Stranded

I woke up this morning feeling a bit unwell. I still went to uni though because it was my turn to present the grand rounds for our last case and didn't want my snazzy powerpoint presentation to go to waste. However, by the end of the day I felt way out of it (physically and mentally) and so took a chance to have a rest on the train ride home. Now, the train I normally catch home in the evenings is an express train that continues up to the Central Coast and Newcastle, which means it travels for long stretches between each stop; my stop is usually the second one - beyond that, I have no knowledge of where the train goes to.

I don't know how it happened, but I woke up to find the train almost empty, pulling into a station that I had never heard of. If I felt sick before getting on the train, it was nothing compared to how I now felt. I was so tired and overwhelmed that I couldn't even muster the energy to get out of my seat and find out where on earth I was. So I just started crying. I know it's stupid - for God's sake, I've travelled overseas alone and been in way trickier situations! But I really just felt so exhausted and defeated. And some days, you really just want to be in the comfort of your own abode.

Anyway, two hours later I finally made it home. Le sigh!

(If you are wondering about the point of this story, allow me to share some insight about a long-standing dream of mine: to own a car and finally stop being at the mercy of the public transport system)/

Back...

...to the old smoke - tall buildings, traffic lights, crowds, chaos, family... oh my, it's only been two weeks but I think I'm going to have adjustment issues :-S

We have to fill out an evaluation form after each placement we do and one of the questions is "How has the experience impacted on your ambitions to practice rurally?" . For me, the experience has been revolutionary. Born and bred in major cities, here and overseas, I've never ventured off the beaten track. I had a lot of misconceptions about life in a small country town, socially and vocationally with regards to working there as a doctor - all of which have been dispelled by this experience. I was expecting the people to be a bit conservative and wary of strangers (not just from the city, but essentially from half-way across the world!) coming in to their town without the promise that they'd give something back. This was certainly not the reception I received; and I'm not sure if it's because Mudgee has a higher flow of tourists than other rural areas, but the people were extremely friendly, accommodating and welcoming. They also practiced good olde fashioned manners, which is a rare sight here: tipping their hats or greeting you as you walked down the street; holding the door open for you to pass; inviting you home for dinner after knowing you for only a few days; insisting that they pay for your coffee every morning!! I also really appreciated the wider spaces, fewer crowds and slower pace of life, much more than I envisioned I would. And of course, everyone really does know everyone elses' business - which may be good or bad, depending on what business of your's they know :-P.

From a medical practice perspective, the main differences that stood out for me were the greater responsibilities placed on GPs and nurses to hold up the health-care system and look after everyone's needs as much as they can. With the exception of regular visitors, they don't always have the luxury of passing the care of someone onto a specialist; so they manage a lot of cases in their clinics or the ED, that a specialist would otherwise take care of in the city. At the same time, the situation isn't as remote as I imagined it would be - for serious cases, care in Dubbo or Sydney is just a referral flight away (and the costs are covered of course). Also, because of the visiting specialists, there is access to a specialist if you really needed to see one in a non-emergency situation, every now and then (which is about the same access you would have if you lived in the city because it takes forever - read: weeks or months - to get an appointment with one in the city anyway!).

Overall, an extremely positive experience for me and I can't wait to return next year. Long-term, if I went into general practice, I wouldn't practice it anywhere but in a rural setting. Anyway, enough ranting from me. I'll let you decide: take a trip and see for youself!

Mudgee, Day 12 - One Last Drink

Last day in Mudgee :-( Dr P was going to be away today so I organised beforehand to spend my last day doing vampiring in the pathology room. I really think with some skills, it's just a matter of getting 50 or so under your belt, before you can rest easy and say, "I can do it" (note - 50 was just an arbitrary number that I've pulled out of nowhere but I'm sure there's been research done showing how many times are ideal). One thing I did notice today though (that I hadn't noticed before), is that I get nervous if the patient is nervous; and I'm consequently more likely to miss :-S They have a bed in the pathology room for people who look like they're "fainters" - I tended to just put anyone who was nervous on there because it relaxed them a bit. I don't know; it probably seems a bit excessive but I guess whatever is comfortable - for the patient and yourself - is ideal, right?

Anyway, off to pack my bags and have one last bubble bath in my killer spa tub. I can't really sleep because if I do then I won't wake up in time for my 6.30am bus, so I'm going to see the break of dawn in Mudgee watching DVDs. I'm down to my very last DVD; my all-time favourite movie, "Sleepless in Seattle". Shameful, I know :-P

* PS - needless to point out, but because some of you give me less credit for common-sense and ethics than you think I may have: YES, the patient's permission was granted to take and publish this photo.

