A Symptom of…

It’s twenty minutes before I leave for work, and Rhys is upstairs vomiting.

This, I think, is a symptom of stress.  If I know him, our finances are a constant source of anxiety for him and his impending start to university is also playing on his mind.  I’m actually hoping for stress, because I know Rhys has started having problems with his gastro-intestinal system that have not yet been investigated.  He is young, but he also has health problems that make the less likely things a little more likely.

Being as stubborn as ever, he is insisting that he drive me the half-hour to work because it means we get to spend more time together.  This means he’ll also have to pick me up when I finish – midnight, which is usually actually 12:30 or sometimes 1:30.

We are both having some health issues at the moment, and it’s definitely time to start working on the stress in our lives and how we process it.  We also need to take better care of our bodies, because they are machines and machines need a bit of maintenance and servicing every now and then.

I think we’re well overdue.

 

Numbers

I’ve had 5 days off, which have been brilliant, but it’s back to work for me.  It goes without saying that days off when you’re finally working mean so much more, but do they have to go so bloody fast?

I’m sucking down coffee even though it’s uncomfortably hot today in the vain hope that at least the caffeine will kick start my brain into work mode.  Hey, we have muscle memory right?  Why not chemical memory?

We have more doctors in the ED this year, so they were able to run 9 teams working 8 shifts a fortnight instead of 8 teams working 9 shifts a fortnight.  I was the one intern that had to split with my team after the first two weeks and join a new team, which was obviously at a different point on the rolling roster so now I get to start working nights again, even though I’ve just finished working nights.

I don’t even remember what it’s like working in emergency during the day.  Apparently there are the occassional periods of time with nothing to do, but I’ve only experienced something totally different.  Also, and unbeleivably, I’m working my first weekend.

I can’t remember whether we are in week 4 or week 5 (quite possibly even week 3) and I’m sure I could just use my previous blog entries to figure it out but it’s all a bit too hard right now.  ED rotation is 10 weeks long, and after that I have 5 weeks of leave.  I am actually looking forward to the down time despite only having started working, but I’m concerned as to how long it will be until my next block of holidays.  Probably during december next year.

I shouldn’t complain – I’ve only been in my job a month and already I have 5 weeks annual leave to use.  I don’t have to accrue it before I use it unlike most people working in other industries, but then again I don’t get to take it when I want.

This is honestly the more boring and direction-less entry I have ever made, but I’d like to get into the habit of blogging regularly.  My boyfriend Rhys doesn’t really get the whole blogging thing, and to be honest I’m not sure I do either, I just know I love doing it.

In other news, we went shopping for his uni stuff last night.  I was so jealous.  I love stationary, and they seem to be making much more interesting stuff these days.  I was practically begging him to buy a leather diary that I liked, talk about living vicariously and about something as trivial as stationary.  Mostly, I’m just so proud that he’s going to uni.  I’m scared and excited for him.  I’m pretty sure he’s just scared at this point.  It took me a while to understand why, but if I try, I can cast my mind back 8 years to when I started.  You don’t know your limits or your abilities until you’ve been in university (or the workforce for an extended period of time), and I’m sure everyone’s first thoughts are either ‘am I going to fail this?’ or ‘I am going to fail this.’  Last night I casually mentioned his accounting class that he’s enrolled in and his response was – with wide eyes and a slack jaw – ‘I’m going to be doing accounting?  I can’t do maths!’

I understand.  I’m an idiot savant with numbers, but without the savant part.

What he doesn’t realise is that he’s about to find out what he’s made of.  It’s a great feeling, and I can’t wait to live it with him.

 

Dr AVC.

The Hardest of Hearts

Every medical student is a dork.  I know - I recently just finished being one, and am in no danger of losing the inner dork.

I’m sure most medical students would love to have a Grey’s Anatomy moment.  Or a Scrubs moment (they’ve probably had one or two anyway).  Most of us will never have a House moment, but God knows we’d love one of those, too.  Well, the other night I had a Grey’s Anatomy moment.

It wasn’t quite what I’d expected or wanted.

To respect everyone involved, I won’t tell you many specifics.  I will tell you that a patient came through the ED having experienced something terrible.  As it turns out, somebody I love has gone through the same thing.  Of course, this patient was assigned to my area.  I’m not sure whether it was tiredness or stress or my being an emotional basketcase at the best of times or even a combination of all three (likely), but I sat there not listening to the nurse as she tried to explain the process of what was required of me – and I felt the emotion build and build until it started leaking from my eyes.

I was rapidly losing control, and being in a densely populated area such as the ED, I just fled.  I left the department and found an empty tutorial room out the back.  It was dark and full of chairs.  I slipped in, shut the door, and just cried.

I value being connected to my emotions, but I know that if I’m going to make it as a doctor I’m going to have to harden-up.

