Epic trip - Surgical Elective to Cuenca Ecuador

It has been a while since I last posted an entry. Much has happened since my last dated entry, and this is why i am finally penning down some thoughts about my surgical elective.

On the 27th of August I left Melbourne for my big trip to South America - specifically to Buenos Aries in Argentina and to Ecuador.

Cuenca, Ecuador and the Fundacion Cinterandes. This is where I undertook my surgical elective from the 19th of September to the 30th of October. The foundation started a Mobile Surgical Unit in 1991 and to date, similar programs world wide such as in Honduras and New Zealand. To date, the foundation has performed some 5000+ surgical operations in various rural towns in Ecuador. Procedures range from typical general surgery procedures such as herniorrhafias and superficial tumour excisions to gynaecological, opthalmological and urological procedures. The mobile surgical unit is also capable of performing more complex procedures such as Cholecystectomies both conventional and laparoscopic.

Before elaborating further, I will divide this entry into separate components, 1. Medical/Surgical and 2. Culture and People

Medicine and Surgery

Being able to experience medicine in Ecuador has been a very very rewarding and unforgetable experience. I had the pleasure of being immersed in both rural medicine and surgery during this elective. For 3 weeks of this rotation, I was in at a regional clinic or 'sub-centro' as they call in here in Cumbe, a small town of about 4500 in population, 40mins from Cuenca. Over here, we got to work with doctors, do consults to practice and improve our medical spanish and above all, the opportunity to experience a new culture and their attitudes towards western medicine. Making diagnoses with the aid of convenient radiological exams or laboratory tests are almost impossible here. Much of the management of patients invovles astute clinical acumen i.e. deciding if a patient has infective or parasitic diarrhoea or a viral illness - and whether to send them home with anti-parasitic or anti-biotic agents or allow the illness to run itself out. The arsenal of medications available for any infection include, Penicillin, Ampicillin, Amoxicillin, Metronidazole and Tinidazole. Pain and fever medications available are Paracetamole and Ibuprofen. Salbutamol for any respiratory distress. In order to get these medications for free, patients have to visit a goverment run clinic - medications in Ecuador from a pharmacy are expensive, and for the poor people here, it sometimes can be almost impossible to afford.

The lack of resources here often forces one to come up with new ideas and innovations to help the community - and such a baptism of fire is an invaluable experience. Home-made spacers from used plastic bottles that I saw was perhaps one of the 'innovations' I got to see being given to patients. Even gloves and handwash are hard to come by. Visiting one of the 'big' public hospitals, none of the above resources that I often take for granted in Melbourne can be found. You can't find a single bottle of Avaguard in an entire floor, that normally permeates the hospitals of Melbourne, or even glove boxes. All these things we take for granted due to its abundance in a first world country, are a luxury. Interns and doctors bring their own gloves, masks, scrubs etc.

Being part of the Mobile Surgery Unit with the Fundacion Cinterandes has been the best experience to date. The ability to provide surgical treatment to communities that would otherwise suffer with pain and disability has never ceased to amaze me. Whats is more, the success rates of the surgeries and complications rates are comparable if not better than conventional operating theatres in city hospitals of the developing world.

During these trips, we served as assistants in surgery as well as instrumentors or scrub nurses. Main post-op care was also provided by the medical students under supervision by the surgeons and anaesthetist. Other than the medical and surgical experiences that I gained by participating in this elective, personal reflection has also allowed me to realize how far I have come since starting medical school. The local more junior medical students would look to us in times of doubt, and under the appropriate situations would be able to provide the correct advice confidently and accurately, whether it was general medical/surgical knowledge or details concerning post-operative patient care.

Satisfaction, is an indescribable feeling; the feeling of contentment, joy, being proud of one’s actions but not necessarily with excitement, all put together. People who know me, know of my passion for surgery, head and neck oncology as well as plastic surgery, yet here I was helping out in straightforward procedures, hernia repairs, excision of superficial tumours, cholecystectomies and tubal ligations etc, and yet I was enjoying it. This was not evident to me, until a friend and colleague whom I was relating my experiences to said to me, ‘Jeremy, you have tasted satisfaction’. This trip has changed my perspective of medicine, delivery of health care and perspective of life itself.

