Monday, January 23, 2012

Volatile

I have been in the operating theatres for six of the last ten working days. In those six days, I have assisted in twenty eight operations. Some of those procedures were the straightforward, common procedures such as thyroidectomy and laparoscopic cholecystectomy; but others were on a much larger, life-altering scale. There's no such thing as a small operation, says the chief resident. What he means is there is routine surgery that's common, but all of them can potentially be life-altering and lethal.

The days have been long; it's definitely no holiday, as many people in the years above me mentioned the elective term to be. Colleagues spoke about having long weekends, half days and other luxuries. I don't quite know what they were doing on their elective, but it could not have been very productive for them. Thirteen hours a day on average with no break for food, water, bathroom or anything. Back to back, nonstop surgery. When I was not in theatre I was in the Burns unit organising admissions, changing dressings, drawing blood and sampling fluid from surgical drains. And I still can't get over the fact that general surgeons look after burns victims.

Due to the shortage of doctors, nurses have began adopting certain clinical responsibilities of medical practitioners, such as dressing wounds. So when I turned up knocking on the door of the hospital saying "I'm ready to work," they were very happy to have help. But I'm no cavalry. However, they were happy to assume that I was and appointed me responsible of the Burns unit on the non-operating days.

I was not prepared to work in a Burns unit at all. My mother told me stories of the horrific burns she had seen when I was young; and the thoughts were enough to knot my intestines enough to ignore food for a couple of days.

It was also discouraging to be conscious of my complete lack of knowledge in the management of burns. But I was and am not in any position to argue with anyone in such a system. I have been asked to serve a population of patients and it's not in my nature to discriminate, even if my stomach is jumping around like a five year old on a trampoline.

There was a stench of bandages, creams and flesh in the air. The chief resident introduced me as "the new doctor on the team" to the nurses working in the Burns unit. They had infinitely more knowledge and experience than I did; so I don't know why he felt the need to gently hint that they'd be following my lead. The nurses wore turquoise coloured scrubs that had Intensive Care stitched on the breast pocket.

After the general surgery team left to continue rounds on the other wards, there was an awkward silence at the reception desk. I broke the tension by clarifying that I would be following their lead, not the other way around. They were quite happy with that, as any nurse would be. "Okay then, wear your mask, gown and glove up."

There were ten patients on the ward and another patient in the Paediatric Intensive Care unit that required dressing changes. I followed the senior nurse into the first patient's room. He was young, and lay in a semi-upright position with his hands thickly wrapped with bandages, resting on two large pillows on each side. She showed me how to take the old dressings off slowly, so not to lift the delicate remnants of dermis and tissue along with the ointment-smothered gauze. She then proceeded to open a scalpel blade and started to remove raised, necrotic skin from the surface of the first patient, who couldn't talk. My body went numb as I watched her slice skin off the young man's arms, chest and face. I asked the patient if he felt pain with the removal of tissue and felt a little more at ease when he said no. The nurse explained that areas of full thickness burns could not perceive pain. The sensory nerve endings were obliterated.

Another nurse created a sterile field for us and opened up a few heavy sponges, saturating them with chlorhexidine. The senior nurse asked me to rub the sponges together so to create a lather and we used this to clean the patient's skin by dabbing gently. This was to prevent infection from accessing the living flesh under the eschar (i.e. dead tissue forming a scab or dry leathery surface replacing healthy skin). He sniffled in pain as he felt the sting of alcohol on exposed skin. He couldn't cry or talk because of the tracheostomy our senior colleagues provided when he came in.

Up until that point, I was oblivious as to why the patient's arms were positioned the way they were. My lack of knowledge was really frustrating me and I promised to devote a few hours of my weekend reading about burns. When the senior nurse asked me to turn his arms so that his palms were facing up, it was clear what he was hiding - the skin on his forearms and elbows were completely divided along a longitudinal incision and the underlying muscle tendons and ligaments completely exposed. When full thickness burns are circumferential, the surgeons divide the skin along these lines to prevent irreversible ischaemia to the distal peripheries. I almost passed out. Knowing the patient was conscious and awake, able to see his own underlying flesh and flinch in agony as I dabbed his muscle layers and fascia brought tears to my eyes. But for his sake, I had to put my emotions aside and focus on getting him clean as soon as possible so he could rest.

