Growth

"Thinking always ahead, thinking always of trying to do more, brings a state of mind
in which nothing is impossible."- Henry Ford



It's been two weeks since I've been employed as a Medical House Officer. I won't comment on whether they were tough or not, rather I've decided to share some tips for persons who will be rotating through any Paediatric Hospital Clinic, however some things may be more specific for my setting but nonetheless they may hold helpful to others elsewhere.

I recently read a devotional entitled 'Growth' which I would like to share before I delve into the tips, so bare with me a while.

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Derek and Jordan were neighbours who agreed to plant a small vegetable garden together. They would each help care for it and share the produce with their families. The friends looked forward to spending time together on the project, but neither realised how involved the task would become. 

It took time digging up the soil and breaking up the hard clods. Planting the seeds required precision. Some had to be deeper than others; some were planted side by side; others were planted eight inches apart; and still others were planted three inches apart. As the seeds sprouted, a portion of the plants required stakes to support them. Watering, weeding, fertilising and cultivating took a lot of time, but the guys kept their end goal in mind. 

Finally, they began to see the fruits of their labor-tomatoes, squash, beans, cucumbers and other vegetables. As they harvested their crops, Derek remarked, "Aren't you glad we don't do this for a living? It's fun, but it takes a lot of work."

The time and energy it takes to grow a vegetable garden can be compared to the effort it takes to "grow" your life. You must fill your life with healthy, nourishing influences. Be careful of what you read, what you listen to, whom you talk with, where you go, and whom you choose for friends. Living a fulfilling life requires planning ahead and maintaining your "soil" daily. The value of your life will be measured by the positive impact you have on yourself and others. 

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These two weeks were all about growth. Being able to work alongside other physicians more seasoned than myself and to communicate as a colleague has shown me that in life, we're all given the opportunity to grow. Some of us require more soil and sunlight than others, but that's alright, the goal is to continue to grow.

I started off with nine other colleagues in the Department of Paediatrics. This department has several areas each house officer is required to rotate through during the three month period on the rotation. These areas are: 

1. Community Clinics (of which there are 2)
2. Team 1 (which is a hospital based team consisting of 3 consultants with various specialties in addition to General Paediatrics)
3. Team 2 (same as above)
4. Accident and Emergency Paediatric Department
5. Maternity Nursery 
6. Hospital Clinics (all previously discharged patients and patients with particular needs are seen here)

Today's post will shed light on the intricacies of the Hospital Clinics and what you can expect on each particular day and ways to ensure clinics run smoothly and on time. 

INTERN TIPS

1. BE ON TIME



This pretty much goes without saying. First impressions are lasting impressions and if you're known to be punctual believe you me, everyone will notice. If you're new to the hospital clinic setting and what all it entails, arriving early affords you the opportunity to speak with the nurses in charge, the Senior House Officer or the Physician overseeing the runnings of the clinic so that you can be informed of the functions of each person on the team and how each clinic is run if there are multiple clinics on the same day.

Arriving early also gives you the opportunity to ask the patients whether or not they are attending clinic solely to get results for tests that were done at their last visit since in our setting depending on the result, you would have to walk to or call the laboratory to retrieve them. Once this is done you can attach them to their notes for the day which will expedite their visit.

When you're new to an area, it takes some time to get acquainted with where things are located and where they belong. Being on time or earlier than scheduled particularly on the first day allows you the opportunity to get a tour of where things are stored, where the bathroom is (staff vs. patient), where the supplies are kept because you'll always be in need of an alcohol swab, tongue depressor or gauze as well as those infamous continuation sheets for the patients notes, growth charts (because every child is plotted) and referral forms.

There are other documents that are dedicated to certain things that you will also need to know-headache diary for instance for patients who present with a history of headaches in whom you're trying to rule out migraines.

At our clinic, all of the necessary documents for the various clinics excluding Infectious Diseases clinics are stored in a brown accordion folder which is placed on the desk in each examination room at the start of the day and stored by the nursing staff at the end of the day along with a cylindrical desktop container that houses all of the tongue depressors, alcohol swabs and gauze you'll ever need.


