Brain Waves

After three weeks being constantly updated on the latest celebrity gossip (bieber oh baby), I needed an outlet to boost my dwindling testosterone levels. Something manly. Something, macho….

Meh, I went shopping instead. Burton had a 50% sale on shirts. Add 10% if you show your student card. Need I say more.

Galway Trip

My peripheral GP placement has brought me to county Galway, a place of significance due to the fact that I once asked the interviewer to send me to Galway instead of Dublin. Let’s not go there. Some other time, maybe.

Eidul-Adha

Free food never fails to gather a crowd. A feast to commemorate Eid, organized by the Malaysian Embassy gave me an opportunity to meet up with many of my long lost friends/fiends.

I don’t know what to make of this, but I found myself congratulating quite a few colleagues who either got new wives or new babies. Speaking of babies, there were so many!

The cuter ones were being passed around, all getting their cuddle time as well pictures taken, destined to end up on Facebook.

I can’t believe typing “facebook” in MS Word causes a spelling error. Get with the times Mr Gates!

Without being judgemental (not), here are a few speech bubbles of what might be going through people’s minds when they post pictures of them holding babies.

Look at me, I can carry a baby without dropping it.

Look at me, I’m parent material.

Look at me, this baby is so cute just like me.

Look at me, Look at me, no don’t look at the baby, Look at me(Ka-ching)

Look at me…… You fill in the blanksJ

If this blog went public I’d be in for some walloping. Hey, we’re human, I’ve posted my fair share of pictures with babies as well.

I might just do that again in the near future just to gauge people’s reactions

Jokes aside babies are just too cute. I felt like stealing one to bring home. (Dear future me, I hope you don’t get into trouble for this)

Disclaimer : I AM JOKING. (Just covering my bases)

Buzan you genius!

Imagine my hand dipping into a huge pail of really smelly but white MILK. (just go with it). It stays there for a whole minute, and I almost GAG because of the smell. My STOMACH growls in protest.

I finally take my hand out of the pail. To my shock, the hand turns purple, then blue, then red again, then back to its normal COLOUR.

I gasp. My fingers start to GROW right in front of my eyes. Blood vessels start to DILATE on the surface of my palms. My whole hand explodes.

The end

White MILK : Calcinosis

GAG & STOMACH : esophgeal and gut dysmotility

Change in COLOUR : Raynaud’s

Finger GROW : Sclerodactyly

Vessel DILATE : Telengectasia

There you have it my fellow nerds, CREST syndrome.

Two chapters into the MEMORY BOOK by Tony Buzan and I already feel the 20 Euros invested paying dividends. Whoopadidooda.

6 months and counting

“You are only 6 weeks away basically completing your undergraduate training,”

Said Nick Breen, one of our General Practice lecturers

“Your level of knowledge at this time is probably at its peak, as you are fresh from completing almost all of your specialties training,” he continued

Gulp.

He was right. My GP rotation would mark the last specialty-training block in the course. In a mere 6 months, I’d qualify as a fully-fledged junior doctor.

To add to the pressure, the exam dates for the finals as well as the convocation ceremony have already been posted.

Gulp.

Psych was a relative breeze. The OSCEs weren’t too bad in terms of the subjects covered. A few curve balls here and there but nothing exceptionally tough or mind-boggling to say the least.

On to the last rotation of my undergraduate training.

Motivation, where art thou?

Marvellously Mediocre

Round one of exams : Done

Status : Two to go

Emotional status : Apathy

I wonder if it is possible to feel both anxious and confident at the same time?

Aine’ (pronounced onyah) was my examiner for the day. Hardly the scariest of tutors around, yet my nerves were starting to betray me as I walked into the huge conference room in the basement of St Vincent’s University Hospital.

Yet despite my heart threatening to dislocate itself from its connecting arteries, the conscious part of my brain was surprisingly calm, almost confident that there was no way I could inherently screw this up.

