Indian Medic

My days in the ward… well are not over, but limited. I have to be present for get rounds presented to me and my co-SRD from the house officers and in turn present to at Grand rounds. Then its off the OPD, where we see patients individually and discuss with the Attendings if needed.

Our hospital, if have not mentioned so earlier caters to a subset of the population whose medical expenses are taken care of by the Government. Its not like Mediclaim or insurance, people don’t pay a penny from their pockets but all expenditure is taken care of up front. I wont go into the details of this scheme but needless to say patients have no clue about the amount of resources the government is spending on them.

The Second factor here is the patients are generally well educated and well informed. So they know what treatment modalities are available for their respective illness and that if it is not available at our hospital then they are aware that it can be made available for them at hospitals on our panel. Well the outrageous things our patients demand… is a topic for another day.

We I have observed in the OPD and the wards both, Multiple cases of Headaches miraculously cured by CT scans.
Interesting huh?

We have our fair share of Migraines and Cluster headaches. Well the clinical diagnosis is migraine is made only after all other differentials are worked up for and ruled out. But the patients I’m talking about have headaches so major, no amount of medication can help their symptoms. But then as part of work up of non resolving headaches, to look for possible Itracranial bleeds or SOLs (Space occupying lesions) we get their CTs done.

And lo and behold, irrespective of the reports the headaches miraculously vanish. Poof!!

99% scans are clean, except for may age related changes etc. But till date I have seen at least a dozen patients making a recovery from getting, what we now call as, ‘Therapeutic CT scans’, almost all of them brain scans. Its quite a joke among us residents, we even make wagers on whether the consultant will ask for a CT or not and whether it will cure the patient or not.

I knows it’s the placebo effect, its psychological …whatever. But our most of our consultants don’t think twice before ordering head CTs for such patients.
What about the money? What about the exposure to radiation?

I have to be in this setup for maybe another 2 years. But when I start practicing in the real world where the patient has to pay out of his pocket, will I order such expensive investigations with such alacrity? Will patients pay for it? Or they’d rather take a second opinion?

Nevertheless the tale of the Therapeutic CT scan has many more editions yet to be added.

But I am here finally through the grit and grime, now as a second year resident or SRD (Senior resident doctor). I was promoted a month back, but it has taken me a whole month to get my bearings right. I for one found the transition from JR to SR a bit tough. I remember as the JR I always used to envy the SRs. ‘All they need to do is sit in the on call room and attend phone calls while I sort through the whole pile of shit and keep them informed about the bad eggs in the ward!!’. Boy was I mistaken.

Now I realize as a JR I had only my ward pile of shit to sort through, but now as SR and the honor of being the Physician/Medical resident on call, I have to sort through the whole hospital’s pile of shit, at least that’s what it feels like.
I mean why does a surgeon or an Orthopod need me to get up and put it one paper at 3 am in the night that their patient of so and so condition with a Serum creatinine level of 4.5 mg% should not be put on Aminoglycosides or NSAIDs and that exactly is why his kidneys have failed.
And this on a repeated basis!!

It really does feel like our department goes about wiping up after the other departments in the whole hospital.

I can only right on file so many times that a patient of Ischemic heart disease with CABG done and LVEF of 15-20% needs to have his fluids restricted to less than 800 ml/d, or else he’ll land in Acute LVF. But when he does get ‘well hydrated’ after his TURP and does land in Pulmonary edema, I am the one needed to rush to his bed side first.

Hmmm… do I sound pissed?
I guess I’m pissed, but I love this job, I love the thrill, the satisfaction out of it.

CONFESSION:- When there is a particular tough patient to diagnose, with inadequate signs to provide a diagnosis, but I work him up on a hunch and it does come right ultimately, I feel just great. Am not proud of it, I feel terrible for the patient but the tougher the puzzle, the more gratifying it is. Kind of like House.MD, just not so much drama.

