D-O-C-T-O—–R

Yes I have my first job to look forward to on Monday. Finally I am a doctor… Stepping into the unknown.

There have been many many forms to fill in and sign my life away. There are many organisations to join up (expensive membership fees!) My colleagues have their annual leaves approved even before they start… gosh I have to catch up.

Luckily I am starting on psychiatry – so I know the going will not be too tough – and it helps that I find it interesting. No night shifts, no hectic admission of over 30 patients in an evening like some other runs.

One silly thing I was smirking about was the fact I am not under the jurisdiction of being a student any more. I smilingly applied nail polish today – happy that I am more of an ‘adult’ now that I am a doctor – I can dress whatever i like (within reason). Some eerie parallels of graduating from high school into university – my glee about independent choice of dress and nails…

I guess compared to others my age – who have 2 kids, are climbing the corporate ladder etc – I am still under the ‘young’ mentality – given that I am a junior of this huge hospital organisation.

I am hopeful that I can regain/reclaim my interests again now that I have just gotten over the final nasty hill of 3 viva voce exams in 3 weeks. Faced with no more formal examinations, I am definitely going to do more exercise, get to all my dancing lessons regularly and best of all – I have enrolled into a German language night class. Surely acute calls and night duty would inhibit these extracurricular activities but I can try!

Thanks for reading my blog on final year medical student experiences.

Fin

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Psychiatry

Today I am illustrating my internal thoughts once again on a few patient encounters.

When a patient is admitted, the psychiatric assessment takes place immediately and physical exams are put off for a few days. So this man in his late thirties came in with a depressive episode with suicidality.

I knew his diagnosis when I asked him permission for the physical exam. However as I got caught up in his physical dramas – he expressed them so clearly with drive – I forgot that he was depressed! I know it sounds rather impossible but it happened!

As he elaborated on his chronic ailments which in turn has fueled his depression, I had an uncomfortable sensation. This man was pouring his heart and soul out by vigorously describing his long standing difficulties with fibromyalgia, haemachromatosis, restless legs, insomnia, constipation with anal fissures which have turned into chronic ulcers… and the resultant hardship in coping with a demanding job and family. All the while I was only doing it as a routine check – a perfunctory paperwork exercise – working on the assumption that the GP had taken care of anything urgent and obvious in the physical realm. You see I had taken for granted and completely forgot about the privilege of the doctor who hears the private history of a patient.

I felt rather guilty that I had treated this exercise as just another routine job on my list . I felt powerless too – I had no magical solution to solve his problems… so why hear them? If I was a patient and I poured my heart out and nothing was done I would feel cheated in a way! Upon later reflection I saw that being listened to is important in healing… But at the time I was caught up in these swirling thoughts and ineptitudes, I forgot to see the whole picture – a desperate man driven to suicide. Thus as a finishing line I said ‘it will be good not to spend the whole day in bed – that will make it harder for you to sleep tonight’.

He paused on his way out hard in thought but would not say what was on his mind. But he was so obviously reacting inside to what I had just said. Then I saw how awkward that would be – if I was fatigued and suicidal and someone told me to get up and move about… I am sure that would be the last thing on my mind. Opps I did not see the whole picture. Cue embarrassment!

My second eventful physical of the day. It was rather ironic. The patient was a middle aged lady who is psychotic, irritable and has many cutting remarks. My senior house officer (J) is a cute blonde who looks rather youthful. The patient took an instant dislike to (J) and started to abuse her ‘awful way of speaking’ (she had hardly said a sentence!) and that she ‘does not look like she has been through medical school’! Thus it is only fair that (J) sent me to examine this patient to avoid buckets of inevitable abuse.

When I walked in with trepidation with the nurse, she exclaimed ‘I am glad its you – someone who KNOWS what they are doing – a qualified medical practitioner!!’  Hahaha did she know I have not even graduated yet! Then she was very gracious to me… all along though I was scared that she will suddenly snap at me. This was not the case as she hollered to the nurse ‘now, I will not be seen by any other doctor than this one here’. I cast the nurse a raised eyebrow… What did I do to deserve this? Then I was sad to not look youthful! I must have looked old?! Oh dear

Next in my mind was that I was not to feel ‘special’ and ‘chosen’ by this mad woman… or be manipulated by her through this. It was only a fleeting issue however as I was more upset that I was not blonde and cute!! I am sure the nurses will have a laugh over this at handover.

