Free time + People I'm grateful to

Currently listening: Rob Thomas - Little wonders (OST: Meet the Robinsons)

Get this widget | Track details | eSnips Social DNA

1. Revisited some my earlier posts when I 1st blogging, and was thinking to myself, did I actually write them? Coz they sounded childish and rather immature.. Oh well..

2. At times I tend to end up comparing with others the things I do..and it can get frustrating when I struggle to comprehend certain people's mindset. Nevertheless, got reminded of Psalm 126:5-6 - Those who sow in tears will reap with songs of joy.

3. Surgical elective concluded with a record number of surgeries witnessed and assisted (on my part as medical student) and a favourable report expressing confidence from my supervisor, which I'm thankful for.. She actually wrote at length about my strengths and areas for improvement. Monash doesn't pay her for my elective, and I felt a bit 'pai seh' when she invited me for her Hari Raya open house, so my way of thanking her and the department? A box of chocolates should do the trick :)

4. Dermatological posting was exciting - lasted only 4 days, but covered most of the skin conditions I would loved to have seen and diagnosed..

5. I requested several books from the main campus via intercampus loan. The people in Sunway initially refused since they only have 1 copy each, instead suggesting for the clinical school library to acquire the books over time. I'm thankful for our librarian here. No doubt it's a case by case basis, but she actually fought for the books on the basis that I'm a final year student. To my amazement, the books actually arrived within 2 days, guess I owed her one :)

A rainy morning at the breast clinic

Day 5 of my elective in general surgery. Honestly, can't really say that I would look forward to becoming a surgeon. It requires good and precise hand technique / skills, involves standing for a long time, and a sound knowledge of anatomy. Need to be on my toes also in reading up because today the specialist asked me, "What is a teratoma?" Patchy as my O&G/paediatric knowledge might be, I was fortunate to have guessed it to be a tumour of the germ-cell lining, but felt bad coz the houseman who answered 'benign ovarian cancer' later got told off, "How come medical student can answer better than you?".

I'm actually beginning to enjoy myself (in 1st week that is), especially since I got to see and do many things, from scrubbing in for assisting in surgeries, to helping houseman in the wards, to examining breast lumps in patients. I told my consultant that the 4-5 patients I helped clerked, examined and diagnosed today in my 1st time ever in the breast clinic exceeded the exposure I gained during my 3rd year surgical posting. Now I really know what a fibroadenoma, galactocoele, lymph nodes etc feels like. My consultant told me that if I wanted more exposure / experience in certain areas I can request for it and she will see what she can do about it. (Actually I do wonder whether she can teach me how to do an appendicectomy as a houseman :p lolz)

p/s: From time to time you will see Chinese patients who exaggerate the minor complaints they have, though it is not serious. Today there was one whom insisted to be seen and given follow up by the consultant (although she does not need another review), whom reminded the nurse - at the next appointment, she does not want to see this patient.

As it rains..

A pretty wet week to end my emergency department rotation.

I learnt that in emergency medicine, you cannot forget your anatomy and physiology.

Chinese patients can be difficult to please. Was asked to look for the patient card for a patient, and my mispronunciation of the patient's name earned me a sarcastic jeer from his wife, "You are Chinese, but don't know how to pronounce people's name properly.."

1 elderly patient with bladder cancer was brought in for body weakness, diagnosed with urinary tract infection. He was supposed to have an appointment with the oncologist at Hospital B*, but the wife thought that he was wrongly sent to Hospital A* where I am posted. The patient was discharged with antibiotics, and the initial plan was for him and his wife to go to Hospital B by taxi, but he complained of being weak and in too much pain to walk. The MO told her directly that there is nothing left for them to do, and despite repeated pleas, they cannot afford to use the hospital's limited number of ambulances to transfer the patient to Hospital B. The option of hiring a private ambulance service was deemed not worth the cost. Eventually, when nobody was looking, I took her aside and explained nicely to her that there is nothing we can do, since it is a policy set in place, clearly delineated.. She promised not to tell the doctors that I lent her my handphone to call her relatives to come and transfer her husband (I know I'm not supposed to, but it's something off the record as I see the need - of course I won't do it to everybody). I think she felt touched lor, as she replied in Cantonese "Thank you ar doctor, you are really a kind person." I think it's a sad case, as she can be heard cursing over the phone of how increasingly cruel and heartless the doctors in government hospitals are becoming, all simply because of a lack of empathy as people are just interested in getting their jobs done.

A baby was discharged from the neonatal ward with a poor prognosis of anencephaly (or some brain problem lar). The next morning, the parents awoke to find their child not responsive, and was most probably no more. They made a police report, and by right the police were supposed to arrange for a post-mortem and some kind of burial permit at the mortuary. It was not done. Before coming to the emergency department, the father brought the dead baby to the ward, going berserk when nobody bothered to explain to him what to do. When it was finally settled, I think it's ridiculous and disrespectful to observe undertakers from some casket company harassing and negotiating the cost of burial from the parents, trying to earn a living at a time when people are in grief.

Medical mumbo jumbo and stuff

Lesson learnt: when you see a patient with chronic liver disease secondary to alcoholic liver cirrhosis, always take the psychosocial history (finances, family situation at home, history of accidents / fights due to subdural bleed), psychiatric history (Wernicke and Korsakoff encephalopathy), gastrointestinal history (variceal and GI bleed).

Woke up early to observe a kidney biopsy on a patient under my follow up. Before I could finish introducing myself, already got scolded by the specialist to stand at the corner - managed to watched the biopsy though, amidst the firing received by the nurses and MO. The houseman whispered, "You are lucky that this is one of the extremely rare cases when she didn't mind, usually she will chase everybody away when she is doing the procedure."

2 on calls this week. Duno why when I follow a particular specialist, you can be sure the night will not end early..

Interesting cases seen:
1. Middle aged Chinese patient with 6 month history of chorea (ruled out Huntington's), CT shows generalised cerebellar atrophy and small vessel ischaemia, the housemen went hunting for autoimmune causes of vascular disease (due to his young age). MRI came back with a long list of findings (which the 3rd years would know better), I could only remember cerebral atrophy and nasopharyngeal carcinoma compressing certain regions.
2. 5-year old girl presenting with exacerbation of asthma, has an incidental finding of dextrocardia.
3. Patient diagnosed to have pemphigus vulgaris by dermatology, but the history sounded to me more like an outbreak of herpes simplex (painful oral and throat ulcers), treated with antibiotics (?URTI) which led to Steven-Johnson syndrome (lesions on upper limb, trunk, lips and neck).
4. Patient with atypical pneumonia, probably due to Legionella from air conditioning.

Old lady from mainland China admitted for pulmonary embolism. Can see that she was really unwell and could not sleep (the nurses transferred her back and forth in the wards to make way for sicker patients).. tried my best to reassure her, the husband and daughter that the cardiologist needs to see her before she gets upgraded to a higher class ward. I think the husband appreciated the concern, despite my broken Mandarin. Looking from a distance, specialist asked my friend, "I thought his Chinese was extremely limited? Looks quite ok to me.." Anyway, need to start reopening my 'Learn Mandarin in 40 days' book.

It's pretty tough being a foreign worker in this country, especially when it comes to healthcare. You fall sick, your employer not willing to foot your medical bill (coz foreigners get charged more on hospital admission), so you see doctors getting phone calls from bosses asking when their employees can be discharged, or requesting a letter to certify him/her as having a medical illness and needing to be deported back to their home country.

Back to chaos I suppose

Currently listening: Amy Sandstrom-Shoyer - Trust in the Lord

Get this widget | Track details | eSnips Social DNA

My classmate commented, "Gary, how can you tell people of such misadventures of yours?! People will think you are a hazard!" It's my way of coping - just coz I tell people or laugh things off does not mean I'm proud of or find it funny, but I suppose it's a humble reminder that I'm surviving daily by God's grace. A friend of mine commented that medical training is perhaps one of the worst forms of training ever - people entrust you with their lives, and you don't know what might happen next with each thing you do.

My ward is PACKED with patients.. It's hot and stuffy, a 9am-5pm day can just leave you exhausted and drenched (patients are sweating despite bringing their own table fans), even with minimal walking. Specimen bags and patient's case notes lying strewn here and there. Things (eg forms, gloves, items for procedures) can just be SO difficult to find, and when they run out, nobody bothers to restock them. Nurses rushing to go off early not giving patients insulin at the right time (need to correlate with meals). A patient who arrived in the ward in the morning being overlooked and not clerked until evening - had to postpone a cardiac procedure. Imagine having to endure the patient's Chinese wife who kept complaining, and complaining, and complaining.. A patient with cardiomyopathy and heart failure symptoms got admitted to the ward from outpatient clinic. The management on the referral letter says '2 pints of normal saline' (ie you know the patient is probably already overloaded with fluid, and you pump in more fluids).

