Sunday, April 7, 2013

When I was Houseman (Part 1)

Preparing the instrument for internal pacemaker insertion. i was assisting my senior medical officer and soon to be specialist to insert a pace maker for a symptomatic bradycardia patient. one of my sweetest memories as a houseman



“When I was houseman, I used to take care of the ward alone and even two wards.” “When I was houseman, I have to do back to back call and never trouble my MO.” “I did CPR continuously from bed to bed.” “I did the operation by myself; herniotomy, appendicectomy, even LAPAROTOMY!” “I did all the procedures, CVP, Peritoneal dialysis, blab la bla.” “I was never blur like you!” “When I was HO, I did those, that, this and everything!”


“Now HOs are very MANJAlitis, everything you do ah! You cry, wanna tell your mom, complaint there and there.” “You are not grateful! Working shift and still doing shit!”


Should we make a full stop to all this crappy conversation! Not only MOs but many specialist are very proud to humiliate the new doctors in training or HO. It is really inappropriate to compare themselves with the present scenarios. I will highlight one by one, the points that usually being used them not to show any disrespect but to find the root cause of why the doctor’s performances are dropping now days.


I’m a HO and I’m not PRO HOs or not taking lightly the concern raise by the senior doctors. Yes! The qualities of doctors are dropping but did the present HO really perform badly compared to the old timer? If so, what are the reasons?


Shift system vs. On Call system


My first posting was O&G and I have to do on calls during that time as well before the system was changed. It was a hell life. Woke up at 4.30 AM in the morning and arrive in hospitals at 5 AM. You have to do your AM rounds and check CTG for patient scheduled for induction of labor and assess the Bishop score. If favorable then you have to insert the prostin and monitor the CTG after one hour and keep one re assess. 6 hours later, you have to decide again whether want to insert the second one or not. In the middle of that, something went wrong than you have to prepare the patient for emergency OT and so on. 

Around 7, then will have to do the morning rounds with MOs and than having a morning prayer with specialist at 8 am. All the cases especially the problematic one will be discussed. Finish with the session,  then we get back to our duty, some run to the OT, labor room, admission center and alternative birth centre, clinics and for a newly comer like me; stay in wards and do all the ‘kuli’ staff. Lunch hour is the golden time when you can take a break. You rather take a nap rather than eating or else you will scrabble and drawing weird shape inside of case note instead of writing patient progress. If you are not on call, then you can go home by 8 if the rounds finish earlier. If not, then you have to wait even up to 10 pm or 11 pm. Those who on call, will stay and complete the 36 hours of torturing.


It was more relaxing when the system was changed. Finally I can see the sunrise and the sunset, take time to rest and do normal human being activities. But yet! You will still have to shed tears and swallow the pain. O&G remains as the busiest department.


People ask, which is better? Shift or on call? Both of them have the strength and weakness. For me, of course I like the on call system as it makes you a tougher and more experienced doctor but then it has weakness as well. You are so damn tired and you can’t focus on the patient. You got easily irritated and get angry over a simple thing. It is pitiful to see patient being scolded for a simple and unreasonable reason. It is a common thing to do procedures like assisting operation and fall in sleep in the middle of operation. Yes! And it is definitely very dangerous.


And when the number of houseman keeps on increasing, you cannot compact the whole battalion at the same time and ends up with one HO looking after one patient. Still you won’t learn much! You will be battling for procedures and some will only look for an escape. There are bunch of HO who will not have the chance to do procedures and lose interest and rather let others to do it. So they just go and grab some coffee, escape from their duty and go to cinema. What a life!


With a shift system, you can have a minimum number of functioning HO, a space for them to learn and do procedures. They will have enough rest and feel fresh to work. They can focus and do job better. Besides, they will have time to explain more to patient about their disease progression and recovery.


Whether we like it or not, shift system is the only way (and can be improved) to give a fair ample time for HO to see the patient. Besides, for me the concern about HO wont seeing much case won’t arise by implementing the shift system. Why?