Mind it though, I am still supposed to be on call for 36 hours with 12 hours interim off. But I am supposed to be in many places at all times, I have to attend calls from the ER and all Physician consluts in the other department wards (Physically not only over the phone!!!), oversee the JRs of all Medical wards, take care of the Dialysis unit and still be the back up for the ICU guys, the list is endless. Man was I wrong about the sweet life the SR!!!

I have grown up though, I am a bit more tougher, I take it in my stride when terminal patients kick it, but when the unexpected, apparently young and healthy ones dies, I feel a loss. I have got a bit of an attitude now, I don’t let people take me on rides anymore, especially my colleagues, who have totally used me to get all sorts of leaves for the weddings and funerals in their families the past year.

The one thing I really want to work on now is my studies. I am totally fraught over how I am gonna study so much.

As the famous Spider man one liner goes ‘With Great power comes great responsibility’. I am supposed to know better, know more, to tell the other fellas what to do, take life or death decisions in the wards during emergencies. Even the nurses and residents of other departments want my opinion on their personal family matters. Obviously, my knowledge has not increased by the same rate/ratio as my responsibilities have. And I am struggling to keep up.
Cant make a fool out of myself in front of the juniors or the attendings.

I get sleepless nights, mulling over the implications of having to know all that I should. I mean I should know everything Harrison’s principles of Internal Medicine has to say by now. But I don’t, I just don’t. The more I try, I more it feels like clutching at straws. I have got a thing about studying, kind of a tic. I can only settle down to study if I know I wont be disturbed for the next 3-4 hours ahead. I need my table and chair, my table lamp, my laptop, my music, my cuppa coffee. Only then can I sit at it.

But such times are rare, and rash-hash studying doesn’t make a dent in my brain. I’m always on the edge, like some day soon, people will realize I don’t have the brains it takes to be a SR.
It feels like I’m on a balancing beam, one slip and I’ll fall great depths, lose whatever good impression I have made on people around me. One month in and I have just barely calmed to put my fears down in words. I have to walk the beam until I am really worthy of it. Worthy of being a Senior Resident with so much responsibility. And the only I can do it is study, study and study. To have the knowledge of what do when, when to do.

Plan to keep up the blogging to keep up the spirits, do need the vent.

Grand Rounds 5:18 is up at MedPage Today hosted by Dr. Val Jones from Get better Health. Check it out...

As an postgraduate student in Internal Medicine, as is obvious, I have complete a thesis or dissertation on some suitable topic. Without which I won’t get my degree. So far so good.
Finding the topic was hell, my preceptor or thesis guide is a a very strict lady, known to eat residents alive if she feels like.
‘Never cross Dr. K,’ - valuable advice from my predecessors.
Thing is she is a diabetologist, so needless to say my dissertation had to do something with diabetes.

She handed me the topic as well, ‘Something on with Diabetic foot’. How vague is that? Well after almost a months work, amidst torturous work shifts, I managed to come up with ‘Something on with Diabetic foot’. (Am being vague here on purpose!!!)

We need to submit a Dissertation protocol to the National Board of Examinations within a month of registrations. So a protocol it was, with the routine aims, objectives, study design, materials and methods etc.

Went through, numerous papers and abstracts to get inspiration for a study design. Spent endless hours online and in the library and muttering about it in sleep, (according to my mom!)

Ah, it was such a day of relief when I finally got her to sign the draft of my protocol, (after multiple corrections, editing, printing, re-corrections, and re-editing and re-printing).

Except to have it made in clear and very concise terms ‘You do know I won’t be signing your final thesis copy, unless you present two papers for me.’

Shit!!!

I have never done a paper before.

Then came the realization that I had somehow managed to come up with the protocol, now I have to run the theories, and assumptions and tests I had blabbered about in there and prove them!!

Shit!!! Shit!!!

I have no clue where to begin. Except that, I have to somehow got to get my hands on a biothesiometer.

Shit!!! Shit!!! Shit!!!

The worst is yet to begin.

