My twelve hour day

I left at 6.30am as I had clinic attachments with Dr Deegan, my giant german consultant on the respiratory team. Despite his size, he moves pretty fast; his 6’6 frame ascending the stairs with surprising agility. I was out of breath by the time we reached the third floor. The clinic was full of people who presented with shortness of breath.

“We’re very lucky. Not one person who checked in this week is over 90,” said Deegan, aptly explaining the demographics of this small hospital. I could only smile at the irony.

Geriatrics is definitely out of the question. Old people just aren’t my forte. Getting a good history from an elderly person is almost impossible without getting into an hour long conversation about her grandkids or her recently dead dog. Not my cup of tea at all.

It’s always been paediatrics, but then again things may change in the years to come.

Advice?

Surgery

“Patients hate to see doctors who look like they don’t know what they’re doing. So even if you have no f***ing clue of what you’re doing, just look confident,” said Dr you-know-who.

I couldn’t agree more....

Cardiology

“Three of the most important things you’ll need to make it through medical school,” explained Dr Laher

“First, learn to walk fast. Second, talk with a loud and clear voice. Third, look smart,” he continued much to our amusement.

Gynaecology

“The coming slides contain some disturbing images of women’s private parts. Feel free to leave the room at any time,” explained Professor O’ Heirlihy.

“I once landed in Saudi Arabia and they decided to check my laptop. They had me in for three hours because of all the vagina pictures. And then I became a gynaecologist,” joked O’ Heirlihy

The long road ahead..

It was almost 7pm. I wasn’t really tired. Just frustrated. It had been a long day.

“Why did you choose medicine?”

That question was asked almost 4 years ago. The interviewer must’ve liked my answer enough to have offered me a place in UCD.

I had only figured out a valid reason the night before, and I told them what they wanted to hear.

Again, that was four years ago...

Bloody Madness

St Micheal’s

During lunch we sat by the pier, overlooking the Dun Laoghaire port, pronounced as “Dun Lareee”. As the pigeons fed on the crumbs that fell off my egg mayo sandwich, I took a deep breath of the cool sea breeze whilst enjoying both the company and the view I had.

Then reality sank in.

St Micheal’s Hospital isn’t the most exciting. Heck, it’s probably the most boring hospital in the whole of Dublin. Or maybe because I was stuck in such a boring team. It could be either

The “cool” doctors

I removed the tape from both my arms. There was no more blood flowing. The bin in the ward was full of sharps, blood stained 'toppers' and used gloves. I wasn't the only one stained with blood.

Dr James and Dr I-can’t-complete-a-sentence-without-saying-f*** allowed us to stick needles in each other in order to perfect our cannulation technique.

I got it in on my third try. Pretty decent, huh.

I couldn’t think of any other word except for ‘cool’ that would describe the demeanour of both the SHOs (senior house officer) that were with us in the empty ward.

I googled 'cool doctor' and this was what came up.

“Now don’t you be scared, it just f***ing blood. Yesterday I had to stick my hand in a f***ing artery for almost two hours while waiting for the f***ing consultant to arrive. I really thought that the patient was f***ed, but he f***ing survived,” said Dr you-know-who.

“I know you’re not supposed to do this unsupervised, but I trust you enough not to kill each other,” said Dr James

It’s too bad I’m stuck in respiratory rounds with a boring team. I would’ve loved to be under their wings even though they’re in surgical.

Cest la vie.

The 'grass' is always greener

House was right. Everybody LIES.

Mr DG, a 50 year Caucasian male, was transferred from Loughlinstown A&E for an oncology consult, on a background of two episodes of epileptic seizures.

He had the episode while smoking ‘grass’.

I found that out after reading his chart.

During the history taking session, he told me a whole different story. And I believed it. He opted out of mentioning the grass he was smoking prior to the ‘epileptic fits’. He also didn’t seem to think it was important to tell me that he had CANCER.

I guess dealing with the big ‘C’ isn’t as easy as it seems.

In conclusion to my two week stint in oncology, it would be safe to assume that I have crossed it out as a potential field I might be pursuing for my specialist training in the future.

Up your Janus

“Tom isn’t here today. So you’ll be my intern,” said Janus in his usual monotonous voice.

I don’t hate him. I really don’t.

Mrs BH was reluctant to let us all examine her. Aimee was up first.

“Examine her cardiovascular system,” ordered Janus.

Next up was Amira.