Mudgee, Day 11 - Happy Bowel Day

A visiting surgeon from Orange came to town today to cover a general surgery list, and Dr J (one of the GP/anaesthetists) agreed to having me tag-along and watch for the day. As it turned out, the surgeon himself was really keen to teach and because most of the procedures were scopes (there was also a lap chole and hernia repair), he had the aid of a screen to guide us through what he was doing, tutorial-style. He also asked questions which, naturally, presented prime opportunity for me display my knowledge (bah! or rather lack thereof!!); so, just in case anyone had a doubt in their mind, let me reaffirm the fact that I really, utterly, hopelessly know nothing :-S But alas, I keep swimming because I live in the hope that oneday I'll be able to stop writing about how little I know (and then you can assume that I've started knowing). Enough about that/...

Overall, it was a very relaxing and interesting session in theatres; particularly since I'd had a bit of exposure to GI diagnostical & surgical procedures last year when I went to Fiji - and also because we just finished doing the GI block at uni :-P Mind you, I spent most of the time close to Dr J's side while he shared some of his insights about anaesthetics. Speaking of which, it was actually pretty weird because in all of the scopes that were done today with a mild propofol sedation, all the patients came 'round at some point during the procedure and started writhing countinuously until more anaesthetic was given - is that normal? Why not maintain the sedation throughout, rather than allowing it to start wearing off before administering a new dose? Hmmm...so, I got a chance to practice inserting IV cannulas as well which, I'm discovering, is a damn-lot harder in real life than on those plastic arms :-S Luckily I only missed once; but I'm still working on getting a smooth technique thing happening here. Once I go back to uni next week, I should probably try to spend more time practising cannulations in the clinical skills lab and working on my "flicking" skills :-P

Anyway (and I just had to add this...), in the evening the Drs took me out for dinner and I had an amazing hot chocolate fondant with mixed berry ice cream for dessert. It was *so* delicious!!

***

Oh, and another thing I wanted to mention: this afternoon, results came out for the mid-yearly exam that I sat two weeks' ago (the one that I was passively shit-scared about failing). Well, somehow - through some means that defy logic and are beyond my grasp of comprehension - I passed (overall and every domain)! Phew! I live one more day then, yeah?

Mudgee, Day 10 - Flying solo in Cas

I spent the day in hospital today, doing cas duty with Dr P. Although I've mostly been happy to just tag along and observe (because as per my previous post, I don't really know anything yet), Dr P insisted that the best way to learn is to swim out on your own. So throughout the day, he assigned me to patients and told me that he was going to leave me entirely responsible for taking their history, examining them, asking him to order any tests/investigations that I thought would be useful, and then forming a management plan. He said that he would let me go as far as I could within reason before intervening if he thought I was on the right track, but otherwise trust whatever choices I made. Argh (but of course it was mostly pretend because he reviewed all the patients again briefly and wrote notes in their folders ;-)!

The idea was probably scarier than the reality because, as I came to realise, he only assigned me patients who (based on the triage nurse's initial assessment) he deemed non-serious or life-threatening. This was completely fine by me of course, as the opportunity to do something like this on a real patient (read: not my perfectly healthy family or fellow med students!) with real signs and symptoms was amazingly invaluable! I was able to continue the whole way without him intervening at all for a few patients (female with an U+LRTI; male with gastro+nausea; female with syncope; kid with fever); but he also stepped in with a few patients who had red flag symptoms that he picked up when I reported the findings of the Hx and Ex back to him. In a few instances, he told me to go back and ask one or two questions that he thought may be significant and which turned out to change the most probable diagnosis altogether. While most diagnoses are based a combination of information derived from the Hx, Ex and Ix; it's scary to think that in some instances, one or two extra/different things swerve the likelihood towards something else. Like this one guy who presented with abdominal pain in his LIF. When I examined him I noticed that he had a scar in his RUQ (from a cholecystectomy) so I immediately took anything gallbladder-related off my list; in fact, I took the liver off my list all together as well and didn't bother to check for jaundice in the sclera because the pain was on the polar opposite end (you can see where I'm going with this right?!). Anyway, suspecting that his symptoms were just a flare up of the diverticulitis he was diagnosed with 3 weeks ago, I asked Dr P to write an order for blood tests, to which he added LFTs. When the results came back, his Bilirubin, GGT and ALP where all elevated so Dr P asked me to go back and ask about the colour of his urine and stools (which I'd completely omitted from the history (!)). Urine darker and stools paler than usual. Anyway, long-story short: it turned out that in addition to the flare-up of his diverticulitis, he also had a common bile duct obstruction.

Another day, another lesson learnt. I really know nothing... but I'm learning.

Mudgee, Day 9 - Diversity

There is an unfortunate misconception that general practice is not as exciting as other medical specialities; with the phrase "coughs, colds, tears & smears" used to depict what are perceived to be the most common presentations to GPs. This time last year, I had just completed the first of my series of GP placements, as part of the first year clinical program, in a busy inner-city GP clinic - and to my disappointment "coughs, colds, tears & smears" were indeed the order of the day :-S Enter GP in the rural setting and oh boy - the difference is remarkable...

