The PGY5 Life

Sorry medblr, this ms5/pgy1 just disappeared off the face of the earth.

I guess I can finally own it, but I’m now a PGY-5 (technically, 4th year in residency following 1 year of internship/ms5) in Adult Neurology.

Honestly, I have no idea how I got this far. Impostor Syndrome is real. I was an average med student, though I did get some distinction in clerkship and internship (just one each year, compared to those with myriads, mind you). Likely, my edge was my med school of origin and hospital of internship, and well, the clerkship and internship awards. All the rest, I probably saved through my interview. I ended up being one of the four selected for my batch, and it has been an immense privilege and responsibility so far. Pandemic situation notwithstanding. I am immensely blessed to still be where I am right now.

This is my last year before boards (again), and I intend to make it count!

Part 1 here!

Currently in the middle of cramming papers, but I’m determined to complete this series before we leave community medicine, so here goes.

Orthopedics Internship

I’ve got to say, I’m a bit disappointed with my caseload in internship compared to clerkship. As an intern, we don’t scrub in night ORs; that’s the clerk’s job. Instead, on a call night, for 8 hours at a time, we monitor patients and carry out orders for one shift, have a rest the next, and then head to the ER to receive (mostly) Trauma patients. 

I only had one OR assist attributed to my name for the two weeks we rotated, but it was an interesting case, one of the first we’ve had in the hospital. It was a joint-sparing excision of osteosarcoma with allograft of the fibula (remembering this off the top of my head!). It probably took 6-7 hours, and thank the heavens I already knew how to run frozen sections as an NSS intern cause that’s what I ended up doing three times for this single case. 

A consolation to the lack of OR cases was my performance in the end of rotation exam, for which I scored more than perfect thanks to the bonus points. Distraction osteogenesis FTW! Do I still consider orthopedics for residency? Well, probably not. I really love the residents though. They’re a fun bunch.

Rehabilitation Medicine Internship

Rehab Med, for a pretty chill rotation, was not pretty chill. As interns, we had exposure to outpatient cases, and we would see a cumulative total of 70-90 patients from 8am to 5pm. The fun part was that we only went on call 1-2 times for the entire two weeks of rotation, and when we did, we had a supervisory role and a free pass from OPD the following day. That means, minimal(!) monitoring for the night, and no seeing patients in the OPD the day after. 

What made my rotation memorable was the party a couple of residents threw while we were on call. Okay, maybe not a party, but a celebration nonetheless. I will not go into details, but let’s just say there was more than just food and drinks that night. In any case, patient safety was not compromised because as we were watching Youtube videos hooked to the call room TV, we were heading out from time to time to check if our patients were okay, and since it was the Rehab ward, they usually were – except for the borrowed Neuro bed we had to monitor every hour. Thanks, Neuro.

Surgery Internship

I have got to say that I made a lot of fond memories during my time as a surgery intern. Part of it had to do with the fact that we rotated during the Christmas break and New Year, and part of it had to do with our clerks going away for the holiday.

It was eight weeks divided into two-week rotations in ER (with OPD clinics), GS1 (head and neck and breast and appendix), and Trauma, then one-week rotations in Burn and a subspecialty of your choice (I picked TCVS, but if NSS was among the options, I’d be the first to sign up).

I personally enjoyed being primary surgeon in simple skin mass excisions. When we were seeing OPD patients, I was thrilled by my resident telling me that he barely had anything to add to my charting (implying I completed the SOAP adequately). That was a great confidence booster.

In GS1, I had the privilege of rotating with residents I had already met and worked with as a clerk. (click here and here for clerkship stories!) I might have impressed one too much (??) since at the end of two weeks, he was cheering me on to be a “Most Outstanding Intern”, which is actually a thing. 

It was during Trauma rotation when I felt like I belonged in Surgery. I was the Trauma intern-on-duty on New Year’s Eve, and fortunately, we only had SIX trauma consults over 24 hours. 

I recall spending the New Year countdown carting a patient (the first Radio patient of 2018) to Radiology cause he was inebriated and upset after an argument with an SO, that he punched a glass window, and to no surprise, the window punched him back (well, almost neatly severing his proximal radial/ulnar artery). So, while I having a great time watching over someone not regretting the preventable consequences of his actions, the other surgeons (including orthopods) were having a great time spilling wine and making noise all over the ER. I was really anticipating the countdown since that was when the Department of Surgery did their Kissing Rounds. I learned earlier that day that my favorite neurosurgeon was also on call (with me 💕 but not really), so I had my hopes set really high. Oh well. I made the first part of the Rounds, though, if that was any consolation. (Yup, it was...sorta.) 

