Internal (Eternal) Medicine: Part 2 of 4
November 7, 1998
Saturday
This is part 2 of the 10-week epic called Eternal (Internal) Medicine. Please send me a note if you did not receive part 1, as I (stupidly) forget to note down which subscribers received part 1.
I forgot to tell you in the last issue that during the 4-week stay in the Medicine wards one’s schedule is extremely irregular. Patient care does not respect the natural 24-hour circadian rhythm by which we arrange our daily schedules (according to physiologists, humans actually live a 25-hour day if left to our own “natural” schedules, but the 24-hour rotation of the earth makes us synchronize our body clocks with the sun’s ups and downs… this partly explains why we feel groggy on Monday mornings, after a weekend with unstructured schedules).
Back to patient care. One can get “decked” or assigned a patient at anytime – you’re lucky if you get a patient during office hours. You can be decked on a pre-duty, duty, or post-duty day… you can even be “deckable” on all three days and end up spending the night in the interns’ callroom three nights in a row. The usual day in the wards starts with an Endorsement Conference, 2 hours of “grilling, roasting and eating” students-in-charge of newly-admitted, newly-dead or newly-intubated (patients with ventilators/respiratory assistance) held Monday to Saturday. A list of all these patient admissions, etc. is written on the whiteboard, and it’s a veritable shopping list from which the residents conducting the endorsements choose a patient to be endorsed. While they deliberate on which patient to select, a high palpable tension level in the room is felt by all (previously decked) students present. The unenviable student-in-charge then goes up to the front of the room, faces the audience and presents his/her case: history, physical exam, diagnostics, diagnosis and differentials, treatment (are you overwhelmed yet?) Along the way, the residents ask questions on ANYTHING related (even remotely related) to your patient’s case. They usually follow-up your answers with a “clinical pearl”, or an important piece of knowledge which would be useful in medical practice -so they don’t just grill and eat you, but feed you as well.
This is called an Endorsement Conference since at the end of your case presentation you’re supposed to endorse the patient like so: “Please monitor vital signs Q2 [every 2 hours], watch out for hypertension [high blood pressure]. If BP [blood pressure] is higher than 160/110, you may give Nifedipine 5 mg SL [an anti-hypertensive drug, 5 milligrams per capsule, under the tongue] and recheck after 15 minutes.” There is such a thing called a “cut-off time”, i.e., 3 am – if one gets decked a patient after 3:00 AM, the patient is not for endorsement that morning. Meaning, if I get paged at 2:50 AM on Tuesday morning, I have to go to the hospital and interview, examine and study the patient’s case before the 7:00 AM endorsement.
Then there’s the paperwork. Thank God again for computers. A typewritten complete clinical history (record of your interview, physical exam, diagnosis, treatment and course of the patient in the emergency room before admission to the wards) can be easily transformed into a clinical abstract (sort of summarized record, shorter than the clinical history) via cut-and-paste. Same thing with progress notes, which have to be written everyday (if patient is “toxic” – a step away from being in the intensive care unit) or every 3 days (less toxic). Viva le cut-and-paste! Instead of writing everything all over again, one just has to add to the file. Then at the very end of the patient’s hospital stay, the student-in-charge has to make a discharge summary containing (you guessed it) the contents of the clinical history and progress notes, plus home medications and out-patient follow-up schedule. When to do all this paperwork? Uh… during the time you’re supposed to be either studying or asleep. Sometimes admitting a patient and doing progress notes make me go home at 12 midnight or 2 am. Then I have to be at the hospital again by 7 am the next morning. Bummer.
Sometimes I’m on duty at the Cancer Institute, where the cancer patients for radiotherapy or chemotherapy (drugs designed to kill cancer cells are injected intravenously) from all PGH departments are. I don’t like it there since (1) most you do is scutwork (for those who have forgotten, this is blood extractions, naso-gastric tube insertion, intravenous line insertions, etc. and you don’t learn much from this, it’s all technique); (2) monitor patients’ vital signs every 1, 2 or 4 hours; (3) get pushed around by nurses who order the scutwork and tell you about patients whom the residents/fellows have ordered referral to other departments (a referral letter has to be dropped along with a clinical abstract, and guess who has to do the paperwork…); and (4) usually – especially at night – you’re the only medical personnel around.
(4) is probably the most medical thing you do at the Cancer Institute. The nurses refer to you patients with symptoms [chills, headache, nausea, etc.) whom you have to assess and maybe treat. Hey, if it’s hypertension, fine – I can handle that. But if it’s something like the heartbeat had stopped (“code”, in medical lingo) and I have to start measures to revive this patient… I know I’m training to be a doctor, but don’t leave me all alone! Remember I’m still practicing medicine under supervision… where is the supervision? Of course, while reviving the patient you’re supposed to call for a licensed MD (namely a resident) but what to do in the meantime? I try my best anyway.
Fortunately, most patients at the Cancer Institute are DNR (do-not-resuscitate status, meaning the relatives have indicated in the patient’s chart that they didn’t want any snore reviving measures and they would just want the patient to exit in peace and without suffering). However, the relatives may refuse to sign a “DNR” and only make the patient DNR while you’re resuscitating (since they now see what we must do to revive a patient – pump the chest, put in an endotracheal tube, etc.)., so I still have to do all the Advanced Cardiac Life Support maneuvers (this consists of CPR – cardiopulmonary resuscitation, basic with doses of epinephrine/adrenaline to start-up the heart). … it’s not as easy as it looks on TV – they look so confident and all (their patients aren’t dead). Stressful.
OK. I’m stressed out too, and this is a long letter. How about part 3?
JOINT is the Journal of INTernship, a series of email messages to family and friends (“journal subscribers”) written during my yearlong medical internship from May 1, 1998 to April 30, 1999. Internship is one of the requirements before taking the Philippine Physician Licensure Examination (also known as the Medical Boards). Journal entries were edited for clarity in January, 2020. Read more about it in the first blog post, Introducing JOINT.
