Med School: Officially over!

Med School: Checked!

I can't believe that I've just finished 5 years of med school! It is so unbelievable that I won't be going back to school...

At the same time, I am excited about starting a medical career...Excited and very anxious as well! The whole load of emotions is very difficult to explain! It's as if I'm happy, sad, anxious, terrified, and in denial..all at the same time!

Honestly, if anyone asks what I do in life, I'm still going to say that I'm a student! Lol well at least until internship starts! Well I'm not a doctor yet and neither am I a student...It's just holidays for now!

To all of those who are still in med school: Good luck guys and enjoy it! Med school is awesome :)

Nostalgia...

It has been a very long while every since I actually wrote something on this blog... So much has happened and I don't know where to start!

Well maybe I should start by saying that I only have 4 weeks left in med school! Yes 4 weeks only and I really don't know how to feel about it! 

I am excited to finally be working next year, terrified about the fact that I'm going to make real decisions about patients, sad that I'm leaving med school and a huge load of different emotions!

5 years in med school and it'll be over soon... I just can't believe it!

I still remember the first day. There was transition camp which was supposed to help us making the transition to med school easier and also allow us to make new friends and everything... Oh the memories! How sweet they are :) Of course, there were bitter ones too but I am happily willing to let them go down the drain :)

I still remember the first time I had to do a power point presentation! I felt so proud of it after I spent hours on it and little did I know that I would spend the rest of my 5 years doing such presentations! And well, I'll probably spend the rest of my life making them anyway too...

I remember the time when I bought my stethoscope...Navy blue of course :) I went with the idea of buying a black one but when I saw the navy blue, I felt completely in love with it! I had to get it for sure and felt so happy just holding it :) I felt like a doctor somehow...

I remember the first time I step into the wards and into the OT. Well honestly, I remember more of the OT, it was a laparoscopic surgery and I had no idea what was the procedure called or even what the surgeon was doing but it felt so great to be just standing there with a mask! Typical junior medical student! lolz

There were so many first times in med school that I will always remember and unfortunately so many last times as well... Last time I walk from my studio to classes, last time I skip classes, last time I have lunch at zz, last time I go to the student doctor shop or the last time I see the hospital...

It will soon be time to close this chapter of my life and to start a new wonderful one but I can't help looking back and feeling sad that med school is indeed over! Most adults I have met have told me that uni days are the best days in one's life and they may probably be right...

I'll miss being a med student...

Confused

Today was one of those days that everything seemed blurry.
I woke up at 6 am and I thought 'Oh my, I feel as if I went to sleep only a minute ago'. I was so tired and somehow 'confused' that I actually took an earlier bus! I should probably be happy about that though...

So anyway...

I am currently doing my aged care rotation and medical students usually are responsible of doing MMSEs on every patient that gets admitted.
So, after lunch, I went to see my first patient and conducted an MMSE on her. She actually turned out to be more oriented that I was!

Me: What day of the week is it?
Patient: Friday
Me: Well, it's actually Thrusday
Patient: Oh really?
Me: Yes

It was only when I was writing her score down that I realized that it was Friday and not Thursday! I was so embarrassed...I quickly apologized to the patient and confirmed that she was correct.
She laughed and said 'I think you need one of those tests too'

It has been a terrible error on my part and could have led to:
1. A wrong MMSE score - meaning wrong assessment of the patient
2. Get the patient confused

In this case, it was fortunate that the patient was well oriented to person, place and time and had no cognitive deficit. If it was someone with cognition impairment, it could have led to more confusion!

Morale of the story: Be focused on what ever you do and always check the date and time before doing an MMSE.

Being on time

I think my previous blog post totally jinxed my day in the OT! From non-happening to completely happening...

It started all well, I woke up earlier than planned, grabbed breakfast and headed up to the OT. But then...I got scolded for being 3 minutes late... Sweet...
Don't get me wrong, I do understand the importance of being punctual and I actually put a lot of emphasis on it so I guess instead of finding 101 excuses of why I was late, I should just accept that I was slightly late and make sure that I arrive earlier.

And for some weird reason, I had decided to not properly fill my logbook and yes I got a bit scolded again! Totally my fault that I did not properly record the procedures correctly on my log sheet.

