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...

A rough patch on the greener grass

Half-way through my GP-rotation and the honeymoon period is definitely behind me. I never expected my GP-rotation to be so exhausting. This is really due to my main GP supervisor, who is just...so... mean! Today I cracked it. Today she made me cry. I'm too exhausted to write about in great lengths; she is simply just so exhausting! I wrote to the clinical supervisor/mentor of my home-base hospital asking for help:

Dear Mentor,

I hope you're well. I'm half-way through my GP rotation and wanted to raise a concern I had with one of my mentors. I have several GP supervisors that I work with in the practice - all of them are really wonderful and I love working with and learning from them. My main mentor, Dr X, however, is really quite harsh and strict. Her feedback is extremely helpful - don't get me wrong - she gives great advice about what you need to know to fill gaps in your knowledge; but her approach and mannerisms are quite destructive. If she asks a question and you don't know the answer, she pulverises you in front of the patient and makes you feel like a failure. I don't know if I'm just a little soft in that regard, but some of my experiences with her have been extremely stressful and quite frankly, just downright hurtful. I've been too scared to say anything to her about it because, all things standing, I think she means well and it's certainly not personal. On the contrary, I have thanked her for her feedback and am doing my best to remedy these gaps in my knowledge. But I still feel really upset about her demeaning approach and I'm not sure what to do. I know we're half-way through and if I can disregard any of my personal response to her approach, there is a lot to be gained from the wisdom she is offering. I was wondering if you can offer me any advice on how to approach this situation? I really want to learn from her; but at the same time I don't want to go home crying every night.

Thanks for you support,

Miss Purple Stethoscope


She replied straight away and told me she'd call me tomorrow to have a chat about it. Very, very grateful for her support; but still feeling stressed-out that this chat will come after a day spent with Dr X and God knows what sort of damage she'll have done to me by then. Thinking of having a mental health day tomorrow, but also feel deep down that it will be like admitting defeat. I know it seems excessive, but I've been tipped over the edge. And I'm a fairly tolerant person... if that's saying anything...

GP-Land...

... is a happy place, with candy-cane and fairy-floss; oh, and no ward rounds or running around a hospital trying to find people: the patients come to you - fancy that?! ... bliss!

***

*Snap out of day-dream for a bit*: I just found out this morning that one of the students doing the John Flynn Program has been placed in the Cocos Keeling and Christmas Islands! OmG! Extremely jealous!! I do love my rural community of Mudgee very much, but c'mon - outback NSW vs Islands in the middle of the Indian Ocean?! Hmmm, at least I now know it's a rural area of need that I can (and will!) venture to in working off my rural bondage.

OK, back to daydreaming...

Dear FMH,

I miss you everyday.

Come up to meet you, tell you I'm sorry
You don't know how lovely you are.
I had to find you, tell you I need you,
Tell you I set you apart.

Tell me your secrets and ask me your questions,
Oh lets go back to the start.
Running in circles, Comin' in tails
Heads on a science apart.

Nobody said it was easy,
It's such a shame for us to part.
Nobody said it was easy,
No one ever said it would be this hard.

Oh take me back to the start.

~ Coldplay, "The Scientist"

Learning how to be a doctor, one step at a time

Saturday night; interim weekend between two rotations. I've just finished the first of my two Surgical blocks (plastics and ortho) - the next one (gen surg) I will do later this year - and am about to start my General Practice block next week. Surgery was pretty awesome, plastics more so than ortho. Despite the early morning starts, the day went quickly as there was lots to do and we normally didn't stay past 5pm (though the surgeries would go past 10pm most nights). There was a pre-med student from the USA doing an "internship" in orthopedics during our time there and she was such as eager beaver, coming in very early and staying late every day; which made us look a bit bad, but hey, it's not as cut-throat here so we don't really feel the need to exert ourselves to excel. My supervisors in both plastics and ortho gave me really positive feedback in my competency assessment form; I feel quite accomplished that after 2 years of getting mediocre marks, my hard work is finally getting some recognition! On a personal level, I feel like I achieved what I set out to do in this rotation in the way of practising my hx and ex skills as well as some basic procedures, particular to a surgical context. I now feel more confident with a lot of bread and butter presentations/skills that I will no doubt encounter again in internship and beyond. Small steps, long way to go.. but I'm getting there, I'm learning how to be a doctor and look after people. Damn it feels good!

Some reflections on psych and surgery

Wow, I haven't posted on here in ages. It saddens me to think that I'm losing the ability to reflect constructively. I don't want to write about my trivialities just for the sake of it; so I guess I could also put my absence down to not having anything to reflect about. But here's a thought or two anyway, to fill the silence, if anything. So, of late, I finished my psych rotation and have started on surgery.

Psych was interesting, I learnt a lot, especially from my mentor who helped me see things with a bit more clarity, in a compassionate and pragmatic light, when all I could see before me was a damaged-beyond-repair, dysfunctional individual. It takes a very special group of people to be able to care about others in that way; and of that, I am quite envious. One of the things I didn't like about the psych rotation though was a particularly territorial (and often just downright rude) RMO - she didn't want students doing anything and would even tell us off for writing on hospital paper/progress notes! I hope her attitude damages her reputation when it comes time to apply for a training program. And that's all I have to say about that.

