Break-it-up

I have a load of uni work that is quickly piling up into a mountain. 11 weeks into the (17-week) semester, I'm thinkin', "crap! what have I been doing all this time?!"

Doesn't help that, mentally, I just want to cruise through this year and put in the bare-minimum of effort required to scrape through. Still, it's dawning on me, "scraping through" still requires public health assignments to be handed in; journal club papers to be presented; and short-cases to be reviewed. Urgh!

One of the habits I've had to get back into practicing, is breaking tasks up into bite-size chunks, and chipping away at a seemingly overwhelming workload one bit at a time.

God that I wish for this year to pass painlessly! Pleeeease!!

In other news, today as I was walking to the train-station, I found myself becoming a nosy-onlooker at the scene of a car vs pedestrian accident. I watched with much apprehension as the ambos scooped up this poor semi-conscious woman (who was just innocently minding her own business, crossing the road at a pedestrian crossing, as you do..) and whizzed her off to hospital. I considered for a brief second running back up to the hospital (I assume they would have taken her to my clinical school hosp; which was only a few hundred metres from the scene of the accident); checking out her management in the ED and seeing that she was okay. But the sight of the pool of blood that was left on the road from her open head injury made me feel quite queasy.. and honestly, I decided that I preferred not to know the outcome, if there was a chance that it was going to be a bad one. *Shudder!* Anyway, I now have a renewed sense of utmost respect and admiration for ambulance officers.

Okay, enough said - time to hit the books!

Things are pretty good at the moment :-)

Dear Blog,

I'm sorry I abandoned you. I have so much to say and yet time - as it always and forever will be - is against me. I've finished O&G, general surgery, paeds and am now on the home-stretch with 4 weeks left of general medicine.

O&G was amazing, but very tiring! I have so much admiration for the registrars who continue to pull through restlessly, day and night. It's an incredibly rewarding speciality and I wish I had the energy to pursue it, but I honestly think that the long hours and exhausting on-call roster would get the better of me. The other thing - more than ever, I've renewed my resolve to work in medical aid work (I'm counting down the years until I'm capable of being able to stand on my own and contribute productively in the field)- and I have a feeling that gaining a fellowship in O&G from here would equip me with more skills that what I would need in a developing world setting. Seems a bit redundant being able to perform IVF and high-tech laparoscopic gynae surgery when what I essentially need to know is how to deliver a baby safely and do an emergency hysterectomy (as a last option to resolve PPH). So I've reset my aspirations and have rechanneled my plans towards becoming an Emergency Physician with a Dip of O&G. I'll write more about it later on, as things progress, and especially during/after my ED term next year, but for now, I'm excited once again. Excited about being in medicine and where it's going to take me. Hip hip hooray!

The other thing I'll mention is how much I enjoyed Paeds! Absolutely loved it and the characters along the way. The Paeds registrar in particular was so enthusiastic and inspiring; her work-ethic really came through and she went out of her way to make sure we (the students) were included in the team.

So 4 weeks left (then 1 week of stuvac and 1 week of exams). I can't believe how quickly this year has flown by! I'm on the homestretch folks! In 6 months I'll be applying for a job; then 6 months after that I will be on my final elective rotation, a few weeks off from finishing. I hope it's come through in this post, but if it hasn't I'll spell it out: I'm really happy, I feel at peace. I'm starting to see the light at the end of the tunnel and feel less like an aimless wanderer than I did when I first started almost 3 years ago. I've learnt a thing or two along the way, and I have a sense of direction of where I'd like to go with this knowledge. If you're reading this and you're still at the beginning of the journey: keep at it. It's seemingly long and endless, but oneday you will reach a point where you can not only look back and marvel and how far you've come; but also look ahead and feel that the road ahead isn't as daunting as it seemed when you first started and that there's no where else you'd rather be than where you are at that point.

Paradoxically...