2. INTRODUCE YOURSELF



With changes being made to the schedule in terms of who goes where each month or every other week, it is important that everyone is aware that you are new to the team or service and it also allows you to familiarise yourself with the persons with whom you will be working over the next few days, weeks or month. 

By introducing yourself to everyone, you'll also have the opportunity based on the ranking to know to whom you are to report and who can actually review your consults and ensure your plan is in keeping with protocol and in the best interest of the patient. 


3. KNOW YOUR ROLE


In the Paediatric hospital setting your role as the medical house officer is to frankly, be on time, see patients, don't get on the nurses or any other team members' nerve and to ensure that you complete everything necessary for your patient. 

At this stage in your medical career, the goal is to gain knowledge, improve certain skills and to ensure that your history taking, physical examination, and overall patient communication is improving and you're asking for help when needed. 

It is imperative that following the review with the consultant, you document everything that was discussed in their presence in the patient's note, you complete all necessary referral forms and fill out any prescriptions they may need and ensure they understand what was discussed BEFORE they leave. In our system, the medical clerk is responsible for making the follow-up appointments, but as the house officer, it is our duty to ensure we inform the patient and/or the clerk of when we're wanting them to return for their next appointment. 

4. KNOW YOUR SCHEDULE



Knowing your schedule allows you to keep track not only of where you're meant to be at a particular time of the day, but also when you have some free time to get other things done. 

If you're like me, a new house officer with some things to follow up in the Human Resources Department then knowing how much free time you may have ahead of time can help you take care of other matters. 

In regards to the hospital clinics, there's usually a clinic every day of the week excluding holidays or during MBBS examination time which is around May/June each year. Here's an idea of our hospital clinic schedule: 

On Monday mornings as you can see, there are three clinics running simultaneously, so on those days it really is a gamble as to which patient you will see. Team 2 patients basically are kids who were admitted on a call when Team 2 was 'on take' or designated to receive the patients on that call. Once they are discharged by the service, they are then scheduled to return to clinic (all at the discretion of the Team) for a follow-up to ensure they haven't had any problems since, or if they did have any medical issues, what they were and whether or not they would need to be readmitted or watched closely before being completely discharged from the clinic. 

The consultants on Team 2 are General Paediatricians with Paediatric subspecialties such as Paediatric Neurology, Endocrinology, and Asthma. 

Like previously mentioned, Monday mornings are a toss-up. The patients needing to be seen in Paediatric Chest Clinic (patients with PTB for example) or the Diabetic Clinic is dependent mainly on the week as these two clinics alternate on a weekly basis. So if this Monday was the week for the Chest clinic then the next week would be the week for the Diabetes clinic. Following the morning clinics which can sometimes run a little late (all depending on the patients needing to be seen and the complexities of their case) is asthma clinic.  

In the asthma clinic, the main goal is to ensure that each patient is controlled on their medications and whether or not they are in need of being stepped up or stepped down based on the severity of their symptoms and their overall diagnosis and assessment. The main questions you must be familiar with asking are mainly based on the symptoms: 
  • When were they first diagnosed with asthma?
  • How did they initially present when first diagnosed?
  • How many hospital admissions or visits to Asthma Bay did they have since being diagnosed? What treatment did they receive?
  • What medications are they on?
  • Do they take the medications as prescribed? If no, why not? Were they on any medication for asthma before? What was the dose? Please demonstrate how they take their medication and when. Do they use an aero chamber? Do they have an asthma action plan? Do they use a peak flow meter?
  • Since their last clinic appointment did they have any asthma attacks? Any nighttime awakenings because they had problems breathing? Any decrease in their activity or exercise levels due to asthma? How often do they have symptoms of asthma such as wheezing or chest tightness? 
  • How many times in the year, or since their last clinic visit have they had to use their reliever? 
  • How many days of school have they missed due to asthma?
  • What are their triggers (change in weather, cold, flu, illness, smoke, dust, pollen, etc)? 
Tuesday mornings there is no Paediatric clinic scheduled. However, all Paediatric interns and Residents have a teaching session at 8:30 a.m. At 12:30 on Tuesday afternoons, there is an Intern presentation session scheduled, from which you are excused by 1:30 in the event the session is running longer than normal so that you can make it to the clinic in time to see patients for Sickle Cell Clinic. 

