many things going through my head...

in the past, I felt that personal things should be kept to oneself, not talked about. no matter how much they troubled you. work, relationships, friends..... im blabbering, but what does it matter, no one reads this blog anyway. its just another outlet for me...

Im seeing someone now. her name is Laura. she's great. I use to dread relationships....boyfriend and girlfriend, losing the freedom you have as a single person....relationship averse....and then I met Laura. you don't miss singlehood when you've met someone you truly cared about. there's so much more to do and see in places you've been before by yourself. It's like travelling alone, I've done that before. Being carefree, being whoever you wanted to be; but then as you travel you realize there is actually alot more you could do and see if you had a travelling buddy, be it a friend or someone special. I use to look forward to weekends, coz it simply meant that I did not have to work. but things got old, and weekends were often wasted just being by myself and not making full use of it to experience things around you....and then I met Laura. I can't wait to see her again even if I just said goodbye that same morning. I can't wait to hear her voice, even when I've just put down the phone...you become someone you don't expect yourself to be, you do things you would not normally do. you put yourself in a position that makes you uncomfortable just so the person you care about is happy...........................


palliative medicine has been quite confronting in all honesty. before I worked here, it seemed to me that the whole concept was the anti-thesis of medicine. In medicine, we help people get better, fight disease...make people better....but palliation was giving up, surrendering to the affliction. It was ok at first, then everyday someone dies......its not the dying that is difficult. They are comfortable and painfree... i hope. we try to achieve that. it is the experience of people coming into hospital, getting admitted.... knowing that they have come to die.......what exactly goes thorough a person's mind when they acknowledge the fact that they were GOING TO DIE. In a medical ward, you might still have the 'reassurance' that doctors will do all it takes to make you better. But in a palliative care ward, there would be no more treatment. There would be no more fight. What exactly goes through a person's mind when they wake up every morning, knowing that the next day is going to be an agonizing wait....and that if they wake up the next day they won't be feeling better, but will be feeling worse.

When a patient of mine's condition seemed to have plateaued and did not look like he was immintely at death's door, we had to find a place for him to go to. A nursing home. he said to me,' so the time has come eh? ' I had no idea how to respond, how do you even respond to something like that.knowing the time is coming, but you just have no idea when that was going to be.....


palliative care is sad. kudos to the wonderful nurses and doctors who choose to work in this field. working in a place where everyone is dying or waiting to die is tough, I have alot to learn.....

disappointed.

today I set myself up for disappointment. thus, this will never happen again.

lost in the cracks

so... early last week whilst I was going about my daily routine trying to finish up with ward work for the morning, I get a call from the radiology registrar. " Hi, I need to see if you still want this CT-scan to go ahead because Mrs XXX's renal function is deteriorating" "Mrs Who??" "Mrs XXX, she was here 3 months ago...." "......er....I have no idea who she is.." " well, ask your registrar, it has her name on the request slip, thanks *click*

me to registrar,' erm, I got a call earlier about some lady needing a Ct-scan, but has deteriorating renal function, do you still want it to happen?" " well, shes got pancreatic cancer, she is 87, she definitely needs someone to be following this up, th escan dosent have to happen urgently, but it needs to happen"

a few phone calls later and another few visits to the radiology registrar, I have yet to make sure this woman's cancer is beign watched. Radiology refuses to schedule a scan until they have evidence that the lady is fit to have it, patients GP is 'part-time' and therefore will not be at the clinic often enough to constantly monitor the renal function and book a repeat scan. Also, patient is NOT IN HOSPITAL.

This situation has bugged me for quite a bit mainly because of individuals refusing to take ownership of a patient who has clearly been seen by them, and NOT ME. Radiology throws at me stupid excuses of rare reactions to contrast if someone's renal function is not up to scratch, GP gives me excuses about the part-time employment. Why can't the stupid radiology registrar just book a date, so that at least some sort of follow-up is in place. Why can't the GP who is in the community just add a reminder to one of her GP programs that is so sophisticated these days?? why am I loking after someone, I have no clue about, let alone not a patient of the HOSPITAL?????

