Day One ... I have to give my acknowledgments to Sr Lewis. She was the charge sister of our first ward. A lady that knew exactly what to say and do for us young resident doctors as we arrived for medical ward duties on our first day. The sense of dread was somewhat alleviated by her calm and controlled manner. I believe I owe my sanity to this God-given woman.
It is interesting that I remember not much else of the first few days or weeks of working, other than the overwhelming relief to have a weekend off and the incredulous sense of being "rich" associated with my first pay cheque. The hourly rate was not good, but the ridiculous hours we worked made the amounts we earned appear huge. Having financially struggled during the years of study, having money accumulating in the bank (and no time to spend it) was a novel experience.
So what are my recollections of my first year of working in hospital?
I learned the value of alcohol. I never liked being drunk - I have been inebriated only twice in my life. Once as a student deliberately at home to feel what it was like, and the second time unintentionally was in that first year of working, whilst drinking in a bus with many other hospital staff on the way to a restaurant meal. Drinking on an empty stomach was a bad idea. I felt so ill both times I have not had enough alcohol to be inebriated again. However, as a young doctor it was partly the social scene and partly the need to relax once a fortnight after the shift rotations brought a Friday evening free of work commitments that taught me that alcohol in moderation was a good thing. (What I know now and what I thought then are different, very different.)
I learned that arrogance came with the territory. Specialists (read "gods") modelled the behaviour, we tried to emulate it ... and it was always out of context, socially and probably also professionally inappropriate. However a problem developed that as one grew a sense of confidence within the workplace it was sometime interpreted as arrogance ... and if it was god seeing this in his understudy, it was perceived as a threat and quashed from a height. With hindsight I can only consider this behaviour pattern to be a means of self-protection, for both the "god" and "godlings in training". Perhaps reasonable theoretically in a primal sense, but entirely dysfunctional, and sadly some doctors never lose this behaviour pattern when the reality is that it is unnecessary and counterproductive.
I learned that when given the pedestal to stand on we "godlings" can say things that are given more power than they should ever be given.
I remember observing my colleagues look after a recidivist patient, an insulin dependent diabetic, who returned frequently (every few weeks) after overdose injections of insulin. She had been labelled as having a "personality disorder" by the psychiatrists (read - "patient with a problem we don’t want to deal with") and a multiplicity of social stresses unable to be resolved by the social workers ... its hard to deal with problems that are experienced by one with a lack of insight. The frustration affected us all. This woman eventually came in under my care. In a fit of arrogance I whispered in her ear, "If you ever come back to this hospital with another overdose I will have you locked up in a psychiatric ward and the key thrown away." I had no right to say this ... and there was not a valid medical or social reason for saying so. This woman did not return to the hospital for nearly six months. When she did return, she had deliberately chosen an isolated place to repeat the deed. Having created the circumstances where she would not be found for a long time and having given herself a lot more insulin than she normally would "overdose" on, she suffered permanent and severe brain damage. She never overdosed again ... she was never again physically capable of doing so. I wonder sometimes if what I said to her was "good" or "bad".
I learned that we are all mortal. Some of our patients died. They died despite our machinations mostly because there was nothing we could have done anyway, some died because we did not know what was wrong until it was too late to do anything about it, some may have died because of what we did to them. A middle-aged man (yes I know that is subjective depending on one's own age, but that is how I remembered him) came into hospital severely unwell, with a high fever. He was complaining of back pain. I was the Emergency Department doctor of the day. I remember him for two reasons. One ... he had no legs. He was an obese diabetic with severe peripheral vascular disease. His legs had been previously amputated above the knees. Second ... I could not get an intravenous line into him. Having become most proficient in this most basic of medical skills, it was something that concerned me. The medical registrar eventually put in a central venous line and the patient was commenced on appropriate treatment and admitted to hospital. That night that man died. I remember the registrar being most distressed. She took it personally. Me, I didn't care ... I was too tired to care. At autopsy we discovered that the man had been slowly developing an aortic aneurysm (hence his back pain) that was small enough to miss clinically (remember he was obese ... and we didn't have the luxury of scanning techniques we have today) and in the haematoma so formed he had developed an abscess (hence the toxic, febrile patient). This man was going to die despite what we did for him. Not that it made any of us feel any different.
Others of our patients died because of what we did to them. Some were going to die anyway, but sometimes what we did could only have hastened their death. A young man (yes I know that is subjective depending on one's own age, but that is how I recall him being described) came into hospital severely unwell, with a high fever. It was on a weekend I had off, but I heard about him and his care. He had septicaemia (that's bacteria in the bloodstream) and was very unwell. He was rapidly assessed, treatment (correct in this case) initiated and he was admitted into the hospital's Intensive Care Unit. The medical resident, as part of the full assessment of the patient, performed a lumbar puncture (intending to take a sample of fluid from around the spinal cord for analysis) ... the patient died "at the end of the needle". "Coning" they call it. It happened because of the combination of raised pressure inside the patient’s head and the rapid reduction in pressure around the spinal cord caused by the lumbar puncture procedure. The pressure differential causes the brain to be forced down into the confined space of the opening at the base of the skull. The stuff of horror stories! Rare, and now these days "coning" is rarer because we now do scans before lumbar punctures ... but gut wrenching to have had it happen. I was grateful I was not the medical resident on for that weekend.
Some may have died because of what we did, or neglected to do, at a time when they would probably have not been going to die. None of us want to think about this ... nor talk about it, but we all will have recollections that have enough doubt about the circumstances of a patient's death to think that our own actions may have been responsible. Yes, I learned a lot about human frailty and mortality that year.
It was also that year my mother died.
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