Make sure you know what you are getting into... [part one]

One of the pieces of advice I was given as a pre-med, and that I frequently give to pre-med students (it's #7 on my Top 10 list of advice for pre-med students) is,

"Make sure you know what medicine is like before you sign up for it."

That was ringing quite loudly in my mind when I started my call shift the other night. I had had a busy week in surgery. There were some really long days of showing up on the ward at 7am then a full day of office then going straight to the hospital at 5pm and seeing emergency patients and eventually taking them to the operating room and getting home well into the wee hours of the morning... with a full day in the office after that.


Most of the surgeries were routine, but some came with the emotional stress of having to tell a patient and their family they had a 50% chance of dying on the operating table, and a 50% chance of us opening them up, finding that we could do nothing, and closing them up to face their death within the next few days. (One patient's response to that speech? "Bloody hell." Yeah, no kidding.)

I also had a long academic half-day full of lectures on things that I need to know but had no energy to learn, that also went late into what was going to be my evening relaxation time.

I had to try and fit in studying for my two upcoming exams in between all that, and then on top of that I tried hard to make time to get some exercise and spend some quality time, either on the phone, online or in person, with the people in my life who mean a lot to me. And no, there was no time for going to my buddy's poker game, watching the Leafs get their butts kicked (I haven't watched one game this season!), an afternoon round of golf, or any of the other things I would have enjoyed doing that resemble this "having a life" thing I've heard so much about.


As soon as I finished work in the surgeon's office for the last day of this tough week, I headed to the hospital to get my pager and start call - and within five minutes of my call shift starting, my resident and I had five patients to see, all of whom were pretty sick. Just as we were trying to figure out who to see first, the pager went off two more times. We didn't get a break longer than ten minutes until 2am, when I got a bit of sleep before the pager started going off again (getting a bit of sleep means it was a lucky call night).

I'll admit when all those pages were coming in right at the start of the shift, I was feeling the stress of the whole week on top of having a lot on my plate all at once, and I fell into a rut I find myself in once every year or so when all the negative thoughts come rushing to me. I find myself seriously asking if I am in the right place, if I made the right career decision, if I will ever be able to treat patients on my own, if I really knew that medicine was like this before I invested all that effort and money into pursuing it.


Fortunately, the five minutes the resident gave me before I had to meet up with him on the ward was just enough time to break down, almost re neg on my no-crying policy, and beg for some strength from heaven.

Fortunately, God was listening and obliged. And all in all it ended up being a really good call shift. For me, that means a night with some varied, useful cases that are important for me to learn how to manage, and with some good opportunities for me to see patients on my own, evaluate their situations, and develop a plan and present it to the resident for their approval and questioning. We triaged those first cases well, and got through them and all the other calls throughout the night, and put off studying for just a few more hours in order to do those therapeutic things like write this post and sleep in late for the first time in a while.

::: part two to come... :::

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Poking a screaming child? That'll put hair on your...

"Bet you feel the testosterone surging through your veins now, eh?" the ER doc supervising me said. "That'll put hair on your chest."

Then again, I'm sure everyone else in the ED (and all the other wards on that floor) also had a snappy comment for me, seeing as how each and every one of them could hear the screams of my patient.

A young girl had gotten a huge gash in her arm after falling through a plate-glass window, and the emerg doc took one look at her chart and handed it to the resident, who handed it straight to me. At that point I was still unsuspecting, super keen to sew up yet another wound. Boy, was I naive.

After looking at the wound I flattered her quite nicely about being such a trooper, such a large gash and all and so little crying.

Turns out that all my buttering up was for nothing, which I found out as soon as she asked if she would be needing a needle.

That's where I went wrong.

She sensed my instant of hesitation before my answer, and took that as her cue to start screaming at the top of her lungs.

The screaming didn't stop. We tried everything from distraction, to warm blankets, to massaging her temples, to topical anesthetic and intranasal fentanyl, all of which seemed to only fuel the screaming, which lasted well into the procedure, despite the gallon or so of lidocaine I used to freeze the wound.

Even though I have sewed many a wound with very little fanfare, this whole experience actually stressed me out a lot -- much more than I expected it to.

You see, I still have enough compassion left that it makes me feel REALLY bad when I know I'm hurting a patient, especially a child, and I get uncomfortable when I see a pouty look, let alone screams of bloody murder and "PLEASE STOP! NO MORE NEEDLES! OH FOR THE LOVE OF...' Yeah, I didn't know 11-year-olds knew that many swear words. Kids these days.

