… before graduation from med school.
went to tasmania for 3 days. freycinet national park was awesome, so was wineglass bay. “bay of fires” – one of the top 10 lonely planet places to travel to before dying.
got an unexpected gift from Dr Coppola. pictures here. will def do a review.
http://www.facebook.com/album.php?aid=358250&id=850900513
off to chennai, vellore, and bangalore over next 10 days for a medical mission trip / holiday. in fact its 70% touring and 30% mission stuff. til then, ciao
Surgeons have to be quick and decisive. Surgeons have to hurt you first so that they can heal you. Surgeons heal with cold steel.
Thank you for dropping by this latest edition of SurgeXperiences, your one and only online Surgical Grand Rounds. Each fortnight, a different host take turns to host and present a digest of the best surgical related posts or articles he/she thinks its worthy for others to spend time reading.Today, it is my turn, and I shall do so in “bullet” style. Enjoy.
Featured
A newly discovered surgical blogs – Dr. D J’s Surgical Adventures. Dr. D J is a surgeon from Mumbai, India. This is how he introduces himself”
“A surgeon with a penchant for writing and a passion for revealing the truth behind the farce that is the Indian Medical Industry.”
He treats us with an account of his living nightmare on a Monday when he started work at 8am and finished on Tuesday 8pm.
“We started laparoscopically, found the rent in the oesophagus, tried to get at it, tried and tried. The liver was getting in our way, the spleen was oozing blood because its capsule was stretched to tearing, the camera kept fogging up, the omentum was playing policeman in the abdomen sealing everything off.” [READ HERE]
He then updates us about that patient whom he spent 12 hours operating on. [READ HERE]
Just to feature another of his not-so-recent post, Dr D J has a M&M incident to tell involving a NG tube and abdominal drain got muddled up. [READ HERE] (P.S. interesting intra-operative picture)
Regulars
We have a triad of posts from the great bongi who blogs at “other things amanzi”. First up, he bemoans the poor state of the state constructed hospitals and the almost funny situation that creates in an emergency:
“to get a patient to theater from casualties therefore you needed to take the lifts…. but, as is typical of the maintenance ethic in south african state hospitals, only one lift worked at any given time. this added a unique aspect to an already high stress resus effort in casualties” [READ HERE]
While we are still on lifts, he has another story of funny times squeezing too many people in the small lift with an intern who has claustrophobia.
“his face was in my face and his eyes glazed over with hatred. i prepared to defend myself, but almost expected a phagocytotic attack” [READ HERE]
Bongi finally shares a little story on why he chose to specialise in Surgery. [READ HERE]
Ramona, a plastic surgeon in Little Rock, Arkansas, reviews 2 journal articles – 1 about peristomal skin complications and management [READ HERE] and the other about abdominal wall reconstruction [READ HERE].
Øystein, a Norwegian surgical videographer, shares with us a new procedure he has developed – “framectomy”. It involves a scapel, artery forceps, and some old photos [READ HERE].
Alice, a surgical resident, who regularly chronicles her ‘quest to become a Christian surgeon’ at Cut on a Dotted Line , tells us how life has been for us recently with night floats. [READ HERE]
Yours truly wrote a little post about surgical extended matching questions and how the options given in exams may not always reflect what one will do in real life. [READ HERE]
Surgical – opinion
Recently, the U.S Preventive Services Task Force issued new guidelines for breast cancer screening. It was met with criticism from the surgical community. Here are some of them:
A practicing breast surgeon, Alison Goldfarb, MD FACS, comments on the latest breast cancer screening guidelines laid out by the U.S Preventive Services Task Force [READ HERE].
Another breast cancer surgeon, Dr Megan Baker, answers a Q&A in this video exclusive. [SEE HERE]
The Swedish are saying “No Surgery” unless you quit smoking. Is this a good policy? Secondhand Smoke gives his reaction on this. [READ HERE]
Cool stuff
Ooh… Books! has an exclusive interview with Dr Chris Coppola, whom we all know from his previous blog at “Made a Difference for That One“. He was featured for his recent book “Coppola: A Pediatric Surgeon in Iraq“. [READ HERE]
Not Yet Published has a spiel on the distinction between physicians and surgeons, going into a little history about the term “mister” [READ HERE]. (P.S. a cool picture of a historic amputation kit awaits)
Has minimally invasive surgery hit the domain of breast surgery as well? [READ HERE]
Or even thyroid surgery? Apparently, a surgeon at Tulane has done the first scarless thyroid surgery. [READ HERE]
Next edition
To be hosted by Steve, an adult congenital health defect survivor! Read more about him here. He blogs over at Adventures of a Funky Heart, definitely worth checking out. You can submit your best surgical posts VIA THIS FORM.
The archives of SurgeXperiences are stored here (Season 2) and here (Season 1).
Subscribe via RSS or email to SurgeXperiences over at this link.
Clinical knowledge exams, at my medical school at least, tends to be not so clinical. For example:
Choose the most appropriate investigation to be performed next.
- A 59 year old male present with severe central abdominal pain radiating through to the back. His bp is 90/70 and a tender pulsatile central abdominal mass is palpable.
