May-June 1998
This is perhaps my first Real day of Internship. My Unit is On Call today, or "Duty" as we say, and I need to be in the Ward by 730 AM. And, for perhaps the first time on a non-exam day, I am up and ready and in the Ward, a bit apprehensive, a bit excited and more than looking forward to my first foray into the netherworld of the madhouse that a typical Jipmer OPD is.
I find that, even at the ungodly hour of 730, the Ward is abuzz. I meet Tomin, who as a first year PG, will suffer the most since he is the first step in the ladder of responsibility. I, as an Intern, merely have to run around the whole hospital and can conveniently blame all the screw-ups on Tomin. Tomin, therefore, is a bit worried and spends the half an hour before Rounds start taking me through the process of "repeating the beds".
Every patient has a clipboard attached to the foot of the bed and this has various sheets of paper clipped on. Nurses reports, fever charts, Investigation charts and Progress reports. I see that the "Investigation Chart" is a huge sheet of neatly ruled lines and columns with tests and their reports arranged date-wise. I also learn that making this whole thing, for every patient, is my job. And will be, till I am in Medicine.
The Progress Report starts off with a date and one standard line for nearly every patient.
"Afebrile, GC Fair". The "Afebrile" gets shortened to "Afeb" as we move from patient to patient and the clock ticks toward 8 AM, which is when the Consultants will arrive and rounds will start. After this line is a numbered list of the drugs and other things the patient is on, and since a lot of these patients are fairly stable, we end up writing today's date followed by "Rpt 1,2,3,4,5......etc". This has to be done with some care however, since a small dose change or a different drug may be needed and so, while seeming simple and routine, "repeating" like this can be a dangerous exercise. Notes for Discharge or Instructions for Investigations are also added here.
With every bed that we pass, Tomin fires a list of things to be done.
"X-Ray", "Send a BUSE for these 13 patients", "Collect these fellows reports", "Echo at 3 Pm today"..and "Golu, these 7 guys need to be discharged today. We need to free up beds for admissions today".
Ah. Today is admission day.
All these instructions are noted in a small diary I keep, a small little pad that fits in my coat pocket and will soon be filled with random patient names, and the tasks alloted for each for the day.
The blood drawing is first. I get forms-white postcard size ones with red lettering for Hemat, yellow bigger ones for Biochem. I arm myself with syringes and needles. I take a roll of white plaster and cut them into small label like sizes. The labels are stuck on the edge of the bed and taken off to be stuck on the sample bottles. I collect a few small glass bottles called "penicillin bottles" and after writing the patients names and hospital numbers, I stick the labels on. Then, I refer to my pad, jot down all the details of the morning and keep all this paraphernelia next to each bed, forms kept under the respective sample bottles ready to be whisked off to the Labs.
Then the fun starts. The key to taking blood is finding a suitable vein. The key to that is twofold. A good light and a good tourniquet. I spend the next 30 minutes in concentrated blood taking, finding veins, puncturing them on occasion, writing forms, filling up bottles and arranging them all in neat piles. These need to be taken to the respective Labs and if finished before 1030 AM, will be taken by the orderlies to the Labs. Else, if we are late, we need to take these samples ourselves and try to convince the Lab people to process the samples that day. This is vital as the results have to be known by the next day's rounds. There is therefore, a controlled rush to get things done as fast as possible.
The X-Ray forms are also white but have green lettering. These are filled up quickly too and handed over to the Nurses who will ensure that it is done by the time the day ends.
This whole running around takes an hour or so and is interrupted by Rounds, in the middle of which I am told to "Bugger, finish off the samples and join us in OPD".
By 830, I am mentally exhausted already. Samples have been collected, forms have been filled, patients have been primed for ECHO's and sundry and the ward appears to have been "settled". Note that I have not been involved in any direct patient care decisions and is likely that I will not be.