“Examine her abdomen,” again in that monotonous Polish accent.

Amira didn’t do too well. Her voice was too slow.

“Hijaz, examine her thyroid gland,”

Shoot. Of all the systems. I looked at Aimee. There was sympathy in her eyes. My mind went blank.

I walked up to the patient and started feeling her neck for lumps. And then I stopped. I ran out of ideas. I didn’t want to shoot blindly.

“Are you done?” asked Janus.

“Yeah I’m done,” I reluctantly answered.

“You did very well,” as Janus pointed to Aimee.

“You need to speak up more, but otherwise good,” addressing Amira.

“And you...you were the worse. I would’ve failed you,” he said unblinkingly.

There you have it. I felt like burying my head in the toilet bowl. Coupled with my bad OSCE results, things have suddenly taken a bad turn.

Waiting for a pick-me-up

Down..hopefully not out

In an Eggshell

A small piece of eggshell fell into his omelette. He chose to ignore it.

After breakfast, he realized he felt some pain in his throat. He chose to ignore it.

A week later he fell ill with fever, chills and general malaise. The eggshell had pierced his oesophagus, causing a slight tear. The wound became infected. He thought he had a common cold. He chose to ignore it.

Another week passed. Paracetomol and Ibuprofen did not relieve his ‘cold’. He stopped ignoring it.

He went to St Vincent’s for a checkup. By then, the infection had spread to the surrounding structures. He couldn’t swallow and was getting worse for wear.

After having being scanned, he was sent to the ENT department for referral. They performed emergency surgery to remove the infected tissue.

The surgery had more complications than expected. The infection was very extensive. They removed his upper oesophagus. And then they realized that the infection had spread to the deeper structures.

He now lies in ITU, recovering slowly. The new nurse gasps at the sight of him. He had a hole in the middle of his neck. His cervical spine could be seen clearly. He was lucky to be alive.

Moral : Beware of omelettes

Calling it a day..

Amateur Transplant anyone?

I heard Aimee talking Amira about an "amateur transplant". I knew I shouldn’t have been eavesdropping, but they were loud, and I was curious.

“Hey girls, so what’s an amateur transplant?” I asked innocently.

“It’s a music band,” answered Amira.

I tried to keep a straight face.

That was almost an embarrassing situation.

http://www.youtube.com/watch?v=xuZl9tRqjoQ

Feeling chesty..

“Hey Aimee, want have you ever auscultated a wheeze before?” I asked my partner

“Why, do you have a patient I can listen to?” said Aimee in her unmistakeable Irish accent.

I let her listen to my chest with her stethoscope. My asthma was back.

Something in the air

Asthma is a chronic disease characterized by dyspnoea, cough and a wheeze. It has no cure. Drugs ie B₂ agonists plus or minus a steroid are taken to relieve the inflammation in lungs.

In a normal healthy person, exposure to harmless substances such as dust, pollen or mites do not illicit a response of the immune system.

In a hypersensitive individual, the activation of the immunological pathway towards these ‘allergens’ cause the bronchioles to constrict.

In severe asthma, a nebulizer with oxygen is needed. Oral steroids, which have far more long term side effects, are also taken to further suppress the immune response.

Asthma can cause death.

Now that wasn’t really a comprehensive explanation of asthma. I would probably get a C if I wrote something like that for an essay. It has been something that I’ve been living with even more so for the past two years.

Before arriving in Dublin, I had not had an asthmatic episode since I was 11.

Ireland has the 2^nd highest amount of asthma patients in Europe, and the numbers are steadily rising each year.

There is something in the air after all...

At least there’s an excuse to skip class today.

Monday Morning Blues

Chitty Chatter

“So how’re you getting on in oncology?” asked the fellow intern.

“Well, it’s grand like, nothing too exciting though,” answered Tom

“Yeah?”

“Well yeah, like most of the patients that come in are like f***ed to say the least,” said Tom

Death Rounds

It was Monday morning. A new day, a new week, with new resolve.

I checked my reflection in the bathroom mirror. Straightened my tie, adjusted my belt buckle and moistened my hair. I was good to go...

“Do you remember Mrs AC, the one you took an ECG from last week?” asked Tom

I gulped. Who could forget???

“Well, she passed away last night, respiratory failure,” explained Tom without really batting an eyelid as such.

Medicine ain’t for the faint hearted.

