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Monday, March 28, 2016

Surgery - the rush

Wednesday: OPD

 My first OPD.

Showered and left early to the ward to finish work there and be at the OPD on time. It was a continuous rush of patients from 9 o'clock till the time PG asked me to go have lunch.

There was everything - Road Traffic Accidents (RTAs), healing and non-healing wounds to be dressed, deep gaping wounds to be sutured, pain abdomen of various kinds.

My first sutures were on the leg of a patient. Neat 3 of them (or 4?). Dr Mayank encouraged me saying "You're a surgeon, ha?" But those were the easiest sutures that day.

While we were incising and draining abscesses, dressing more wounds, etc. a serious RTA patient came, unconscious. The PGs took direct laryngoscope and intubated him, called up ICU duty doctors for emergency, gave a slew of drugs, gave CPR multiple times, etc. But he couldn't be saved. I was pressing on the AMBU bag for a while and I don't even remember when I handed it over to someone else.

Nothing would stop more patients from coming in. The rules of work applied quite strongly here. Nobody else would do our work and we had to do them sooner or later.

After lunch, the rush mellowed a bit. But there was still work for everyone. Students filled in holi colours needed suturing. Quite close to the eye. I was scared to touch the temporal artery. Left it to PG.

While debriding a wound in another patient there was a bleeding artery. And the PG just ligated it in a second.

Evening came in quite soon. We had one patient with pain abdomen and history of typhoid fever that we had to do an emergency OT for (for intestinal perforation). I went to the OT, submitted the list. There was an orthopaedic surgery going on from 3 apparently which was still going on to go on till 8. Our patient would have to wait for that to be over.

Things like these and it was night quite soon. I stayed in the OT to watch the laparotomy and saw the surgeons closing the ileal perforation. They biopsied the edge of the perforation which I sent for evaluation. I went straight to a hotel from there to have dinner. It was 10.30 in the night by then.

Back in the OPD there were only occasional cases coming in. By now, the casualty OT became the place for Ortho, ENT, and surgery. We had a few more road traffic accidents and assault later in the night.

There was a child who had a scalp wound and there was a lot of blood draining and turns out you can stop bleeding and suture all in one.

There was a goonda gang in which one person got hit by a wicket and had a wound on the scalp. I had to suture it and the scalp was pretty thick but somehow I managed to get one suture through. The rest had to be put by the PG. I would later realize that I should have been locking the needle holder every time I hold it for better control. The entire gang came in to take photos while I was dressing this guy up and I had to ask them to go outside (because they were scaring me).

Around 12, the PGs gave us an algorithm to manage cases that come up in the night. Mostly pain abdomen. We then started taking turns to sleep. I slept from 12 - 4 in the Unit Chief's room (where there were 3 others sleeping, including one on the table).

After 4 there were only three patients who came in, with pain abdomen. I managed them and it was morning by then!

Thursday: Dressing

 At 8, Abdu would come back from sleep and let me go to hostel to become fresh. I rode my cycle slowly, took a shower walking like zombie, and came back. I had to go to the endoscopy room to write down the reports. Saw the duodenal opening of stomach and ?Ca esophagus and things like that.

Joined dressing after that.

If I remember correctly I gave a blood transfusion today for a patient with lipoma in his forearm and low haemoglobin.

Friday: Good Friday 

There was no OT today because "Good Friday". Went to JK grounds in the morning for our second match in Kreida '16 football. The first match was on Wednesday morning which we lost 0-1 to 2k14. Today we drew 1-1 with 2k15 and our only goal was on technicality (the defender touched the ball while it was a goal kick and we kicked it into the goal and something along that line).

Today I had two work after dressing. One was to monitor hourly the abdominal girth of a patient whom we are suspecting intestinal obstruction. And the second was to give blood transfusion to a patient who was losing blood in stools and had grown pale.

The latter guy didn't have any attender but I took his consent and started blood transfusion. The sister scolded me a lot for this because apparently if something happened to him the question that would be asked would be "Why did you do blood transfusion without having an attender? Whom did you ask before doing so?" etc. Apparently, patients can't make decisions for themselves here. Weird world. Anyhow I've decided no more blood transfusions without permission of the entire family.

