The 3 month-old doctor

When most patients see a doctor in hospital, they assume she’s been practicing for years. No one thinks the doctor might only be 3 months old.

And when some nurses with decades of experience see a new doctor, they assume the doctor knows more than he really does and more than they do – despite knowing the doctor just graduated from medical school.

The only people who consistently recognize how little we junior doctors know are the senior doctors.

It’s a pity then, that they’re so often absent when things get hairy.

Half the time in hospital the nurses won’t even address me by name. They just say “Excuse me doctor!” with an unsettling air of deference to someone 10+ years their junior.

You have to learn quickly to recognize your new name.

And when nurses become anxious about a patient whose blood pressure has plummeted, they calm themselves when they see you leaving the patient’s room: “It’s fine” one says to the other. “The doctor has seen him.”

You have to learn quickly to recognize your burden of responsibility.

Learn quickly.

Imagine reader, that YOU – assuming you’re not a doctor – wake up one morning to find yourself on a surgical ward. A senior nurse comes to you and says:

Doctor! Mary Simmonds has just been transferred to the ward from ICU. Should we clamp the NG? Should we flush the drains? When do the clips come out? Shouldn’t she be on her usual anti-arrythmic? And could you chart some more fluids?

There’s not another doctor in sight.

Just you.

How do you feel?

That’s how I feel. I’ve never heard of Mrs. Simmonds. I have no idea what operation she had, when she had it, or how long she’s been in ICU or why. It follows, that I have no idea where her clips are, what her drain is draining, and what her usual medications are. Does she need more fluids? Does she need her anti-arrhythmic? Why was it stopped?

I haven’t a clue.

I need to learn quickly.

But first I have to say the 7 words that I’ll be repeating on an hourly basis every day.

I don’t know. But I’ll find out.

First stop: the patient’s medical record: a collection of two-hole punched sheets of paper in danger of falling out as the holes have ripped, covered in the unintelligible scribbles of 30-odd people: interns, residents, specialists, overtime and evening doctors, nurses, physiotherapists, and dietitians. I can recognize every 3rd word of every 4th entry.

Maybe the blood results and image reports will shed more light on Mrs. Simmonds, so I head to the computer.

BEEP BEEP BEEP

That would be my pager.

I’d love to ignore it, but it won’t stop beeping until I answer it. I call the extension that flashes up:

Hello this is humanb. I was paged?

Yes doctor! John Reynolds has dropped his blood sugar on ward 3B and his respiratory rate is in the yellow zone. We need a clinical review.

Um okay. I’ll be right down.

So I’m off to ward 3B. On the way, another nurse sees me…

Oh doctor! Lionel Wiggins needs his medications recharted.

Okay, but that will have to wait.

But he’s due for his insulin before lunch!

BEEP BEEP BEEP

That would be my pager again.

Hello this is humanb. I was paged?

Yes doctor! Tom Black is being discharged this morning. Transport is booked for 20 minutes from now. Have you written his discharge summary? We need it before he goes.

I have no idea who Tom Black is.

BEEP BEEP BEEP

Hello this is humanb. I was paged?

Yes this is pharmacy. You charted Rita Lightheart for metaclopramide 4-6 mg TDS. Didn’t you mean 10mg TDS?

Uh…

And she’s also charted for tiotropium and iotropium. They’re the same class of drug – one long-acting and one short-acting. Do you really want the patient on both?

Um, I don’t know. But I’ll find out.

I hang up.

So what was I doing?

Another nurse:

Ah! Doctor! Mike Borne’s cannula has tissued. His urine output is only 10 mls per hour and the night doctor charted 2 litres over 12 hours but I need a new intravenous line and he’s got really crappy veins. The medical student tried, but no luck. The patient will only let us try one more time and then he says he’s done!

BEEP BEEP BEEP

That would be my pager. I go to answer it, but headed my way is a Consultant, i.e. an Attending Doctor, i.e., a senior doctor under whose name some of my patients have been admitted, i.e., one of my Bosses.

