Thursday, March 31, 2011

……for surgery.

Things that made my day today:

1. The big sarcoma enclosed within the semimembranosus.

2. This standing stool. Period.

3. And I’m tall.

Wednesday, March 23, 2011

Welcome back to Surgery!

Things I’ve done so far, 3 weeks into my electives in the amazing state of Sarawak:

1. Seen 3 blind men, literally, “the blind leading the blind”, trying to cross the road, despite traffic approaching! And therefore, escorted them and saved some lives (?) hahaha~~
2. Missed my flight for the first time in my life.
3. Cycled on the busy roads of Malaysia, and survived! Bicycle 1, Malaysian traffic 0.
4. Punctured the tyres of our bicycles, and got stranded somewhere in the city…. Malaysian Road 1, Bicycle 0.
5. …Luckily, we managed to squeeze the whole bicycle into the back seat of a friend’s car, twice, and got home safely.
6. Super rapid two-lane bowling session!
7. Said Hi to bats, orang-utan, weird insects, crocodiles, macaques, and monkeys etc.
8. Ate Sago worms! Yum!
9. Being part of a 20-people entourage/team ward round.
10. Spoken the most Malay in my whole life.
11. Seen the largest spleen yet.
12. Walked a lot – up to 10km in some days!
13. Conquered the Mulu Pinnacles Trail – 2.4km nearly vertical upwards, 10 hours return!
14. Got stranded in the middle of the river in a boat.
15. Stayed in a traditional Longhouse, where there’s no fan at all, and lights & electricity are only available from 6pm to 9pm only.
16. Chicken-danced everywhere! – next to a big round about in the city centre, on top of the Pinnacles Climb etc.

And the adventure continues. =)

MENTAL HOSPITAL PHONE MENU

Hello and thank you for calling The State Mental Hospital.

Please select from the following options menu:

If you are obsessive-compulsive, press 1 repeatedly.

If you are co-dependent, please ask someone to press 2 for you.

If you have multiple personalities, press 3, 4, 5 and 6.

If you are paranoid, we know who you are and what you want, stay on the line so we can trace your call.

If you are delusional, press 7 and your call will be forwarded to the Mother Ship.

If you are schizophrenic, listen carefully and a little voice will tell you which number to press.

If you are manic-depressive, it doesn’t matter which number you press, nothing will make you happy anyway.

If you are dyslexic, press 9696969696969696.

If you are bipolar, please leave a message after the beep or before the beep or after the beep. Please wait for the beep.

If you have short-term memory loss, press 9.
If you have short-term memory loss, press 9.
If you have short-term memory loss, press 9.

If you have low self-esteem, please hang up our operators are too busy to talk with you.

If you are menopausal, put the gun down, hang up, turn on the fan, lie down and cry.
You won’t be crazy forever.

If you are blonde, don’t press any buttons, you’ll just mess it up.

xD

I must say, before I started oncology/palliative care, I have always been interested in the field, not the medical technical part of the field, more of the human side of the field, the so-called “wishy-washy” part of the field, the holistic approach to patient care.

What I’ve learned from Oncology?
- that the field is the epitome of Evidence-Based Medicine (EBM)!
- that people who look healthy or well might have cancer cells invading all over their body!
- that people can survive cancer without any problems
- that people can go through chemotherapy without losing their hair!
- that people can go through chemotherapy without much problems.
- that there is increasingly more and more people surviving cancer, who have fought off cancer, and who are now deemed as cancer survivors!
- that a cancer diagnosis changes everything!!!!
- that a cancer diagnosis is a pain in the ass, as it is a chronic and dragging condition, generally develop slowly, requiring a lot patience and long term care! (annoying!)
- that anyone with cancer or know someone close with cancer get to sit on the emotional roller coaster (albeit reluctantly!)!!!
- that human are amazingly strong beings!!

The last one seems to be re-emphasised over and over again when I go through each rotation, regardless of the specialty.

Palliative Care, however, is a whole different field.
I remember being majorly inspired by the lecture on death given by our Palliative Care Director (She’s so awesome!), so I was really looking forward to the 1 week we have.

And boy! It’s soooo not for me at this point of my life.
It’s just too confronting and too depressing.
You see dying people everywhere!
(although some could argue all of us are dying anyway, at different rate.)

I love the philosophy behind Palliative Care, the holistic approach, the availability of time (ironically) to get to know your patients, the emphasis on quality of life and dying with dignity. Love them all!