Job done and as I was seeking the safety of the nurse’s station – a chronic schizophrenic on the other team beams at me and says ‘did you get your blazer at store so and so?’ Evidently my answer must have been her fave store as she followed me and started chatting away… I dunno… maybe I still haven’t gotten over the residual fear of a ‘psych patient’ as I was instantly on my guard  and crying out inside my head ‘patient – doctor boundaries!!’ Obviously I was stirred up by my patient from before who had bestowed on me positive attention… and now another one! I was polite and suitably chatty made a nice exit all in all. But in the end – ultimately ashamed that I am still fearful of a psych patient… stigmas abound within my mindscape. Help! And so it goes that stigmas can exist rampantly within a health worker who should know better.

So – here was a day on the wards once more.

The mentality of persuation

Have to say I really enjoyed my stint on my general practice run. It was delightfully focussed on the presentation at hand as well as looking at prevention at times. There was a lot of variety – minor surgery, paediatrics, elderly, psychological etc etc. There are inherent frustrations with it but it is an easy way to be part time and enjoy life as well.

Then it was a gentle easing into psychiatry. I have to say I have not enjoyed it as much as I did last year. Perhaps I have not seen many interesting presentations. Perhaps my short attention span is not so in awe of this whole new field that I had never come across before last year. Maybe it is the chills I get now from the flashbacks to One who flew over the cuckoo’s nest or Girl, interrupted – whilst observing things on the ward. I had watched these dvds in my holidays to get in the mood for psych!

One snippet of psych: I chatted to a very intelligent guy with bipolar disorder. He had done a masters in English literature – Shakespeare and Chaucer. Something I studied long ago fresh faced in university… However his life was in disarray partly stemming from his tendency to come off his meds and go off the rails. My team thought it would be of benefit to me to talk about his meds to him so he can have a better understanding of them. (I am unsure if this is a wild goose chase – I mean come on- he has been an inpatient many times and I am sure meds were discussed every time. So it must be a learning exercise for me).

He started talking about how sodium Valproate makes him sedated and knocked out. And feels he can cure his illness with natural remedies and good lifestyle…

I was hesitant internally whilst outwardly I was firmly telling him why he needs to go on the meds. This duality disturbed me. I wondered why I should be pushing for valproate – a drug I have never experienced myself, a drug I only know it from textbooks but not in reality – when he feels that it knocks him out and it is a foreign substance that he is medicating himself with. I know that it controls his bipolar symptoms and keeps him stable but this was not convincing for me deep down to fight his claims with.

I continued my argument saying ‘think of it as a supplement – like having iodised salt, it is like valproate salt…’ And thought – whatever doctor I become – I will only work in an area where I fully believe in my treatments and believe in its success when offering it to people.

What is bothering me currently is in the inpatient psychiatry ward, you are treating people who do not want to be treated.  It is obviously part of their illness – but I need time to think this through and come to terms with the anti-psychiatry literature.

I really enjoy the reading around psychiatry – it is more in tune with ethics and other philosophical thinking – which I think drew me to it last year – a respite from the mind numbing science shoved down your throat in all the other medical and surgical specialties. Its dumb that doctors can be so single minded about evidence based medicine – there are limitations with that line of thinking which is not often thought about.

However -aside from the initial interest psychiatry generated – I need to work through whether it really appeals to me by working around – circumferentially – in true psychiatry style- considering all the negative rap and anti-psych thinking – before I feel I really understand what this specialty is about. To work through why so many people hassled me about psychiatry when I was positive about it last year. Is it true with me too or are they short sighted?

Wisdom Teeth

Because I have seen very anxious people before anaesthetic (and it is not pretty), I was determined to keep a calm manner for my wisdom teeth removal with conscious sedation.

To get to this day, I had consulted two dentists and two maxillofacial surgeons over some months. It would be correct to say that I was running out of cash!

One dentist looked at my teeth for less than 30 seconds before declaring that she could not do it. I was referred to a max fac surgeon who was kindly and gave me mouthwash and insurance tips. However he was too busy to operate on me during this one and only two week break of my university year.

As I was pondering this, I got the biggest oral abscess I have seen in my life (after exaggeration). It was bulging and round and encroached onto my other molars and the pressure of it on my lingual nerve started to make my tongue lose sensation…

Driven by the loss of sensation of a vital part, I visited another dentist who gave me antibiotics and had a look at my OPG scan and confirmed once more that ‘nay it is a surgical extraction’.

Thus with this and many episodes of sore gums and pericoronitis I decided to find another maxfac surgeon. He had a nice but brisk manner – and I don’t think he ever said much to me really. If he did, it was in a very rushed sort of way.  He had a warm voice but a funny nervous type of snort at the end of every sentence which was odd! He just handed out some info sheets regarding the procedure and aftercare and I would wait until my holidays.