I had put a lot of work in perfecting my case, endlessly editing, re-editing, and re-re-editing.

I knew she wanted it to be concise yet detailed. No beating around the bush. It is understandable that after listening to 10-20 people present their cases, one’s concentration would tend to drift. This meant that it was a matter of sentencing and word choice, which would determine a huge percentage of marks this time around.

“You did well, good job,” said Aine’

Applause?

Neh.

I’ve learnt over the years that in UCD, to “do well” means, “Congratulations, you didn’t screw up, but that doesn’t mean you’re getting an “A”. So a C would indeed suffice.

Soldiering on, an MCQ and an OSCE to go.

Rambling on..

I would like to present the history of MRS X, a 55-year-old lady who was admitted four weeks ago due to alcohol dependent syndrome and low mood, with a 10-year history of depression, and a history of hysterionic personality disorder

History of Presenting Complaint

This is her second admission for alcohol dependent syndrome.

MRS X had her 1^st drink at 17, and admitted to “heavy drinking” since her first marriage at 19. She currently drinks 10-30 bottles of beer a day, mostly at night. Her last drink was 2 bottles of beer, the night before admission.

With regards to alcohol dependence symptoms,

She has developed tolerance, needing more than 20 beers to get intoxicated; she only drinks beer, showing a narrowed repertoire of drink. She denies any changed in her alcohol preference. She prefers to drink alone, but does occasionally drink with her friends. She still enjoys gardening and walking her dog. She has never tried to abstain from alcohol, and continues to drink despite the being aware of its negative effects. She admits to have a strong desire and losing control when having a drink. She had a road traffic accident 20 years ago due to drink driving. She does not take any illegal substances, and does not gamble. She has had no hallucinations or seizures.

With regards to her low mood; MRSX has no anergia and no anhedonia. Her appetite and weight is fine. She has sleeping problems, with difficulty falling asleep, and denies any early morning waking or disturbed sleep. Her libido is normal. She also admits to being in financial difficulty.

2 weeks ago she took an overdose of seroxat, and was admitted to SVUH A&E. She described the attempt as an impulsive one, with no prior planning, and with no intention to die. Her reasons for it were to “forget her difficulties” and as “a cry for help”. She immediately notified her family, after taking 20-30 pills. There was no will or suicide note. She felt regret for what she had done, and had no plans to commit suicide.

With regards to personal history

MRs X was abused and hit by her father when she was a teenager. She denied he drank. In terms of education, she got through high school, then married at 19.

Her relationship history reveals an annulled marriage, attributed to her alcohol problems. She has one daughter and currently maintains a good relationship with her.

Mrs X admits to having subsequent unstable relationships with many men throughout her life. She recently broke up with her long-term partner of 22 years, who had been living in Spain for the past 4 years. She feels that it has “somewhat” contributed to her excessive drinking

With regard to employment Mrs X has problems at work. She skipped a “few days” due to alcohol effects. She also has received multiple warnings due to poor performance. She attributes it to the new HR officer who does not like her.

Forensic history. She was arrested once due to drink and driving 8 years ago

In terms of patient insight, MRs X wants to change but NOT WILLING to fully give up alcohol. She is uncertain that abstinence is for her

She feels that her troubled life lead to drinking, and that her drinking has NOTHING to do with her troubled life.

She is willing to enter the rehabilitation programme to help her cut down on her drinking.

Management Plan

Biopsychosocial approach :

Bio : maintain the current medication, seroxat 30mg Daily

History of Depression was not clear, obtain more information, contact GP

Monitor withdrawal symptoms - tremors, seizures etc

Disulfiram/Acamprosate : consider, though patient does not want to completely abstain

Psychosocial

RPU, SMAG

CBT

Monitor emotional symptoms,

Psychoeducation on addiction (insight)

Collateral history from family.

Damn. I hate pysch

Crunch Time

“A good little bit of heat in ‘ere, righ’ lad,” said the naked old man beside me.

