James is a third year College of Intensive Care
Medicine (CICM) trainee currently working in Bendigo, Victoria, where he has
started his ICU [Intensive Care Unit] training. After
completing a science degree with honours, James went on to study Medicine in
his hometown at the University of Wollongong in NSW. James completed his
internship and residency in NSW at Hunter New England Health and is
passionate about expanding critical care training and career opportunities
in rural and regional Australia.
I was asked to write this article to shed some light
on the day-to-day of working as an ICU Registrar in order to help JMOs
perhaps interested in pursuing a career in intensive care make an informed
decision about how to go about it and what they are getting themselves into.
I have found that ICU presents a fairly large day-to-day variation in terms
of the volume and nature of work, particularly in smaller regional ICUs such
as the one I currently work in. Then there are the differences between
working day or night, which aren’t insignificant. This variability is one of
the aspects of ICU that I find appealing, however, doesn’t lend itself well
to distilling all of the aspects of the job into an account of one day.
I think it would be more appropriate to do a “year in the life of”, but I’d
probably violate my word limit. So how do I make this post useful for you,
dear reader, the JMO staring into the abyss of having to commit to a career
choice? For starters, I think it is important to give things some context
and tell you a bit about myself and how I ended up here. I’ll then discuss
the things I enjoy about the job as well as things that I didn’t expect and
some of the harder aspects. Finally, having only recently been in the
position where I had to make a decision on my career path, I’ll give you
advice I would have given myself three years ago.
When I graduated in 2013 I was keen on surgery, or at least I thought I was.
I always liked scrubbing in on big cases as a student and holding a
retractor or two. I told all of my friends and colleagues I was keen on it.
I kept telling myself I really was keen on it! I went overseas and presented
at conferences, and got in the good books of the right people. I had a
surgical SRMO job lined up, but as my 2nd postgraduate year progressed I
realised that my heart wasn’t really in it.
During this time, I was doing an ICU term in a regional hospital as an RMO
and thrown into the deep end, manning the unit overnight and looking after
ventilated patients and patients on dialysis. I felt like I had learned more
during that term than any I had done to that point. I got along really well
with the consultants and the nursing staff, and was sad that the end of the
term was nearing. Unfortunately, by that point, the PGY3 recruitment had
finished in NSW and I was left wondering how I would go about getting an ICU
job the following year. Fortunately, a newly minted consultant from
Victoria, who would later become an important mentor for me, was doing a
locum in the ICU where I was posted. She encouraged me to apply for a
registrar job at her home hospital, and the rest is history.
Students embrace Highlands
James Garrard, Ronald Murambi, Hannah Jones, Yolante Eeles, Taleitha Atkins (Source: Southern Highland News)
I had to move away from my friends and family,
convince my girlfriend (now fiancée) to come with me, and contend with the
daunting prospect of stepping into a registrar job in my third postgraduate
year. It was all worth it in the end, and I consider myself very lucky that
this opportunity presented itself when it did. I’m well aware of others
facing the stressful prospect of not finding a job in their desired field.
The takeaway message from this is to go into any junior doctor rotation with
an open mind, and to be receptive to and take advantage of opportunities
when they arise.
Working in ICU is satisfying on a number of different levels. I enjoy the
immediacy of it. If there is a problem with a critically ill patient, you
have the resources at your disposal to change their management and assess
their response all in a short timeframe. Last week at the end of a night
shift I admitted a gentleman in his 70’s who was still working on his farm
in the 40 degree heat. He kept taking all of his antihypertensives and
metformin and wound up with an anuric kidney injury. He was very acidaemic
[A condition of raised blood acidity - the state in which
the pH of the blood has fallen below normal] and quite confused and
drowsy, with the thousand-yard stare of critical illness and a respiratory
rate of about 35.
I took him up to the unit, put a dialysis catheter in and started dialysing
him just before my shift ended. I returned that night to find a different
man, awake and chatting about how relieved he was that he didn’t feel so
sick anymore. You get feedback on your actions almost immediately! This
continues with the procedural aspect. It’s a good feeling when you see the
tip of the central line you inserted projected perfectly above the
cavo-atrial junction on a chest x-ray. It’s an even better feeling, however,
seeing the smile on my resident’s face when they successfully get their
first CVC in despite trembling hands and a fogged-up face shield. I also
enjoy the culture, which I think is quite progressive compared to some other
areas of medicine which remain quite hierarchical and old-fashioned.