As doctors, from day one of our medical training we have to work in close proximity with the other major members of the medical profession, the Nurses. They are there in every hospital or clinic or nursing home working diligently by the side of the MDs, treating patients and dispensing the medication.
But do we ever stop to say thank you to them, except as a part of the cursory thanks we mutter at, say, when they have assisted you in a procedure or examination? Do we ever realize that we as medical practitioners, the ones in active medicine at least, are so dependent on the nursing staff that we couldn’t function one day without them? And are we glad enough that we have them?

In general, the budding doctor encounters the nursing faction of medicine, when the clinical rotations begin. The clinical career of invariably every medical student begins with a sense of superiority complex, a snobby attitude and an upturned nose towards the nurses. 99% of them fall flat on their faces in the first few days, when they realize they know zilch and are the most un-needed, superfluous part of the medical team. The wise ones make friends with the nurses and all rotations are smooth sailing for them. You can get invaluable guidance and instructions from the seasoned nurses who where there long before you came and will be there long after you are gone. From blood sampling, to starting and intravenous drip, to passing a nasogastric tube they are the ones who teach you the tricks.

Having been part of the ICU team at my hospital for well over a year now, I am acutely aware of how much of what I do most of the day (and night) is dependent on the nursing staff. We have a team of eight staff nurses and one in charge. It’s as well oiled a team as can be. Each one of them is well trained in the care of critical patients. Not to mention all of them are thoroughly knowledgeable and hardworking. Some with solid clinical knowledge, excellent at interpreting the worst of arrhythmias on EKG and some with an angelic healing touch doing away with patients discomfort in a jiffy and yet some with the keen eye of experience instructing me to watch out for a particular patient, apparently stable that minute. ‘He is not looking good to me, he may crash any minute.’ And they do crash, no matter what their vital parameters or Blood gases or EKGs say!

I know I can rely on them no matter what, can catch some shut eye in the on call room trusting them to monitor the worst of the patients. There is one lady in particular who can pass a Ryle’s nasogastric tube, like no body else can in the worst of old fellas with toothless roomy oral cavities, when no matter what you do, the damn thing just coils up in the recesses of the pharynx, sometimes exiting through the mouth or at times even through the other nostril!!! And I as a resident have no other option but arm myself with the laryngoscope and Magill’s forceps to try and pass the tube under vision and sedation, (if the patient is not zonked enough already). But now I let Sr. M, have a shot at it, before I boot up. Also she can manage to find cannulate veins in the thickest, most edematous of arms around. And good lasting veins at that!! She is truly a God send.

Here in India, most of the private hospitals have done away with the traditional white gowns and white caps of the nurses. But government institutions as is ours, still adhere to the same old dress code. They are all attired in pristine white uniforms, with their hair neatly tied up, white caps, white stocking and white shoes. I can imagine how they must instill some kind of hope in the sick patient’s hearts. They are the ones who are in maximum contact with the patients, often acting as the messenger to inform me of the latest complaint they have.

As doctors, we do the history, the examination, the notes and order writing. But their job is so much more than just to carry out those orders and charting temperatures. Making the patient comfortable, showing them genuine kindness, listening to the patient’s grievances, tucking them in at night and everything. Not to mention the other tasks normal people would find queasy doing for their own family members like sponge baths and bed pans. And most importantly, packing up the bodies of patient’s who didn’t make it, to be handed over to the next of kin.

I don’t know about other institutions, but in our hospital it’s part of the nurse’s job, with the help of the attendants to do the needful when the patient expires. As the doctor, I am there with the patient till the last minute giving CPR or emergency intubations etc with watchful, hopeful eyes on the monitor. If he dies, its my responsibility to break the news to the family, and do the necessary paperwork. But am I there with the patient after they are gone? Most doctors consider it a personal failure when the patient dies on them. I do too. Initially when I came to work in the ICU, the inevitable number of deaths would simply overpower me. it would take a lot of deliberation to go out and declare the patient. Its never uncomfortable on any doctor, but I used to take it extraordinarily tough on myself, almost as bereaved as the family. I would simply walk up to patient, after declaring to the family, say a goodbye and a sorry. Then simply shut myself in the on call room for the onslaught of tears.

