Friday, 27 June 2014

On Becoming a Doctor–Internship


image1967 Saskatoon, Saskatchewan. 

We packed up our Volkswagen Beetle and, with some trepidation, headed off to beautiful Saskatoon, “the city of bridges” to begin a new adventure, my medical internship.


In order to be unleashed on the public, every doctor had to endure at least one year of what was called a Rotating Internship.  That means, you become part of the house staff of the teaching hospital, usually a facility of your choice, where you become more or less a slave, performing duties at the pleasure or whim of more senior house staff, attending physicians or obstreperous head nurses.  You must remain on call night and day for weeks or months on end and attend to the most menial or important task asked of you regardless of how you are feeling or your level of fatigue.  You may find yourself in the operating room, delivery room or the wards to which you are assigned any time of day or night, often without the opportunity to rest or eat and often sick as your immune system has worn out.  On one occasion, I worked for 52 hours straight without a rest!  We received the grand sum of $400 per month which worked out to a pittance of much less than a dollar an hour.

While “doing hard time” as an intern you have to be willing to bear the scorn of more senior staff responding to them with a friendly smile and a sincere “Yes Sir!!”  On the rare occasion that you have a bit of time on your hands you are expected to review patient files or study your books and medical journals.  Someone once told me before I began my studies that “you will be going through seven years of hell.”  It wasn’t quite that bad but there were times when I thought that person was close to hitting the nail on the head and I did endure the odd glimpse of hell!

clip_image001Arriving at the University of Saskatchewan Hospital, we brand new, wet behind the ears, interns, brimming with our new found but not yet practical knowledge, were issued our whites (so we could easily be identified as a potential slave, I guess). Then we were bombarded with orientation instructions regarding the policies, rules and regulations of the hospital, layout of the facilities and introductions to the staff.  We were also conducted to the windowless intern’s and resident’s quarters where we would spend many, many long nights trying to grab bits of shut-eye.  We were then assigned our initial rotations and off to work.

My first rotation was in psychiatry, which was OK as there were not as many emergencies requiring us to get up in the middle of the night to administer to patients who were mostly sedated anyway.  We might get the odd call regarding something mundane such as “Mrs. So and So needs a laxative,” but it was otherwise relatively peaceful.  However we were invited to register for shifts in the emergency department (ER) and they would pay us an extra $35 per shift which seemed to be a lot of money at the time.

clip_image002The U of A psychiatry department where I was initially exposed to this important branch of medicine was more of a Neo-Freudian psychoanalysis style of service compared to the U of S department, headed by Dr. McKerracher, a former wartime military psychiatrist, which leaned toward the more practical psychotherapy model.  I found myself performing Pentothal interviews, administering shock treatments and trying to help patients find ways of coping with their problems.  Most of the folks admitted to the ward were psychotic, as less serious patients were treated as out patients, so this was a good introduction to dealing with psychoses.  One of the more memorable admissions was the young man responsible for the “Shell Lake massacre” in which he had murdered his complete family with a .22.  There were also other violent criminals who were kept in a lock-up section with police guards. I was glad that the police were there as some of the inmates were unpredictable and could become very aggressive and violent.

I also spent quite a few shifts manning the ER and Poison Control Centre and preferred the late shifts as they were not overly busy except on weekend nights.  ER work was interesting and exciting – you never knew what the next case would be.   In addition to the usual heart attacks and other medical emergencies, there would be at least one gunshot wound per week, the odd stabbing and auto accidents and burn injuries.  We would stabilize the victims and then send them off to the appropriate ward for longer term care, which was fine with me.

  This was also a time when open chest cardiac massage was falling out of favour and closed chest resuscitation (CPR)  was now becoming the normal method.  I did perform many of these and most of the candidates survived despite the occasional rib fracture – mind you, fractures are easier to heal than death!  One of the most noteworthy events related to this was a man in cardiac arrest who was brought to the ER by ambulance.  The Code 9 team worked on the patient for over an hour but there was no sign of life, so they gave up.  Some student nurses who were observing this drama asked permission to try CPR just for the practice and feel of working on an actual human.  Well, that man walked out of the hospital three weeks later!!

The next rotation was on Paediatrics.  I enjoyed working with the kids but the cancer victims broke my heart as they usually died.  One of the many kids that I cared for had a brain tumour and would just lie in bed moaning all day unless his parents were there for their weekly visit from a military base where the father was stationed.  I used to read to the unfortunate lad every night when I had the time and he would quiet down and fall asleep, but I also had to drain cerebrospinal fluid from his head every day and that didn’t please him.  God, I hated that!  One of the little boys dying from cancer, an only child, was visited every day by his parents who were now past having any more children.  One day, they brought a stuffed toy called “Buzzy Bee” and it stayed with him in his crib.  Every time I see one of these or a similar stuffed toy, I think of that poor child and the terrible sight of the heartbroken parents as they cried over his little body.  There are so very many memories that are impossible to erase.