- A 29 year old male presents with 1 day history of periumbilical pain that has migrated to the right iliac fossa. Examination reveals local tenderness in the RIF and raised WCC.
In question 1, the diagnosis is no doubt a ruptured AAA given the hypotension and central abdo pain radiating to the back. What i understand is that you do not waste time with imaging (which under exam situations, i would clearly put CT abdomen) and you take the patient to the theatre for a laparotomy. This is supported by Case Files : Surgery, and the relevant case was written by Henry Veldenz, Chief of Surgery at Hardin Memorial Hospital, Kentucky. I quote:
“For a patient presenting with AAA rupture (back pain, hypotension, and a pulsatile epigastric mass), operative open repair is the most available and most potentially life-saving therapy. If AAA rupture is clinically suspected, the patient should undergo emergent operative repair. There is no role for radiologic imaging if clinical impression is a rAAA – the delay involved in obtaining imaging is too risky for the patient compared to a potentially negative exploration”
Going off on a tangent, for rAAA, if this patient presents to a hospital which has no vascular surgical cover, you would no doubt if a transfer to a nearby hospital which has a vascular surgeon on cover is better for the patient’s outcome. Would this delay in transportation make a difference? This is a question we tried to answer with this paper.
68 patients presented to the hospital with an onsite vascular service (group A) and 33 presented at sites without a vascular service (Group B)… the significant difference in time to operation between the two groups did not influence patient outcome, nor did the lack of an “on-site” vascular service lead to selective intervention….
The conclusion we drew has workforce planning implications, e.g. if the administration wishes to extend vascular surgeon service to a peripheral hospital in a particular health network.
An image you wish you wouldn’t have to see on a computer monitor. (image credit: learning radiology)
In question 2, classic appendicitis. We recently had such a question in our GP written exam, and one of the options was “no further investigation required”. Other options relevant include abdo U/S and abdo CT. I chose the first one. When the diagnosis is clear, there is no need to waste unnecessary resources. I raised this point with Dr Alice, a surgical resident in USA, who blogs at “Cut on the dotted line”. I did learn something from her comment. I love how she described it as “fun” to convince her attending to operate without a CT in a ?appendicitis.
Alright, rant over. Cheers
Thank you for chancing upon my blog somehow. Whether you are some SEO person assigned to increase your client’s visibility in this increasingly cluttered WWW, or a bored somebody perusing medical blogs, or a fellow medical student, or better yet, a doctor who is actually spending time reading the ramblings of “that blogging medical student”, i welcome you humbly to my blog.
so what’s been happening in my life so far? well, i just finished my Family Medicine rotation. 9 weeks just zoomed past like that. in your mind, perhaps family medicine is all about coughs, cold, routine blood pressure check ups. for some part that is true. there is a lot of preventative health stuff going on – BP control, diabetic screening, colon/cervical/breast/prostate cancer screening, vaccinations, diet, lifestyle. if you enjoy explaining such stuff to your patients, then great, do Fam Med. otherwise, u might, just like me, find it a ‘tad boring. GP-land is not as exciting as they make it out to be, at least at Monash. see, we get this Professor of General Practice, who incidentally wrote THE bible for general practice. his name is john murtagh, and mention this name, most if not all australian trained doctors will know him. he is synonymous with excellent general practice teaching and care throughout his career. “General Practice” is in its 4th edition, and prof murtagh has written numerous other books to aid GPs all over the world. how is GP different from internal medicine then? shouldn’t we stick to Harrison’s Principles of Internal Medicine? oh yea, to me, i still value american medicine higher, and harrison’s is the gold standard of internal medicine for me. CMDT 2010 is also something i use frequently. however, GP texts tend to focus on primary presentations, e.g. murtagh’s book has a section with many many chapters on first presentations, e.g. cough, back pain, chest pain, headaches, etc. the symptom is the topic of the chapter, not a particular disease. patients don’t present with a left bundle branch block, they present with syncope and lethargy.
anyway, its all part of training to be a doctor. most avid readers know i want to be a surgeon. however, i dont want to be a cut em and dice em brainless surgeon, if that even exists. probably exists in the preconceived notions of unlearned individuals who probably never had the honor of working or learning under surgeons. or in comedies like scrubs. nonetheless, i want to have a broad base of medical knowledge to back up my future practice, which is why im studying so hard now. more than ever. partly because of exams, but also for the future. 4th yr is the yr of our big MBBS exams at Monash. 5th yr we’re pretty much on our own, trying to get good letters of recommendation from various consultants so we land an intern job in a hospital of our choice.
so yea, im preparing for it US-style. im working my way through lange step 2 CK Q&A, and Kaplan Step 2 CK Qbook. they shd put me in good stead with int med, surgery, psych, obgyn and pediatric clinical knowledge. lets hope monash exams ask stuff similar to step 2ck standard! otherwise its still good prep for step 2ck which ill take next yr
kudos, thats enough for an update in the midst of exam prep!! take care now, thanks for dropping by, and i promise more frequent posts after exams.
oh and if u want to host SurgeXperiences, let me know! gimme a yell. the only online surgical grand rounds needs you!
a 75yo icteric woman noted to have multiple lesions in her liver that on CT imaging are suspicious for metastatic CA. which of the following is the most likely source of the PRIMARY cancer?
