Tuesday, September 30, 2008

ortho internship, 3

thus began the 3rd week of my internship, wherein my previous intern left to become a resident, and i got shunted to the infection side of the ward (see previous post) to help for a few days before the new rotations take place.

the past 2 days have been a whirlwind, i somehow made it through chaotic morning rounds (there aren't proper rounds in ortho, apparently. the attendings just come one by one and you grab the case notes and run after them madly and try to scribble down their orders desperately whilst hoping that someone else is with whatever other consultant may come along).

tuesday was especially bad because i'd woken up at 440 am, checked my clock, realised i had to wake up at 530 am instead and fell back to sleep - and i MISSED MY ALARM COMPLETELY. omg. thankfully my hall master gave us a lift down to hospital! i have never loved staying in hall so much, ever. :)

and just on time too, i reach the ward station just as the 1st consultant (one of my favourite too!) has finished the first file. i managed to catch the rest of his orders :)

rest of the day is pretty uneventful. i've grown to love the long-stayers, they're like my own!

there's this old man with MRSA in a ward cubicle by himself (he has to be isolated), and his 2 grown daughters (old enough to be my grandmas!) hover by his bedside protectively all day. if i should even approach his bedside with a kidney dish for blood taking, they jump up protectively and start giving me the evil eye, and demanding to know exactly what i am doing and why so. whilst i do appreciate their concern, i don't exactly speak their language and i can't explain myself very well.
i understand that their father has been in hospital for over 2 months now after a fall, resulting in an NOF #. shortly after hip replacement, he managed to dislocate his prosthesis in hospital and developed MRSA and has been bed-bound since. the infection isn't clearing up (we've been doing vanco troughs and infection markers religiously, hence the blood taking). in a bid of desperation (perhaps out of seeing the patient everyday), the attending decides to schedule a "closed KIV open reduction of Left hip posterior dislocation" in the OR that day, and leaves it up to me to tell the family. i break the news none too gently (i'm really crap at this) and the daughter bursts into tears promptly.
it's pretty sad, isn't it? i really do feel sad that their dad has to be in hospital for so long and has so many bad things happen to him.
on the other hand, i wish they would just let me get on with my work and stop unloading all their emotions on me. it's very frustrating, and it makes me hate them unintentionally.
just yesterday, i was ordered to do another septic workup on him and bemoaned the fact endlessly. as i walked into the cubicle, i was super pleased not to see any of his relatives around, and managed to do my work fairly quickly. i was feeling really pleased with myself then, but also guilty.

it's not like we're subjecting him to extra tests that needn't be done, we do need to track the decreasing trend of infective/inflammatory markers and the vanco levels to ensure he's getting proper treatment. but as an sub-intern/intern, there's nothing much we can do other than that. the attendings have no clue about medical management, they refer widely and loosely. i have written some of the shortest and crappiest referral letters ever (read: dear colleague, thank you for seeing this patient. pls refer to attached summary and advise. thank you). sad to say, this is the standard in ortho. i initially tried to write decent letters with a short summary and relevant points and investigations but gave up after my intern told me to forget it as the medical people reviewing the letter usually just ignore the summary because it's so poorly written.

it's quite appalling, the general lack of care. the attendings only seem to want to get into the OR, they dont' really seem to notice the patients

just the other day, i was confronted by a very angry Infectious Diseases (ID) attending, demanding me to go through the file with him. i cringed as he pointed out each and every mistake in documentation - chief ones being:
1. "wound is clean and dry" - attending
this was followed by "wound is oozing haemoserous discharge" - intern
and "milking of wound soaked 3 gamgees and gauze pads" - nurse clinicians

2. "pls review for possible infection" - attending
and no labs for blood/fluid/tissue cultures or septic workup of any sort was initiated.