Here I am, in the middle, having to ensure that this lady's cancer is not left to fall through the cracks. She's 87, probably not fit for surgery, and my registrar reckons she might do with radiotherapy?? even non-invasive, it it not without its side effects as we all know.

this is ridiculous. a woman with cancer, and no one seems to care, just because she's not sitting in front of them. I wonder, how many patients are unfortunate enough to fall through the cracks like this woman?? How many individuals have missed out on early diagnosis or intervention, because someone far away decides that a scan needs to be cancelled, and then left up to some one else, in this case me, who has no familiarity whatsoever with this person to make sure things are in order. Am I handling this because it is my responsibility as a doctor with a duty of care to this patient who's notes happen to fall into my lap OR am I handling it because I am a fellow human being?? if so, why are the others shifting responsibility?? am I trying to do the same or convince myself that I am not by putting my thoughts into words to seek clarity...I do not know.

Internship!!

Jan 12th 2011 was the day I commenced my internship. The day of being a doctor had finally arrived, after 5 years of ups and downs in medial school, the day that all us medicos look forward to from day 1 of medical school with excitement as well as trepidation. The first day of the rest of our careers had just started; real responsibilities and real consequences can happen with our actions and omissions.

It's been 2 weeks since I started, but I have only just been able to find time to pen my thoughts down. So I start of 2011 and internship in the town of Mildura, 8 hours northwest of Melbourne by car or a 1 hour flight. Mildura is closer to Adelaide then it is to Melbourne. Twas' a long and quiet drive up, uneventful, but rather enjoyable. This was also during the floods and I was lucky to have driven off from and through Echuca, abotu 1.5 hours before it flooded through. When I was going through, the Campaspe river was already looking to overspill the banks and onto the roads. Thank god!

Internship for me has started with General Medicine and the Mildura Base Hospital. A small and cosy rural hospital sufficient to meet genereal medical and surgical needs. The last 2 weeks has been busy. I did my first cover shift as well as my first weekend. working in medicine has been pretty good so far. lots to learn about medicine, dealing with patients and also equally as importantly, dealing with annoying nursing and pharmacy staff.

Cover shift

Cover shift is worst when yoru fellow colleagues are not organized and do not prepare the paperwork necessary for admitting or discharging patients. sometimes the patients come through, lying there in a bed and none of the medical staff seem to be aware that they are suppose to be there. Also, looking after and making decisions for patients that I had no idea of, from their demographics to their actual medical/surgical condition , this was sickening as it takes up a lot of time going thru the files and charts just to get a vague idea of what is happening and I need to do for the patient. Also, you have the nursing staff and pharmacists hounding you for discharge papers, scripts.............. and there is only 1 of me working.

Hospital Staff

So far, most of the hospital staff that I have met and had dealings with have been very approachable and helpful. The registrars have been great, welcoming us and supporting us in our daily dealings with patients and other staff. The consultants have been more then welcoming in inviting us to the team and making us feel comfortable on the job. However, needless to say there are always the annoying ones who try to pretend to 'advocate for the patient' but in actual fact are hindering the recovery of patients. And then there are the others that try to get you to cover up for their mistakes, re-writing scripts because they have given the wrong dose or sometimes even the wrong medications. They politely ask you to write up medications to help settle patients 'IF they get too agitated in the night' but the medication is more for themselves so they won't have a busy night. stupid irresponsible nursing staff, making us irresponsible just so they can have an easier time.

I was speaking to other friends, fellow interns and seniors who've just completed internship as well as registrars i've worked with before as a student, telling them how frustrating it can get as an intern, where you try your best to make things easier for yourself and everyone else. There is no escaping it. Either way I lose. When I make things easier for nurses, I lose because I become more busy, When I try to make things easier for myself by getting organized and doing tasks in advance, I also lose, because I just get more work to do. Such is the life of the lowly medical intern.

This is my first, and hopefully my last Medical rotation for the rest of my career. I have 8 more weeks of this to get through.

In my 2 weeks of experience, I think the way to make things as easy as it can get for an intern is to be organized and prioritize the work that has been give to you. It takes a while to get use to the way thigns are organized in a new hospital, ward, a new team. But we all get there eventually, and I hope they get easier with time.

where do I belong?

I have just come to realise that being overseas for such a long time, even with the great experiences and memories that you take away, the main downside is that.. you don't make good friends like you do back home, but when you are away for too long, people from home forget that you exist.....

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.