BLOG: International medical graduate, ICU and July 1st

BySaleh Aldasouqi, MD, FACE, ECNU

It’s 11:45 pm, July 1st, his first call in the ICU and his first day of Internal Medicine residency. He came all the way across the continents and oceans to end up lonely “in the ICU,” from day one.

After less than an hour of interrupted sleep, full of nightmares, he was paged to go “stat” to the unit to admit “his first case.” Half asleep, fighting a deep, big yawn, he started taking the history and physical examination (H&P). He started with the chief complaint and then moved to the history of the present illness (HPI). Everything here is abbreviated, he had noticed earlier.

The poor resident is a postgraduate first year (PGY-1) from overseas and totally new to the system. He had heard a lot about the ICU rotation at the City Hospital from senior colleagues, almost all of whom were international medical graduates.

He was able to get 1 hour of poor quality sleep, listening to the advice of his colleagues.

“You never know when they call you for a patient crashing!” one said.

“A patient crashing?” he thought. “What terminology! Welcome to America!”

Earlier in the day, all the others had left the unit and he was left alone. The unit was full except for one bed, and the rest of the day until this paging went quietly. He finished his final “completion” rounds little after 10:45 pm.

The first disaster he faced was his name. It wasn’t until he came to the United States that he realized he had a difficult and tongue-twisting long name: Kirazukomishitanzi. When he was asked to spell his name, he had a hard time doing so in his first few days.

He finished the assessment of the patient and called the operator to page the attending on call. “Spell your last name please,” she asked. To his surprise, the ICU attending, Dr. Ziggherdson memorized his full name from day one.

He was given the usual advice about how to approach the attending, “Be brief but informative,” they said. This was the moment he wished he would never have to experience. He wished the ICU was full, so he would have no new admits. However, that would not work, he was told that if that was the case, he would then get an overflow admit in the cardiology critical care unit, or CCU, or even the transitional unit, or TU.

Another hassle he faced was measurement units. He was used to kg, cm and Celsius instead of pounds, inches and Fahrenheit. These measurements become a thinking concept that translates into learned perception of dimensions, weight and temperature.

Amidst a playback of these atrocities, he asked the operator to page the attending on call. “Could you please page Dr. Ziggherdson?’

“Yes, Dr. Kirazukomishitanzi. What have you got?” she asked.

And there he goes, just about midnight; “brief but informative” is still ringing in the back of his mind: “Chief complaint: dizziness since the afternoon. HPI: Mr. John Baker is a 67-year-old male who was playing cards with his friends in the backyard, while his wife, Elizabeth was preparing dinner in the kitchen. In the middle of an exciting round, Mr. Peter Poker, who was seated across the table noted that Mr. Baker was pale and sweaty. At that time Mrs. Baker appeared, offering iced tea for the party; she also noted the pallor on her husband’s face, she…”

“Dr Kirazukomishitanzi, can you be more brief?,” the attending asked.

“Yes Doctor,” he said. “Then the patient started feeling dizzy and had a headache. He has been having frequent headaches recently. A week ago, the Bakers were camping in the Smokey Mountains and he had to take…”

“Dr. Kirazukomishitanzi, can you tell me what brought him to the hospital?”

Then he got confused and his adrenaline started to rise, he lost the sheet of paper where he wrote a draft of the H&P. Not knowing what to do, he turned to Mrs. Baker who was standing near the ICU door.

“What brought Mr. Baker to the hospital?” he asked, desperately.

“The ambulance,” she answered.

Hearing the conversation in the background, and trying to control her temper: “Doctor, I mean what was the problem that brought him to the hospital?” Dr. Ziggherdson asked.

“Yes, the dizziness,” he said, now stuttering.

“And why was he admitted to the ICU, for dizziness?” she asked, still keeping calm.

“No, he was having…” trying to recollect his thoughts.

“What other problems does your patient have?” she asked impatiently.

Again turning to Mrs. Baker: “What other problems does Mr. Baker have?” he asked.

“Well he has problems with his son Jerry, who would not listen to his dad,” the wife answered in the background.

“Doctor, other than problems with his son?”

“He has some problems with the bank,” the wife again in the background.

“Dr. Kirazukomishitanzi, please, I mean other than social and financial problems; I mean medical problems,” she said.

“Oh, you mean past history? But I am not through yet with the HPI,” he answered with some pride, thinking he had just won a round with the attending.

“Alright, how about the review of systems?” she suggested.

“Review of systems? Yes, headaches,” he answered proudly.

“Doctor, pertinent,” she requested.

“Yes, this is pertinent,” affirming in a rather challenging voice.

“Tell me how?” she inquired.

“He has been taking a lot of aspirins for these headaches lately,” he answered.

“Oh, do you mean that his current problem is related to ingestion of aspirin?” she asked, starting to appreciate his apparent competence that was masked by total shock of his first call in the ICU.

“Yes, he has upper gastrointestinal bleeding and he is hemodynamically unstable,” he explained.

“So, you know, why did you not speak up?” she wondered sympathetically.

“I didn’t have a chance,” he replied with a sigh of relief.

“OK, what is your plan for management?” she asked giving him a reassuring gesture of confidence.

“Normal saline wide open, type and crossing matching…” and he goes as fluently as a running river!

The End!

* This work was presented by the author at a farewell graduation party for the Internal Medicine senior residents; the author was one of them. This is a fiction drama with apparent exaggerating. Names of places and persons are fake. However, the message of the author is to express from a personal point of view and a lived experience — the difficulties and hardships that international (formerly foreign) medical graduates face in their endeavors to come to the United States for training.