Be prepared to leave the clinic around 4:30 or 5:00 on a Tuesday. Since there is only one Sickle Cell Clinic per week and one Paediatric Haematologist in The Bahamas, this clinic is one of the well-attended clinics (which translates to sometimes 10+ patients). Punctuality to this clinic is essential mainly because there are so many patients to be seen and sometimes plenty of pathologies to be exposed to which means the teaching opportunities are endless. 

When seeing patients in the Sickle Cell clinic it is vital to ask the following questions: 
  • Since their last clinic visit have they ever had the following: fever? chest pain? dyspnea? cough? 
  • Age of diagnosis? 
  • Last date of crisis? 
  • The number of hospitalizations and the reason (acute chest vs. vaso-occlusive crisis)? treatment while in hospital
  • Number of transfusions if any
  • Steady-state
  • Immunization history
  • Current medications their on and whether or not it was changed at any point
  • Any symptoms of anemia (fatigue, lethargy, pallor, etc)?
  • Abdominal distension or pain recently or in the past? Any surgeries in the past?
  • Dehydration status (water intake)
  • History of jaundice
  • Any exercise intolerance or cold intolerance or history of swollen joints? hands or feet?

When you're assessing them, be sure to look in their mouth and refer if needed to a dentist if you happen to see a number of dental caries or poor dentition. Also, be sure to review the tanner staging and comment on the Tanner stage. The consultant in our clinics loves to ask about the tanner staging as well as the surgical history and the conditions sicklers are prone to which would result in them needing to undergo surgery. 

Wednesday morning clinics are dedicated to Infectious Disease clinics. Be sure to speak to the Senior Registrar or the head nurse in charge of this clinic as this clinic runs differently compared to the others. They will be the ones to advise you on which patient they would prefer you see and how to go about conducting your consultation. This clinic runs fairly smoothly because the nurses are so efficient.  Once this clinic is done, be sure to get a bite to eat in between. Technically afternoon clinics are scheduled to begin at 12:00 p.m. however, the team may decide to work through a break so clinics can end a few minutes earlier. 

Neurology clinics can be long as well but they are filled with learning opportunities so be sure to make the most of your time there. Wednesday afternoons are usually for follow-up patients so reviewing their drug levels and reading EEGs to determine if medications are to be adjusted. Sometimes though, you may have one or two new patients who were referred to the Neurology clinic that is seen on a Wednesday afternoon as opposed to a Thursday. One main tip for the Neurology clinic in addition to a detailed CNS and MSK examination, be sure to complete a mini-mental status examination where needed. For example, if the patient has some developmental delays and during the exam appears to be cognitively impaired. It will help in your assessment when you're presenting to the consultant.

Thursday- all day- you'll be stationed in the Neurology clinic. Team, 1 clinic patients are usually seen by the senior house officers and more seasoned members of the Paediatrics department. The physicians in charge of the Neurology clinic will be the ones with whom you are to report and who will be responsible for dismissing you from the clinic. 

Friday's are usually interesting clinic days where you don't really know what to expect. The neonatology clinic sees patients who were admitted to the Neonatal Intensive Care Unit at the hospital and discharged. Some patients may be in the clinic for results of a karyotyping study that was done or just to know whether or not they will be discharged from the clinic altogether.  Fridays can be an early day depending on what needs to be done for a patient and how many patients the Consultant has to see. 

Although our schedule says Cardiology clinic and consults, since there is no Paediatric Cardiologist in the public setting of the hospital this clinic, unfortunately, doesn't exist. 

5. BE PREPARED


Nothing beats preparation. 

That said, prepare yourself each day for the worse. Pack your bag with snacks, water, lotion, hand sanitizers, extra gauze, alcohol swabs and don't forget your diagnostic kit (since clinics aren't furnished with them). By preparing yourself for anything you'll ensure that you aren't loosing anytime from your consultation with a patient because you're either looking for something or dying for a bite to eat. 