It was the archetypal “Irish” way of mentioning the plainly obvious in order to start a conversation. We were after all in the sauna.

It had been a long day. My two-hour session in the library was followed by a two-hour session in the gym.

The over-exertion of both the mind and body was probably a coping strategy for what had happened earlier in the day.

The mark sheet for the formative (ie : useless) MCQ read :

14.5/40

A clear fail.

Whilst the results had no bearing whatsoever on my overall GPA, it was a telling sign that things aren’t all too well in terms of study.

A week to go. And I’m still writing.

PS : No, I don't go into the sauna naked

The Cuckoo's Nest

End of Summer

“Are we ready people?” said Dr Matt Sadlier, our chirpy tutor on the first day of class.

His enthusiasm was met by groans. Summer had ended. Welcome to final med. It’s official.

Ciaran and I were paired up to attach with Dr O’Gara, the addiction team consultant. Yes rugby fans, he is in fact the brother of the legendary full back Colin O’Gara. More about him later.

Psychiatry and the media

Prior to my psych rotation, my perception on what psych really is probably measures up to the general public; crazy people intent on hurting other or themselves. Case and point: Hannibal Lector sprang immediately to mind.

What I found out was that psychiatry deals with a whole load of other “stuff” that are genuinely medically treatable, with both pharmacotherapy and an element of psychotherapy.

My initial first few days in the wards were let down stemming from my over the top imagination on what a psych “facility” should look like. Again I blame the movies.

There wasn’t anyone running around naked. No one set themselves on fire. And they don’t wheel people around in white straps. Overall it has been pretty tame so far. Save for the odd lady who followed me around the hospital because she thought I was a spy. Lol.

Acceptance

The ward rounds in psych are totally different from the medical ones. The patients are interviewed on a one-to-one basis. All cramped in a room consisting of the consultant and his registrars, psychologists, occupational therapist, social worker, nurse, and of course medical students, yeay.

Also different to my previous experiences in medical teams, I actually feel part of the team.

“What just happened in there?” asked Ciaran, looking quite puzzled.

“I’m trying to make sense of it all,” I answered.

“They actually acknowledged us! Oh god, I feel so needed” added Ciaran

Being part of the team really ups your motivation. For a while at least.

My first psych interview

“ I’ve thought about it you know, ending it all,” said PT, who was battling depression

“What do you mean” I asked, taking good care not to put any thoughts into his head.

“I thought about hanging myself. But I never thought I could go through with it” he continued.

The interview went on for almost an hour. We delved into his childhood, relationships, family problems and a whole host of issues that one would never think to share with a stranger. I guess part of the appeal of psych is having that privilege of information, which is why confidentiality is a huge part of it all.

Some of the stuff gets really dark and messed up. For some reason, it affects me more than I’d care to admit.

Suicide in Ireland

Ireland has been a relatively religious country over the last century. Suicide was definitely frowned upon in the old days. In fact ,suicide was a capital offence up to 1993. In other words, if one failed in an attempted suicde, the punishment would be death. I lol-ed so hard. Gotta love the Irish.

“I’m an alcoholic”

MOG was an alcoholic. She didn’t want admit it at first, but the signs were all positive. She even scored 3/4 in the CAGE questionnaire (google it). Throughout our conversation she revealed to me a lot about her torrid past, the abuse she endured as a child and her series of failed relationships with numerous men.

At some level I felt we developed a connection, evidenced by her brutal honesty on what the root of the problem was. Alcohol.

Admitting that you’re an alcoholic is as easy as it is made out to be. It’s a huge first step toward recovery. Most patients take a long time to see that it wasn’t the beatings, or the abuse;or the bullying; or a whole crapload of excuses, until they admit they have a problem with alcohol.

“You know, there must be something about you. I’ve never been so open to anybody before,” admitted MOG.