Being a doctor is great. Being able to do something to change the trajectory of a human beings medical outcome or life is an amazing skill to have. This has now come to be my personal encouragement to work in medicine. The money, the prestige and respect that comes from the job whether earned or by association are important things in anybody’s personal life, but now I strongly feel that it is the intangible rewards that really keeps me going when the going gets tough.

Vacation time

Travelling alone has opened my eyes to the world. Learning a new language has helped the experience so much I cannot imagine how much less of an experience I would have had, had I not picked up Spanish beforehand. Before this, I use to have the impression that people who lugged backpacks around for trips that seemed to have no end were simply escaping the realities of life, to prolong the inevitable meeting with what they had left behind in the first place.....nothing much to desire.

But now, having met so many different types of people from all over the world, Germany, Austria, Brazil, Argentina, Ecuador, Ireland, South Africa, Korea.. I am incredibly envious of people like that. Taking a long trip is a huge commitment. A commitment to put life, normality, comfort zones on hold while one decides to leave and sometimes be a totally different person for an uncertain amount of time. Could I ever put my life on hold to pursue such experiences? If you asked me this question before my trip, I would not even consider that question worth answering. put my life on hold?!?! What about surgical training? writing papers? research? decorating my CV with all sorts of prizes and accolades?? I was a fool back then.

Now, all I want is to plan for my next trip. Fulfill all the experiences that I want and should have as a young person before stepping onto a train which is my career which has no end station. We are young once, youth will leave us that is for sure, but jobs are always there no matter when you return. That said, is easier said than done. Now having completed medical school, a new 'title' added to my name and another academic degree, we shall see where life takes me.

My trip has also shown me that, there is so much to see around the world, so many cultures to experience, so many different people to meet and so many different lifestyles to appreciate. I want to see the world, I want to live my life, the way I see it fit.

Gynae'oncology...death... and the cancer monster

its 4 weeks into my gynae'oncology rotation and so far it has by far been the best rotation I have yet since starting the clinical years. I have been treated with respected and accorded the duties and responsibilities of a junnior doctor and never made to feel like I was a burden or hindrance in the team. The doctors, Kym the fellow, Annie the Registrar and all the consultants have been very understanding and nice. I could not have asked for a nicer working team. I was going to write about this on friday, but somehow things just got pushed to now, monday 1250am. Anyway, What I wanted to write about was a particular patient (DV) I have helped managed in the last 4 weeks. so last friday she was making those terminal groans and moans that all dying people do, and she was in pain. It was not a comfortable sight at all. And being in that same room with teary eyed family members wasnt an easy thing to deal with. The worst thing of all is knowing how things can change so rapidly. I saw her well and walking (despite her incontinence/fistula) issues, she was still alive so to speak. Now, it would be a miracle to see her still around when i turn up to the hospital tomorrow......I do not really have much to say or rather cant thing of anything else to put down.. but this I will never forget.

End of Gen MED....

I've just finished my Gen Med rotation for 5th year and I must say I enjoyed it much more that I had initially expected.most fortunate enough to have nice and friendly consulant, registrar and resident. perhaps the only downside was to be paired with a moron, who has shit for brains. Taht being said, I have learnt immensely from this rotation. I personally feel that after the rotation, I' have indeed taken a wider step towards becoming a doctor. a much longer stride compared to breast surgery I must say. Writing, referrral, discharge summaries, pathology slips, radiology requests, scripts.. etc are now second nature. Clinical acumen, procedural skills and the like, I think i've made huge improvements in those areas as well. I got to DO so much more in this rotation than in any others from 3rd year,. This is the beauty of being a FINAL year medical student.much experience, and no responsibilities. My registrar feels I have a split temperament, suited for either surgery or medicine. As much as I enjoy the challenge of diagnostic and management dilemmas in Medicine, the lack of decisiveness and certainty makes it hard to bear as a career.

I cant see my self doing medicine, I think its for people with far more patience than I do possess. Patience, thats also one thing I feel I have improved on quiet a bit after having to tolerate the tomfoolery and foolishness of an almost clinically incompetent medical student. One still begs the great mystery," how did he end up passing high school?" much less getting into medicine. People ignorant of their ignorance greatly bother me, especially when I have to be patient and understanding; and allow them to share their opinions. I look forward to Gynae-oncology which is coming up next. Back to the operating theatre, where I feel I belong. the wards are a more cheerful place, but nothing surpasses the focus and decisiveness of a competent surgeon.