The Internal Medicine assignment was also interesting, especially from a diagnostic perspective as this was, after all, a university hospital and the cases were obviously more exotic than in most facilities.

OROne of my favourite rotations was on the surgical wards, though the workload was extremely high as they were short of interns and I was responsible for three wards rather than the usual single ward. I had to “live” in my little room (or cell) for sometimes a month at a stretch though most of the time I was dragging myself around the wards.  There were various surgical specialties in the hospital, being one of the largest in Saskatchewan.  So, I was exposed to cardiovascular, thoracic, neurosurgery, general surgery (my least favourite though not as tedious as neurosurgery) and traumatic and plastic surgery, my favourites.  You never knew what you were going to see or do in the next few minutes or hours.  I also enjoyed plastic reconstructive surgery though working on the burn unit was disheartening.

I’ll never forget Mr. P., a welder.  He was brought in from a high steel construction site with over 80% third degree burns.  One of his co-workers thought he would play a joke on him and, while he was welding a joint, threw a bucket of what he thought was water on him.  It turned out that it was paint thinner, not water, in the bucket and turned poor Mr. P. into a human torch.  He suffered through weeks of almost daily surgery but finally succumbed to a bacterium (Pseudomonas aeruginosa). 

Another fire victim was a chap who worked for my father and I had known him for many years.  When I was a little boy, he used to let me ride around with him in the heavy road construction equipment.  On the night of the accident, he was lighting flare pots when one of them exploded and set him on fire.  I visited him often and, to help him with his pain, prescribed cases of beer which we were allowed to do.  Alas, he too died from infection.

Gunshot wounds were interesting because bullets would ricochet around the body damaging various structures, so one minute you were repairing an intestine and the next an organ, vascular system, thoracic or nerves.  Hippocrates apparently once said “If you want to learn surgery, follow an army” and I thought this would be appropriate training for a military doctor.

Sometimes you couldn’t do anything to save a trauma victim and the kidney transplant team would be standing by.  U of S was one of the pioneers in kidney transplants but there was not the technology at that time to preserve organs, so the recipient had to be opened up on the operating table ready to receive the kidney.  On occasion, the trauma victim survived despite the poor prognosis so we would have to stitch the recipient back up and send him or her back to the ward to await another potential donor.  It is wonderful to see how transplant science has progressed so far from those primitive times.

Between operations, the surgeons would usually sit in the doctor’s room in their greens, drinking coffee and discussing politics, the economy and sometimes, even surgery.  One of the surgeons was quite racist and, on more than one occasion, asked me to show the more senior, but foreign house staff how to perform various operations, so I would end up as the surgeon and the resident would be first scrub!  I learned a lot about surgery from that and, more importantly, the patients survived.

Our brother, Graham, who was living with us at the time, had a Siamese cat named Foo Ling.  Poor Foo was born with an umbilical hernia and a twisted tail (and I think he was not at the pinnacle of the cat intellectual totem pole).  Fortunately, one of the med students was a veterinarian and agreed to help me fix the hernia and neuter Foo and our other cat for the price of a few beers.  However, the vet had never done an umbilical hernia, so I scrubbed in on the procedure one day in the OR and was able to perform the operation on poor old Foo who was anesthetised and strapped to Pat’s ironing board.  All of the cat operations that Saturday afternoon were successful and we all (except for the cats) anaesthetized ourselves with the beer while Pat was tasked with monitoring the two creatures’ temperatures with a rectal thermometer.  Oh joy!!

Being the sole intern on the three surgical wards had its drawbacks, however.  I was often up all night admitting patients and ordering appropriate tests and medications or assisting in the OR.  The Chief of Surgery was kind of a miserable New Zealander who took great joy in belittling and cajoling the house staff.  One night I was in the OR for an entire night assisting one of the cardiovascular surgeons with a bleeding abdominal aortic aneurism, finishing the procedure at 0735.  The Kiwi chief surgeon berated me for being 5 minutes late and then, as we stopped at each bedside, would ask me to list off the morning’s lab results, which of course I had not been able to see.  At every bedside, he chided me for not knowing the results and I decided on the spot that, perhaps surgery was not for me if I had to endure that sort of humiliation for another four to six years.

Obstetrics was another matter.  Delivering babies was a very happy event most of the time, though it usually involved being up all night.  95% of the time things went smoothly, even though these were often high risk deliveries such as breech births, forceps deliveries or Caesarean Sections.  However, when things went wrong, for example a haemorrhage, they usually went wrong extremely quickly and there was very little time to react and you had to do exactly the right thing to save the lives of the mother and child.