A trick I picked up (to reduce the number of times of the patient being poked, especially if he/she needs daily bloods), is to take blood from the IV cannula after its insertion and flush it later with heparinised saline. However, I think the patient must be wondering why a section of his hand suddenly swelled up like a balloon, but no blood is coming out into the syringe.. when the blood eventually came, it was clotted and unusable - ie houseman need to retake blood, IV needs to be re-done at another site.. *swt*

I volunteered to insert a urinary catheter for a renal failure patient with acute urinary retention due to an enlarged prostate. It seemed normal enough, with little resistance, and when it went in, there was a tiny bit of clot and clear urine flowed out. A few minutes later, I was wondering why the urine was changing to tea-coloured, and subsequently to my (and the ward staff's) horror, the urinary bag filled up with blood (gross haematuria) - had to immediately order blood tests, contact the blood bank to group and hold some blood for transfusion, refer urology for irrigation and ultrasound. Great, will only find out what actually is the problem tomorrow (hopefully not my fault) - what else could go wrong?

Final few days in Melbourne Part 1: Hospital

At the final team meeting, our consultant made a mention that it was my last team meeting, and wished me all the best as I fly home, after all the hard work - surprisingly even my registrar nodded his head in agreement, and the nurses and allied health people gave some applause for a job well done *happy* :p

So the next day I brought a box of chocolates for the ward staff whom I befriended, and the nurses returned the favour by inviting me over for lunch (they had potluck since it was 1 of their colleague's birthday) - so imagine me as the odd medical student sitting at the table, with a bunch people from the 'aunties' age group :p It's actually quite a multicultural ward, with staff from Malaysia, Europe, Philippines, India etc. (even some patients are non-English speaking!) Anyway, as we were having lunch, the doctors passed by, stuck their head in, and gave the 'What is my medical student doing with the nurses?' kind of look.. :p Lunch break!!! lolz


So this is the view of my 2nd hospital from the outside and below is the medical student lounge in the hospital - it has...computers, pantry with a fridge and microwave, water dispenser, sofa to sleep on, plasma TV!!!

Give and take away

Be careful what you ask for
Before I went to sleep on Sunday night, I asked, "God, can give me more motivation and make me more hardworking ar? Coz I felt as if I am being lazy and have not been doing much work.. The next day, a new consultant turned up in the ward and start bombarding me with quizzes and questions on basic and clinical sciences. Some I know the answer to (and managed to dodge), others I need to look up. And he did that for ALMOST every patient - My goodness, that was the LONGEST ward round in a while..

Prayer development ministry
Thankful that I went. Know your identity and in whom you find your security.

Oceania Convention 2010
Gold Coast in 2 days time. Heart preparation required.

It's a bitter pill to swallow..
..when you realise that you won battles but not the war.. when something you thought had gone well in the past did not turn out as expected when you reviewed it a second time around. Felt like one of the pillars of strength which you have built on all this while, suddenly being reduced to dust. Nevertheless, there were several reasons for me to feel upset, but delving deeper to the root of the problem, it took a song on the train ride home to serve a gentle reminder - (the lyrics speak for themselves) and also to give thanks in all circumstances.

Currently listening: Laura Story - Bless the Lord

Verse 1
You give and take away for my good
For who am I to say what I need
For You alone see the hidden parts of me
That need to be stripped away

Verse 2
And as You begin to refine
I'm learning to let go and rely
On One who walks with me
As hard as it may be
You're teaching me all the while to say

Chorus
Bless the Lord, O my soul
All that's in me bless Your name
Forget not Your power untold
Not Your glory or Your fame
For You came to heal the broken
To redeem and make me whole
Bless the Lord, O my soul

Bridge
Though my faith may falter and my strength may fail
I pray for eyes to see
The richness of Your mercy shown to me
Bless the Lord, bless the Lord

It's all about You

Currently listening: Reuben Morgan - With All I Am

Decisions can be hard at times; so do we actually mean it when we sing,
"Though none go with me, I still will follow (x3), no turning back, no turning back."

Belated Connect sharing

Monday - Delirium workshop at Peninsula campus
Wednesday - SIM centre, final day

This week, I only had the chance to be in the aged care rehabilitation ward on Tuesday, Thursday and Friday - and I was feeling quite tired after long days for SIM centre in the city. Anyway, what happened was that I tried to be more proactive in terms of taking initiative, so I will be the one who arrives in the ward early in the morning before the doctors' rounds to help get things done. For this, I think I found favour with the resident and registrar (who although still scolds me, actually teaches and guides me through stuff in front of the computer). Not sure if the other student paired with me is happy about it though, doesn't look like it, with sarcastic remarks about me needing hearing aids when I found it difficult to catch her accent (by the way, she comes late for ward rounds and goes home during lunch).

Although our consultant supervisor will be leaving this week, he indicated to me that he will discuss with my registrar before filling up our assessment form for the rotation later when he is free. Nevertheless, my partner cleverly sneaked to the office to grab both our assessment forms and arranged with the consultant to get them out the way on Friday. I suspect she plans not to show up in the wards for the next 3 weeks with her assessment form out of the way. That essentially means while she has completed her 2 modules, I have 4 modules to cram overnight on Thursday before the assessment (including the additional health systems module that Malaysian students have to do). As I was typing out my thorough patient history and results according to the study guide, one thing which I don't really need is for people to tell me that I am wasting time by doing it as a long case (all she had was just a copied summary of the patient notes for brief discussions with the consultant). I supposed it frustrated me that I just felt like grumbling and complaining, "God, its NOT FAIR. She gets more time to read up and prepare, and she gets away with such things."

But I got reminded of Colossians 3:23-24 - 'Whatever you do, work at it with all your heart, as working for the Lord, not for men, since you know that you will receive an inheritance from the Lord as a reward. It is the Lord Christ you are serving.' Who are we living for? Today, as we go into our workplace / universities, our boss is not the employer who pays our salary, or the institution which offers us scholarships, or your supervisor whom you are worried what marks he will give you - our boss is J.E.S.U.S. We do not do things for the sake of pleasing man / our personal benefits. People may cheat their way and take advantage when their boss is not around (or call you stupid in the process for not being like them), but it's ok. Sooner or later, people will notice the difference, and like Matthew 5:16 puts it - 'In the same way, let your light shine before men, that they may see your good deeds and praise your Father in heaven.' To cut the long story short, as I upheld it unto God's hand whatever the outcome (nothing more I could do), I managed to complete all my modules for Friday, and scored pretty high marks from my consultant too :-) My registrar took me out for coffee, and somehow was able to unexpectedly see how God opened a way for us to start informally chatting about Youth group (music and singing, church etc).

Get this widget | Track details | eSnips Social DNA

耶和华，你是我的神 (Jehovah, You are my God)
讚美之泉 (by: Stream of Praise)

耶和華你是我的神，我要時時稱頌你的名，
(Oh God, You are my God. I will always praise Your holy name.)
你是我的盾牌，是我的榮耀，又是叫我抬起頭的神。
(You alone are my shield, my glory. Lord, You are the lifter of my head.)
縱然仇敵圍繞攻擊我，在你懷中必不怕遭害。
(When my foes surround me in the night. In Your arms I will not be afraid.)
你是我的神，我所倚靠的，你同在使我完全得勝。
(I will trust in You, for You are my God. In Your presence there is victory.)

Surrender

"When there is much prayer, there is much power. When there is little prayer, there is little power, and when there is no prayer, there is no power." -Charles Spurgeon-

My cardiothoracic surgery rotation ended, and the final week set up an opportunity for me to prepare something for last week's Lifegroup Connect Sharing. Basically, I walked up to my professor's office to arrange the time for my case presentation, but it turned out that he was in a research meeting. Although I was told that I don't have to waste time attending it (since I don't understand much on their research projects), I decided to take his invitation and sat through with them (although I was feeling quite sleepy) - what have I got to lose? It's in my allocated timetable. I decided to check that I'm researching the right thing for the presentation, and to my dismay, I was told to change the topic coz it was not something related to my patient's condition. Where in the world to find time to re-do everything with journal references when the deadline is tomorrow morning?! That night I had a very terrible headache, could not do anything at all.. After a time of prayer, decided to get some rest instead. Woke up at 3am in the morning, and surprisingly somehow managed to string together a few articles in that 2 hours before I rush off to catch the bus. That morning, I think I was a bit overwhelmed when I saw my friends actually did a thorough research and meta-analysis / systematic reviews, and included almost all the patient's test results. When my turn came, I think I stumbled a bit here and there (mind you, my presentation was a simplified 'Aortic stenosis for dummies' sort of presentation with a few reviews and guidelines strung up together, but still looked convincing enough I suppose - I was looking at my professor's facial expression throughout the whole presentation), but I was truly thankful that he marked it off with a pretty good score and comment: "Very good presentation, shows good understanding of topic." (phew..)