Shall we do a round?

He wants me to walk with him as he sees his one patient who is stable. I have to scour the ward looking for the medical record and medication chart fast enough so I can hear everything he’s saying at the bedside and then diligently record his findings and plans going forward. Only there are no more blank pages in the record, so I have to dash back to the nurse’s station to get paper. I miss what he’s said at the bedside, but he doesn’t notice. I record his plan and he’s off. He won’t be back on the ward again for two days.

Meanwhile, John Reynolds on 3B still needs a clinical review…

BEEP BEEP BEEP

Hello this is humanb. I was paged?

Yes this is Lesley at Pre-Admissions Clinic. You’ve got 4 patients here who need to be seen. They’re all booked for surgeries later this week. Two of them have been waiting for 30 minutes now.

Um, okay. I’ll be down as soon as I can. 

I’m starting to feel weak, and then I realize that I haven’t had anything to eat or drink today. Also, my bladder is starting to feel paralyzed from being full for the past 2 hours.

There are so many things I’m supposed to do and so few things I know how to do.

Well I know how to pee. I’ll go do that.

On the way from the toilet, I see the patient tea trolley, so I grab a packet of cookies.

Now what? My mind goes blank. I’m not sure where to go.

Oh yeah, John Reynolds on 3B.

But a patient catches my eye and calls me over.

Nurse! I need a bottle, I have to go!

He’s not my patient.

Sir, let’s press your call button and a nurse will be over. 

I reach for the button but he grabs my arm.

Nurse! I need a bottle now!

I see that he actually has a urinary catheter in, so he doesn’t need to pee in a bottle; but he’s delirious and doesn’t know this.

BEEP BEEP BEEP

Deep breath.

I silence my pager.

I close the patient’s curtain and check to make sure his catheter isn’t blocked, but actually draining urine. I smile at him and explain that he doesn’t need a bottle and show him his catheter. He settles down. I squeeze his hand and smile good-bye.

On leaving his bedside I think about what’s left to do. I start prioritizing things in my head.

#1 Keep your cool.

#2 Stay kind.

#3 Remember the point.

John Reynolds on 3B isn’t well. He needs a doctor.

So off I go.

It turns out that John Reynolds has lung disease and an anxiety disorder and often has a respiratory rate in the yellow zone when he’s distressed. His blood sugar has dropped but it’s barely below the lower limit of normal, and it goes up nicely with a simple glass of orange juice.

Orange juice.

Next time…

I’ll tell my Boss, “I’m sorry sir, but there’s a few more urgent matters that I need to handle first.”

Next time…

I’ll ask for help from other junior doctors and suggest to nurses that they seek another doctor’s help if it’s urgently required and I’m busy.

Next time…

I’ll get more information from nurses about the patients who need clinical reviews so I appreciate the level of urgency. I’ll also make simple suggestions over the phone – like giving the patient some orange juice and re-checking the blood sugar in 15 minutes.

Next time…

I’ll pee when I have to and eat when I should.

You learn quickly when you’re a new doctor.

But never quickly enough.

Top Posts 2010

I started this blog in 2006 under the same name – human behavior – but under a different URL: americaninoz.wordpress.com. Back then it was truer in form to a ‘blog’ as I tended to reflect on current events, so posts were best read when current. It was also truer to the URL, as it focused heavily on my experience and perspective as a Yank in Australia.

These days the blog is shifting more into a reflection on human behavior as I consider my own experiences and the actions of those I observe from day-to-day.  ’Human behavior’ is so all-encompassing a subject, that I’ll no doubt end up writing about seemingly dissimilar things. And by the look of the WordPress Report for 2010, I’ve already covered many seemingly dissimilar subjects.

Below are the top 10 most viewed posts for 2010. This is not an accurate reflection of the most read posts, as you can read a post on the main page without clicking its permalink. But it does give you an idea of the range of subjects covered this year. That’s not terribly interesting though. What IS interesting, however, is what interested readers.

