Stress Rising

Once again, it's taken me a long time to write anything on here and the word 'busy' creeps into my mind. I really don't like using that word because it is patronising; it portrays that there are other things that need to be done before one's attention is diverted elsewhere. It's quite sad when people are told that one is busy, because I feel that it implies that those people are not important, not worthy of our immediate attention. How must patients feel with such words.

This weekend was quite good. Work was busy and I caught up with my girlfriend and my good friend. We all went to dinner on Saturday night and it was a fantastic experience. However, my lack of sleep really didn't help. I have had rocking sleeping patterns this passing week because of my mother's operation. She had a laparoscopic cholecystectomy performed along with two core liver biopsies taken. She had the procedure on Wednesday afternoon and was discharged from hospital on Friday morning. 

Unfortunately the day of her operation was hell for me. I had to take the day off from my clinical attachment three days after joining my team. I had the admissions committee meeting in the early afternoon, which went until the early evening, but leaving early was something that needed to be done because I had to present my research findings to the summer research scholarship judges. After that, I didn't go back to the admissions meeting and decided to head to the hospital. We waited for several hours before mum was admitted to the word after the operation. Dad was there with since 0600 and I felt guilty about being absent during the day. 

I couldn't take any more time off from the attachment, so I decided to drive back to the hospital on Thursday morning. Knowing that I wasn't going to see mum until the weekend, I thought I'd visit her bright and early in the morning at 0530 before I joined my team. After visiting her for a short time, I had to cruise for over an hour to get to my allocated hospital and slap myself several times so I didn't fall asleep behind the wheel - it's starting to get dangerous. 

Staying out late on the weekend coupled with work and more driving really took it out of me. So, I decided to sleep for 10 hours on Sunday night and could barely wake up. My body wanted more sleep, more rest. It's difficult for me to put my mind at rest when I sleep because I still think about the events that happen during the day and other things that are important to me. I always make a list of things I need to do before I fall asleep and that list is seldom the same the following morning; so I spent the night modifying the list, but that's probably not an accurate description of what really happens when I sleep - more of a dumb joke really. 

It's Monday evening and I'm quite tired from today. It's been a long day again and I really need some more rest. My room mate and I are getting along very well and I'm really happy that we're living together - it's a really good relationship and I think it's really going to help me get through this year. My room mate pointed out how he has no idea how to study for this year and I feel the same way, so we started discussing the assessments and because he's attached to a different team, I was very confused when he talked about the examinable materials, as I hadn't heard of them. I decided to look it up and didn't find much for my attachment, which started to stress me out. 

It seems that we are plunged into chaos again. I've got no idea about what to do with this year - how to study, how much to learn and what to do. I need to sit down and do my work. I haven't had any time for it.

This situation reminds of our orientation week in the first year, when the head of assessment was asked to brief us on what we should expect in terms of exams. He concluded his presentation with this:

You must all love examinations because you have signed up to a program with an unforgiving assessment component. The truth holds that if you are failing in your examinations, it is highly probable that you are also failing at life.


Ever since I stopped studying, I haven't had a chance to work out properly, haven't sorted things out with my extra-curricular activities and haven't managed my finances. I have to work this out.



I really have to work this out.

A GP's story

It only felt like I slept 20 minutes and before I could feel anything else, the alarm was screaming at me. I got up and sat on the side of bed, staring at the wooden planks of the floor, trying to see if I could see in between them. Spacing out was something I had to do before my body really knew it was awake. 


So I'm shirtless and it's cold... almost time for a coffee. But before I could, I needed to check that I was really awake, that the reality does exist. I turned around and saw her: my beautiful wife, curled up on her side. It looked like she was smiling as you would when you have a pleasant dream and you mumble a few words at best, but they make no sense anyway. Then I knew I was awake - it was her hemiparesis playing up. That was confirmed by the spastic paralysis of the part of her forearm I could see - pronation of the proximal radio-ulnar joint and palmar-flexion at the wrist compounded with flexion of all proximal and distal interphalangeal joints. I was definitely awake now. The clinical mindset was established well before I closed the bedroom door behind me. 