(a) stomach (b) lung (c) colon (d) cervix (e) pancreas (f) gallbladder (g) eye
ANSWER:
traditionally i think i would answer (c) – colon. it is the most relevant answer to surgeons because of the possibility of resecting the mets and 5yr survival rates are about 50% even with met colon ca.
however, against my better judgement, a friend who responded to this facebook post, answered EYE. at first i thought it was ridiculous, but further pursuit revealed an emedicine article that suggests otherwise: http://emedicine.medscape.com/article/369936-overview
a 1982 study quoted
Analyzing the data from 9700 consecutive autopsies in patients with 10,736 primary cancers, Pickren et al found that liver metastases were present in 41%.[1,2] They found that the primary sites most commonly metastasizing to the liver are the eye (77.8%), pancreas (75.1%), breast (60.6%), gallbladder and extrahepatic bile ducts (60.5%), colon or rectum (56.8%), and stomach (48.9%).
- Pickren JW, Tsukada Y, Lane WW. Liver metastases. In: Weiss L, Gilbert HA. Liver Metastasis. Boston, Mass: GK Hall Medical Publishers; 1982:2-18.
- Pickren JW, Tsukada Y, Lane WW. Liver metastasis. In: Weiss L, Gilbert HA, eds. Analysis of Autopsy Data. Boston, Mass: GK Hall and Company;. 1982: 2-18.
Welcome to this fortnight’s SurgeXperiences. This is edition 308.
Without further ado, let’s check out the best in surgical blogging!
Regulars
Buckeye Surgeon take a (painful) trip down memory lane as he came across some survey published in the Archives of Surgery talking about public vs health professionals’ viewpoints on end-of-life interventions. [READ HERE]
Dr Chris Oliver, a UK orthopod, who chronicles his amazing journey from obesity to trialthons, shares 2 articles on his blog about lap-band and battling the obesity epidemic. [READ HERE] [AND HERE]
Marianas Eye, an ophthalmologist working in Saipan, shares his column contribution to the Saipan Tribune about healthcare reform. [READ HERE]
Dr Bruce Campbell shares another piece of his great literary writing in “The Save”. [READ HERE]
Just so we don’t forget, even though he’s been off the radar a bit, Surgeonsblog still has many fantastic posts worth reading. [READ HERE]
The Independent Urologist has some tips on how to quickly capture a patient encounter in the EMR within 5 minutes. [READ HERE]
IntraopOrate replies to an email from a “surgery addict” and sheds some light on how to get to be in the OR more often! [READ HERE]
Aggravated DocSurg rants about how doctors (really) think. [READ HERE]
Blogging about research
This is gaining popularity at the moment all over the medical blogosphere. I guess medical bloggers are realising it is much easier to provide an opinion via a blog than to write a letter to the editor or comment about it formally in the journals.
Are mastectomies overly used for breast cancer treatment? The latest JAMA issue, which focuses on surgical care, has a study that reports otherwise.. [READ HERE]
Plastic Surgery 101, penned by Dr Rob Oliver a board certified plastic surgeon, shares his thoughts on this as well [READ HERE]
In the same JAMA issue, comparison is made between prostate cancer surgeries done the old fashioned way, or the new sexy way with minimally invasive techniques – often with the assistance of Da Vinci robotic system. WSJ Blogs give you the low-down. [READ HERE]
Military-related
The work which supports the healthcare of the military or those hurt in war zones are indeed commendable.
Military pediatric surgeon Dr Coppola has recently published his 2nd book about this time in Iraq. His book is now available for pre-order. Reviews from many notable authors have been fantastic! [READ HERE]
Dr. Donn Chatham, who heads the American Academy of Facial, Plastic, and Reconstructive Surgery, has announced a new program to help soldiers who sustain serious facial wounds. The program, called Faces of Honor, aims to provide more expert care in surgically repairing soldiers and veterans who may not have access to cutting edge treatments in their veterans administration hospitals. [READ HERE]
Professional misconduct
It is sad that increasingly surgeons are dominating the medico-legal scene.
2 plastic surgeons in Singapore are fined S$2000 and S$5000 by the Singapore Medical Council for professional misconduct: one failed to provide supervision for a laser lipolysis procedure performed by a nurse, one performed cell therapy involving the injection of animal foetal cells into patients for anti—ageing and rejuvenation purposes. [READ HERE]
A Pennsylvania plastic surgeon is being investigated for possible bribery. [READ HERE]
Special events
Over at the Clinical Congress of the American College of Surgeons, a trauma surgeon paints a bleak picture of the U.S. trauma system — 38% of the U.S. population may not be covered by a statewide trauma system. [READ HERE]
Many bloggers were off this weekend to the BlogWorld Expo at Las Vegas, including Bongi all the way from South Africa. Ramona who blogs at Suture for a Living, shares a little poem about her trip and provide links to all other similar posts about the great time they had. [READ HERE]
NEXT
Sorry no announcement about next host yet. But meanwhile, you can still submit your best surgical posts VIA THIS FORM.
The archives of SurgeXperiences are stored here (Season 2) and here (Season 1).
Subscribe via RSS or email to SurgeXperiences over at this link.