Storm of the century
I have learnt to trust the weather forecast in Melbourne, no matter how hot and sunny the morning is, if the afternoon forecast is rainy, it WILL rain. Found out the hard way as my friend dropped me off at the library after lunch as the weather was a bit cloudy, and half an hour later - I was stuck in the library amidst the one of the worst hailstorms and which shattered windows and flooded downtown Melbourne. You have hailstones as big as tennis balls. Well, there goes plans to attend the Moomba festival - in fact it got cancelled as people fled for cover. Even the roof at Southern Cross train station collapsed.


sur-ren-der verb
1. to relinquish (something) to the possession or power of another
2. to yield or resign (an office, privilege, etc.) in favor of another
2 things:
a) I find Emergency medicine a struggle, notable from the simulations where I still have a lot to learn as I fumbled here and there..
b) Aged care rotation is not really a holiday / relaxed posting as some would put it. True, people do go home at 2pm, but for me, I am attached to a Malaysian registrar, and of course knowing where I come from, he pushes me to meet his high expectations lar.. and in that midst, scoldings form the routine for 2 consecutive days.

"I'm pushing you, since in the Malaysian education system, they don't teach you in the wards how to manage fluids / write case notes / order and chase test results, since you mentioned that interns do most of it and you end up as a passive observer. When you come out as houseman, you are just expected to know. So take the next 6 weeks to learn it well."
"I expect you to take a proactive and participative role, not just come for morning ward rounds and stand there acting like a ward clerk."
"Don't you know we are not suppose to write with blue pen due to medicolegal reasons?"
"Can you improve on your handwriting? It's hard to read!!!"
The resident often gets the afternoon off, so the registrar will be stuck with a lot of work at that time, he will be chasing tests and nurses will just come and dump a stack of file by his side for the patients' warfarin doses to be charted. In my previous urban hospital posting, I did not get the opportunity to do admissions because it is the job of the residents (the hospital sort of has a rather strict hierarchy system on the roles of different healthcare staff), so in my 1st admission, I realised that for rehabilitation patients, you need to trace their old notes and discharge summaries - that means going through patient case files as thick as Murtagh's General Practice. I think the 1st 2 times I presented, I wonder whether who will die 1st, me or the registrar (from the way he looks stressed at me, he might get a heart attack).
My consultant is leaving, so the registrar is doing bulk of my assessment.
I figured that instead of listing down examination findings, I might as well try using pictures to simplify my message. Problem was that I was a bad artist, and my diagram resulted in the registrar giving the horrified *swt* look and the nurses in the ward not knowing whether to laugh.. (Note: patient deidentified)
I assumed the 3 drug charts chucked to me by the registrar belongs to my patient, so I copied everything, only to realise that 1 of them belonged to another patient when he checked later. Dangerous, patient can die if given wrong drugs. Got scolded - "You know for the past few days you have been going home super late (6pm) because of such mistakes.. it is UNACCEPTABLE."

Seriously, I needed a break. But I appreciate what he was trying to do in preparing me for housemanship in Malaysia. I just need to let go, to take the plunge although I might not see where it leads to for now.

Great Ocean Road trip
Uploaded some photos on Facebook - check it out :p


Prepare for rain
You've watched it so many times, read about it even more - but what does it mean to prepare your field for God to send the rain? What is your field by the way?

Currently listening: Laura Story - There is nothing

Verse 1
Lord I come before you to honor and adore You,
For who You are and all that You have done,
But Lord I am not worthy, my heart is dark and dirty,
Still somehow You bid for me to come.

Bridge
So clothe me humility,
Remind me that I come before a king.

Chorus
There is nothing, there is nothing,
More precious, more worthy,
May I gaze deeper, may I stay longer,
May I press onward to know You Lord.

Verse 2
May our time be sweeter, may I be a keeper,
Of the promises I make to You in song,
And Lord may I remember these moments of surrender,
And live my life this way from this day on.

Bridge and Chorus x2

Metcall. Metcall. Unit: Cardiothoracics

Week 2 - Let's get the show on the road

1st day of the week was boring, so after ward rounds I decided to sneak into the department next door: Cardiology. I've never seen certain procedures being performed before, so when I saw the list in the ward of scheduled angiograms, implanted cardiac defibrillators and pacemakers.. I decided to pop in to their cardiac catheterisation lab for a look. The cardiologists are friendly and the nurse told me to put on a lead apron, a lead skirt and a thyroid guard (something like a mini pouch around your neck).. at the end of the angiogram, I walked out of the room feeling like wanna die man.. the lead suits are HEAVY and tedious to wear, like carrying a huge backpack.

Decided to come back in later that afternoon to observe a defibrillator being put in (like a pacemaker) - suited up since it's like an operative procedure. My goodness, the nurse (not the doctor) grilled me on the cardiac anatomy. Indeed I learnt something new - the right ventricular lead goes into the heart via the superior vena cava, so how does the left ventricular lead goes into the left side? Good question, since you can't really poke the pulmonary vein or aorta (high pressure).. apparently in the right heart, you find the entry into the coronary sinus and into the cardiac veins on the surface of the left heart. So my homework was to read up cardiac anatomy.. had to leave midway as the cardiology registrar was having trouble locating a good cardiac vein site.

I must admit that I did struggle as well during this rotation, as I was finding it hard to be organized with the amount of medical information to handle – not knowing how to juggle between reading up on the specialty I am in, and revising my basic sciences, even Year 3 students answered anatomy questions better than me in tutorials, and other Aussie Year 5 students know things and can relate with the doctors on stuff which I didn’t even know. I was also quite concerned about assessment modules which I have to write up, unsure whether I am doing enough to satisfy my supervisor’s expectations, or ‘under-doing’ it. Anyway, I did ask God for something good which I can share this week, since I was rostered to give testimony during Lifegroup.

2nd day of the week, I woke up and looked at my alarm clock. 6.30am already???!!!! Aiyoh, here we go again dashing to the bus stop without a proper breakfast.. but fortunately I informed the resident beforehand that I was going straight to theatre.. Managed to witness the surgery for the patient whom I clerked last week, but he encountered difficulty because he had a urethral stricture - they could not catheterise him (I think even the urology team who came ended up traumatising his urethra), so they put in a suprapubic catheter instead. The surgeon expressed concern that infection might compromise this surgery to replace his stenosed aortic valve, since his previous admission was for urosepsis - so he suggested postponing the surgery coz it is not something urgent. I was like, "What? Err... God, can make him not postpone ar? Coz if not, it will already be too late for me to find a patient to follow up pre-op, op and post-op - coz its a short rotation. And I do not believe in copy and paste exactly from the notes without seeing the patient, which other people do." The surgeon decided to go ahead eventually. Yay, and I do thank God for this little blessing, but then I asked God, "Can You take it 1 step further ar? Coz I believe You can do much more than we can ever imagine."

After the gruelling 7-hour surgery on this patient, I was told they are starting a heart transplant case next door - it was a golden opportunity coz if I'm not mistaken, I was told that the hospital is the only heart and lung transplant centre in the state of Victoria, and one of the biggest and busiest in Australia. Furthermore, they don't do transplants very often, only an average of around 2 per month. 1 team of surgeons operated on the patient, the other consultant and registrar flew off 7am that morning to get the donor's heart from Cairns, Queensland. So the plane was scheduled to land at 4.45pm, and a helicopter would be bringing the heart and the surgeons to the hospital from Melbourne airport. I dashed to the emergency department at 5.15pm, and asked the receptionist perhaps the most silliest question I have ever asked in my life (Oh might as well, since I might never get such a chance in the future): "Hi there, I'm a medical student attached with cardiothoracics, and I understand that they are flying the donor's heart in for a transplant via a helicopter.. Can I go to the helipad please please? *innocent look*" I think the receptionist also look at me one kind *speechless* duno how to respond, but yay, I followed the nurse to the hospital's helipad (a restricted area). It wasn't anything special lar, just for the experience coz I was imagining my photo being taken like one of those ER doctor drama series running from the helicopter with the patient on a stretcher - I think it looks COOL :p lolz but anyway, nothing dramatic - just as the chopper landed, immediately we made our way to the theatre. It was a crowded OT, as many people wanted to watch, but could not get a very good view. Oh well, saw one half of it, the other half should not be that much of a miss as they connect the heart to the blood vessels. Left around 6.30pm. What an exhausting day.