The day

I came in suitably fasted and I had gotten up early so I could have my legitimate fluid intake before the surgery. The lovely nurse with a bedside manner (which made up for the surgeon’s lack of) took my obs and later the surgeon came in and placed an IV line.

I was not looking but I knew he made me bleed in the process. “Good back pressure you have there” he commented and looked sheepish… This did not bother me as I do this to my patients on a regular basis!!

I was given sunnies to wear which annoyingly rode up on my face as I kept smiling nervously- my good old cheeks kept pushing them up. IV sedation went through and we were ready to start.

The local anaesthetic was rather uncomfortable but much more bearable as I was at the beginnings of a sedated state.

At one point there seemed to be chips of something in the back of my throat and I started gagging and coughing. I am unsure how it was resolved but it was not an issue after my initial complaining and coughing. I have a hazy idea of it being fished out possibly? Or that could have been imagined.

During the procedure, I did not feel much going on in my right side at all. I had a vague recollection of my upper right molar being done but none whatsoever of my right lower one. When the surgeon went to my left side – I started to be able to follow what was happening- this side hurt a lot more.

I also recall how annoying it was for me at the time to hear them chat away to each other (surgeon and the dental assistant) and not talk to me. Lol, I know this was absurd but I still bristled inside while they yarned on about seemingly useless things.

For some reason I kept tensing up my muscles and voluntarily relaxing them. I am not sure if this was my anxiety or a drug effect. Another thing I laughed about later was the fact I kept tilting my head back as far as I can (I had practiced this the night before in mentally preparing for this operation) to be told to put it to neutral!

When he announced that he was done I was surprised and alarmed as I was ‘sure’ that the right lower one had not been done… it had been a comfortable ‘15mins’ (which was more like over an hour).

So while he dictated something, I asked how much midazolam I had been given. This was the med student getting the better of me as well as the curiosity coming from just having done the anaesthetics attachment. He said ‘oh, 6mg of Midaz and 50 micrograms of Fentanyl’. I was a bit miffed as I was never informed about Fentanyl. It would not have really mattered as I would have probably agreed to Fentanyl anyway but it was the principal of having only been mentally ready for midazolam. Oh well- I am sure I benefited from this intraoperative pain relief.

Thus it was my first experience of an opiod and a benzo. I can’t pinpoint the exact effect of the fentanyl but the effect of midaz was interesting.

After the procedure, while I was waiting on the dental chair and gazing at the paintings and the windows I was bathed in this weird sense of clinical happiness. The textbooks would probably call it euphoria. For me I would not qualify it as euphoria but it was a strange sense of wellbeing without any reason to feel so well. I was quite warm and happy and surmised that this must one of the reasons that people get addicted to opiates.

Later, I was thinking of this feeling at home, whereby my feelings about this state had changed to one of eeriness. It was such a bland happiness – so artificial – it scared me in hindsight.

Many hours passed for the local anaesthetic to wear off. It was quite amusing to see the progression of this. The whole of my two cheeks were numb and it was so strange. And despite my efforts to slather my lips with vaseline pre-op to protect them – they had been bruised and particularly my bottom lip started to swell up.

You have this certain helplessness as your bottom lip starts to swell of its own accord and you cannot eat in a coordinated manner. Because I had not had any food for the last 13 hours I was rather hungry. Thus it was funny for me to realise after I finished my soup that some of it had trailed off and had made its way down my chin… ‘An introduction to being elderly’ I thought grimly but not without humour. Luckily the lip began to behave soon after this and I started regaining my feeling in my upper cheeks.

I am glad I did not have facial palsy from the local anaesthetics like my friend did after her teeth extraction. After the sensation returned to my cheeks and my lips recovered, I did not feel bad at all. No swelling, not much pain – I thought ‘wow it’s no big deal!’

But after I regained feeling in my chin – the pain started to come on. I guess the analgesia had worn off. I controlled it with ice and my friends came over with soft foods (the yoghurt without pips was extra thoughtful) and we watched 3 movies in a row 🙂

Post op day 1

The regular drug intake is such a lie. How can you take a drug every 6 hours a day even when you sleep – you are hardly like to get up, eat food with your drugs in the middle of the night! I guess you would if it was life and death – but then you would have nurses who administer it for you in that situation in hospital. Even with witnessing the annoyance of doctors for patient’s non compliance – it is ironic that I can’t comply either. Same goes for salt water rinses for two minutes, 5 times a day. I think my best effort is three times a day.

Anyway because I was not diligent or mildly negligent in this aspect, I woke up at 7am with pain!! Aaargh. So I was forced to get up after 4 hours of sleep and make myself something to eat with the drugs… I guess this was the payback for getting off lightly on the first day. After a few hours I fell back into sleep.