Death is a subject you simple have to deal with day in day out. She was the third patient that had died on me. And I faintly felt a twinge coming somewhere from the base of my heart.

It’s surprising at how cold you have to become in order to make it through med school. The thought of death is scary. Facing it every single day, even more so in the cancer wards doesn’t make it any more so bearable.

I whispered a silent prayer for Mrs AC. May Allah have mercy on her soul.

Hanging in There

Club Juice

As per usual, Dr Gullow made it a point to buy us coffee. Though he doesn’t drink coffee. He always drinks this cool looking berry smoothie.

“*****, what would you like?” asked Dr Gullow. I blurted out "club juice" simply because I managed to read the first line of its description. It seemed decent enough.

As the juice lady started to mix my drink, I observed the ingredients she used. Banana, Orange, and strawberries. And then she poured in some ‘brown juice’ into the concoction. My heart skipped a beat. I took the juice anyway.

Did I even dare take a sip?

The team was chatting animatedly about communism. I wasn’t paying attention. I was studying the plastic cup that held my Club Juice, wondering what secret ingredient had been put in. I took a deep breath and sipped anyway.

I found out what the brown stuff was. GINGER!

It burned my throat. I was close to puking. And there was three quarters of the cup left. I peered over Dr Janus’ shoulder to the neon sign. I scanned again for “Club Juice”. I was right. GINGER.

Who the heck puts ginger mixed with juice.

Moral: Read the sign. Don’t rush in.

The ECG

“Thanks *****, we’ll go to cardiology to confirm the diagnosis,” said Tom. I was panting. My heart was racing. Tom had no idea on what had just transpired.

Should I tell him?

30 minutes ago....

“*****, do me a favour and do an ECG on Mrs AC...”

I had done an ECG only one other time. This would be my first procedure unsupervised.

As I went to the ward down the door to grab the ECG machine, I noticed that Tom had asked Mrs AC’s children to leave the ward so that I could perform the test in privacy.

I drew the curtains to shield her from the prying eyes of other patients. She was asleep.

“Mrs C?, I’ll be doing a short procedure on you just to test your heart. I need you to be awake for this procedure, and I promise that it won't hurt a bit”

“Mmmhh,” she responded through her oxygen mask.

I proceeded to stick on the pads required at the correct position on her body. I had to expose her chest to get underneath her left armpit. She didn’t complain.

Then I realized that I had round out of pads. No biggie.

“I’ll be back in two minutes Mrs C, I just need to get some more pads,” I assured her.

I darted out of the ward, asking the nurses whether they had any to spare. I went from corridor to corridor till I reached St Charles’ ward. There were plenty in the store.

Mission accomplished. Time to get back to my patient. As I walked out of the store room, I realized that I had lost my bearings.

I was freakin' lost. Shoot.

I totally forgot to take note of the turns I made or any other significant landmarks that would’ve led me back to Mrs AC.

I calmed myself down and played it by ear. Through some miracle I made it back without making a wrong turn. I had only been gone for 10 minutes max.

As I entered the ward, I heard groaning. It came from Mrs AC. I dashed through into her cubicle.

Her oxygen mask had fallen off. And she was bleeding through her nose. It was a horrible sight.

I called out for a nurse while readjusting her oxygen mask, not really sure if I was doing the right thing. The poor thing was gasping for air.

She began to settle down as she got more oxygen. The nurse came in and gave a hand in holding the mask to her face.

If I had taken a wrong turn in getting back, she might’ve died. The reality of what I had just did sunk in. I was somewhat lucky that things didn’t spiral out of control. I could’ve never predicted that her mask would fall off. It was just one of those things.

PS: I did manage to perform the ECG despite the drama

Another day...

Medical Hierarchy

At the top of the food chain is the consultant. He comes in twice a week to review the patients under his care. I met him for the first time today. He was wearing a pinstriped grey suit, with a bright purple shirt and tie. Eccentric to say the least. Definitely a big-shot. With an unmistakeable American accent, he calls most of the shots in deciding the best way to treat these cancer patients. Whether it was to enrol them in a drug trial, or to defer them to the surgical team, he definitely had an aura of authority.

The specialist registrar, Dr Giuseppe Gullow was second in command. He is around most of the days, and also handles the clinic. The first thing I noticed about him was his attire. This guy knew how to dress well. Oh, and he’s from Milan.

