Calm

I'm back living around the corner from the hospital and I'm looking forward to getting back into it. The one thing about being in surgery is that you are considerably distant from your patients compared to the medical teams. Everyone is just coming and going; most of the time people have questions but because surgical teams see them so early in the morning or when their doped up with analgesics, they seldom have a chance to ask any of them.

It's been a very unproductive long weekend, but I'm optimistic. I just sat down and spent an hour summarising some of the research I've been doing outside the assessable material and it's shaping up quite well. My supervisors and I have put in quite a respectable amount of effort and the good news is that it is amounting to something promising - we're not just farting in the wind; hopefully it'll lead us to higher truth that will help medical students throughout their studies and beyond.

Getting back into the momentum of surgery is exciting, however it's sad that I only have a few days left on the ASU team - two weeks was definitely not enough and given the public holidays, it was more like 7 days. I'll probably make time in the evenings to expose myself to surgical patients again, but that will come in time. Next week, I start Colorectal surgery, which has quite a bit to do with Surgical Oncology and I'm expecting it to shake me up some.

For a change, I feel calm. I want to get back into the motions and start again. I want to visit the gym and get back into being fit and healthy. Eating well and sleep adequately. Cutting costs for the moment is crucial as money has become temporarily scarce. But no matter -- for a change, I feel calm.

For a change, I'm smiling and for me, that's very unusual.

Let's hope that it doesn't fade quickly and that optimism drives education forward.

Hope with me.

Taking a Break from a Break

I haven't written in a while and it's because I'm feeling lazy. It's the Easter long weekend and I just can't bring myself to studying anything, despite knowing how ridiculously behind I am in my work. Every year it seriously feels like failure is right around the corner and I just manage to scrape through.

Perhaps I've convinced myself that this is routine and that I'm simply going through the motions of surviving the assessment unit's cunning and horrible multiple choice questions.

Or it could be that I just can't be bothered anymore. Every time I take a break from studying or clinical work I feel guilty - I should be studying because there is always things that need to be learnt, always more patients to see, examine, assess, investigate and manage.

It's all about procrastination and I'm using this long weekend as my procrastination period. I just hope it doesn't follow me into the end of my surgical rotation. It's been following me most places and it's so easy to get distracted with the internet, computers and people in general.

So I am blogging now because I don't want to look at the medical core curriculums that are going to be tested; all four of them... and the surgical core curriculum, that will test most all surgical specialties and some subspecialties.

I am worried.. but right now, not enough to do anything. I can only hope that I don't pay the ultimate price... that would be a cause of a lot of suffering. Too much.

ASU

The Acute Surgical Unit service is not unique to my hospital, however all of its protocols and practices are. The evidence-based surgical approach to the emergency patient requiring surgical intervention is renewed and refined weekly by consultants as well as the senior registrars.

This service is designed to deal with what is known as the acute abdomen - the general surgical emergencies. Broken bones, punctured lungs and central nervous system trauma are of course dealt with by their respective specialties: orthopaedics, thoracic and neurosurgical teams.

Interestingly, one could come to call it the Acute Stupidity Unit, not because the team is retarded or its members idiotic; but because the people that refer patients to us do not seem to understand our role and what we do. It is a well-known fact among the medical and nursing staff that ASU is a general surgical service; not a "call whenever you need something" service.

Albeit helping at anytime would be lovely - it is not practical in the surgical setting and there are patients who are critically ill, requiring intervention quickly at all hours of all days of the week.

So let me explain to you two scenarios I saw yesterday with the ASU Registrar (reg) that puzzled me.

Scenario 1 -- The painful Abdomen


We were in the middle of booking an emergency case in the operating theatre for urgent colonoscopy after the patient's systolic blood pressure dropped to 80 from 130 secondary to a significant PR bleed. We had to identify the source of the bleeding and unfortunately the CT Angiogram was unsuccessful in demonstrating anything useful.

While this was all getting sorted, the ASU reg got paged from the O/G reg.

ASU Reg: ASU Reg


O/G Reg: Yes, hi. This is Gynae reg. One of our consultants saw a patient in his rooms with left iliac fossa pain, which was suspected to be caused by a haemorrhagic ovarian cyst and asked the patient to present to the emergency department. He then contacted me to ask for your assistance.