We dried his skin with clean sponges and covered all the burned flesh with cream and ointment, depending on the depth and tissue layers exposed. After that we literally draped him with gauze and the junior nurses bandaged him up.

"Was that alright?" asked the senior nurse as we got out of our gowns.

"It was fine," I lied.

"Okay then. Wash your hands and do the same with the remaining patients."

Four hours of wound dressing was emotionally exhausting. The majority of the patients were not passed their thirties and a tragic proportion of them were children.

It was awful. I felt so guilty for wanting to ignore these people out of fear of being squeamish. They needed help so very much. And I didn't realise how complex their management really was.

There's so much to learn and I do feel I owe these people a debt of volumes of study and attention. They need so much help, support and depend on us not only to survive the massive acute pathophysiological changes, but also to mobilise and return back to normal living, whatever that may be to someone who is cosmetically destroyed. The psychosocial support is the fundamental component of ensuring these people can develop hope again; and I pray that their loved ones still see the same person before them when they are released with the unspeakable reminders of survival nobody would ever want to bear.

Sunday, January 22, 2012

[General] Surgery

What does it mean to be a general surgeon? In my eyes it has always been a surgeon capable of many operations involving a wide range of organ systems. "The jack of all trades, master of none" really described their work to me. However, the metropolitan hospitals in Australia had compartmentalised the specialty. It was broken down to subspecialties including head and neck, upper GI (gastrointestinal), breast, endocrine, hepatobiliary, colorectal, surgical oncology, trauma, transplantation. During their training, registrars were exposed to most if not all of these disciplines after which they could decide the range of operations they would practice for the duration of their careers. The very essence of the word 'general' was lost in a knowledge storm; an influx of knowledge impossible to keep up with.

So then, was it possible to practice as a generalist in the true sense? I asked myself repetitively. Could there be a way one could still be capable of performing a wide range of operations competently? Safely? Apparently it was still possible but limited to the rural and remote areas of the country; where thousands of people were begging for medical attention. Unfortunately the majority of doctors have consolidated into the major cities of most developed countries, leaving developing countries and country-towns up to the loyal locals... the people with the moral fibre and courage to fight against the odds.

Given my elective term is in general surgery at a metropolitan hospital in the capital of Turkey, I expected the same compartmentalisation. It could not be possible to perform a wide range of operations on such a large population. The consultants must share the workload based on the disciplines, I thought.

When I started, it was quite the opposite. The general surgical department's medical staff were divided into four groups of consultants, residents, interns and medical students irrespective of the subspecialties. Of course, certain surgeons performed more types of the same operation than others and vice versa. There were no subspecialties.

The operating list on my first day in theatre included:

  1. Laparoscopic cholecystectomy, indication: cholelithiasis
  2. Laparoscopic Nissen fundoplication, indication: gastro-oesophageal reflux disease non-responsive to conservative therapy
  3. Abdomino-perineal resection, indication: T3N2Mx ano-rectal carcinoma 
  4. Total thyroidectomy and right lateral neck dissection, indication: papillary thyroid cancer and lymph node metastasis 
  5. Exploratory laparotomy and Hartmann's procedure, indication: large bowel obstruction on a background of abdomino-perineal resection for T2N2M3 ano-rectal carcinoma
I couldn't believe my eyes. After scrubbing into all of those operations on my very first day, it was clear to me: it's possible to be a 'general' surgeon. 

Hope is kindled. 

Saturday, January 7, 2012

Experience vs Knowledge

We are all familiar with the eternal battle between the young and the old, the smart and the wise. In most cultures, whether or not elders have any form of education is irrelevant; what matters is they have lived, understood and gained perspective. Modern history, as we all know, is dynamic and ever-changing. Context varies from person to person, profession to profession, country to country. Two identical events happening 50 years apart have unique effects on populations, even if history repeats itself from time to time.