I employed the use of ice throughout the day as well as paracetamol with codeine for that breakthrough pain in between the non steriodal dosing. Despite all this I gloated in my mind that this pain – bad enough as it was – was nowhere in comparison to my 10/10 pains of dysmenorrhoea.

I actually cannot recall much of this day! It passed by with reading and a movie I think. I was quite tired by my recollection.

Post op day 2

Waking up at 11am with pain, pain, pain wasn’t pleasant. I think the running out of analgesia overnight is terrible as it means half the day is spent playing catchup to control that pain. And that was exactly what I did.

I realised the pain I had on this day was the worst ever. I could feel all the swelling inside my mouth… arrrgh… not on par with my worst ever pain but close to unbearable at certain times.

It was noticed that the capacity of my stomach had shrunk. Even in this short period of a change in diet! I get full from not much by ‘real food’ standards. I mean eating a few fruits would hardly count as a meal for me normally but now making those fruits into a smoothy would have me quite satisfied in terms of satiety.

Then in the evening I had the unfortunate incident of loose motions… and very painful lower abdominal pain. Could this be a karmic follow up of my insolence or disregard yesterday on the forces/deity of pain? This incident was followed by 3 more episodes… I am very grateful to my hot water bottle. I wonder who invented the blissful invention?

I was first suspecting the food I ate – gastroenteritis… then a better differential came along à drug effects. The most likely one being diarrhoea as a side effect of the Diclofenac. Perhaps pseudomembraneous colitis could be a feature. After all I had the risk factors of being female and having been on antibiotics – metronidazole. I looked it up in my favourite online reference – emedicine. The treatment itself was metronidazole or vancomycin – so I hope I will recover.

Although the colicky abdominal pains were bad at the time, in hindsight not my worst pains ever. I am not gloating however – superstition can play a part in the human psyche however laughable it can be. Even though the thought of my 10/10 pains makes me shudder – in effect it has given me a higher pain threshold? I suppose from the ‘training’.

Then a different worry floated across my mind. I know one patient – my age that got gastroenteritis with vomiting and diarrhoea after her wisdom teeth extractions. She was on her non steriodal drugs but got very dehydrated and this culminated towards renal necrosis and her being on dialysis.

This is a worst case scenario, but I could not help think about this and thus I tried my hardest to keep rehydrated. I also want to stock my cupboards with pedialyte…

Post op day 3

After I finally could ignore by abdominal troubles, I fell asleep at 12am – I woke up with pain in my mouth at 2am. This was the exact time I should be having my next dose of NSAID… What a nightmare – if I ate more food I could trigger more diarrhoea but at the same time I did not particularly want to just tolerate the pain and be sleepless nor did I want to get a peptic ulcer by not taking food with the NSAID…

So in a rather irritated mood I went to the kitchen and decided I had enough of this soft food shite! I ate a piece of bread with hummus and an icecream cone like a trumpet with nuts and hard chocolate. It hurt but it made me feel better and rebellious in an absurd way! I read in bed afterwards and slept again.

As I was leaving the throes of a dream which included a swimming pool, a lovely house within it and seeing a friend who recently went to Japan and exploring the grocery stores of Japan I was slowly waking up and thought – why does ice reduce swelling?

I cannot believe I had never really thought about this before! I guess my mouth is swelling from tissue death from the operation. All sorts of channels would be destroyed – lymph, arteries and veins and general tissue rupturing.

How can ice help… it could constrict the mass the water takes up to reduce swelling (marginal probably!) it could constrict the arteries which pump out blood therefore fluid. This can help reduce the increasing swelling. But what about the other aspect of vessel constriction? If the veins constrict – they cannot take away the fluid. However I just realised that the veins are probably wrecked anyway so maybe it stops the backflow of ooze to reduce swelling.

Once swelling is reduced perhaps it allows healing to occur in a timely fashion which would mean swelling can be further gotten rid of. I will look this up – as well as the invention of hot water bottles.

It’s a funny diet I have been subjected to for 4 days. It consists mainly of fruits made into a smoothy, yoghurts, pumpkin soup, rice congee, potato and gravy from KFC. To be honest I am getting quite sick of them actually.

I did eat a banana this morning in an attempt to replenish my low potassium from my unfortunate bowel activities of last night.