I spent today sitting-in on consultations with the good Dr P in the hope of absorbing via osmosis a thing, or two, or ten of his multitudinous praiseworthy skills and habits. I was treated, in return, with a day full of peculiar presentations that I thought only existed in textbooks. Shingles, intussusception of the small bowel, neurosarcoidosis, Barrett's oesophagus, excessive bruising with denial of trauma (leukamia... or physical/sexual abuse, perhaps?), polymyalgia rheumatica, colovesicular fistula... Whao! Inevitably, the more experienced medical students/doctors/nurses out there are rolling their eyes at me a-la-"been there, done that!", but seriously, I'm just overwhelmed by the diversity.

Two truths were thus confirmed for me today:
1. I know nothing.
2. Rural GP really demands that you know your thing.

Seriously. Le sigh.

Mudgee, Day 8 - A Dose of Anaesthetics

At some point during the past year and a half year of my medical training, I fell in love with anaesthetics. I think the attraction is due to a combination of the common scientific territory that it shares with my undergrad major (neuroscience); the largely controlled nature of the field ("control-freak" here!!); the fact that it has changed surgery in a way that only the invention of antibiotics can rival; and the quirky combination of theory and prac work involved. So it was without hesitation that I took up the opportunity to hang out with the anaesthetics team during today's dental surgery list at the hospital. The procedures (mostly extractions) were done by a visiting dentist who comes up from Bathurst to Mudgee once a month; while the anaesthetist was a local GP-anaesthetist (Dr L) from the team of five at the medical centre.

All up, there were five procedures - three children and two adults - done under a GA. I was hoping to get a chance to intubate but when it came to it, I didn't feel comfortable practising something I didn't know very well on children (and unfortunately the adults had class III and IV airways, so again, not ideal for practising on!!). But no big deal - there'll be plenty of opportunities to practice in due time. I still got to cannulate and take bloods off patients before their procedures; plus I was assigned to "check-lung-sounds-are-present-and-equal-post-ETT-insertion" duty :-P

They say that anaesthetics is like flying a plane - smoooth execution of take-off and landing are crucial and make up the majority of the anaesthetist's role. Part of the take-off involves calming the patient down and reassuring them - no easy task in adults, let alone children. Luckily I'd gotten some insider tips from my good friend Andre who is an anaesthetics nurse, particularly in the way of making the induction like an adventure for the kiddies: "Hey kid, would you like to go into outer-space?" *Cue overhead lights* "Whao! Your rocket is ready! Just put on this astronaut (gas) mask and off we go counting down for lift off - ten! nine! eight! seven! six!...". They're asleep before five! Pretty neat stuff, yeah? Of course the landing is somewhat trickier :-S People tend to get quite irritable and aggitated after a GA - they'll try to sit up and some trash about wildy. This is where it helps to have strong and sturdy assistants around (particularly if, like me, you're not so yourself)... or else start working on upper body strength if you're planning on going into anaesthetics cos you sure as hell will need it!

Throughout the day Dr L gave me little tutes on the drugs he was using. My favourite is Suxamethonium because you can actually see it working it's way up the body via fasciculations that travel from the toes to the eyelids. Light sedation with Ketamine is also pretty interesting, especially if you have any conversations with the person during the procedure and then ask them what you talked about after the K has worn off. Twisted ;-P What's your favourite?

Mudgee, Days 6 & 7 - Weekend Road-Trip

My parents came to visit me for the weekend after I couldn't stop raving to them on the phone every night about how gorgeous my little country town is! We went for a drive around the region into neighbouring townships - up to Gulgong, then down south to Lue, Rylstone and Kandos. I'm somewhat perplexed now as to why people choose to flock en masse in coastal cities leaving vasts of endless spaces inland largely uninhabited. Seriously? Country NSW is breath-takingly beautiful and relaxing; the winding roads, open fields, rolling hills... I'm going to feel a bit claustrophobic when I re-integrate back to the city in a week's time :-S Here are some pics from our trip:


















Oh, and my weekend wasn't totally med-free. Dr P called me at 11pm on Saturday night, telling me that he was going to do an emergency Caesar if I wanted to watch? I think I'm some sort of Caesar magnet - everytime I'm due to watch an NVD it turns into a Caesar. In between this placement and my overseas one last year, I've seen 10 Caesars to 1 NVD (well, to be honest I was on a surgical rotation last year and only ducked in to labour ward for an afternoon in the hope of seeing at least 1 NVD :-P). Anyway, it was still beautiful to watch last night, especially when the dad started crying. Awww *warm and fuzzy!*.

Mudgee, Day 5 - Things happen at night in small towns too

Exhausted! Dr P and I were on cas-duty in the ED this evening after spending the day taking "walk-in" consultations at the medical centre. I just got home and I'm *so* exhausted! Let's recap what happened (again I'm conscious that it's a small town so in this instance while I am going to write about what happened, I'll change any obvious identifying features):

5.30pm: arrive at cas - Dr P asks me to interview and examine a patient who suffered a workplace injury to his right hand, then heads off to maternity ward to attend to a case that I'm not involved in. Middle-aged man, with an obviously deformity in his right hand just proximal to the 4th MCP joint (and causing the right knuckle to become inverted). Complaining of pain and weakness, but on examination his motor strength, range of mobility and sensation are normal. DDx: sprain, strain, soft tissue injury, fracture? Report back to Dr P who has returned from maternity. Orders an X-ray which reveals a spiral/oblique fracture to his 4th MC. Can't really do much in the way of "fixing" these kinds of fractures with a cast (I guess the intrinsic muscles, tendons and fascial sheaths of the hand have an inbuilt stabilising "cast" within them) so we bandage it up for him and ask him to return if the pain get significantly worse over the next few days.