This morning my uncle and I took my aunt to work. The sun was barely in the sky and blankets of ice coated the sidewalk. Mum couldn't get her usual amount of rest because she's been coughing for a few days. My aunt was telling my uncle to start her on an antibiotic, despite having no formal medical education. I was in the back seat and even though my knowledge was readily available (there is no on-off switch), neither of them felt the need to ask me anything. They were more comfortable doing what they have been doing. I understood what this meant; how knowledgable I might have been was not relevant and the explanation for this was quite simple: I'm Generation Y.

I decided to respectfully protest my aunt's decision to give my mother antibiotics, explaining the concept of antibiotic resistance (mum has been on antibiotics for about a month now). She fell silent and quickly responded but it works for me, whenever I feel sick I just take a couple of tablets and I'm all better the following morning.

Despite this being against any antibiotic protocol written, I nodded politely and gently mentioned that the entire course must always be taken. She agreed, but insisted that she would feel better after the first dose.

One of my English teachers in high school taught me an interesting proverb: Experience is a hard teacher for she gives the test first and the lesson afterward. This must be the concept of Generation X to overcome the knowledge-tsunami Generation Y are exposed to.

She seemed hell-bent on feeding her those antibiotics and I know she only means to help mum. But educating a person in the previous generation is rude, disrespectful. So I sat quietly and thought about the variation in hepatic and renal metabolism of medications between people, the perception of side effects and the risk of pseudomembranous colitis due to recurrent antibiotic exposure.

Of course I cannot talk about any of this. I'm a stupid, silly little medical student who has next to no experience in choosing medications (partially true); so who am I to give advice to people twice my age? Son, we'll just keep doing what we do and in time, we'll get better.


That's the curse of being junior staff; barely anyone takes you seriously.

All in all, Generation X's perception of Generation Y is quite biased and even though some of us are outgoing, risk-taking, technical gurus; not all of us are inappropriate, or have the intention of being condescending. Either way, we've all worked hard to get to where we are, just like Generation X has to get to where they all are.

Until their perception of us change, I'm afraid very little intervention will be effective. And by the time we're old enough to be taken seriously, the next generation will be seeking our attention.

Generation Y by Generation X

Meeting

Being overseas for a couple of weeks now, it was about time I visit the hospital where my elective term will be taking place. I contacted my supervisor yesterday who wanted me to meet the General Surgical fellow (known as a head assistant) this morning. No problem, I thought.


Choosing this hospital was no accident - it's the same hospital my parents met before embarking on their journey to Australia. Dad worked as a perfusionist for a few years before moving to becoming a scrub nurse in Cardiothoracic Surgery for eight years, then moving onto Neurosurgery for four years. Mum graduated from the Faculty of Nursing here and worked in both the Emergency Department and in the Orthopaedic, Traumatology and Reconstructive Surgery operating theatres for ten years. My uncle lives quite close to the hospital and he's been kind enough to put a roof over my head during my stay here.


He explained the route to the hospital and I made my way to there with mum. Despite being sick, she insisted on coming to show me around, but I was sure the hospital had changed from thirty years ago. It was only a few kilometres and took us about half an hour to get there.


The suburb was a complex made up of a few hospitals each with their respective Faculty of Medicine. Walking towards the hospital I was assigned, the sheer number of people running around made it perfectly clear how busy the place was. I was trying to work out which hospital was busier but then it seemed obvious: every hospital is busy. The demand was always out of proportion than the supply. 


My parents adored this hospital and it was the best hospital in the capital during their careers. The corridors and stairs were made of marble with silver railings. What a beautiful sight it was. I felt happy the hospital board felt the need to make patients, friends and family feel welcome in the corridors of the unwell. Everybody spoke formally, people paid attention to each other. 


As I entered the General Surgical Outpatients Clinic (known as a Polyclinic), the atmosphere of chaos was clearly palpable. People were desperately lining up, pushing in and out with the secretaries rushing to phones, talking to staff and trying to answer people's questions. I decided to wait patiently, but everyone kept pushing in and I didn't blame them; it didn't frustrate me. In Australia, it's the opposite: it won't be busy, you present yourself to the front desk and the receptionist expresses her knowledge of your dependence on her job to ensure you see the correct doctor by making you wait while she finishes her game of solitaire. After this first impression, she asks you if she can help you as if you've irritated her, interrupting her from what she really should be doing. For the record: I haven't encountered a male receptionist thus far, so please don't take the "her" and "she" as derogatory or sexist. 


