You know you're a doctor when...

You believe that all bleeding stops ... eventually.
You find humor in other people's stupidity.
You believe that 90% of people are a poor excuse for protoplasm.
Discussing dismemberment over a gourmet meal seems perfectly normal to you.
Your idea of fine dining is anywhere you can sit down to eat.
You get an almost irresistible urge to stand and wolf your food even in the nicest restaurants.
You plan your dinner break whilst lavaging an overdose patient.
Your diet consists of food that has gone through more processing than most computers.
You believe chocolate is a food group.
You refer to vegetables and are not talking about a food group.
You have the bladder capacity of five people.
Your idea of a good time is a cardiac arrest at shift change.
You believe in aerial spraying of Prozac.
You disbelieve 90% of what you are told and 75% of what you see.
You have your weekends off planned for a year in advance.
You encourage an obnoxious patient to sign a self discharge form so you don't have to deal with them any longer.
You believe that "shallow gene pool" should be a recognized diagnosis.
You believe that the government should require a permit to reproduce.
You believe that unspeakable evils will befall anyone who utters the phrase "Wow, it's really quiet isn't it".
You threaten to strangle anyone who even starts to say the "q" word when it is even remotely calm.
You say to yourself "great veins" when looking at complete strangers at the grocery store.
You have ever wanted to hold a seminar entitled "Suicide ... Doing It Right".
You feel that most suicide attempts should be given a free subscription to "Guns and Ammo" magazine.
You have ever had a patient look you straight in the eye and say "I have no idea how that got stuck in there".
You have ever had to leave a patient's room before you begin to laugh uncontrollably.
Your favorite hallucinogen is exhaustion.
You think that caffeine should be available in IV form.
You believe the waiting room should be equipped with a Valium fountain.
You play poker by betting ectopics on ECGs.
You want the lab to perform a "dropkick" screen.
You have been exposed to so many X-rays that you consider radiation a form of birth control.
You believe that waiting room time should be proportional to length of time from symptom onset.
Your most common assessment question is "what changed tonight to make it an emergency after 6 hours / days / weeks / months / years)?".
You have ever had a patient control his seizures when offered some food.
Your idea of gambling is an blood alcohol level pool instead of a football pool.
You shock someone with an unrecognizable rhythm ... until you get one you DO recognize.
You believe a book entitled 'Suicide: Getting it Right the First Time' will be your next project.
You call subcutaneous emphysema "Rice Bubbles".
Your immune system is so well developed that it has been known to attack squirrels in the backyard.

(adapted form a source for nurses but I think it's more applicable to doctors in ED in Australia)

Introductions

Well I feel a bit bad for not introducing you avid readers to the family of people who work in Emergency. They're an eclectic bunch with their own idiosyncrasies... but they're not too bad.

1. The triage nurse
Job description: to ask people what's wrong with them and make sure that the people with gunshot wounds or heart attacks get seen before the people with a sore toenail that's been there for 5 months.
Personality type: usually very task orientated and abrupt, knows the 'frequent flyers' to ED and warns you of them, often provide valuable advice about the patient's social situation before you see them (such as "the guy who dropped her off was carrying a great big knife" - always helpful to know!)

2. Ambulance officer
Job description: They are the delivery boys of our pizza shop. Except instead of getting rid of our products, they bring us more work. Thanks! Supposedly have some kind of training in first aid and some basic medical stuff, they love to run around with their sirens blazing and picking up the old ladies who 'had a bit of tummy pain'
Personality type: although they see a lot of action, they love to laze around after they've dropped off their customer and flirt with triage nurses or admin staff. Nige-phobes in that they often travel in packs and all arrive at the ED at once so they can hang out together, but having the undesired effect of making the doctors inside panic when they see 4 ambulances pulling up at once.