6.00pm: attend to an elderly woman with colicky pain in her RUQ who is febrile and has been vomiting all day. Suspected cholecystitis - confirmed by an ultrasound (which shows multiple gallstones in the bile duct) and something in her blood-test (maybe a raised wbc count, GGT and alk phosphate levels?). Call Dubbo Base Hospital to get a surgical consult - surgeon advises to "wait it out" before considering a cholecystectomy. Inform patient and send her up to the wards.

6.30pm: Dr P attends to a patient with abdominal pain and sends me to see an elderly man with "flu-like" symptoms. Take a respiratory history and examination - patient is in obvious respiratory distress and his lungs sound pretty crappy (crackly, wheezy, gunky). Pneumonia, swine-flu (!), LRTI, bronchitis? Report back to Dr P who orders a CXR, which reveals diffuse interstitial lung opacities consistent with pulmonary fibrosis. Oh, and he had some LRTI.

7.00pm: Start talking about whether to send aforementioned man up to the ward where he could potentially infect other people but never finish discussion because a code is called to maternity. Dr P bolts, I bolt after him then realise it's probably for his special-case patient so I stop, turn around and walk back to the ED. As I walk in I look down and realise there are a couple of spots of blood on the floor. My eyes quickly follow a short trail around the corner to a man collapsed on the ground, drenched in blood. Lots of blood. Everywhere. Lots and lots of blood everywhere. On his pants, on his top, all down his back, all over his face and covering the entire back of his head. He's semi-conscious. All of a sudden, the nurses see him too and about five people simultaneously find the nearest pair of gloves and run up to him. We discover pretty quickly that he's bleeding from the back of his head (occipital region) - puncture wound that's severed a major artery completely. God Almighty - the head is such a bleeder! I stick my finger in the wound while the others find guaze/padding. We somehow manage to get him on a bed with my hand now applying pressure through thick padding directly onto the wound. It's futile - I can feel the bleeder throbbing and the pad saturated with blood. Warm, free-flowing blood is unnatural and creepy. One of the nurses tries to cannulate him and misses, once, twice, seven times!! He's lost so much blood his peripheral vessels are shutting down. His BP is ~ 85/40 and skin is icy cold. She eventually gets in and starts a free-flowing bag of saline. At some stage someone realises that because Dr P is attending a code in maternity, we don't actually have a doctor with us (!), so Dr J (a GP-anaesthetist) who is the second doctor on-call gets called in. He puts in another line (also misses a few times!), then orders an x-ray to clear his C-Spine because we find out that the mechanism of injury is a fall on the head. C-spine cleared, pupils equal and responsive to light, patient semi-alert (can squeeze hands and move toes) - patient positioned laterally and I can finally release my hand of its compressive role. Dr J inspects as best as he can with blood still gushing out of the wound then implants his pinky firmly into the bleeder while he sorts out what to do next. Many attempts are made to stop the bleeding - all in vain though :-S Finally tries to settle things down by stitching everything he can latch onto the needle together, both edges of the wound, and prays to whomever it is he believes in that the patient doesn't develop a massive epicranial haematoma. Does the trick (or so it appears)... bandage and clean him up (realise that he looks quite handsome without the veil of blood all over his face!). Keep him in overnight in the ED. Someone finally gets a chance to sit down and suss out what actually happened - find out, amongst other things, that he DROVE HIMSELF TO THE HOSPITAL!! Oh. Dear. Lord.

8.30pm: find Dr P and watch him attend two teenagers who had a head-on collision whilst playing foodball, leaving each with a pretty impressive cut - the first above his right eye, the second on his left cheek. The former gets stitches, the latter gets glue.

9.00pm: three patients in a row attend complaining of abdominal pain and episodes of vomiting. I'm told by Dr P that, being a Friday night, the key task is to rule out the worse case scenario (ie - need for surgery) because then arrangements can be made for transfers to Dubbo or Sydney ASAP.
- First patient: 10 year old girl complaining of pain over McBurney's point, has obvious guarding, but nil tenderness, rigidity, rebound tenderness or loss of appetite - appendicitis therefore unlikely. Is shit-scared of needles and thinks that I'm hiding one in my pocket that I'm going to pull out surreptitiously and jab her with - I assure her that I have no such intentions. Send her home and asked to return if worse.
- Second patient: 18 year old girl complaining of nausea and a generally-distributed cramping pain. "Any chance you might be pregnant?" - "Nope, I have an Implanon". Patient suspects it might be from a dodgy sausage roll. Good enough to leave it at that. I give her an IM gluteal shot of Maxalon and Buscopan and she's discharged. Asked to return if worse.
- Third patient: 3 year old girl - was febrile and vomiting earlier in the day but currently asymptomatic. Mum seems frustrated that her kid is now perfectly fine and happy when a few hours' ago she wasn't. Dr P tells her she did the right thing by acting on instinct and that kids have a tendency to oscillate symptom-wise when they're ill. Panadol, sent home, asked to return if worse.