Finally, I was asked to see the receptionist manager on the staff side of the Polyclinic. She took me to the front door of the fellow's office. Doçent Dr. AK was the name of the General Surgical fellow. He was tall, showed little facial expression and had very long arms. "Doçent" is a Turkish word I haven't quite made sense of; it either means "Fellow", or equates to PhD. When I asked my father what it meant, he said the only way I know you receive the title is by performing an operation asked by an assessment committee made of up senior specialists and they watch your technique, ask you questions while you operate and intervene if you are incompetent. Either way, I knew it was a senior title, which didn't help my anxiety. 


He asked me my name, where I studied and what year I was in. When I explained I was in final year, he said:


Here in Turkey, the final year students are in fact Interns. So you will start on Monday with the senior resident. Make sure you buy yourself a white coat. Your assigned resident will give you a pager, locker key and doctor's ID. Do you have any questions for me?


I thought this would be an appropriate time to mention the difference in meaning of the word "Intern" between Turkey and Australia. 


You'll be fine. Oh and you do know how to scrub in right? 


"Yes sir, I do."

Good. You'll be expected to attend everyday. Rounds start at 0730 in the Burns Unit on the third floor. I cannot guarantee your finishing time. There will be operating lists every second day in the elective theatre. I'm very glad you're here, we are need of assistants. 


We walked up to the Burns Unit and I briefly met the senior resident. We exchanged nods and a quick word. After the quick encounter, the fellow and resident left to discuss other matters. I spent the next hour working out where the hell everything was with mum was my guide. I was grateful for her help but her eagerness to explain past times was not reassuring! 


It didn't sink in - on Monday, I was adopting the equivalent position of a Junior Medical Officer (JMO) in Australia, which is another phrase for Intern. I'm not sure if it has sunk in at all. After we left the hospital, I bought myself a white coat. 


I've spent the last couple of days wondering how it's all going to go. It's funny isn't it? In my last entry, I wrote that being in final year doesn't mean I was anywhere near ready and now all of a sudden, I'm expected to be. 


A different type of pressure is also exerting itself on my shoulders. I'm not only a guest to this hospital, I also am a representative of my Medical School back at home. I can only hope I don't look too much like a moron. And I pray I end up spending most of my time in theatre - in that setting, at least I won't have to speak or answer too many questions. If there are questions in theatre, it's almost always anatomy anyway. That sort of reminds me: maybe I should brush up!

Friday, January 6, 2012

New Look

As I look back on the year 2011, I realise how happy it really makes me to know it's last year, not the year ahead. 2012 is today and will be for the remaining days of this year. This makes me happy and I am excited to see what this year holds for all of us.

The first thing I had to do was to change the appearance of my blog because I believe the previous setup was quite bleak (for people reading my posts mobile devices, you won't notice the changes) and I wanted to started the year with a pleasant theme.

A proportion of you would describe my posts as bleak and to some extent, they definitely are. However, elements of realism accompany those posts. I wish to continue writing here, providing insight for you and I, reflecting on the things I have seen; and read my posts from time to time. One can practice medicine for all eternity and still come across a baffling history, examination and investigation result. All colleagues have a different set of experiences to each other and even if there are occasional common grounds, their perspective and interpretation of the events are still unique.

I was reading a book called The Checklist Manifesto, which astoundingly stated "there are more than 2,500 documented surgical procedures in the history of medicine." What is staggering about this is not the number of procedures, but how many variations of each procedure there are, from the pre-operative preparation, incision-site and type, to the post-operative fluid management protocols. This clearly explains the concept of practicing medicine and just because I am a final year medical student, doesn't mean I am 755 of the way of becoming a good, safe and competent doctor.

Like most normal people, I developed a number of resolutions for the coming year, but unlike most people, I didn't write them down or consider them any more than a daydream. However, I will get to that when I arrive at my residence (ironically one of the items on my list is to reduce procrastination as it can never be eliminated).

I wish you all a very happy, healthy and prosperous 2012.