​Waking up before the first day of a grown up life

Monday. 5:15 am. I just woke up from a crapy sleep. I was nervous, anxious and agitated. My stomach was romping at full speed and so was my bowl. I had no appetite and if I was to eat, I would have easily vomited. So I stayed hungry. It was my first day on the job as a medical intern. Probably the worst thing about it all was that I did not know where to go, who to report to. I had no previous information. Nobody of the people in charge told me anything.
At 6 am I drove out to the hospital. It was a 30 min ride. I arrived at my destination and parked my car, checked in (yes, we have a special e-card to check in and out, to measure our time spent at the hospital, “working”) and walked to our dressing room (luckily I have a college, who had already been working there as an intern, to show me the way).

Dressing up for the occasion

I put on a pair of freshly washed white pants and white jacket, attached my badge and a pen, put my stethoscope in my left jacket pocket and my Oxford Handbook of Internal medicine in my right jacket pocket. I asked my colleges to show me the way and I was ready to go. I somehow managed to find the way to the rapport room, where I was supposed to show up on my first day at 7:30 am.
When I walked into the room there were a couple young doctors. I think there were three of them sitting and looking at their phones. I introduced myself to every single one of them and we shook hands, found a place to sit and I waited for the rapport to start. Soon many other senior doctors started walking in and at 7:30 it started.
Doctors who were on call during the weekend introduced all the patients who were hospitalised during the weekend and everything that was going on at that time. By the way, it is not a very big hospital. There are 6 departments (Cardiology, Respiratory, Gastroenterology, Diabetes, Infectious diseases, and ICU; Hematology, Rheumatology dep. are included in those previously mentioned) and each has somewhere around 10 beds available. After this was over, coordinator for internships introduced me to everybody.

Boring two weeks at the ICU

For the first two weeks of my internship, I was in the Intensive Care Unit (ICU). It was quite a pleasant experience. On my first day, I was told what I was supposed to do and all the things I can do. My job was to examine and check the patients every morning. So that’s what I did. I’d asked them how they were feeling and if they are in any pain, then I’d listened (auscultated) their heart and lungs and a regular medical exam. I wrote everything down on a special paper in front of every patient bed. Then the senior doctor arrived and we went through it, I’d told them what was changing and what was different if there is anything new with the patients. We prescribed all the medication that was needed for them. And that was my job.
Nothing special, nothing difficult. If was quite ok for the first two weeks of my first job in my life. Though I did learn a few new things. For instance, I’ve learned to use the Ultrasound and tried to perform a basic ultrasound exam. They’d said to me, if the ultrasound was not in use, I could’ve just taken it to a patient and play around with it. Because the only way to learn how to use it is by practicing. You just have to put in the hours and keep on trying. It takes a lot of time to get used to it and to eventually master it. Quite soon I’ve started seeing some internal organs and was getting better at it every day. I was reading a lot of ECGs too. Because at first, it was really difficult for me to notice any subtle differences from the normal ECG.
That was my first two weeks. Like I’ve said, nothing special and lucrative.

Finally some action

​Then I’ve moved on, and I was working in the emergency department and I still do. The department of Internal medicine emergency room (ER). Sometimes it’s quite challenging work. You have to check and examine the patient and write everything down, then you consult with a mentor or supervisor if I’ve ordered the correct laboratory tests. We don’t do lab tests as doctors do in the US or France for instance, where you check for everything and just throw a fishnet. We first take a look at the patient and then we decide which labs we are going to check. I’ve even worked with some doctors who really care about this. If you order some labs, you have to be sure and you have to know why you ordered that. They keep asking you what is some test going to tell you about the patient, so you have to be careful what you order. You simply don’t just throw in the net and catch whatever you catch. You have to know what you are doing.
That is, and it still is the quite interesting part of the job, because I actually do something, I don’t just stand there and watch. I finally get to play a doctor.
The patients, for example, come to the ER and they say they have a really extensive pain in their abdomen. I take the history, I perform a medical exam, I order laboratory tests or some X-Rays or whatever is urgently necessary. And I basically do everything by myself at first. I look at the results and I create a picture of what disease is supposed to be the cause, I take the documentation and go ask my supervisor what he thinks. So far I’ve been pretty successful with my diagnoses. That we quickly discuss the patient and make a plan, what we’re going to do next if antibiotics or additional tests are needed for example.
It’s quite challenging sometimes, but sometimes it’s quite boring.

The good, the bad and the ugly

I remember one day I was working in the morning from 7am to 3pm and there were almost no patients at all in the ER. There were three patients in the whole morning. There is a day when you just don’t have anything to do. Which is great from the patient standpoint, but at the same time it’s pretty bad and it sucks being a doctor. You just stand or sit there waiting for something to happen. You’re waiting for Godot.
There was also one case the other day that I still remember. It was a guy who has a Wolf-Parkinson-White syndrome (WPW syndrome). I didn’t know it at first, but I just saw his ECG and there were those characteristic delta waves (look at this picture). Even for a guy like me, who’s not interested in internal medicine, but seeing WPW syndrome in real life, was almost as interesting as surgery. But if I was seeing those syndromes on a daily basis, it would’ve been super boring.

