Complications

I'm at the point in time where there is so much work I have to do and I don't know where to start; it's disabling. Like most colleagues in my year, I am afraid of upcoming examinations. The only reassuring advice we exchange between us is don't worry, you know more than you can recall.

This post is actually a story within a story. In Gravity II, I mentioned attending an interesting hernia operation with the ASU consultant, Dr. HL. I have been thinking about something that happened during the laparoscopic repair, though I thought writing it in Gravity II would make it ever so long!

So the insufflation had kicked in and the patient's abdomen was distended to the point where carbon dioxide was seeping out through the laparoscopic incisions. The camera kept getting blurry and it was annoying Dr. HL, even with the new camera. I just stood there, hands folded together in the I'm scrubbed and would love to help position. Everything was going well until Dr. PF walked in from the back of the theatre.

Dr. PF was the hospital's only thoracic surgeon. He was a good teacher and was well known for his short temper with junior staff. It's not every day one consultant walks into the theatre during another consultant's case and it was plain weird because he's come to see the upper GI surgeon.

G'day Dr. HL, what are you doing? Sorry to interrupt. 


Hello Dr. PF, it's a hernia repair. What brings you into the realm of the inguinal canal? Aren't you in the rooms this afternoon?


I got called into a neurosurgical case. There's been a complication. I need your advice.


What's the story? 


There's a 40-year-old lady with metastatic breast cancer diagnosed 12 months ago. She had cervical spine metastasis resulting in a fracture of the C3 vertebral body. They reduced it with hardware 6 months ago. They went in today to replace the hardware and perforated the posterior oesophagus. 


Oh no. What happened?


It's an anterior approach. They called in another consultant to contain the bleeding, but it seems they are worried about oesophageal and laryngeal extension. Now I've had a look and it seems the larynx is intact, but there is definitely a hole in the gullet. We'll need you to have a look at some point. They're still trying to contain the bleeding, so come when you have a chance. 


Sure. I'll be there in about 15 minutes. 

Okay sure. 


What a tragedy. This poor lady. I couldn't stop thinking about her that night. I hadn't met her, and I wish I visited her in theatre, but I didn't think it was professional given the circumstances. It's times like that where we just need to step aside and let senior staff manage the situation.

But I still think about her. I don't know her name, where she is now and what the outcome of the operation was. There was talk about an oesophageal stent, but it's only what was going around. Hopefully I'll run into the consultant and find out what happened.

Then again I'm still thinking about the poor lady with the bowel perforation after the hysterectomy. I've bumped into the upper GI registrar but didn't have the chance to ask him how she was going. I'm accumulating these patients within me.

Tribute

The first time I met Dr. FM was in my first year during the elective summer surgical program. He has a small stature and is very reserved, speaking when he absolutely had to. This was when I realised that English was not his strongpoint. Back in the surgical program, getting my head around the "layers of surgical principles" was a challenge. It still is a major challenge; the only difference is I'm a more competent surgical assistant now (self comparison to when I was in first year).

One afternoon I was eating lunch in the staff cafeteria and it was quiet that particular day. It was early January and many people were vacationing. I was about half-way through my meal when I noticed Dr. FM looking around for somewhere to sit. He noticed me waving and smiled, then joined me. Simply nodding, he started to eat slowly and didn't speak very much at all.

It's not very hard for me to talk myself silly, but I was doing what I could to stop myself. I decided to ask broad questions.

Where are you from? 


Iran. 


So you were trained there? 


Yes. I went to the University of Tehran. 

Are you married?


Yes. My wife is a doctor in Pathology in Tehran. 


Oh so you're out here alone?


Yes. 

Any children?


Not yet. 


He didn't seem to be getting any more comfortable from my attempts to break the ice. Sometimes awkward silences are less awkward than awkward conversations. But it still didn't sit well with me. I wanted to break the ice. This guy looked like a nice person. He was much too polite to be a surgeon.

So was it difficult to get a training position here in Australia?


Very difficult. The requirements are unbelievable. 