“You should really consider this as a career,” she added.

I smiled.

Yeah. Right.

Vindication

“Interestingly Dr O’Gara, one of our patients, MOG told me during our one-to-one session that she felt that talking to a certain medical student was more helpful compared to the treatment and counselling she’s been getting during ward rounds with us,” said Roisin the occupational therapist

All eyes focused on me and Ciaran. I looked down not knowing how to react.

“Was it you?” ask Dr O Gara

“Yes I think it was” I answered, still looking down.

“Well ladies and gentleman, I believe someone is starting to show a knack for psychiatry,” he said, winking in my direction.

Old-age psychiatry

I have nothing against the elderly. Let me rephrase that. Excluding family and friends, I feel that I wouldn’t able to tolerate treating old people. If given a choice, I would stay away from any branch of medicine that deals with them.

It’s just simply depressing.

One of the patients, CK, is a 63 year old woman, who just a few weeks ago was swimming in the 40 foot (off the shores of Dun Laghoire), but then developed severe depression due to an unknown cause. Since then, she has regressed to the point of developing hallucinations that she “smells rotten”.

She also has delusions that everyone else is talking behind her back on how smelly she is. I can’t help but feel sorry for the old lady each and every time we meet on the ward. The thing is, for these patients, their experience is undeniably real to them. This means, she wakes up every morning to the stench of rotting flesh; she walks around corridors hearing voices of people talking bad about her. Now how would that make you feel?

Her constant tearful episodes and genuinely sorry state has affected the whole team as well, probably me more than anyone else. Old age psych, another tear jerker.

A conclusion, somewhat

Im in my 5^th week and already feel like a veteran on the wards. With the OSCEs ever so close, it’s a wonder why I haven’t gotten the palpitations I’m so used to by now. The lack of anxiety is proving to be a factor in my general laziness and reduced drive to actually pick a book up to study. Distractions are aplenty and in fact welcomed in order to mask the reality I dread to face each day.

Am I losing the plot? Or is it just the (hopefully temporary) depressive state induced by my time in the psychiatric wards?

I don’t know.

And so it begins

“Ni apa pakai baju gelap ni! Kau ingat kau ni SYAITONNNN ke pakai gelap-gelap?!” bellowed the A&E consultant.

“ KASUT! No brown shoes mister!!!” he continued.

Welcome to Malaysia. My ‘home’ for the next three weeks.

(note I refuse to name the hospital for fear of legal action, it shall henceforth be known as MH)

Final Med

“So who do we have here,” said Dr Ding, the elective coordinator. There were about 20 students from all over the world, converging to do a short stint in MH . Most of them were Malaysians studying medicine in Russia.

“Ah, I see we have students from Dublin. Final year summore” She continued

The room was silent. All eyes were on us. It dawned upon me that the tag ‘final year’ medical student has its own merits. Though I had a feeling that most of them would be disappointed with these so called ‘final years’ on show that day.

“Would you like to share something with us, seeing that you have been very privileged to study in such a high esteemed place, di negara mat salleh....”

I looked at my partner. Awkward silence ensued.

I finally found some saliva to ramble on about ethics, taking great care to praise the national system for producing very competent and skilful doctors compared to their European counterpart, which focused more on the professionalism aspect.

That seemed to impress her enough for the time being.

She went around the room asking questions. It was clear by then that she held us in high regard.

“We are expecting a lot from you, and hope that you can share what you’ve learnt with us” she added.

So no pressure huh?

Impetigo?

It would be hard to describe my shortened stay at MH. I skipped the last week due to a suspected impetigo infection. Though I cast some doubt into the diagnosis made by the local GP, as there were no typical crusty lesions associated with impetigo. No complaints as I took the last week off.

How to Take Blood, by a Medical Assistant

1. 1. Don’t bother washing your hands

2. 2 Prepare your gloves

3. 3. Use the gloves as a tourniquet (!!!!)

