What is a CRH Internship like?

So here we are, one year out of medical school. Internship is behind us and we’re venturing out into the world of fully registered medical practice. And the question one everyone’s (no-one’s) mind is, what is internship at CRH like?

Internship anywhere in Jamaica and the Caribbean is rough. The high patient load and typically low resources keep our clinical practice particularly inventive, and adhering to evidence based medicine is a lot like playing whack-a-mole (just when you think you’ve hit the nail on the head, it’s disappeared and you have to try again).

I chose CRH for my internship for a number of reasons. Montego Bay is my hometown. Because it’s a Type A hospital we see more complicated cases and therefore get more clinical experience. Compared to the other two Type A hospitals, the patient load is a balance between overwhelming and nonexistent and the staff are (for the most part) approachable.

Surgery, Internal Medicine, Pediatric Medicine and Obstetrics & Gynaecology share the same basic traits no matter where in the world you practice. What I have found different is the slant of intern duties. In my opinion, a CRH internship gives you primarily clerical experience. Any additional medical experience is dependent on the interest and enthusiasm of the individual intern.

Broadly speaking, the intern’s job is to see or SOAP inpatients every morning, round with the consultant, carry out requested procedures and tests, and follow up the results of these tests and act on them. Variations of this theme can have the intern seeing or clerking new patients in the Emergency Department, making interdepartmental referrals, organizing procedures off the compound, administering medication etc etc.

At the end of the day the intern’s is tasked with making sure the patient gets whatever they need to get better and get out of the hospital.

A lot of your time is going to be spent writing request forms, writing referral forms, writing notes in the docket and writing orders for medication. Your practical procedures will primarily involve phlebotomy and placing intravenous accesses. There will be times when you don’t feel like a contributing member of the team and there will be times when you’re the one leading ward rounds. There will be plenty of opportunities for learning, and in the same breath you will feel stifled by your supervisor when they only want you to be a scribe and a gopher. Brush these moments off and look for teaching moments. They’re not always obvious, but you can learn something from everyone.

Surgery

On the Surgery rotation, interns spend six weeks in General Surgery and six weeks in a surgical specialty such as Urology, Orthopaedics or Paediatric Surgery (Neurosurgery didn’t take any interns at the time). There’s a lot of hands on experience to be had here, participating in major and minor operations like laparotomies, appendectomies and the ever-frequent digital amputation. It’s impossible to leave this rotation without knowing how to suture and the basics of pre-op and post-op care, especially since the intern is the one leading the ward rounds, the one with primary management of inpatients.

Paediatrics

Paediatric Medicine divides your time in two six week blocks of the paediatric ward and the special care nursery. Here you learn attention to detail, the importance of acting on the results of investigations and how to handle stress. While on paediatrics you pick up skills in lumbar puncture and intravenous access placement, medication administration and infection control. Interns on Paediatrics are responsible for  administering all IV medication, which is something unique to CRH. If this doesn’t sound daunting, it should. The ward capacity is 20 patients (each. For the ward and the SCN), who require medication up to four times per day.

Medicine

Internal Medicine is a straight three month block with no sub-specialization (small chance of getting some Nephrology exposure). Patient load is high, resources are low and most of your patients are frequent visitors to the ED. It can get frustrating, especially if you like ‘saving people’ because the majority of patients are repeatedly sick because they are non-compliant. There are a lot of social and economic reasons behind this non-compliance but tertiary facilities are the ones feeling the brunt of that primary care failure. This is where you hone the twin skills of BLS/ACLS and breaking bad news. The practice of Internal Medicine is roughly the same across the board, with variations in level of academic exposure and access to resources (CRH falls low on both spectra).

