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.

Of pizza delivery boys and gynaecologists...

That's a wrap for Obs and Gynae as well as Paediatrics. I end this splendid year with a gynae joke from one of our professors.

What do gynaecologists and pizza delivery boys have in common?

.....

.....

.....

They both can smell it, but can't eat it.

Keep lol-ing, till my next rotation..

Labour Day

I barely arrived at the Coombe, when a lady had already achieved full dilatation. Within minutes, I was in my scrubs and ushered into delivery suite 6.

Then the screams began. I felt my nails dig deep into my arms as Liz pushed with all her might. Then it stopped. She calmed down as the contractions subsided. So did I.

She was in stage two of labour and was expected to have a normal vaginal delivery.

The contractions continued on for at least half an hour. Then I saw the head. Then the shoulder. Within minutes, a baby girl was born. She weighed 7pounds 6oz and was a healthy baby.

There was minor bleeding. The mother was fine. My arms were slightly scratched due to the pressure from my own fingernails. Again, the mother was fine. I think I bled more than she did.

The whole process was intense. Throughout the pushing stage, I found myself pushing as well, almost willing the mother to push harder. Each time the baby's head surfaced, it disappeared right after the contraction stopped.

By the end of it all I had the urge to go poop from all the pushing. Lol

The parents were absolutely delighted with their new kid. I’ve heard stories on how it is such an emotional experience. Mmeh.

I honestly felt nothing. I guess at this stage, I’m just totally dead inside. The stress of this wretched year was really taking toll on me. Plus it was midnight and I had just started my shift. Happy days...

Bruised Cojones

Professor Foley is a brilliant tutor. His algorithms and approach towards tackling the final OSCEs are nothing short of genius. However, it all comes with a price..

Being the old-school professor he is, fear and abuse is an integral part of his teaching methods.

As per usual, I somehow drew the short straw and was forced to present a history during his weekly tutorial.

Foley: do you know what cojones is?

Me: err-

Foley: Balls! It’s Spanish for balls!

Me: err-

Foley: Right, to do well in the exams, you’ve got to have cojones. If you get nothing else from today, get that point in your head.

Me: Right. (knees starting to buckle) So I’d like to present the case of Mrs. UF, a 52 year old married probation officer from Carlo, who is para 3+0, with her last menstrual period on the 6/5/11. Mrs UF is in the hospital for an elective vaginal hysterectomy....

And then it began. I was tortured for almost an hour, as my colleagues could only stare and take notes. It was all they could probably do as Foley tore me apart, delivering blow after blow to my cojones.

I took one for the team, as the rest of the class took really useful notes on what not to do during the exam day. By the end of the session, my balls were as sore as hell.

Dragon Lady

She is simply known as the dragon lady. Possibly a female version of the Prof, but deadlier.

On Mondays, dragon lady goes through a list of patients in the gynae theatre. I almost ate my heart out when I found out that I had to examine one of her patients.

My partner had left me alone to face dragon lady. She was too scared to even go near the operating theatre. Some friend huh.

It was eerie silent as the theatre staff awaited the arrival of the dragon lady.

The SHO warned me to stay out of her way or risk physical and mental harm. Legend has it that dragon lady once threw a metal cusco speculum across the room to an unsuspecting medical student. I did some stretches beforehand just in case I had to duck and avoid any instrumentation thrown at me.

I kept a safe distance from her, careful not to get burnt by her fiery breath. I was gloved and holding a speculum, ready for my first vaginal exam.

The prospect of putting your finger up in a woman's vagina was less unnerving than the stare I got from the dragon lady when she noticed me.

She had smelt her pray.

"Who are you?" she asked as sparks flew out of her nostrils (just go with it)"

I'm a mm-medical student, my name is..."

"Do you think I care what your name is?"

"errr.."

"What do you think you’re doing with that speculum?! Do you expect to do an exam on this lady? Have you even asked my permission?!!"

My knees went weak. I kept silent.

"Well no use just standing there, get to it!!"

I scurried to the operating table and inspected the patient's vulva. It was normal. The speculum exam was also normal, no signs of uterine prolapse.

Then came the vaginal exam. I parted the labia with my left hand. I then inserted one finger, followed by another into her vagina. It was very uncomfortable and I couldn’t tell what I was doing.

Then came the questions. "So what’s the normal size of a uterus?"

I had no clue. Blank face.

“Are you listening to me?”

“Erm, I don’t k-know”

The Dragon Lady didn’t flinch or look at me.

My eyes were on her hands, ready to duck at any sudden move she made. Somebody gonna get hurt real bad.

Then came the surprise

"That’s actually a very good answer" she said.

My face was like “huh?”

"Too many doctors nowadays pretend to know stuff when they're really better off admitting they're human"...

My ignorance finally paid off.

Saying I don’t know actually saved my life.

Far-tales part 2

Dr CP was going through a neonatal exam. Our patient was 4 hours old, and was sent to the NICU for observation as he was underweight.

"Whooa, that was a big bomb you sneaky fella," she exclaimed as she was demonstrating the moro reflex. Patrick the baby didn't seem to care. He was sleepy.

Then a second 'bomb' was released. This time, she opened the window as it was increasingly clear that Patrick was about to poo.

The onslaught continued throughout the tutorial. Everyone thought it was adorable that lil ol paddy was having the time of his life dishing out fart after fart.

Then came the nappy check.

Surprise, surprise. The nappy was clean.

Little did they know that the silent bomber had struck again. I smiled a triumphant smile. Let's hope they don't come across this blog. Lol

Samuel L Jackson

I kid you not! I had to look twice to make sure that it wasn't really Mr Jackson examining me for the neonatal OSCE. It wasn't. Haha


"Demonstrate the MORO reflex" said the Samuel L Jackson lookalike.

The MORO Reflex

It involves literally 'dropping' the baby, eliciting a 'parachute-like' posture. It is a clinical exam used to assess the baby’s neurogical reflexes. Oh, and after you drop the baby, you're expected to catch it.

It’s one of those pass-fail parameters used to check if one has ‘been around’ in the wards. Anyone who drops the baby immediately fails the exam.

I felt strangely confident as I took my time to position my arm right beneath the 12 hour baby girl. She didn’t even have a name yet. Deep breaths.

I lifted her head. Then her back followed.

It lasted less than 2 seconds. I caught her in my right arm (not as dramatic as it seems). Both her arms flailed out immediately. Textbook moro reflex.

"Perfect, that was good technique you showed there" said Samuel.

I lived to fight another day...