It's 0638 and the first lot of patients will be arriving at 0730. My sister-in-law drives the kids to school on Mondays because my baby can't anymore. The coffee's way too hot and it's almost 30 degrees outside. Monday mornings are always hectic because the practice is closed on Sunday. It's always the longest day of the week... always.

Working out what tie to wear with the shirt I snatched blindly out of the closet is the easiest decision to make for me: I just don't wear one. Fuck that. I can't be bothered working out what piece of material matches the other. 


Good; I'm in my car and the time reads 0647 on the dashboard, which is fast... or my wristwatch is slow again. Time is always relative but regardless of whether I'm ahead or behind schedule, I'm still speeding. Traffic laws are made to obstruct traffic and some of us agree that they are made to be broken. Plus I've got patients waiting; they're probably outside.


The anticipation is always the same when I walk towards the front door - the receptionist has opened and patients are lined up at the desk; or I have forgotten my keys and people are waiting outside. Today was the former; always good not to wait awkwardly with patients outside. You know they are there to see you and somehow they all expect to be triaged while you're waiting for the receptionist to arrive. "First come, first served dude." 


A few dozen patients later and the time is reading 1103, which means the drug rep will soon be around with some morning tea. As a doctor, my job was to eat their food and pretend to be interested on the outside; laugh out loud on the inside. Their advertising campaigns don't entice me, but I do enjoy their food. 

Back in the office now and it's time to continue with the consults. I call the next guy in and walks awkwardly with a bag in his left hand. Adam has schizophrenia and he complains of a dry mouth. I tell him that this is common with his medications and that there's little I can do other than give him some drops or lozenges. My glasses remind me of my age and the use of my index fingers to type reminds me of my old-fashioned urge to toss the computer at the wall and write with a pen on a piece of blank paper. 


While I'm tediously typing up his prescription, I hear a zipper that I presume is Adam opening his bag so that he can put the prescription away and so I continue swearing under my breath at the typo's.


All of a sudden *thud* - a pain on my back. Hmmm.. that's odd. Then *thud* and again *thud*. What the fuck is this pain all of a sudden? I try to ignore it while I type and then three quick ones...


*Thud*
*Thud*
*Thud*


I turn around and realise it's Adam and he's holding a knife that's dripping fresh blood over the floor. It's my blood. "Get away from me!" I yell and fall onto the ground. He advances towards me and I kick him back with my left leg. Adam stands still while I start gasping for air and he calmly picks up his bag and starts walking out of the room without the prescription. 


"HELP! Stop him!!" I yell at the top of my lungs and realise they're probably collapsing. I shouldn't test them right now. The other GP comes out and sees the trail of blood off the steak knife Adam's holding. "Stop right there!" he orders and Adam, being a psychiatric case, turns around and says "Okay." 


"Sit down and drop the knife!" 
"Sure. No problems here."


The ambulance arrived and the paramedics rushed in to find me on the floor. The other GP was making other phone calls to the police and what not. I'm hoping he's calling my wife but I can't be sure. We're not on very good terms anyway. They help me up onto my own examination bed and start doing my vitals. My blood pressure's dropping and my pulse is going sky high. Typical signs of hypovolaemic shock and I'm still not feeling delirious - this sucks. 


"Doctor, we've got some IV saline the ambulance that I want to hook up to you before we make our way to hospital so I'll insert a cannula." 


"Just do whatever you need to do. You've got my full consent - don't stop to explain shit." The paramedic nodded and went to insert an IV line; he missed and it hurt.


He missed again and I'm wondering how much time has passed since I've started bleeding. Finally, on the third attempt, he flushed it through successfully. "I was just about to offer a hand," I said sarcastically. He laughed back nervously. 


48 minutes later I was in the emergency department getting resuscitated. I remember all this because I didn't lose consciousness and was already hooked up to a bag of salt and water to calm my circulation's emotional response to this God-awful situation. 


Next thing I know, I've got a few specialists lined up introducing themselves as a general surgeon from here, a vascular surgeon from there and a thoracic surgeon from up somewhere else. "Okay, can we get on with it?"