Obs/Gynae

Finally, Obstetrics and Gynaecology is the Other surgical rotation, where instead of gunshot wounds and pus filled abdomens you get happy bouncing babies and failed abortions. The scope of your exposure ranges from suturing multigravid vaginal lacerations to contacting the Centre for Investigation of Sexual Offences and Child Abuse (CISOCA) for your 13 year old patient with pelvic inflammatory disease. OB/GYNs balance surgery and medicine remarkably well, with a smattering of paediatrics (neonatal jaundice has to be diagnosed by the OB/GYN intern before referring to Paeds) and the general atmosphere of the department is one of bonhomie. Interns on O&G  don’t have very active roles in patient management (most of the decisions are made by the consultant, with the intern carrying out the orders) and the consultants round daily so you’re never really on your own (pros and cons, here).

Conclusion

CRH definitely has its ups  – interns have the option for on-compound housing, for instance – and its downs – necessary machines get broken, a lot. And at the end of the day the decision about where to do internship is multi-factorial. I wish I could offer a comparison among internship sites in Jamaica or even the wider Caribbean but alas. I’m not so lucky enough to have enough friends in high and low places.

I will say this: no matter where in the island or Caribbean you do internship, almost everyone will be prepping for USMLEs or some other foreign licensing exam. Internship may feel like the worst year of your life (and in some ways, it is) but it’s just a stepping stone to postgraduate qualifications and the start of your actual medical career.

The Unfortunate Business of Death

Breaking bad news at one in the morning
Is not part of the prescribed medical school curricula
Real life has no point score for empathy
Patience
Directness
But conversations twist as they need
And break when they must into tears
Screams
Silence
Five minutes.
(Is an exam, not the ending of a life)

Chasing Creativity

The muse of inspiration is a very elusive fellow. The mole in Whack-A-Mole comes to mind, or that crafty Bugs escaping poor Elmer Fudd. Maybe it senses my subconscious’s mixed feelings towards creativity (like, why did I choose such violent analogies?) but whatever the reason inspiration is certainly not sleeping in my bed at nights.

Of course, if being inspired isn’t part your day job, it’s much harder to clear the cobwebs from your boxed up dusty mind at whatever odd times you can snatch to first be inspired then find the time and will and consistency to write or paint or choreograph. If you’re not in a state of continuous and conscious open-mindedness (as, for example, in my day job where being closed off happens whether you want it to or not) your task is that much harder.

My problem isn’t getting inspired though. I frequently think of topics I’d like to talk about at length, or story ideas to get on paper (someday) but at the exact moment of inspirational breakthrough I am nowhere near pen or paper or laptop. I’m in a taxi, or about to head out to work, or in the middle of seeing a patient and my brain goes ‘We’ll just file it away for later’ and it goes the way of the Dodo.

(I cannot be the only person whose brain does this).

The obvious solutions are to jot down a quick line on my phone so I can remember at least what I was so inspired about. Or to walk around with a voice recorder (or, again, use the one on my phone. Ha.). But, that quick line on my phone often fails to capture the essence, the vivre, of my brief excitement. The line goes dead and hangs limply in black pixels, mocking me with its wasted potential. Repeat ad nauseam.

Perhaps the real solution is to quit my day job and roam the streets, laptop or notepad in hand, digging for inspiration like a coal miner: grubby, starving and desperately grateful for the light of the sun.

Dawnchaser

I love travelling.

I love the quiet stillness that enters my mind when I’m riding along though noisy traffic or empty back roads with serene pastures. There’s a weight that feels lifted off my shoulders, a loosening of the usual necktie of anxiety and suddenly I can breathe. I can think without over thinking. I can decide without second guessing. Best of all, I can sleep.

Travelling in the wee hours of the morning is even better because now it’s combined with the mysterious delight of being awake when no one else is. That feeling also leaves me at peace and content.

Maybe this is a metaphor of some sorts. A reminder to cherish the journey more than the destination.

And isn’t that the whole point of life anyway?

Conquering Duty Anxiety

I really don’t like being on call at the hospital.

Yes, someone has to do it. Yes, we get paid overtime to do it. Yes, this is how we gain experience as doctors. But all of those logical structured reasons fade away when I’m startled awake at 1am by a nurse calling about the patient in cubicle 5 who won’t stop bleeding.