I can imagine. My father believes that some of the Australian-trained doctors couldn't pass the exams you've written!


He raised his eyebrows. Where are you from?


Turkey.


And then he started asking questions about my ethnicity and immigration. The ice was finally breaking!

I always struggled to understand why Australia is so strict with accepting overseas applicants.

He obviously didn't know about the catastrophe of the Bundaberg Base Hospital in Queensland and of Dr. Jayant Patel, infamously known as Dr. Death. It is a horrible story and after reading a book about it, I appreciated the gravity of what had happened and why overseas doctors were scrutinised heavily and examined extensively before admission.

I spent the next ten minutes explaining some of the things Dr. Patel had done to patients.

After a few minutes of absolute silence, he said I can understand why now. It wasn't such a bad conversation after all and I was happy to help clarify the reasons behind the strict admissions process. It should've always been so stringent.

Lunchtime was finally over and I was off to theatres.

Fastforwarding to second year medicine, like in first year, we were only at the hospital one day a week. What I soon found out through gossip was the work of Dr. FM. At the time he was the Upper Gastrointestinal Registrar (General Surgical rotations are 6-monthly) and given that one of our Professors of Surgery was an Upper GI surgeon, Dr. FM was under very close observation.

Rumour grew that the Professor and other consultants allowed Dr. FM to operate unsupervised. Apparently the scrub nurses noticed that his techniques were very unique and not practiced by the Professor or other consultants.

One of the nurses then told me his background:

After Dr. FM finished a morning list in theatres, the rostered scrub nurse approached him while he was writing up the peri-operative notes.

I'm sorry to interrupt you Dr. FM, but I just had a burning question.


Yes?


Well the nursing staff have noticed that you operate unsupervised and that your techniques are very different from those used by the consultants. Could you shed some light on this?


Everyone had obviously been eager to hear his answer. He was shocked and cornered. Silence.

Yes, I do have different techniques to the other doctors and they have been letting me operate unsupervised. I was a Specialist in Transplantation Surgery, so I finished all my general surgical training before my fellowship years in Iran. 


The response was silence. Nobody knew what to say.

This guy had been operating as a 'surgical registrar' for 2 years and not once did he openly declare himself as a specialist. Never was he rude to staff or arrogant. He held the patient's hand, never made people wait and his phone was always on. He apologised readily when appropriate and was always happy to teach medical students.

I remember when I was in Colorectal Surgery this year. We were on rounds and he was the Registrar for one week when the other Registrars were at a national conference in Adelaide. After seeing the second patient on rounds, he asked us (i.e. resident, intern and medical students) what we knew about enterocutaneous fistula. All of us looked at each other and shrugged. We continued rounds and after seeing the last patient, Dr. FM took us to a room and said let's talk about fistula. He was kind enough to discuss the theories, principles and management of surgical fistula for 90 minutes; something no other Registrar did.

The Riddler

So this is a tribute to one Dr. FM. The man who kept to himself, never declared his brilliance and is always there for the patients, medical students and staff. The one guy who is an example to all Surgical Registrars... a reminder that humility, modesty, courtesy and respect are not lost. They live on in surgeons. He carries a flame that must spread and I hope one day, I can follow in his footsteps.

If it looks like a Duck and walks like a Duck...

My friend told me a joke recently and I wanted to share it with you.

A Physician, Pathologist and Surgeon go hunting in a park. This park is special because only a particular type of duck can be hunted; the other birds and animals cannot be. Of course one needed to know what this duck looked like and its characteristics. They take the hunting in turns.

The Physician clutches his shotgun and walks forward. He hears some birds take off in the distance and there's one in particular that looks like the duck. He cocks and aims, follows and follows, but doesn't shoot. It looked like the duck, but the characteristics of its feathers and beak appeared unusual and so I was reluctant.

The Pathologist was next. Again a bunch of birds took off and she drew her gaze toward one and followed it with her rifle. I could definitely shoot it, but it's features look somewhat different to what I had in mind. Then again I've never seen one fly so freely. The only way I could ever shoot it is if I knew that it was actually the duck and I don't. 