4. 4. Using your bare hands, find a vein in the dorsal aspect of the hand and stick a brannula in

5. 5. Push in the brannula and take the needle out

6. 6. Stick the needle into the chair (!!!!!)

7. 7. Take blood as needed.

8. 8. Dispose of clinical waste into yellow bins

The Tutorial

She was a third year medical student from Moscow State University. Chloe was her name, and she was my partner down in A&E. If I could use one word to describe her, I would choose ‘innocent’

I made it clear from the start that I would have my own schedule, and made up my own rules. Chloe was very diligent and followed me around wherever I went. She also wasn’t shy in asking questions.

“Can you teach me X-ray ah?,” she said in her unmistakeable Chinese accent. She was from Jinjang.

I picked up the film and held it against the light. As I was explaining to her the basics of reading a chest X-ray, a few more Russian students joined in. I acknowledged their presence and welcomed them. Suddenly it turned into a crowd.

I realized that I was in the middle of giving my first tutorial. Soon enough, one of the doctors walked in and interrupted.

“Excuse me doctor, is this room free?” he asked, looking directly at me

“Sorry, I’m just a medical student, of course we will leave this room at once. I was just talking through a chest X ray with my colleagues here,” I explained, feeling very embarrassed.

He was nice enough to let me use the room. The tutorial continued. They were actually jotting stuff down. God knows if what I said was even half true.

Half Day

My mornings would start at 8am. The teaching in the A&E department was good. It usually lasted for an hour. After that my partner and I would trot up to ward 27, where another classmate of mine was stationed. There we joined a ward round that usually lasted an hour or two, depending on the patient count. All in all it was a solid routine. My day would end at noon-ish. I wasn’t going to exert myself and stay the whole day.

WARD 27

There had to be at least 50 patients in ward 27. It was a general ward, and they presented with varying illnesses. The acute cubicles consisted of suspected TB infections (almost unheard of in Dublin), HIV, and alcohol withdrawal. Dengue was also a prominent disease that one would be expected to know inside out if practicing in Malaysia. I knew nothing.

The beds were very close to each other and privacy was at the bottom of the list. Patients all wore the same fungi green overalls. The ward was stuffy and smelt like pee. It was depressing and felt like a prison.

Pakcik rasa....

One of the patients presented with warfarin overdose. He developed bruises due to an elevated INR, caused by ingesting too many warfarin pills.

He had a artificial heart valve that necessitated the use of warfarin, a drug with severe side effects if used without caution. His valves were replaced due to rheumatic fever, again, almost unheard of in Dublin.

“Pakcik, apasal pakcik makan lebih itu Warfarin?” asked the consultant, evidently of Indian origin.

“Oh, sebab pakcik tengok banyak lagi pil tu, jadi pakcik makan aje bagi cepat habis. Lagipon pakcik rasa....” he went on to explain how he made a decision on why he thought it was prudent to increase the dosage of the drug.

The consultant frowned. So did the rest of the team. We were dealing with ignorant people and couldn’t do anything to remedy it.

PUASA?

I made it a point to ask Chloe if she understood everything that went down in the ward round earlier.

Chloe : Can I ask you a question?

Me : Sure, go ahead

Chloe : Kamu ini bukan melayu ka?

I somehow knew where this was going. I’ve had enough of people dissing me about my Indian heritage. I let her continue anyway

Me : Kenapa, awak ingat saya orang mana?

Chloe : Kamu bukan orang Singh ka?

I humoured her even further

Me : Why do you say that?

Chloe : Sebab kamu tak puasa?

That caught me completely off guard. Curious indeed.

Me : Bulan puasa lambat lagi

Chloe : Tapi kenapa kat ward ada patient yang ada itu ‘sign’gantung tepi katil, “PUASA”?

Oh so naive!

