THE FIRST DAYS OF MEDICAL INTERNSHIP

THE FIRST DAYS OF MEDICAL INTERNSHIP

After a long futile search for house Job placement across the federation, the limit of my endurance was almost approaching a breaking point when I felt the power of divine Providence. I was almost at the verge of giving up the medical profession to pursue my other God-given talents and to disentangle myself from the yoke of intellectual stagnation when a turning point eventually appeared.

We had been asked to commence work without any atom of delay even though our appointment letters were still being processed. Overwhelmed with the joy of new job placement, no one could raise an eye brow against non issuance of appointment letter prior to assumption of duty. After all, the long time idleness was beginning to give way to a busy schedule which we had earnestly desired.

The resident doctors in the hospital had been on industrial action for a couple of months. Being the backbone of every tertiary health institution, the hospital had been suffering from a severe dearth of manpower. The management had then taken advantage of the situation to recruit and deploy new interns without any delay. We were to alleviate the hospital of the paucity of medical personnel created by the absence of the resident doctors.

I was posted to a very busy unit in internal medicine. The absence of the resident doctors seemed to have further increased the work burden on me. We saw the patients all alone, made our diagnosis and instituted our management protocols. We would only call the attention of our consultants in the areas where we were really confused.
Our unit together with the cardiology unit were always on weekly casualty call which begins from eight o'clock in the morning of that day to eight o'clock in the morning of the following day.
The duty roster for the monthly call schedule was released on the midnight prior to the first day of the month. I had been baptized with relatively more frequent calls than my older counterparts as had been the norm in the hospital's modus operandi of call allocation. It was believed that the new house officers should be assigned more calls than the older one's to enable them acquaint themselves with the basic skills of the medical practice within shortest possible time.

In the first casualty call during my entry into the unit, we were three house officers. I was placed on a ward call to take care of the inpatients in the female medical ward. This involves the administration of drugs to all the patients and handling any health emergency that would arise in the course of the call. The other two house officers were to remain in the Accident/Emergency.
The ward call begins at 4:00pm. Hence, I was to stay with the other house officers in the casualty department, clerking patients until the tenth hour when I would depart to the ward. I had clerked three patients. One was a case of congestive cardiac failure secondary to uncontrolled hypertension and the other was a case left foot ulcer on a background of uncontrolled diabetes. The third patient was a case of left cerebrovascular accident with right hemiplegia. She had a significant number of the risk factors of the pathology. She was an elderly woman in her mid seventies, morbidly obese, hypertensive and diabetic for ten and fifteen years respectively and had not been compliant with her medications and follow-up. She was deeply unconscious, unarousable to any verbal or painful stimuli. Her blood pressure was markedly elevated and she had an abnormal cyclical respiratory pattern that waxes, wanes and comes to halt which is expressed as Cheynes Stokes breathing in the medical term. I had informed my consultant about the patient over a phone call and he had instructed me to admit her into the female medical ward and commence her immediately on intravenous mannitol to decongest her brain.

At 4.00pm, I left the Casualty to proceed with my ward call. As a novice in the medical internship, one of my greatest challenges was to secure an intravenous line on patients. Taking a sound clinical history and doing a relevant physical examination was not a problem to me because that had been adequately dealt with during our days in the medical school. However, I had never set an intravenous line on any patient neither had I made an attempt to do so prior to my commencement of internship. We never took that serious because our older colleagues would always advise us that the most important thing is to read our books and pass our exams. Thereafter, every other thing shall be sorted out as soon as we begin to practice. It was then that it dawned on me the need to carry every thing along at every stage of learning. Forseeing the challenges of intravenous cannulation, I had painstakingly taken out time out of my tight schedule to keenly watch the casualty officers cannulate newly arrived medical inpatients.

Are you a new house officer?' they would ask as they see me fastidiously watch them insert the cannula into the vein. I had tried to put my observations into practice by attempting to quickly cannulate few patient that just arrived at the casualty before the attendance of the casualty officers. Among the few I tried, I only succeeded in getting that of a young man whose vein was apparently ideal for intravenous cannulation in the hand of an amateur learner as against the vein of the elderly patients which are usually tortuous and wobbling.
Over the time, I had discovered that one of my major hindrances in setting intravenous line was my extraordinary unwarranted humane tenderness that triggers a spontaneous repulsion to continue after one or two futile attempts that had caused pain to my patient. This is contrary to some of my colleagues who could puncture a patient ten to fifteen times without any whiff of emotional disturbance.