A phone conversation in the ward between a nurse and the wife of a Chinese patient who spoke little English, discharged after a bypass surgery:
Wife: Hello, my husband you discharged.. he on the toilet floor not moving.
Nurse: You saying he collapsed at home? Quick, you need to call an ambulance! Bring him back here for observation.
Wife: Har?? Why call ambulance? Wait I check on him. I think he waking up a bit.
Nurse: Ya, but you still need to call somebody? Your family doctor?
Wife: Nobody around. Close already. How ar?
Nurse: That is why I said... CALL AN AMBULANCE!!!!!!!

Usually I fast and pray over lunch, but for the past few days my stomach has been playing up, so I decided to have some food at the cafeteria on one of the days. Unexpectedly I bumped into an old friend, who used to be a senior I met in 2006 during transition camp. I haven't seen him for a long time already, so we chatted a bit, I think he's 1 of the residents in the ward upstairs. 1 thing I totally did not expect was that he found out that I was doing the same rotation he was a few years back, and immediately he asked me for my so that he could email me his modules and let me have a rough idea of how to do it.. I was just left amazed yet speechless..

Indeed, I started off these 2 hectic rotations not knowing how I will pull through, but God has taught me to lay down myself, put my trust in Him as my source of help, and as Philippians 4:6-7 would mention, “Do not be anxious in anything, but in everything, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and minds in Christ Jesus."

Musings from Ward 3CTC

Week 1 - "Cardiothoracics in the house!"..

..was what my registrar would say over the ward's microphone as we set off on our 1st ward round at 7.30am. We started late. Seriously, did not know what to expect, having swapped over from neurosurgery. My registrar made me examine almost every patient we see (basically most of the patients had a sternotomy, so just press on their sternum to check for clicks / instability, listen to heart and lung sounds - something which I definitely need more practice in). Also learnt to write more in the notes and be more proactive - assisting the residents and registrars.. took blood, did an IV on a frail, cranky aboriginal lady - although her veins are rather small, thank God managed to put it in - the resident was so encouraging as he told me don't be put off by patients who may not want you to poke them, you just have to find a way around that, and try until you get that drip in by practice. He even took the effort to look for interesting patients for me to examine :-)

I looked at my 1st day patient list and there was... 40 patients? *swt* when we finished rounds, found out that the consultant wants to come in and see his patients, so have to re-do half of the rounds. By the time we were done, 12.30pm already (for me, it's the LONGEST WARD ROUND EVER) - had to dash off for a break.

Overall, 1st week was kind of uneventful, so I decided to follow the timetable given by my supervisor. Sue told me that I need to attend a cardiac meeting on Wednesday afternoon coz my supervisor will be there. After that meeting, tried unsuccessfully to go off, coz then the cardiologists came in and we have a meeting in the seminar room. At that time, was wondering what is this 'Catheter conference' slotted in my timetable - by the time I found out, it was this BORING session where the cardiologists went through ALL the patients which they did an angiogram and Doppler on throughout the week, and plan for surgery with the cardiothoracic surgeons next week. Seriously by the time it ended around 6 something, almost fell asleep..

I came across Sue's patient, and was asked to follow up her history and do an examination. I think she doesn't see me as an angel as I asked to have a look at her stoma as part of my full examination when I reached the abdomen, but never mind.. I tried.

An 60-year old lady was admitted to the ward because she had to undergo a surgery to remove a metastasis in her lung.. she was in pain that morning, and when I had a chat with her while taking her history, many things she did not know, because she doesn't care. "I'm old. It's my family who wants to know, it doesn't matter to me. I have the right to the way I want to live my life." Then she went on trying to convince me to perform euthanasia on her because she believes every patient should have their own right in deciding what they wanna do with their own life. But as I probed deeper, I do sense a poor soul hurting deep inside. A life spent battling cancer can take its toll on you. And there in bed she laid, bearing a grudge against her current state, unable to join in the weekend picnic with fellow family members. It's just difficult to understand that people who rejected attention and care from others, are actually those who need them the most. Passed her a box of tissue as I walked out. She said she will look at my facial expression during the next day's ward rounds to have an idea of the biopsy results.

I was clerking a patient when she suddenly complained of feeling of unwell - nurses were called in, they did an ECG and made her rest. A nurse explained to her, "I think what you are having is what we call a vasovagal attack. What were you doing when you felt funny?" She said, "Talking to Gary?" Everybody looked at me. Wow. So now I give patients vasovagal attacks. Next day, as were doing rounds, this patient suffered a heart attack in front of us. *Swt* Had to declare a METCALL (ie emergency over the speakers)..

Overall it was a quiet week. Nothing much. At 3.30pm, my residents will tell me, "There is nothing much, you can go home."

Provider

The AUD3500 travel grant came in already according to my parents. For me, it's not just money, I believe it reminds me of the importance of holding on to certain principles.

What happened was we were supposed to be given a certain amount of money to subsidise our expenses. I think it's not something which they were obliged to, but our seniors got it, so we are supposed to get it too. That's until Monash announced that the grant was withdrawn.

A petition was drawn up asking Monash Sunway to re-consider the plight of the students and re-instate the grant. I asked Ethan, and basically he shared that it's a grey area evaluated on a case by case basis - but the general principle is not to go against authority which God has put in place. So I decided that we can provide input / suggestions, but no matter how blood-sucking Sunway becomes, or lousy / incompetent / corrupt people in authority are, pray for them and submit - unless the need arises to look towards a higher authority. God put them there, God will remove when the time / need arises (eg elections, circumstances etc). Despite a few friends and classmates pestering me that it was only a form of appeal, I was the only one in my batch who refused to sign the petition. Not to say I'm proud or I am well-to-do financially - seriously it was not easy as I do need the money (and if I was the kind of person I was last time, I would have been the 1st to jump at it) - but I believe in doing the right thing. That's why I do not support political activism. I pray "God, You know my need. You will provide."

I was in JB later in January, and dropped by for a casual chat with my clinical coordinator regarding my visa, and also our problem with the grant. I passed her a copy of our offer letter which stated that we are supposed to receive the subsidy. The next day, she called and told me that she forwarded a copy of the offer letter to the Head of School and academic staff in Sunway, and they were surprised - they had not seen it before and did not know that this was contained in the offer letter. All this while, from what I understand, I think they were wondering "What is this grant which the students keep asking us for.." Immediately Australia was contacted and arrangements were made with the Sunway finance department. What has been an unresolved headache despite 2 months of fighting - solved in 2 days through the power of asking.

Final chapter of neurosurgery

Day 13 - Another day of madness

"With Christ in the vessel we can smile at the storm
As we go sailing home"
-Sunday school song-

I was at the pre-admission clinic when Ben and Anna tried calling me at 10.15am. "Gary where are you?"
Me: "Err.. I'm in the hospital?"
Ben: "You do know we have law class now right? 10 o'clock.."
Me: "No I don't. Where?"
Ben: "In medical building, Monash Uni, Clayton.."
*swt*
Ben was trying to tell me over a not-so-good phone connection that the tutor said if I'm going to be late, take my time, but I heard it as "If I'm going to be late, my name will be written there as coming 1-hour late and will be blacklisted." So I rushed back to Clayton by bus-train-bus-on foot in a record 45 minutes, only to find most people dressed casually. Apparently, if you have tutorials on that day, you don't have to attend hospital activities. It is literally.. a HOLIDAY which I was not aware of. *swt*

Anyway, I had to go back to the city hospital coz:
1. I left my bag there
2. It's the 3rd time I've to reschedule my MCR with the registrar coz he is busy.. I hope he does it today.
So off I went in the train headed towards Melbourne, where dark clouds and lightning ahead revealed that a thunderstorm was raging in the city. Just at that time, I received a phone call from an unknown person, who turned out to be my supervisor. He asked me where am I, and I mentioned that I'm rushing back to the hospital coz I had class before that. To my horror, guess what he said? "Gary, what time are you arriving? Later you go to the seminar room and do your presentation on Back Pain which you have prepared on Monday.. I will be marking you today."