The time between the Ward and OPD is spent in a quick 10 minute nicotine top-up in the shacks outside. This break is likely to be noticed by my ultra-thin Senior Resident but Tomin is in the loop and he won't mind. I also note that the Duty Room outside Ward 21-the Paeds Duty Room has a rather large loo I mark as a potential nicotine rest stop area, which will come in handy in case there is no time to go out to the shacks.
I make my way across the Corridor linking the Hospital to the OPD block, past hordes of patients and their attenders, past orderlies and stretchers, past fellow doctors and Interns, past the yellow benches and chairs that lie scattered along the walls and into the Medicine OPD, marked, as all OPD's are, by a yellow metal board hanging from the door with a number. In this case, number 65.
The OPD is deceptive.
There is a Registration counter outside where new patient Registrations will go on till 11 AM. This means that anyone who manages to come by then will have to be seen. The patients come from far and wide, often spending the previous night in the Rest House on campus, or very often, on the footpaths and pavements on the roads. Most of them are really poor, many have complaints that do not need to be seen in a referral centre like Jipmer, but they are here and so are we and therefore, see them we must.
The OPD has large windowed rooms where we all sit round a big table. The table is covered by a neat white tablecloth partially covered by the same forms I saw in the Ward. Chairs are arranged all round, some for us and some for patients. A couple of examination beds lie against the wall with a green privacy screen, some orderlies hang about waiting for instructions and we wait the arrival of the first set of patients.
It's a nonstop, constant stream. When the day is finally over, I counted more than 400. My Tamil is immediately tested.
"Enna kashtam", ( Whats the problem), I ask, which is followed by a stream of Tamil I can't understand. This improves over time but in the beginning, a lot of time is wasted getting interpretations from Tomin, Josy and whoever is around. Many patients have the "KKK" syndrome which is a Tamil abbreviation for "Myalgia, with nothing else". This is frustrating but these patients are the fastest to dispose. A prescription slip with pre-stamped medicines (Paracetamol, Multivitamins, Septran etc) exists and we just tick them off and call for the next patient.
In the middle of some speedy disposals, a uniformed staff orderly will stand and hover just out of the line of sight, but irritatingly at the edge of one's peripheral vision. He will then come up and in a pseudo-hesitatant voice, say "Saar, Staff", expecting to be seen first. As a newbie, I often comly, but I soon realize that I am being taken advantage of and so in a classic passive-aggressive manouever, I take the proferred case sheet and proceed to put it at the bottom of the mountain of the pile of case sheets. The man is now stuck. He will be seen, but after everyone before him has been seen already. This will not make me popular, but then, I'm not in a popularity contest.
There's the usual gamut of cases-Strokes, heart disease, GI problems. Most are "worked up" (by me, of course), a process that involves more form filling and explaining where which investigation is done. In the process, I learn a lot of Tamil. This goes on and on and there is very little time to do anything at all. In the middle of all this, I get a call from the Ward about some form I mislabeled and so I run back, fix things and run back, sometimes taking the chance for another quick nicotine top-up, this time in the Ward 21 loo.
On one of these Ward 21 occasions I walked into a class being taken by the Head of Paeds, walked straight through to the loo, smoked it up and then walked back straight out, staring straight out with smoky fumes following me.
And then it's 1030 AM. The clock runs very quickly when one is this busy and at this time, half of us drop pens and walk out. This is a time-honoured tradition of "Tea". Half the Unit walks out, with the stragglers rushing to finish their patients and we all troop out, KRS leading the way, to the Canteen outside.
The Canteen is located across the road from the Hospital next to the STD Phone booths and at this time of day, is very crowded. Half the hospital seems to be here. Various OPD Units, orderlies (called "Brothers" and "Sisters"), students, Interns. We grab chairs, sit around a metal table and I collect orders for tea, coffee and usually vadas. We spend the next 15 minutes drinking tasteless tea, saccharine coffee and oily vadas. The break, however, is very welcome and I enjoy every minute of this respite.
Back to the OPD, the drama continues and inspite of a feverish pace, the patient crowd outside does not seem to end. Some are sent directly to the Ward, some are sen to Casualty to be worked up there, some are kept for further discussions with a Consultant or a Senior Resident but most are just sent home with various prescriptions.