Tonight I am looking forward to a potluck party where I am unsure whether they are joking but they have promised me 18 different icecream flavours! I hope like mad it will be true 😀

Post op day 4

I held true to my research and instruction. I stayed up last night until 2.30am to take my drugs on time so the falling half lives rule works to my advantage… this aspect was well done – however I did not foresee me getting some very new reflux while trying to sleep… Win some lose some…

My searches have lead to the information that the ‘hot water device’ was used in the 16^th century and the first patented rubber hot water bottle was by Mr Penkala.

It is of note that going to the medical library yesterday to pick up some gorgeous books I ordered– The map that changed the world, One hundred years of solitude and Tom Jones – I had come across this distasteful idea across my mindscape once again. The medical school building, for me, somehow came to symbolise oppression of individuality and darkness… It had come across my attention that I currently did not enjoy internal medicine or surgery… what is left for me?  I do appreciate the beauty of being a surgical specialist but after being near the end of my medical degree…  I just feel that general medicine stifles my feelings of ‘creativity’ (that is if I had any!) or my persona…

Medicine can be so narrow minded – or am I to blame to allow myself to be sheltered or hide within this narrow focus on life? It was a bit disheartening to play a game of Cranium with my friends – some of which had dropped out of university/ was on the dole/ never went to university…

I know – it is dumb to judge people by whether they went to university or not – it is merely an arbitrary measure of their ‘intelligence’ – it probably reflects more about whether that person is a conformist or not.

Anyway what bothered me was the fact my friend who is on the dole sits at home and watches TV and movies all day.  I thought secretly of this as ‘wasting precious time’. But they seemed to know so much more about general knowledge and the world than I did…

I mean I cannot really even feel good about my ‘knowledge of medicine’ as they seem to know quite a bit from TV anyway!  However laughable this may sound. And besides I am no world expert on medicine despite studying it for 6 years… sigh. I mean some may consider 6 years of study as rather short in some respects!

My superficial judgements are coming into the fore and it shows how easily my meager confidence in anything can be affected.

However I digress – as this is a blog on the journey of my wissies! My defence is that I got 4 wisdom teeth removed – thus I am allowed to fall 4 points in wisdom?

So I woke up with the pain improving into an ache – the throbbing on the left worse than the right.

A nice image from last night was gargling the opening of the right cavity (the stitches seem to be way too tight on the left – perhaps that’s the cause of the pain) when out came a tiny individual browned twig of a broccoli– it had been there for at least over a day! It was very cute.

At the post-op check up, the staff had marvelled over the fact I was not in one bit swollen or bruised. I am quite thankful for that. Unfortunately I am intimately acquainted with the dirty word of the day – Alvogyl- it serves to plug the hole where my teeth used to reside – and presumably soak up the inflammation of the area.

It is quite foul – I describe it as a strong type of antiseptic mouthwash/ strong toothpaste taste continually leeching from my gums into the saliva. Such a horrid taste… yuk yuk yuk

I had no idea I needed two follow up appointments – that’s the poor communication skills of that surgeon for you. My second visit cannot be done as my holiday finishes and I have to go on attachment to another town. This he had never considered or known! Thus I have to track down a buddy of his to flush out the rest of that horrid Alvogyl stuff.

I am continually sucking on lollies to drown out the taste. No wonder it tastes so foul – it has local anaesthetics (lignocaine and eugenol), other chemicals and ofcourse that ‘natural’ mint flavour! Eww

Post op day 5

Although the Alvogyl has totally intensified my already established dislike of spearmint flavours, I realised to my surprise that it at some point during the night gave me NO pain whatsoever! Wow that was great! While my NSAID tablets remain, I have finished my course of Metronidazole.  I am now the proud person to go totally off any more analgesia.

You see, although I like the effects of Diclofenac, I was constantly worried about the side effects of renal and gastric damage! Now I can be a free person that is finally good at swallowing pills :p this was a skill that used to evade my sensibilities.

I have left now one last follow up appointment to get rid of the Alvogel traces. Hopefully I will remember to mention that there is still one last stitch remaining (or hopefully he will spot it).

It is confirmed that I have 2 small retained roots in my left molar space – and I will wish they will not cause any troubles in the future.

Thanks for reading my Wissie teeth diaries!

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Ps- There are many names for wissies over the world:

Holland – ‘Far back tooth’

Indonesia- ‘Younger tooth’

Japan- ‘Tooth unknown to parents’

Korea – ‘Love tooth’

Thailand- ‘Huddling tooth’

Turkey – ‘20^th year tooth’

Resus bay and arrest calls

My flatmates and I went out for drinks to celebrate our first ever offers of doctor jobs. It was great – we all got accepted by our first choices. After we came home the others zonked out but I was still pumped… and was still up when my trauma pager went off. It read: cardiac arrest ICU.