10.00pm: Monitor Mr Head-Bleeder for an hour, taking his blood pressure manually on a regular basis because the damn machine isn't working properly. Dr P attends to his case in maternity. Chat to the nurses about working in a small rural town hospital - highs, lows, in-betweens? All are, for the most part, very happy and feel supported by the system. They tell me about the recently-released management guidelines that are designed to assist them in situations when a doctor is absent. Main complaints are about locum staff covering 24 or 48 hour weekend shifts - "they're rude, inconsiderate, unattentive, inefficient and clearly doing it for the money" (apparently they get over $5000 to cover a weekend - shit, no wonder NSWHealth is in debt!!). They give me pointers about how to get on the nurses' good side, which I note down very carefully.

11.00pm: since the ED is clear and there is no one waiting to be seen, Dr P and I decide to call it a night and retire to our respective abodes. Technically-speaking we're still on-call but we don't have to be at the hospital if we're not needed. I'm so totally exhausted even though the night is still young. I'm shaking from the thrill of having spent my first evening in an ED - I think I've found another favourite niche of medicine.

Above all, I'm rather impressed that things happen at night in small towns too...

Mudgee, Day 4 - Your Doctor May Love/Hate You

This is sort of beyond the topic of rural medicine, but in light of some of observations that I've made over the last few days, I wanted to comment a bit about doctors' personalities. There's a scene in Moulin Rouge where Satine makes a remark with regards to her profession along the lines of, "I'm paid to make men believe what they want to believe". Now, far from comparing doctors to courtesans, I feel like in some ways we do that as well.

This has mostly stemmed from observing the behaviour of my mentor, Dr P - who is an absolute darling with his patients (and to be fair, with everyone around him). During their time whilst under his care, he makes every patient feel - then and there - like they're the most important thing to him in the world. Regardless of how trivial their presenting complaint is, he has no limits on the amount of energy and care he expends on each person individually. As a habitual "eye-roller" myself, this has managed to concurrently kill me and also give me an enormous amount of respect for his ability to sustain such a consistently high level of compassion.

Moreover, however, the cynic in me has started to question the extent of his seemingly endless attention-giving spurges. I mean, he looks after at least 20-30 different people on any given day - and each person is left feeling like, "wow , this person really is genuinely and unconditionally concerned about me and only me!" - so that's a damn lot of people who feel supposedly uniquely loved by their doc. Now, I'll assume that because Dr P is by and large a normal guy, his display of such affections for his patients is mostly just him doing his job very well. So, call me naive in asking this - but does the general public know that it's all really a part of the job?

I don't have my own GP (I just go see the "next available person", who is usually a locum, at my local medical centre when - if - I ever need anything), so thankfully I've never believed that I'm anyone's whole world in a medical context. However, I won't deny that the idea of unrequitted concern and attention by a respectable member of society is very appealing and certainly a trap that I could fall into (now don't y'all start thinking I'm deprived, a-la-Freud), but seriously, you get what I'm saying right? Anyway, my point is - despite the appearance of genuine concern for you and only you - truth is, your doctor "cares about" hundreds of other people and you only have a very minute slice of their love pie. Go find attention elsewhere. *Rolls eyes...*

Okay, that was my random BS post for the week... I told you I have a lot to learn in the domains of compassion and humanity.

***

Onto what I got upto in the town of Mudge. So today, the good Dr P set me up in a consultation room to interview and examine patients on my own; outline DDx, Ix and a Mx plan; before presenting back to him. It was actually a lot of fun despite the fact that I had to shamefully display my lack of talent or abilities to all involved :-S I saw some pretty cool stuff though - people in rural towns get sick too, who woulda thought?! Ha! Then in the evening, Dr P invited me over to his place for dinner with his family which was quite delightful. Which reminds me, can I point out that being a rural GP is by no means the family friendly "life-style" option that I envisioned it to be? Dr P leaves home at about 8am every morning and does not return before 7pm - sometimes later. It's pretty intense because there are only about 10 doctors between his practice and the other medical centre in the area that look after GP consultations during the day and share hospital shifts at other times with additional roles as obs/gyn, anaesthetics and ED physicians. There is a MASS shortage of doctors (especially female doctors, of which there are currently none working in the the medical centre that I'm at) and it takes about a month to make an appointment to see your GP (they have "walk-ins" but you have to wait for hours and you're seen by who-ever is on walk-in duty for that day so there's little in the way of consistency there). Also a lot medical investigations like MRIs and EEGs have to be done in external hospitals with these facilities (usually in Dubbo or Sydney) - which is inevitably frustrating for the patients when these tests are ordered (and I would hazard a guess that most people would be tempted to just not get them done if it means having to travel for a couple of hours out of town). So, yeah, just some interesting thoughts... I'm on-duty in "cas" with Dr P tomorrow - it's a Friday night so it should be interesting, yeah?