The former guy also needed a Contrast Enhanced CT scan so we could confirm it is intestinal obstruction and figure out a cause too. I was supposed to talk to the radiology department and get it done on an emergency basis. His creatinine, urea, etc were normal so there was no contraindication for using IV contrast. But it was 1 o'clock by then and they asked me to come and convince the next day's staff.

Saturday

This day from morning my work was to make sure to get the CT done. I managed to convince today's staff even though they first said that surgeons should be bold to open the patient since the X-ray showed clear signs (multiple air-fluid levels) of obstruction. Nevertheless, they fixed 2pm as the time and asked us to be punctual or forget the CT. We got it done and there was indeed obstruction and some free fluid in the peritoneum with nothing much except these in the report.

Sunday

We did emergency surgery for that person today and saw that there was a perforation which led to peritonitis which led to ileus which lead to obstruction and distension of abdomen. There was a lot of suctioning of fecal matter to be done before the abdomen was closed.

Monday, the 28th

Major OT. Meanwhile the patient with blood in the stools got esophageal banding done in the endoscopy room. Now the esophagus can't bleed any more. But he still has to find an exchange donor for the blood I transfused him.

In the OT we had a lot of cases. Goiters, Thyroglossal cyst (sistrunk's operation), the lipoma in intramuscular plane in forearm, Ca Breast, Appendicitises, Haemorrhoid, and a hernia.

By the time I took the case sheets from the anaesthesia PG the rounds were over and there was no work left.

In the night some of us went to Kalamandira to see this drama called "Top" (in Kannada) which nobody understood (even Kannadigas).

Surgery - feeling comfortable

On the first day my PG had asked me "Hey, how do you like it here? Feeling rushed and busy?". I replied "it's okay". I like rush. I like having a hundred things in my mind. But I like it only when I feel comfortable and confident about the things I have to do.

And on day 1 I wasn't so comfortable. I didn't know what to do and everything had to happen in a jiffy. But over the next few days I started feeling comfortable. I had this aha-moment when I realized "Aha! It's all about the patient. Our duty is to make life the best for our patients." And if we think from that perspective, everything becomes easier.

Saturday: Dressing

Dressing is required for most patients with large wounds and especially diabetic patients. Wounds tend to get dirty with dead tissue and pus (promoting bacterial growth) and debridement ensures there is nowhere that bacteria can grow comfortably. But good debridement is a difficult skill to achieve.

I'll write about hydrogen peroxide, povidone iodine, spirit, sterile gauzes, pads, gloves, etc on a later day.

Sunday: Free Day

This is a relaxed day where we don't have complicated cases to monitor. After rounds, the entire unit went to have tea. Back in the wards I asked my PGs whether us interns had to come back later for rounds. They said "Yes, come for evening rounds at 5.30 and night rounds at 8.30". I asked them, "Oh, so 3 rounds in a day?" "No, there's also another at 10.30pm. Coming for that?"

That evening the seniors were hosting "Summer Dreams" their graduation day. It was a nice night. Dr BM Hegde was the chief guest and apparently didn't have any eccentric thoughts that night. I missed the movie the seniors made because I was helping the Malayalis edit the audio track for their dance. And that dance was simply superb. Later I was managing the computer playing the karaokes and songs, working together with Ganesh, like all these years. Met L.I.'s super cool mom while having the "high" tea which became the "long" tea because of the queue.

It was during the graduation day dinner that most of us saw each other for the first time properly after internship started two days back. And that's when I realized that we had to sign in an attendance register in the office every day morning. People who were doing night duty were sneaking in and eating while we were leaving quickly to sleep early to report for duty on time next day. Gone are the sleepless nights of student days.

That day when I woke up I had a very weird dream. I was vomiting into a tub in which my PG had vomited already and which was actually meant for the patient whom we had just put Ryle's tube to vomit into. Brain seems pretty absorbed.

That night I was reading this "House officer's survival guide" which helped me gain more confidence.

Monday: Major OT

In Major OT there are no local cases. So, there's no need to give test doses. Or rather, the anaesthesiologists will take care of that part. I ran to the wards to take BP before the OT starts. Didn't forget to sign the attendance register today (for all three days). But we still haven't given the reporting letter that the unit chief signed on the first day to the office.