Then finally the chick that mattered finally showed up - the anaesthesiologist. "Fuck, about time man." 


"Yes, we're wheeling you up to theatre now. I'll intubate you there. Here's some midazolam to sedate you now." Before I could say anything I was off in sedation land - a land established simply by a pause in the last thing you remember until you wake up. Incredibly confusing. 


Waking up in ICU and realising I was the patient was quite interesting - I was wondering what the hell all the lines were on my chest until I realised that, once again, I wasn't dreaming. My wife was there with my eldest daughter. They were both smiling at me and crying... as they would. 


I've been looking after God's work for 30 years; his creation that is people... his functional creation. Living an honest life, delivering care and raising a family are hard to juggle. My faith has only recently been shattered. 


My wife had a stroke. 
I diagnosed my father with Alzheimer's disease and my mother with end-stage kidney failure. She's on dialysis. 
I've got 2 mortgages, 2 car loans and 4 children that go to private schools. 
And now, I'm in a position where my whole life has to be put on hold and I am physically and biologically prevented - I cannot sustain my normal activities for now. Maybe never. Who knows?

Finish What You Start

Clinical is never finished when we are dismissed - not for me. It is my understanding and strong opinion that for the past two years we have learnt the science of medicine and acquired some form of appreciation of the art of medicine. We are held together by a code of obligatory ethics, regulated by a national board. However, choice is far different than obligation and the two seldom parallel. Choice is a freedom, a component of living and is expressed in different forms depending on its context.

I have been learning medicine for two years and I refuse to turn off the ability to recognise disease regardless of where I am, what I am doing and who I am with. Based on the vocation I chose, not profession, I owe it to the people that have entrusted me with their stories, loved ones, secrets and embarrassing moments - I owe them focus, conversion of thought. Concentration on their concerns.

Most of the time, my ideas are dismissed or thoughts ignored - a choice I must come to accept; a freedom a patient has every right to.

So in that philosophy, every person out there is a patient epidemiologically. Therefore, everyone deserves to be screened, at least primitively, regardless of the demographic setting. Therein, lies the problem within me.

I do pay attention to people's behaviour, even my friends. Jumping to conclusions, developing hypotheses; dismissing something, considering other theories. However I do try to listen, I try not to get easily distracted as I kept getting reminded as a child and still do as an adult by others.

You could probably tell by reading my words that my thoughts are rather disjointed. What I originally thought I'd write when I typed the title above is actually very different from now. That means I spend a considerable amount of time poorly trying to recall and recollect my original thoughts; sometimes so desperately that I omit the relevance of what I was thinking. It is most embarrassing.

What I really wanted to write is that I truly feel so alone - when I was in my first year, my patient doctor tutor, MG, was a specialist and a general physician. He made clear the importance of professional distance not through his principle of words, but through his actions; we were all kept at arm's length away from him. We all knew what was too close through abrupt reminders. I remember making a statement that he didn't seem unfamiliar with:

These patients are suffering - I really wish there was more we could do. How do we know that have good living conditions?


MG always paused before answering something and the pause was awkward because he was staring at you like a hawk. He constantly assessed not just your words, but your character, persona and posture. A lot more is said by the body than by word of mouth. And his response was:

What do you suggest we do Doruk? Do we go to the extent of offering people a place to stay and some money for rent? 


I suddenly realised that it was not practical.

We do the best we can given the circumstances. 


My goodness, was I disappointed! As short-sighted as I am, not considering the depth of the philosophy of others, I promised myself that I would always be close to the people I wanted to help.

Tonight I found myself taking a history over coffee, realising that I was discussing clinical concerns with a friend about his weight loss. I had the same persona as MG - it was obvious. My questions relayed my concerns, but the tone was steel.

Cold to receipt with a chilly abruption of blood sending the information to my friend's brain - comprehension.

It is clear to me, through my impression of the choice I have made, that is to serve humanity by restoring multi-faceted function to sustain a quality of life that is fathomable and compatible with what any person perceived before presenting to me, that I must never stop thinking. I cannot stop.