After psych I went back to my secondary home-base hospital to start on my surgery rotation. I did three weeks of plastic surgery there - which was everything I could have wished for in a rotation. The team I was attached to were amazing clinicians and teachers; and the RMO was just wonderful (*so* different to the psych RMO bitch). She was happy for us to get right in there and help out as vital members of the team. I got lots of practice in doing speedy histories and examinations when a plastics consult was called for in ED; interpreting hand x-rays (most of the cases where hand injuries); ward management of plastics patients; scrubbing and suturing; removing K-wires; as well as the usual cannulas, bloods and plaster casts. It was actually quite a refreshing change to go from the long-winded and twisted complexities of a psych patient to the straight-forward flow-chart style management of a plastics patient. Plus I loved being back in my home-base hospital: everyone is so friendly and there's this lovely feeling of comradery among all the staff. I have to say, these experiences are definitely steering my preferences towards internship at a smaller hospital in a couple of years (still too early to think about that though, so I shan't get ahead of myself).

Now I'm back in BTH to do two weeks of orthopaedics surgery (currently in my first week). It's been okay; I feel depressed about leaving my lovely plastics team, but that's not to say that I'm not getting along with the orthopods either. The consultants are very friendly and welcoming (one of them bought us coffee this morning before rounds) and are very happy for us to scrub in on their surgeries and attend their clinics. I scrubbed in on a total knee replacement today, which was tres cool and neat! I guess I don't really have a sensible explanation as to why I think it's "okay" rather than "great"; maybe it's just a relative thing, like, it's "okay" relative to plastics. The teaching has been pretty good though, especially from one of the registrars who (despite my annoyance at him calling me random names like "Billy" and "Med student no. 2" instead of my own name - wtf?!!) is kind enough to explain every process of whatever operation we're doing and talk to us about the presenting disease process. Anyway, I'm glad there's a long weekend coming up, I need sleep!! Will update again soon, tootle-pip!

Mentally Exhausted

Having just completed the first week of my psychiatry block, I thought I ought to take a minute or two to reflect on the week's past events and experiences. On the first day of my rotation, I was assigned to work in the ED and PECC Unit (Psychiatric Emergency Care Centre) with the psych team at a big tertiary hospital (BTH) in a somewhat notorious area of Sydney. The other members of my group were allocated mentors in the actual psych ward to follow around/work with - I assume there will be a swap-over at the half-way mark so that we may experience both settings. In brief, the experience has been more exciting and yet more exhausting than I could have ever imagined.

My shift is from 2pm-9pm everyday - partly so my time wouldn't coincide with other students' from other years/med schools, and partly because that was the busiest period in the day for the ED psych team. My team look after people who present to psych voluntarily or are brought in involuntarily.

The voluntary patients form the minority of presentations. These are generally cooperative patients - mainly middle-aged business men and women, or young overseas travellers - who are facing acute psychiatric crises (anxiety, panic attacks, adjustment disorders, suicidal ideations) that they want immediate help with then and there. Once they're cleared medically by the ED doctors (all patients have to be cleared medically before being been by psych) the psych team has a chat to them (read: talk for over an hour sometimes) about what's been happening now and in the past; determine their level of "risk"; before deciding whether to keep them in for observation in the PECC Unit overnight or referring them to the hospital psych outpatient service.

Now, in mentioning that the BTH that I'm working in was in a notorious part of Sydney, I really meant notorious for the involuntary pscyh patient presentations. In NSW (and possibly Australia-wide), a person can be scheduled for involuntary detainment/assessment/treatment by a mental health team under different sections of the law. What that basically means is that if a person is deemed to be (acutely) "Mentally Disordered" or "Mentally Ill" and are at imminent risk of harm (to themselves, their reputation, others, or by others) - the police, ambulance, community, or medical practitioner can bring them into/make them stay in hospital for a period of time until further action for their management is decided, against their will (of course the finer points of this are many, I'm just trying to be brief). This is actually a big deal, because there aren't many areas of the law here that restrict a person's freedom in this way and I guess if you haven't really thought about it in much detail, it's quite confronting to see how this arrangement takes place with some of the less-cooperative patients. Mind you, most of these patients are floridly psychotic and have very little insight about what's going on. But a couple of the patients we saw were presenting with first episodes of pscyhosis so the signs were very subtle, and would probably not be given any consideration in a different setting, e.g. laughing or smiling inappropriately during the interview. It's hard to put these signs forward to a patient that there might be something not quite right going on. Understandably, these patients denied having any abnormality, but were lucid and somewhat insightful enough to be upset by an involuntary schedule.

Despite all the prep-talks we were given about not getting emotionally-involved or upset by the stories around us, it's really hard not to feel anything, especially with the younger patients who are brought in with first episode psychoses. As my supervisor said, "the worst part is the process of going crazy.. once you're there, you don't have enough insight to realise what's going on". It's quite sad, I think.

Everything aside, the experience has been very eye-opening and fulfilling. Hoping to share more thoughts with you later..