Today is also "Duty Day", which means that our day will just merge into the Casualty where we will be till 8 AM the next day. We take turns for lunch, come back fast and some of us head off to the Casualty while some stay back to finish the OPD.
I have various other things to finish. I look at my notepad and make a note of the results of the morning's investigations to be collected. The Biochem (BUSE-Blood Urea, Sugar and Electrolytes) reports are in the Biochem Lab on the 2nd floor next to the Surgery Wards. I head there where I see a huge register marked with long ruled lines and columns with patient names, hospital numbers and results. I sit and match these with the list of names in my pad and then proceed to find the forms I had filled in the morning which now have the results entered against the tests I had ticked off.
This is easier said than done and often, I can't find a form or worse, a request has not been entered. In the latter case, I run back to the Ward, draw another sample, send it to the Lab, plead with the Lab Assistant and heave a sigh when he scowls with an air of superiority and says "Come back in 2 hours".
The X-Rays are collected from the Radio Department located in one corner of the Ground Floor. It's a darkish place and houses the X-Ray machines and all and sundry Radiology equipment. There is no CT Scanner or MRI. The procedure is the same. Match the list I have on my pad with a list of names on a huge register, note the X-Ray numbers and then manually sort out a massive pile of X-Rays. When I find one that belongs to me, happy fireworks burst in the mind and one more task is ticked off.
All of these are then taken to the Wards and kept bedside ready for the evening rounds. The Investigation Charts are updated.
A huge sigh of relief is taken.
I walk down to my bike, head off to the shacks or Snappy for long teas and smokes but not too long. The boys are waiting for their Intern in the Casualty and it's time for Duty.
This is perhaps my first Real day of Internship. My Unit is On Call today, or "Duty" as we say, and I need to be in the Ward by 730 AM. And, for perhaps the first time on a non-exam day, I am up and ready and in the Ward, a bit apprehensive, a bit excited and more than looking forward to my first foray into the netherworld of the madhouse that a typical Jipmer OPD is.
I find that, even at the ungodly hour of 730, the Ward is abuzz. I meet Tomin, who as a first year PG, will suffer the most since he is the first step in the ladder of responsibility. I, as an Intern, merely have to run around the whole hospital and can conveniently blame all the screw-ups on Tomin. Tomin, therefore, is a bit worried and spends the half an hour before Rounds start taking me through the process of "repeating the beds".
Every patient has a clipboard attached to the foot of the bed and this has various sheets of paper clipped on. Nurses reports, fever charts, Investigation charts and Progress reports. I see that the "Investigation Chart" is a huge sheet of neatly ruled lines and columns with tests and their reports arranged date-wise. I also learn that making this whole thing, for every patient, is my job. And will be, till I am in Medicine.
The Progress Report starts off with a date and one standard line for nearly every patient.
"Afebrile, GC Fair". The "Afebrile" gets shortened to "Afeb" as we move from patient to patient and the clock ticks toward 8 AM, which is when the Consultants will arrive and rounds will start. After this line is a numbered list of the drugs and other things the patient is on, and since a lot of these patients are fairly stable, we end up writing today's date followed by "Rpt 1,2,3,4,5......etc". This has to be done with some care however, since a small dose change or a different drug may be needed and so, while seeming simple and routine, "repeating" like this can be a dangerous exercise. Notes for Discharge or Instructions for Investigations are also added here.
With every bed that we pass, Tomin fires a list of things to be done.
"X-Ray", "Send a BUSE for these 13 patients", "Collect these fellows reports", "Echo at 3 Pm today"..and "Golu, these 7 guys need to be discharged today. We need to free up beds for admissions today".
Ah. Today is admission day.
All these instructions are noted in a small diary I keep, a small little pad that fits in my coat pocket and will soon be filled with random patient names, and the tasks alloted for each for the day.