See you in 2 weeks!
I haven’t been posting much… So what’s been happening?
Well, i’m currently doing my 9-week Family Medicine posting. We get attached out to the General Practice once a week. On Mondays, Wednesdays and Fridays, we go to a central teaching location at the Department of GP where we get didactic lectures and clinical skills tutorials, where they hire simulated patients for us to practise our history taking/management. The focus is now less on history taking, and more on using the 10-step management plan devised by Professor John Murtagh, a guru of family medicine and author of a textbook called General Practice.
Anyway, i’ve also been doing some of the assignments that come along with this GP rotation, which i shall not bore you with.
What else? I completed editing of the SIHS newsletter for Summer 2009. You can download it from Adam’s website here (pdf file). The feedback has been positive.
Another thing i was busy about was finding out about General Surgical Residencies in the USA and about electives during my final year, in SDN forums and such.. I changed my mind from doing the Mobile Surgical one in Ecuador with Cinterandes, to doing as many rotations in USA as possible to get more letters of recommendation from US faculty to boost chances of residency application success. So i hope that comes to light. Also spent quite a bit of time deciding which USMLE Step 1 materials to get and finally got down to it. The SDN people really got great results, at least those that post on the forum! Most have >230/99. I do hope i will be one of those posting such great scores in the future. Probably gonna take it in 5th year between Apr – June 2010.
Other than that, my girlfriend is coming to Melbourne for a visit, so that should be awesome. It’s been a long time since we first started dating; i ought to close the deal sometime soon! Probably at the end of internship or something.
Also been helping out a friend to train for the Melbourne Marathon. we are taking part in the half event. what is cool is that next year, my brother, the legendary ultra marathoner in Singapore ( i say this because he has been getting quite a bit of media for his crazy running enthusiasm) will be taking part in the Mind Alpine Challenge with me. its a 100km event that scales 5-6 peaks in the alpine region in Victoria. will be gawdfully tough and i have some events lined up to help me prepare for them!
- 24 Jan: Mansfield to Buller – 50km (http://www.aura.asn.au/MansfieldToBuller.html)
- 6 Feb: Cradle Mountain – 82km (http://www.cradlemtnrun.asn.au/index.php?option=com_frontpage&Itemid=1) only 60 allowed, first come first served.
- 20-22 Mar: Mind Alpine Challenge - 100km (with my bro d’ man!) (http://www.rfv.org.au/Alpine%20Challenge%202010/home)
Medical practice is not knitting and weaving and the labour of the hands, but it must be inspired with soul and be filled with understanding and equipped with the gift of keen observation; these together with accurate scientific knowledge are the indispensable requisites for proficient medical practice.
Of shock therapy, schizophrenics, and the obssessive-compulsive medical student (part 4)
… this is a continued series of my reflection of my 9-week psychiatry rotation. read the 1st part, 2nd part, 3rd part. I have previously written about my Paediatrics rotation, and most recently my Obstetrics and Gynaecology rotation.
Aged Psychiatry
How apt for my 9-week Psychiatry term to come to an end with patients in their twilight years. I spent 2 weeks at an aged care centre consisting of a rehab, geriatric and aged psychiatry facility. There were 3 components of our stint here – aged psych ward, behavioural support team (BST) , and intensive care team (ICT). The aged psych ward consisted of mostly demented and depressed patients. There were the odd schizophrenic ones. A patient i saw from CL psych the previous week was here as well. I went out on a visit with the BST once, and that was to an elderly man who kept turning on the taps in the nursing home where he was residing. ICT tends to the patients who had just been discharged from the aged psych ward. I also went out on a visit with them once.
After getting a feel of how to interview demented and depressed patients, i sought to do other more “exciting” activities. They do some ECT sessions here, so i attended one. “Shock therapy”, as it was commonly called, isn’t as bad as it sounds, or popularly portrayed in mainstream media. Apparently it has had quite a bit of bad press. With pictures like these, who could blame them.
ECT has advanced quite a lot and now, patients only received 3 seconds of electrical voltage placed strategically on their foreheads (some unilaterally, some bilaterally). After which, they sustain a 20-second or so brief period of seizure activity. Usually ECT comes in packages of 6. They have no idea how it works, but it does. Majorly depressed patients with melancholia have reported feeling much better after. Schizophrenic symptoms can go into remission. It works wonders.
Some other thoughts
Finally, we recently had a tutorial on chronic mental illness. During the tutorial, several issues came up. We were given a brief overview of the Community Care Units that the Psychiatrist was heading. A multi-faceted approach including neuropsych, occupational therapy, family intervention, psycho-education, social support for carers, dual diagnosis management, social skills development, vocational rehab, is emphasised. Then we started talking about institutions and asylums. Australia was de-institutionalised some decades ago. Unfortunately, some patients fall between the cracks and not suited for CCU care or residential services. The psychiatrist herself was reflecting as she told us, was she chemically restraining patients (E.g. those with chronic schizophrenia) just so their psychotic symptoms are controlled well enough to fit into society just because we cannot provide adequate services for them?