I actually am looking forward to be a Gen Med intern next year. But we'll see what happens, this "working" and not getting paid deal is starting to take its toll on me. 2 rotations down, 3 to go before my awesome elective in Ecuador. Cant wait. till then. peace

old and sick

I have come to this conclusion with absolute certainty. I rather be dead than old and sick. It's very sad, for both individual and family, when one is old and sick, lying in a hospital bed with no hope for revovery; the only path is a slow, painful, seemingly unending journey to deaths door. Oxygen masks, endless needles, numerous blood tests to no good end...... the menial things human beings do to hold on to something that is as good as gone. I guess its easy for me to say now, but after having to bear witness to similar sights day in and day out, it just dosent seem like a big deal anymore, when death comes knocking at your door, even the newest technology wont help you breathe no more...

learning curve.....

so in the past 3 weeks i've been taking 3rd year medical students, helping out with some of their clinical skills assessments and giving short tutorials here and there. it wasnt until today that I truly experienced what my previosu tutors must have felt, the frustration that one gets when students (while enthusiastic and eager) do not appear to grasp the importance of certain aspects of the teachings that Im trying to pass on. " Guys, please go home and read up on the following......." in the near future, " guys, can you tell me the following.....". 1st time, you give them soem leeway, 2nd time, you get frustrated, and 3rd time, you start to think that maybe, there was just something in the message that you are trying to put across is not CLEAR enough. its pretty damn frustrating, when 3rd year medical students still behave like they are in pre-clinical years; expecting to be lectured on and doing minimal self-directed learning. The learning curve when one gets to clinical years of medical training is a steep one. I'm very thankful I had someone to direct me when I was in 3rd year. Im jsut trying to do the same for other that come after me, to the best of my ability, and sometimes its just frustrating.

update 1 - needle-stick patient is HCV positive. so now I have to do blood tests for the next 6 months. damn.

unlucky

today I suffered a needle stick injury. the patient has a hx of IVDU and ETOH, and is riddled with tattoos. blood test so far has been good. hopefully nothing bad happens from this. When i got home and decided ot heat up some soup, I forgot to open the lid up enough, and my soup exploded in the microwave. fuck me.

life and death

today I saw a man literally come back to life. whilst the events had taken place over a course of approx 10 days, the progress has been remarkable. an elderly man who suffered a fall and a brain bleed, managed in intensive care and later recovered on the wards. Unfortunately for this man, he then developed blood clots in his lungs which sent him back to intensive care. this was where I first met him and heard of his story. The ICU is a scary place. Machines, tubes, needles, bottles, scurrying of doctors and nurses. Background noises of pumps, machines, patients coughing, choking, gurgling, the list is endless. Here I saw the same man, hooked up to the same instruments and looked after like every other patient with a serious problem. here every patient is broken down into numbers and percentages. the wonders of modern medicine are endless. where a man once laid on the brink of death, where family members had given up home on improvement and signed an advance medical directive. this man is now walking up in the wards, cheerful and talking. if you didnt see him over the course of the week, you could not fathom the strife he was in.

transition camp...2010

so this year I decided to attend Transition camp, which is the orientation camp for 1st year medical students. It's been a while since my own transition camp and I was curious to take a look back in time, to see if I could recognize the changes that have taken place over time, in terms of my own maturity and development as a medical student. The last 2 days have been great. I think it is worthwhile for people to often look back and think about previous milestones in their lives i.e. first day of med school, first day as a medical student, end of first rotation in Final year etc...

confused looks aplenty, shy faces, and anxiety. The look of the fresh medical student on their first days of university learning. Only now that I think about 4 years ago, when I was in a similar position, do I ask myself if I was at that point just as clueless and helpless as these freshies. Certainly didnt feel like it, but most likely that was the case. As was I 4 years go, these new 'kids' have no idea the changes that woudl happen to them as they progress through the years; they might very well know where they will end up, but the journey and experiences ahead still remain a mystery. We as the tutors and guides at the camp impart our previous experiences on to them, hoping words and pearls of wisdom would give them a clearer path in which to navigate from the first day; and in doing-so I personally have reflected much upon my own change in the past 4 years, and also wait in anticipation of whats to come in the next 4 for me.