ASU Reg: So you're saying your patient has known gynaecological pathology that could be causing the acute abdominal pain and you want me to do what exactly?


O/G Reg: We would like you to see the patient. 


ASU Reg: What the fuck for? You're telling me that there is gynaecological pathology in the pelvis that could explain the non-specific peritonitis in the short-term and the localised peritonitis eventually. The pain is in the left iliac fossa, the other common differential for now is diverticulitis and you've told me that the patient has proven gynaecological pathology.

O/G Reg: Yes. So could you go and see her? 


ASU Reg: I can go and see the patient, but there will be no recommendation unless there is a clear-cut cause for abdominal surgery. I really don't see the point of this phone call. I also won't be able to see them until our emergency list is complete. Until then, you are responsible for the patient's resuscitation. I am not accepting care.


Of course all the profanity poured out of his mouth after he slammed the phone down. The Consultant and I heard half of the conversation until he filled us in.

We just got back to organising the emergency procedure for the patient at hand.

Scenario 2 -- The Rib fractures


We just finished the emergency colonoscopy on the patient as described above. The pager screams again, it's 2000hrs and the ASU reg still hasn't had a chance to hand over to the night ASU reg.

ASU Reg: ASU Reg


Emergency Reg: Hi, yes thanks for calling back. We've just had a 77 year old female present after a fall with 2 minimally displaced rib fractures. However, she also has acute pulmonary oedema. We were hoping you could come and see her? 


ASU Reg: I'm sorry I must have misunderstood. Are you saying the patient sustained rib fractures after the fall and also has acute pulmonary oedema?


Emergency Reg: Yes. That's right.


ASU Reg: What is causing the patient's acute pulmonary oedema? 


Emergency Reg: The rib fractures. 


*Silence*


ASU Reg: Okay. Rib fractures do not cause acute pulmonary oedema. The most appropriate option here is to medically correct her pulmonary oedema before reducing the rib fractures. 


Emergency Reg: Yes, but she's in a lot of pain and requires analgesia and I think the best option would be to reduce the fractures first. 


ASU Reg: First of all, the thoracic team would be involved in rib fracture reduction. Secondly, analgesia secondary to rib fractures on a background of acute pulmonary oedema makes absolutely no sense. The case is "acute pulmonary oedema on a background of rib fractures." You have no evidence to suggest that the oedema was the result of a fall because you don't have serial images disseminated in time. 

Emergency Reg: What do you recommend then?


ASU Reg: Well, contact the Cardiology registrar for urgent management and make the patient known to the Thoracic registrar. In the meantime, you might want to check the patient's haematology to assess anaemia for acute bleeding, back that up with haematocrit and perhaps assess renal function so that if you decide give the patient diuretics - you don't destroy her kidneys while doing it. Other then that, you might want to use some common sense. 


*SLAM*

In the operating theatre, the Consultant and I were listening again. Interestingly, we had the help of a Gastroenterologist with the patient we just finished and he also heard the conversation... but chose to ignore it.

The ASU reg and Consultant just exchanged looks, and the nurses were having a good laugh.

Acute Surgical Unit... hmmm.

Heroism

Why is it that we recognise the efforts of people after they have died?

I am thinking of the Australian soldiers who gave their lives fighting a war in foreign land under the impression they were preserving the Australian way of life. And with that thought and those intentions, they gave up quality time with their families, good food, a bed and a roof above their heads. They literally, as we say, dropped everything.


But we do not hear about them. We know they are there and as a populous, we have no idea what their names are or who they are - What are they like? What did they do back at home as men and women in society? Until we realise that all of that is irrelevant because they all have one thing in common: they wear a uniform that represents our freedom, our way of life and our ability to do whatever we like back here, in safety.

Truth be told! We do hear of them... We remember their existence, their sacrifices and acknowledge their families, losses and all those they left behind to serve millions of people they've never met. We hear of them when they are dead. When they are done and dusted.

Let's face it - the only time we are recognised for the efforts we partake in life is when they are significant enough to change everyday living (or not) and also, when we die trying.

Take Albert Einstein for example: a man of unparalleled genius. He proved Isaac Newton wrong with the effects of Gravity. Little did he know this, however. He was pondering the characteristics and properties of light and by proving it to be the fastest travelling 'substance', he disproved Newton's theory of instantaneous influence. Without a history lesson, the truth is, Einstein eventually believed that through uniting forces of Gravity and Electromagnetism, he could understand the forces and their behaviours within the universe. Unfortunately for poor Einstein, another group of physicists were working on the Atomic theory at the same time, making his efforts feeble, despite him dropping everything.