Anyways, at the end of call, since the Trauma residents were promoted to second year status effective January 1, 2018, before shifting out, the Trauma resident-on-duty was all "Mags-surg ka ba? Tapang mo e. Mag-surg ka na.” (”Are you going into Surg? You’re brave/assertive. You should go into Surg.”) I still think about that conversation a lot.

There was another similar exchange that happened shortly after this time, January 5, to be exact. I had a brief interaction with my favorite neurosurgeon (let’s say Dr. P for simplicity) (who was rotating in Adult Neurology) and my Neuro service senior (2016) turned Neuro Chief Resident (2017) turned stroke fellow (2018). The ex-Chief Resident was encouraging me to apply to Neuro residency after graduating (and passing the boards) and then Dr. P was saying “Aren’t you going into NSS?”. Which led into casual contention as ex-Chief Res insisted I was going to apply to Neurology. Anyways. I also still think about that a lot.

We transitioned from Trauma into Burn. Thankfully, we were again working with residents we already knew. One was my ER surgeon-on-duty back when I was a clerk, the chief was one of the residents in OPD I endorsed a case of EIC when I was an MS3, and the rotating resident was one of the first-years we worked with just days prior. They were very pleasant people and engaged us a lot in learning. 

We had a patient that our block fondly remembers (bless her soul, may she RIP). She was only a year old and had flame burns taking >90% TBSA after being rescued from her burning home. Her older brother did not survive. I had the opportunity to scrub into her escharectomy, and by the end of it all, we were wondering how much of her original skin she still had on her. What happened to her was tragic and preventable. We eventually learned she succumbed to septic shock about two weeks later, and I don’t think there was an intern in our block that didn’t mourn her.

In TCVS, I had the greatest privilege of scrubbing not into just one, but two open heart surgeries. The first was a coronary artery bypass graft (CABG), and I had the opportunity to stand and assist in harvesting the saphenous vein, and then in holding the plegic heart as they did the bypass. (According to the attending, I should “hold it like a hamburger”.) The feeling the first time I saw the ECG tracing flatline as the bypass machine did its job was absolute amazement. The heart was completely still. The second time around was for a mitral valve and tricuspid valve replacement. The meticulousness involved in the work is purely breathtaking. It was there I learned one must be confident with knot tying and throws, especially since securing the valves involves these basic techniques, and a mistake anywhere could lead to a valve malfunction. Someone’s life truly was on your hands in this kind of work. 

And the truly wonderful thing I realized was that not once during those operations – that took up my entire working day (from say, 8 am till 3-5pm) – did I feel impatient. Each moment observing the operation firsthand was filled with wonder and interest. Time really flew by, and not once did I feel a pang of hunger, boredom, or nature’s call. I think I might need to talk to my kidneys about this, but I was amazed by my own stamina. If ever I do pursue surgery, I hope I can keep this outlook. I hope this is true genuine interest in the field and not just enjoying the sheer novelty of it. It might feel different once I’m the primary surgeon, carrying the weight of a person’s life with my hands.

My rotation in Surgery made me seriously consider a career in it. I had fun, despite the toiling work which mostly involved doing paper work, scheduling imaging, inserting foley catheters/IV lines/NG tubes ad nauseam, retrieving imaging from the different wards (there are at least four, not counting borrowed beds and referred patients). It all paid off, and I genuinely enjoyed the rotation. 

Hey, guys. Sorry for dropping out of the radar for the good bulk of my internship.

My last update was September. I can't believe how time has flown. I'm on the last stretch of my last year of medical school. It's a shame I wasn't able to update as often. The IM wards sucks the motivation out of you faster than you can say burnout.

But don't worry, I've been well...and still as indecisive of what I'm going to pursue after internship.

Nonetheless, here's an update of the months I've missed.

Psychiatry Internship

I had a spell in the first half, leading me to be very unmotivated. It reflected in my evaluation that I just wasn't very keen on checking on my patients' mental status.

One of us had family matters to attend to in the week we were in wards, so I ended up taking call for 24 hours and another half on a separate day to cover for my colleague's absence.

The only consolation was the second week which we spent in outpatient. I was in a better mood this week. After seeing 1-2 patients for a full psychiatric evaluation, which would take half the day, we'd be dismissed. There was a lot of free time.