3. Comms clerk
Job description: To do all the dirty work of phoning up and getting a hold of extremely difficult people to contact. Whereas on the ward you would spend hours wasting time chasing down surgical registrars who refused to answer their page, these lovely people get them waiting on the line for you then announce over the intercom "Dr J to the bridge, surgical registrar on the line" thereby saving you the pain of having to find them.
Personality type: Anyone who can hunt down a surgical registrar must have a fair bit of tenacity and perseverance. They are generally very friendly for people who probably cop abuse all day from disgruntled doctors and are much more efficient than the switchboard.

4. The radiographers
Job description: To Xray anything that hurts in the Emergency Department because we are too precious to go across the hallway to the 'real' radiology departmant. They are a highly organised SWAT team of imaging and are veiled behind their magic lead-coated curtain.
Personality type: Reclusive. They rarely venutre out except to grab the next patient and then hide back in their little room devoid of sunlight or human touch. They make Quasimodo of Notre Dame look like a social butterfly.

5. The ED nurses
Job description: Never (I repeat NEVER) to be confused with their less evolved cousins the 'ward nurses', the ED nurses pride themselves on getting to wear blue scrubs like the doctors and being able to [gasp] insert IV cannulaes and take blood. Their job is to constantly hassle the doctors to find out what the management plan is so that they can enter their 'times' into the data collection system to make the State government look good for the upcoming election. They are also prone to the vice of the ward nurses known as the 'tea-break' which means that although you are not allowed to even relieve yourself, they may take all day to administer those medications if it even looks like interfering with their mandatory union-provided tea-break.
Personality type: generally less amoebic in intellect than the wards, they have let this confidence brew into disdain and can be more aggressive with interns who they don't trust* however provide a refreshing change because most of them 'want' to be in ED.

6. ED consultants/staff specialists
Job description: to run the department and direct medical care whilst keeping an eye on those dodgy young junior medical officers to prevent any mishaps and bad media coverage for the hospital.
Personality type: anyone who chooses to work shift work beyond the age of 35 is generally highly driven and does not want to 'settle' into the mundane life of general medicine. Often like to balance their career with extreme sports or vehicles and believe that every other department in the hospital revolves around them. Often willing to abuse ward registrars for not seeing the ED patients and will gloat about it afterwards.

7. ED registrars
Job descritption: To help run the ED whilst studying intensely every aspect of medicine so they can become like the above-mentioned consultants. Also run the entire ED on their own between the hours of 11pm and 8am when they have cortisol induced hypotension which they relieve by carrying around a large bottle of caffeine such as a 2L bottle of Coke Zero or the like.
Personality type: Not quite a boss and no longer a scut-monkey** they still have some humane aspects but enough cynicism to help them get through each day. Usually complaining non-stop about how overworked they are (which is true) they spend their spare time either doing extreme sports again or writing letters to our boss asking for more fellow registrars to be employed to share the load.

8. ED Interns and Residents
Job description: To see patients in the ED and then not really think too much about them because they have to present them to the boss anyway. Pretend to know something whilst really knowing they know less than they should. Try not to kill too many people*** and not pick up any gomers (old people) within the last hour before they leave. Have a glazed look after night shift which indicates their apathy and incompetence by the end.
Personality type: Over achievers who start to panic when they realise they may be out of their depth sometimes. Often seek outlets for their crazy wokring life, like drugs or chatting up allied health staff in early hours of the night shift.

And so here we have our wonderful world where we all run around in a noisy fast paced frenzy. This last week I have been doing night shift was has been a blast. Eating junk food with nice nurses (including a girl I used to know in high school) and having 'intern teaching' from a bleary eyed registrar at 5am. I've seen all sorts of diverse things such as a newly-diagnosed-brain tumour, a completely dislocated wrist with no sensation or pulse, a security guard who was beat up, chronic 'period pain', hyperventilation syndrome, someone with a lack-of-direction in his life (very urgent thing at 5am in the morning!) and am never ceasing to be amazed at what things people classify as an 'Emergency' in the wee hours of the night.

Can't you people read the sign? It says E-M-E-R-G-E-N-C-Y!