The blood drawing is first. I get forms-white postcard size ones with red lettering for Hemat, yellow bigger ones for Biochem. I arm myself with syringes and needles. I take a roll of white plaster and cut them into small label like sizes. The labels are stuck on the edge of the bed and taken off to be stuck on the sample bottles. I collect a few small glass bottles called "penicillin bottles" and after writing the patients names and hospital numbers, I stick the labels on. Then, I refer to my pad, jot down all the details of the morning and keep all this paraphernelia next to each bed, forms kept under the respective sample bottles ready to be whisked off to the Labs.
Then the fun starts. The key to taking blood is finding a suitable vein. The key to that is twofold. A good light and a good tourniquet. I spend the next 30 minutes in concentrated blood taking, finding veins, puncturing them on occasion, writing forms, filling up bottles and arranging them all in neat piles. These need to be taken to the respective Labs and if finished before 1030 AM, will be taken by the orderlies to the Labs. Else, if we are late, we need to take these samples ourselves and try to convince the Lab people to process the samples that day. This is vital as the results have to be known by the next day's rounds. There is therefore, a controlled rush to get things done as fast as possible.
The X-Ray forms are also white but have green lettering. These are filled up quickly too and handed over to the Nurses who will ensure that it is done by the time the day ends.
This whole running around takes an hour or so and is interrupted by Rounds, in the middle of which I am told to "Bugger, finish off the samples and join us in OPD".
By 830, I am mentally exhausted already. Samples have been collected, forms have been filled, patients have been primed for ECHO's and sundry and the ward appears to have been "settled". Note that I have not been involved in any direct patient care decisions and is likely that I will not be.
The time between the Ward and OPD is spent in a quick 10 minute nicotine top-up in the shacks outside. This break is likely to be noticed by my ultra-thin Senior Resident but Tomin is in the loop and he won't mind. I also note that the Duty Room outside Ward 21-the Paeds Duty Room has a rather large loo I mark as a potential nicotine rest stop area, which will come in handy in case there is no time to go out to the shacks.
I make my way across the Corridor linking the Hospital to the OPD block, past hordes of patients and their attenders, past orderlies and stretchers, past fellow doctors and Interns, past the yellow benches and chairs that lie scattered along the walls and into the Medicine OPD, marked, as all OPD's are, by a yellow metal board hanging from the door with a number. In this case, number 65.
The OPD is deceptive.
There is a Registration counter outside where new patient Registrations will go on till 11 AM. This means that anyone who manages to come by then will have to be seen. The patients come from far and wide, often spending the previous night in the Rest House on campus, or very often, on the footpaths and pavements on the roads. Most of them are really poor, many have complaints that do not need to be seen in a referral centre like Jipmer, but they are here and so are we and therefore, see them we must.
The OPD has large windowed rooms where we all sit round a big table. The table is covered by a neat white tablecloth partially covered by the same forms I saw in the Ward. Chairs are arranged all round, some for us and some for patients. A couple of examination beds lie against the wall with a green privacy screen, some orderlies hang about waiting for instructions and we wait the arrival of the first set of patients.
It's a nonstop, constant stream. When the day is finally over, I counted more than 400. My Tamil is immediately tested.
"Enna kashtam", ( Whats the problem), I ask, which is followed by a stream of Tamil I can't understand. This improves over time but in the beginning, a lot of time is wasted getting interpretations from Tomin, Josy and whoever is around. Many patients have the "KKK" syndrome which is a Tamil abbreviation for "Myalgia, with nothing else". This is frustrating but these patients are the fastest to dispose. A prescription slip with pre-stamped medicines (Paracetamol, Multivitamins, Septran etc) exists and we just tick them off and call for the next patient.
In the middle of some speedy disposals, a uniformed staff orderly will stand and hover just out of the line of sight, but irritatingly at the edge of one's peripheral vision. He will then come up and in a pseudo-hesitatant voice, say "Saar, Staff", expecting to be seen first. As a newbie, I often comly, but I soon realize that I am being taken advantage of and so in a classic passive-aggressive manouever, I take the proferred case sheet and proceed to put it at the bottom of the mountain of the pile of case sheets. The man is now stuck. He will be seen, but after everyone before him has been seen already. This will not make me popular, but then, I'm not in a popularity contest.