10 A Four-Year Old’s Revenge
9 New word: globus hystericus
8 When doctors cry
7 Art Break: ‘To Do’ List
6 O Positive
5 Adios Facebook
4 The healing power of crafts
3 Last days
2 This is Sydney: Jacarandas
1 The Book that Moves People

Art Break: Home

My mother spent her birthday here in Sydney and her present this year was something I knew she’d love: a painting of her house in Virginia. The house is our first house after decades of apartment life, and the only home her grandchildren have ever known. I was even married in the house, on the front lawn. A local band played on the porch, and our next door neighbor happened to be a preacher, so he walked over to preside over the service. A few tables with umbrellas were situated on the lawn along with a small wooden dance floor. And our own barbecue grill was rolled out to the driveway for the cook from a local barbecue joint to use for making pulled pork. It was a great wedding.

So the house has special meaning for us.

Pastel on paper, 26'' x 16''

I did the picture in pastel. I had originally tried to paint it in oil, but that was a spectacular failure. I’m still learning pastel painting at the same time as my drawing develops, so there are some serious problems with this picture. But I like how the picture commands your attention. You can appreciate it close-up and at a distance, for what it is. It’s naive but it’s got impact. I’m getting better with light. And the place looks cheerful and serene.

But my favorite part of the painting is the inclusion of my mother’s grandchildren:

Pastel on paper, detail

They’re crudely portrayed but I’m working with thick and chalky colored sticks on a small scale. What I love about this section is how so few lines so clearly suggest each girl. You know which one is which. I think they’ll love seeing themselves painted with bright colors in a picture hanging on their dining room wall.

But what I love most about this picture, is that if my family should ever decide to move from here, they’ll never leave that house behind.

Happy birthday Mom.

humanb

Last days

After five long years, yesterday was the last day of medical school.

And today is just a Thursday.

It was all rather anticlimactic in the end. I spent five years socially unhappy as a black American in her 30′s among a cohort of Australian fresh-out-of-high-schoolers. I was sick of school before I even started the program. This was my 3rd degree. That’s not a boast, but an admission of my fear and insecurity about entering the adult world of grueling work days and heady responsibility. I spent every semester not certain that I’d pass it. I was plagued with doubts about my older brain’s ability to keep up with the best and brightest of Sydney. And let’s be honest, most of the kids in this program were Asian, and after growing up with American stereotypes seared into my subconscious, I was convinced that every kid named Grace, Wu or Apresh was going to wipe the floor with me in class.

In the end, I graduated with much higher than average marks. Oddly enough, I think it was precisely due to my being an imported, 30-something year-old oddity. I had no parents to please, no burden of expectation, and no campus social life to distract me. Already married, I had no boy troubles. Already degreed, I had made all my college mistakes and had already done to death the all-nighter, so I was over it. Anything less than 7 hours of sleep was unacceptable. Of a different generation, my approach to doctors was one of easy and comfortable deference, but friendliness and self confidence. They were just people, after all, and many of them not much older than me. So I stood out for my supposed “maturity”. Of course, my being the lone black American made it inevitable anyway.

Looking back, it was not an academically difficult enterprise, medical school, and it was actually less work than I was expecting. But it was grueling nonetheless. There was no joy. I couldn’t see the end of it. It seemed to take forever.

And then yesterday it seemed to end quite suddenly and without fanfare.

Few students showed up to my hospital this last week, and to the doctors with whom I had been working for only a few weeks, Wednesday was no different from the day before. They’re used to students and junior doctors changing every 8-10 weeks and patients changing more frequently than that. I may have stood out, but I wouldn’t stay in their thoughts after I’d said good-bye.

