A year of hell some describe it as. And I won’t deny that. A year you’ll face challenge after challenge, hurdle after hurdle, but remember you only need to last 1 year. 12 months. 365 days. Theres no time for self pity. Trust me, I was in tears of just pure shock for the first two months of internship, but after finding my grounding I really did enjoy my work. Remember this is the only time in your entire medical career where it is perfectly acceptable to be lost and confused. You need to use this opportunity to ask questions and learn. It’s going to take more than just staying awake, its going to take a lot of hard work and dedication to get through.

Below are some tips that helped me get through internship.

• Sleep

Anywhere, anytime. This was my policy and probably the most important. Its’ well known that you get minimum hours of sleep during your internship which is why during our induction at the hospital, our medical superintendent stressed the importance of sleep. Monitoring patients with dengue in leaking phase meant that you need to monitor their vitals hourly which is not just taxing on the patient but also on your sleep. As is ambulance transfers, because the journey can be long and  so can the wait at the hospital you transfer your patient to.

As strong as you think you maybe, without sleep you are more prone to illness and your efficiency as an HO will decrease. So get that beauty sleep. A few hours here and there throughout the day even. You need it more than you think.

• Work carefully. Work fast.

The number one skill of a good HO is to be efficient. You have to work fast, but also work carefully, especially in paediatrics. Remember that all drugs have to be calculated according to their body weight. You are dealing with some serious drugs, and it is you who prescribe them so the responsibility lies with you. For instance, gentamicin can do more harm than good, especially on a patient’s kidneys so it must be stopped after day 5 is complete. Remember it is only the job of the nurses to give the medication. It is your responsibility as a junior doctor to check drug charts. I was lucky to have consultants who checked the drug charts so if we hadn’t checked it and there was a mistake, we were in for a long scolding. I say lucky because this is how I learnt to be more responsible and more careful. No matter how busy the ward is, even if there are 2-3 children to a bed, it is your responsibility to ensure that each child gets the best possible care.

In surgery, allergy and past medical history is most important because I have seen more than my fair share of incidents that occur when patients do not volunteer this information. I had a patient who underwent an emergency appendicectomy for perforated appendix, but she failed to mention that she had on occasion used a inhaler for asthma even though I had specifically asked her if she had asthma. On trying to extubate her post GA, she went into severe bronchospasm and had to be admitted to the ICU. So be careful. Patients are difficult. They do not understand the gravity of with-holding information so when you take vital information ensure that you inform the patient of how serious these questions are.

• Discharges.

Discharges take up most of your time as an intern and even though it may seem the least important on your priority list, its’ vital you get it right because discharge cards are scrutinised all the time – by other doctors, transferring hospitals, etc. There is an art to writing discharges, and this you must perfect in order to be able to finish your work faster.

Look to your seniors for help – more likely than not there will be atleast one day of handover from your seniors and how to write discharges should be asked. Once you get the hang of it, you’ll be writing discharges like a pro. Remember that discharge cards should contain only the essentials and important things. Get your diagnosis right (diagnosis also needs to be written on the BHT), the history used to come to your diagnosis, important examination findings and the management (including the name/dose/frequency of the antibiotics used with the duration given). For surgical discharges, the surgery should be written on the front of the card. If the patient is to be reviewed then remember to write your discharge in a clinic book.

I had a consultant who would take pictures/bring the discharge cards to the ward if he comes across a mistake in the private sector and the person who wrote the discharge card would be in for a good telling off. Harsh you may think, but we quickly learnt to be more vigilant and more practical when writing discharges.

• R-E-S-P-E-C-T

It is no secret that the Sri Lankan healthcare service has a pecking order. You are the most junior in the team and you don’t go straight to a consultant. Theres the RHO, SHO/MO, registrars, senior registrars and only then the consultants. I was lucky enough to have consultants that we were able to contact directly in the case of an emergency, but this is not always the case.

The seniors will determine how your internship goes. So just some practical rules; don’t be a smart ass, don’t talk back and just be a nice person. I have had some amazing SHOs who have taught me so much and others much less. Your internship experience largely depends on the opportunities given and it is your seniors who give you your opportunities. So be wise. You got to give respect to be respected.

• Inform seniors.

So sometimes you get stuck.

For example, theres a child with dengue leaking and for one hour his urine output is 0.5ml/kg. So what do you do? Increase the IV fluids? Make the mother wake the child up every hour to increase the oral intake? wait another hour and see? So many options, so not sure. In the final month of your internship you probably will have the answer to this, but before you reach that if you’re not sure you should inform your senior on call and make sure you document this on the BHT.