On that note, it brings me to wonder about allocating funding for a healthcare system. Who should decide these allocations? Just to state a common example: should we continue to pump money into neonatal intensive care units to sustain the lives of these little ones? Some of them are born very prematurely (e.g. under 24 weeks) and not many can survive. Round-the-clock NICU care is expensive and there is no guarantee of their survival. Even then, their young lives will be troubled with numerous complications, e.g. bronchopulmonary dysplasia. Should the money then be spent on the elderly in geriatric wards, aged care facilities and nursing homes? After all, these people have worked hard their whole life, contributed to the society and economy and now it should be society’s turn to look after them… Are we then forced to make a decision as to which life is valued more? Should we?
Concluding thoughts
I first started Psychiatry with a negative preconceived notion. I exit having enjoyed some of it, especially so after writing this long reflective piece on what i thought about this entire 9-week sojourn. I doubt i’ll pursue a career in Psychiatry, but at least i had a taste of it to confidently i wouldn’t want to do it for the rest of my life. I’m encouraged by the fact i attained a Distinction for my 5000-word Psychiatry Case Report, but i received some help from tutors. All in all, I’m certain I’m to face some psychiatric conditions further down in my career, and I hope these 9 weeks can adequately equip me to deal safely with them. Besides, it also helps me to understand the mystery of the human mind much better. I remember keenly a tutorial on Personality Disorders. The tutor commented, “Who are we to judge and segregate how one acts into various sets of conditions known as Personality Disorders?” Of course, he did go on to explore how some of these conditions like OCDs can significantly impair one’s daily functioning and that is when these people seek the help of psychiatrists or psychologists. I’m glad that now i can vaguely make out different personality traits in people i come across and friends as well through conversations. And surely, you would have derived my obsessive-compulsive trait (apparently quite common in medical students) in trying to finish this entire reflective piece in one sitting. I hope you enjoyed reading about my experiences, and i look forward to hearing your comments.
Of shock therapy, schizophrenics, and the obssessive-compulsive medical student (part 3)
… this is a continued series of my reflection of my 9-week psychiatry rotation. read the 1st part, and the 2nd part. I have previously written about my Paediatrics rotation, and most recently my Obstetrics and Gynaecology rotation.
Child and Adolescent Psychiatry
Persons under the age of 16 afflicted with mental illnesses can be a sensitive and heart-wrenching situation. I was attached to Child and Adolescent Mental Health Service (CAMHS) community clinic. I sat in consultations with a Paediatrician who has a special interest in Autistic-Spectrum Disorders. She was clearly very enthusiastic about this, and displayed it by providing with numerous education articles she wrote. She asked me to spend some time to read them all, and provide a summary to her. Remembering some of these online quacks i’ve come across while blogging, especially the passionate blog articles by Orac regarding anti-vaccination, i asked her take on all these. This was replied by her printing off a lengthy book review of Paul Offit’s “Autism’s False Propets: Bad science, risky medicine and the search of a cure”. I appreciate her keen efforts to quench my thirst for knowledge.
Of course, Child and Adolescent Mental Health isn’t all about Autism. I sat in some consultations with some of the Psychiatry Registrars and we saw patients with conduct disorders, learning difficulties, and notably one with significant substance use. The polysubstance abuse was causing him to have disturbing visual hallucinations of himself getting killed in various graphic ways. A few others i remembered were teenage girls with eating disorders. What is sad about some of these cases is a consistent pattern surrounding an unstable family environment – mum divorced and recently remarried, dad and mum are separated and had previous histories of heroin abuse, etc. I feel a surge of melancholy as i wonder about their future. They will be the next person committing suicide from the Westgate Bridge, or the next up-and-rising drug dealer in town, or more scary yet, the next patient i see in the Emergency Department as an intern, treating them from paracetemol overdose or multiple lacerations on their forearms.
Consultation Liaison Psychiatry
This week prove to provide a more acute perspective to Psychiatry. Medical patients in the main hospital who develop or have a psychiatric condition may require some form of psychiatric care. This is when the CL team is called. At where i rotated, owing to the vast numbers of inappropriate referrals, the CL team necessitated a referral form faxed to their office, with a full MSE completed. No other requests would be entertained. The acutely delirious granny in the geriatric ward who was suffering from a UTI, or the aged grandpa, admitted for treatment of his pneumonia, who was found attempting suicide for the 2nd time on the ward. A most memorable patient was a 68-year-old lady who presented with weight loss, malaise and lethargy. CT scans revealed multiple mets and the primary tumour was not found yet. Prognosis is poor and she was receiving chemotherapy. Understandably, she displayed signs of major depression. When the CL reg was notified, he told me that sometimes there is more to Psychiatry than to just start the patient on some medications, like in this case, a tricyclic antidepressant. “Sometimes they just want to talk. Let them whine to you. They just want someone to listen to them.” And so we did, for nearly 2 hours we listened intently to this woman’s story, and found out her depression did not just start after the discovery of her cancer, but years before after she broke off with her ex-neighbour. This affair was undiscovered, but culminated in her selling her property via him (he was a property agent) and him dying suddenly of prostate cancer. She was filled with remorse and regret. I certainly hoped the time we spent helped her a little, even just a little.
This CL week gave me an insight into some of the common problems i might face as a medical or surgical intern on the wards. What makes a good referral, when should i refer, what expectations do i have for the CL psych team.