Today there was one multinodular goiter and one pleomorphic adenoma of the parotid gland being operated. Actually there was another MNG in the list. But it was too late and this surgery was postponed. When I asked the PGs though, they said "Sir said we will do it in the ward itself. Didn't you examine the swelling, it is a single large swelling, isn't it? So we'll use something called a crow's leg and put it in between and pull the swelling". Very funny.

That night, Fadnis brought his brand old Yamaha RX 100 motorbike and we had one square round around the hostel wroom vroom.

Tuesday: Wards

Nothing special in wards. Checked BP and pulse. Then, turns out, there was an emergency surgery for a burst abdomen early this morning for a female patient. She was in surgical ICU. I had to give her a blood transfusion. Yes, that would be my first. But turns out the lady had not passed urine either. So I had to catheterize her too. I had learned how to do it, even watching a youtube video previous day, and so I did everything correctly till the actual insertion of catheter into the urethra and then I couldn't find the urethra. Finally the sister came to my rescue finding the urethra, inserting the catheter, then filling the balloon with water, connecting urine bag, etc.

Then I got the blood from blood bank (like I had done it previously in paediatrics) and the sister again  taught me how to cut the outlet, prick the sterile transfusion set into it, and start transfusion without spilling blood or making it all unsterile. Not to forget, I got the consent signed before the transfusion started. I then started monitoring the patient continuously for any signs of adverse reactions. There wasn't any.

Before we left, the sweet sister gave me and Abdu and even Abhishek a piece each of the kalathappam she had got as gift from a Malayali PG.

Friday, March 25, 2016

Surgery - fitting in

On 18th, we made mental calculations about which surgery unit we would be posted to, when they would have OT, etc. and then reached surgery office around 9. There was a table full of dates written against our names according to which the first half would have general surgery straightaway, being divided into units in order (A,B,C,D,E,F,A,B,C,D,E). The first half of the other half would be in Anesthesia. 3 of the remaining people would be in pediatric surgery and the last 3 would be posted in neurosurgery or plastic surgery. As expected, me and Abdu were in C unit of general surgery (headed by Dr Madhu). (After all the diarrhea cases we took together in pediatrics, one more joint venture for us).

Right next to the postings matrix were the wards displayed. I saw that our unit had the wards 10 & 15. I headed to 10th ward and there on a chart paper was displayed prominently what days were what for our unit - "...Friday - OT..." it read. And we ran to the operation theatre.

Friday: Minor OT

I quickly changed into  OT scrubs and went inside where the PGs were preparing cases and waiting. I introduced myself and was asked to first report to our HoU. By then Abdu came and we saw the anesthesia interns sitting and writing letters to their HoD and we wrote a letter each too. When Dr Madhu came in, he congratulated us on passing and asked us to work hard and signed our letters saying we did report on 18th.

Then the OT work started. Our main work in the OT is to enter surgery details in the OT register, send specimens for histopathological examination, give test dose of local anesthetic (patients come directly from OPD to minor OT to get minor swellings, etc removed), watch surgeries and try to learn, and be around and be helpful (help surgeons scrub in, get vicryl, spirit swab, etc, bring tablets, injections, etc from the patient's attenders outside, collect case sheets, attend phone calls for the surgeons, etc).

I knew how to open vicryl without making it unsterile. And that's all I knew. One of our nice PGs, Dr Pradeep, taught us everything else.

First, we get a plastic container from the patients' attenders to put their specimen in. We also get the ubiquitously useful Transpore™ (which is a surgical tape that you can tear with your hands). Then, as soon as a thyroid nodule, appendix, cyst, or swelling is out, we take them in this container, add formalin to it and label it. Subsequently, we fill the "histopathology requisition form" with the details of the patient, the specimen, the preservative used, etc. and brief history which we give the patient's attenders outside along with the specimen so they can take it to the pathology department for evaluation.

For patients coming from OPD to get their swellings removed under local anesthesia, we need to give a test dose of the local anesthetic to ensure they don't have an allergy against that. I saw Dr Pradeep doing 5 of these in less than 2 minutes and I did the next 2 in 2 minutes each. Spirit, 0.5mL in syringe, push intradermal, withdraw, throw the syringe and needle. Repeat.