* one notable example was when I was told at handover round that a patient was to be admitted to the psychiatric ward once a bed was available. I was pestered non-stop by a senior ED nurse because it wasn't documented in the notes. I looked through the notes and found a clear entry from the ED consultant saying "Patient discussed with psychiatry registrar and for admission under the psychiatrists" Apparently that was not good enough and I was forced to 'reaffirm' this directive with a rather irate psych registrar at 5am in the morning.
** "Scut-monkey" is a term used to describe me and other junior med officers cos we end up doing all the crappy jobs that other doctors dont wanna do cos we are the bottom of the food chain.
***One shift started with a new registrar introducing himself to me and saying "I don't care how many of these patients you kill, as long as you don't link them to me in any way" - I hope he was kidding?

Mad Season

I knew it was the beginning of silly season when the tacky Christmas trees appeared in the foyer of our Emergency Department.

And I don't mean silly seaosn cos of the festivities, but cos of the stupidities.

ED never fails to amaze me as I see bizarre presentations walking through those glass doors.

A young 27 year old male presented to ED in extreme pain. He was swearing profusely, looking very embaressed and had a worried wife with him. Turns out he had injured his male reproductive organ whilst procreating and had heard a 'snap' and immediately rushed to hospital.

Most of the females were trying not to snigger as all the males in the department winced in sympathy. He was urgently given lots of morphine by a nice male doctor as we all tried to work out how once fixes this 'broken' organ.

Eventually the surgical registrar gave him the all clear and we let him go with lots of ice packs and our sympathy.

I then picked up the next patient on the list who had 'high blood pressure'. Turns out this guy had measured his blood pressure at home and it was (*gasp*) 160/100! So he decided he needed to come into Emergency to get it sorted out on a Sunday night. Needless to say I wasn't overly impressed.

But I must say I am really getting into the suturing business. I end up suturing most shifts and enjoy sticking the anaesthetic in and then making nice little stitches in people's severed digits or lacerated heads.

And so after a week of wokring the evening shift, I get two days off before starting the graveyard night shift in ED. It's a token break before sacrificing my sleep-wake cycle on the altar of the public health system.

And so today I got up and had a lazy picnic lunch on the beach with some other doctors who were not working. We ate junk food, we basked in the sun, we argued over the attractiveness of girls passing by and we fought off the leering seagulls. And all of a sudden the weight of work lifted off my shoudlers and I realised that underneath it all, I'm still a person... and I can enjoy life in between the craziness of hospital.

And so tomorrow will be another such day of brunches and shopping and movies....

Ahh.. tis the season to be jolly!

ER

Well finally I have come to the final term of my internship. And what a fitting end to an interesting year.

After honing my meal breaks to an art and de-skilling from medical school, I've been sent downstairs to the land know as the Emergency Department.

Now for those of you who don't know, there is an upcoming State election due next year which can mean only one thing. Time to crunch some numbers and show the public how wonderful and 'happy' the public hospital system is. And the best way to do that is to make the flagship of public health (the ED) reduce its waiting times. And so we are left with a bunch of junior doctors being told that their job is not to provide medical care (unless they're dying and even then that is debatable*) but to triage people and refer them to ANY admitting team. In fact it doesn't matter if you don't know the test results, if you know they need admission just admit them (much to the dislike of medical registrars).

And so we 'click-off' our patients and take thorough histories on people who are so vague/unable-to-speak-English/deaf/mentally-deficient and then procede to "buff and turf"** to the wards.

I must say at first I was a bit shell shocked cos I had no idea how the system worked but now I've grown to get used to the pace and it's actually a lot quieter in Emergency than on the gastro wards.

I was a bit scared the other day when I had to revise some obstetrics and thankfully avoided having to do a vaginal examination on the poor lady. I managed to diagnose a lung abscess on chest Xray and then got a pat on the back from the consultant.

But then today I found my new favourite activity...

Suturing!

That's right. I stand here today testifying to the fact hat one year ago I hated surgery. In fact I despised all surgical procedures and couldn't stand them. But I am now a changed man. I have learnt to appreciate the joy that can be derived from stick needles and sharp objects into people and fixing things with your hands and not with your head. You can just zone out and relax while you infiltrate with some local anaesthetic and then make nice wound closures and sew nice pretty surgical knots.