Anyway since I did not record that I performed bag-valve-mask during the days I have been in the OT, I was asked to do so on the patients who came in for ECT. I guess I should somehow be thankful because I finally managed to learn (under pressure) how to properly maintain an airway and manually ventilate a patient.

The rest of the day was quite normal if I may say so.  I observed an epidural being done and had an opportunity to observe how the anesthetist manages a patient with multiple co-morbidities, which was interesting and confusing at the same time.

My anesthesia posting is not so bad after all!

Anesthesia

It is ironic how every time something interesting happens, I think about writing it on the blog but by the time I reach home, I’m too drain out to even type it out.  And eventually, this poor little blog is left neglected.

Well anyway, I am now doing anaesthesia and I’ve been meaning to share with you my thoughts about how I am finding this new rotation.

Even before starting anaesthesia, I had this voice in my head telling me that it was going to be a boring two weeks in the OT but I had to remind myself to stop being judgemental and to give it a chance.

I must say that it was one of the few rotations where I got a proper introduction by the clinical supervisor and later on, we attended a small clinical workshop on intubation. I have had three days in anaesthesia so far but I haven’t had to chance to intubate any patients yet. I hope that I will have the opportunity to do so later on in the rotation.

How the days go about depend entirely on who I am attached with. There are some doctors who are enthusiastic to teach, others who happily answer all of my silly questions and then there are those who do not want to be disturbed and who don’t want me to touch anything at all.

Sometimes I take a small stroll out of the OT and go observe the ECTs that are being performed. I think that my love for psychiatry takes over me from time to time and I think it is pretty obvious at times. One anaesthetist turned to me and asked ‘Are you interesting in psychiatry?’ and I happily nodded of course!

I usually spend the rest of my time in the OT reading my book and asking questions if the doctors are willing to answer me. Otherwise, I stared at the GA machine or watch the surgery, wondering how long did the surgeons trained to be where they are now.

Anyway that is how my first three days in anaesthesia have been so far.  I hope that I will enjoy myself during the rest of the posting.

Do not guess!

After a patient was stabilized in the red zone, the ED physician gathered all the students around and asked us to interpret an ABG.

A simple answer like metabolic acidosis was not enough... I forgot to add with hypoxia! And being dramatic in nature, the tutor sure had his way around making us (or at least me) feel like a total idiot. He kept on questioning us about different aspects of an ABG as well as how to deal with a patient with acute pulmonary oedema. Unfortunately, we all made the biggest mistake when answering some of his questions: GUESSING!

Anyway after what seemed to be a lengthy bedside tutorial with him, one of the main message was:
When you are in the ED and you don't know something, say you don't know and do not guess as this might lead to the death of your patient!
He added that if we were in the medical wards, we could go ahead and guess and come back one month later and change the diagnosis....as I said, he is a bit dramatic :p

Well, lesson learnt! I think that as a medical student, even when I am not sure, I either tend to guess things or say what I am thinking.
I think that this has both its advantages and drawbacks.
Speaking your mind during a bedside teaching is actually beneficial in my learning process and it also shows that your mind is working rather than just nodding like a parrot.  But in some instances, especially in emergency cases, guessing would probably lead to the death of the patient!

I think the message he really wanted to bring out was to know your limitations as a doctor in terms of knowledge and abilities and to accept the help of more senior personnel when you are unsure about what to do.

New Hospital?

A while ago, there was this elderly gentleman who came in to the ED with chief complaint of body weakness that started after a sudden fall.

After a while,

Patient: Excuse me, can you please tell me in which hospital I am
Me: You are in the emergency department in *hospital name*
Patient: Oh I see
Me: Do you live anywhere nearby?
Patient: Yes I do live very close. I thought the ambulance brought me to another hospital because the place looks brand new!

I couldn't help but chuckle...The hospital I am currently placed at is pretty old. According to one article I previously read, it was built in 1882 and of course, since then, there have been quite a number of renovations.

The ECG Machine

Usually the student nurses are the ones who push the ECG machine around in the ER and they're usually the ones who put on the leads, ect... I, being a med student, usually helps in placing the limb leads and often, I'm more interested in the ECG itself (woops)

So today in the red zone, there were no student nurses and the nurse had disappeared for a while so we (me along with my medic friends) were the ones who had to do the ECG. That's quite easy actually, the leads were put in the correct positions, the wires correctly positioned...but somehow, when I pressed start, nothing happened...