When I was on pediatric medicine I would have a lot of anxiety to deal with on duty. It’s terrifying to be the first responder to a critical situation when you’re not 100% sure you can handle the case. To make matters worse, I was dealing with babies. Delicate (yet somehow also borderline indestructible) little human beings. In the beginning I would have regular panic attacks and palpitations, but as time went on I got more comfortable handling the common emergencies. I became more confident in my abilities, and could usually rest assured that if there was anything I really couldn’t handle, I could call my senior.

The most pervasive part of duty anxiety for me, though, the one that crops up on every rotation regardless of my self-confidence is the uncertainty about being called. You can never tell whether a night will be calm or hectic, whether you will be called ten times in one hour or once for the whole night. And that kind of unpredictability is anathema to me.

As humans we like to think that we have control over our universe. As interns we have all kinds of superstitions for keeping emergency duties light. Knock on wood to keep the bad karma away; when you notice that a night is being particularly uneventful, you can’t say so out loud or you’ll jinx it.  We do these things to try and hold on to the idea that we can dictate how a night will progress just by monitoring our actions.

But letting go of duty anxiety means letting go of the crazy notion that what we do or think will somehow impact the chances of a patient taking a turn for the worse. Or will somehow keep a hundred people from turning up in the emergency department in the middle of night.

It won’t.

The night will unfold as it was always going to unfold, whether or not you stay up having the world’s most intense staring match with your phone, whether or not you knock on all the wood. Whether or not you try to grab a few hours of sleep or comment on how quiet the wards are being. All the superstitions are doing is tricking you into thinking you have some measure of control, so that you think it’s your fault when the emergency duty turns into a madhouse. “I have 3 emergency surgeries because I didn’t knock on wood this morning”.  It sounds completely illogical, because it is. But that’s usually the nature of anxiety.

I have found that the best way to conquer my duty anxiety is to relinquish this idea of control. To let the night progress as it will, without trying to force it into whatever hopes or expectations I might be harboring. When I do that, when I go about my tasks and breaktimes free from the thought that what I’m doing will make or break the night, I find that I’m a lot less anxious and a lot less tired too.

Getting Okay with Being Happy

There are two tragedies in life. One is not getting what one wants and the other is getting it.
-Oscar Wilde

Does anyone else find that they are most miserable when they finally get what they want? I’m not talking about the feeling of almost-but-not-quite-satisfaction when you have nothing else to wish for (and come on, we’re human beings. There will always be something else to wish for). I mean the other feeling. The feeling that there’s something wrong with you being happy.

Am I crazy? Yes. Am I alone in my craziness? I really hope not.

My life has been coming together in a way that is entirely surprising and entirely unfamiliar to me. So far everything is on track (I am knocking on ALL the wood, universe): my career, my personal life, my finances. And I’m a little bit (okay, a lot) baffled by how coordinated it all seems. Granted, on the inside I’m still a wibbling mess trying to pass off as an adult. But on the outside and in the big picture things look kinda sorta maybe okay.

And that freaks me the hell out. Instead of enjoying the good times while they’re here I am anxiously waiting for the other shoe to drop. For the storm after the calm. When will this all be dragged away from me, I wonder frantically. How long can happiness be mine??

As if there’s something inherently wrong with me being happy. As if the universe in some way needs to balance out this time of contentment with an equally horrible tragedy. When in reality no one is taking stock of the good times to balance them out with bad, and for God’s sake what is so wrong with being happy?

Freud blames my parents. I blame the messed up way my mind works sometimes, tricking me into thinking that I’m only doing well if I’m suffering. Why do our brains lie to us? Is there some magic way to stop the lies, or at least ignore them?

Maybe the only answer is the daily reminder to be gentle with myself, and appreciate each moment as it happens. Which is a good enough answer for me.

It’s a Good Morning

Last night I did yoga for the first time.