Then there was another interesting patient today. I took a picture of abdominal X-Ray (look at this picture). That was a patient in shock, her blood pressure (BP) was around 50mmHg, she was unstable, she was sick, vomited, she was bloating. Her abdomen was really big and tender, stiff. And if you were to palpate it, you would feel that the upper part of the abdomen was really hard and rigid, while the lower part and suprapubically (above the pubic bone) was soft. What we did then, was to consult a surgeon, who said it should be operated. But not at that moment, we should first stabilize the patient, so that she wouldn’t have vomited and her blood pressure was above 70mmHg and stable. Afterward, we decided to insert the nasogastric probe (a small tubule, inserted through the nose down to the stomach) and suck the content of the stomach to release the tension. Once inserted, there was first an explosive puff, due to air coming out of the stomach, then a black fluid with smelly odor started to flow out. It was black in color, mostly due to the presence of blood and stomach sour fluids. And it really stank, the smell was awful, similar to the extensive smell of vomiting, but even worse. We managed to relieve the tension by emptying the stomach. We gave her some intravenous fluids and waited for her to stabilize. Unfortunately, this was happening in the afternoon, right before our shift ended and the afternoon team took over, so I don’t really know what happened to her next.

Think first before you act and what’s wrong with the organization?

​There are some really interesting cases that you can see while in the ER. But there are also some extremely stupid cases. Some General Practitioners (GPs) send you everything. And that presents a real problem because you have to deal with those patients, even though nothing’s wrong with them and you’re going to send them home anyway without any therapy. But you just have to take the history, perform the exam, and order some laboratory tests, just so you can rule out all the emergency diseases and conditions, like heart attack, pneumothorax or whatever can kill you in a matter of minutes. All that takes time, around an hour to get the lab results, while the other patients are waiting. But like I’ve said, you cannot really know that nothing is really wrong, until you’ve examined them and took the blood samples. You cannot just tell them to go home because you think nothing’s wrong with them. You have to be objective as modern medicine doctrine and law implies and demands.
Sometimes you really get pissed, when some GP sends you that kind of patients, while at the same time you have ten patients waiting for you, who actually need treatment and care.
I think there should be much better way of triage, the assortment of patients that get through the funnel and to the ER. When you first walk into the ER, there is a triage team, which examines you and decides, whether you’re going to the surgical or internal medicine ER. I believe there should be a better team there and to sort those patients and to even decide which patients need urgent care in the ER, which can go and wait for a specialist regarding their disease or condition and which patients to send back to their GPs. A lot of the cases can be treated at the primary level with the GP and Family medicine doctor. I don’t know whether they don’t know how to treat it or don’t know what it is, they don’t recognize it, but I recognize it as an intern, I believe that a specialist should have realized what’s going on and not send those patients to the ER.
There were a couple of patients who were sent to the ER from their GPs because they’ve had a CT scan, which showed they have tumors in the lungs for example. The other day, there was a patient who got to the ER first thing in the morning, because she just got her results from her CT scan and it showed there is some tumor formation in the lungs. Her GP decided to send her to the ER for that. Like, what are we supposed to do with that?!? We were all like, what the fuck? What are we supposed to do with a patient, who just got the results and the CT scan showed that she might have cancer? That is not something you take care of in the ER. The GP should’ve known that, and this patient should’ve been sent directly to either to an oncologist or to a pulmonologist, but not to the ER. We don’t have anything to do with this and cannot even do anything about it. We can’t treat it, we can’t perform any more CT scans or MRIs and confirm it again. That kind of patient needs treatment and proper care on a different level, with a different specialist.
And I believe that should be fixed. That kind of things should’ve been fixed. Maybe we need some control? But that is currently out of my hands because I’m still just a junior doctor an intern and nobody listens to me.

They just don’t care about you, especially if you’re young

I’ve had also one funny experience. There was a patient. Actually, there were seven in a row, patients who were sent to us because of the possibility of them having deep vein thrombosis (DVT). That’s basically a blood clot in the veins of the leg which can be fatal if this clot tears off and flows via veins, through the heart, and to the lungs, you can have a pulmonary embolism and that can be fatal. After all, I was examining this patient, we ordered some laboratory tests, like D-dimer, which tells you if there is some clothing in the body. If D-dimer is high, then there is something wrong with blood clothing and it could be due to DVT, but it can be due to many other things. Even an infection can cause high D-dimer. If it’s normal, it’s not DVT. But if it’s high, and the patients has clinical signs of DVT, like leg swelling, edemas, warmth. This patient had those signs, his leg was really warm and swollen, I’ve measured the circumference of the legs and there was about a 5 cm difference in circumference. So we had positive clinical and laboratory signs of DVT and to really prove it, you have to perform an ultrasound examination of those veins and to see where the blood cloth is. When you do, it confirms it and the patients need treatment, some anticoagulants, like heparin to melt blood cloths. And I as an intern, I’ve called the radiologist, but nobody picked up the phone, tried again and still nothing. So I decided to go there myself. I told them we have a patient who has clinical and lab signs of DVT and we need the ultrasound to confirm it right now. The Ms. Radiologist just looked up to me and told me, she can’t do it now, because she has too many CTs to perform. And I was like oh, my god. It takes you five minutes to do it… So she just sent me off and walked back to my supervisor, and he got pissed, so he called them and they just said ok, bring the patient. I was shocked, simply because I was an intern, nobody gave a shit about me. If I was a specialist, there would be no problems, but instead, my supervisor had to call them and demand that they perform an urgent ultrasound exam. But what are you going to go… you have to grow up and grow up stronger.

I’ve been working in the internal medicine ER now for four weeks, I have two weeks left. From now on, I will try to post my “daily blogs” regularly, since this is just a recap for the last six weeks.

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