I was quite puzzled for a while when I realized that I didn't plug the machine into the socket! Woopsie...

*stupid meeee*

Fire safety, soldiers and tutorials

The day in the emergency department starts off with a small prayer at 8 am sharp followed by some statistics about the previous day; number of admissions, ambulance calls, etc...

Today was no different, except that I arrived one or two minutes after 8, and the morning meeting had already started! Tomorrow, I will be on time! Urgh I hate being late and have always made it a point to be punctual but I wonder what has been happening to me recently...

The day in the ER was alright, even though I don't think I learnt as much as the previous days. We had to attend a talk on fire safety and I had no idea what the speaker was talking about as it was all in Bahasa Malayu. I guess some of the things he said were funny because the audience laughed a few times. 

I was placed in the green zone today.  There was an english speaking patient who came in with a chief complaint of chest pain.  After a while, it was quite clear that he his problem might be psychiatric in nature. The story he had to tell seemed interesting but I was chased out of the cubicle. So, I have no idea what happened to him. 

The rest of the patients came in mostly complaining of chest pain or shortness of breath.  

A funny story though is that a soldier came in to the yellow zone after having experienced a fit. He was talking in malay, so I had a very faint idea of what he was saying. I understood  that he said his body was aching but I wasn't sure what he added. The rest of the medical students and a houseman all walked off. Another fellow medical student turned to me and said 'run. run'. It turned out that the patient threatened that if he was not given pain killers, he would punch someone. He added that he did punch a doctor some time back! I'm guessing that's the reason why every body walked away all of a sudden...

The afternoon tutorials were way more interesting. The topic was basic life support and advanced cardiac life support. Definitely something interesting and exciting! The tutor gave us several scenarios and took us along the different algorithms. 

It makes me wonder how I will act if a patient collapses in an air plane...I understand what needs to be done in such a scenario and I can even recite it out for you, but if it really happens, I wonder if panic will strike me and paralyze me. Well, it is probably to avoid these situations of panic that we are trained several times during med school.

So that concludes my day. Time to relax now and go through the ACLS guidelines one more time.

A day in the ER

Last night was bad. A night full of nightmares and needless to say, when my alarm went off at 6 am, it was hard for me to even open my eyes.

I still had time ahead of me. My shift was not supposed to start until 8 am and that left me with almost 2 hours to get ready. Unfortunately, I was so tired that I fell back asleep and woke up at 7.45 am! Of course I was late. And of course, of all days, it was today that there had to be a clinical skills workshop for the medical officers. Medical students were also asked to joined.

I arrived at the skills lab 15 minutes late and when I entered, everyone looked at me! Awkward! 

Anyway, it was actually quite interesting and a variety of scenarios were simulated and the management plan briefly outlined.

A funny or not so funny simulation was that once the patient/dummy was pronounced dead, after a while, the mannequin started to make some noise. You can imagine the uproar in the class! And the specialist indeed said that it once happened to him that after failed resuscitation, he declared the death of a patient, who somehow revived a while later! And the patient remained alive for another 24 hours before moving on.

Indeed, it has happened various other times and this phenomenon is actually called Lazarus syndrome. It is basically when a patient's blood circulation restores itself after a failed attempts of resuscitations.

Later in the afternoon, during the ward rounds, the consultant also mentioned that he heard of a similar case whereby a dead patient was sent to the mortuary and the patient came back to life! 

This is why he said, that after declaring the death of a patient, he/she should be monitored for another hour or two to confirm the death of the patient.

This is starting to sound spooky now! Let's move on, I do not want to have anymore night mares tonight.

The rest of the day was quite interesting as well. I did have an opportunity to see patients coming in with various conditions, such as atrial fibrillation, injuries, sepsis, ect... 

Another story I want to share with you was that I breeched the universal precaution today! And I didn't even have a choice :(

One of the doctors was doing an ABG and I was standing somewhere nearby. After obtaining the blood sample, she rushed me to apply pressure on the puncture site...of course, I was without gloves! *Scream* I made sure I was not bleeding from my fingers and washed my hands thoroughly afterwards. I wonder why some doctors rarely wear gloves or even worse, wash their hands before and after touching patients!