Mudgee, Day 3 - Venepuncture Heaven

Today I died and went to venepuncture heaven (aka the pathology clinic). One of the first things I learnt in med school was how to take blood - I've practised countless times on fake arms, friends' arms and familys' arms; but by jolly, the thrill has yet to wear off! I guess the biggest difference in today's session (as opposed to previous venepuncture stints) was that I spent the entire day doing it, in the spirit of "practice makes perfect".

Venepuncture isn't a particularly difficult skill to acquire by any means; but the anatomical variations are enough to spice up the procedure and keep you in a hypervigilant state. It was particularly interesting, from an educational point of view, to be exposed to such a wide array of antecubital fossae - from the knotted and jumpy veins hiding underneath the thin, wrinkled skin of Mrs Senior-Citizen; to the deeeep, non-palpable veins lurking underneath the too-thick subcut layer of Mr Morbidly-Obese. I know it's hard to guage improvement with these skills because of the variable presentations, but I feel so much more confident now with getting harder veins; deciding on what to do next on realising I've missed the vein; as well as the pre- and post- set-ups. These aren't particularly challenging tasks either, but it takes a bit of practice to develop a systematic way of going about a multi-tasked procedure without looking:
a) Awkward
b) Figedity
c) Like a complete idiot who has no idea what they're doing
d) All of the above
I don't know, it's hard to describe; I mean, it's just venepuncture right?! But I'm starting to feel a bit like a significant portion of successful procedural medical work involves coordinated and efficient execution of tasks; done, of course, with as much confidence as your situation permits. It's not what you can do - but how smoothly you can do it. This is where practice comes in.

Anyway, the day also saw me do some deltoid IM injections (immunisations galore!), give desensitisation therapy antigens, and take out lots of sutures :-S Again, the "practice makes perfect" rule applies here. On the whole, another invaluable day of exposure and practice - it's going to be really hard for me to go back to doing BS theorical learning when semester two resumes in a couple of weeks.

So, off to make dinner and then watch some DVDs. Oh and in case you were wondering, I missed two veins today (out of about fifteen). I'm getting there...

Mudgee, Day 2 - Theatre Day

So, everyday Tuesday is "Theatre Day" at the medical centre. What this involves is the doctors taking it in turns to use the day surgery room to perform various procedures, including draining cysts/abcesses, putting in and taking out Implanons, biopsies, doing skin grafts, etc; but of course, being in an Australia setting - and a rural one at that - most procedures involve excising suspected BCCs and SCCs (basal and squamous cell carcinomas). I spent practically the whole day in the theatre, and was obligingly accommodated for by all the doctors during their procedures. Most of them operated on the "see one, do one, teach one" principle; and so they demonstrated to me how a certain procedure was done before letting me have a go. Again, very confronting (I really don't like being thrown in the deep end!!) - but seriously, pure gold in terms of experience. I was very impressed with how despite there being only one room, the system was very efficient and practical - most procedures took only 15 minutes so quite a few cases were done throughout the day (and I wasn't fobbed off to stand in the corner for the entire day either).

Later on in the afternoon. Dr P and I went down to the hospital to check on a little bub born three days ago who wasn't sucking or feeding; had vomited the expressed breast milk that was given to him via an NGT; and was more or less sleeping like a sloth since birth (read: totally lethargic and somewhat unresponsive to the world around him). In brief, he was having a pretty rough start. We spent a good half hour or so setting up a drip to administer IV fluid therapy (the poor little poppet didn't even whince while he was being cannulated even though he was jabbed like a pin cushion before it was in). Then the doctor decided it would be best to transfer him to a big tertiary hospital in Dubbo or Sydney, so the rest of the evening was spent working out the logistics of that - calling different hospitals, organising an ambulance to drive mum and bub to Mudgee airport for the helicopter ride to the tert hospital, preparing bub for the flight, writing out discharge forms, etc. There was so much to get done, and so many people working at different ends to try to get this baby looked after - but really, the whole affair was pulled off quite smoothly and they made it out of Mudgee before I'd even left the hospital!

I guess what I learnt today is that some things have a quick fix solution; others don't. So, unlike the worlds of business and commerce, medical practice cannot always operate according to a cost-benefit system; where the greater your input, the better the outcome. And I don't know if it's just the emotional factors (being a tiny little munchkin and all), but I found myself thinking that the hours spent helping just that one patient had just as much value (if not more), than crunching (in production-line style) through a full day of consultations, caseloads and procedures

Mudgee, Day 1 - Welcome to Mudgee

You know that the school of life is out to teach you a lesson or two when you discover, just 10 minutes before it's due to leave, that the train that was supposed to take you to your rural town for your placement has been cancelled... And you find yourself stranded at Central Station with an excessive amount of heavy luggage... And your pride won't allow you to call your parents to ask if they can please rescue you... And it's dusk... And cold... Oh, and did I mention that your destination is about 5 (public transport) hours away?