That phone call nearly gave me a heart attack on the train.. THIS IS CRAZY!!!! I thought since he didn't have time on Monday, let's just modify the slides a bit nicely and do a lecture notes handout to include when I'm handing in the copy of my assessment to him. Little did I know this cropped up. "Seriously GOD I DO NOT WANT TO FAIL.. eh you are the one who brought me here so better help me leh, I may not be able, but You are." I think I prayed so hard that my supervisor asked me in the seminar room "Gary, you look nervous.." (what an impression to give - of course lar, especially when you are presenting a half-baked 20-slide presentation which you did not even read up for and risk being bombarded). I was wondering what else he has up his sleeves, and you know what? He called ALL his registrars and residents to come and observe me giving the talk. ^_^"

Amid the talk while heavy rains rage outside, I will admit I was nervous, fumbling a bit here and there, and not knowing answers to some questions, but I thank God that he did not scold, instead used it as a teaching session for his registrars (he is a good teacher by the way). At the end, I did not expect it, but got commended for a good talk. Very thankful :-)

My case presentation patient (whose operation got screwed up by histopath as mentioned previously) had B-cell lymphoma relapse.. Before leaving, I just dropped by the ward for a visit. Her daughter and husband were seen crying as the haematologist explained to them another operation she was scheduled to undergo next Tuesday. Just as I was hiding behind the door taking a peek, a nurse asked me what was I up to. I told her that I'm a medical student following up on my patient, and if they need some time by their own, then could you pass this box of chocolates to them - saying it's from me? The nurse scolded me, "Oh come on, what's there to be afraid??! Just go, I'm sure they won't mind." Next thing I knew, I was at the door, with a shy-look.. "Err.. hi there? Sorry I just finished work and I actually duno what else I could say or offer to help, but I figured of just handing in a little token of appreciation. Hope she gets well soon."

I could sense everybody in that room felt grateful about that. Walked home in the evening rain (coz I forgot to buy an umbrella), but 1st time I actually enjoy being under the showers - a refreshing reminder that His mercies are new every day.

Day 14 - All's well that ends well

I decided to go hands on today, and I'm proud of it. I helped in putting on fluorescent markers (something like tags from sci-fi movies) on the patient's head which is used for mapping the brain via MRI before surgery. I tried putting in an IV, but for someone who has not cannulated for more than a year, rusty already.. equipment here look a bit different, so I had a nice nurse to guide and teach me what to do.. luckily patient was quite forgiving despite the botched attempt. After the IV was put in, the resident had to tell me that now they need bloods taken (and I think the patient was a bit grumpy after the IV to be poked again), so the nurse taught me a shortcut :p (use a syringe to withdraw around 10ml fluid from the cannula until you are sure that the fluid coming out is pure blood, then quickly stick in the vacutainer..) It was a pre-operative ward (all patients who go here need IV cannulas and venepunctures), so I am welcome to go there and practise as many times as I want to (conveniently located beside the cardiothoracic ward where I'm going next).

Tagged along a resident, who showed me that if you want things to be done efficiently and quickly your way:
1. know all the shortcuts and stairways in the hospital to save time getting from point A to B
2. be nice and appreciative to the admin people.. if the healthcare staff can't help you (eg if you want an urgent scan), usually the admin people can help you get things done (can tell that this guy has a charm among the female colleagues :p)

My registrar finally was able to sit down and do my MCR (ie case assessment with me).. he was very keen to teach, and I had to apologise to constantly bothering him. Nevertheless, I mentioned that I should be doing more reading, he told me that I actually have the knowledge - it's just applying it in situations when it is hidden somewhere in your brain. "When you start off in medicine here, you will realise that most of the things you will be doing is paperwork. Not so much of medical knowledge needed - more of experience and determination.." I had a good chat with him for the last time, he signed off both of my 2 MCRs, and though I did not expect to do well in a tough rotation compared to cardiothoracics (whose supervisor was said to be more lenient), he gave me full marks for each criteria.. I was stunned and speechless. *I SERIOUSLY DON'T BELIEVE IT* "You know, of those who previously came to this rotation, you were one of the few who always stayed back until late, even the nurses had to prompt you to go home. So all the best - go, you will make a good doctor."

I duno what the future holds in cardiothoracic surgery, and I do hope I pass my PIA, which is the eventual final assessment grades given by my current consultant supervisor, but as I walked out Ward 2 East for the last time, I was eternally grateful to a faithful God, and was reminded that as we seek 1st His kingdom and His righteousness, putting His principles 1st, all things will work together for the good of those who love Him. End of story.

Currently listening: Keane - Somewhere only we know

Little blessings amidst the gloom

Day 11

As a result of not sleeping on Sunday, I came home the previous night exhausted, and retiring early in bed, forgetting to set the alarm clock for the next day.. As a result, instead of waking up at 4.30pm, I was horrified to see my clock showing 6.05am, and the sun already rising in the far distance. No time for breakfast, so I grabbed the 1st pair of clothes I see as I opened my wardrobe, and off I ran to the bus loop. This is not to be a good day, as I had to sms the registrar that I'm arriving late.

Rounds already started, and later had the opportunity to follow one of the residents who was a Monash graduate and went through the same posting I did. Great, he would know what I need to do in the wards, and I do get more work to do (eg writing referrals, examining patients and reporting findings to him, calling up GPs for patients' results and medications etc)..

Neurosurgery is a competitive unit, or so I found out, where residents compete against each other to earn a good references from their consultants to move on to a higher level (registrar, specialist).. not a very nice thing to do, when a resident jumps on the opportunity to go to the operating theatre / clinic where consultants can see them working, and leaving the other poor guy to settle things in the ward.

2 3rd year medical students joined us for rounds, and after that I followed them to the clinic, where we tagged along with a consultant. He was plain rude, a quick talker and won't hesitate to scold people (I misunderstood his question, and he scolded me "No, don't give me that s**t!") But the way he grilled us and a fellow resident on the neuroanatomy of the spine and lower limb dermatomes was AWESOME, I walked away from that session remembering more than I actually ever read up before this!

Was asked by some 3rd year juniors to supervise them revising their neurological examination, so took them around the ward looking for patients. Ok, let's see how well I do if I were to apply to Monash next time as a lecturer.. I hope it didn't turn out like the blind leading the blind, but I think it wasn't too bad, only that they ended up giving me homework to look up some stuff which I didn't know that time.

Afternoon was spent in OT where I actually planned to observe a microvascular decompression for trigeminal neuralgia, but instead ended up bumping into the Professor and Head of Neurosurgery. Freaked me out a bit when he actually invited me to scrub in, coz a friend of mine once mentioned that he's a very strict person, though he likes to teach. Was actually praying very hard that he will not ask me any neurosurgery or neuroanatomy questions coz if cannot answer then embarrasing leh - got 3rd years watching along (luckily he didn't).. I felt privileged that he asked me to assist him with the registrars in doing the lumbar peritoneal shunt revision, a 2-hour operation up close beside the patient.. Wow, experience of a lifetime!

Day 12

Afternoon was super boring, that I actually wanted to sleep. Clinic finished late, and my modular tutorial with the registrar was postponed again. I do hope we can make it up, coz I hope to get everything done by this Friday..

Morning was different though, as we saw a 90-year old man post-fall with a subdural haemorrhage (ie bleeding in the brain) and was unable to go into OT for operation coz suddenly deteriorated in the ward with a very bad pneumonia. Anaesthetic team decided he was too risky for surgery, while medical team was considering withdrawing his antibiotics. After the counselling session with the wife and daughter, I felt prompted to go and sit down and have a chat with his wife.

She was pretty responsive, and we talked a while - about Greece and Malaysia (they are Greeks by the way), about people, about family, about life..She shared how she had been married to the husband for over 50 years, and they moved to Australia from Greece 45 years ago. She is an Orthodox, and though I may not understand their custom for having a priest come over and sprinkle a drop of wine onto his lip for some kind of ceremony, I do see how closely-knitted the family can be, everybody from grandchildren to uncles will come by to visit.

"It's unfortunate that though we talk to him, he did not seem to recognise us anymore... The other day, he woke up in the emergency department and immediately asked for his shoes. I told him why you wanted your shoes for as you need to stay in hospital. He never liked being bed-ridden, even at home he wouldn't let anybody into his room upstairs, as he claimed he got work to do.. now memories of those times just seem so distant away.."