At least there were moments to mark the occasion…

My crush – a doctor with whom I had done a rotation – cornered me at one point in a room where I sat alone. He maintained one of his famous penetrating stares and enquired about my future and my exam marks. He told me repeatedly that I was a great student and that others had said as much. (Ooh, that means he asked about me…). He gave me small, awkward smiles and I blushed. With any other doctor I would have given them a bright smile and a bone-crushing hand shake in good-bye, but he made me still and shy. It was a special moment at the end of an era. Sweet and tense.

And the doctor with whom I had been working, who I suspected found me brusque in that way Americans seem to be, had surprisingly kind words for me.

You know I’ve seen a lot of students, interns and registrars come and go. There are those that try to do as little work as possible, and there are those that really take responsibility for their patients. I know you’re going to be in the latter group.

I gave her a big, bright smile and a bone-crushing handshake.

And perhaps to reinforce her faith in me, minutes later a woman approached me that I had met briefly 8 months ago. We had engaged in some chit-chat then. I wasn’t sure what her role was in the hospital. She approached me for help. She had a patient in the psychiatric ward who needed an intravenous line (cannula), and there was no one on the psych ward to do it, as the patient refused to let the sole male doctor who could, complete the task. I found it curious that she would ask me on a medical ward full of doctors, but I went happily. I’m sure my supervisor and our team found it just as curious.

When I arrived on the psych ward, I was told I had to insert the cannula in the busy lunch room where the patient was seated beside other patients and grumbling about another woman’s failed attempt to cannulate him. He was emaciated, with mobile veins that eluded needles and he was very disagreeable to getting poked again. After I inserted the needle and didn’t get a sense that I was in the vein, he began shouting that I didn’t know what I was doing and that he wouldn’t tolerate it anymore.

Who is this girl? She hasn’t a clue what she’s doing! Take it out damn it! Take it out!

It’s alright sir. She’s an expert. This happens. Just one more try, the woman said.

One more try and then that’s it! You go away! No more!

I inserted the cannula on the second go, smoothly and with skill and confidence that eluded me even one year ago. I thanked the man for his patience and I was thanked profusely in turn by the woman and other staff on the psych ward. And as the woman hadn’t been familiar with our brand of cannula (having come from London), I opened up a second cannula to show her how they worked. She was grateful.

When I returned to my team, I explained that I had went with a woman to cannulate a patient, and one of the doctors on the team said:

Yes, that was Dr. Demint [name changed].

Who? I asked.

The head of the Psych Department.

Oh.

And she had asked me for help. And she had welcomed my instruction on our equipment. And she had entrusted me with a task where had I failed, the patient would have refused any future attempts to his own detriment.

That made the last five years kinda worth the pain.

And her humility and willingness to seek the help of a medical student didn’t inflate my ego. It humbled me. I saw so clearly then that doctors do best by their patients when they know their own limitations, when they seek help, when they put faith in each other. When they check their egos at the door. When they’re a team.

And now I’m a member.

For a brief moment I felt like part of something bigger than my own life. I was no longer an oddity here. I fitted in. I was a cog in a machine of good intentions and service. I was a doctor in the making.

And then I took the hour-long drive home for the last time. Went to the local movie theatre. Bought a beer and a bag of sweet chili chips and watched the latest Harry Potter. Went to bed and woke up this morning to just another Thursday.

Already my memories of the last five years are fading. When I start working at a new hospital in January, I won’t remember how I know the things I do. I’ll feel as if I’ve always known them. And I’ll be too busy stressing over the multitude of things I don’t know and have to learn fast because a patient’s life is on the line.

How is it that the last five years of my life could be fading so fast? It must have something to do with my 30-something year-old brain. I don’t hold on to things very well. I keep only the fleeting emotions connected to periods of my life, little more.

So today doesn’t feel at all like the first day of the rest of my life, or the end of an era.

It feels like Thursday.