This evening I patched up a surfer who got on the wrong end of his surfboard fin and made a nice 10cm gash on his head. 20 minutes later he had a nice set of needlework on his scalp. Then a bit later I had another patient come in with a laceration to his eyebrow/eyelid. As I took his history he began to use medical phrases like "Um yeah, I saw the wound edges were nicely apposed" and asked if he was medically trained... turns out I was stitching up a psychiatrist! (no pressure there now!) But by the end I had a nice set of stitches that in 7 days time will come out and leave a very nice cosmetically-pleasing scar along his natural skin lines. Ahhh... I should have gone into plastics!

I have discovered that ED has it's own advantages too. Like being on shift work. I have realised that I am NOT a morning person and do not 'function' until after midday. And so wokring from 2pm till midnight all week is fantastic for me. It means I can sleep in, go for a swim and still have time for lunch with my 2 pharm girls*** before going to work being fully awake and ready. Add to that the fact you work 8 day fortnights and ED is not that bad after all. And so this week I've been getting outside and enjoying the beautiful sunshine on my shiny bald head.

Ahh... summer is almost here!


* Last week of my Gastro term, we had a patient almost exsanguinate in ED becasue they had been 'admitted' under us and as we weren't able to come and see him (due to our other 30 sick patients). ED just said "It's on your own head now, he's admitted under you" and so my Prof came down and cannulated and did bloods on this guy who was dying on BiPAP and gave him some much needed frusemide.

** See the book "House of God" by Samuel Shem. It refers to the process of making a patient look good and turfing them to someone else to sort out. It's soooo true!

*** Yes, my old pharm girls from the wards have been keeping in touch and we catch up for lunch. Gotta say, those chicken burgers are to DIE for.

Anecdotal Antidote

In order to relieve the pressure of the last few weeks, I thought I'd include some of the nicer things in life.

Like teaching medical students.

I must say that I really do enjoy having these future doctors running around our wards.

Whether it's their unjaded enthusiasm or their quirky questions which display how much they do (or don't) know about the human body and life*, they remind us what it's like to be young and what ideal medicine is about.

And so this week I was pleased to receive a page from a 3rd year girl asking if she could watch me put in a cannulae** as he wanted to learn how to do them. And so despite the rest of the wards falling apart around me I agreed and walkeddown to the ward to take a break and do some teaching.

Found the med student and talked her through the procedure, explaining what equipment to gather and how to use it. Unfortunately the cannuale was needed on a sick dying man and so it wasn't really appropriate to let her do it, so I let her watch and then after that offered to let her put one in me.

And so after a year of putting them into patients, I finally had a cannuale put into me. It wasn't that bad actually. The girl missed and was nervous so didn't firmly push it in... but eventually she hit the vein and the look of excitement on her face was reward enough. The nurses passing by gave me strange looks but who cares... their fluid orders could wait.

She then turned around and asked "Can you put one in me so I can know what it feesl like?"

2 minutes later she was sporting one too.

It's little time outs like these that make work bearable.

* One such example given by a friend was "Um so what's a checkout chick?"
** the plastic tubes with needles that drips attach to to give you intravenous fluids

It is finished

So Dr J hasn't posted for a while.

What happened? Had he forgotten about his loyal readers? Had he nothing exciting to write about?

No.

He was getting hammered by the ever-increasing list of inpatients on the Gastro ward. After ballooning to almost 30 inpatients, I had little time to relax, let alone put pen to paper (or whatever it is that bloggers do). And so I sincerely apologise and will give an update for life so far.

Gastro sucked. Words really cannot convey how awful the last few eeks of work have been. My workload almost doubled, my bosses halved (away on conferences or taking days off etc etc), my number of wards quadrupled (from 2 to 8) and my average leave work time was 7pm.