Einstein died trying to prove the unification of the forces of Gravity and EM. Does this make him any less successful than those who introduced Atomic theory? According to the nature of humanity, it does.

Think about this: if we had two people working on a theory with opposite hypotheses as to the outcome of the theory, we could assume naturally that one of them would be incorrect. Let's say both of these people worked vigorously for 10 years to prove their theorem. Eventually, one of them come out as the victor, announced through publications, maybe some media attention and acknowledgements from the relevant communities depending on the breakthrough's significance. But what of the other person?

Both people worked for 10 years, vigorously. Maybe one worked harder than the other; perhaps more efficiently... or it could be that one of them just got lucky with a hunch. The rhetorics can drive you mad, which is how I am feeling now...

People do not get recognised for their compassion, dedication, selflessness and humanitarianism these days. We either have to do something heroic, like saving ten families out of a burning building, or die trying before we are paid tribute for our efforts, whether successful or not.

Lost Soul

As typical as it sounds, I knew I wanted to do medicine since I was a child. People ask the question of "why" all the time and it's easy to pass it off with a simple sentence for the person answering and also for the person asking the question. Chances are the question was not meant to evoke some philosophical response because that would be socially inappropriate. No, what was expected was a short, blunt blurb on why you chose your career that you worked endlessly for in but a few words, because that's all it deserves.

Well, at some point when I was sitting down during my first two years of medical school, I came up with the comprehensive answer as to why I wanted to practice the art of healing through medicine and surgery.

Please let me share it with you:




"Medicine bestows upon thee knowledge and experience to meet the responsibilities that members of the community have bequeathed unto us without ill faith. I shall adopt these responsibilities after the criteria for my competence have been fulfilled to meet the needs of the community to the best of my ability through altruism, devotion and love. The individual patient's illness must, through evidence, be recognised and resolved promptly. The patient is one, but many; to be treated as one and through compassion and care, may be done no harm. Thereby medicine is to be learnt, practiced, refined and taught through methods defined by the university with the intent to serve the community without discrimination."


You see, the above explanation to the question "why medicine" took me a long time to synthesise. As one could fathom, it can take plenty of effort to translate emotion into literature. But the truth is my devotion to the patients and people around me really won't be noticed until I serve everyone I possibly can in what time I have left in this world and I die trying. Because there will never be a stoppage of patients - there will always be people who need help. Either medically, or any other nature of help.

I must help those around me as much as I can, to the best of my ability, until my feet can carry me no more. And if I cannot uphold this simple, yet incredibly significant principle up to the standards of today's society... I must die trying.

RACS Short Course

Blue skies - a nice start to any morning reminding us of the heart-warming weather we regularly miss most days of the week, if not all of them. The hospital was limping along in its journey of healing, morbidity and mortality, guided shrewdly by bureaucracy. Walking into the outpatient's clinic, one could see the endless faces fixated on you. Expression of hope, relief that someone has arrived with the curative potential. It is the neurosurgical registrar and two medical students behind him. Little do the patients know who's who - in their eyes, it is very likely that they see the specialist with two doctors to assist him. Our clothing are all the same with badges pinned somewhere on our shirts, blouses or trousers... not really legible from a distance and too awkward to peer at up close since they are usually pinned next to the crotch or by the breast.

Today, however, is a unique day with an event in the outpatient's clinic after the patients are seen. The Royal Australasian College of Surgeons (RACS) has organised a formative assessment for the general surgical candidates before their actual examination - something of a rehearsal before the play. This process involves as much theatrics as it does knowledge. The candidates are from different hospitals with different backgrounds, highly variable exposure with the common potential to heal with steel tested vigorously by the College.

In the afternoon, I was to be a volunteer to help with this nerve racking event. For the candidates, the hospital organised patients with known surgical problems to come in and discuss their issues and problems, guided by an examiner who is a subspecialist in General Surgery. My role was to greet the patients, offer them refreshments and take them over to their designated rooms until the candidates arrived for examination. That got rather busy and eventually the candidates arrived. A few of the patients were actually inpatients with real-time issues and it was so selfless of them to come and volunteer their time to assist these candidates with their examinations. I wished we could offer them more than sandwiches and cheap coffee.