3. days worth of not seeing the patient yet documentation shows that the patient is unwell

etc etc

i couldn't help by cringe as he berated the surgeons. he ended it off by saying, "even if you beat me to death, i won't come here if i need ortho surgery!" and "don't EVER be like them if you want to be a surgeon in the future!"

quite mortifying. i'm seriously thinking harder now.

and of course, how can i end a post without talking about the resident drug addict?
he's been admitted in and out of hospital, has had 20 over operations in ortho, has lodged more than 20 complaint letters against interns, residents, nurses, cleaners etc.
and has been walking up and down the wards demanding for morphine injections and raising a hell lot of noise in general, being rude to everyone.
the irony of it all? in his complaint letters, he calls everyone rude, and himself a defender of the wrongs, the righter of injustices etc etc. quite ironic that he mentioned sueing his own brothers in the same letter.

on the bright side? (there's always a bright side). i had to set a plug on an 85 year old gent with a shoulder carbuncle, and he entertained me lots, kept quiet whilst i set the plug, joked with me afterwards and generally made me feel lots better :) when doing his post-op review, he was still cheery although in lots of pain, and politely asked for a jab to stop the pain. what a gentleman! :)

patients. love them? hate them? you decide.
but like i said, i still love my job. :)

Wednesday, September 24, 2008

ortho internship 2

this week has so far been a mixture - there was a tonne to do on monday!

my overflow ward actually had many things to do - my intern was actually happy that he could pass his time usefully instead of bumming away in the lounge reading the papers. and we finished everything in our usual slow and languid fashion by 1245, just on time for him to go post-call at 1 pm. :)

after a long slow lunch (everything is long and slow in ortho, i have realised), i head over to the infection side (septic arthritis, MRSA, osteomyelitis etc) to help my friend with some bloods.
after we get yelled at by the ID consultant ("don't let the files touch the table! don't touch the curtains! wash your hands! blah blah blah"), and realise just how unsterile and unclean we are and feel ashamed, we balk in horror at the amount of blood tests he has ordered - 4 culture bottles (2 sets) and 4 tubes (including a coag studies and a cross match) = more than 20 mls of blood in all.

and this patient has cardiac and renal failure (really really oedamatous hands) and is BMI +++ (obese is right) and has MRSA pneumonia and really really really small tiny bad veins.
:( :( :( :(

so we prep culture sets and sterile gloves and mournfully head to her bedside and beg her into letting us do our work. to our great surprise, she hardly flinches when my friend does an arterial puncture (we thought it'd be kinder than waiting for her small tiny veins to drip 25 mls of blood slowly), and i try to rouse her to ensure she's not coded on us!!! so scary.

and the arterial puncture doesn't work - we try on both radial arteries and still NO BLOOD. dang.
so we look for femorals but with BMI +++ it's a little hard to feel (since we are so inexperienced and new) so i suggest to my friend we use the PICC line instead (peripherally inserted central catheter - for long term iv abx use, costs about $700 to insert. ack). after getting permission from the nurse, we try our hardest to draw blood, but NOTHING COMES OUT!!!! :(

i run to the nurse and tell her we can't get anything from the PICC line, and she freaks out and comes with saline to flush the line. and whilst she does it, i watch and realise that : you have to UNCLIP the PICC line to give the saline flush.

after the nurse leaves, i quietly tell my friend that "hey, we didn't unclip the line!"
and he is right in the middle of a 3rd radial puncture.
and both of us look at each other and burst into hysterical laughter, right in the middle of the ward, right in the middle of the procedure.
we can't help ourselves, we've just spent 1 hour trying desperately to draw enough blood!
i think everyone thought we were mad but really, we were so suepr relieved when we used it and it worked. THANK GOD!!!! :D

after this, when i stood up from the patient's bedside, i was whoozy! goodness me.
so i thought we could go home - it was 5.20 pm and our day ends at 5 pm!
but no, the intern says to clerk a new case (with active pulm TB!) and the 2 of us are ready to faint. hahaha.