And it was interesting to see different people perspective to their own mortality.
The best of it all are the ones who have accepted and at peace with their imminent death, who take it so gracefully, who still laugh and live their life, whatever left.

One of them was Mrs CN, who is 78 year old with terminal cancer.
Her sense of humour amazed me.
One of the funniest moment was when our consultant was listening to her chest and commented on how good her lungs was, she, without a blink, uttered slowly and nonchalantly:
“Yea…. I’ve been on dope.”
All of us burst out with laughter!!!

But then the next day we saw her being really depressed and all.
And you wonder how much of the humour is true.
Emotional roller coaster sucks.

Then you see dying 26 years old, who has yet to reconciled with his parents.
It’s true. It’s the young ones that makes it all so much harder.

Most of all, you see the confused patients, who gradually lost their sense of self.
On one hand, perhaps that’s a good thing for the patient in that they are so out of it that they don’t realise it all.
(Although the worst are the ones who still have a bit of insight about their confusion. To realise fully that you are deteriorating is the worst.)
But on another hand, it’s the confused patients that family members found the most difficult, I guess.
Imagine seeing someone dear to you deteriorate and not being able to do a thing.
Sucks.

Yes, there’s a lot of emotions in the palliative care ward.
3 years ago, this would be something I like.
To be able to feel. To contemplate. To think.
But I don’t know, 3 years onwards, I’ve realised that sometimes it’s just so much easier to just ignore it all, desensitise yourself, detach yourself.
And it makes me wonder whether it’s a good thing afterall???

You really need to be sure of your view on your mortality to be able to work in the field.
And at the moment, the world’s just opening up for me.
Life. Live. Love.
The end of it all is still not something that I’ve understood. Yet.

I was lucky enough (or some may say unlucky) to not being there when 2 of our patients died on the same day. I don’t know how I would handle it all. I don’t know.

But I guess as medical students, it’s a rare opportunity for us to have an oncology rotation, and even more so, a palliative care week.
I’ve certainly learned heaps, more on a personal development point of view than anything else.

I don’t know where to start, hence I’ll just provide snippets here and there.

[Warning! Verbal diarrhoea ahead!]

For the first time in my life, I have:
+ changed dirty nappies on the tiny little newborns
+ got pee-d and poo-d at.
+ held a sub-2kg baby in my arms.
+ learned how to stop little babies from crying (“Don’t you like sucking my latex glove covered pinky?”)
+ helped with kicking start a new human life.
+ learned how to drive the ultrasound probe, and looked pro at it (Thanks to the great instructions of my lovely professor, he makes anyone look good!)

Snippets from the academic blog posts reflective writings I submitted during Paeds:

Today, I came across an emergency situation involving an increased anxiety and stress level. I was in delivery suite with a Paeds doctor, awaiting the arrival of a baby who may or may not require resuscitation. Once the baby was born, we immediately noticed that he wasn’t crying and moving actively. We recognised the abnormality and started to rub his chest to try to get the baby to start breathing on his own. However, the baby was very slow to react. I panicked as I didn’t know exactly what to do, and the panic was reflected on the doctor as well. It was evident that both me and the doctor weren’t very sure of what we were doing.

First thing I learned, as morbid as it may sound, is that human being can still survive on a haemoglobin level of 22! I related K’s symptoms to adult Medicine, and remembered that most of us would start to panic if an adult patient has a haemoglobin level of less than 70. It amazes me how resilient and strong children are.

A few of us then set out on a mission to spend some time playing with them, with the initial goal of making them smile. And I must say, it felt so good to see them both smile at the end of our ‘play session’. It certainly made my day.

I have come to realise that these children, despite having intellectual disabilities affecting their cognition, each and every one of them still retain their unique and quirky personalities. At the end of the day, the most important lesson that I’ve learned from these children is to never forget to see them as a person, a unique individuals just like any other child, and never label them according to their disabilities. It is important to focus on their abilities, rather than their disabilities.

There is one more week to go before the Paediatrics term ends, and two more weeks to go until our two weeks well-deserved holiday arrive. And I truly can’t wait for this consecutive 26 weeks term to end.

Various factors have been mentioned that may have contributed to burnout among medical students. The factors commonly quoted in the literature include academic pressures, workload, financial concerns, lifestyle changes, sleep deprivation, exposure to patients’ suffering and deaths, and student abuse [......] lack of control over or decision-making capacity in patient care, increased competition with fellow peers, and moral distress arising from inconsistency of values taught in preclinical years and the reality of clinical practices.

