The call
The human body is an amazing creation. It is a very vague memory, my working life in Melbourne. A year in the system here and I struggle to remember what exactly I was busy doing at work back then.
I write this on a post-call day having worked 30 hours straight. I saw my call room only once last night. I was only able to pray before the nurses started calling me about new patients. The sweetest thing about being on-call? It is that ultimate crash into your own bed post-call. The feel of the body landing on the soft mattress as your joints cry out in relief and the ability to sleep in peace - an activity often taken for granted. Pure bliss I tell you.
As I was finishing up my afternoon rounds for my ICU patients, the clock hit 5pm and I started getting called for new patients.
"Hi Doctor, calling from A&E observation room. There is a new cardiology case of unstable angina. No bed available yet. Please clerk the patient within 4 hours. Thank you!" says the cheerful nurse on the other end. I can imagine her documenting in her notes - Doctor so and so informed at 5.01 pm of new admission and advised to clerk patient within 4 hours.
I guess dinner would have to wait as I received another call within 15 mins for a case of acute pulmonary oedema who had just arrived to the high dependency unit on non-invasive ventilation and the emergency doctor was waiting for me to handover the case to me. As she rattled on the case, I asked the next pertinent question whether a repeat ABG had been done since. She stared at me and I knew the answer was no. I glanced at the patient's wrinkly wrist that was covered with a few bruises. Darn, I can see a difficult arterial line coming up. I hope the femoral pulse is good. It occurred to me I had come a far way from my old comfort zone.
The equivalent to the medical registrar in Oz; medical officers here essentially do the job of the medical registrars of admitting all new patients. Once I had informed my colleagues that during my medical postings in Oz, it was the responsibility of the registrar to admit patients and all that the medical officers had to do when the patients arrived on the ward was to follow up on the management plan. I don't say this anymore because I am not sure what to answer when they then ask me, "So what did you all actually do?". I struggle to tell them any worthy things. Surely I had done more but it all seems like a vague memory now.
The clock had hit midnight and so far I received calls for 11 new patients. It was my responsibility to admit them, reach a diagnosis and institute a management plan based on the diagnosis I had arrived to. The emergency department was on a vengeful streak and delivered a total of 16 new patients to me overnight in the space of 13 hours. I was mentally cursing the emergency officer who had admitted a septic patient to cardiology because the troponins were mildly raised and the ECG had some T wave inversions.
You see here the emergency department has admission rights. So you can pretty much get anything under the sun to your cardiology unit.
In addition to admitting new patients, I had to also cover any issues that crop up during the night for the remaining patients under my department including patients in the intensive care unit. And we all know the intensive care nurses call you for every single darn electrolyte imbalance. Usually it is when you think you hit a lull in the night and start to head back to your call room and start to imagine that crash into the bed.
"Doctor, just calling you to inform you that patient's latest pCO2 is 76. Do you want to change the Bipap settings?"
"Doctor, patient on CVVH - the phosphate is low, do you want to replace?"
"Doctor, the ECG reads ST elevation, can you come review the patient please?" Erm the patient came in with a STEMI...so....
These calls can get annoying when you're busy admitting new patients as they interrupt your train of thought. Sometimes the nurses just refuse to deal with the situation themselves and just turfs it to you without trying to solve the situation.
"Doctor, the patient's family is here and are quite demanding. They want an update from the doctor now...."
What an update at night?? From the covering doctor who has so many better things to do then go speak to a demanding family and explain why their mother's phlegm isn't getting better or why she can't seem to sleep in a cubicle of 8 patients with a bed-bound, demented patient calling out in the corner for no particular reason.
Sometimes families just have no clue.
I think I've come a long way and I know there is so much more to go. I've learnt to manage more and do more in the 9 months that I've worked here than in the two years I was in Oz. It is not a competition of skills or a comparison of which system is better. Quite simply, it is a matter of survival. You have to be competent because you are essentially the 'admitting medical registrar' when you're on call. At least 5 times a month you give up your precious sleep to do this duty.
Of course there is always a registrar who you can call if you have really no clue why the patient got admitted in the first place - however the registrar is not there to stand behind you and pat your back and 'approve' everything that you do - just so you can have the security of knowing if anything bad were to happen, at least the registrar had 'seen' the patient too.
It doesn't matter if one is intending to be a physician trainee in the future. Any medical officer posted to a medical department has to do their share of medical calls and hence they all must be able to diagnose, treat and manage common medical problems from heart failure to diabetic ketoacidosis to severe pneumonia to acute stroke, status eplipeticus and sepsis. Knowing how to treat means you have to know what drugs to prescribe and how to prescribe them. No diabetic acidosis protocol to guide you and no MET call team to call when your patient is acutely seizing.
I can see why many final year medical students fail their final exams here. Some have had to repeat it a few times. Many of the students I knew during my medical school days who cut class and just scraped through the supplementary exams would not have made it past the MBBS exams here. It is not to say that who is the better trained medical graduate. But in a system where medical officers have much responsibility, the graduating doctors must know more and are expected to be able to take on more.