It was made even better with the parents shooting me the look of death the entire time for causing harm to their little angel. Fortunately, the father's claim that he wouldn't be bothered by the blood soon proved to be quite false, and the emerg doc saw him starting to reel and whisked him away, saying "OK, come with me, you are sitting down over here. Put your head between your legs."

As well, with all the the flying fists and limbs I was pretty scared of buring the syringe or suture needle in my own hand.

In fact, I was even more stressed that I'd be poking the care aide holding the child down. Keeping this saint happy had risen to a very high priority ever since she set aside one of the leftover hospital meals for me (which, despite being hospital food and looking like it had already been digested once, was still food).

The procedure finally ended, and she finally went home, and a strange calm fell over the emerg. In fact, with the young girl gone I could only really hear monitors beeping, ambulance sirens, nurses shouting, and other patients yelling, which was so much more quiet than when that girl was there.

Later on, one of the doctors told me that he used to feel bad poking children because they would cry so much. "Then," he said, "I had my own kids, and realized they cry all the time... even if you are not doing anything to hurt them."

That did make me feel a bit better. But I was still so worked up when it was all over that I considered going to the homeless gentleman and ask if he was gonna finish that bottle of rubbing alcohol he was using to get drunk (tuition is due soon, so I am trying to get all the free hospital food and free alcohol - of any form - I can get). I figured if dealing with the screaming child didn't put my hair on my chest, perhaps some isopropyl alcohol will.

Either way, any more shifts like this and I think I'll start losing hair rather than growing any more.

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The call any med student in Emerg is waiting for: "There's been a massive accident."

It was shaping up to be quite a boring shift. Only a couple hours to go, and nothing very interesting. There must have been a notice in the paper that the super keen medical student (myself) was going to be working a shift in Emerg, because there really could not have been any other explanation for the massive numbers of people showing up in droves with a chief complaint of "I have a runny nose."

Then suddenly the night got very interesting. Here's the play-by-play.

6:30 pm :::
A call came in from ambulance dispatch, and the unit clerk quickly summoned the doctor and charge nurse to keep them informed: "There's been a massive car accident down in the valley. A minivan and a car carrying six people in total crashed into each other head-on, somehow got entangled to the point where they were attached, and then both went over the side of the bridge, careened down an embankment, ran into a few trees and then burst into flames. We're setting up for massive burns, tree trunk impalements, major trauma and who knows what else. The medevac helicopter will likely take out the most serious victims to the larger hospital in the next city over, so we'll likely get a few of the less severe tramas...but by the sounds of it, even those will be pretty serious. By the time they get them extracted and bring them in, they should be here in about 50 minutes."

6:40 pm :::
There is a buzz around the department. The night shift MD shows up to start what he had hoped would be another routine shift, and is instead informed about the upcoming chaos, with several curious other ER staff crowding around to hear the briefing. More reports have come in - the area is too heavily forested, meaning the helicopter can't land. All the traumas will be brought in by ambulance to our hospital!!

7:00 pm :::
The night resident has been paged to show up earlier, the afternoon shift MD (whose shift was just ending) made the decision to stay a bit later, and people are busy in the trauma bay setting up IV bags. The care aides and clerks are suddenly finding solutions to the longstanding province-wide 'no beds in the rest of the hospital' crisis, magically clearing up four beds in emerg in anticipation for the incoming carnage. I'm helping out a lot, too, I'm told, by going to see a patient who had a bookshelf fall on her head. And another runny nose.

7:10 pm :::
Another report comes in. The meat wagon won't be in with what's left of the survivors for yet another hour; it seems as though the army or search & rescue might have to be called in to access the area. There's even a suggestion that there might even be gunshot wounds if the drivers got into a road rage argument after the dust settled. In the meantime, my patient with the bookshelf falling on her head turned out to only end up having a textbook fall on her head, the rest of the shelf narrowly missing her body. Her friends were quite concerned, and brought her in. Oh, and she also wants me to assess her runny nose.

7:20 pm :::
The latest from the disaster zone is relayed to the physician: there is an indication that things may not be as serious as they were initially thought. Three of the people walked out of the accident unscathed, but the other three still seem to be pretty serious. No word on the accuracy of the gunshot rumour. For my patients, I continue to prescribe kleenex, one of the few things that I as a medical student can actually dole out, like it's nobody's business.