Finally, it was the Surgeon's turn. He cocked his rifle and looked around. He heard some chirping and another bunch of birds took off to fly. He aimed carefully and followed one in particular, which didn't look much like the duck, according to the Physician and Pathologist. Then he shot it down.

After a period of silence, the Surgeon looked over at the Pathologist and said: Hey.. Go and have a look at that. See what you find and let me know. We'll go from there.


Typical.

Gravity II

I just finished my first cup of instant coffee in three weeks. I cannot describe how much I enjoyed it. Ramazan has really shown me how important the small luxuries and comforts really are. Last week was pretty insane for me because I had lecture day on Monday, then evening shift that night. I was on call for Tuesday afternoon, then on Wednesday afternoon. This was for the labour ward and it was good. But sleep and normal daily living went out the window.

On Wednesday evening, after assisting the Midwives with two births and breaking my fast with hospital food, I decided along with my colleague, that it was time to go home and study. It is clear that sometimes when we are not useful and also when we're not learning anything, it might be more important to just find a room filled with books and spend hours reading one after another.

So my friend and I left to go back to the accommodation. I was ready to pass out. From the looks of poor G, so was he. Walking home required us to walk past the Operating Theatre entrance. I thought I would just see if there is anything going on in there, but G was smarter than me... he left without stopping.

I asked the reception RN if there was anything on right now.

.....

There's an emergency laparotomy going on. It will be starting in about 15 minutes. Right at that point, the ASU Registrar came out... Dr. FM; one of the most amazing surgeons. I will have to write about him in another entry.

Hi Dr. FM. I heard there's an emergency laparotomy. Can I be of assistance?


Yes. We're down a registrar. Evening handover doesn't start until 1900 and the junior registrar has to see the consultations in emergency. Come and scrub in with me until the consultant arrives.


Sure. I'll go and get changed.


How could I say no? At least I wasn't hungry. I could survive another few hours.

I arrived in OT6 just in time for the patient to go under General Anaesthesia. Dr. FM was looking through the CT scan done in the emergency department.

This patient is a 47-year-old female who presents with abdominal pain, vomiting and offensive vaginal discharge for the past 24 hours. She was discharged from the Gynaecology ward 8 days ago after undergoing Laparoscopic Vaginally Assisted Hysterectomy. On examination she is pyrexic and tachycardic. Full blood count demonstrates leukocytosis of 26,000. This CT scan demonstrates small bowel distension as well as free air under the diaphragm. We are concerned about a small bowel perforation. 


Shit.


It gets worse. Her appendix ruptured at the age of 8 and she developed multiple abdominal adhesions. This probably compounded the risk of perforation. It's going to be a difficult operation. Let's scrub.


Okay I know I'm doing my O&G term and I thought I would deviate into General Surgery for the night.. and I ended up back in Gynaecology land. Well almost. It made me giggle. Lucky I was wearing a mask.

The senior Registrar on the evening shift arrived. Dr. PB was furious - he was also scheduled to be the on-call Neurosurgical Registrar. That baffled me somewhat and then I realised Dr. FM was equally baffled. After a brief introduction, he was dissecting along with Dr. FM while I retracted.

Nothing could be heard in the theatre once we reached the peritoneum. The room stank of faecal matter and our gloves were covered with it. The small bowel was distended to the point of looking obstructed, but it was actually the reaction to sepsis secondary to perforation. There were serosal tears, multiple perforations 3-4 mm apart in the ileum and patches of pus all over the small bowel. The offensive vaginal discharge could now be explained: it was an entero-vaginal fistula.

Dr. FK arrived - the rostered ASU Consultant for the evening. He relieved Dr. FM, who was actually doing Breast & Endocrine this term but scrubbed in as the most senior Registrar. He quickly identified the ileum involved and decided that the only option in this poor lady's situation was small bowel resection & stoma. 8 litres of saline later, the poor patient's abdominal cavity appeared clean. The stoma location was not ideal as it was adjacent to the laparoscopic port scars, which hadn't healed. The laparotomy wound had to be partially closed with a negative pressure dressing; requiring revision every 2 days. All in all, it was a shocker of a case and the patient now needed HDU admission.