But in the later months, I grew tougher, it’s still very upsetting to lose a patient, but the tears don’t come anymore. That I guess is because, I used to think that declaring death was the toughest thing to do. But when I saw my colleagues, the white attired ladies, tending to the mortal remains of the patient after they have passed on, often comforting the relatives at their first glimpse of their departed loved one, cleaning them up, even giving occasional hair-washes to remove the blood and gook (Sr. M, again here), something not expected of their duty, I think to myself, do I really have the toughest job of all? I guess not.

In the government medical institutions, the hierarchy of the nursing division is essentially four tired. Simply put we have the Black belts, the Red belts, the Blue belts and the White belts. Sounds like Karate? Mostly is. The Black belted people are the head honchos, the Matrons, assistant matrons or Nursing superintendents, the Red belts are the ward incharges or supervisors, the Blue belts are the staff nurses doing the main work and the White belts are usually students or novices. Out Red belt or Sister Incharge is a firebrand. Almost sixty, with just about a year left to retire, she is the most disciplined, assertive, person around. She runs the ICU on a real tight leash, but things function so smoothly when she around and there is never any dearth of resources on her watch. She feared by one and all to the point of veneration. She makes it her own personal agenda to train all us fledgling doctors in the needed administrative know-how and forms at everything. As Kim at Emergiblog puts it she ‘babysits’ us all the time, and our head of the department and dean turn to her to get updates on the residents behavior and general demeanors. Everyone in our team is fearing the day, not long off, when our watchful motherly Incharge will retire and we will be left in a soup.

As I mentioned my contact with nurses began early in my medical career as normally does, but I learnt the hard way how decapitated we would be if they were not around. We were having severe shortage of hostel boarding in our Intern year, and we, as interns were technically eligible for boarding neither at the Undegraduate hostel nor the postgraduate hostel. The administration promptly ordered the 35-40 of us out on the streets. As if, we would go down without a fight. We went on a strike, a very vociferous and raucous strike at that, almost bringing the hospital daily working to a standstill, for we had the backing of all the undergraduate and postgraduate students. Consequently, the dean bowed down and we were allotted quarters in the nursing students hostel, which was overcrowded as well, on a temporary basis till something solid could be worked out. Needless to say, this did not go down well with the nurses and they put up a days token strike in protest.

We thought we were shutting the hospital down by our rallies and protests and shouts, we were in for a very rude shock. There were no angry slogans or rallies from the nurses, nothing overt. They just simply did not report to their duties. Man! Was it havoc!!! Wards and OPDs just fell apart, nobody knew what to do. Patients just lay there, with no body to care for them, no medication administered, no treatments carried out. The consultants were so lost, it all transpired into anger at us the interns, for being the root cause of the all that evil. We all got explicit instructions from the dean and consultants, that till the whole matter was sorted out and the nurses came back, we interns would do everything required to keep the wards running, I mean everything. The vitals charting, food distributions, medications, injections, bedpans, dressings everything. Or else we wouldn’t get the necessary rotation completion certificated.

Needless to say, it was the goriest day of my life, for I was posted then in Obstetrics, in the post partum ward. We did it all, with heads high, but am sure our batch will never ever forget that particular day, when the nurses striked. The situation cleared out by evening, when the dean made alternate arrangement for our boarding with amazing alacrity. So I know I can’t function without my nursing support system, even if I wanted to.

The state of affairs in India is changing though, consequent to the occurrences probably in the developed nations. The latest generations of nurses are all migrating out in India in search of greener pastures. International hospitals are luring them away with better pay packets and perks to boot. Its prevailing almost in epidemic proportions now. The US, the UK, the UAE are all running real short of good quality nurses and here in India there is a surplus. So it all fits. The Indian government is getting smarter though, they are trying to stem the efflux by introducing 5-10 year bonds to fulfill before anybody can leave the country. I don’t know how far it has been successful, though.

There is nothing else to say I guess, except that every doctor should make a better effort at recognizing the contribution of the nurses to the medical field. We do need them whether we realize it or not, the White caps.

Dedicated to all the nurses out there… KEEP UP THE GOOD WORK!!!