At first I was taken aback when my registrar asked me to call a house officer who had mismanaged a patient overnight. I couldn't see myself reprimanding my junior. It just was never done in Oz. Sure you get interns, fellow medical officers who you know have been really laxed in their management. But at most colleagues would just gossip and spread 'that dodgy doctor rumour' around but no one would take the responsibility of calling them out.
During my first few medical calls, it always unnerved me that the Professor of Medicine would come in at 6.30 am and read all my admission notes of the new patients I had admitted. Watching him from afar flip through my notes, I couldn't think of a single consultant who I had worked with previously who would be so diligent to go through their junior doctor's work overnight. While I was drawing up lorazepam to give to my patient who was acutely seizing - I know that had it been a similar situation back in Oz, I would have the medical registrar next to me, the MET team surrounding my patient and that the nurse would be drawing up the intravenous medications and administering the medication for me.
I had stepped into a completely different medical system. A system where I go running to the crash cart when my patient goes into ventricular tachycardia and apply the pads to shock them and giving stat orders for anti-arrhythmics from a system where my first instinct would have been to get the IV trolley and ask the nurse to call the MET team. A system where my patients arrest on me and I shout orders to get the intubation trolley and give my best attempt at intubating rather than wait for the anaesthetist to arrive. A system where I perform examinations in Hokkien and explain diagnoses in Malay.
"Cik sebenarnya Cik telah mengalami serangan jantung yang agak merbahaya. Kita perlu buat angiogram dan tebuk cik punye arteri dan masukkan perwarna untuk tengok ada sumbat di urat jantung makcik. Kalau ada sumbat, kita akan masukkan besi kecil untuk bukakkan sumbatan itu supaya saluran darah cik lebih baik."
Cheh boleh tahan doctor Melayu ni.
Working 30 hours straight does take a toll. No doubt. And the next day we return to work for a normal 8-5 day. Yet it is not so much the lack of sleep that returning doctors should worry about when they choose to work here. It is whether you can adapt to the an efficient medical culture, be willing to take on a bigger responsibility and take the necessary measures to ensure you can competently manage patients under the stress of being on-call, lack of sleep and having no MET team to call upon.
Every call is a test to your doctoring skills. Every call completed makes you a better doctor and more experienced one.
As they say, the sick ones always come through the night and all the exciting things happen after hours. What more when you're the first doctor they call when that happens.
I write this on a post-call day having worked 30 hours straight. I saw my call room only once last night. I was only able to pray before the nurses started calling me about new patients. The sweetest thing about being on-call? It is that ultimate crash into your own bed post-call. The feel of the body landing on the soft mattress as your joints cry out in relief and the ability to sleep in peace - an activity often taken for granted. Pure bliss I tell you.
As I was finishing up my afternoon rounds for my ICU patients, the clock hit 5pm and I started getting called for new patients.
"Hi Doctor, calling from A&E observation room. There is a new cardiology case of unstable angina. No bed available yet. Please clerk the patient within 4 hours. Thank you!" says the cheerful nurse on the other end. I can imagine her documenting in her notes - Doctor so and so informed at 5.01 pm of new admission and advised to clerk patient within 4 hours.
I guess dinner would have to wait as I received another call within 15 mins for a case of acute pulmonary oedema who had just arrived to the high dependency unit on non-invasive ventilation and the emergency doctor was waiting for me to handover the case to me. As she rattled on the case, I asked the next pertinent question whether a repeat ABG had been done since. She stared at me and I knew the answer was no. I glanced at the patient's wrinkly wrist that was covered with a few bruises. Darn, I can see a difficult arterial line coming up. I hope the femoral pulse is good. It occurred to me I had come a far way from my old comfort zone.
The equivalent to the medical registrar in Oz; medical officers here essentially do the job of the medical registrars of admitting all new patients. Once I had informed my colleagues that during my medical postings in Oz, it was the responsibility of the registrar to admit patients and all that the medical officers had to do when the patients arrived on the ward was to follow up on the management plan. I don't say this anymore because I am not sure what to answer when they then ask me, "So what did you all actually do?". I struggle to tell them any worthy things. Surely I had done more but it all seems like a vague memory now.
The clock had hit midnight and so far I received calls for 11 new patients. It was my responsibility to admit them, reach a diagnosis and institute a management plan based on the diagnosis I had arrived to. The emergency department was on a vengeful streak and delivered a total of 16 new patients to me overnight in the space of 13 hours. I was mentally cursing the emergency officer who had admitted a septic patient to cardiology because the troponins were mildly raised and the ECG had some T wave inversions.
You see here the emergency department has admission rights. So you can pretty much get anything under the sun to your cardiology unit.