Retracting and suction for hours on end can be exhausting. It was now 2230 and Dr. PB was happy for me to leave.

I got dressed and I thought in order to catch up with my sleep patterns, I would take Thursday and Friday off. Thursday was not too bad and I got some work done. Friday I caught up with one of my friends and had a meeting with my research supervisor. I didn't get very much done.

The weekend was really busy with work. Who knew catching up with family was so time consuming? Not that I'm complaining. It's just not helping my stress levels.

So back to today. I left for my hospital from my parent's place and didn't get in until 0900, but the other two students had already reserved time with the OT, where I'm scheduled this week. So it was time for me to finish my ethics essay on Elective Cesaerean Section. Back to the hospital I went for the NICU tutorial in the late afternoon. That didn't happen, so I thought I would go back home to do some work and cook dinner (normally I have canned soup).

But wait... there's more!

I decided to go to OT reception to check the theatre list for O&G tomorrow. I'm scheduled with the Uro-Gynaecologists in the morning, which should be interesting.

The reception RN recognised me from last week. ASU's operating now in OT6 again. Urgent case, if you're interested. 


Right. Do they need help?


Not sure. Give them a buzz.


Okay.


*Rings Theatre 6*

Hello theatre 6. 


Hi. Medical student here. Does the ASU team need assistance?


Well there's only the Consultant here. I'm sure he wouldn't mind your help. I'll just ask him...... Yep. It's fine. Come on in.


Thanks. Now I have no choice.

Dr. HL is the ASU Consultant today. We've seen each other around, but never worked together. He didn't interact much at all other than to introduce me to the case. But most of that I got out of the patient's files.

70-year-old female transferred from BMD Hospital with abdominal pain. CT scan demonstrates an obstructed indirect inguinal hernia. I will be repairing it Laparoscopically.

So I started scrubbing and then the ASU Registrar showed up. At that point I knew I wasn't going to be needed in there, but I scrubbed anyway. As the third wheel, I stood there and watched the screen while the surgeons operated Laparoscopically. The interesting thing was that there were two hernias! The first was the one demonstrated on the CT and the second was a direct inguinal hernia containing what appeared to be a lipoma attached to mesentery. It was interesting to watch how it was repaired with mesh.. both at the same time with a technique known as peritoneal stripping with post-reduction mesh and closure with PDS. I asked to be excused just as the suturing began because I had done nothing the whole time. They were happy to let me go and I was happier to leave.

It was now 1700 and I could break my fast in 40 minutes. As I left the change room, I ran into Dr. HC, one of my friends and a Resident applying for Basic Physician's Training next year. He asked to catch up so I walked him to the Doctor's common room. I saw a few Interns and Residents I met over the year; they were wondering what I was doing on hospital grounds after 1600. Funny if you ask me. At that point, all their pagers went off at the same time: MET Call - Paediatric Ward. We dropped everything and ran, all six of us. We bumped into the ICU Consultant on our way there. At least now we had a leader. Thank God! The room was already packed when we arrived. The ICU Consultant took over care and relieved the six of us.

As we left, I promised Dr. HC that we would catch up again soon and made my way toward the exit. Until... I ran into Dr. BM, the senior Registrar in Geriatrics.

Hey mate how are you?

Good thanks, Dr. BM. How are you? 

Well thanks. I've been asked to speak to a patient's family about end-of-life decisions. Care to join? 


Of course. 


Okay. This is an 89-year-old lady who came in with malaena and a Hb of 61. They transfused her in ED with 3 units of packed cells and went ahead with a CT of the Chest, Abdomen and Pelvis. There appeared to be a deep-seated duodenal ulcer explaining the malena. However, there was also goitre with retrosternal extension, hepatomegaly with multiple lesions enhancing on arterial phase, a soft gallbladder mass and also an irregular lesion in the lower lobe of the right lung. The prognosis is poor. The Gastroenterologists scoped her last night and confirmed the ulcer, injected adrenaline several times but could not reach the base. So the family needs to be informed of what happened last night and also about the CT scan results. 