(to be continued…)
Of shock therapy, schizophrenics, and the obssessive-compulsive medical student (part 1)
My 9-week psychiatry rotation is about to come to an end, and i thought i’ll continue my reflections on this year’s rotations. I have previously written about my Paediatrics rotation, and most recently my Obstetrics and Gynaecology rotation.
I must admit i first approached Psychiatry as a specialty in a reserved and guarded fashion. We were first exposed to snippets of it in 1st and 2nd year, where we were taught components of a Mental State Examination, including cognitive assessment via the Mini-Mental State Exam. A memorable moment was our Clinical Skills exam (OSCE), where we had a simulated patient suffering from acute psychosis. We were just several months into our medical training, and as infants, were expected to conduct and sustain an interview with a hugely uncooperative patient, and thereafter report back on our MSE findings. I swore I hate psychiatry from then on.
My preconceived negative sentiments toward Psychiatry as a specialty did not improve when in the first week, we had observed interview sessions in front of our group of 10 or so students. The clinician selected a patient unknown to us and himself and with proper consent, brought this patient into the room full of students. My colleague and I set off to interview her. She was extremely guarded, and constantly stared me down. There was certainly a lot of transference and counter-transference going on and i had to be careful not to project her hostile feelings back onto her. She was, for the most part, unwilling to engage and did not give us a good sense of why she presented. Halfway during the interview, she stood up and surrendered. “Stop trying to get into my head! I don’t want to do this anymore!!” She promptly exited the room, and we were all quite taken aback. Thankfully, this was not met with any major clinical sequalae and she settled without chemical restraint after a while.
Community Psychiatry
My 2nd and 3rd weeks took place in a community clinic where patients were case managed. The case manager is often a social worker or a registered psychiatric nurse. They have clinical reviews by registrars or consultants periodically. I found these incredibly boring, to be honest. They were mostly well managed and their psychotic symptoms (most had some type of schizophrenia) were under control. There were also dedicated sessions of “Clozapine reviews”, where treatment resistant schizophrenic patients are reviewed medically after being commenced on the atypical anti-psychotic. They require weekly FBEs because of the rare but serious complication of agranulocytosis. Weight gain can sometimes a problem as well.
My fortnight there was also highlighted by some outreach trips to a certain undisclosed rural location, about an hour’s drive away. I was fortunate to have a registrar who liked to teach and also delighted in imparting his perspectives into psychiatry. He particularly emphasised things like being able to work in a team with other health professionals. The psych nurses seem to like him a lot. I hope i can be one such doctor in the future, with great rapport with the nurses.
A memorable patient was one who was suffering from major depression with melancholia. Everything about her looked depressed – she wore dark clothing, looked dishevelled and unkempt, walked and talked slowly, loses concentration from time to time, lost weight, reports insomnia and her affect was blunted and restricted in range and reactivity. That is not one i will forget for a while.
My fortnight ended off with a bam when we saw a very angry patient who received some electroconvulsive therapy (ECT) some months ago. She suffered from retrograde amnesia, a common self-resolving complication and was very cross about it. She claimed the doctors treating her did not explain to her properly these matters and treated her without her consent. To complicate things, she had a history of paranoid schizophrenia characterised by delusions of religious grandeur. ECT is not usually indicated for schizophrenia.
What I felt to be a confronting issue was Christian patients suffering from mental illness. At what point do you acknowledge that there is a mental illness stemming from chemical imbalanced in your neurological pathways, and at what point do you say that you need to rely more on God to overcome depression, for example. I still do not have the definitive answers, but i am keen to put forth an explanation that certain people are indeed more prone to mental illnesses genetically or chemically and the beauty of it is that God has granted wisdom to researchers and doctors to invent and use psychiatric drugs to successfully help these people cope better.
(to be continued….)
“A boy of about five walked towards me, his hand held open, asking for food. I felt nausea as he appraoched. “He is cursed,” Hurzi cautioned. “There are more like him coming from the villages.” At first I thought the boy had been shot in the face. He had a gaping hole eight inches in diameter just below his right cheekbone. The jawbone was exposed, and the flesh around the opening was rotting black. Through the hole I could see his tongue moving as he tried to talk to me. He was suffering from cancrum oris, a very rare effect of prolonged starvastion, where immunity is all but nil and the normal bacteria of the mouth proliferate and begin feeding on proximate flesh. I had only seen old pictures of it in tropical medicine textbooks. This was real, and for a moment I had to turn away. Disease follows hunger and will likely kill before the body expires from starvation.”
- James Orbinski, when he was serving as a medical coordinator in Baidoa, Somalia, with “Doctors without Borders”
Picture of a boy suffering from “cancrum oris”. Deliberately shrunk. Click to enlarge.
An Imperfect Offering is a good book. I definitely recommend it to any health professional or anyone interested in Humanitarian Work or International Health.
Dr Vijay, a practising radiologist from India, has just hosted SurgeXperiences for the 2nd time at his blog “scan man’s notes”. SurgeXperiences 226, is the 50th edition and the final one of SurgeXperiences season 2.
Official SurgeXperiences logo, courtesy of Vitum Medicinus.