It might be damaging to me, but so little is gained if we do not sustain damage. At least, hopefully, such damage is repairable.

Decompensation

I really thought I had a good grasp of time management at the beginning of 2011. Yet, time is suspended above me and it's chaotic patterns really are influenced by the slightest of movements. It aches past at the slowest of rates, making the wait for a person to get off the phone to be forever; suddenly it fast-forwards right before you.

Many people told me to stop working when I started the third year of my studies. I have had a minimum of 2-3 jobs since 2006, after my two operations - when I realised the importance of being functional while I was young. My father stopped working when he was less than 50 years old because of his pain from a variety of conditions, including the bone disorder I have inherited. It was a reasonable recommendation. You really need to study and you have to make time for yourself.


It is very easy for people to make judgements about my personal circumstances when they are not me. Similarly, it is very easy for me to reach conclusions about things that don't directly involve me, which is a problem because I really can be insensitive sometimes. There's always room for improvement.

Since the program started, I have already picked up a few more responsibilities. I maintain the position of an auditor for one of the specialists at the hospital I'm currently training in. I am still a radiographer on the weekend, public holidays and occasional weekdays. I am also a lecturer at the university I am enrolled in the school of medical radiation sciences. On top of that, I have been meaning to finalise my summer research scholarship of organising a teaching session for medical students - so I am also affiliated as an unofficial lecturer for the medical program - for now. I am looking to expand the summer research scholarship into a masters in philosophy because I am not eligible for honours. I have already started another research project looking at the management of oesophageal perforation. On top of this, I am organising the World's Greatest Shave event again for the Sydney University Medical Students, which will be happening in little over a month's time.

As if this is all not enough, I have applied to the radiology department of the hospital I'm training in for a job as a night-shift radiographer or for an on-call position.

So the point of this entry was to outline why I feel time is slipping past and I mostly blame my thoughts. I'm constantly preoccupied and never have not a worry in the world - I don't understand that concept and I also don't understand the concept of a holiday.

My girlfriend always tells me that travelling is about sight-seeing, experiencing different cultures and so much more. For me, a holiday is sitting with my feet up on a big lazy-boy recliner and staring at something, preferably a static object like a wall or another chair. Perhaps things that do move that do not require much interaction, like a bird or the wind. I would love to go travelling but even with the eight hours of sleep I'm getting, it really does not feel like it's possible. My body is resting; my mind is constantly working. Most of my sleeping feels like I'm spending more time trying to work out what my dreams are than actually just dreaming.

I'm going to end up being one of those people who live in 5-minute intervals. At the moment I'm on hour-intervals. I can see people or interact for an x number of hours, so that's not bad. People can put up with that. But even then, most of my day goes to medical experience and being as useful as possible. Seeing as though we're in a healthcare system that is short-staffed and has barely any money to provide staff relief, it is the medical students that fill in the blanks. That's the way the world works at the moment - it may be unethical and we can debate it.. but all we'd be doing is delaying what truly is the inevitable: medical students make a difference to staff numbers and if competent, must be utilised to increase efficiency. Like with any familiarisation process, the person trying to sort out their environment ends up being the bearer of the inefficiency and everyone is weighed down by it. But once the momentum is up and running, it is impossible to stop.

Looking forward to the weekend is something everyone craves at the end of the week. I'm wondering how on earth I'm going to get up early again. Sleeping early has been how I overcome the fear of waking up late. And my weekend's booked out well before it's arrived. There's no time to rest the mind.

Study at work, work during study, research during clinical, see patients during study, work during research, study at clinical, clinical at work... Sometimes I forget my function and my role - I end up being ahead of myself or even worse, not doing the adequate amount.

Am I burning out again?

The Long Case

It's only been a couple of weeks into my first senior year of medical school and feeling sleep deprived, stressed and concerned on a constant basis has become almost second nature. When I start something new, I always start off by giving it my best, my full attention. As time slowly etches my gloss of perfection to the core of reality, I realise that I have committed myself to so many things that I thought required perfection. Some demand it; others are flexible. There is always some element, some degree of expectation of it. Lingers as it does, at the back of my head more often than not and I realise that it's mostly always right in front of my face and yet, always beyond me.