And my final post sums up my experience in Paediatrics very well.

It always amazes me how much I’ve gained and learned from each clinical attachment. Unlike the first two years of university where didactic lectures were the focus, from third year onwards, being placed full time in hospital, rotating through different wards and specialties, meant that we were constantly faced with a steep learning curve. 

Paediatrics is no exception. The field is vastly different to other specialties that I’ve come across so far. First, the physiology and bodily functions of children are so different to adults, which meant half of what we’ve learned so far does not apply to this population of patients. Even though we have had lectures during conference week 1 on Paediatrics, it still feels like a whole new field. Everything is done slightly differently, from history taking to examinations, investigations and treatments. I personally had to orientate myself around in the first few weeks of the term.

From the interesting cases we presented for Paediatrics Grand Round last week, I’ve also realised children compensate really well when there’s a change in their homeostasis. Often they don’t become symptomatic until the very last minute when they just crash. Therefore, they are so much stronger than adults, recover faster and survive worse. As a consequence, our medical practice needs to change to accommodate them, which essentially highlights how diverse the medical field is. 

Having said that, Paediatrics isn’t just general medicine practiced on tiny human beings, it is more than that. Because the main task of being a child is to grow, play and learn, monitoring of a child’s wellbeing and disease prevention are the two big domains of Paediatrics. A child’s social circumstances, such as parents, siblings, peers, performance at school, are as important as his/her diagnosis. And because children are not able to advocate for themselves, as medical practitioners, we have the duty to advocate on behalf of the children, and sometimes it means reporting to the Department of Community Services (DOCS). 

A major learning issue that I’ve gained out of this term is learning about the interactions with people with disabilities and their family members. I was constantly challenged during my two weeks at Mater Dei, felt out of depth not just because of not understanding the conditions, but also because of the impact on my personal beliefs and values. I was amazed by everyone that I’ve come cross, from the children, to the parents, teachers, and even the taxi drivers that transport these children to school everyday. The dedication, patience and extensive knowledge about the children and its impact on the people surrounding them are just astonishing. And I’m glad I came out of Mater Dei greatly inspired, and more importantly having an understanding that these children are just like any other persons, they have their own personalities, their likes and dislikes, and rather than focussing on their disabilities, it’s better to focus on their abilities. 

Lifelong learning is what Medicine differs from other professions. Because Paediatrics is such a diverse field, and the Paediatrics wards are run by junior/Paediatric Residents (RMOs), the essence of Medicine can be observed day in day out. Regular teaching sessions are conducted not only to medical students, but also to all medical practitioners. There were times where we, as medical students, impart new knowledge to other medical staff via our presentation on a topic. Personally, I’ve learned first hand about the importance of continuing education from the neonatal resuscitation that I attended with a doctor who is now more experienced because of that one stressful incident that we both went through. 

Last but not least, feeling burnout was a constant feature in the first few weeks of my rotation in Paediatrics. As medical students from UWS, we are lucky enough to have had lectures on the topic and its coping strategies. However, when it comes to facing burnout in reality, it is really harder than what was mentioned by the lecturers. The important thing, though, is to recognise the feeling of burnout, and then willing to seek help. Application of appropriate coping strategies is the next steps towards getting back up from the trough of our learning. Burnout will be a constant threat in our medical careers. To learn how to cope with it during my time as medical student would certainly be beneficial to my future practices.

And the verdict?
Paediatrics is definitely high up the list of specialties that I would seriously consider.
Who doesn’t want to work with those cute little innocent kids?

Makes me wanna steal one home. XD

I am seriously considering going into the field.
And I wonder, why? What drawn me?

Where do I start?

Looking from a medical point of view:
~I love the physician side of things, where there are a lot of meaningful negotiation and communication with (not ‘for’) patients, with women.
~I love the ongoing care of pregnant women, especially when at the end of it all, a human life is created.
And even if turn out badly, I want to be able to offer my service and support.
~I love the flexibility and a wide range of management options, that vary according to the stages of life the women are in.
~I love the mixture of sub-acute routine care and acute emergencies in the field, keep me on my toes!
~I love how intimate and close-knit the field is.
~I love womens health, and the importance of caring for women in a male-dominated world (letting my inner feminist shine! XD)
~I love the surgeries. Be it the chaotic Caesarean section, the meticulous laparoscopic surgeries, or the blood-y D&Cs.
~I love the mixture of Medicine and Surgery which the vast field has to offer.