Since I was in acceptable hospital-ish clothes and we lived close by, I thought it would be a good idea to sprint to ICU. I could just think of all that adrenaline- within ampoules and pumping out from each medical personnel’s’ adrenals. How exciting.

But once I got there the action was over – in a good way – as the patient had only needed atropine.

The night duty doctor explained to me about the patient and said ‘good on you for running here’. However I did not hear the majority of what he said about the patient history and situation as I belatedly realised that my breath may smell like alcohol!!!

I generally flush red with alcohol and I hoped that my rosy glow was attributed to my running haphazardly to ICU! LOL ‘I hope I don’t smell drunk’ was the only thought turning over and over in my head!

Thus by trying to enhance my learning experience, I could have given a weird impression – if that doctor smelt any whiff of alcohol. Man it was funny.

My first view of trauma resus was in 4^th year – a major MVA victim – I stood in the sidelines as the melee of health personnel coordinated together to examine and support the patient. I was not really involved and it is a passive memory.

This week I had full on hands on contact with resus. I was given the role of chest compressions for this poor young 12 year old girl who had collapsed riding her bike home from school. There was a flurry of activity of anaesthetists with airway, intraosseus access, femoral art line etc…  Everyone there it seemed – the paediatrician, general surgical reg, many many anaesthetists, ed physicians, nurses, advanced paramedics…

The girl had a past history of surgical repair of transposition of the great vessels. She came in lost to the world with a VF rhythm… looking so pale… as we commenced CPR and a doctor asked how long CPR had been going on from the start – it was 35mins. A sudden thought flashed through my mind which was: ‘she is not going to make it – she is going to die’. The thought was very alarming but would not budge… I dutifully continued compressions. It was the first time I pumped down on a real person.

The team carried on for another 30 mins of CPR fluctuating between VF and PEA. Adrenaline, amiodarone and shocks were all part of it. Then a doctor asked if anyone had any objections to ceasing support. He asked three times to confirm cessation of support was in agreement – everyone was so eerily quiet.

We all pulled away and covered the child with a sheet so her older sister who had just arrived could come to see her without foreign objects embedded in her sister.

The senior staff seemed to disperse and get back into seeing the next patients…

I was a bit distraught and somewhat dazed. We had lost someone so unexpectedly who was so young and full of life merely an hour and 10 minutes ago.

It was nice how everyone was individually supportive – through the next few days I was asked by various people involved if I was ok. It was nice having that channel of communication had I needed to talk at various stages. I mainly talked to a consultant who was sympathetic and my flatties.

Given the shock and sorrow of the resus situation initially – it was gradually replaced within me -unknowingly- to now hold a feeling of adrenaline and energy. That is why that night after celebrating, and not fully sober, I was pumped to experience more action…

Although I am intrinsically mildly against/ lazy doing medical procedures, compared to talking in a consultation, I now regard resus quite differently. I hope the next one I am involved with is successful.

Animating times on anaesthetics

I have enjoyed anaethetics far more than I expected. I seem to like things that I can have a handle of in a short length of time. For instance, psychiatry. There is a well defined limited amount of things to cover before you realise or feel like you ‘get it’.

Perhaps things like that is good for student days to feel like you can picture yourself in those doctor’s shoes but I worry that once you are in a specialist stage, it will become too boring? I know that will never be the case given the diversity of the patient case load and other quirks of the job – but that is an unfounded fear for you.

Out of the two week stint in theatre, I will elaborate on one eventful afternoon. I will start off with my perspective and then reveal what the others thought. Funny how everyone’s brains (and consequently the realities) operate and work in different ways.

I was chuffed on this particular afternoon as I had all my bad habits of self taught IV cannula insertion refreshingly blasted out the window. Thus I could insert a perfect cannula in a women who had the thinnest wee veins (which just the day before I would have never dreamed of inserting!) I felt mega happiness with my new found technique. I felt like a Spartan II of Halo when they had the improved MJOLINER suit fitted.

This experience all came about as my course supervisor (Dr H) encouraged me to get really slick with IV cannulas on my time in theatre. This advice dwelled in my mind for a week and a half before I managed to get myself out of my fug of apathy and mindset of ‘I hate procedural things’ and later expressed an interest in having a go.

I had never injected a bleb of local anaesthetic before. Its funny how I have seen it done so often but I did not know the particulars to look out for – so the learning points from all those times I saw it being done were rather lost as I recall fixating on the rising bleb of local and nothing else!

It turns out the other detail that completely escaped me was the fact that this technique can use one hand to act as the steady point on which the other hand can rest on to hold steady.