To inform my seniors I use the SBAR format which is Situation, Background, Assessment and Recommendation. Example of a conversation with my senior:

Situation: Good evening/Hi Akki/Aiya, Rashmira here. Sorry to disturb you, but I’ve been monitoring the 12 year old child in the dengue leaking phase and the urine output rate for the past hour has only been 0.5 ml/kg.

Background: The child was not on any oral fluids as she was sleeping, but IV fluids are going at 1ml/kg/hr.

Assessment: Her heart rate is 92 bpm and her BP is stable at 100/70.

Recommendation: I’ve increased the fluid rate by 1ml/kg/hr. Should I put an oral target or continue monitoring?

If you have already managed the child and just want to keep the senior in the loop, you can tell him/her that you just called to inform them of your management. I once gave a child IV midazolam to settle refractory seizures and the child went into respiratory arrest before the SHO could arrive so after that I would always inform the SHO before giving midazolam. Respiratory arrest is a known side effect of benzodiazepines and so before you give diazepam/midazolam always keep the ambu bag close by! In surgery, if I suspected a patient has appendicitis but wasn’t 100% convinced, then I would send blood investigations urgently (FBC, CRP) and keep the patient nil by mouth and only then inform the seniors (informing them that I would recall with the blood results). Ofcourse if the patient was in a lot of pain and unstable, then I would inform the senior first and trace blood investigations later.

Point is that you need to inform your seniors because if something goes wrong then its’ your fault. So always inform seniors if you aren’t sure or if there’s an emergency to be safe and always document the time you informed them and their management plan. Use the following link to learn more about the SBAR format:

http://www.oscestop.com/Handover.pdf

• Don’t know? Ask.

As a new intern you don’t know much and that is normal. They key is to ask. Don’t try to be too smart and do something you have no idea how to. Your seniors are there to help you so ask. You may get scolded, but so what. It doesn’t hurt to ask. You are never going to improve your skills or learning without being taught so ask.

• Transfers – be prepared.

If you work at a peripheral hospital you will need to accompany critical patients on transfers for a variety of reasons. When you get to the hospital you transfer to expect not to get the best welcome. Nobody wants to get more patients, especially when they’re critical so their patience will be minimum.

Before transferring it would be beneficial to inform the receiving hospital. If its’ to NHSL trauma, then call the Resuscitation room and inform them. Before transferring you should also know the patient. Read through the BHT, make sure you understand the course of the patient’s care and any X-rays/reports must have their findings documented on a card. The surgeries carried out, drugs given (including dosage, frequency and duration) and the management recommended by your consultants must be documented. On the transfer form remember to document why you are transferring: i.e. for neurosurgical opinion.

Before you depart ensure that you have all equipment and drugs necessary incase of an emergency, i.e. sucker machine, ambubags, IV sedatives (if the patient is intubated).

Be prepared – if you suspect your patient is unstable, intubate them. Any trauma patient should have a cervical collar and also insert an urinary catheter. This will minimise the scoldings once you get to the transferring hospital.

Ambulance rides are rocky so remember to take an anti-emetic before you start your journey even if you aren’t someone who gets car sick. Remember to take water and some food if possible because you can never be sure of how long you’ll have to wait (The NHSL ‘R’ room once kept me for 6 hours till they found an ICU bed for a patient).

If a patient dies whilst transferring you have to take the body to the nearest hospital.

• Intro. Methods. Objectives. Results.

Internship is a busy year, but if you can dabble in some research that would really help you in the future. Find out of local and national academic sessions/conferences and keep an eye out for when they call for abstracts. Talk to your consultants to discuss possible topics to research. Simple audits don’t take up much time and if done well can be chosen as oral/poster presentations. Basic statistics is a useful skill you can use to improve your research. Keep an eye out for any interesting cases which can be submitted as case reports to both local and international journals.

• Me-time

Internship is a taxing time, not just on your mind, but also on your body. In addition to sleep, it is important for you to get some ‘me-time’. Some time away for you to just de-stress and breathe. I can honestly say that this was the hardest for me. I found it very difficult to detach from the ward and my patients. Whenever I slept I would always wake up suddenly, scared I had missed an important call concerning a patient. I would call the ward in the night from my bedroom just to trace investigations and to find out the status of any critical patients. It all became a bit much.

People de-stress in many ways. Some turn to the bottle, others to movies and food. I wouldn’t so much recommend the bottle, but I can definitely say that the girly-girl that I am always enjoyed watching a tv episode or two with a nice facemask on. Whatever floats your boat basically! Find something that helps you destress.

I hope all the points above help you power through internship. It is definitely no walk in the park, but you will come out of it more confident and a better clinician. Good luck!

I’ve been asked to do a pro and con list about internship which I will do soon! As always I would love to hear from you! Contact me if you have any queries.