Quickly.

Dr AVC.

Making Light

My first shift working the resuscitation rooms with a registrar was strange.  I’d never been involved in a resus before, but I was told to observe a particular resuscitaton attempt while I was on elective at another hospital.  The patient had taken a drug overdose in an attempt to kill themselves, and succeded.  There wasn’t even a history of mental health problems.

Anyway, I was surprised to find that mostly, resus shift was just annoying.  Because I was allocated to a section of the department as well as resus, I was constantly being interrupted and my jobs kept getting neglected.  Don’t get me wrong, I’m not saying that the resus cases were not important.  They were quite a challenge for a junior like me.

I remember the first case well.  I had just introduced myself to the registrar on duty and said ‘this is my first shift in resus,’ when a patient was wheeled in by the ambulance officers.  The patient was covered in blood.

As the story from the ambos turned out, the patient had tried to slit their own throat.  Looking closer, I could also see a lot of small, neat lacerations to the face.

‘Okay, then you can handle this first case,’ I was told.

Quickly getting over the shock, I said my ABCs.  Yes, the airway was open and un-damaged.  The patient was breathing, circulatory obs were normal…

Once I was satisfied that the patient wasn’t going to physiologically decompensate, I began to ask questions about what had happened.  I asked why they had tried to do this, and was told ‘because overdosing on pills keeps failing.’

Later that night on the drive home, I kept thinking about this patient.  It made me think also about my time in Mental Health as a medical student, and how I’d hated it, but not for the usual reasons.  I was always mildly offended by how the staff in MH treated the patients.  Yes, I know I hadn’t spent a fraction of the time around these patients that they had, and they were probably sick of seeing and hearing the same things, seeing the same patients re-present etc, but still I balked a little at the coldness of it all.  What I liked least of all was how I would let my day affect me long after it had finished.  I would stew on the patients; little things witnessed or said to me during my day in MH stuck with me.  I felt some of the hopelessness that I saw in so many eyes.

Mental Health is something we are beginning to focus on, finally.  It affects so many people, but we are all so quick to brush it off.  Its callous but at the same time I think it reflects human nature, and in that I can understand most people’s motivation.  Most of us like to understand things, and we also like to help when we can.  When we are presented with issues that we can neither understand nor solve, we feel prostrate (no, not your prostate) and useless.  None of us likes to feel that, so we rebel against it; we minimise the signficance of the things we can’t control.

There is still so much stigma associated with mental health issues, and I think this is largely due to the fact that we can’t see it, we can’t understand it, and often we can’t do much to change it.

Mental health is important.  Understanding and reserving judgement can go a long way.  We can’t ignore it and make light of it.

No Accident

Because I have no life (and because I’m putting off calling the bank to discuss personal loans), I’ve been trawling the blogosphere looking for other junior doc writers.  I found this guy, and was pleasantly surprised to read this post, which is exactly what my boyfriend and I were talking about last night.

I always tell people I’m currently working in the ED.  I just assume they know I mean the Emergency Department, but the boyfriend asked last night why I call it the ED and not the ER, like some other hospitals around.  I find ER (Emergency Room) a little American, which doesn’t make it wrong obviously, but mostly my issue is with the word ‘room’.  Have you ever seen one of these departments?  It’s not just a room.

Then I remembered that back in the day, it all used to be called A&E – Accident and Emergency.  As far as I know, it’s not been called Casualty here, but I’m quite likely wrong.  I’m almost certain one of the hospitals down south still calls it the A&E, but at my hospital there is just a sign that says ‘Emergency’.

I know it’s all semantics, but honestly it just makes me think ‘why can’t we get it together and just standardize something.  Anything, at this point, would be good.’

Most nights it feels like the sign outside says ‘Forgot to go to the GP today?  Come on in.’

Dr AVC.

I Used to Know How to Swim

The first few weeks – if I haven’t mentioned it enough – have been tough.

There is a lot of adjusting to do, and I feel like I’ve slipped 20 IQ points below the current medical students in a lot of ways.  No matter how cognizant I may think I am when clerking a patient (working him/her up), I will always sit down with the consultant and give my brilliant handover when they ask ‘what’s the answer to this simple, generic question that a first year medical student would have answered?’  Or something similar.

No matter how hard I try, there are always things I miss.  I’m constantly needing to tweak, always phoning the lab to add on a CRP or going back to the patient and awkwardly informing them that I need to do another vaginal examination so that this time I might remember to take the swabs.

What gets me through each shift, which is fraught with danger (read: being asked anything by particular consultants), is generally the knowledge that while I do cock things up a little, I’m at least safe.  And of course, this means my patients are safe.