It’s not all a nirvana of saving lives, machines that go ping and
down-trending lactates, however. ICU is often the final destination of a
tragic journey for many patients. One case that did keep me up at night was
that of a young man who had unintentionally overdosed on long-acting opioids
and was found the next day by his parents in respiratory arrest. He was
resuscitated and did make it to our ICU, however with such a prolonged
period of hypoxia he had no chance of a meaningful neurological recovery.
Difficult conversations are plentiful, and although you become well-equipped
to have them, some are still very hard.
The working hours and rosters can be very tough; a recent audit by the AMA
placed ICU registrars in one of the highest-risk professional groups for
fatigue and burnout. I have definitely spent a few hours sitting on the
lounge at home after my 7th night shift just staring at the wall, having a
mini existential crisis. I’m lucky to have a supportive partner, caring
bosses, and colleagues I am comfortable to debrief with. I’ve quickly
learned that to last in this specialty, you need to be self-aware and
willing to seek help from others when the going gets tough.
I’d like to finish by offering some advice I wish I had given myself in my
first two years out of uni, which isn’t all that long ago. The tumultuous
JMO years are fresh in my mind, and I’ve got a different perspective on
things now that I’m past them. There are a lot of very driven and ambitious
people coming out of medical schools these days; people enrolling in
Master’s degrees earlier and earlier, scoping out referees on their first
day on the job, arranging meetings with directors of training. Whenever the
topic of careers came up in conversations with my fellow interns, the theme
would inevitably gravitate towards how hard it is to get into said
specialty.
I often felt like it was a bit of a mad rush to get a foot in the door and
get started down a certain career path. This is all fine if you’re that type
of personality, but I found it daunting as all hell. Ignore all of the
noise. I think it’s important not to worry too much about what your
colleagues are doing in terms of career development, and to run your own
race.
AN intensive care registrar working at
Bendigo Health believes La Trobe University’s plans to open a
medical school in Bendigo will worsen the rural doctor shortage, not
solve it. Dr James Garrard says the new $600 million Bendigo
Hospital should instead be allowed to grow into a centre for
regional specialty training, allowing graduates to stay in the
regions to complete their training.
He is among the many young doctors forced to relocate to Melbourne
to carry out about six years of specialty training, rather than stay
in Bendigo. La Trobe University has proposed to open the Murray
Darling Medical School, in conjunction with Charles Sturt
University, adding 60 students per year each in Bendigo, Orange and
Wagga Wagga.
Dr Garrard said increasing the number of medicine graduates would
not help the rural doctor shortage.
“There already exists a strong presence of excellent and
enthusiastic medical students who spend substantial amounts of time
in Bendigo from Monash and the University of Melbourne,” he
said. “The solution is careful planning and development of the
training infrastructure that is already in place. “In
addition to the benefits this would present to the community, it
would also mean that trainees such as myself could settle in and
complete the bulk of our training in Bendigo.”
The number of medical graduates in Australia more than doubled from
1503 in 2004 to 3441 in 2013, while the number of specialty training
places has not increased at the same pace.
The Australian Medical Students Association has opposed the plan
from the outset, and agrees that the proposal takes away from
efforts to improve specialty training in regional areas.
The Murray Darling Medical School is proposed to include longer
periods of medical study in Bendigo, compared with Monash and
Melbourne universities.
La Trobe University Vice-Chancellor John Dewar believes the plan
would be a “catalyst” for governments to increase specialty training
opportunities in regional areas.
The university is seeking funding from the federal government for
the $46 million plan. A spokesperson for La Trobe University said
the Murray Darling Medical School would be an “improvement” on the
current system in Bendigo. “We agree there’s a need for additional
regional specialty training for doctors,” he said. “There simply
aren’t enough doctors in regional Victoria. Our proposal would be
three to five times more efficient than the current system.”
(Source: Bendigo Advertiser)