"I suppose like the doctor explained just now, probably he hears you all, it's just he could not respond coz of his condition." I did try to offer some assurance..

"Well, look at him now.." *points at the cachectic patient lying in bed, gasping desperately for air on the ventilator*

*silence for a minute or 2*

"Are you married?", she asked.

Wow, now where in the world did that come from..

She added, "Marriage is not easy, you see everything as beautiful before you get married as a couple, but once you get together officially.. phew, troubles aplenty.."

We had a good laugh. As I was leaving, though I felt a bit nervous not knowing how she would respond, I shared that I'm a Christian and offered to pray for her family and husband - that if it's God's will then heal him, otherwise pray for peace and His comforting presence as they go through these tough times.. What I lack in clinical acumen, I try to make up by caring for my patients. She was actually touched and so grateful, that she said, "Last time when I was admitted to hospital, there was a couple, Malaysian also, in the same ward.. they too offered to pray for me. I think it is good, as it never hurts to do so. Thank you very very much" she said in a choking voice, tears starting to well up in her eyes. Then it caught me by surprise when she offered me a box of expensive chocolates. "Have 1." I was a little reluctant, but relented when she insisted. "Sorry, it's just that I'm a shy person.." She responded by saying something which I will never forget for a long time, "You are still a baby.. but you are going to become a doctor... and many times you are going to see things which are difficult, which are not easy to handle.. so you cannot be weak, you have to be STRONG. Look at me, I'm almost 80 years of age and I had breast cancer inside of me despite the surgery, but I tell myself I'm still going to fight on. So should you."

Her husband was projected by the consultant not to survive beyond 48 hours as we try to make a palliative care referral. Despite our efforts, we end up confirming time of death as he never made it past that afternoon.

Day 10 - It's about performance

I literally did not sleep much over Sunday, only 1-2 hours, rushing my supposed long case and 'Back Pain' presentation. And still, could not get it done. My visit to the city to follow up my patient was a waste of time - due to inefficient public transport on weekends. So anywayz, as the hour approaches at 1pm, I was panicking over lunch as the resident suggested that I should at least know what I'm talking about, the reason for including certain points, so that I don't get shot down left-right-centre. As I entered the room, 1 of my registrars told my consultant supervisor that he was happy with my performance, and the consultant asked him, "Really? So how much he bribed you?" *swt*

So I was alone with that consultant in the seminar room (scary wei), and as I went through my presentation, he was happily sitting there enjoying his lunch box. But I was really thankful that he did not ask any particularly tough questions, though I look a bit awkward when could not answer a few things. After my presentation, he even nicely showed me how I should include CT scan photos of the patient in my presentation, instead of just copy and paste the results. Then, he sent me off to get lunch (I didn't coz fast and pray, but I was quite surprised he was in a good mood)..

Then things changed during clinic, when he made me clerk and examine 3 patients, and write in the notes (ie act like a doctor, then he will evaluate my case notes).. drawback was everytime he saw the patient with me, I was a bit nervous and tongue-tied while presenting to him, and he asked all 3 patients "How you find the medical student? Should I pass him? Coz he still not up to my standard you know.. Just say he's not good you know, and I will make him repeat the whole year all over." The patients were a bit 'pai seh', so they just give face and say, "He is nice." (I think I better not go back to clinic, coz if 1 patient not happy with me, then gone case) But I must say that most of his patients are happy with him coz when he performs surgery, he pays particular attention to cosmetic aspects of the patients (especially females).. 1 old lady was so happy that her brain tumour was removed with a keyhole surgery over her eyebrow (nobody even noticed the scar much), whereas other surgeons wanted to make a wide incision across her forehead.

I duno why I always get foreign patients whom I have difficulty with communication. This time it is a middle-eastern guy who was telling A-Z of his headache symptoms.. Anyway, last case of the day, of all things to do, my consultant asked me to clerk a patient with a rather.. complicated history. Retroperitoneal tumour debulked, with some remaining parts left at the L5 region to preserve neurological function, currently on annual MRI follow up. Let's see, she's got splenectomy for ruptured spleen, pancreatitis, hypothyroidism, pernicious anaemia, and now sciatic nerve pain. And you want me to present that? 6pm when everybody has left the clinic, I was still sitting there writing everything from start to finish, including management plan. Anyway, that last patient was a memorable one, coz she was pretty cheerful and smiling throughout the whole interview, despite her predicament.

End of Week 2, Year 5

Day 9

I suppose being a good listener does not only encompass areas of sharing with other people, but also on ward rounds, when you have to really listen to what the registrars are blurting out at a quick rate, and sieve through what's relevant to write in the patient's notes (not easy, since I tend to zone out early morning), but at least my note writing abilities have improved. I now take almost half the patient's case files on rounds for write-ups, and can do 2-3 discharge summaries per day.

The problem with neurosurgery is that when I asked the resident, "How many interns are there in the ward?" the answer is NONE. Since neurosurgery is a rather sub-specialised field, residents do the interns' work. Most interns are in departments with broad scopes such as general medicine or surgery, where Year 5's can at least see what to do. I had to ask what is the job scope of an intern in Australia, since I'm literally walking around the wards aimlessly like some blur, dumb fellow not knowing what to do most of the time.. "Oh, interns basically help run the ward (run the ward? for me run around here and there got lar).. clerk patients and present to the consultants on rounds, do referrals, liaise with staff from other departments when it comes to investigations.. basically you got to know your patient.." Ok, not too much different from housemen in Malaysia, but the way I'm going, I think I'm on the right track, except could have been better..

1 suggestion which I might consider forwarding to Monash for Malaysia campus' final years who are coming over to Australia next year is to have a slightly earlier 1-week orientation (so-called informal grace period) for exposure to the hospital and ward environment (be it exploration, ward rounds, sit in clinics etc), since the interaction with patients/staff and way things are done can take a while to get used to.

17 year old girl admitted to emergency department for a cervical / spinal fracture due to a high speed motor vehicle accident. Ended up a quadriplegic. Enough said.

Why me?

Our Daily Journey (ODJ) had an article which spoke to my heart for the past week of devotion. Basically the author is a cancer survivor who wonders why did God let him survive and not others, why did he have to go through certain things. Then, it mentioned about Hannah, how she cried out to God in anguish because she could not bear a child for a long time, and eventually God blessed her with a boy, Samuel. Samuel went on to become a prophet, to anoint David king over Israel, the line where Jesus would later come from.

Lesson is that God hears our cries when we face difficulties, but then He reveals His will based in His good pleasure. Regardless of the outcome, we can respond in faith by praising Him for who He is. It is ok to wonder "Why?" sometimes, but we can trust in God's sovereign, loving hands all the time.

Yes, I dread the ridiculous hours to wake up and go home when other people can go home at 2pm or enjoy the weekend, neuro is my weakest aspect of medicine, and it does not help that I have 2 presentations to be assessed by my consultant supervisor this Monday (prayers appreciated - thank you :p). The list can go on, but I've learnt to see that there is some good to it - it prepares me for housemanship, it trains up my neurological examination; since I can practise it as many times as I want it, I get to assist in brain surgeries which might only be a once in a lifetime experience, and I learnt to count my blessings as He sustains me.

Speaking of sustenance, I was going to wait 5 minutes for the 6.30pm bus back to Clayton from the hospital but the standstill traffic jam all the way to the train station was terrible. But if I wait for the 6.30 bus, I might only arrive in Lifegroup around 9 something at night, as it is I'm already missing dinner. So I was deciding whether to walk (you got to be kidding, after a tiring day, with my lousy stamina and the train station over 1.5km away).. but then I decided, "God, I wanna honour You. I choose not to compromise or miss LG" So I did. And as I went on, I overtook not 1, but 2 of the buses which had left earlier, and as I crossed over to the train station, I caught up with the 3rd bus which supposedly left at 6pm. Hopped onto a train after a few minutes and I'm off.

Now, a new problem arises. Clayton has not buses until 7.39pm. 2 Huntingdale buses leave at 7.14 and 7.15pm respectively. I told God, "I need a favour. Can make this train go a little bit faster and make the buses delayed until I arrive ar?" It's a problem coz a number of people were complaining that the trains arrive after the buses had left. I arrived at 7.19pm, and as I ran over to the bus stop, guess what - there was a bus over there, and it was literally EMPTY!! Waiting there for me as if it had been sent specially prepared to pick me up :p

Little lessons which just made my day.. when doing something for God, don't look at the task at hand, fix your eyes on Him, coz He is able to do much more than we can ever imagine :)

You know you had a bad day when..