The consultants arrived and I offered them refreshments and showed them to their rooms, where they would be the examiners and so they could meet the patients they would be presenting.

The main consultant running the show, Dr. HN is a General Surgeon in the true sense - a surgeon that has not subspecialised in anything, but rather can operate on any part of the human body except for the central nervous system and the heart; perhaps orthopaedics have a better grasp on the bones as well. She told me to get as much out of the experience as I could, seeing as though I was the only medical student to volunteer.

Take your medical student badge off - let them assume the worst. You can be a formal observer and as far as they are concerned, you're from the College of Surgeons.


That was very exciting - I was to be treated as a colleague, not a subordinate. It was exciting because I could watch some of them in the examination setting and apply what little knowledge I had, while they thought I knew much more than they. Of course, I was an observer - I could not speak or do anything other than watch, which was a privilege in its own right.

Aside from writing everything I saw, I just wish to point out how important to most basic clinical skills are to medicine - not the extensive knowledge of Bailey & Love's Short Practice of Surgery. How much  we take for granted, such as introducing ourselves and asking for permission. How important our posture and body language is to patients, what it might portray and how different that may be from our intention. How incredibly important our responses are to patients when they answer questions...

Many of the candidates, according to Dr. HN, were far from ready for the formal examinations in three week's time. True, the nervousness, anxiety and ultimate fear of uttering "I don't know" would be disabling in any examination, but in my eyes surgeons are to be those people who can respond quickly and effectively under pressure. Yes, general surgeons need to have a vast amount of knowledge on many regions of the body, many surgical techniques and their principles; so it may be reasonable to think that they could forget the basics after reading the complexity behind the most common operations.

Yet, some of these candidates were far from ready to become consultants. They couldn't "consult" the examiners! Interestingly the College of Surgeons allows candidates to decide when they are ready to sit the test. So submitting an application to be examined really means that you have read enough, seen enough and done enough to declare yourself as ready to be tried by the panel of who one considers peers.

The successful registrar may submit their application to sit the final examinations, but they must never forget that one can never see enough, one can never be exposed to enough medicine or surgery to be completely sound in any specialty. Every patient is a new challenge and doctors must meet their unique needs, address their personal, social and professional issues, while offering them medical or surgical therapy that is known to work on the general population satisfactorily based on valid scientific evidence and sound clinical judgement.

Fellow Students

I started the day off with the Neurosurgery team - the first surgical team I've met that starts at 0800, rather than 0700. It's now evening and I haven't worked out why they start at 0800, seeing as though their theatre list starts at 0800 and they have patients to review from the days before. Interesting.

Another medical student bumped into me - she's from Hong Kong. She stopped paying attention to me when I told her I was a medical student as well. My shirt and tie must have convinced her that I was a registrar or something and I hate how being well presented is synonymous with higher rank. People think there is glory in medicine, in surgery... truth be told, there is glory only in your ego if this is how you feel. There is a satisfaction from helping another human being and that is the result of good knowledge, plenty of experience and inflicting pain on hundreds of people in the form of mistakes. There is no glory in this journey - only the fact that we will be covered in blood, urine, shit, pus, or any other bodily fluid one could imagine and if we're really lucky - maybe we'll be covered with all of those fluids at the same time.

So the student and I were discussing a spinal CT scan of a patient who presented with sudden back pain after a fall to the ground associated also with motor deficit of both lower limbs. The axial images were of the thoraco-lumbar region and one could see anterior to the spine, the abdominal viscera. This student from Hong Kong in her final year thought that some calcification within the liver were in fact gallstones in the gallbladder, even though the anatomical locality was completely inconsistent. So I told her I thought it could be calcification of the intrahepatic ducts, or perhaps calcified vessels, which could not be tracked on a non-contrast CT scan. She didn't respond. I decided not to tell her my background in medical imaging and the associated knowledge in cross-sectional anatomy.

Well I finished my finals, so I should know anatomy by now. I paused and thought I'd brush her up with some questions. She got some basics right and I thought it might be patronising to ask about the gross anatomy. Then I asked her about the muscle attachments of the diaphragm to the abdominal wall and the spinal insertions. She knew the muscle names - the right and left crus.