Saturday morning, 3.30am, overnight shift in ED. I had just gone into the on-call room for a shut-eye when one of the interns popped in to let me know that the ambos were bringing in a middle-aged male in cardiac arrest. There was six of us in ED: an ED physician, 2 interns, 2 nurses and myself. Did I want to see it? "Hell yeah!" I thought, this is the only medicine worth seeing as far as some med students are concerned. Things are somewhat different on the other side now, you'll see what I mean.

He looked his age, but a little worse for wear. He'd been intubated by the ambos; and had defib pads on his bare chest. I stood back to watch as the scene unfolded, wanting and unwanting to be involved... it's a hard feeling to describe. A few minutes in, one of the interns told me to grab a pair of gloves and get ready to take over chest compressions. "Wha..? Err, okay.." I took over after from the start of a new cycle - and in that instant, I crossed the line; I became involved, in more ways than I wished to be, as events would later unfold. I'd done CPR before - on a 90 something year old already half-dead, dying old man in Fiji, just because protocol dictated we do so. At the time, I appreciated the practice, felt kind of sorry that I broke his rib cage, and was secretly grateful when they called it. This was so different, so much more intense, so much more involved... I'll keep coming back to that word. It was an intensely highly-sensory experience: I could smell the patient's sweat; hear the ventilator beep, puff and whirrr; feel the crunch beneath my hands as we'd surely broken his ribs; and see his empty eyes staring up at me. If anything, the eyes gave it away - he wasn't going to make it, even I knew that. In hindsight, I wish I didn't have that initial hunch that he'd already left us - I wonder if I would've compressed harder and more wilfully on his chest if it weren't the case? I wonder if that would have made a difference? Several rounds of compressions, a bolus of atropine or adrenaline, stop and re-assess, rotate through and do it all again... we gave him a fair go. Initially because it seemed he was gasping for air though the ETT, and then when that had stopped, for closure. And then we called it, just like that. Machines turned off, ventilator detached. Time of death: 04:05.

We stood back for a few moments to quietly reflect on what had happened and pray to whatever we believed in that he was is a better place now. Then one of the nurses looked up at me and said, "he's from a Middle-Eastern Muslim background, I think the family would really appreciate if you're there when Noel (the ED physician) tells them." It wasn't a suggestion, they all nodded in agreement and it was decided. Nothing in the world can prepare you for delivering the information we were about to. Nothing at all. We lead them into the family room - his wife, kids, brother and sister in law. Typical Arab-style, the extended family were all in the waiting room. Noel started to ask a few questions about how our patient came to be: straight-out-of-a-text-book heart attack presentation - so classical, it was heartbreaking. His wife recognised he was having a heart attack and urged him to go to the hospital. Shit! If only... ? Or maybe it wouldn't have made a difference... ? Who knows... ? Noel asked a few more questions, before finally putting it out there that, "we tried very hard..". The message passed over them. Noel looked at me and I said in a faint voice in Arabic, "God has taken his soul, may He have mercy on it".

The rest is of inconsequence. Life happens when you least expect it and people react in ways that they know how best to. The outcome is the same, no matter who delivered it, but I hope that being there in this sensitive moment made the situation a little bit easier for them. For me, suddenly, everything else in the ED that night seemed so trivial...

To be honest, I hated being the bearer of bad news to this family - worst feeling as far as the future doctor in me was concerned; more so than losing the patient I think. This family could have been mine, easily; the situation was so eerily close to home after what had happened with my mum last year. I was involved in a way I haven't been in a very long time, or ever even, with a patient and their family. But there's a lesson to be learnt in everything we do here. In the past few months before this happened, I'd noticed myself becoming increasingly blase about the people around me as patients and my role as a carer. A lot of the time I haven't even bothered asking the patient's name and I guess I've pushed this concern to the side thinking, "detachment in medicine can only be good", or they say so anyway. And then this. I won't deny that I've felt quite sad for the last few days, but now that the dust is starting to settle, I feel refreshingly at peace with the idea that I've at least felt something towards someone who I was looking after. It's paradoxical, I know. Guess I just didn't realise how much I missed it...

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 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...