SurgeXperiences was set up to be the definitive Surgical Grand Rounds in the medical blogosphere. A surgically focused blog carnival featuring all the best posts related in anyway to the diverse field of Surgery.
SurgeXperiences was first started 1 July 2007. It is hosted by various hosts ranging from surgeons to anaesthesists to radiologists to students! It is on every fortnight and each season lasts approximately a year.
- Season 1 [Jul 2007 - Jun 2008] had 24 editions. An archive can be found here.
- Season 2 [Jul 2008 - Jun 2009] had 26 editions. An archive can be found here.
A big and special thank you to all previous hosts. Your time and efforts do not go unnoticed and i hope the traffic this carnival brings you is sufficient of a motivation to host another time!
Here’s to all 50 and 50 more!
Welcome to the 25th edition of SurgeXperiences – the one and only Surgical “Grand Rounds”, where the best surgical-related posts are gathered into one succinct post every 2 weeks. Thank you for dropping by, and because i’m in exam mode, i shall present this edition in a Q&A fashion; enjoy!
Regular contributors
Q: What is “cell phone elbow”?
A: It is the layman term for “cubital tunnel syndrome”. For a detailed writeup, hop on over to Suture for a Living to have an expert tell you all ’bout it.
Q: We all know experience makes a difference, especially in surgery. But has this ever been validated by a study?
A: Yes! Aggravated DocSurg tells us so, in “I see Jimi in the mirror!“
Q: Who has had an eccentric superior and not know how to react to his comments/jokes?
A: Bongi! He tells us a story about his professor of thoracic surgery.
Q: What is Buckeye Surgeon suggesting over Quality Assurance Committees for physician-initiated healthcare reform?
A: Cost effectiveness! Why? Read here.
Q: What is “Dr Bard Parker’s” take on the working hours limits on surgical trainees nowadays?
A: “kids these days” sums it up. Link on to hear what he’s got to say over at his blog “A chance to cut is a chance to cure”!
Q: How can one cope better with having ‘difficult conversations’ with patients?
A: Find out here as Dr. T (Notes of an Anesthesboist) shares her experience on the recent ‘difficult conversations’ she has had.
Q: Is it possible to be ruthlessly kind, especially in the teaching of medicine?
A: Perhaps, as Bongi (Other Things Amanzi) relates an incident about treating a patient with a 3rd degree circumferential burn.
Newbies
Q: I notice there are not many Australia surgeon bloggers.. Are there any new ones who decided to write about their cool surgical lives?
A: Yes! The diary of a surgeon is revealed! Over at Crikey Bulletin, which features Prof Guy Maddern from Adelaide.
Q: What is it like after vision correction surgery? Is there someone who can tell us about his/her experience?
A: “I was surprised to discover I was immediately able to open my eyes and see normally.” Read all about it from web architect Matt Raible’s blog.
Q: What is the caption for the following advertisement? Who is the advertiser?
A: The caption is “Plastic Surgery Loans“. It is an ad by Fortis Bank.
Q: Speaking about plastic surgery, what is the title of the book Dr Maria Siemionow recently published?
A: Face to Face.
Q: What is this book about?
A: Dr Siemionow recounts her experience of leading a team who successfully performed the world’s first full face transplant at Cleveland Clinic. [link contains an exercept of the book as well]
Special tribute to a great surgeon
Q: What TV show did the late Prof Chris O’Brien (renowned head and neck surgical oncologist) star in?
A: Prof O’Brien was featured in an Australian reality medical TV series called Royal Prince Alfred, which showcases interesting cases and the doctors who work at this top Sydney hospital.
Q: What did Prof O’Brien die of?
A: Glioblastoma multiform, diagnosed in 2006. (source)
Q: What is the title of the book he wrote?
A: “Never say die.” Linked here is a 60-minutes interview with him after he was diagnosed.
Q: Who treated Prof O’Brien?
A: Dr Charlie Teo, a top (and some say controversial) neurosurgeon. When contacted, he said this of his former colleague, “People face death in many different ways but he faced it with such dignity and tenacity … he taught me some great lessons on life….. He knew that he was fighting a formidable enemy and yet he still remained very positive until the bitter end.”
Surgical care
Q: Do doctors really read through the patient notes?
A: Apparently not, as Buckeye Surgeon discovers in a case where he recommended hospice care for a patient, but no one listened!
Q: Is it right for a surgeon to leave post-op care to the hospitalist?
A: No! Certainly not the not-so-Happy Hospitalist, who hears from another hospitalist that an orthopedic surgeon has been doing so and only seeing the patient on the discharge day. To quote, it’s “one of the worst examples of patient abandonment I can imagine.”
Q: How many pounds did Wrexham Maelor Hospital pay for surgical blunders made there over the last 3 years?
A: HALF A MILLION! Read more here.
A pinch of humour
Q: Is there a comic about medieval surgery that could make me laugh?
A: Maybe. Check one out at scanman’s posterous.
Q: What not to do or say when asking for an autograph from a sports star?
A: I’ll leave you to find out from yet another tale from Bongi, entitled “skande“
Some announcements
Q: What is so special about the next SurgeXperience edition?
A: It is the 50th edition!