I’ve been talking about it for years – of course the closest I’ve ever come was attempting a two hour instructional video and giving up after the first five minutes. But last night under the stars in the instructor’s backyard with a light summer breeze brushing against my straining muscles, crickets and muted traffic playing background music I pushed myself to keep up and finish what I’d started. It paid off. I woke up this morning feeling refreshed in a way I haven’t felt for a long, long time.

The only sad thing is that Montego Bay doesn’t have many opportunities like this. For a city that is jam-packed with tourists and expatriates our culture is ridiculously under-globalized. And once these opportunities spring up they’re usually available to only an elite group of people (uptowners). The Western end of the island is struggling to keep up with the East, even though Kingston is the only city on that end that’s spearheading development.

Still, I am grateful for the expansion of alternative hobbies and activities in my hometown. Dance classes are becoming more popular, cafes are patronized more often (and by people who aren’t tourists). Now there is yoga (there has probably been yoga for a while). And while these opportunities wax and wane in response to public support and financial solvency, I hope there will be a gradual evolution of fun (and healthy!) things to do in the second city.

We can be more than just our beaches (but we do have awesome beaches).

What to Expect when You’re Interning

Internship starts, not with a bang or a whimper, but with a barely noticeable intake of breath. Not a deep breath, a regular resting one. You don’t notice it until you do. That’s the only excuse I have for why there are no entries in my journal until six whole days into my intern year. I will attempt to recreate those first few steps now.

If you’re completely unfamiliar with internship in Jamaica, here is a brief overview. If you already know everything there is to know, feel free to skip this next paragraph.

When medical students graduate from UWI they have already applied to work at one of five several government hospitals (and one semi-private hospital) qualified to supervise medical interns. What follows is a 12 month long, somewhat supervised trek through the four basic clinical specialties: General Surgery, Paediatric Medicine (babies), Internal Medicine (adults) and Obstetrics & Gynaecology. This experience is unique to each hospital (and each intern), but overall we’re expected to emerge from this year with the skills necessary to become a fully licensed medical practitioner. (Don’t worry, nobody tests you on these skills. Which is probably why so many bad less than stellar doctors slip through the cracks).

At my hospital, we received a one day orientation the week before we were scheduled to start working. I think this is the standard. We were introduced to key members of staff (bureaucracy, meh), discussed the housing situation (lacklustre at best), were given a tour of the facilities (too big to walk around without getting tired) and then spent two hours delving into grim and gory details of everyone’s favourite topic: remuneration.

Predictably, the session left us entirely unprepared for the actual first day on the job.

I started my internship in General Surgery and I remember feeling small. Not unimportant, just literally small. Like a child. In final year, patients would laugh when I approached them for procedures, asking if I was still in high school. And here I was not six months later as their doctor, their first point of contact with the surgical team. My first ward round passed in a blur of unfamiliar names, familiar diagnoses and trying to sign my name quickly enough to move on to the next docket.

It got easier. Those patients who were handed over to me left. I got my own patients. My handwriting got quick (and sloppy). I became familiar with the system through trial and error. I asked questions, I did things the wrong way, bore the scolding with chagrin and did it properly the next time. I learned how to brush off the rudeness that you encounter on a sometimes daily basis, grit my teeth through collecting and administering medications (because this is not my job*), learned how to smile the right way to get a porter’s help**, and how often to call the radiology  department to actually get my patient’s goddamn x-ray.

If you ask me (and you are asking me), those are the skills an intern needs to learn and learn quickly. Your medical acumen is already there, you’re already familiar with every procedure they expect of you (it is okay to need supervision; my point is you’ve heard of or seen them all before). What you need to survive is the knowledge of how to navigate the complex social and professional sphere that is the tertiary medical facility. How not to step on toes, when to step on toes, what the unwritten protocols are and how to use them to your advantage (hint: they mostly involve doctors’ egos). I could write a book on helping the fresh faced med school graduate survive, a pocket-sized guidebook probably, but a book nonetheless. Yet here I am, giving it away for free. (I’m tucking this idea away for my first book though. Obviously).