What has been really interesting in the shift from medical student to doctor is that I now actually care about the pay debacles that are still going on (touch wood, I’ve not been affected), and  I also feel compelled to care about the fiscal aspects of the job.  While there are certain things I am liberal with, such as giving Ondansetron for persistent nausea (Ondansetron = rather expensive, at least compared with Metoclopramide, the first line drug for nausea), I will now hesitate to order a CRP because now I know it costs $50.

At the end of the day, I think it’s smart to know the ballpark unit prices of things like a chest x-ray, or a transdermal Fentanly patch and direct therapy according to price and what is the cheapest option, but never at the expense of the patient.  There are a lot of things that influence how you manage a patient, and the health budget should definitely be a part of that decision making process, but I think people need to exercise restraint and not let it pervade.

If someone needs an MRI, then so be it.  We’ll fork out the money no problem.  Refer a patient who has no need whatsoever for an MRI and you’d better have a thick skin.

The bottom line is this – it’s all about the bottom line.  Public health care doesn’t make money, it chews through money.  If we don’t make smart decisions and minimise costs where possible, then we’ll eventually not have a government-operated health system at all to look after us.  And I sure as Hell don’t want to follow the full-privatisation models seen elsewhere.

Anyway, it’s 1:25am and I’m rambling because I’ve just finished an evening shift.  Still getting used to the fact that they’ve made each shift longer for the same pay.

Wait, what the Hell?

Dr AVC.

Nights and Day

It’s been a busy, busy couple of weeks for me and all the other interns who’ve recently started new jobs.  The learning curve has been steep, and it’s mostly been a great ride so far.

Most of my shifts have been evening shifts, meaning work from 3pm until midnight.  Some have been days, or 8am until 5pm.  I like the evening shift, although calling another department for a referral can be a little trickier at 11pm, and several times I’ve been questioned as to why I’m calling (and waking the doctor up, and yes – that is his baby crying in the background), and if I even needed to call.  Once, all I could offer was ‘my registrar asked me to call.’

Must remember to think for myself occasionally.

Last night, that was practically my mantra.  I made small omissions such as forgetting to ask pertinent questions of the patient or forgetting to order a test.  Of course I could simply go back to the patient and ask the questions, and in most cases I could call the lab and ask them to add on a test, but all of this just lengthens an already lengthy process.

In emergency – particularly in a busy emergency – there are always ambulance officers waiting to hand-over patients so that they can get back on the road to pick up more patients.  The wards upstairs are always willing to accept patients for admission from us, if they have empty beds.

There is a flow system that includes everyone from the paramedics to the ED to the medical and surgical wards, and everyone is responsible for keeping things moving so that patients get to where they need to go, and new patients can be seen.

And you can probably tell from this that those small omissions that ultimately obstruct this flow are not cool.  Anyway, all I can do is try to be better each time I work.  Last night was a step backward, and I’m not keen to repeat that.

I’m working nights for the rest of this week, which means 11pm until 8am the following morning.  I liked these shifts as a student, but I think I’ve said before that everything seems to change when you’re actually the junior doc on shift.

I’m hoping this shift tonight will be different to the one that finished at 1 this morning.  Night and day different.

 

Dr AVC.

Judgement Day

Well, that’s the first week of being a doctor done and dusted. There wasn’t a lot of doctoring to be done, but there was a lot of information. My head is swimming.

There are a lot of things you learn in medical school, such as how to take a history from a patient, as well as examination and procedural skills, and formulating management plans. There are core skills that we work on, such as communication and our ability to use reason to guide us through clinical decision making (called clinical reasoning, for obvious reasons).

What they can’t really teach you is clinical judgement.

This is the ability to use those communication skills to convey your clinical reasoning to another person, take their advice, and then reassess the situation to formulate an updated plan. In short, it’s more about executing or extinguishing decisions you’ve already made.

This skill was highlighted for me earlier in the week when I was told to prescribe a pregnant patient a medication on discharge. I did so, but a more senior doctor asked me if I was prepared to give the medication in question to a pregnant woman. I had researched the drug on the relevant database and had decided that the drug was safe to give in pregnancy. When I said this to the more senior doctor, she simply said ‘I would never give that.’

Prepared to throw the prescription away, I turned from the doctor only to hear another doctor (of equal qualification) state that it was safe to use during pregnancy, and was in fact the protocol of my department to give the medication, as was it the protocol of the obstetric hospital in the city.

At this point, I was confused and frustrated. The patient was waiting to go home. I was due to go home. And I was no closer to understanding the situation, when the doctor a year above me tapped me on the shoulder.

“This is where you use your clinical judgement. There are two senior doctors here giving you contradictory advice, but at the end of the day it is your signature on the line. It’s your decision.”

Now, I know I am qualified to make this decision, and that it was impossible to hurt the patient with this decision. But right then there was a lightbulb – yes, I have some of the same checks and balances as a medical student in that I have to report to seniors – but now there are decisions that I have to make regardless of the advice given to me.