One horrible night I was alone on the ward as usual, delivering several infants, when Pat called and told me that she was in labour.  Upon her admission, I called the attending physician who quickly arrived along with the senior resident.  After an uneventful delivery of our healthy daughter, Kirsten Jean, Pat was taken to the recovery room and I had a couple of more deliveries.  One of the nurses frantically called to tell me that my wife was haemorrhaging severely.  Indeed, it was the worst post partum haemorrhage that I ever saw in my entire career.  Her attending obstetrician told me, when I called him, to relax, that I was just a “nervous papa” and to try to get some rest.  Even the nurses couldn’t convince him that something was seriously wrong and I was left responsible for her care. Over the ensuing hours I ended up setting up an IV, starting a Syntocinon drip, cross matching her for blood and giving her five units before the specialist finally arrived.  It had been like one of those terrible nightmares where you are trying to run away from something and your legs are like lead pipes and you can hardly move.  I went home at the suggestion of the Obstetrician.

A couple of hours later, the hospital called and informed me that they had just operated on Pat and that I could see her in the recovery room.  When I reached her bedside, she looked very pale and I couldn’t detect respiration or a pulse whereupon I shouted for the nurse who tried to take her blood pressure and then called a Code 9.  Pat was taken once more to the OR as I waited, pacing nervously back and forth in the doctor’s lounge.  Finally, I was informed that I could see her in the ICU (Intensive Care Unit) so I walked in and saw that she was breathing, had a detectable pulse and her colour was returning. Once again I went home, this time having stopped and picked up a bottle of rum – man, was I angry!  They say that alcohol doesn’t help situations like this, but, I swear that this rum helped more than milk or water would have!  I don’t know who the heck “they” are, anyway.

Wouldn’t you know it, Pat developed puerperal fever (a post partum infection) and her stay in the hospital was prolonged.  It seems that doctor’s wives are more likely to have more problems than other new mothers (I have no statistics to prove that – it just seems that way)!

I happened to be in the ER one night when the chief of a local band was brought into the hospital.  It seems that a couple of the residents of the reserve got into the booze and attacked the poor old chief with hatchets, fracturing numerous bones and causing deep lacerations.  He also had been scalped, but the scalp was still attached by a narrow strap of skin and could be stitched back on.  He spent hours in the OR while the numerous wounds were closed and bones reset and pinned.  Some weeks later he developed what is called  a Curling’s Ulcer, a gastric ulcer that may occur after severe trauma and it was haemorrhaging.  We took him to the OR and opened him up.  He had also been a bronco buster and there were many, many adhesions in his abdomen, making the procedure very long and complicated.  However, we were able to stop the bleeding and, by some miracle, he survived, walking out of the hospital over a month later.

One of the strangest cases was that of a little girl who was tobogganing on the bank of the South Saskatchewan River next to a wooden ski jump one Sunday.  Apparently, she lost control of the toboggan (as if there were actually any control) and ran into the structure.  Her abdomen was pierced by a 2 by 4 that went in from the front and out her back, by the grace of God, pushing aside and not damaging vital organs.  So she was brought into the ER and rushed to the OR for emergency surgery.  It was the practice of the hospital to call the patient’s family doctor as a courtesy.  Her GP had the reputation of being a rather obstreperous old coot who was prone to interfering, so the resident told him that his patient had a “splinter” whereupon the doctor instructed the resident to “remove the darn thing.”  This was done.

I could go on and on, writing about the many interesting, dramatic, sad and strange cases that I encountered as I spent the years of medical training up to that time.  Now it was time to leave the hospital and really learn about medicine.

imageIt was a tough, but exciting and rewarding year.  How did I cope with the really hard and disturbing parts and carry on though many times I felt like giving up?  First of all there was my family, Pat, Laura and then, Kirsten, my two beautiful daughters, plus my brother, Graham.  They gave me a strong sense of responsibility and motivation to complete that which I had started.  I also had other interests, like constructing radio controlled model aircraft along with my fellow aviation enthusiast, Graham.  I also took up photography and used the bathroom in our rented duplex as a dark room as I recorded the people and events in the life of an intern and the sights of beautiful Saskatoon.  When I was in my deepest and darkest period, I ordered a red 1968 Camaro Super Sport, the dreaming about it distracting me from some of the terrible things that I saw and experienced.  I used to keep the brochure on the table beside the cot in my Spartan intern’s room (or cell?) and when needed, I would pick it up and dream of the freedom of the open road.

But I made it!

Anaesthetists know nothing and do nothing,

Internists know everything and do nothing,

Surgeons know nothing and do everything,

Pathologists know everything and do everything,

But it’s too late!

As told to me by Dr. Neville Crowson, my mentor and friend and a great pathologist

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