The SHO which I am currently attached to is Dr Janus something. Polish. And his breath smells. But overall he’s definitely a nice guy. Always ready to teach and test my knowledge.

At the bottom of the food chain is the intern, Tom Drew. When he bends over, you can almost bet that you’ll see into his butt crack. Believe it. I’ve actually grown used to it. Tom has made life as a medical student bearable. Whether its sharing tips for the exam, doing procedures I shouldn’t be doing, as well as finding the best patients for me to examine, Tom never lets me down.

Of course, the last in the lot, the medical student. Me. So in a regular ward round, Dr Gullow will strut around in his expensive suit, followed by Janus in his Tommy Hilfiger khakis, Tom with his shirt half tucked in, and me in my white lab coat. There you go.

Lunch

“There are three types of traditional Italian pizza,” explained Dr Gullow while sipping his smoothie. Tom was busy texting. Janus and I were listening intently.

As I was emptying my third sugar packet into my cup of tea (I like ‘em sweet), Gullow had since moved on to bashing Americans for spoiling the word ‘pepperoni’ which meant ‘peppers’ in Italian as opposed to the round thin meat slices pun on the regular beef pepperoni pizza.

“How could you spoil a pizza with pineapple, anchovies, ......” BEEP BEEP BEEP!!

All three pagers went off at once.

“CARDIAC ARREST IN ST ANNES,” cried one of the interns on the cardio team. That was my ward. In less than a second, my table was empty. Janus, Tom and Gullow were in full flight towards the ward. I noticed than Gullow brought his smoothie along. I too wasn’t finished with my tea. I had taken only one sip. I guess I’ll bring it along as well.

Huge mistake. The minute I started walking, the cover on my cup fell off. I didn’t notice until tea was splashing onto my hands. It hurt like hell. I wanted to scream. I dashed toward the nearest bin and threw it all in, spilling more in the process.

I couldn’t care less. I had to make up ground to catch up with the team. Bloody embarrassing!

When I arrived in the ward, the cardiac emergency team was already set up. One intern was doing CPR. The patient was unconscious and unresponsive. He was in V-Fib, so they shocked him. His left umbilical hernia was flopping up and down while the intern was doing chest compresses.

“Clear” screamed the doctor in charge. They shocked him four times. I was pushed out of the way as the room was too small to accommodate a lowly medical student such as myself. I have a feeling that he didn’t make it through the night. Welcome to my life...

On Oncology...

ABG

“I think we shall let him do a few ABGs today, I’m sure he’ll enjoy it,” said Dr Janus, my polish Registrar in Oncology

“Enjoy? I don’t even know what an ABG is!!!!”, my thoughts threatened to scream out in panic. Shoot.

I kept calm throughout. As Dr Janus left for his clinic duty, Dr Thomas, my shadow intern for the day went to get a sandwich. I quickly flipped through the ‘medical bible’ for ABGs. Ah, just in time.

“So what does ABG stand for?” asked Dr Thomas (who wanted to be called Tom), with his mouth half filled with what looked like a ham sandwich. He was hungry apparently.

“Arterial Blood Gas,” I answered while giving my oxford handbook a loving caress.

“Brilliant, do you know how to do one?”

“Hmmm...not really”

An ABG is a procedure where one sticks a needle into the patient’s artery to obtain an arterial blood sample. The sample is measured for oxygen pressure, carbon dioxide, etc. Shall not go into the details.

Err..NEEDLE? BLOOD? PATIENT?...right. What a start to my 1^st day on oncology wards.

................

“This might hurt a bit, just hang in there,” words of encouragement to the patient (and myself), as I cleaned the targeted area with a swab.

“Just take your time and be confident that you’ve found the pulse. Be confident! Do not make a wild guess. Readjust your position. You’re a bit too far...”

Tom was giving instructions while I was looking for the pulse. The patient was wearing a CPAP (continuous positive airways pressure) mask. He looked nervous. He had the right to be.

“Bismillah,” and in went the needle. Missed the artery. Readjusted the needle. Nowhere to be found. There was no blood flow into the syringe. My heart sank. Bad start. The patient was already wincing in pain. I had to withdraw.

Tom took over. He didn’t do any better. 3 attempts hit a dead end. The patients vessels were very hard to find. He had gone through a series of chemotherapy treatments. That contributed to the weakness of the vessels.

Tom moved on to the other hand, frantically searching for an elusive artery. On what must’ve been the 5^th poke of the needle, blood came gushing out into the syringe. I could almost feel the relief Tom was feeling.