So my dear superviser anesthetist (Dr O) barked out that my hand was shakey in the local injection – I was quite thankful as that had not registered in my mind as all I knew to look for was raising the bleb (of this i had done successfully).

The next part – i was advised not to tap all over the dorsum of the hand – something I did abit blindly, i admit, because I was never sure/ confident in my hit and miss cannularing techniques – it was also reflected in my next skill. As I pushed the cannula into the skin, my aim waved all over the place – just because I was not sure – and did not want to poke into irrelevant structures.

I never realised I did that either! so that was fixed up quickly. Funnily enough I was concentrating on the tasks so much the other nuances went over my head!

As a result of this supervision and guidance by Dr O, I got all the 4 patient’s cannulas in! At one point Dr O pulled my head upwards to put it into the correct position he felt i should be in. At that time I felt abit weirded out by this sudden moving of my head but I appreciated the gesture of my mentor and he was known to be a bit eccentric (the mild unease was easily put aside – after all I did ballet training as a child and someone moving the way i held my head, or my arms was normal)

Through it all he begrudgingly said ‘you are getting the idea’ – of course I was – i got them all in! My airway management skills were satisfactory too.

At the end he said something that probably was the closest thing to a compliment: ‘you are not bad for a student’

That made me feel good and I was quite thankful that he clearly indicated to me what i was doing wrong and what i was doing correctly. This meant I had a new confidence with the airway and circulation procedures.

My overall course supervisor (Dr H) had earlier checked with me repeatedly how my day went and if I was alright. I mean my supervisor of the day (Dr O) had a reputation for being abit of an oddball but nothing that I found off putting at all. I reassured Dr H and said it was all fine – although he continued to look mildly concerned!

The next day I was in theatre with Dr H and the nurses from the previous day. As soon as I walked in, it triggered the nurses to rush over and start telling Dr H how Dr O was being horrid yesterday and started listing all the ways.

One nurse apparently had to reassure two patients that all was well with their hand as Dr O had barked out command, after command such as ‘NO!! you are wobbling’ etc. The patient reassurance part was never registered by me in any form! And the constant barking out things unnerved the nurses who thought he had deviated from his ‘best behaviour of the morning into a horrid teacher by the afternoon’. They even went as far as to say ‘it was painful to watch’ and looked at me with concern…

Huh? that was weird. I can understand how they may feel but it had not bothered me at all – infact i thought that day was a success as I learnt so much from the clear feedback. I hope I am not a sucker for abuse?!

I feel their concern would be justified if I had found Dr O upsetting or I had visibly wilted under his barking. However I talked back to him, was never flustered and my composure never changed (at least to me!) I mean I never had to think about or try hard to remain calm and strong/ composed etc that day – if such effort was required, then I would know I was upset – but that didnt happen at all so my conclusion is that I was unphased.

With my unaffectedness of it all the nurses eyes grew round. I guess for me it was a one off incident where I had many gains to rejoice whereas for the nurses it would be a cumulative thing – to see student after student berated and barked at. They said ‘that is not the way to teach’.

I got another unexpected compliment: “you will go far in medicine then dear – with your thick skin’.

Whats funny is that I dont consider me to have a thick skin at all – I am quite sensitive – if you had read my other posts you would know for sure- I mean the other day I had not steeled myself to see a termination of pregnancy (in the past I knew that was what I would see for the day and would have mentally prepared for it) it was on the list out of the blue and to see it happening suddenly and unexpectedly as I was bag masking was a shock. Thus as I left the operating room I was in tears – That does not constitute a thick skin!

Interesting how everyone lives under their expectations and assumptions to see an event in an entirely differing way.

I felt kindly towards the nurses – looking out for the student – I guess it must have become routine for this particular doctor. But they do not realise – medicine is full of strong personalities and I have had my fair share of weird doctors during my course of study. I guess after my battering in general medicine I am a stronger person?! especially given that I inherently sensed that Dr O had good motives to instruct me and that was his particular style of teaching – he was not attacking me as a person – just my underdeveloped skills!

Anaesthetics and !ED!

Hello world,

I shall update you with the latest adventure. I have finally finished up with GM (hopefully – as my gen med results are awaited…)

I was doing well on day #2 of anaesthetics. Day #1 consisted of an introduction with a friendly anaesthetist who was really nice and said ‘ I wont tell you everything as we can only take in so much’.

It was cool – I fumbled with a few oropharyngeal airways, pushed in a laryngeal mask airway and got to grips with the head tilt chin lift.

The airway positioning on a dummy is dead easy (so many puns in my writing today!) but it takes more muscle on a real person. I felt much more confident after day #1.