Medical students are known to be good academically and their examination technique is well-established given that we all have sat more examinations than most professions require. However, there is one exam that is notorious for intimidating medical students and that exam is called the Long Case. You are given one hour with a patient to do whatever you like: you can spend it on taking a history (obtaining their reason for presenting to you) and or spend it on examining them. At the end of the hour, you are given twenty minutes to compile your thoughts and following that comes presenting your findings to two specialists from a different area health service.

So it doesn't so much test knowledge, it tests cognition. Did you compile a hypothesis based on what you heard, saw and felt? Did it all make sense? Is it a consistent, structured presentation? Are you competent in communication?


The good thing for me was that I was interested in presenting long cases and I had heard about it last year anyway. In fact, I presented a few long cases to my patient-doctor tutor last year. ML was one of the dozen hand-picked patient-doctor tutors for the second year students at our hospital. Apart from volunteering his knowledge and expertise to students, he was an Infectious Diseases specialist as well as being a phenomenal General Physician. He is a Fellow of the Royal Australasian College of Physicians and the Royal College of Pathologists Australia. He has done a Masters in Clinical Epidemiology. He is an Examiner for the Royal Australasian College of Physicians in the specialties of Cardiology, Neurology, Endocrinology, Infectious Diseases and Nephrology; as far as I know. His endless knowledge, respect of the patient and infinite persistence to help really inspired me. I wanted to show him that not all of his efforts were in vain.

So came third year and it is recommended that we practice performing long cases at least once a week. I was given a patient by the Geriatric registrar and I was ready. So I took my hour to speak to the patient, examine him and come to a conclusion. Instead of the twenty minutes allowed to compile thoughts, I had until the next day because this was just practice. Unfortunately the Geriatrics registrar had his hands tied with new consultations he had to make in the Emergency Department and asked me to postpone my presentation. I didn't want to forget the case and wanted to present it to someone. I paged ML and he was available. Meet me in my office in twenty minutes. I was ecstatic, not because I had something to do, but because I felt I had made a good case to present to this physician; a person I felt I owed something to for all his time, dedication and sacrifice to the patient first, to education second.

When I'm waiting for someone, the beginning feels incredibly slow and then, after a certain point, time just flights right past. I end up finding myself in the other person's presence wondering how long I've been sitting there. ML was in his office, desk full of papers and two textbooks in front of him. Guilt crept in as I realised I was distracting him. Okay, when you're ready.


In my limited experience, the first thing doctors do when you're presenting a case is close their eyes - envision the patient in front of them as if they had seen them first hand. Interrupting medical students during practice was also common, so that the examiners could give feedback in the mock exams. It was good because they were much more comprehensive with their feedback but the downside was, it felt like the presentation cumulatively dropped in quality as more feedback returned. Unfortunately, most feedback is negative. You are not interrupted when you're doing well. Some doctors do provide positive feedback and you have that warm feeling of success, that you made a difference. Eventually you realise that those doctors who give positive feedback to you are giving the same to everyone, making them optimistic and supportive people, which is great - but the gravity of their words drop in reliability. Well, at least that's how I feel. It could mean that I'm satisfying the requirements of a medical student, or it could mean that I have fulfilled his or her expectations; a rarity indeed.

                                      

After an hour with ML, I was almost in tears.

My confidence waned, my bubble of inspiration perforated with the physician's reality - the sting that is the Physician's touch: you've got a long way to go.


You walk out with a smile of embarrassment and they probably return a smile of pity. Composing myself, I left his office after I thanked him.

Keep calm man.. Just keep calm.


"You're a fucking idiot - how could you think that way? You know better! Fucking re-write the presentation and deliver it to the Geriatrics registrar in a palatable fashion. Seriously... You're using statistical probability to determine differential diagnosis. So what the hell was the purpose of taking a history and performing those examinations?"

Just pick up the pieces, put yourself together and move on to that next day. There's no room for grief.