You realise however, that you have indeed learnt life-skills over the years and that you are more resourceful than you imagined, when - one train and two bus rides later - you manage to still make it there before midnight.

And so began my first John Flynn rural placement...

***

So where am I exactly? I'm in Mudgee, a town in central New South Wales, about 260km north-west of Sydney. Mudgee has a population of ~ 9000 people and the district is famous for its fine wine (oh the irony of a strict non-drinker being sent to such a place!); gourmet food; and fresh rural produce including cattle, sheep, wheat, olives, fruit, tomatoes, corn, honey and dairy products.

I'm staying at this gorgeous hotel in the "city centre" called the Cobb & Co Court Boutique Hotel, which is deliciously cosy and comfortable. The town itself is very quaint and organised, with typical country town qualities that I could definitely get used to: no traffic (and therefore no traffic lights!), wider roads, close proximity of destinations, no apartment blocks or high-rise buildings, kitsch cafes and quirky little shops. Each house is neatly set on half-acre block of land, with a well-trimmed garden and a white-picket fence: think Lego-land.












My mentor (Dr P) is a GP who, as with most rural GPs, also has training in obstetrics/gyn. Along with a team of five other doctors (as well as nursing and allied health workers), he works at one of the the local medical practices and the district hospital. Originally a Sydney-sider, he moved to Mudgee about 5 years ago for the greater opportunities that rural practice offers GPs to diversify and undertake procedural work.

I started the day by joining Dr P on his quick morning round at the hospital. The doctors at the medical practice have a rotating 24 hour "cas" (ie, casualty department or ED) roster at the hospital - and, of course, whomever they admit while on duty becomes their patient for the duration of the patient's hospital stay. Dr P saw the three patients whom he had admitted the previous day; before we scooted off to the medical practice for his consultations. Because Mudgee is such a small place, it's going to be very hard for me to write about what I saw without disclosing potentially-traceable private information :-| I think I can safely write though that the casemix of patients were very different to what I'd seen on my Inner Sydney GP placements last year. Whereas "tears and smears" were the dominant presentations in the latter; a lot of today's consultations were more acute and serious (some even requiring immediate hospital transfers and admissions). Prac-wise, I was asked to do various examinations and then report back to him; a task that I found concurrently challenging and extremely useful. These opportunities present rare moments where I feel like I may have actually learnt something in the last one and a half years. But I still have such a long way to go, and not just in terms of medical knowledge. Case in point: my mentor is the epitome of the compassionate and considerate listener; he is very giving of himself and, rather than rolling his eyes at those patients who (it seems to me) just come in for a chat or to complain about something trivial, he treats everyone like their's is the most important case to him in the world. I could definitely take a leaf from his book.

Anyway, tonight Dr P is on-call (from home) for all obstetric cases at the hospital and, because I took up his offer to contact me and pick me up on his way to hospital if anything comes up, I'm sort of "on-call" too . He's expecting one birth this week, but he thinks she may hold out till tomorrow. Personally, I have secret hopes for him to get called in tonight (I keep checking my phone every two minutes and am even considering wearing my scrubs to bed :-P)... we'll see.

I'll leave you with some photos of where I'm staying and the surrounding area:

P!nk

I just came back from doing a first aid duty at the P!nk concert. I'd heard feedback from members who'd covered the weekend concerts that it had gotten pretty rowdy towards the end; but, being a weeknight and all, I thought the crowds would behave themselves tonight. Well, let's just say that the good people of Sydney proved me wrong and demonstrated quite passionately that a weeknight is no barrier to getting pissed off your head and committing associated acts of general stupidity. But hey, I should probably allude indifference at this stage for the sake of upholding the golden rule of working in health-care: we don't judge here (*rolls eyes*).

Anyway, it actually wasn't too bad (and really, from an educational point of view, one person's misfortune is another person's treasure :-P). We had a few mosh-pit nasties - mainly sprained ankles, crowd-induced heat exhaustion (probably precipitated by dehydration from the alcohol), and intoxications of varying degrees/aetiologies. A lady with a sprain injury asked us if we could take her to the first-aid room to x-ray her ankle so as to make sure it wasn't broken (seriously?!)... I asked her how much alcohol she'd thus far consumed. We haven't set up a portable ED for you here woman! Seriously?! One of the teams had to deal with an attendant who fell down a flight of stairs as she was leaving the venue and knocked her head hard on landing. Apparently she was pretty out of it but they couldn't tell whether it was from alcohol or a potential head injury. Not cool :-/ I wish people would look after themselves a bit more sometimes (ha! The defining public health issue of our times, eh?). Le sigh.