Inside the OT that day we had a laparoscopic appendicectomy, some thyroid swellings, and many swellings here and there. I was too dazed that day to remember anything. But I do remember assisting in excising a cyst in the arm of a person. Mopping up blood, cutting suture thread.

After OT, the PGs made sure we ate puffs before running back to our wards to do a quick round. Around each bed the faculties would be on the right side of the patient, the PGs on the left, and us interns and nurses at the foot of the bed. The senior PGs briefly present the patient's condition and the unit chief gives orders on what to do for the day for each patient. One patient was just being shifted from OT and I was asked to put a Ryle's tube for that patient! I was stunned but the PGs told me they would help. Then we went to the female ward and the PGs put Ryle's tube for a patient there (which she kind of aspirated first).

At the end of the rounds, the unit chief asked us interns to split ourselves in between our two wards and exchange after 15 days. I decided to stay in the male ward where I waited for the PGs who disappeared to put the Ryle's tube for my patient. They were surprised to see me waiting when they returned and put the tube swiftly. Then, I was about to be asked to put a urinary catheter, but that patient didn't need it.

The PG then told me that the primary duty of house surgeons is two things - BP & BT (Checking blood pressure, and making blood transfusions happen.) I was supposed to go to hospital by 8.20 next morning to check the BP of all patients.

That day was only the first day I started skipping lunch. Maybe the energy and enthusiasm that first day brings, I didn't even go to Aroma bakery for an egg roll. Back at hostel I realized that I would be scared of not knowing how to do catheterization, how to give blood transfusion, etc that I better do it quickly and be comfortable about doing it again. I would soon get a chance to do both.

Tuesday, March 22, 2016

Rules of Work

I had one day of internship under my belt before the actual beginning date of internship on 18th March. This, thanks to my senior who had to prepare for his fantastic dance item for their graduation day on Friday (19th).

Even before that, on 12th, when the final years organized a "summer slam" fun event for seniors, I got one hour in paediatrics emergency (receiving) ward alone (with PGs). That is when the PGs taught me how to manage fever, cold, diarrhea (+dehydration), etc; with dose conversions for pediatrics. In there, though, an intern's main task is to monitor the children continuously. Check their SpO2, check their BP, check their pulse, check their respiratory rate and make sure they are all healthy. When checking for SpO2, if the fingers are too small or the child is too wobbly, you can use the toes. I wrote down all numbers in case sheets and it took more than the hour I was supposed to stay there.

But then, on 17th, when I was in the same ward from 11 o'clock till evening, things were much more fun.

Thalassemia. There were two major children that day. I had to fill their case sheet up, making sure to not miss an enlarged spleen while doing the per abdomen. The PG collected 4 blood samples each from them. Apart from cross matching sample and complete haemogram (+peripheral smear) sample which they needed every month when they come for transfusion, that day we took a sample each for ICTC and HBsAg - because they are at risk because of frequent transfusions. After despatching the parents with the samples (especially to the blood bank with a requisition letter indicating the blood group), I had to fill up the thalassemia registers - one to just note down every patient who comes with thalassemia (to track down thalassemia), and one with dedicated pages for each patient (to track down the patient).

By then the patients would have returned with the requisition approved from the blood bank so I can go and collect the blood. And they have a thalassemia register too (apart from the normal blood register and requisition register). In essence, everything is written down everywhere. The blood bags will be readied with name of the patient, blood group, donor number, and so many other details. I have to carefully enter those details in all registers checking they are all right. But, first thing to remember is, remove your shoes while entering the blood bank.

Back at the hospital the blood must reach ambient room temperature before being given to the patient and if it takes a long time before you can start transfusion put it in the fridge like I did. One of my patients didn't have a IV catheter yet and I didn't know how to put one yet and so I had to wait for my seniors to reach at 4 before starting transfusion. But, as you will read in the below paragraphs, it didn't start at 4 as planned.

Mantoux test. This one is simple. Take an intradermal syringe (insulin syringe?), take the tuberculin from the refrigerator. 5 TU (tuberculin units) (0.1mL) is all we need. Give it intradermally to get a small raised area. Draw a circle around that with a pen so there's no need to hunt for it when reading the reading between 48 and 72 hours.