Day #2 commenced. I did fine answering questions about different agents of anaesthesia. I saw the vocal cords and epiglottis in a 6 year old girl whilst handling the laryngoscope! yay

I followed the little girl into recovery and the doctor told me to stay and watch her ‘wake up from the operation’ to see for myself what it was like. The nurse joined in and said some children are like little monsters as they can thrash around on waking. How ironic this comment will become as the latest events unfolded…

Now I have a 2 year history of dysmenorrhea (painful periods) that is somewhat abated by Synflex/Naproxyn (the happy blue pill). I had taken one this morning and I had the usual background pain that I just tried to ignore.

Funny through the last ten minutes of theatre, I had the smallest tinges of nausea. Anyway I was in the recovery room listening to the doc and nurse whereby my feeling nauseated increased. I felt slightly weak on my feet but managed to keep things together. The doc left and I was left with the girl and the nurse. I felt light headed and got myself a stool to sit on. As I started to sit on it another nurse who was at the nurses station came rushing up to ask if I was ok. I did have some foresight but not fast enough! I went on to sit and had to continue downwards by sitting onto the floor. I moaned – ‘I feel dizzy’.

It was amazing how fast the nurses moved! They all appeared out of nowhere to swoop in and lift me onto a bed. I felt hot and sweaty and dizzy. It as such that I had my eyes shut the whole time while I felt nauseated still. I heard in the distance – her heart rate is 42! to be asked ‘do you normally have low heart rate?’ I said no. Someone asked if I had any pain anywhere. This was a great relief as I did register pain that was amounting in severity by the second…

So basically I had a typical presyncopal episode triggered by my pains. Oh my, these pains were 10/10 in severity, constant and made me writhe about like a mad woman. Too bad this did not help relieve it in anyway. I felt very hot and thirsty. I had severe pains like this right before I got prescribed Naproxyn but that would be a 9/10 pain (dimmed by the mists of time? i mean i did have to lie down and writhe for half the day then) but that pain came and went. By this stage I was in extremis. I threw my scrubs top off and kicked my shoes off (oh dear – poor nurses) and I was very bad at keeping the sats probe on! Thinking back I would have been not the best patient…

This continued after a while and the strangest thing was was the urge to go to the toilet but not being able to pass anything. So weird it freaked me out. The orderly and a nurse took me to ED.

Wow it was so weird to have other people take responsibility for you. Amongst fervently wishing for something, anything to take away my pain, at the same time I marveled at how efficient and fast I was travelling on my little wheeled bed. I am grateful for all who were involved in making sure I was in the right place. Including the heat pack which did not help at all initially but later on did.

I was in pain in ED for about 5 minutes. Then amazingly it abated. Just like the high tide that pulls away when it is the time to. I was left again with the background intermittent pain – which on a normal occasion I would be rather unappreciative of – but after this worst ever wracking pains – (I fear for childbirth now – as I got a nice taster for it) I was meekly relieved to have back again.

I got an ECG (my first one ever) and lying and standing blood pressure. Its amazing how brusque some nurses are to a fragile and worn out person! And funny how the simple question ‘what happened today?’ made me talk to her about what happened as if I would to a friend or family member to be cut off into the next question which was abrupt and unrelated – like ‘are you allergic to anything?’…

I hope when I am talking to a sick person in ED as a doctor I never come across like that.

The diagnosis was severe dysmenorrhea with presyncopal episode.

It was just bizzare how everything just happened so unexpectedly. I turned from a upstanding young medical student into a lying writhing wreck on the bed to be wheeled off into the emergency department. The intensity of these pains worried me and all those nurses. Atleast in the ED I knew the protocol of investigations and the questions that are asked by the doctor. It made me less scared compared to a member of the public would have felt but it still was an odd experience.

Weirdly enough how the pains abated. After getting over the shock of it all- i actually was quite thankful and sorry that I must have been a demanding patient when I was hot and parching, to kicking off my shoes – this to me was the worst as well as writhing off the bed pretty much to be lifted off again. Oh my- what a handful. And to take off the sats probe to as it pinched my finger!

I presume the little kid waking up from her anaesthetic would have been a lot tamer than me.

Then I felt compelled to buy the staff in recovery a box of chocolates for their efforts- and me having been an extra patient- not part of their job decription. I guess we are in the caring profession. Although what a surprise for them to see me walk in after 3 hours looking much better.

This was the tale of a medical student disconcerted to be put into the position of  a patient – with little warning or preparation. I definitely experienced the ED first hand. Oh dear though as I will be studying in ED  in a few weeks time – but on the team I usually am on- the doctors.