Looking from a personal point of view:
~I love the blood-y business! Have I mentioned I love, love the blood stains on my gloves at the end of surgeries? =)
~I love the messiness of it all, as strange as it sounds (probably related to my fondness of things that are so called ‘ugly’ or ‘yucky’, yet totally ‘real’ and ‘normal’ in reality.).
~I secretly love the hectic schedule, and the euphoria and satisfaction I get driving home in the middle of the night after a long day’s work.
~And I love talking and working with, and for women.

The only concern though, was the long years of training, and the possible long/night shifts.

I have not made up my mind yet. It would be an ongoing decision-making anyway.
But I must say, all of the sudden, GP, Orthopaedics and Sports Medicine seem so much less interesting!! =)

Thoughts?

I felt that it was one of the most challenging areas I’ve encountered, both as a medical professional and for the patient, because of the intertwining nature of mental illnesses and their impact on all areas of life – from education, accommodation, and occupation, to the establishment and maintenance of interpersonal relationships.  These are things which sometimes those without mental illness can take for granted.I felt rather helpless sometimes, despite the biological and psychotherapeutic options that were available.  Social constructs are not so easy to ‘fix’.  As such, treatment and management of the psychiatric illness is not possible without addressing all 3 factors – biological, psychological and social. And yet, there are factors which seem out of our control and which can complicate and perpetuate mental illness. This contributes to the chronic nature of mental illness, and recurrence is almost certain.

Those with childhood psychiatric disorders will almost definitely require lifelong treatment. They would require support from their family through the various stages of life, and these needs can change accordingly. Education and support for their family thus also need to be considered as part of the long-term management.

Talking to patients in psychiatry communicated to me the need for holistic assessment much more firmly. Many consultations felt very personal to me, and few fields allow you to delve so deeply into another’s psychology and sensitive areas of their personal life history.

‘Textbook learning’ (or these days, moreso digital learning) is something that I feel can never be replaced because there needs to be a way of obtaining fundamental principles of knowledge. However, particularly in psychiatry, it would have been a very poor and deficient experience if one could not appreciate the lessons you learn from just talking to people – be they patients, patient’s families or the members of the care team.

Being around psychiatrists, mental health nurses, allied health and case workers gave me a variety of different perspectives about mental health and illness, and as a whole, I was able to appreciate the integral role of each member in the team. I also was able to gain valuable insight into my own mental health from seeing how they coped with the emotional and psychological load that comes with being burdened with the life stresses of other people.

Psychiatry is not for everyone; however, there is no shortage of interesting characters. I don’t know, I’ve always been a bit of an internaliser and analysis is one of the things I like to do anyway. I like exploring my own, and other people’s psychology. And here, I for once was given the time and legitimate reason to do it without sounding like a complete creep, lol. I think this term just made me more aware of the scientific spin that you can put on it.

PS. ECT is boring. We arrived at hospital at 7.30am, got to the OR to be shown and explained: ‘This is a machine’. The procedure barely lasted 2 minutes, and 2 psychiatrists came bursting through the door simultaneously AFTER everything was over to ask if they were needed. Need I say more? You still have to get it checked off though!

I would talk about my blossoming relationship with Evange through all of this, but…you might throw up. LOL. What’s the feminine equivalent of a bromance? A man-date? Cos that’s not what we have/are.

Not even a little bit, not even at all.

On Wednesday, as part of my attachment, I attended the Eating Disorders Clinic at Browne St with Dr Hay.  I felt that the patients I saw were representative of the population, although Dr Hay did say that it would be skewed because it is a specialist clinic.

Patient A was an 18yo female who came with her mother, but was seen alone. An issue that came up, even before the consultation had begun, was my presence in the room. Although the patient had previously consented to having a medical student present, it came into light that her father was a practising consultant in the SSWAHS. In this case, maintaining patient confidentiality would be even more paramount. The patient was however, very obliging and had no issues with having me present, which I am grateful for. In keeping with what I have discussed before, I was aware of the beliefs that I myself brought with me. There were issues within the family dynamics that was a possible perpetuating factor in her condition. The fact that she came from a family of 3 sisters prompted me to reflect on my own family dynamics and how I could be impacting upon my own 2 sisters.

Patients B and C were also interesting as I was given a glimpse into the process involved in CBT (cognitive behavioural therapy) and also when hospitalisation is warranted for eating disorders.