Me : (still very polite) Oh that means that they’re not allowed to eat due to disease or imminent surgery, bukan puasa sebab ramadhan

Nurse Wars

After seeing patients in the acute cubicles, I disposed of my mask in on of the many bins by the side of the bed. The ward round continued.

Suddenly I heard a shrill voice from the end of the corridor.

“Ni siapa buang mask kat sini?!!”

A few of the patients even woke up to watch the drama unfold.

I looked for the source. It came from a smurf-like figure in blue uniform and white tudung. Only that smurfs are cute. She looked like more like a troll.

“SIAPA?! CEPAT MENGAKU!!! NAK SAYA CHECK CCTV KE?!!” the Troll went on.

I took a deep breath and stepped forward.

“SIAPA KAMU?”

“Saya medical student”

“MEDICAL STUDENT! BELUM DOKTOR PON DAH TUNJUK PERANGAI! KAMU TAHU TAK KAMU TAK BOLEH BUANG MASK DI SINI!!!

Despite me having at least 10 inches in height advantage, she made me feel really small. I looked to my left, Chloe stood next to me for support. Good girl.

The rest of the students cowered behind us.

I was on my own though. I picked up the mask and threw it in the yellow bin after being told to do so.

“KAMU TAU TAK SAYA SIAPA?! SAYA HEAD NURSE DI WARD NI. KAMU KENE REPORT KAT SAYA TAU, BUKAN DOKTOR. SAYA PERMANENT STAFF KAT SINI, SAYA YANG JAGA KAMU, BUKAN DOKTOR”

I merely nodded disinterestedly. The rebel in me surfaced

“KAMU INGAT KAMU BAGUS SANGAT KE HA?! BELAJAR OVERSEAS JAUH-JAUH, TAPI PERANGAI MACAM SAMPAH!”

I continued to roll my eyes. I could see that I was pissing her off further. I knew she couldn’t do anything.

It was a mask. As if that would be the cause main of infection in a ward crowded with TB and HIV patients. I kept my thoughts to myself.

Yes, she had a point. But her method of embarrassing me in front of the whole ward was in my cards unacceptable and unprofessional. Then again they don’t bloody teach professionalism in Malaysia do they?

Pre-Conclusion

At times, it was very hard to see myself working in this environment for the rest of my career.

I hate to be the pretentious one. The so-called overseas final year med student. Yang tak tahan panas. Yang banyak tanya soalan. Yang skema pakai glove time ambil darah. Yang asyik-asyik basuh tangan lepas jumpa patient. Yang sibuk tutup curtain mase nak jumpa patient.

Darwinism has its merits in the concept of 'survival of the fittest'. To survive the houseman years, one must be able to adapt to the surrounding change, so as not to be driven to 'extinction’. However it remains to be seen, whether I would be able to maintain thus far the values and principles i have learnt as an 'overseas' trained doctor-to-be. I challenge myself to uphold upon these principles, and not be diluted amongst the current (sorry to say) archaic habits of the local doctors. The question remains to be answered. Am I strong enough for this?

Conclusion

No, I don’t wish to end on a negative note. Most of the posts were written when I was in the heat of the moment, ie pissed off at the world for treating me so bad. I do look forward to the challenge.

Dr Ding summed it up nicely during our initial briefing.

“I find that Russian students may lack so basic core knowledge when it comes to practicing medicine. However, they are so used to being shouted at that most of them do make it through the houseman programme. Students from UK and Ireland on the other hand, have this perception that no one can marah them because they are so used to the environment in Europe. Let me tell you that most of them cannot tahan and end up having emotional breakdowns in the middle of the housemanship. My advice to you is to toughen yourself up, learn to be patient, and most of all accept that fact that you will be shouted at, you will be insulted and you will be scolded. Then I assure you that you can make it through,”

Dublin has spoilt me. I lived in a cocoon where consultants fart rainbows and interns break out into random songs at will.

As I prepare myself to face my final year in Dublin, I can’t help but wonder what the future holds for me.