Sometimes, there is flying

I don’t work in the kind of profession that offers travel benefits. I’m not whisked around the country or region or world for business (or even pleasure) but sometimes – one time, really – there is flying.

I don’t work in the kind of profession that waits for you to feel better to do your job, that gives you sick days without a grudge or lets you sleep when you’re tired. My job makes you stay up straight for 36-48 hours. It forces you to save dying patients somewhere into your thirteenth straight hour of being on your feet. To think coherently and organize an inter-hospital patient transfer by army helicopter (because we don’t have actual medical helicopters).

Then my job expects you to fly a patient to the other end of the island, long past the time when you should have gone home to your boyfriend and your cat (your cat will never love you if you keep this up) while making sure this patient keeps breathing until you can get her the help she needs.

My job is endlessly demanding. Forcing tired, gritty eyes to watch the rolling greenery  of the Cockpit Country, while deep inside your sleeping brain you wonder why the government wants to destroy this last bastion of nature, uninterrupted. Peer down at hidden away houses so high up in the hills you wonder how they got the cement and blocks that far. Watch buildings, light posts melt away to ponds and trees, the odd farm here and there.

To fly, lost in your thoughts and the steady roar of the engine that is fighting gravity for you. To fly until you leave behind the hills and valleys and peaceful farms and blend again into well-paved roads, multi-level architecture and

Look, there’s the hospital now. My job forces you to stay awake for hours and hours with no thanks. No pat on the back.

But sometimes, there is flying.

What is a CRH Internship like?

So here we are, one year out of medical school. Internship is behind us and we’re venturing out into the world of fully registered medical practice. And the question one everyone’s (no-one’s) mind is, what is internship at CRH like?

Internship anywhere in Jamaica and the Caribbean is rough. The high patient load and typically low resources keep our clinical practice particularly inventive, and adhering to evidence based medicine is a lot like playing whack-a-mole (just when you think you’ve hit the nail on the head, it’s disappeared and you have to try again).

I chose CRH for my internship for a number of reasons. Montego Bay is my hometown. Because it’s a Type A hospital we see more complicated cases and therefore get more clinical experience. Compared to the other two Type A hospitals, the patient load is a balance between overwhelming and nonexistent and the staff are (for the most part) approachable.

Surgery, Internal Medicine, Pediatric Medicine and Obstetrics & Gynaecology share the same basic traits no matter where in the world you practice. What I have found different is the slant of intern duties. In my opinion, a CRH internship gives you primarily clerical experience. Any additional medical experience is dependent on the interest and enthusiasm of the individual intern.

Broadly speaking, the intern’s job is to see or SOAP inpatients every morning, round with the consultant, carry out requested procedures and tests, and follow up the results of these tests and act on them. Variations of this theme can have the intern seeing or clerking new patients in the Emergency Department, making interdepartmental referrals, organizing procedures off the compound, administering medication etc etc.

At the end of the day the intern’s is tasked with making sure the patient gets whatever they need to get better and get out of the hospital.

A lot of your time is going to be spent writing request forms, writing referral forms, writing notes in the docket and writing orders for medication. Your practical procedures will primarily involve phlebotomy and placing intravenous accesses. There will be times when you don’t feel like a contributing member of the team and there will be times when you’re the one leading ward rounds. There will be plenty of opportunities for learning, and in the same breath you will feel stifled by your supervisor when they only want you to be a scribe and a gopher. Brush these moments off and look for teaching moments. They’re not always obvious, but you can learn something from everyone.

Surgery

On the Surgery rotation, interns spend six weeks in General Surgery and six weeks in a surgical specialty such as Urology, Orthopaedics or Paediatric Surgery (Neurosurgery didn’t take any interns at the time). There’s a lot of hands on experience to be had here, participating in major and minor operations like laparotomies, appendectomies and the ever-frequent digital amputation. It’s impossible to leave this rotation without knowing how to suture and the basics of pre-op and post-op care, especially since the intern is the one leading the ward rounds, the one with primary management of inpatients.

Paediatrics

Paediatric Medicine divides your time in two six week blocks of the paediatric ward and the special care nursery. Here you learn attention to detail, the importance of acting on the results of investigations and how to handle stress. While on paediatrics you pick up skills in lumbar puncture and intravenous access placement, medication administration and infection control. Interns on Paediatrics are responsible for  administering all IV medication, which is something unique to CRH. If this doesn’t sound daunting, it should. The ward capacity is 20 patients (each. For the ward and the SCN), who require medication up to four times per day.

Medicine

Internal Medicine is a straight three month block with no sub-specialization (small chance of getting some Nephrology exposure). Patient load is high, resources are low and most of your patients are frequent visitors to the ED. It can get frustrating, especially if you like ‘saving people’ because the majority of patients are repeatedly sick because they are non-compliant. There are a lot of social and economic reasons behind this non-compliance but tertiary facilities are the ones feeling the brunt of that primary care failure. This is where you hone the twin skills of BLS/ACLS and breaking bad news. The practice of Internal Medicine is roughly the same across the board, with variations in level of academic exposure and access to resources (CRH falls low on both spectra).

Obs/Gynae

Finally, Obstetrics and Gynaecology is the Other surgical rotation, where instead of gunshot wounds and pus filled abdomens you get happy bouncing babies and failed abortions. The scope of your exposure ranges from suturing multigravid vaginal lacerations to contacting the Centre for Investigation of Sexual Offences and Child Abuse (CISOCA) for your 13 year old patient with pelvic inflammatory disease. OB/GYNs balance surgery and medicine remarkably well, with a smattering of paediatrics (neonatal jaundice has to be diagnosed by the OB/GYN intern before referring to Paeds) and the general atmosphere of the department is one of bonhomie. Interns on O&G  don’t have very active roles in patient management (most of the decisions are made by the consultant, with the intern carrying out the orders) and the consultants round daily so you’re never really on your own (pros and cons, here).

Conclusion

CRH definitely has its ups  – interns have the option for on-compound housing, for instance – and its downs – necessary machines get broken, a lot. And at the end of the day the decision about where to do internship is multi-factorial. I wish I could offer a comparison among internship sites in Jamaica or even the wider Caribbean but alas. I’m not so lucky enough to have enough friends in high and low places.

I will say this: no matter where in the island or Caribbean you do internship, almost everyone will be prepping for USMLEs or some other foreign licensing exam. Internship may feel like the worst year of your life (and in some ways, it is) but it’s just a stepping stone to postgraduate qualifications and the start of your actual medical career.