7:40 pm :::
Word arrives - the ambulances are on their way! One is coming Code 3 - lights and sirens - with the major trauma victim. The other two will follow, as they're coming routine, without lights and sirens, as their patients aren't too serious. The afternoon shift doctor figures that she may as well go home, since things aren't as bad as they first seemed.

8:00 pm :::
Things have somewhat died down, until the first ambulance is heard in the distance bringing in what must be the major trauma victim. A crowd of ER staff instantaneously gathers at the ambulance bay entrance to greet the incoming disaster. Notably absent from the crowd are the seasoned veterans among the emerg staff, and the doctors, who are going about their own jobs.

8:05 pm :::
The ambulance has screeched to a halt, and the paramedics are throwing open the rear doors to reveal their mangled cargo. The crowd that gathered utters nearly an audible, collective groan of disappointment as the patient is wheeled out of the ambulance, sitting up on the stretcher, laughing and joking with the paramedic, without so much as a single indication of major burns, tree trunk impalements, or missing limbs or appendages. In fact, the patient has a makeshift splint on one of his legs, and other than that, appears to be completely well. The patient is deemed non-urgent, and the doctor sends me in to see him. He explains that the accident was pretty much a fender-bender that ended up with his car ramming the guardrail. And despite having what might have been a broken leg, he says that it doesn't hurt that much, and that actually the major thing bothering him right now is his runny nose.

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She was one of those 'natural' people, and the odd x-ray terrified her.

She was one of those 'natural' people, who always wanted to do things naturally, and even the odd x-ray terrified her. Too much radiation. She once wore a cast on her arm for 6 weeks after falling off a horse, for what could have been just a sprain, just to avoid the two x-rays it would have taken to rule out a fracture.

So, obviously, getting a mammogram was out of the question.

Her doctor tried over and over again to explain to her that a mammogram gives you a very minimal amount of radiation, the same amount as living in a city for 7 months (0.7 milliseverts) - the average U.S. citizen is exposed to 3 mSv per year of 'background' radiation.

The mammogram would have picked up her breast lump long before she felt it, long before it was diagnosed as cancer, and long before she would have to get her breast surgically removed.

A few years later, she started losing weight suddenly, then one day coughed up a startling amount of blood. She had never smoked, so lung cancer never even crossed her mind. Fortunately the radiation dose of 1 chest x-ray (0.1 mSv) no longer scared her, given her past experience, so she got the x-ray her doctor recommended to check it out. Unfortunately, however, breast cancer can spread to the lungs, which is what her doctor found on the x-ray. She died a few weeks after I met her in hospital, surrounded by her family, and countless beautiful flowers and cards showing how much she would be missed.


The week before she died, she said to her doctor over and over, over the sound of her oxygen and between short, gasping breaths, "I should have listened to you. I should have gotten that mammogram."


I had a conversation with another patient last month who is younger than my dad, an incredibly friendly and cheerful man, who is dying because he was too afraid to have a doctor stick a finger up his bum. Had he done that, his prostate cancer would have been discovered a long time ago, long before the it had the chance to spread to his spine, ribs, and legs, forcing him to live his last few months unable to get out of bed and suffering from excruciating pain every time he tried to take a breath. While you are celebrating Christmas with your family this year, his family will be celebrating their first Christmas without him.


It takes a lot to wrap my head around the fact that I am meeting and treating patients who will be dead very soon.

It's harder to accept the fact that a good number of these patients, who drink litres of alcohol a day, smoke like a chimney, don't get off their couches, and especially those who don't bother getting screened for cancer, could have had much longer lives.

Yeah, the screening tests we have aren't perfect, and some of them are uncomfortable and seem a bit undignified. But they do save lives, and so if you are in that age group, there is no excuse to not get them done.

This is not the place to get medical advice, so talk to your doctor about getting a prostate exam, a pap smear, or a mammogram. Sooner rather than later, please.

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If this post ends abruptly...

Note - I'm writing this in the hospital as I'm on call, so if it ends abruptly it means I got paged and have to run and was up all night and didn't get the chance to finish it.

While most of my call shifts have been pretty interesting, tonight seems to be very slow. So far, I've just been sitting around in the library, doing noth

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