I don’t want people to think that junior doctors are running around making life-and-death decisions for their patients, because that’s not what happens. There is much more regulation over what an intern does for the sake of patient safety. Some decisions, however, such as the type and volume of intravenous fluid to be given and certain medications are up to us.

In the end, I sat down with the patient and explained the situation to her, explaining that one drug was more effective than the other, but had not undergone the extensive testing that the other had. As a result, it didn’t have the high safety rating that the other drug had. I also explained that the modest testing the effective drug had undergone showed that it was safe to use. The choice was up to her, and she made her decision.

I know there will be some people out there who think I took the easy way out by letting the patient make the decision, but I would argue against that. I already made my decision – that either drug was safe and could be effective with the correct dosing. What it comes down to is this – when you have the chance as a doctor to let the patient be involved in their own health care – you should do so.

I’ve learned a valuable lesson. More valuable lessons to be learned, I’m sure!

Dr AVC.

Tomorrow is Not Just Another Day

Tomorrow is the first day of work. Technically.

We start with orientation week, which must include a lot of information because it goes for a week. I’m not so much nervous or excited as I am eager to get things rolling. Don’t take this the wrong way, because I am excited to start working as a doctor, but I’m just so relieved to be getting money.

My boyfriend and I are moving out of our place this week, and we’ve just come back from a much deserved holiday overseas, but we have practically no money left. We’re doing the math, and there’s just not enough for all our bills and moving expenses.

Because we haven’t had time to find a new place, his parents have very kindly offered to let us move in temporarily. We need this time to get back on our feet before we find a new place closer to the university my partner Rhys will soon be starting at. Im feeling trepidatious; there’s a bit too much uncertainty and upheaval for my liking, particularly when I’ve just started a new job. But I guess this is life. Better get used to it, huh?

My way of thinking has been ‘get yourself in a little good debt, because you’ve got a steady income starting soon,’ but I’m not so sure we’ve succeeded in keeping the debt ‘good’.

In any case, I can’t let money worries play on my mind too much. I have a feeling there’s a lot of information coming my way. I’d be lying if I didn’t say I feel a little guilty going to work while Rhys finishes cleaning the apartment and packing all our stuff up, but maybe that’s because I’m not used to being a productive member in a relationship. After all, we need my job to live off.

I guess it’s nice to be useful in a way I never have been for anyone before, but I can also feel something settling on my shoulders.

It feels suspiciously like responsibility. But you know what? Bring it on.

I’m up for the task.

Dr AVC.

Attention Medical Students

Medical school is great.  It’s also horrible.  There’s so much to do and learn, and yet it seems when you finally approach graduation, large holes begin to appear in your knowledge.  Not medically related stuff, but the process of getting a job.  After all, this is what we studied 7 or 8 or more years for, right?

So for the Australian contingent, and only those in Queensland (sorry, a bit limiting, I know), here’s the deal:

• Medical Registration.  Obviously very important.  Mostly done online through www.ahpra.gov.au – the Australian Health Practitioner Regulation Agency.  Registration opens later in the year, and your school should tell you about this.  Provisional registration costs $336.  You should apply for this before your course is completed, as it can speed the process up.  Your school is also required to tell AHPRA when you have officially completed your course, and your application will not progress until this is done so.
• Hospital Paperwork.  Pretty straight-forward, and the hospital will contact you.  You may require verified copies (a JP must be hunted down) of ID for this as well as Medical Registration, so it’s a good idea to get 5 or so copies of every document verified.
• Provider and Prescriber Numbers.  Apply for these through Medicare.  On their website, under forms in the health professional section, you will find application forms for prescriber numbers.  You’ll need to fill these out and return to Medicare.  It’s free, but you’ll need your medical registration number (from AHPRA) to complete this form.  Keep in mind it can take up to a month to process this, and the last thing you want to say on your first day as a doctor is ‘sorry, I can’t prescribe drugs or sign off on radiology requests for a while…’

Take note that provider and prescriber numbers are different entities, and you do need to apply for both.  This can be done on that Medicare form.  The most important thing to know is that provider numbers are location-specific, meaning if you’re expecting to do placement outside of your hospital in intern year you will need to apply for a second provider number to cover you while you’re at that placement.  Make sure you contact your hospital administration division prior to commencement.

I think that’s about it.  There are a lot of functions surrounding graduation, or at least there were at my school.  Graduation breakfasts, alumni parties etc.  Enjoy this time.  It might be the last time you get to hang out with your classmates before the real world hits.

If at any stage you find yourself waking in the early hours wondering if you’ve forgotten something, just ring your hospital and ask what information is outstanding.  At the end of the day, all of this paperwork is to satisfy them.

Dr AVC.