Q: Who is the lucky blogger who gets to host SurgeXperiences on this very special occasion?
A: Dr Vijay, who blogs at scan man’s notes.. Be sure to submit your posts via this form. SurgeXperiences 226 will be hosted in 2 weeks’ time on 28 June 2009.
Q: Can i subscribe to SurgeXperiences using RSS or email?
A: Certainly! Do so over at this link.
Q: Where can i check out previous editions of this awesome surgical blog carnival?
A: The archives of SurgeXperiences are stored here(Season 2) and here (Season 1). Feel free to check them out!
~ ~ ~
Let’s round up with a joke (that carries a little tinge of politics), courtesy of In From The Night:
“Three Californian surgeons were playing golf together and discussing surgeries they had performed.
One of them said, “I’m the best surgeon in California . In my favorite case, a concert pianist lost seven fingers in an accident, I reattached them, and 8 months later he performed a private concert for the Queen of England.”
The second surgeon said, “That’s nothing. A young man lost an arm and both legs in an accident, I reattached them and two years later he won a gold medal in track and field events at the Olympics.”
The third surgeon said, “You guys are amateurs. Several years ago a woman was high on cocaine and marijuana and she rode a horse head-on into a train traveling 80 miles an hour.All I had left to work with was the woman’s hair and the horse’s ass.
I was able to put them together and now she’s Speaker of the House!”
Fascinating pictures from NY Times’ coverage on Tanzania and its high maternal mortality rate. Ether, if i’m not wrong, is a very old-fashioned way of anesthesia.
One of my clinical tutors at the hospital i rotated for Obstetrics & Gynaecology is semi-retired now; he comes in weekly for an antenatal clinic and gives us weekly tutorials on mainly obstetrics. I can see that is his passion. Often, he goes to sub-sahara Africa for medical missions. He liaises with the government officials and recently i heard him speak at one of the Friday morning CME meetings, where he talked about maternal mortality at Sudan. He reflected about his experiences and how the introduction of misoprostol easily dropped the rates of maternal mortality (hugely contributed by uncontrolled post-partum haemorrhage). According to UNICEF, in Sudan, there is a maternal mortality ratio of 1,107 deaths per 100,000 live birth. In Australia, the rate is 8-10 per 100,000. What a stark contrast eh? Between 1991-96, 1 woman died in Australia of PPH. Most of the 1107 women who die per year in Sudan die of PPH.
My 9-week Obstetrics & Gynaecology rotation ended today. I clearly remember attending one labour ward night shift (9pm to 7am). I was quite happy because one of the ladies consented to having me around, watching and learning. It was indeed a privilege to attend their birthing process. The lady was in stage 1 labour, so nothing much was happening. The midwife was checking some of the drugs and preparing them. She taught me as she did – syntocinon, ergometrine, misoprostol … we use this if there is PPH. sync is to help the uterine contract.. in the event of a PPH, we might use ergo, miso PR, etc.
If only the women in Sudan had access to these drugs …
My time in O&G land was an eye-opening experience. I attended many theatre sessions; that was where i could do Vaginal Examinations under Anaesthesia! Women really didn’t care what happened when they’re knocked out. Most threw in that comment when i asked them as they waited in the pre-surgical area. It’s weird though, most had no palpable pathologies. I did feel a couple of retroverted uteruses though. No adnexal masses. I stopped doing them when i hit the minimum of 5. We have a logbook to sign off. One of which was to watch 1 hysteroscopy. I ended up watching like 3o or sth. I can almost do one if they asked me to. Just have to know how to fiddle and connect the hysteroscope and attach the Hartman’s bag.
I loathed Obstetrics. That’s because as a student, you follow the midwife. No offense to midwives, but i don’t find their job very interesting. I admire their patience and preserverance in sticking around with a women for her labour. Gawd its long and boring. I would much rather be a resident, who usually only comes in a couple of times to pop their head in and check how the woman is progressing. And they come in for the final crowning bit. Push! Damnit woman push!*
* ok, not they don’t say that.
Gynaecology is so much more interesting. In fact i like it. I scrubbed in for 2 total abdominal hysterectomies, one for a uterine myosarcoma and another for a massive 10cm fibroid.
Another cool pic i had from my iPhone was that of a dermoid cyst. Now to understand this, you have to know that dermoid cysts can have ectodermal derivatives in them – epithelial tissue, hair, skin, even teeth! Too bad this one had no teeth!
So anyway, that’s that. We also had a week where u follow a private consultant and experience the life of a specialist. He practises mainly obstetrics. He tells me an average OBGYN does about 120 deliveries a year, he does about 3 times of that. A quick search of his name yielded recommendations on Bubhub, and other mummy forums. its nice that he can see sisters of sisters, friends of friends who all like him so much, and even a GP who refers her patients to him for specialist care! he provides her complimentary antenatal and obstetric care! he made me reconsider obstetrics, but warned me of potential lifestyle issues. and oh, the malpractice coverage is huge! but i think if i ever stepped down that path, i might focus more on gynaecology, particularly gynae surgery, e.g. oncology, or endometriosis interest, etc.
that’s O&G in a nutshell. my exams are next friday 12 june and the OSCEs are on 16 june!