....

The Reality of Cancer

“He doesn’t have long. He’s going into respiratory failure. I took a good look at the ABG results. Tom was right. Even though the CPAP Oxygen was raised to 90%, from an initial 60%, our patient showed a drop in is pO2 levels. He wasn’t going to make it. Tom called for a meeting with the patient’s family...

Wiki Rules

“There are two types of bone metastases. Lytic and...What is the other one Tom?, asked Dr Janus.

“I’ll look it up for you,” replied Tom as he googled the answer. Wikipedia was his reference.

Conclusion : doctors are human.

ECG in A&E

“Get yourself down to A&E, I’ll be waiting for you there,” said Tom through the phone.

.............

“Alright, we’re going to do an ECG on Mrs X”, said Tom. I knew what he meant.

I was going to do an ECG.

It wasn’t that tough. The instructions were simple enough. She was an elderly patient who had a background of non small cell lung carcinoma. A very straightforward and uncomplicated process. I didn’t botch this one up.

As the reading for the ECG was being printed, Mrs X cast a look at me.

“Is everything alright Mrs X?” I asked.

“No, no, I’m grand. Is this your first day in the wards?” she asked with a twinkling smile.

Indeed it was....

The OSCE

OSCE day 1

It was Ankylosing Spondylitis. Shoot. I was almost sure it was Rheumatoid Arthritis.

1 down. 9 to go. The 1st of the OSCEs (oral exams) were held in UCD this morning. It consisted of a 10-minute history taking session with an actor who had a ‘disease’ that had to be figured out by a comprehensive ‘interrogation’. Easy?

He had back pain on a background of Crohn’s disease. Simple and innocuous enough. There was something not adding up to the whole picture though. He had a history of trauma which caused a prior back injury, but it didn’t really explain the sudden onset of pain with a severity of 8/10.

After the patient revealed he had morning stiffness lasting a couple of hours every day, the only thing that I could think of was Rheumatoid Arthritis (RA). I thought I had it in the bag.

Rookie mistake. I suddenly remembered the list of seven diagnostic criteria required for RA, AFTER leaving the examination room. Brilliant. I had only gone through it the night before. I was sure I had it nailed. He had only ONE out of the seven symptoms…Shoot

It didn’t help that my patient played the uncooperative role. He didn’t answer any of my questions voluntarily unless prompted further. It made things worse. Nerves were already taking over from the beginning. I loathe the fact that many of my other classmates got patients who told them everything even without them asking. Shoot.

It wasn’t all bad though. I did manage to get almost all of the symptoms except the parasthesia he suffered intermittently. And allergies. Come to think of it, I think I forgot to ask him to describe the pain. Shoot

It’s over though. Hopefully it serves as a lesson to me. NEVER RUSH INTO THINGS!

I end this post with a quote from my beloved Clinical Examination textbook :

“Never miss an opportunity to inspect a patients’ faeces…”

Faeces.

PS: The guy beside me is probably suffering from COPD or Asthma judging from his unproductive cough and expiratory wheeze.

OSCE day 2

Another day of OSCEs. This time it was physical exams, ENT and ophthalmology.

Physical exams was a screw-up. I had to have picked Dr Maurice Stokes as an examiner, no favours there. I had to do a peripheral vascular and neurology exam on the lower limb. For some inadequate reason, my nerves inadvertently gave in (again).

Overall, I breezed through neuro, as I had a lot of practice beforehand. But peripheral vascular disease was a tough one. I couldn’t even remember if the posterior tibial pulse was on the medial or lateral side of the malleolus. I ended up palpating both sides, luckily finding it on the medial side and earning another ‘tick’ in the assessment box.

I forgot the fine touch test, as well as temperature assessment. However, in truth it was a botched up attempt to intergrate both systems together, as evident with awkward moments total silence when I was trying to figure out what to do next. Alas, I can’t really complain.

Smack in the middle of the ICCI library yet again. Supposedly studying for the remaining two days of exams. I’m dreading Friday. Obstetrics, Gynaecology, Paediatrics and Psychology in one go. 75%. If I pass, might as well skip the finals and hop on an early flight home.

This post has been completely pointless. An almost diary-like entry despite earlier intentions of NOT trying to do so. Figures. Then again. It’s my blog. It’s relatively anonymous. There you have it.

Cheers