Previously, Housemanship period is only 1 year or three posting. But now, with the extension of training program to two years, definitely they will see more variety of cases from various departments. 4 moths per department and you will have 6 departments all together. Grossly, you will see around the similar number of patient.


And of course they will always a succumb bag who stupid and ‘manja’ enough to demands for more luxury time. There was given flexi time but still demands for two straight roll weekend’s holiday. Are you joking? You think this is a work where you sit near the counter and gossiping?  You are saving life and not a joker. Give a little sacrifice as a sign of respect to your profession. Once you become a doctor, time did not belong to you. I think this people not only exist during present HO time but since the previous time as well.


HOs are useless!

It is a sad thing to hear this word. Have we ever wondered why? They keep on barking that HO’s are incompetent of doing procedures. Despite of their log book but still fail to meet the preset criteria.


In my hospital, I was lucky. We are so lacking of MOs (previously) that we are entrusted to do many things. Patient come in to admission center for hypertensive in pregnancy with sky rocketing BP, you still can manage. Give a stat IV labetolol, second dose of IV labetolol and then inform the MO. After discussion, then you may start the Labetolol infusion or considering the Magnesium sulphate.


In other posting, we are allowed to do CVP short or long line. Femoral catheter, UAC/UVC, chest tube and many more.


Sadly, in many places, HOs are not given chances probably because they are too many of legal suit, new MOs and I don’t know about the other thousands excuses! It is surprising to hear that there are hospitals that did not allow HO to insert the CVP, UAC/UVC. In some hospital, prostin can only be inserted by MO. You cannot set the TPN for the neonates. They only can observed or assist. Surprisingly, some of them not even had given chances to perform intubation, chest tube and lumbar puncture.


In certain places, they are never being given chances to look after patient in CCU, NICU, High dependency unit and Emergency department Red Zone cases.


I will never forget that my MO used to come out of his working hour just to supervise me inserting the femoral catheter. I’m not going to forget that I’m 90% almost always fails doing procedures at the first time.


For me, the first hand experience is very important. You may fail for the first time, second time and third time. But every time you fail, you will always learn a new thing. I fail my first and second time of intubating pediatric patient. I fail my first lumbar puncture, central line, UAC insertion. I think, not many procedures that I manage to perform it during first attempt.  


I was very lucky to have MOs and specialist who keeps giving me chance. When I fail to intubate a child, I was given the next chance and I succeed. I fail my first LP, central line, UAC insertion but it get better with the 2nd, 3rd and fourth time.


It is a sad thing that HOs are being labeled as useless when they are not given chances to improve themselves or give a shot to do procedures. They are many factors contributing to this. Put aside attitude problem among the HO, it is greatly contribute by the system, fear of legal suit, and the specialists’ attitude as well.


Apart from that, there will be a day when you are not lucky that you keep fail doing procedures. It’s like a wheel where you will be on top and on the bottom upon next time. And yeah! There will also be a certain area of which you will be having difficult time or not gifted enough to do it. As for me, I find out that I always fail to insert arterial line to neonate and all my attempts fail. I’m very bad in inserting branulla to the severely premature babies and I think I only manage to insert once or twice only. But as my principle goes, I will not going to give up and I set a aim that no matter what, I will give one shot to try. Only one shot! If I fail, then I’ll definitely hand it over to someone more experiences. And that person definitely the staff nurse, and on rare occasion, it’s your senior doctor.


Therefore, despite of straight away calling a houseman as useless. Please consider to give them chance to learn and supervise them. When you are intubating the patient, why don’t you allow your HO to give one attempt? When you are inserting the UAC/UVC, why don’t do it together and share it. You insert the hardest part which is the UAC and let your houseman to insert the UVC. Learn to trust them so that they will grow.


To be continued………
Allah Matlamatku, Rasulullah ikutanku, Al Quran pedoman hidup, Syahid impianku.

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