What's more amazing is the awestruck look, and reverence these first years have when they learn that you (or I in this case) are not a FINAL year medical student. It's like final year medical students have some magical powers to captivate and attract. These very same feelings I had, when meeting final year medical students of yesteryears. While it feels good, it also somehow imposes a greater burden on learning and the continuous pursuit of excellence. The most drastic change I feel is the difference in sense of uncertainty I notice I had, as a result of interacting with these bunch of 1st years in the past compared to now. I'd like to beleive Im quite the self-assured, confident and bold doctor-to-be right now, and no longer the 'unsure medical student'

this has certainly been quite the introspective experience for me. feels like yesterday when I was at this camp myself in 2006. and now, in only a matter of months I will have become a Dr myself, with real responsibilities to society. It scares me, but it excites me even more.

Final year

so I just arrived in Melbourne yesterday and have now finally settled in to my new place. it is spacious, it is gorgeous, it is going to be a fun house. Final year will be a testing year, despite the 'relax' nature of it all, i intend to give it my best when im on the wards, clinics and in theatre. its going to be a taste of what is to come in 2011, and when that time I comes i intend to be fully prepared. 2010 is going to be an awesome year of fun, learning, and out of this world experiences. FINAL YEAR MED STUDENT, ECUADOR, SPANISH, MBBS here I come.

p.s. http://www.facebook.com/album.php?aid=2055511&id=212900539&l=e8e44f7bc9

check the pictures of my new home for 2010.

2010

its been a while since my last blog post, and i attribute this to exams and also laziness, not that anybody is reading. conversations like this in my head happen quite often. I fear medical studies has pushed me towards a psychiatric condition.

jokes aside.

so 2009 has finally come to an end. What a long it was and what a relief that a new year has dawn on us, with so many exciting things waiting to happen. so my 4th year of medical studies have just gone by like that, and I have passed my final exams. unfortuately I did not do as well as I had planned to at the start of 2009. Resisting distractions and practising delayed gratification has not been my strongest suit thus far in 2009.

Being a final year medical student this year, I have mixed feelings about what lies ahead. I am excited about finally being at the top of the Medical student hierachy; where the juniors look upon you with this ardent fervour as I once did to my seniors when I was in 1st and second year. not having any more crucial exams in 2010 has been something all of us have been looking forward to since the day we enrolled in Medicine. My elective to Ecuador in September remains the highlight of my calendar this year. On the flip side, there is the pressure that this will be the final year I get to consolidate all that I have learnt in the past 4 years, to be a competent intern come 2011. On top of this, the pressure to have the knowledge that the junior medical students seek when on the wards; to not be outdone by the very same junior medical students in front of tutors and physicians. Knowing how easy it is for me to get caught-up in busy-ness or lull, I have decided that I will use the time that 5th year promises to provide to study well and be well prepared for the MRCS exam, which I will try and attempt in 2011. hopefully I see this resolution through with a good attitude; afterall i have bought the textbook. Mastering spanish to a competent conversational level is also on the cards as I prepare for my trip to Ecuador.

So now I am actually back in Singapore for the summer holidays and it really feels good to be home. It has been long since I have been able to enjoy the company of family, best friends and above all the comfort of home. I have mostly been going out, clubbing, golfing and playing games on the PS3. In the past 3 weeks, I have met more people here in Singapore than in Australia whom I will actually continue to maintain friendships. This has been something that I have long been missing whilst studying overseas in Melbourne. Being in the company of friends whose company you truly appreciate and enjoy, then the skin-deep, superficial patronage paid to you as a foreigner in a foreign land. having mentioned this, come June/July 2010 I will have to make a very important decision as to where I would be working in 2011. I know for sure, that I will pursue my internship in Australia and let things happen from there on. It would be the smart choice. But there is so much to consider when making decisions like that, job scope, training exposure, opportunities, salary, lifetyle, friends and social life etc...

Much will be happening this year, and there will be much to think about. For this moment, I will just immerse myself in the holiday spirit, focus on what is in front of me and not worry about what is going to happen.

Happy New Year to all, and may 2010 be a better year than the last.