Shit.

Yes it is.

The patient's two daughters (of eight children), one grandson (of twenty five grandchildren) were present. We arrived to them crying beside the patient, who was asleep at the time. After 45 minutes of explaining the situation, it was about the right time to discuss the NFR (aka DNR) order. They agreed to NFR with the exception of blood transfusion, fluid replenishment, antibiotics and total parenteral nutrition if need be. So many tears. I wish there was more we could do.

It was finally time to go home and break my fast. It was now 1900.

I might stay back and appear to be over-enthusiastic, even obsessed. Yes, it might be that way at times, but more often than not, I am pulled into situations.

That's not to say I'm complaining. There is nothing more satisfying for me to know that I can be of use to someone, somewhere. Nothing makes me happier knowing that my retracting, suctioning or scribing might just decrease morbidity and mortality.

As Sharp Incisions describes in my favourite post: Sometimes Medical Students have an important part to play among all the chaos, particularly in the Emergency setting.

2 Weeks

I've been sitting here for about half an hour trying to figure out what to write. I came home an hour ago from the hospital after a night-shift and a few hours of studying and being on-call for the Labour Ward after a few short hours of sleep. I am so tired.

Ramazan has knocked me around with sleep and life in general. I haven't been able to study, study or eat properly for two weeks now. I'm not complaining - I'm very happy to have maintained it for this long. It's the first time I'm taking it seriously and it's my own personal challenge to complete the month out of respect to those without the basic necessities.

My weekend was good - I got a chance to see the Med Revue, which is held every year by the Stage 1 students. This year's Revue was fantastic, but I must say it was on par with my year's efforts. It was a great night of laughs and entertainment - I haven't had so much fun since going to Cairns. One of the most important functions of the Revue is to mock the system, make it clear how ridiculous it can be and also shoot some people along the way such as the Dean or some of the academics, particularly one of the Professors of Anatomy.

A part of one scene in the Revue was dedicated to the lecture I gave the first year students! The scene was a patient being seen by one of the doctors, who paged the superhero team to work out what's wrong. The first superhero being Superwoman decided to have a look at the patient with her x-ray goggles and then said Hang on! One view is one view too few!

That was the principle I taught them in my first lecture and I obviously emphasised it enough for them to mention it in the Revue. I thought of it as a friendly message.

But the high tide is approaching. Our exams, assessments are but a few months away and I am far from ready. My lack of sleep and motivation have made preparation quite difficult coupled with a few busy days at work. I haven't had much to do with critical thinking because being paired with a Midwife in the Labour Ward doesn't evoke much conversation about clinical medicine. They are more interested in the women and of course their outcome, which is appropriate and fair. It however gives me the perfect opportunity not to study and just observe and that is something the Professor of Obstetrics emphasised Grasp what's going on around you. It'll make a whole lot more sense to you.

My issue is that I have been leaving the Hospital everyday with this emptiness. I am not as useful as I was back in the Medical and Surgical wards. Those days feel so far away. Add the feeling of not learning anything on a daily basis... I'm putting out my flames with gasoline.

It's time for bedrest after a very long 48 hours.

Myopia II

I'm getting rather frustrated with the way O&G is run at my hospital. The lecturers keep emphasising clinical exposure time and time again since that's where the examination questions are. Yet, there are so many lectures scattered throughout the day that it's almost impossible to do so. It's my third day in NICU and I've only been able to attend one ward round and spent but a few hours with the Residents; the rest of the time we have lectures and tutorials.

A 2nd year medical student approached me recently. He knew my background in Medical Imaging and asked me to deliver a lecture on the topic to his cohort only at our hospital, as it would be impossible for me to go to every other clinical school. I agreed to start with a lecture on Imaging the Brain, the first of which I delivered yesterday. I will deliver it again tomorrow as the year is divided into 2 groups attending clinical days at different times.

