school notes, I found the journal detailing everything I had seen and done during my first visit there. Needless to say, I couldn't throw it out. So, come this Sunday, I'm getting on a plane to Fiji. I will be spending a week beforehand away from the hospital (will try to post along the way); but eventually return to CWM for a 2 week placement... back to where it started at the beginning of the beginning; but now, at the end.

Standing outside Colonial War Memorial Hospital, Dec 2008

Welcome to my blog!

2011-11-15T11:04:00.000-08:00

I just found out that I've passed my final exams for medical school. So, what happens next? As a clueless intern, the answer will reveal itself over the course of the year...

Although by no means the exemplary model of a fresh medical graduate, I hope that through this blog I can shed some insight about the work involved and also keep friends and family updated on what I am doing (because I have a tendency to disappear for long periods of time and emerge many months later without much accountabilty of where I have been nor what I have done..).

Welcome to my blog!