From my viewpoint , having completed almost 75% of my internship I can tell you unequivocally that at some point you will fuck up (the scale of fuck-up varies widely and depends entirely on you). You will feel like you’re the worst, most incompetent intern that ever interned. And then you’ll survive Paediatrics, and you will feel like you can conquer the world. You’ll reach a point where it gets better and you’ll survive this are’t just aphorisms any more, they’re universal truths. You will surprise yourself.

Unless you quit halfway through. And that’s okay too! It’s better to figure out from early that you hate this job and run away to  rob run a bank somewhere. Everyone isn’t for Medicine and this is fine.

The first part is hard, and the middle part, and I think the bit at the end is going to be hard too. Every three months you start over, start learning something else. Carry the good lessons with you, drop the bad habits and keep your wits about you. If all else fails, remember, it’s only twelve more months***.

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* Here I feel obligated to add that helping patients get better is my job. And if that involves getting their medication, mixing it, administering it, wheeling them down to x-ray or up to operating theatre by myself while manually ventilating so their oxygen saturation doesn’t fall below 95% then that is what I have to do.

**Before anyone gets into a feminism/sexism snit I would like to point out that each gender has its advantages in the hospital hierarchy. The guys get nurses and other female staff to do any and everything for their patients just by flexing a bicep. Therefore I am not above using my femininity to get shit done.

***Unless you’re a foreign-trained intern who failed their CAM-C exams. Then you could be here for a long, long time.

All My Underdogs

All cultures have rituals that mark the stages of life: birth, coming-of-age, marriage, birth again and death. No one ever promised that the shift from one stage to another would be easy, would not sometimes involve dragging you kicking and screaming onward with the passage of time in your life. Maybe that’s why these rituals exist, to celebrate change and make it a little less scary.

People are less scared when they’re surrounded by friends and family. Never mind that you just turned 16 and your body is a raging mass of hormones doing terrifying things you’ve never done before (armpit hair? Eww). Never mind that you’re about to enter a legally and socially binding contract with one person (you hope forever) and create a life with them. Never mind that a screaming, wriggling tiny human has just appeared in your arms wholly dependent on you for food and security. No, never mind.

Because you get to be surrounded by people who care enough to support you and offer hand-me-down advice and kitschy statuettes and less-than-adorable baby clothes. These are the big changes, the life-affirming steps that everyone seems convinced is in the right direction.

But there are other changes too, quiet ones. Steps that aren’t quite on the beaten path.

Sometimes change isn’t celebrated, it’s questioned.

  • ‘Are you sure this is wise?’
  • ‘Why fix it if it isn’t broken?’
  • ‘I just don’t think he’s right for you’.

Or it’s condemned.

  • ‘You’re not the person I thought you were’
  • ‘He’s just going to take advantage of you’
  • ‘Abortion is murder’

But all types of change are surrounded by swirling insecurities (I’m gaining weight and body odour! What if we get divorced? How do I know what her cries mean?). It’s just that one set of choices gets a gold star from society while another set gets swept out of the way like broken china.

But not today. Today I’d like to celebrate our off-kilter decisions, the choices your instincts whispered were right despite your mother’s voice yelling the complete opposite. So raise your glass if you are wrong. . . in the right way.

Here’s to divorce parties and starving artists, pro-choice options and falling in love with the ‘wrong person’*. Here’s to starting over (and over, and over). To marriage-less, love-filled partnerships; to childlessness by choice (and not by choice *hugs*). To careers that fill you with passion and purpose. To the lonely, often painful, steps to self-healing. Here’s to walking away, and running toward something wonderful (or something that could be wonderful – you’ll find out when you get there. The point is you’re running).

Your choice might not be celebrated, but it is loved and supported. Just like you.

 

*Not the abusive person, not the person you think can be saved, not the addict either. The other wrong person.

Day in the Life of a Paediatric Intern

This post originally titled, Waving the White Flag. (It’s Kleenex).