The universal precautions definitely need to be reinforced! 

A lesson I learnt today was to make my own judgement as other doctors can also make mistakes. As one of my friends once told me, I have to trust my own clinical examination and judgement and not let myself be biased with what others have to say. Indeed, from now on, no matter how tired I am, I will think before I agree with the doctors!

There are of course many many more stories in the ER that happens but if I keep on writing, the post will never be over...

I wonder what the rest of week 2 in the ER has in store! So, stay tune for more :)

Death

It was maybe around 10.30 am yesterday, I can’t clearly remember the time. The buzzer went off three times, which meant that a patient was entering the red zone.  Some of the staff and most students ran to the zone, and so did I. 

What I saw was definitely not what I expected. The first thing I noticed was that an exchange student was doing chest compressions on a patient. The whole team was working on resuscitating the latter. It looked nothing like in the movies. It was somehow chaotic but the staff knew what was to be done. No one panicked and people were still going on with their usual conversation as if it was absolutely normal.

After a few cycles, the patient was unable to be resuscitated. No one actually called the time of death, as it is usually done in the movies. It was all over in a few minutes.

And this was the first time that I saw a person pass away in front of me…

I always expected it to be traumatic and I thought I would have trouble holding my tears, but it was not. There was a peaceful atmosphere in the room. I knew that the medical team did their best and that it was time for the patient to move on.

Later on, when I was following the ER physician on his teaching rounds, it was initially hard to focus on what he was saying as the patient’s wife was crying and screaming nearby. I almost had tears in my eyes but I reminded myself that this is what doctors experience on a daily basis. We can’t let ourselves be affected about what happens to a patient as this can endanger the lives of the remaining patients in the wards.

So yes, it was my first experience where I saw a patient move on. It made me realise once more that life is indeed short and that it can come to a stop at any time.

Psychiatry

So I met up with a friend today at lunch and I was telling him that I wanted to do psychiatry as my elective but I wasn't able to get a placement in psychiatry and I got oncology instead, which was my second choice.

In the cafeteria
Friend: Psychiatry? You wanted to do psych as an elective?
Me: Yeah, I like psychiatry. It's really nice
Friend: Really? Are you mad?
Me: Huh? What's wrong with psych?
Friend: Well you're seriously the first one saying that psych is interesting
Me: *Roll eyes*

Honestly, yes, I don't know a lot of people who like psychiatry. In fact, most of them hate it. A few more example:

In the library last year
Friend who likes psych: I'm doing psych as an elective
Me: Oh lucky you!
Other friend: *Laughs out loud* So basically you're doing nothing for your elective
Me: Sigh

Waiting for the lift
Me: How do you find psych?
Friend at the end of his psychiatry posting: It's alright, you don't need to think too much
Me: Uhuh yeah I guess so (but then I was also thinking *If there was nothing much to think of, why did our class dragged on for so long?)

Ok so I get it, psychiatry is not famous among medical students. But how about in the world of doctors? Yeah the other specialists do back-stab each other!  *evil grin*

In the lecture theater, going through some exam questions
Pediatrician: Oh that question cannot be a child psychiatry problem because it's short and to the point. There is always a long paragraph if it's dealing with psychiatry.
Audience: *laughed out loud*

Discussing the previous day mock OSCE
O&G specialist: Come on, was it that hard to see that the picture showed a uterus? Ok maybe it was hard. Let's ask a psychiatrist and see if he'll be able to recognize the organ
Me: *OMG did she just say that?*
Psychiatrist - maintained his composure and didn't utter any comment.

Well, you know what? I bet psychiatrist spend a great making fun of other doctors who have no clue how to manage a psychiatric patient.

One example of a clueless O&G specialist about psychiatric diseases:

In the clinics
Medical Officer: This patient came in with blah blah blah and she is a known case of depression
Specialist: Ah depression. You have to be careful about what you tell her.Otherwise she might turn into schizophrenia
Me *Trying so hard not to laugh*

What else is left to say? Psychiatry is definitely not one of those specialties that people want to get into. As for me, I still think that it was one of my most interesting and amazing posting so far!