Day 8

1. One of the cases that early morning for the registrars to operate on: Husband abuses wife. Wife smacks husband in the skull with a baseball bat. Horrible fracture on the left with brain herniating out being pushed by (surprisingly) a massive extradural bleeding from the right side.

2. Registrar gets a call of fractured spinous process admitted to neurosurgery due to fall of a bike (should be trauma). Bad mistake of unncessarily increasing the workload of the department, with 4-letter F* words flying out as she stormed out to the emergency department.

3. Consultant supervisor asked the residents how is the medical student doing, whether they teach me stuff..
Resident: Yeah, good good!! he did a lot of stuff - writing discharge summaries, chasing test results etc.
Consultant: Sure? Should I pass him?
Resident: Yeah yeah you should!
Consultant: You don't have to be too nice to him, you know? Otherwise later you get interns and residents that give you a headache in the future. I train good doctors, not mediocre ones, so my job is to exterminate them in the bud.
*swt*
Anyway, remember that temporal lobe tumour guy who wanted a video of his operation? Got discharged, and nothing a good buddy-like handshake couldn't fix.

4. At 4.00pm, I followed my prospective long case patient into the operating theatre, to undergo a stereotactic brain biopsy +/- EVD and CSF collection (whatever lar, can't remember the full name of the procedure).. Suppose to be a straight forward 30-minute procedure through a mini burr hole, but the operating registrar unluckily cut a passing vein (initially thought he miscalculated and hit the sinus).. My consultant had to come in (despite being in crutches.. boy did he reminded me of Dr House) to drill out a piece of bone and burn off the bleeding.. Then, something wrong with the machine which is suppose to map out areas of the brain. Consultant considered doing the tumour biopsy free-hand (which was common 20 years ago, can you imagine in the 21st century?)..

After finally obtaining a specimen, he requested for a chair to sit as his legs are getting tired. I pushed the chair with small wheels for him, but forgot to lock it down for grip. What happened? Upon leaning back, the chair became unstable, and he came crashing down on his back in the OT. *swt* He was on crutches and apparently re-injured one of his legs which was immobilised due to an accident. (I hope that is not the end of my rotation and assessment)

I helped arrange for histopathology to do a frozen section so that can decide further course of management in theatre itself, and I told the histopathologist that we will come over in 30 minutes (registrar's instruction). By the time we were done, it was 6.15pm. Lab already closed, and most staff had gone home. Lesson learnt: take note of the person-in-charge's name at the other end of the phone. Can't possibly leave the patient like that for an hour, so the unfortunate decision was made to close up. Couldn't even collect CSF for tests coz to everybody's horror from the CT scan, if the brain lesion is not cancer, but an abscess, then patient will die from infection once exposed to CSF.

Cut the long story short, left the hospital at 7.45pm, walked to the bus stop and train station in the rain (I don't have an umbrella), had dinner at McD, and arrive home 9.30pm. This is madness.

Never ending work

Day 6

I suppose when you are sleeping an average of 5 hours from Monday to Friday (waking up 4.30am), you will have to learn the art of sleeping and studying anywhere, anytime - on the bus, on the train - even when it is not that conducive.

Communication is a headache.. try clerking someone who speaks Russian as her mother tongue and needed a friend to translate for her.

Clerked a guy who came in for nothing apart from homonymous hemianopia.. Scan showed he had a brain tumour. By the time we ended, he just had to ask me, "Can you help me ask the registrar whether I can have a copy of my operation video?" "What for?" I asked him. "It's a once in a lifetime life-saving procedure. I just got to invite all my friends to watch it together with me in my living room so that they know what I went through!" *I was seriously trying very very hard not to laugh..*

Day 7

I learnt never to bargain with a registrar's instructions - got scolded coz I wanted to follow up a patient on the 7th floor whereas she asked me to go with another registrar to levels 3 and 4.

Anyway, this registrar whom I followed - although he looked rather intimidating from afar (never smiles), but he's actually quite nice, gave me a few tips for the presentation to my consultant supervisor. He even paid for my Latte during the break (apparently he's British and it's a common custom for registrars in the UK to occasionally treat their interns for coffee.

Scrubbed into the operating theatre (OT) for a cranioplasty, and as I did, my consultant supervisor walked by. "Enjoying neurosurgery? I'm sure you do. (before I even had a chance to answer) Eh *gestures to the registrar*, watch the medical student closely ok? If this procedure becomes infected, I swear I will rip your testicles out!!!" Before the surgery even started, was asked to put on the sterile handle for the overhead lights.. duno why suddenly the light flipped upside down, hit my hands, and now the scrub nurses look at me one kind as I have to change gloves. *swt*

Never mind, it was a fun surgery.. saw the scalp being opened and they put a titanium plate to cover the previous site of a cerebral abscess, where the skull was malformed.
Registrar: Would you like to drill in the screw into the skull for the plate?
Me: Can I?
Registrar: Do you want to? You know, one of these screws cost $50 you know, so the more you put in, the happier the department handling them will be. How does it feel to be saving a person's life with that? Still wanna do neurosurgery?
Me *telling the nurse*: You know, he's been asking me that question since Day 1.
Nurse: What did you tell him?
Me: Well, I told him I'm considering internal medicine. Then, when I saw his facial expression change, I put a disclaimer at the back "But I would take it into consideration."
Registrar: See, hilarious or not this guy? Do you like what you see?
*at that moment, 1 of the screws I was screwing slipped and fell into onto the scalp.. temporary moment of silence from everyone. nvm, I manage to get a few other screws in*

Another registrar asked me to read up about wound management and tell him the A-Z of it tomorrow.

I was fortunate that in the wards, when the consultant asked whether I have been behaving, the registrars said yes with some compliments (but in actual fact, got grilled like crazy). Consultant reminded me of my presentation and long case this Monday, which I will probably spend the weekend doing. Back pain or neck pain, suppose to cover anatomy, epidemiology, clinical presentation, management.. Long case? Oh yes, I should go and follow up on my patient who is to undergo surgery for a biopsy tomorrow. Found out that, unfortunately coz of a problem with the BrainLab machine, surgery got postponed. Fine, I got another patient whom I clerked who might be suitable - the guy I mentioned above with a temporal lobe tumour.. scheduled to have a scan done today and operated tomorrow. Found out that - his surgery got postponed to next Wednesday. Great, how do you find a patient to follow up then?

I was done in the wards by 3.30pm, and the residents asked me to go home, nothing else to do, but I was about to get my MCR on Fluids and Electrolytes graded by 1 of the registrars. In the meantime, got asked to write a patient's discharge summary. Then, by the time rounds ended, it's already 6pm, and the registrars are getting cranky. My brain already shut down that I could not remember what I studied last night.
Registrar: What is the conclusion of the SAFE study on crystalloids and colloids? (yes, they expect me to read a journal article).
Me: No difference between usage of crystalloids and colloids in ICU patients..
Registrar: What? Hey, you got read the whole thing or not? Or just the abstract. Faster go and Google on the PC its relevance to neurosurgery and come back let me know! (Answer: Colloids result in higher mortality. Results of study does not apply to neurosurgery coz of small sample size representing that group)
Registrar: Good, you are well-versed in your fluid compositions. How you manage a patient with head injury? What fluids you give? (am I suppose to know this? I thought only surgery in general) (Answer: instead of 3L of fluid, you only give 2L coz of risk of cerebral oedema)..

Acid base balance was something I was not that well-versed in, so when I got asked:
Registrar: What is the normal value of PCO2, PO2, HCO3 etc (ok lar, I admit I've been relying too much on given referenced figures on the lab form)? What I want you to do, go back.. read up on respiratory and metabolic acidosis and alkalosis, what causes it, how do you manage it. Come back and present to me on Friday, THEN only I sign your assessment sheet? Fare enough? I was an intern before, so these are important things you will need to know, otherwise.. next year doctor already right? Ok?

Getting home later and later.. reach at 8.30pm..

And the drama continues in neurosurgery

Day 3

Assisted while the resident performed a lumbar puncture on an elderly lady, supervised by a registrar.. It's good to see her smiling again at me, after an agonisingly long wait for the painful procedure to be over.. Got to practice my blood taking skills again with the pathologist, though one patient was swearing and cursing away at us (he can't move, but he felt the pain).

The resident I was shadowing left her jacket at the bedside, I grabbed it for her, and her handphone fell out of the pocket onto the floor, and the cover came off. Ooops..