Yes, the crura are important for the insertion of the diaphragm to the posterior abdominal wall. At some point, the crura are divided and structures pass through the chest into the abdomen. What passes between them?


She thought that this was a no-brainer and decided that all the arteries, nerves, veins, vessels and anything coming from the chest would be going through this opening. I smiled and told her that there were three openings, all corresponding to different topographical locations in the mid-sagittal plane as well as different spinal levels, depending on their function and relationship to the peritoneum. She looked at me funny.

I explained the names, levels and the structures passing through the openings - she looked at me blankly and said: You really know your anatomy. The issue that I had with that comment was that this medical student, not 5 minutes before me asking her anatomy questions, was telling me how she opted to do head and neck surgery.

Now if anyone has ever been exposed to any form of head and neck surgery, they can easily tell you the complexity of the anatomy and that an approach to formal dissection of any structure in the head and neck, requires sound anatomical and physiological knowledge as well as the associated embryology with each structure.

Interestingly, head and neck surgery is a subspecialty in general surgery, which is a specialty in its own right. How is the genius medical student who has finished all of her exams really going to consider applying for any general surgical position before knowing any form of anatomy of the abdominal cavity?

This leads me to really say that medical students are in fact, book smart. They are brilliant with their notes, books and summaries - excellent in study groups, on their own in the library and discussing any topic over coffee. What we're not good at is sitting down with patients and really understanding their view, how they feel, what their symptoms are and how to examine them.

The neurosurgical resident and I were discussing surgery and he told me a short story about a Vascular surgeon that he was assigned to during his student years.

"The essential knowledge is not technical expertise or retraction, but it is in fact the ability for you to manage the patients pre-operatively and post-operatively. I can take a fucking monkey with me to theatre so they can adjust the light, retract the tissue and suck blood out of a wound. Surgical expertise is gained through practice, which comes with time. Human anatomy never changes; human physiology never changes. Pathology does not change. We need to understand these important fundamental topics before we learn the technical expertise of surgery and its implementation. We need to manage the patients after their operations - that is the ultimate challenge."

A Moment's Silence

Japan has endured much punishment from mother nature this year. Despite the fact that I do not follow the news regularly, I get some glimpses of the gravity of their situation. I feel for every Japanese person - a country full of culture, history and amazing people.

I have been fascinated with the Japanese culture since high school and have wanted to go there since. It is on the top of my list of places to travel, though I doubt travelling will happen anytime soon due to the disaster status of Japan and also my professional and academic commitments here.

One thing I wanted to get involved in since starting medical school was Medicines Sans Frontieres - Doctors Without Borders. In my first year, they held a meeting out in the city for medical students to spark interest and after about thirty minutes of their talks, I developed doubts about them. What made MSF unique was their political disposition; they would not intervene with support and reinforcement until politicians or parties in the crisis area would comply with their demands. I understand that to an extent: they need to ensure their people are safe and out of harm's way, though I don't think that can be guaranteed in conflict areas.

But I digress - this post is about Japan and recognising that they are truly suffering. Being one of the hardest working races in history, I'm confident that they will bounce back in due time. Until then, my heart goes out to all those affected by the disaster.

Welcome to Ophthalmology

I started my new rotation in Ophthalmology this week and it will only be going until Friday and then it's back to the main departments of surgery. It was refreshing being in another hospital for this rotation; the hospital I am assigned doesn't have an Ophthalmology department and that did frustrate me until I started.

Equipment was plentiful in this clinic - abundant with technology and more than a simple variety of tools for many complex assessments of the eye. It was bewildering to see that such a tiny organ be so very complicated to assess. Truth be told - it is beyond complex.

The clinic was huge and it didn't take long for the waiting room to fill with patients. This waiting room was particularly unique; it easily seated fifty people and every time I walked out of a consulting room, everyone was fixated on you. It was very uncomfortable.

I was one of three students starting today for a week. Not being a fan of one of the students there made me feel awkward before we started. Luckily we were split into different groups and the embarrassment was only temporary. I know that sounds arrogant, but there are some people you just know rub off on you and when you're standing beside them on one end of the room while the consultant is on the other, that room suddenly gets small, stuffy and I'm suffocating really quickly, first of embarrassment, then of humiliation.