Stress

The surgeon says: Our job is the most stressful. Standing for hours operating on patients and when it's time to go home, another patient in urgent surgery rushes in.

The physician says: Our job is the most stressful. The other departments refer too many of their patients to us. Don't they know how to treat a simple pneumonia?

The obstetrician says: Our job is the most stressful. We deal with 2 lives while the other doctors only have to worry about one life.

The emergency physician says: Our job is the most stressful. We work under a lot of stress and we're the front liners!

I can't help but be amused!

Emergency Rotation Day 1

It’s time to say byebye to Ob/Gyn and hello to Emergency!

Here is an account of what happened today.

I roughly woke up around 5 am because of a strange dream that I can’t really remember but I’m pretty sure it involved medicine…maybe I should consider it a nightmare? I don’t know but that’s beside the point.  I laid down in bed until 6.30 am when it was time to get ready and have breakfast.

We had a small intro/orientation which lasted less than two hours and we were then sent to our wards.

First note to self: Do not wear skirts or dresses. It’s way too cold inside and knowing how cold intolerant I am, wearing dresses would be like committing suicide. Do not wear high heels too (doesn't really apply to me since I hardly ever wear them). 

I must say that the staff is quite nice and it’s actually hard to know who are the specialists or the medical officers. They all wear that black jacket with their name stitched on it. I guess after a week, I will be familiar with the staff.

Anyway so moving to the interesting part of what actually happens in the ED. Well it is basically divided into three zones: red, yellow and green where patients are sent according to their medical emergency. Red means very serious patient!

So one of the first patients I saw came in with sepsis secondary to necrotizing fasciitis. The house officer asked me to put on my gloves and feel the crepitus over the skin lesion. I was so ‘excited’ that I was having trouble putting on my gloves and when she hurried me, well I ended up putting my gloves the wrong way! I hope no one noticed… well I was also asked to describe the smell of the lesion. The smell must have been pretty strong because even with a blocked nose, I was able to smell it just by standing next to the patient. The patient was then transferred to the wards for further management.

The next patient was a young lady who came in with a chief complaint of heavy per vaginal bleeding. Her hematocrit was low and she was tachycardic. An abdominal ultrasound was done with showed some kind of cyst but no definite diagnosis could be made.

In the meanwhile, another elderly lady came in complaining of shortness of breath and chest pain. It was quite hard to get a history from her. She mainly replied ‘don’t know’ to everything. An ECG was done for her, which showed some kind of heart block (I think). This brings me to the second note to self: revise ECG! I was unable to make a diagnosis based on the ECG, which is quite embarrassing, considering I’m now in final year.

I have no idea what happened to the last two patients because the specialists wanted to meet all of the students and gave a small presentation. And he stressssssed on being professional and wearing a proper attire.

And that is the end of my first day in the emergency department. I hope that it’ll be as good as the other rotations and I’m pretty sure it will give me an opportunity to refine my procedural skills!

Preparing for Ob/Gyn

My ob/gyn rotation is finally over. Those three weeks were indeed quite interesting and I've had the opportunity of seeing a vast number of patients with diagnoses ranging from cervical cancer to ovarian teratoma to molar pregnancy.

So how should you prepare yourself prior to an ob/gyn rotation?

I find it easier to study according to the wards I was placed in; for example, while being in the gynecology wards, it makes more sense to study gynecology rather than obstetrics.

The books/resources I used were:
1. Gynaecology by Ten Teachers
2. Obstetrics by Ten Teachers
3. Women's health. A core curriculum
4. Emedicine

Reading List for Gyneacology
- The menstrual cycle
- Abnormal bleeding
- Dysmennorhoea
- STIs
- Contraception
- Infertility
- Miscarriages
- Early complications in pregnancy
- Genital prolapse
- Incontinence
- Menopause
- Cancers (cervical, breast, ovarian)

Reading List for Obstetrics
- Antenatal care
- Medical diseases during pregnancy
- Labour and Delivery (Make sure to know how to read a partogram and a CTG)
- Preterm Birth
- Obstetrics emergencies

Ob/gyn allows you to have a very good hands on experience, so make sure you grab every opportunity to learn.

Good luck!

The Labour Room

Ah the interesting unethical things you see in the labour room!