I forgot a few times to pack my bag the night before with snacks that I eat and had to wait until the clinic was over to get something. Let me tell you, the last thing I wanted to eat was peanuts. 

By knowing what clinic you're to attend the following day, you're able to read up on common topics so that you can take advantage of having a consultant present to discuss topics with and why certain things were suggested for a patient's management. 

6. BE WILLING TO LEARN AND TO TEACH


It's all up to you to make the most out of this year of internship. Although you've successfully completed all requirements of medical school and attained a degree in Medicine, it is important to remember that learning is lifelong. 

The clinic settings afford you the time and opportunity to learn. You are in a setting with persons at different levels in a particular specialty who are still learning themselves. Most times they're excited to discuss something with you and to guide your thinking. 

Once you've been taught, it's important to pass that knowledge on to the medical students who may be present in the clinic as well. Remember you were literally months ago a student, continue to be kind and willing to teach. After a while you'll realize you won't need to ask all the time the dosage of certain medications and why you're checking the levels of Tegretol in a month as oppose to a couple of weeks (remember autoinduction?) and you'll be now able to store new information. 


7. BE WILLING TO HELP


Regardless of your position on the medical totem pole, you always find that you're in a position to help. A colleague may be in with a difficult patient and in need of a radiological report but they're unable to move at the moment if you're free to, why not offer to run and retrieve it? 

What I've found over the last two weeks in clinics is that a little goes a long way, especially if persons were on call the night before and weren't able to get a night's rest. 


8. COMPLEMENT SOMEONE EVERY DAY


Compliments go a long way! 

From a simple "you look nice today" to "the way you handled that situation was impressive, you did a great job with that" can create an environment that is comfortable to work in and to grow in. Once people realize that you're teachable, genuinely nice and have great work ethics, your daily experiences -despite the unforeseen circumstances that may arise (i..e that close call with explosive diarrhea or having kids pee on your lap) will be so rewarding. They may even have a ripple effect that changes the culture. 


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My very good friend Dr. M was so kind as to send a video of his tips based on his two weeks in the Hospital in Scarborough Tobago. I've posted it below. 


If you're a new House Officer or an experienced one please share in the comments section your tips and tricks on how you survived your initial weeks of internship. 
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Foundations

"Time is a gift and to use it wisely is admirable"-Renewing Faith Publishing








Did you know that the Empire State Building was built during 1930-31 in a record one year and 45 days? It is known to rise over 1,453 feet from the ground with 103 floors of steel, limestone, granite and brick weighing in excess of 365,000 tons. A total of 1,860 steps extend from the street level up to the 102nd floor. 

Given this construct, the building doesn't sway. It gives, but only to a total extent of 1.48 inches in 110-mph winds. The architect took great pride that the building's movement off center was limited to less than 0.75 of an inch on either side. So what holds up this mighty building and keeps it standing so tall and proud? A 55-foot deep foundation of steel and concrete embedded in solid ground. 

A crew of 600 men working day and night dug the foundation for this engineering marvel in just 45 days, but without these extreme footings, the building would not possess its strength.- Devotional January 2017, Renewing Faith Publishing

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As graduation season rolls on, like the Empire State Building, the members of the graduating class of 2018 worldwide, took the necessary steps to ensure their foundation of knowledge was deeply rooted. I can attest that many sacrifices were made as the New Year began which trumpeted the countdown to graduation. Study groups were formed with persons whom we knew only in passing that blossomed into the most wonderful of friendships. The fickleness of those who we perceived to be close friends was exposed and as life would have it, the ball kept rolling. 

Each day, we saw just how much our lives were like this architectural giant. From the inception of medical school, our character was shaped, as we advanced, we noticed how easy it was to stand tall with assurance in spite of our challenges because we knew our feet were grounded on a solid foundation. 