Dr. SF took me under her wing and she was unique. My colleagues had the pleasure of attending with registrars - I was with the Staff Specialist. Some things were meant to happen. She was very polite to her patients and taught me consistently with each patient. There was such a variety of people coming in to see the doctors, orthoptists, optometrists and nurses for evaluation. It came as quite a surprise - I didn't appreciate the gravity of how common eye disease really was until this morning.

After spending the morning seeing patients, it was off to theatre. We only saw about ten patients and there were so many more waiting outside. One of the nurses was telling me about how common it was for patients to wait 3-4 hours easily to see one of the doctors and abuse the other staff about waiting times. We are constantly reminded of our inadequacies - even if they are beyond our control as medical staff.

I watched a cataract extraction and insertion of a synthetic lens - a very common procedure. There were only four booked in the afternoon and I decided that I would give myself an early mark. I spoke to Dr. SF and she was happy for me to go, which was pleasant. Coming home during daylight hours is definitely a luxury for most of us.

Driving home was a hassle but it gives me a good amount of time to reflect on some of the things that I saw today. The good thing was that I decided to catch the train in from my parents' place this week so that I can spend more time with them. That should be good and the distractions plentiful!

Something did hit me on my way home: I spent the whole day with Ophthalmologists. These are people who have all studied relentlessly through undergraduate and or postgraduate medicine, honours or masters and definitely a PhD. It didn't actually click for me how unbelievably smart these people were when I was walking with them the whole time today. What a privilege it is to be in their company. I was happy that I didn't feel the intimidation of being in their presence on my first day, though I'm sure my nervousness was obvious.

As a society, we decided that our vision is in fact the most important sense above all others. Of course, such a valuable organ, a crucial component of everyday living, should clearly be looked after by the most precise of surgeons; the most dedicated. I can only hope that this is the rationale behind the justification behind endless research, competition and cut-throat medicine in Ophthalmology.

In my eyes, all organs are important. We are a whole and God willing, one day we can all treat our patients that way.

Feedback

Today was my last day on the Upper Gastrointestinal Surgery team. It was a short rotation of only a fortnight and most days I felt that I was a shadow behind the registrar and interns. After a few days of pestering the registrar about filling out the forms for my assessment, he finally agreed to stick around and do them with me.

I was asked to perform an abdominal examination on a patient with marked clinical signs. I don't usually have trouble with clinical examinations, though things changed quite quickly when I had the surgical registrar watching me. It only took a few moments before he started asking me questions about what I would do and what they meant. Soon, I just started fumbling everything, making mistakes and answering in the form of questions, almost to clarify my own answer. He reassured me that he wasn't trying to intimidate me, but I suppose intimidation comes with it.

We walked outside and spoke about some of my clinical examination techniques and I confessed that I hadn't done a single abdominal examination in the surgical rotation thus far. He was upset about that and asked me why I hadn't practiced on the patients under his care. My response was that I was preoccupied with other tasks. Eventually I realised, after a long stare, that it was my commitment and my responsibility to practice during my time on his team. Fail.

He then gave me some feedback on the term altogether.

"Some doctors have the ability to walk into a room and establish a rapport with patients. Trust and commitment. Dissipate concerns quickly. This is your goal. This is my goal."


I took a while to take that in. My communication wasn't very good and that required improving, however this would take me a very long time to change.

"It's not your behaviour that needs to change for this to happen. You have to change as a person before you can communicate more effectively with your team members and also your patients."


This was hurtful and he realised that, but he had a point. A good point.

"Every single examination a medical student, intern, resident and registrar endures has flaws. All of the examinations have some element of technique that can be learnt without grasping the content or knowledge that is being tested. Except one test."


He paused for a while. I was pondering about the Viva Voce examinations, but quickly decided one could easily fly through that one as well.

The answer wasn't that obvious, but when it was expressed as it was, it became clear as day.

"The only test a medical student and doctor has to pass; the only one that ultimately matters is the one that has the patient as your examiner. When you are lined up against a bunch of your colleagues and a patient chooses you to take care of them. That test, is flaw free."


What a profound thought.

I wondered then what patients thought of me. How did I behave toward them? Did I make them comfortable? All the things I have practiced myself with patients - did they feel taken care of? Was the courtesy obvious?

My thoughts were replaced with doubt. Soon... I was drowning in it.