On more than one occasion I came very close to just walking out the door and throwing my pager under the wheels of the nearest bus. One particular day my registrar pushed me so far that I almost cracked but lucky for him he saw the look of anger in my eyes and quickly pulled back and offered to buy lunch so I wouldn't explode.

This last week I was getting paged so often that it was stopping me from getting ANY work done and so my registrar had to go down and tell the nurses off on my behalf for harassing me so much.

I wore my heart on my sleeve and this warned those who were wise to stay away and not disturb me unless it was urgent. A few naive nurses were not so lucky and copped an abrupt phone barrage.

One day after being pushed very hard all day, I needed to go to the bathroom. However I was not even allowed the luxury of relieving myself without my pager going off 3 times in 5 minutes.
And so I stormed out of the lavatory to the nearest phone and called the number that had interrupted me.

"What's so important that you had to page me 3 times? Is it an emergency?"

[It wasn't]

"So why did you need to page me 3 times in 5 minutes? Have I ever NOT answered my page? Does the fact that I didn't answer make you think maybe I was busy? Am I still allowed to go to the bathroom?"

[Nurse on high horse starts yelling at intern down phone]

So I charged down to the ward to sort it out only to find the head nurse comforting the nurse who I had argued with and telling him to relax.

"Look ... here's the doctor now. He's oming to fix up the problem... there's no need to get angry at him.. see.. he's writing that medication up now"

I gave the greasiest glare I've ever given to them and sulked off to the other ward to complain to my intern buddies. However I later found out that that nurse has a history of being inappropriately rude and had been warned prior and was now suspended because of his alteration with me. And just to top things off, apparently he has a psych history and is off his meds.. so now I'm expecting to bump into him one late night in the carpark as he seeks his revenge. Sigh.

The last few weeks I've barely been able to make it through each day. The stress and the suffering of going to work each day made me feel sick. I didn't eat lunch at work for a whole 2 weeks cos I was 'too busy'. I was burning out and crashing fast.

And so on Friday I walked onto my ard for the last time. With a smile.

The nurses said they had never seen me so happy before. I even laughed with them. They said that I had done a great job seeing as how crap my job was. I knew that in their own disturbed way they knew something of my pain.

I did the round with my registrar for the last time and spoke my lats words to my chronic alcholic/liver patients. I recharted med charts for the last time. I did my last ward discharge summaries. I said good bye to the allied health staff and shared some celebratory Maltesers with the pharm girls.

Prof filled in my term assessment and gave me a perfect score. He took me into the endoscopy suite and offered to let me do a gastroscopy (stick a snake like camera down someone's throat into their stomach) on one of our long term patients. Nervously I declined, knowing that if I touched that scope, I'd find it too easy to get hooked and maybe even start considering physician's training.

And then at 4:45pm, Prof and my reg and I went down to the hospital cafeteria to have our final goodbye. We sat around lamenting the hospital system (and it's lack of money) whilst we sipped our hot drinks and chatted.

The finally it came. After 10 weeks of living through hell, those words came out as life giving encouragement.

"Well J, I just wanted to say, that you've done a really good job! I know it's been very hard for you becasue we've had so many patients. In fact, you've had more patients this term than the other interns had earlier this year. And we're sorry that you didn't have more registrar supervision, but you've really been amazing"

And then my aggressive tough-guy registrar nodded his head and concurred "Yeah you've had it the worst so far this year but you've done well."

And in that instant all those weeks of angst and anguish dissolved into my hot chocolate and slid down my throat out of sight. It was finished. I had run the race and survived. And finally my master was saying "Well done good and faithful servant" .

And so I walked out of the hospital that night with my head held high knowing that although very few will understand what I went through, I can be proud. Internship IS like what you see on television in shows like Scrubs. It's a rollarcoaster of exhaustion and relaxation, of pain and joy and of maturation from students into doctors.

Now all that lies between being an intern and being a resident is this little thing called the Emergency Department. That's right. Dr J heads off to play "ER" for the rest of the year and prepare to emerge from the cocoon of internship next year.