When doctors cry

To wrap up my medical education, I’m spending six weeks as a pre-intern working in the geriatrics ward of a Sydney hospital. I had already done a geriatrics rotation, but I love caring for the elderly, so I wanted to do another. Instead of choosing the brilliant male geriatrician under whom I had studied before, I chose a female geriatrician – a painfully soft-spoken woman with delicate features and a Buddhist-like self-possession. I had chosen her because I recalled hearing her struggle with the ethical implications of managing a patient once; so I thought she would be a great doctor from whom to learn about the ethical minefield of managing patients in the twilight of their lives.

Last week during our daily rounds, we paid a visit to a patient who had been in the hospital with us for two long months. She had just celebrated her 84th birthday the previous day. This woman had suffered through countless infections and despite multiple antibiotics, never seemed to improve very much. She was also unlucky enough to develop a severe allergic reaction to an antibiotic we had given her, and had to watch helplessly as her skin peeled off in thick layers from her face all the way down to her toes. Not surprisingly, she grew weary and exasperated with her stay in hospital. By the time we saw her on Thursday, her skin was looking close to normal and she seemed sadly resigned to her prolonged hospital admission. But she hadn’t been eating. And she spoke only when asked a question.

How are you doing today?

Alright.

The female geriatrician examined her, reviewed her blood tests, and then asked the patient’s daughter to come out into the hall with us. She told the daughter that she felt it was time to withdraw the multiple antibiotics and invasive intravenous line that was delivering them. She explained that the best care for her at this stage involved providing her mother with every comfort measure possible. The daughter understood.

After the daughter returned to her mother’s bedside, the doctor turned to us – her team of two junior doctors and one medical student. Her round, brown eyes started to water and redden. She began to sniffle. And her voice quivered when she spoke:

She’s been with me so long.

She didn’t try to hide her tears from us. Far from it, she even asked the male junior doctor to fetch her a tissue. When she first explained to the daughter her decision to withdraw treatment, I was shocked and ambivalent. But it wasn’t until the doctor showed me her watery eyes that I was overwhelmed with sadness.

Is it impractical for her to return home? I asked.

There was a quiver in my voice too. I quickly blinked away the beginning of tears and swallowed the growing lump in my throat.

No, it’s not practical, she said.

As we left the ward, I noticed that the female junior doctor was quiet. I looked to her and she said:

It’s so sad because the doctor is crying.

I thought that was interesting.

It was almost as if we junior doctors had already – and maybe too quickly – become immune to the sadness of a patient’s death. It was as if we needed a cue from the doctor to be sad. Or, maybe we were sad – not at seeing the end of a life – but at seeing human suffering in the form of a doctor brought to tears. We expect them to be stoic about the loss of their patients – especially the 84-year old ones.

Or perhaps we aren’t immune to the death of patients, but rather simply less invested. The senior doctor was the one responsible for this patient’s care. She made the clinical decisions. She was the person most responsible for returning this woman to health. She did her best, and it wasn’t enough.

I don’t know if her tearful reaction was a common one among doctors, but it struck me as unique. It comforted me too. Here was a geriatrician with decades of experience treating people over 65. She would have few patients who lived for more than two decades and many dying every year. But she could still cry.

This doctor impresses me in other ways, too. She always insists on closing the curtains around a patient’s bed when she examines him, while some younger doctors couldn’t be bothered in their single-minded focus to do the job. She’s always touching or holding the hands of her patients, especially the demented ones. She’s always speaking softly, visibly showing her concern, always making time – even to understand the ramblings of a patient who’s become delirious. And she always involves family in patient care – going so far as to invite them behind the curtain to oversee her examinations.

It struck me as interesting then, that she saved her tears until she was away from the patient’s daughter. I think the daughter would have been comforted by those tears. It’s a moving image when doctors cry.

The next day we approached the patient’s room on our rounds only to find the curtains pulled closed.

The patient had just died.

No tears came from the doctor that day. Only the sincerest condolences to a family visibly shaken. The family thanked her for her care and concern. And they meant it.

They knew the doctor was crying too, if only on the inside this time.