I'm not kidding when I say what made me happiest during my Psych OPD rotation was the fact I had two afternoons – Wednesday and Friday – at the Neurosurgery OPD. I remember the big fat lie I told my favorite neurosurgeon when he asked me whether I knew how to remove sutures. With confidence, I replied to him "yeah". I think he called my bluff cause he checked in on me and even got hands-on. Let me just say, he left more sutures in than I did.

I'll never forget my colleagues coming in for backup on the second OPD after I called. We were running late for an orientation for the next rotation and thankfully they were just close by. I've never forgotten this favor.

Internal Medicine Internship

Nothing gets more scut than IM. We spent 4 weeks in the ward, 3 weeks in the emergency room, and 1 week in intensive care.

My first 2 weeks in the ward, I was handling patients. I won't forget my patient who – after tolerating weaning from intubation and blowing off his CO2 enough to be awake so we could joke about how he'd celebrate his 84th birthday that was in a week's time – suddenly coded one night while I was on call. He never made it to his birthday, but I'll forever remember his daughter's gratitude for taking care of her father until the very end.

My patient's passing was the first on my list of mortalities. We admitted a patient with terrible bleeding parameters caused by her leukemia. She didn't look like she would make it, having been intubated and comatose. She had such a loving husband and two sons. The way my hospital works, one of her sons was queueing at the pharmacy when she coded. It was a heartwrenching moment. I didn't want this child to not be there when his mother passed. I ran out of the ward and looked for him. I tried not to alarm him then but told him it was urgent. We almost sprinted back, arriving minutes into chest compressions. Their devastation devastated me as they told us to stop resuscitative efforts. She was gone just hours after I lost my last patient. The unconditional love this family had for their wife/mother made me terribly homesick of my own family.

I'll add that the day after that, I lost another patient, this time to septic shock. I forever blame our health system for killing that patient. On top of the causative agent, he was killed because we couldn't load his antibiotics on time, nor even give it at the time that we should. It was a preventable death, even though inevitably he would succumb to the cancer on his neck. We could still have prolonged his life.

ER rotation was scut to the extreme. We come in from 7am to 7pm, carry out blood extractions, scheduling of imaging, retrieval of results, and vital signs monitoring for a total patient load of >60 patients in the emergency room. It's not even supposed to get that bad. Then we endorse to the next intern, go home and rest from 7pm to 7am the next day, where we'd see patients at the OPD and monitor at the Cancer Institute until 5pm and then repeat the cycle of scut from 7pm until 7am, and then have the day off until 7am the following morning. And the cycle goes all over again for 3 whole weeks. It's no wonder I neglected to post. I was too tired to even complain.

My favorite memory was meeting this patient I had seen as an OB patient months before as a readmission to the IM service while I was rotating. I almost didn't recognize her, but I'm glad she remembered me, even though our treatment of her (and her husband) in the OB department was far from ideal. She lost her baby months ago under us, but in the meantime she had put on weight. From cachectic, she looked normal now. I dunno, continuity of care makes me happy in this place where we rotate too short, patients tend not to return for follow-up, and follow-up schedules take too long.

Apparently we're one of the few institutions that offer an internship rotation in intensive care, and I'm glad we've had this opportunity. From clerkship to internship, I would have completed 3 weeks of rotation in the ICU. There was a lot of learning as the maximum capacity was 12 beds, as opposed to 50+50 in the wards (not counting borrowed beds in other wards).

My memorable patient in the ICU was a lady admitted for SLE in flare. She was so edematous and difficult to line, and at one point she was in isolation because she had a positive PTB smear. I wasn't on call when she passed, but I was so inspired by her husband, who, without fail, would visit her every day, at least three times a day. I want unconditional love like that someday, but I don't want to come into any situation that would require me to be admitted into the ICU.

We tend to remember the patients who passed, but I also did have success stories. One was a young boy, bedridden for the last few years cause he got shot in the back while taking a bullet for a friend. All was well until his mother stopped turning him, and he got bad bedsores. I do remember him from the wards, and it turns out he was admitted to ICU for pulmonary hemorrhage. He was in poor health, but he was awake on intubation. Everyday we were working to wean him from the vent, but it looked like his diaphragm wasn't strong enough to breath for him without the machine. I was shifting out when he got extubated (tolerated, thank goodness!) and was stable enough to be sent back out to ward.

So concludes Part 1 of my updates. Turns out I had a lot more to write than I initially planned. So I'm cutting it into 3-4 parts, each concluding with a major rotation.

Part 2: Ortho, Rehab, Surgery.

Part 3: ORL, Ophtha, Pedia.