Due to the vast numbers of patients visiting that day, I had plenty of alone time to talk to Dr Hay about…psychiatry. Haha, but as you do, conversation topics tend to drift off into areas you otherwise would not have had the opportunity to explore unless in a casual one. I learnt that as a medical student, she had done her elective in Manitoba, Canada. She talked of it fondly, and her recall was kind of amazing. I think it added a new dimension to her I hadn’t seen before.  It also somehow culminated in her buying me coffee, so…yay? LOL.

Patient C had the lowest BMI of any patient I have ever seen before (12.6) and had multi-system impairment (predominantly cardiac and renal). Despite this, I could see the inner struggle that she was having, coming to terms with the potential weight gain she would have in hospital. Dr Hay talked of the conflict she was experiencing inside herself – one side voicing the need to lose weight, and one side wanting to overcome the disease. It was clear which side was winning at the time in this patient, and that even with hospital care – it would be a long and difficult path ahead for her.

To build on the last entry I wrote: (backdated to 16 Feb 2010)

I have often pondered the role of women in medicine, particularly what they each personally wish to aspire to. We all seem to recognise the balance that we will eventually have to establish maintain, especially between work commitments and family. Not infrequently, we wonder whether this balance is achieveable, or realistic. Sacrifice is something that we are forewarned about. ‘Are you *really* ready for this profession?’ is something we were constantly asked before medical school.

Hence, this registrar’s story was inspiring to me. I think you need a pleasant reminder once in a while, that things may be hard, but they’re still possible. It was like listening to a modern-day fairytale.

In continuation of what my experiences have been on this rotation though, I have still been seeing more patients come through Waratah House. However, the importance of social history has once again emerged in that I am being constantly reminded that history-taking is not a static process –patients with long-standing social issues will frequently require assistance from mental-health services (both community, and unfortunately, there are also readmissions to in-patient care). Their histories are always evolving.

A difference (among many) between the way the psychiatric ward is run and the way a medical ward would be run is that patients have intensive follow-up, and I have commonly seen symptomatic patients discharged. For example, Ms X was a patient diagnosed with chronic schizophrenia who had been abusing alcohol in order to help her sleep, but in the past had also multiple suicide attempts by overdosing on benzodiazepines. On discharge, she seemed euthymic and wanted to stop drinking. She was sleeping better, and had no suicidal ideation. On attending a meeting at Browne St (the community mental health centre) the week after, her caseworker reported that she had resumed drinking a bottle of white wine a day again to help her sleep, and would continue to do so unless she was given more sleeping tablets. The dilemma arises as she is known to stockpile and overdose on these. The solution was to try and encourage her to obtain weekly Webster packs.

Also, because of the association between one’s social environment and various psychiatric conditions such as schizophrenia, post-traumatic stress disorder and substance abuse, if there are ongoing social issues, the patient will be unlikely to fully ‘recover’. One instance of this that I witnessed was in a patient who had been in WH for two weeks, suffering from depression. He had seemed to be doing well, he was no longer suicidal and stated that his sleep and mood were slowly improving. Over the weekend, he had leave to be with his wife (coincidentally, it had also been Valentine’s Day that Sunday). When he came in with his wife the following Monday, she promptly stated ‘I want a divorce’. This will not only likely put him at greater risk of falling into further depression again, but he now has other social factors that need consideration such as future accommodation, deterioration of support networks and financial independence.

One patient encounter has stood out to me so far this week, because it is not something I was expecting and not something I have had to do very often (yet). A 48 yo man was brought to WH yesterday from PECC, with what seemed to be symptoms of a psychotic episode (auditory hallucinations, fear of persecution, paranoia). This man did not speak or understand any English, and an interpreter could not be booked for the day of his admission. Hence, I was asked to spend some time with him and take a full psychiatric history. I ended up speaking to him entirely in Vietnamese, and found him to be quite coherent and responsive. I was surprised at how much information I obtained, as I had been doubting whether I would be capable of conducting an interview in Vietnamese (considering I have no medical vocabulary in the language).

I went home that afternoon and told my parents what I had done at hospital that day (something I try to do as much as possible, because I don’t spend as much time at home these days), including this encounter. I realised that talking to him had reminded me of the time my own father was in hospital, and how isolating he had found the experience – not being able to communicate with anyone or understand much of what was going on.

A take-home message: “Countertransference exlains why therapists need to do their own therapy.”