All-in-all, it was a pretty busy and interesting night. Ooh, and as for the concert itself - amaaazing!! Probably not to everyone's taste, but I'm a big fan of P!nk so I really enjoyed it. I even managed to capture a few shots ;-P

So much to do, so little time

Now that I'm on the other side of my hideous mid-yearly exam, I can start doing/thinking about other things. Unfortunately my brain is so full to the brim (nay, overflowing!) with mental to-do lists that I've been tossing and turning for the past hour trying to fall asleep, but to no avail. I need to off-load.


St John's First Aid duties and shifts at work:

• Wednesday 10/6 (1830-2300) - "Pink Concert" First Aid (FA) duty
• Thursday 11/6 (1600-2100) - Shift at work
• Friday 12/6 (0830-1530) - "SACS Fun Day" FA duty - CANCELLED
• Friday 12/6 (1800-2100) - "Fire Water" FA duty
• Saturday 13/6 (0830-1730) - Shift at work
• Sunday 14/6 (0930-1500) - "MS Walk/Run" FA duty

Social and family stuff (not many on this one!):

• Wednesday 10/6 (1330-?) - Lunch with Raidah
• Return calls and reply to long overdue emails, sms and facebook messages :-S
• Try to spend at least a few hours with the 'rents, sis and bro-in-law :-/

The varsity list (sadly, it's never truly holiday time):

• Finish off CCS notes (--> week 17)
  
• Print BSC notes for past 17 weeks including anatomy to take to Mudgee (don't ask...)
• Do week 17 and 18 group LOs and submit online
• Prepare week 17 grand-rounds presentation
  
• Write up past 5 weeks' worth of reflections for professional portfolio and update clinical skills log-book

Preparation for Mudgee:

• Pack bag --> clothes/toiletries, steth, scrubs, varisty work, lap-top, camera, dvds and books
• Practice clinical examinations/skills that I may need in Mudgee: taking/writing/summarising a Hx, antenatal examinations, injections, suturing, cannulations, intubations
• Withdraw some $$$ from the bank to take with
• Buy some sustenance food (ie chocolate) for long train ride to Mudgee
• Get a present for my mentor (any ideas??)
  

Miscellaneous:

• Clean room
• Apply for a credit card
• Call Centrelink
• Sleep, if there's time left-over :-P

(Indicates they've been done, yo!)

Nobody knows

I get a bit frustrated sometimes when people make assumptions about the medical profession, and associated lifestyle, which I suspect aren't necessarily true. "Suspect", I write, because as a 2nd year student I personally know very little (yet!) about what's actually involved. However, some truths that I have come to observe, for example, include the fact that it's really not a very glamorous job, nor does it necessarily lend to a particularly comfortable lifestyle, despite the money that may (or may not) be involved, etc, etc. In brief, I feel like people on the outside rarely appreciate the demands and realities of the profession. Big deal, yes? Well, not really... because earlier on this evening, I came to realise quite an ironic twist to this phenomenon (which is probably already obvious to the well-organised mind): how much do we know about other peoples' professions?

So, my best friend Jess has just started teaching this year. First year out of uni, she's landed a full-time job as a kindergarten teacher at a well-established school. Now I don't know about you, but the image that's conjured in my mind when I think of teaching kindergarten is that of having a jolly-good time finger-painting and story-reading to a group of cute and innocent, rosy-cheeked, 5-year olds (let's add rainbows and bunny rabbits in the backdrop for good measure). Right? WRONG!! What she described to me tonight over dessert and coffee, was nothing short of trying to tame rascals in a juvenile detention centre. She has this child in her class with demonic tendencies who frequently breaks into violent outbursts and starts to throw things at the other children and my poor friend. Then there's the kid who likes to sit under the desk for reasons only God will ever know; and of course, being sheep, other kids follow suit and rebel accordingly in their own wicked way(s). Play-ground duty --> more like zoo-keeping duty!! Put those aside, the real challenge of course, is trying to deal with the bureaucracy of the place; with an unsupportive principal and his humble side-kick ass/principal, who turn a blind eye, tell her to pull herself together and do her job :-O

They don't know what we do; but then again, we don't know what they do either.

What would you do?

So while I fix my blog, I thought I would share this thought-provoking (albeit random) quote that I stumbled upon while I was flicking through one of my cousin's photo albums on fb. I believe it was taken at the University of British Columbia in Canada:



Simple as it is, it really moved me, no actually - scared me - when I first read it. I'm a massive control freak - I spend a lot of time finding out exactly what happened, what's happening and what's about to happen. But this... this... this just challenged me in such a peculiar way. I have an exam tomorrow and I know there are going to be a lot of questions that I won't know how to answer. But all that is just trivial compared to this question. I really don't know how to answer this one. What would you do?

Well, that's just annoying...

I was trying to clean up my blog and delete unpublished posts when I accidently deleted ALL my posts. Aw :-( Does anyone know how to retrieve lost posts? Grrr... this must be some sort of punishment I'm getting for procrastinating rather than studying for my mid-yearly exam tomorrow. Le sigh!