Sedation. Kids who need MRI scan can bob their heads in all directions to confuse MRI machines. To prevent them from moving you inevitably have to put them to sleep. Either do this naturally or with lorazepam. Pushing drugs is tricky. First you block the backflow through the catheter by holding firmly at the wrist. Then you open the catheter and attach your lorazepam syringe. Then you unblock the vein at the wrist and push the lorazepam slowly. Then block again while you remove the lorazepam syringe and attach the saline syringe. Push the saline so that the lorazepam goes inside all the way and not stay at the catheter. Finally, you close the cap while the kid slowly goes to sleep. All this is wasted if the kid wakes up by the time they are inside MRI machine. And that happened to my patient thrice that day.

Death. I was learning how to put a venous catheter from the senior intern who came at 4. And then, this baby came with "difficulty in breathing". And while I was putting the pulse oximeter on the toes I realized it won't show anything because the senior put the stethoscope on the cardia and there was no activity. They then threw torchlight into the eyes and there was no pupillary reaction. All I had to do was stay back while my senior asked all the relatives to go out and called in a male relative to whom he broke the news. But the whole family knew within minutes and there were some cries but I was lost in writing thalassemia registers by then.

Work. It was getting late and I was staying longer than I had to, so I just reminded my senior who was taking over about the blood transfusion and slowly left and that's when a parent whose child wasn't sleeping under MRI machine came to ask for a doctor to accompany and give sedation. My senior asked me to leave nevertheless saying it's not my duty time. And just as I was outside, I was called by the intern I was replacing because he was called by the PG to accompany the patient and give sedation. And there goes rule #1:
Do not run from work, it will come behind you.
 So I went back. Filled syringes with lorazepam (the senior intern filled this and I'm still confused about the dilution) and saline. And went with the parent to reach the radiology department. And there the mother was waiting with the baby sleeping on her and she broke the news as soon as we reached "the baby slept and we took MRI". So, corollary to rule #1.
Sometimes, if you delay work just long enough, you might not have to do it.
 But I realized over the next week the rule #2
Do not let work get piled up. Do them as soon as you can.
 My actual first posting is to surgery department. I will write about it in the next post.

Monday, March 21, 2016

Disclaimers

I have been thinking a lot about the legalities of posting about my hospital work in this blog. As I think about it there are several problems that arise by me writing. But, I cannot not write and lose these posts forever. So, the following disclaimers apply for any post on this blog or any article I link to.

  1. What is written here will not be substitute for medical advice. I might cook up crazy hypotheses and write here. If you follow them and die, do make sure I won't be held responsible
  2. By I, I mean, I, my college, my friends, my teachers, my seniors, my juniors, my textbooks, my websites, my linked articles, their authors, and so on. Nobody shall be held responsible for what happens to you because you read this blog.
  3. The thoughts on this blog are entirely mine and even if I'm writing about others' thoughts, it is my thoughts on what I think are others' thoughts and therefore still my thoughts.
  4. Do not think you can use any work in this blog to sue me or my college or my friends, my teachers, my seniors, my juniors, or anyone I mention or miss in this blog. I could be writing things that never happened. For all you know, all this work is fiction and if they bear any resemblance to real life events, they are only coincidences.
  5. I might change any writing on this blog at any time (including these disclaimers). 
  6. No, we can't have established a physician-patient relationship because you read this blog.
  7. Basically, if you use this blog as a part of any argument (including but not restricted to legal fights), that argument shall stand invalid.
Now, about patient confidentiality. I will make sure no patient identity is revealed, leave that to me.

Let's just hope this goes alright.

Tuesday, March 8, 2016

And we begin

I had begun calling myself a doctor from the moment I finished the last practical viva. When I was traveling all last month I could only think of going back to hospital and starting work as an intern. But when on Sunday the result was announced, I had to triple check it wasn't a computer error.

I probably have the lowest mark in my batch. At least, in Obstetrics & Gynecology I have the lowest possible mark in theory. And that too I wouldn't be through had it not been for the theory viva which gets added to the written papers.

But that doesn't matter now. Because now I get hands-on. I will have "my patients". I can be workaholic. I can do as I learn. I can write the original case sheet now. I can make a difference.

The excitement reminds me of the first week of dissection. Eagerly waiting around the cadaver to bring the scalpel out and slice through the skin. That feels like yesterday. Time flies. And this next year won't be any different. And I don't plan on missing out on any moment of it.