We learnt suturing.. on pork bellies. The other supervisor from cardiothoracic asked us to join his teaching at 1 of the labs, and when we opened the fridge, phew!! Full of pork in cling wrap (and maybe a few hearts and livers also).. duno how many years have they been there :p I suggested maybe we should take some home for good old 'Bak Kut Teh'..

Day 4

I never liked radiology, looking at CT scans and X-rays.. so during today's neuroradiological meeting, I was trying very very hard not to fall asleep, despite the coffee.

Today bumped into a big-shot, the Professor / Head of Neurosurgery at the clinic after he came back. My consultant supervisor wanted me to clerk and present to him (duno why he like to make me suffer in funny ways :p). Clerked the patient anyway, one with sciatica / slipped disc (ie back pain), and she kinda got offended when I touched on her unemployment and asked her family history regarding her mother with dementia, whom she was taking care of full-time at home. Anywayz, cleared her case with one of the registrars, since my consultant was busy.

Next up, clerked a patient with neck pain radiating to the right arm. It's a challenge clerking patients in Australia, coz they don't answer questions in the format you wanted them to (in Malaysia, doctor ask 1 question, patient answer 1 question). Here, they will either scold you if they feel your questions are irrelevant, or go off tangent when answering your questions, which was exactly what happened with this old lady. But I do sympathise with her in that she had titanium inserted into her cervical spine C5-C6 for ACDF (whatever that is), then she shared about her abuse by her ex-boyfriend who assaulted and kicked her in the neck and head, and how she is discriminated by her boss due to her lack of interpersonal skills (I think she almost wanted to cry already). But something is not right, how can neck pain C6 present with tingling sensation all over right arm and forearm.. I think the nurse who chaperoned me do a full upper neurological examination also quite horrified with the way I made this lady turn her neck and move her arms up down left right (can hear abit of crepitus).. I asked my registrar to come and see her, and after asking a few questions, took her hand - positive Tinel's sign. Diagnosis: Carpal Tunnel Syndrome. Pfft.

Next up, helped a resident to run and errand by collecting a radiological CD from the emergency department. Got delayed, since this guy at the department got abit overexcited and was trying to show me around where they did the MRIs and CTs. It's already past 6pm, and when all the registrars and consultant have left the ward, the resident said, "Oh dear, we forgot to send Gary home." Latest I have ever finished. Arrived home at 8pm.

Malaysian medical student goes Aussie

Day 2 of neurosurgical posting

Registrar: Eh you, later you scrub in ya, assist me with inserting a ventriculoperitoneal shunt. You know how to scrub in, right?
Me: (blur look since I last enter an operating theatre half a year ago) Err..yeah? U mean the handwashing and gowning part right? *proceeds to show handwashing gesture*
Registrar: .....*horrified look*.... Oh.my.lord..
Nevertheless, I remembered a bit here and there, and managed to assist during the surgery.

Next we witnessed a craniotomy for a patient with small cell lung cancer metastasised to the temporal lobe. My consultant supervisor joined in and operated.
Registrar: Gary, come over here and help me with the computerised CT scan.
Me: Ok! *rushes over and pressed the monitor screen a few times*
Everyone: *again, a horrified look*
Registrar: Ehem.. Hello dude, its not touchscreen lar.. the mouse is over there.

I put a stool behind the surgeons who are operating so that I can stand on it to have a clearer look. Another medical student who was assisting didn't see it, and tripped, and..... (on 2nd thought, never mind)

Nearly walked into the glass wall of the emergency department.

Registrar said nothing much in the wards, so can go home early - 4.30pm.

Triple post

Back to the start, where a new beginning awaits (I hope)
It has been a journey back to where it all started.. Before I came to Australia, one thing shared that has been a struggle and prayer point for me on behalf of my shepherd and caregroup in JB is the need to learn to listen and be humble. So happened that somehow that point hit home when the 1st Sunday service I attended here - the topic was none other than, 'Putting on the mantle of humility'.. How God works in higher ways I just could not comprehend :-) I'm only here for 12 weeks, still seeking God of what I should do (or can do) in those 12 weeks, and also in terms of decision-making. Things I observed of what people do, and listened of what some said, actually made me ponder on why we do the things we do..

Get this widget | Track details | eSnips Social DNA

Currently listening:

改變我，改變世界 (Change me, change the world)
讚美之泉 (by: Stream of Praise)

許多次，我就像是那浮雲，不知要往哪裡去。
(Many times I wander with no future, without a place I could go)
而如今我可以停止追尋，
(Now I know it's Your voice calling out to me)
是你的愛填滿我心，引領我與你同行。
(You've touched my life, filled me with hope, drawing me closer to You)
耶穌我懇求你，來改變我的生命，
(Jesus I ask of You, come change my life forever)
使我在患難之中喜樂與剛強。
(And when all my hope is gone, let me take joy in You)
耶穌我懇求你，使用我來改變這個世界。
(Jesus I ask of You, change me to love and to change the world)
賜我信心與勇氣，邁向這新的世紀，
(With faith I can live each day, to stand and proclaim your name)
願你榮耀的國度早日降臨。
(Establish Your kingdom here full of glory.)

Food outing
We went to Sofias - this Italian restaurant in Camberwell.. and to show you how large the portions are, check my Facebook later when I upload the pix.

Why I nearly KO on Day 1 of Australian posting
My posting is in the city, so since the orientation briefing starts at 8am, to get there required me to wake up at 5.45am (didn't get a good night sleep though, woke up at 2 and 4 am respectively), take the 1st bus from the Halls at 6.37am to Clayton. By the time I got dressed its already 6.30am, so I had to dash to the bus stop although was feeling super sleepy like a zombie.. Upon arrival at the hospital, after a short orientation briefing, we were sent to look for our supervisors. Mine for cardiothoracic surgery was away, so we decided to look for the neurosurgery one instead.

As we entered the seminar room, he was seated there, and looked at the 3 of us one kind.
Consultant: Now, I might as well be honest and give you the shock treatment now, so that you guys can work harder later. Firstly, I don't care what you think of me, but I will not hesitate to fail you if I'm not happy with your performance - and I will not apologise for it, for I am a very hard person to impress. You should count yourselves privileged that this is the most sought after rotation in the whole of Monash, with over 100 students fighting for it, and sorry to say that we can only accomodate limited students at any 1 time (around 3-4). Is this your 1st choice?
Me: No, we were allocated (do we have a choice? apparently Australians do have a preference).
Consultant: Ok.. tell me, what will the patient with L5 radiculopathy present with?
A group member: Foot drop.
Consultant: Yes, foot drop! Both of you knew it but hesitated. I don't like that. This will not be tolerated. I'm going to give you both homework - pick 1 of back pain or neck pain. 1stly, come up with a 20-minute presentation on the topic regarding causes, reasons for referral, evidence-based treatment etc. And I want PEER-REVIEWED JOURNALS.. Don't copy and paste from textbooks or websites coz that insults our intelligence. 2ndly, clerk a patient, follow that patient pre-op, during the surgery and review him post-op, then present to me a detailed long case. These 2 will contribute to me marking your PIA assessment, clear?
Me: *swt*
Later got clinic from 2-4.30pm, and I asked the registrar whether we are done for the day, and he told me to ask the consultant.
Consultant: What? Eh, you come here.. *points to registrar* Medical student wants to make a move wor.. How ar? Not yet even 6pm.. I tell you what, this hardworking registrar of mine came and slept overnight at the hospital previously when she was a medical student, and she got to see all the late night exciting cases.. She is on call tonight. You follow her to the wards now, and do whatever she asks you to do, until she decides to dismiss you. And make sure you come in before 7am for rounds every weekday morning (meaning I have to wake up at 4.45am for the next 6 weeks, since cardiothoracic surgery rounds also start at 7am)..
Registrar: *sympathetic* I think ar, you better not plan anything or go out for the next 3 weeks. Neurosurgery is fun, you see.. but it is only so if you know your stuff.

My quiet time and plans would have taken a beating, and I'm not really the smartest of students (neuro is my weakest point), but as I sneaked in a short devotion over lunch fast and pray, I got reminded of a line from the movie 'Facing the Giants'..

David Childers: Why would God make me so small and weak?
Larry (father): To show how mighty He is.

I know it's a challenging 3 weeks, but I wanna believe that I will pull through by God's grace.

Psalm 121:1-3; I lift up my eyes to the hills — where does my help come from? My help comes from the LORD, the Maker of heaven and earth. He will not let your foot slip — he who watches over you will not slumber.