A lady in labour was slapped by the medical officer for not pushing adequately! A slap! I mean come on, it was her first time in labour and wouldn't it be more correct to explain to her gently how to push rather than slapping and shouting at her? Besides pregnancy and birth are 'supposed' to be a great experiences but for this particular patient, it certainly was not!

The other thing that leaves me baffled is the fact that vaginal exams are conducted in front of 15 other people during ward rounds! I can't imagine how embarrassing it must be for the patients... Besides what is the point of 15 people observing a VE? It's all about feeling for the cervix, ect...

And of course, it's so obvious how single mothers are stigmatized by most of the medical personnel. Are we not supposed to respect patients and their choices?

These are only a few of the many similar experiences I witnessed so far... And I guess, there will be more

Ob/Gyn Day 1

3 weeks of pediatrics over and time to move to O&G
And the change is indeed drastic. No cute kids to play around with and everyone is so serious as if there is a tsunami coming close! I guess it is because of the pressure that obstetricians have to face on a daily basis.

Well, I guess my first day was not too bad, even though nothing much excited happened.

I woke up early and made myself some breakfast but strangely enough I fell back asleep and woke up at 7.45 am! I was planning to leave my house at this time...sigh
Well luckily the rush of adrenaline allowed me to take one of those 2 minutes showers and to get ready in 3 minutes!

I arrived a little bit late at handover rounds for my first day! urgh but I guess no one really noticed... We, medical students, always seem to be invisible most of the time.

Handover rounds were followed by ward rounds, which was well nothing special. There was a few patients with heart conditions who were closely being monitored and we stood behind as the specialist reviewed the patients.

Next, we were told that there was a suturing workshop and that we should attend. Suturing! Yay!
That was interesting indeed as it allowed me to review the basic suturing and knot tying techniques :)

Simple first day indeed!

Peads On Call

Who ever said that on calls were boring? (Hmm alright, maybe I did mention it a few times)

Well not today. My friend and I were looking at an X-ray that was handed to us by the specialist on call. She originally wanted to show us how far the umbilical vein catheter has gone in.

On looking at the X-ray, my friend pointed out to the left side of the chest and said 'Hey what's that?'
'Looks like the bowels' I said
'Err diaphragmatic hernia?' he replied back

Yes indeed, it turned out that the patient was referred to the surgical pediatric team to rule out a diaphragmatic hernia!

It was indeed interesting to see a patient with such a condition.

Bedside manners

It is alarming how rude doctors can be to patients! Yes I have definitely witnessed it with my own eyes for the past two years. Some doctors just lack bedside manners!

I’ve seen patients getting scolded when they complained of pain and I’ve seen patients being disrespected when they refused medical treatment.

I often wonder: what is the use of being a smart doctor who can diagnose any diseases but who lack compassion? I think that being nice and respectful to patients is the most important part of patients’ care. Yes, knowledge is important, but being respectful and having good bedside manner are even more important.

The following extract is from an article written by Dr Centor about bedside manners.

‘Most physicians understand that good medical care involves both science and art, and one cannot easily separate the right-brain activities from the left-brain activities when providing patient care. Excellent physicians develop a relationship with the patient. They engender trust through their approach. The physician-patient relationship is special, because patients come to us in vulnerable situations. They depend on us to make diagnoses and prescribe treatments, but they also depend on us to help them make good decisions about managing their problems.’
(http://www.medscape.com/viewarticle/737495?src=mp&spon=25)

I couldn’t have described it any better. A good doctor-patient relationship is essential to good patient’s care.

I hope that future doctors will remember that medicine is indeed a noble profession and that they be respectful to patients.

Tunnel Vision

During the ward rounds today, the Head of department of surgery said something that I thought was very interesting.

Mr. AR is a patient who has been in the wards for around 2 months. He has had extensive burns over his lower limbs after a seizure. We grew used to the sight of this frail looking man over the past few weeks and today, the consultant reminded us not to have a tunnel vision.
By tunnel vision, he meant that at times, doctors are so used to see a patient with a known diagnosis that they often forget to look at the other issues that the patient might have. In this case, he was actually worried that the patient might be suffering from malnutrition as the catabolism rate increases in patients with extensive burns.

Indeed, this is something I would not have thought of. And another lesson learnt!