There's the usual gamut of cases-Strokes, heart disease, GI problems. Most are "worked up" (by me, of course), a process that involves more form filling and explaining where which investigation is done. In the process, I learn a lot of Tamil. This goes on and on and there is very little time to do anything at all. In the middle of all this, I get a call from the Ward about some form I mislabeled and so I run back, fix things and run back, sometimes taking the chance for another quick nicotine top-up, this time in the Ward 21 loo.
On one of these Ward 21 occasions I walked into a class being taken by the Head of Paeds, walked straight through to the loo, smoked it up and then walked back straight out, staring straight out with smoky fumes following me.
And then it's 1030 AM. The clock runs very quickly when one is this busy and at this time, half of us drop pens and walk out. This is a time-honoured tradition of "Tea". Half the Unit walks out, with the stragglers rushing to finish their patients and we all troop out, KRS leading the way, to the Canteen outside.
The Canteen is located across the road from the Hospital next to the STD Phone booths and at this time of day, is very crowded. Half the hospital seems to be here. Various OPD Units, orderlies (called "Brothers" and "Sisters"), students, Interns. We grab chairs, sit around a metal table and I collect orders for tea, coffee and usually vadas. We spend the next 15 minutes drinking tasteless tea, saccharine coffee and oily vadas. The break, however, is very welcome and I enjoy every minute of this respite.
Back to the OPD, the drama continues and inspite of a feverish pace, the patient crowd outside does not seem to end. Some are sent directly to the Ward, some are sen to Casualty to be worked up there, some are kept for further discussions with a Consultant or a Senior Resident but most are just sent home with various prescriptions.
Today is also "Duty Day", which means that our day will just merge into the Casualty where we will be till 8 AM the next day. We take turns for lunch, come back fast and some of us head off to the Casualty while some stay back to finish the OPD.
I have various other things to finish. I look at my notepad and make a note of the results of the morning's investigations to be collected. The Biochem (BUSE-Blood Urea, Sugar and Electrolytes) reports are in the Biochem Lab on the 2nd floor next to the Surgery Wards. I head there where I see a huge register marked with long ruled lines and columns with patient names, hospital numbers and results. I sit and match these with the list of names in my pad and then proceed to find the forms I had filled in the morning which now have the results entered against the tests I had ticked off.
This is easier said than done and often, I can't find a form or worse, a request has not been entered. In the latter case, I run back to the Ward, draw another sample, send it to the Lab, plead with the Lab Assistant and heave a sigh when he scowls with an air of superiority and says "Come back in 2 hours".
The X-Rays are collected from the Radio Department located in one corner of the Ground Floor. It's a darkish place and houses the X-Ray machines and all and sundry Radiology equipment. There is no CT Scanner or MRI. The procedure is the same. Match the list I have on my pad with a list of names on a huge register, note the X-Ray numbers and then manually sort out a massive pile of X-Rays. When I find one that belongs to me, happy fireworks burst in the mind and one more task is ticked off.
All of these are then taken to the Wards and kept bedside ready for the evening rounds. The Investigation Charts are updated.
A huge sigh of relief is taken.
I walk down to my bike, head off to the shacks or Snappy for long teas and smokes but not too long. The boys are waiting for their Intern in the Casualty and it's time for Duty.
The term used for "sending patients home with a prescription" is "dispose".
ReplyDeleteAs a current intern in JIPMER, cant stop wondering how much has changed and yet so little has changed. The same rush for finishing sampling, the same crowd with mostly KKK syndrome, the irritating ‘staff’ patients … The HIS is now being used and has changed a lot, good in that we no longer have to go and collect results (unless emergency samples)/ Xrays but then even prescriptions in OPD have to be entered in the system so cant stop envying your days there. Instead of seeing patients, all we ending seeing are their files, interns now being relegated to taking care of raising every patient’s meds
ReplyDelete