Where to start with Paediatrics? The current headlining scandal? The mind-numbing, soul-crushing duties? The prickly staff? The demanding work days? How about all of it, all at once, the way it is in real life. Nothing about this rotation happens in an orderly fashion. One time our senior registrar scolded us for not completing discharge summaries on time, saying “they are just as much a priority as dealing with procedures for patients on the ward and from clinic and giving medications”. If it’s one thing Paeds has taught me, it’s that everything can be a priority, all at the same time.

But all this non-stop action has succeeded in murdering my already feeble immune system so that I am now sick. With the flu. Probably. Or tuberculosis. Probably (not). If you know anything about me, it should be that I do not handle illness well. I handle it like a boy, really. Which is probably sexist to say but we all know it’s true. Boys are complete babies when they get sick. And so am I. I curl up in the foetal position and demand soup in a voice that sounds like death colded over*. I am utterly useless at anything involving physical, mental or emotional energy and I sometimes fantasise about using telekinesis instead of getting up to retrieve my phone from the counter five feet away.

Going to work today was entirely out of the question, so I used my leftover energy to feel guilty about calling in sick. I know what a Paediatric work day is like. I also know that I have duty tomorrow and I had to make the decision to take today off so that I could have some reserve of energy with which to survive that 36 hour beat.

This is what a Paediatric work day is like for me:

Starts at 8AM (unlike Surgery which would start at 6:30-7 because the earlier you arrive, the earlier you leave. On paeds you leave late no matter what). At 8AM you see patients on the ward until ward rounds start at about 9:30.

Ward rounds end at about 11AM when you start the day’s procedures which include taking blood, collecting urine samples and sending patients for investigations (like xrays etc). This is for patients admitted on the ward, as well as patients here for the day for a review or patients sent up from clinic.

All intravenous medications are administered by the interns, on a strict schedule. Medication also has to be ordered daily from the pharmacy because they don’t send up more than one day’s supply. This means writing up several charts and getting your senior house officers (SHOs) to sign them because your signatures carry no weight.

Then there is other paperwork like writing discharge summaries and prescriptions for the patients leaving. And there is following up of lab results, mostly cultures from microbiology, that require one of you to go into the lab for about an hour to write down results from the 3-4 books that serve as records.

All this takes you until well into the afternoon and suddenly it’s 3PM and you haven’t stopped for lunch. You just gave the 2PM medication but you can’t eat yet because this baby needs an intravenous access (a ‘drip’) and another baby just got admitted from Accident and Emergency (A&E) needing blood and urine cultures.

There are three of you working but it doesn’t seem like enough. The SHOs will ask “Are you the only one doing procedures? Where’s Dr. So-and-So?” and you will calmly explain that Dr. So-and-So is giving medication while Dr. What’s-Her-Face is in A&E seeing referrals and there’s no one left to help you and they will press their lips together and give you a look which you’re pretty sure does NOT mean “That sounds rough, I’ll help you” and instead means “Well. You’re just gonna have to get your shit together” and you move on with your day. Breathe and move forward should be the mantra of Paediatrics.

After you finish procedures, following up the regular lab results for the samples you took off in the day can take you beyond 4PM because some result always comes back abnormal and needs to be acted on. I don’t like to leave that kind of work on the duty intern because duties are rough enough without adding work that’s carried over from in the day. So I never end up leaving before 6PM and usually leave around 8PM.

I’m not going to get into my eating habits because my aunt reads this blog and would probably have a conniption but suffice to say I would not turn down the offer of a live in chef. Or maid. Or professional masseuse. Or all three in one so I’d only have one monthly fee. Am I setting the bar too high?

Fuck it. The bar was high before I even got here. This whole time I’ve been trying to brush it with my fingers, on tiptoe, stretching furiously toward some untouchable standard. Today I got to rest my aching body/mind/soul for a teensy bit. Tomorrow it’s back to the rack.

Flecti non frangi.

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(*Because death warmed over sounds a little too pleasant. Like Death already got soup and a blankie and now he’s pleased as punch. Although I have been told that my sick voice sounds very sultry so maybe my voice actually is warmed over).