In addition to admitting new patients, I had to also cover any issues that crop up during the night for the remaining patients under my department including patients in the intensive care unit. And we all know the intensive care nurses call you for every single darn electrolyte imbalance. Usually it is when you think you hit a lull in the night and start to head back to your call room and start to imagine that crash into the bed.
"Doctor, just calling you to inform you that patient's latest pCO2 is 76. Do you want to change the Bipap settings?"
"Doctor, patient on CVVH - the phosphate is low, do you want to replace?"
"Doctor, the ECG reads ST elevation, can you come review the patient please?" Erm the patient came in with a STEMI...so....
These calls can get annoying when you're busy admitting new patients as they interrupt your train of thought. Sometimes the nurses just refuse to deal with the situation themselves and just turfs it to you without trying to solve the situation.
"Doctor, the patient's family is here and are quite demanding. They want an update from the doctor now...."
What an update at night?? From the covering doctor who has so many better things to do then go speak to a demanding family and explain why their mother's phlegm isn't getting better or why she can't seem to sleep in a cubicle of 8 patients with a bed-bound, demented patient calling out in the corner for no particular reason.
Sometimes families just have no clue.
I think I've come a long way and I know there is so much more to go. I've learnt to manage more and do more in the 9 months that I've worked here than in the two years I was in Oz. It is not a competition of skills or a comparison of which system is better. Quite simply, it is a matter of survival. You have to be competent because you are essentially the 'admitting medical registrar' when you're on call. At least 5 times a month you give up your precious sleep to do this duty.
Of course there is always a registrar who you can call if you have really no clue why the patient got admitted in the first place - however the registrar is not there to stand behind you and pat your back and 'approve' everything that you do - just so you can have the security of knowing if anything bad were to happen, at least the registrar had 'seen' the patient too.
It doesn't matter if one is intending to be a physician trainee in the future. Any medical officer posted to a medical department has to do their share of medical calls and hence they all must be able to diagnose, treat and manage common medical problems from heart failure to diabetic ketoacidosis to severe pneumonia to acute stroke, status eplipeticus and sepsis. Knowing how to treat means you have to know what drugs to prescribe and how to prescribe them. No diabetic acidosis protocol to guide you and no MET call team to call when your patient is acutely seizing.
I can see why many final year medical students fail their final exams here. Some have had to repeat it a few times. Many of the students I knew during my medical school days who cut class and just scraped through the supplementary exams would not have made it past the MBBS exams here. It is not to say that who is the better trained medical graduate. But in a system where medical officers have much responsibility, the graduating doctors must know more and are expected to be able to take on more.
At first I was taken aback when my registrar asked me to call a house officer who had mismanaged a patient overnight. I couldn't see myself reprimanding my junior. It just was never done in Oz. Sure you get interns, fellow medical officers who you know have been really laxed in their management. But at most colleagues would just gossip and spread 'that dodgy doctor rumour' around but no one would take the responsibility of calling them out.
During my first few medical calls, it always unnerved me that the Professor of Medicine would come in at 6.30 am and read all my admission notes of the new patients I had admitted. Watching him from afar flip through my notes, I couldn't think of a single consultant who I had worked with previously who would be so diligent to go through their junior doctor's work overnight. While I was drawing up lorazepam to give to my patient who was acutely seizing - I know that had it been a similar situation back in Oz, I would have the medical registrar next to me, the MET team surrounding my patient and that the nurse would be drawing up the intravenous medications and administering the medication for me.
I had stepped into a completely different medical system. A system where I go running to the crash cart when my patient goes into ventricular tachycardia and apply the pads to shock them and giving stat orders for anti-arrhythmics from a system where my first instinct would have been to get the IV trolley and ask the nurse to call the MET team. A system where my patients arrest on me and I shout orders to get the intubation trolley and give my best attempt at intubating rather than wait for the anaesthetist to arrive. A system where I perform examinations in Hokkien and explain diagnoses in Malay.
"Cik sebenarnya Cik telah mengalami serangan jantung yang agak merbahaya. Kita perlu buat angiogram dan tebuk cik punye arteri dan masukkan perwarna untuk tengok ada sumbat di urat jantung makcik. Kalau ada sumbat, kita akan masukkan besi kecil untuk bukakkan sumbatan itu supaya saluran darah cik lebih baik."
Cheh boleh tahan doctor Melayu ni.
Working 30 hours straight does take a toll. No doubt. And the next day we return to work for a normal 8-5 day. Yet it is not so much the lack of sleep that returning doctors should worry about when they choose to work here. It is whether you can adapt to the an efficient medical culture, be willing to take on a bigger responsibility and take the necessary measures to ensure you can competently manage patients under the stress of being on-call, lack of sleep and having no MET team to call upon.
Every call is a test to your doctoring skills. Every call completed makes you a better doctor and more experienced one.
As they say, the sick ones always come through the night and all the exciting things happen after hours. What more when you're the first doctor they call when that happens.
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