The female medical ward was filled with a pretty number of patients unlike the male medical ward that was scanty. I started with a preliminary ward round which entails moving from bed to bed, sorting out the patients that were on intravenous drugs and those that were critically ill and taking the necessary precautionary measures on them. At the same time, I was fervently preaching against the deliberate dislodgement of intravenous cannula by some mischievous patients who like to create more work for the doctors. I entreated each patient passionately to help preserve their intravenous lines at least throughout my period of call. Any patient with loose intravenous cannula, I would grab her hand and tape it firmly with the aid of a plaster. This, I did before commencing the intravenous drug administration. Hardly had I finished administering drugs to the inpatients when I heard the sound of a device wheeled into the ward. Behold, it was the patient that I had earlier clerked in the casualty. She was being brought in on a gurney by the orderly. I was not bothered by her arrival into the ward since it was just to give her the prescribed intravenous drugs just as I had done to other patients. Without any stretch of imagination, I had thought that the patient must have been cannulated at the casualty as had been the custom but to my utmost chagrin the patient had been left without any trace of cannula. Why has the casualty officers decided to punish me this night?' I exclaimed agonizingly under my breath with my feelings not overtly expressed. Yes, I knew what it means to secure an intravenous line on such patient. She had all the three factors that makes intravenous cannulation difficult based on age, sex and body habitus. Setting intravenous line is relatively more tasking in females than males due to the more adipose tissues obscuring the veins in the former. How much more in addition to the feminine disadvantage, the patient is now old and morbidly obese as was the case with the patient. As I looked at her closely to find which vein to use. There was no trace of any across her upper and lower limbs. I tied a tourniquet, allowed some time for the vein to engorge yet nothing showed up. I gently hit the skin with the palmar surface of my hand to render the vein visible. I did several other manipulations including hanging the limbs downward but all to no avail. I could then deduce that this was a typical case of a blind procedure. I tried to recall my knowledge of human anatomy with respect to the course of vein.
At this moment, my stomach mumbled and I remembered that I had not eaten since morning after the little breakfast of tea and bread. I thought of rushing to the cafeteria to have my dinner before proceeding further with my venous adventure but as I checked the time, it was 9.00pm, too late to meet anybody at the cafeteria.
I had to bear the hunger pangs and continue with the procedure in a spirit of stoicism. I exchanged between the blue-head and green-head cannulas but none could solve the problem.
This time, I employed the service of the patient's relative in shining a touch light at the site of the procedure as a means of aiding the visibility of the vein. I then brought a seat, sat beside the patient, held the hand at a closer range and began to apply my visual acuity in detecting any bluish tinge along the skin and my power of palpation in feeling any engorgement. However, none of these was helpful as no vein was rendered visible or palpable. After much failed blind attempts, I was almost losing my fortitude. I bent my head in intense contemplation, thinking on the way forward. The inmates of the ward could see how hard I had tried without success and they were moved with pity towards me. One of the patient's relatives who observed me from a distance went to the extent of pleading with the senior nurses in camera on my behalf.

'Ma, please, could you come and help this doctor? He has been here for a long time trying to set line on a patient'. She said. In her little mind, she thought it was an easy task for the nurses.
A group of nurses walked down the aisle of the ward towards my patient's bedside. They could see my intense struggle and exhaustion. It was written all over me. My eyes had even turned red from excessive straining to see beyond the skin and subcutaneous layers as though it was possible.

'Doc, well done!' They hailed and walked back to their station. None could render a helping hand because they understood the inherent difficulty associated with that particular patient's cannulation.
I was now thinking of taking a brief rest before continuing when another nurse passed by.
'Doc, you won't forget this night!' She exclaimed, laughing sadistically.
I had just untied the tourniquet and removed my hand gloves when a tall slim girl appeared from the blue. She was a fellow house officer in my unit and had come from the Accident and Emergency to collect a blue-head cannula from the ward. The moment I saw her, I heaved a sigh of relief. Messiah has come! I exclaimed in my heart. Being an older house officer, I believed she had acquired more skills than me. I gave her the blue-head cannula and asked for her help. She tried the first time without success, the second time, third time and the fourth time. By this time my mental relief has begun to experience a rebound tension. It was really the climax of my clinical experience. 'What else can I do if she doesn't succeed?' I thought. It was fast approaching mid night. I was afraid of what might become of the patient if not placed on drugs or infusion till the following morning. Hence, suspending the intravenous cannulation was not in my options. When the fourth attempt had failed, she quickly untied the tourniquet from the forearm and tied it above the patient's elbow at my suggestion. 'If I don't get it this time, I have to leave, they are already calling me to return back to the casualty' she said. I resorted into a non vocal prayer. My mood momentarily transformed in a solemn and sober manner. She wiped the skin around the elbow with cotton wool wet with methylated spirit and then aimed at the large vein within the cubital fossa. She inserted the cannula almost horizontal to the skin surface and advanced a little. She then withdrew the trochar and there was a sudden gush of blood through the cannula. She then advanced the remaining part of the cannula gingerly into the vein and covered the tip. It was a triumphant moment. I vigorously tore out some pieces of plaster with which I reinforced the cannula on the skin.

Thank you very much!' I said. 'You're welcome ' she replied, as she scurried back to the casualty. I then began my intravenous infusion and drug administration until 1.30am. The few hour sleep I had that morning was quite invigorating despite the incessant bouts of hunger pangs probably because I had offered in my best to the patient.

SON OF THE KINGDOM STORY...