I attended a lecture today on Uterine fibroids among other things and was actively thinking about Radiology as well. And I remembered a very peculiar instance of "myopia" that I experienced during my General Practice term.

It was the afternoon of a cold day early last month and we saw a young lady with concerns about irregular periods and heavy bleeding. Without going into all the details, we decided to refer her for Ultrasonography to assess the uterus, adnexa and pelvis.

A few days later, she presented with the results - images and report from the Radiology consultant. The GP discussed the results, which were normal and provided some options for symptomatic relief along with further investigations.

After the consultation had finished, he handed me the report and asked me to read it. Double check it for me will you?

So I did. It's a normal report.

He started laughing and said read the top of it again. I was confused initially and then it sunk in:

Thank you for referring this very attractive uterus for sonographic investigation of her heavy menstrual bleeding and irregular cycles.

He picked up the phone and asked to be put through to the reporting consultant.

I'm going to fax you a report you did a day or so ago on one of my patients. Please read it and call me back when you've finished.

Presumably the radiologist asked what was wrong with the report. Just have a read of it and let me know what you think.

We faxed it across. About 10 minutes later we got a call back from him.

Laughing, he said Shit... I'm sorry about that.

No problems, so long as the findings are correct. The GP shook his head.

You'll be thinking about that one for a while, won't you? And I definitely will be.

Losing sight of the objective can be so easy sometimes...

The Holy Month

This year, I have decided to take Ramazan (aka Ramadan) seriously. In fact the most seriously in my entire life. In the past, I did not understand the gravity behind it and up until last week, that lack of understanding persisted. My parents were never religious, but my mother occasionally asked me to pray for the good of all and for people. To be religious in the Turkish community in any country was in fact a political statement that the current Republic should be overthrown and replaced by an Islamic State. This is my family's view on the situation, though I know now that people can be religious for personal reasons, definitely being completely oblivious to what political they may convey.

But putting political views aside, I decided to take this Holy Month seriously because of an incident last week that taught me the true essence of tribute.

It was about 1900 hours on a Wednesday evening when I got home from hospital, "starving". Luckily I went to the local shops and bought myself some vegetables to steam and a nice piece of steak, which I was going to prepare that night.

After preparing my meal, I sat down with my plate of steak and veggies to watch the news as I do when I eat dinner. All was well until the reporter talked about the Famine in Sudan. Thousands of people left without food, clean water and walking days on end to receive aid from Charity. It was absolutely awful. There I was, sitting there eating my steak and vegetables, watching these poor people walk, collapse and die from malnutrition and dehydration.

I felt sick. I wished I could do something there and then for them. But in my current state of play, I knew there wasn't much at all I could do for these poor people.

It occurred to me that Ramazan was the best tribute to these people. My personal choice and spiritual message to them and to those around me that there are people out there in the world that I've never met and might not ever meet, who lived days and weeks without food, drink and the basics of life.

To fast means to wake up in the early hours of the morning and to eat breakfast and drink water, to pray for those without the basics and to halt food and water intake for anywhere between 12-16 hours, depending on the Lunar Calendar this year.

I am going to do every day of the 28 days. I am going to pay respect and tribute to these poor people around the world, some living here in this beautiful country that I call home.

I will remember how amazingly lucky I am to have access to a wardrobe, bed, sheets, a roof and a window. A shower, toilet and toilet paper. A towel, soap and a sink with running water... hot and cold.
I have access to a computer with internet, a chair, a desk to study and electrical lighting. I can listen to music, borrow textbooks and write with pens of different colours on many different types of paper. There's many more to be grateful for.

We are so very lucky. And if I remember these basics, like I do now every day without food and drink, I feel incredibly relieved, happy and essentially at peace that I do not take any of it for granted. That is how I pay my tribute to these people all around the world, regardless of their religion, race and gender, or any other dimension of racial differentiation.

Hopefully when the time is right, I will do more than fast to help those in need.