well, all is said and done, but i still love my job. i walk the hallways knowing that there are crappy days and there are good days, but i still love my job :)

on the bright side, yesterday and today was bliss!!!
i took off at 1pm yesterday and went to watch mamma mia (fabulous!!!) with my friend who was post-call (i wasn't post-call but my intern said i could leave) and we didn't even need coffee to stay awake! :D

and today my precious stethoscope died on me :( there goes $700 :( i hope it's under warranty!!!!
but we ended real early too and i'm back here typing this at 530 pm :D

bliss :)

Friday, September 19, 2008

ortho internship

ortho internship has started!
and it's not quite like medicine internship.
it's another month of pretending to be a doctor and trying to learn how to be a proper intern.

on the bright side, it's been fun :) i've gotten to do backslabs and casts! i'm learning post-op reviews and what drugs to order.

on the dark side - it's really quite boring. there is NOTHING TO DO because i'm handling overflow patients (those not in the ortho wards) and they're all long-stayers and very stable. so my intern and i will see them every morning on our rounds (no attendings or residents, just us both. horrifying) and chart up whatever we think. i'm learning just how different ortho charting is from medicine (think very very short and to the point), and i guess that's the attraction of it to some people.

i've already found a patient i adore :) she's smiley, never refuses my blood taking skills, always has a cheerful word for me despite my pathetic-ness about knowning, um, nothing. she really really brightens up my day every morning on rounds!
sadly, she also has an iatrogenic epidural abscess (from a lumbar laminectomy) that's been evacuated, but her wound isn't taking well. when i did the wound inspection today, the edges weren't apposed or granulating, the only thing holding both sides together was the stitches. :( v sad. my intern said to leave it for a few more days, we'd check again on monday and pray for the best over the weekend. i hope so too!

so far calls have been a farce - i've gotten to go home at 830 pm the night i was on take :) in part, this is due to there not being any rooms for us to sleep in, as well as having no new cases come in.
however, i stayed back to wait for my friend to travel back together one night this week, and ended up helping her with her ward call (meaning that you see all cases in the ward - such as low/high hypocounts, giving 1st dose antibiotics, doing procedures etc) which was SO BUSY. omg. thankfully between us both we managed to help the intern out a fair bit and we left at 11 pm, utterly shagged out. whew.

still, i'm thankful for being free as compared to being horrendously busy (like some of my classmates on the colorectal team) where they go home at 10 pm on a daily basis. NO THANKS.
i would like to work hard, but this is also my final year and i want to rest and study as well - i'll work hard when i need to (like on call) and when i should (as an intern). but for now, i'll enjoy my time off and use this time to study for the fast approaching finals! :)

Friday, September 12, 2008

derm is finally finally finally OVER.

all the cramming and studying desperately for a short 5 minute exam at the end of 2 weeks. it feels a little anti-climatic.

and it was a total letdown.

right now i'm just too tired to say much, but as most of my class, it's unlikely i'm going to pass. i still love dermatology very much, but really, today's test was AWFUL.

Monday, September 1, 2008

of rashes and itches

ear candy: the ting tings! :)

we've started a 2 week rotation in dermatology. it's only the first day today!

so far, i've sat in a psoriasis clinic (oh those poor patients!) and seen numerous viral warts being removed. ouch.

i've also learnt that to do derm, you need to do an MRCP, which kind of puts paid to all my hopes and dreams of doing derm!

i used to think that derm was for the lazy and weak (please shoot me), being influenced by general surgeons (i was young and impressionable back then!) in the early days of medical school, who had no qualms slagging off dermatologists as being lazy and headed for a good life, where money and time were in abundance. little did i realise i would fall in love with the visual nature of the "spot" diagnoses of dermatology, the quick consultations, the ability to impact patients's lives so greatly (even if the conditions aren't life threatening).

i regret dismissing it so lightly before! derm has had me enthralled with rashes, bullae, scales, warts and more. (i still have to admit i like OB/GYN more though)
but it's a highly competitive specialty and i, being closer to the bottom of my class rather than the top, am not likely to get in, even more with the need for an MRCP (my medicine is in a highly woeful state).

so i guess i'll just enjoy derm whilst it lasts and look back on it with fondness :)