Life update: Reflections after a month in Orthopaedics

Can you believe that I’m in my third posting? I swear I was just tiptoeing around my supervisors, and courteously asking (sometimes begging) my seniors to help me with difficult bloods, IV cannulations, and literally anything I didn’t know how to do. Now here I am addressing my medical officers by their first names, cursing under my breath from being slowed down by first posters, and finding myself inserting IV cannulas for an entire ward because these newbies can’t tell a vein from a tendon to save their lives, or the patients for that matter.

I’m being nasty, of course. I am pleasantly surprised to learn what kind of senior I am becoming, and the kind of work ethic I employ. Now that I no longer want to quit Housemanship, there is so much more energy I have access to that allows me to find the silver lining in my days, and the work I do. If I sound hideously optimistic, it’s because the last month was tumultuous, and force feeding myself fortune cookie advice is a survival strategy I’m trying out which seems to be working. All I can say is, if I were to describe my life as a Star newspaper Sunday horoscope reading, it would say:

Romantic and family relationships take a back seat this moon cycle. Try to divert your attention towards the workplace, and you will find satisfaction. Don’t despair, and remember that the meaning of life is what you ascribe to it.

Anyway, in three days, I hit the one month mark, and guess what? I’m still tagging! As you go through the departments, tagging becomes so much more tiresome, and not the same way it was in the early days. You catch on a lot faster, more so because the cumbersome aspects of day to day hospital ins and outs are etched in your being, but it’s finding the time to fulfill all those pesky off-tag requirements that end up taking up most of your energy, and as you will soon learn, isn’t easy.

What are the off-tag requirements for Orthopaedics?

In my hospital, you are meant to tag for fourteen days. On day 10, you take a written test, which if you pass, means you can go back home at 8pm instead of 10pm. Because my batch had already survived the combined hell of surgery and internal medicine, we were allowed to take this test on day 8. Unbeknownst to our supervisor, our seniors have already shared the questions with us, so we know exactly what is going to be asked. However, memorising these answers isn’t a bad thing, because it is information crucial to surviving in the department. Drug doses, identifying fracture sites, immediate management of orthopaedic emergencies etc.

So you’ve passed the written exam, what then? We’re meant to submit our tagging logbook, which includes us being able to independently clerk cases, enter the operation theatre (OT) six times (remember, we had to do this in surgery too) and perform procedures. By the way, this is the one department that allows house officers to get their hands dirty, and I mean, really dirty.

We can amputate dusky, infected, gangrenous toes, debride and deslough wounds festering with flesh-eating bacteria, deroof blisters, assist in reducing fractures and cast them after, suture skin savagely torn apart from high impact traumas, drain bulging abscesses, repair nail beds, refashion chewed up appendages, and of course, learn how to administer the appropriate nerve blocks so our patients don’t pass out from the pain of it all.

Sounds doable, but why haven’t I off-tagged then?

As usual, it’s because of politics, and a brain dead house officer in charge of arranging our rosters. Disclaimer: I know, and genuinely like our leader as a person, but the choices they made is the singular reason why everyone, barring one person who completed their requirements two days ago, is still tagging. Why?

Okay so, the leader is in charge of making the schedule and allocating house officers to respective posts for the day. These posts are:

• clinic
• OT
• ward
• J-room (where all the procedures happen)/
• or periphery, where we manage patients in different wards because the primary team is medical for example), and the district hospitals.

So here’s the bullshit bit: To fulfil the criteria in our logbook, we need to be allocated to peri and OT. However, the medical officers in charge of overseeing these posts often want house officers who already know what they’re doing because obviously, it makes their job far easier. So, to avoid that debacle, there is an understanding that the freshies will be assigned to the ward in the mornings, and then descend to the J-room after 5pm to clerk new cases and perform procedures, or enter the OT if there is an ongoing operation.

This is the expectation. But the reality is…

There is so much ward work, that for the entire first two weeks, the walls of the ward were all I ever saw. Okay, there were a few peri days, but those too saw little to no procedures, and finding OT time just seemed futile, so here I am, complaining about the injustice of our house officer led tyrannical tagging system.

The thing is, taggers are the most abusable man power. We don’t get paid for all the overtime hours, and when our work quality suffers from our chronic exhaustion, we’re too numb to give a second thought to all the verbal abuse that ensues. At the end of the day, patient care gets compromised, and the exasperated exhale is all we have to show for the end of our long, long nights.

Speaking of patient care, there is a reason why all hell is breaking loose in our department. A stellar combination of insufficient seniors to guide the freshies, and an influx of first posters in the department. I remember a day when I was doing my discharges after a sleepless night shift, and the morning shift medical officer kept ordering me to do work that wasn’t meant for the post-night person because the newbies just could not (through no fault of their own!), or the time I entered a night shift and noticed so many morning plans (urgent scans, procedures, blood transfusions etc.) not carried out because there was literally no one who flipped through the records after specialist rounds.

It was complete chaos.

Then one day, our specialist in charge of house officers rounded us all up, and addressed that “housemen performance is at an all time low”. From that day, the system changed to how things should have been in the first place. We were divided into batches of juniors, intermediates (where I fell into with my batchmates), and seniors. Then we were put into teams consisting of each level of seniority that would respectively work in the two wards, and cover the periphery, for two weeks, before rotating. This way, we had time to learn and grow under supervision in every area we were expected to function. They also brought back “tag OT”, which means tagging you joins the OT with a senior, who will teach you everything you need to know.

I was glad to see a change, albeit resentful that this had to come two weeks after I had already been here. They chucked me into the peri team, and my last week was immensely fruitful. I always say that “peri life is a good life” because you walk around a lot, get to clerk fresh cases, spend a lot of time doing procedures, and are not confined to the mundanity of ward work. Suffice it to say, I believe I am ready to off-tag, and will submit my logbook once I get my mentor to sign off once I’m back at work.

Besides tagging drama, what else have I reflected on?

• Something I really wish my seniors would have taken the time to explain to me is what I like to call “the flow”. What happens from when the patient arrives, to when the patient leaves? The admission to discharge trajectory is not only important, it’s routine. Yet miraculously, people find creative ways to botch some step each time.
• Another made up phrase: Procedural integrity. What do we need to check before performing a procedure? How do we properly administer analgesia? Where do we learn the correct way to do things? From our seniors, our medical officers, or our surgeons? Is it more important to be hasty, or to be precise? Is human anatomy a guessing game?
• What are some things first posters need to learn now? Yes, blood taking and IV cannulation is paramount, alongside immediate management of medical emergencies once they start working night shifts, but that's not all. I am both shocked at the lackadaisical attitude they have towards the all-important “passover”, and immensely grateful that my own seniors taught me as much as they did when I was still blooming (read: dumbass first poster during surgery), otherwise this transfer of knowledge could never take place.
• How important it is to take consent properly, and advise patients, and their families on post-operative/ rehabilitative care. If you think the idea of losing a digit or limb is depressing, you are absolutely right.

Each of these bullet points will likely manifest in video form which I will link appropriately in good time. I think this about wraps up my reflections after a month reading x-rays with diligence, recalling bone names, and wrapping everything in sight with gauze, Gamgee, and crepe bandage. I’ll end this post with a quote from my brother who insisted I should be thrilled that I am halfway through Housemanship even though technically I am not:

Orthopaedics is just a bunch of carpenters fixing bones instead of furniture, so this department is as good as done.

Let’s hope he’s right. I hope you guys had a good weekend.