Monday, September 6, 2010

Internship: Term 1 – Relief/Nights

So I guess it's been a while since I wrote about medicine here. Oops.

My first term as an intern was relief/nights. This means that you fill in for other interns and residents who are on holidays, and you do anything from 1 to 3 blocks of night shift, covering half the wards in the hospital.

It's not really an ideal first term, because there's no continuity and little supervision. But many had done it before me, and there was no point whinging about it - I just had to get on with it.

I started with 3 weeks on a Geriatrics ward at a small peripheral hospital. It was a great way to ease me into the workings of the hospital system, eMR, procedures, etc. And one of my closest friends from uni was allocated to the same ward as me - bonus!

After that, I did a week with a very busy General Medicine team back at the main hospital. Gen Med is the dumping ground for most non-surgical/non-chest pain patients who present to the Emergency Department, and therefore a lot of my time was spent arranging consults with the subspecialties (e.g. Respiratory, Gastroenterology, etc.), hoping that they'd agree to take over care. I also wrote LOTS of discharge letters.

Next up was 2 weeks at another small peripheral hospital, this time doing Rehabilitation Medicine. It was really dull. Not much happening. Although I did get a chance to practise my venepuncture skills, because the vampires blood collectors don't service that hospital each morning.

I then had another week in Gen Med back at the main hospital, with 1 day of Paediatrics thrown in to confuse me! The Paeds day was very quiet - they didn't really need me. I did a few new baby checks, wrote 2 discharge letters and some medication charts, and that was about it.

To finish off the term, I had 2 blocks of nights - 7 nights in a row, with several days off before, in between, and after. The nights sucked about as much as you'd think they would. Basically you work, come home, have breakfast, sleep, get up, have dinner, and work. I lost a few kilos by skipping lunch for seven days! (I did have some - mostly healthy - snacks each night of course.)

I covered 7 wards:
  • 4 medical - Gen Med, Neurology, Cardiology, and Coronary Care Unit
  • 3 surgical - Orthopaedics, Urology, and Vascular.

A resident covered the other wards, and there were medical and surgical registrars on call too.

Each night, after handover from the evening team, I did a round of the 7 wards - depending on the night, this could take from 2 hours to 5 hours or more! Then I'd aim to do another round closer to the morning. On weekdays, the surgical teams arrive from about 6:30am, which cuts my workload in half. Most PACE calls (see below) were received around 6am, when the first observations (vital signs) of the day were taken.

The intern is first on call for theatre, so that means I had to assist on Caesareans. I don't normally have any problem with blood, but seeing and touching that much blood in the wee small hours made me a little bit woozy.

I couldn't believe how busy the nights were. Not all of them, but most of them. I think my longest break was about 2 hours. I hated my pager. Common pages were for people with hypotension or low urinary output. Medication pages were for pain relief and sleeping tablets. The most common things listed on the whiteboards on each ward were requests for fluid orders or cannulas. I'm not a fan of waking a patient at 3am to do a cannula, so I always asked the nurses why the patient was having fluids and whether we could let them sleep a bit longer. Many of the jobs on the whiteboards can be left until daylight, or even for the day team to do.

And then there were PACE calls, which means that a patient has breached specific parameters (e.g. high/low blood pressure, high/low heart rate, high/low resp rate, etc.), and you have half an hour to review them.

Finally, there were arrest calls. I attended several arrests, and did CPR for the first time, and then many more times after that. There was one particular arrest that really rattled me, and I was pleased that the nurses on the next ward I visited were happy to talk through it with me.

There's not as much support at night, but I found the nurses to be mostly wonderful. I was on great terms with a lot of them by the end of my 14 nights - to the point where one nurse paged me at 3am to see if I wanted something on her Maccas run! The medical registrars were very helpful too, and understood that I might call them about seemingly trivial things, because I was so new and still learning how everything worked. That said, there were a couple of nights where I didn't need to call the registrar at all. Amazing!

I actually had an incredible 'circle of life' experience one night - about an hour after a patient died following CPR, I helped deliver a baby. Quite a privelege.

I handled the fatigue fairly well. I'm lucky that the place I'm living in is an old unit block, so the walls are solid. I can't hear a thing from the apartments either side of me. I wore earplugs and an eye mask, and managed to get a decent amount of sleep most days. The weekends were the hardest.

So I managed to get through the first term mostly unscathed. I feel like more of a doctor now, but still a total newbie. A lot of my medical knowledge came back to me, but I still think I need to be doing a bit of study here and there. I'm really thankful for the access to online resources such as UpToDate and Therapeutic Guidelines. I've made good use of those during every single shift, I think. Not to mention MIMS and AMH.

Best things about my first term as an intern? A regular pay packet, and days off.

My second term is in Emergency, and I'll have more to say about that in early November.