Today is the last day of my third internship rotation. Moving on from Gen Med A into Colorectal next week.
Ironically, now, I wish for my Gen Med rotation to be extended. Primarily because of, the awesome registrar that our unit currently has. Not only I think he’s a fantastic and dedicated medical registrar, the three of us in the Gen Med A work very well together. Teamwork. Clock-work teamwork for the last three weeks. Delivering care just like the way I prefer. Sensible clinical decision and unhurried by the bed pressures.
Unfortunately, I only have the chance to work with Dr. JW for one week. The other two weeks, I was working the gen med cover job. However, that one week was probably the highlight of my Gen Med rotation. I would remember it for a few reasons. The events during that one week, the things that we did, had definitely caught the attention of many in the hospital. It was also the first time I participate actively in a MET call.
I’d put my recollection into words here, to be remembered for years to come.
“I tell you what, Xiao. We gotta head home on time today and hopefully I can take my afternoon off today.”
It was a Thursday morning, a day that Dr. JW and I were expecting a relatively relaxing day. We’ve been slogging since Monday, working with some of the more complicated patients but all the referals’d been made and had plans outlined for all of them. We’d never have seen it to be the day where anything that can go wrong, would go wrong.
Our first patient of the day was a gentleman in his 70s, coming in with unstable BSL for management. We were planning to “sell” the patient to Endocrinology team for transfer of care, considering that we did not identify any other issues that would be sorted out under the General Medical unit, besides the poorly controlled sugar level, with episodes of hypoglycemia. That’s why we skipped our normal routine and started our ward round with him. I shall address the patient as Bill here.
We walked into the patient’s cubicle to find patient was fast asleep. JW went on to try to rouse the patient while I went through the history to know the events overnight, if any. I promptly told JW that patient developed a hypoglycemia the previous evening with altered GCS and BSL of 2.1 and managed promptly with 50% dextrose by the covering doctor. Otherwise, no other significant happenings overnight.
The alarms bells in our heads started ringing when the patient was not rousable. He was fine the day before. A check of the vital signs revealed no readable BP, tachycardia, afebrile and normal saturation. Manual BP revealed no BP as well. In the next few seconds, my registrar and I went to work. Reflexively, I went to palpate the carotids and radial pulses, while JW auscultated Bill’s chest. Carotids present, radials absent while JW was reassured temporarily by the presence of heart and breathing sounds.
JW called A MET. We needed more hands.
It would be minutes before the ICU hands came. In the minutes, I’d have delegated various jobs to the nurses.
“I need a bag of ice. I need extra bredmas. Get me the portable phone, need to call X-ray. Get the IV trolleys here. Get the ECG.”
I belted out orders,crisp and clear, as if I’ve been through this a dozen times before, but in reality, I have not. I tend to evaporate into the thin air, whenever a MET was called because, most of the times, there were more than enough experienced hands on board, and interns were not normally required at all.
Meanwhile, JW put the patient on supplementary oxygen, checked the carotids again and quickly went through the history to look for possible precipitating causes. I palpated patient’s femorals and reported to JW.
“Whatever we are dealing with now, the good news I think we still have a systolic BP of 70 mmHg.” Which was something I happened to have read yesterday. With that, I thought that the intraabdominal organs particularly the kidneys were still being perfused but that was only the beginning of our troubles.
The ICU registrar then hurried in. She looked a little bit flustered, probably not expecting a MET to be called so early in the day. She received a brief handover from JW who thought that we were most likely to be dealing with a septic shock ,while I get the portable X-ray organised. We need to get fluid into Bill fast. JW and I tried unsuccessfully to put large bore cannulas in. JW managed to get a 20G in though and got the fluid running. Bloods were sent.
A stat dose of vasopressin (?Aremin) was then given. The ICU registrar dejectedly told us that there was no ICU bed available in the hospital. She seemed unsure what to do next for the patient considering Bill would definitely need an ICU bed for further management. She was woken up from her seconds of deep thoughts before another MET call was called over the P.A. system. JW sensed her hesistancy and suggested that it would be best that she went for the other MET call and he could probably handle Bill himself. JW after all, aspired to be an intensivist and recently concluded his ICU rotation. In truth, JW might be more experienced than her in critical care, considering the registrars only recently moved onto their respective rotations.
“What now, JW?”
“WTF is this! We need an ICU bed. At the very least, we need a bed, a monitored bed. He would need a CVC and it can’t be done in this ward. Farking hell!” JW’s not in his most friendly mood at that moment.
“You want a monitored bed? I have a suggestion. I learnt during my covering shift that the Coronary Care Unit next door doubles up as our HDU in this hospital. Probably not as good as ICU bed that you need here, but they are monitored bed and should buy us some time for an ICU bed.”
“All right. I will speak to the CCU in-charge.” Off he went, swearing and muttering to himself, probably to vent off his anger before trying to speak nicely to the CCU in-charge. The CCU staffs wouldn’t be happy at our request, but we just gotta what we gotta do.
I went back to the patient and attempted ABG and cannulas again. With no radial or brachial pulses present, I was hunting blindly and unsuccessfully for the ABGs. I had no luck with the cannulas as well. I swore silently to myself at my incompetency. X-ray was taken. IDC was inserted.
JW came back to the patient five minutes later with an even blacker face than before. Looks like the suggestion did not go too well with the CCU staffs, but we got what we wanted – a monitored bed.
Bill was then transferred to CCU. JW got on the phone and tried to get the consultant’s assistance. We’ve got a covering consultant for the day but he was unable to make it to the hospital till later in the day. The ICU registrar was caught up with the other MET call. That just turned JW’s face blacker by the minutes.
However, he was still nice enough to give me some words of encourgement. “You did very well, Xiao. I am very impressed with what you did in there just now. I am going to run this very sick patient as an ICU registrar. Can you move on with the ward round yourself? I will catch up with you later.”
I smiled at what he just said to me. He just meant that I would run the round as a medical registrar today. I was pretty excited, rather than intimidated. I might not be at the level of a medical registrar like JW, but I was pretty confident I could handle the patients in the wards safely and sensibly. I was shouldering the work of a registrar and an intern. In between my ward rounds, I put in cannulas, made referrals, made phone calls to nursing home for collateral history, rewrite drugs charts while discharging patient, writing up plans etc.
I caught up with JW a few hours later. He was still busy with poor Bill, arranging for a transfer to a private hospital’s ICU bed. That was about the only bright spot of our very bad day that patient had private insurance cover for him to be eligible for transfer to private ICU. JW was very happy with what I did on that day and what we did as a team.
JW clocked out soon after Bill was transferred. I clocked out at 7 p.m with a very satisfying smile on my face, knowing that I have accomplished something very well.
The next day, our unit became the story of the day, for what we had accomplished the day before, turning some heads in the upper echelons as well.
At the end of the rotation, JW gave me the best assessment of my performance I could possibly think of.
Retrospectively, I thought I could’ve done better with the cannulas. However, I am glad and surprised at myself too, for performing so well in times of stress and uncertainties. Perhaps, I do need a little bit of anxiety for my peak performance. Would ICU be my calling? Who knows?
I have not felt so accomplished for a long time. I’ve aced my Gen Med A rotation here:)
P.S. This story is purely fictional. Please read it with a big bowl of salt. Any reference to any characters in real life, is never intended and coincidental.