It may have taken us longer to grasp, however, we learnt to Q-TIP (quit taking it personal) because at the end of the day when a patient's life is on the line, whether or not we are friends with our colleagues is not important, rather having respect and a mutual understanding and a common goal of placing the needs of the patient first is all that matters. 

We sat exams, we performed and we even exceeded our own expectations and now stand proud, not because we made it, rather because we recognise that it was not by our own strength but that of God, that we overcame. 

So to all of my fellow graduates entering the working world or advancing to higher academic heights, remember that despite crossing this hurdle, a new chapter has begun and new challenges await you. 

As Dwight L. Moody once said "character is what a man is in the dark". The people you encounter each day notice how you act and react in various situations. Persons you don't even know form impressions of your character and integrity just through observation; the test is not behind, it now lies ahead. 

Keep stepping out in faith and don't ever forget that God has already placed Jesus Christ as the one and only foundation (1 Corinthians 3:11 NLT) stay grounded in Him. 

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Love in Medicine

“There is never a time or place for true love. It happens accidentally, in a heartbeat, in a single flashing, throbbing moment.” ― Sarah DessenThe Truth About Forever


It was late August 2013 as I boarded my flight to St. Augustine Trinidad, mentally prepared for the inception of medical school, but emotionally destroyed.

The time came to cut ties with the one who I had known and loved dearly for roughly seven years. Heart-broken and confused, that four hour flight to Trinidad and Tobago was spent trying to erase every memory we created and stopping myself from replaying the conversations I had with him prior.

As the wheels met the tarmac at Piarco International Airport, I raised my sunglasses, wiped away the tears that I tried so hard to stop from flowing, repeated silently to myself "time to shine! no baggage! go and get it girl!"

For the first time in a long time, I was single and not interested in love or the semblance of it.

Naturally, without my searching or effort, I was met with my fair share of suitors. I found it interesting that the moment I wanted to be alone like cockroaches at the height of darkness, eligible bachelors were suddenly bold enough to voice their interest, but I digress.

My first semester in medical school came to completion and to my surprise it was my last semester that I was single as well. During the first few months of second semester, I gained a friend. As our friendship grew, so did my interest in him and little did I know that was mutual.

During my most difficult moment of medical school, he was at the centre encouraging and supporting me, reminding me that there is always hope as long as God loans us breath and although my health was being tested, it was not the end of my story or my journey.

From then to now, I've found that we've both strengthened one another and honestly that is vital in a growing relationship next to strong communication and commitment.

As a medical student, it is important to stay focused on achieving your goals, however, don't be a "Mr. Scrooge" and shun those who may be placed in your life for a lifetime. Love comes when we least expect it and God has perfect timing. What begins as friendship can evolve into a beautiful relationship.


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"To have a good friend is one of the highest delights of life"- Author Unknown

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I'll leave you with this story from a planner I received from my best friend Andrea last year. It was entitled "Friendship"; it reads:

  Alex and Judson were hiking through the Redwood Forest of Northern California. They marvelled at the extreme height of the trees, the massive trunks of some, and the overall density. Coming across a park ranger , Judson asked, "For trees this huge, how deep are their roots?"

   The park ranger explained that the redwoods actually have a shallow root system. Instead of growing deep, the roots spread out over great distances right under the surface of the ground, and intertwine with one another. Because the roots are wrapped together, the trees are able to grow taller and withstand storms. The great strength of the forest comes from the roots of all the trees helping to support each other.

  As they continued on their hike, Alex and Judson talked about how their lives were a lot like these trees. When they stood beside each other and helped each other, they always felt more strength and energy. They were glad they could count on one another for support.

In medical school as well as through life, 'in the same way as the roots of the trees, you need to know who you can count on as friends to be with you through the good and difficult times. This occurs when you demonstrate the same commitment to your friend' (however, it may not always be reciprocated). As it takes more than two trees to hold each other up, so it may be in your life, you may find yourself with a flock of friends or a select few of persons with whom you can depend on. 'It is important to let God intertwine your lives. his strength will sustain you through any of life's storms, and He will help your love life and friendship grow closer together.'


Dear friends let us love one another, because love comes from God- 1 John 4:7