I must say my retirement from blogging is not because I have stopped writing entirely, but in fact i remained active in writing — only in a different form. Traditionally, we have established doctors who used to write in medical journals get fed up and decided to start a blog and write whatever they wanted without peer review. I sort of went the opposite way. I used to blog, now i try to write and get published. So far i have got 12 accepted papers, including a recent high profile Archives of Surgery commentary entitled “A President’s Emergency Plan for AIDS Relief for Surgery: A Call to Action for Surgical Care in Low- and Middle-Income Countries.” (PDF AVAILABLE in LINK)

http://www.ncbi.nlm.nih.gov/pubmed/21930994

You can easily pubmed me as “Jeffrey Leow” and you can see my work.

I am currently doing my surgical posting during my 1-year housemanship. I will be applying for surgical residency in Singapore, and continue to be very interested in surgery in developing countries, as such the focus of most of my published work.

I am intending to go to Tanzania in March-April 2012 for a surgical mission and survey of the district hospitals. In addition, in Nov 2011, I am going to San Diego for a global surgery conference entitled ASAP Meeting — more details: http://cme.ucsd.edu/asap/
It’s more of really an excuse to go to the USA and get MOHH to sponsor me to go — and i have to present an abstract on cancer surgery in Malawi. Making that poster now..

Thanks for following and have a good one. I will probably update this blog as i embark on those 2 upcoming journeys. But you know, facebook is kinda easier.

meanwhile, i am back in singapore enjoying the tropical climate and trying to absorb what has changed and what hasn’t. singapore is undergoing a revolution-transformation. we recently had 2 casino / resorts open, the Youth Olympics just concluded yesterday, the F1 night city circuit (one of its kind) will come soon, OK no i do not work for the Singapore Tourism Board.singapore definitely has much more buzz about it compared to just 45 years ago when it was merely a sleepy fishing town … we have come far in 45 years to become one of the richest cities / countries in the world. we are not  in the OECD countries however (not sure why so). we are open and welcoming to all foreigners and in fact sometimes the citizens feel that the government does not exhibit enough protectionist policies.

on a personal level, time back in singapore is always great because i think i feel back home. the concept of where home is has been in my mind recently. What’s home? Familiar sights, smells, food, language, people? Or wherever your loved ones are? or is it wherever you were born and spent the majority of your life in? i spent 20 years of my life in Singapore – completing my pre-tertiary education and serving a 2-year conscript requirement. i spent 5 years in melbourne pursuing my medical degree. it is no wonder i feel more home in singapore. however, if i spend the next 30 years in another country, will that place be my new home? what about people who  spend time in multiple countries multiple years? is home where your citizenship lies?

(by the way, singapore does not allow dual citizenship, though you are welcome to be a permanent resident of as many as countries as you wish.. but did you know also that the ministers are not allowed to have a PR-ship elsewhere?? perhaps as a show of patriotism )

i guess what im saying is, i am not sure where my future lies. neither does my significant other. we just know we should be together. the big day isnt far away n i do not anticipate it exceeds 2013. i wonder to myself, if i send invites to my blogger “friends”, would they come to visit this tiny island and share in my joy?

Believing that I cannot better reflect what the various excellent bloggers already have in their own words, I hereby present some of our regular surg bloggers’ recent posts!

Regular surg bloggers

Reflections in a Head Mirror – Two world collide

“There’s a consult downstairs, Campbell. Go check it out and I’ll catch up with you later.”

“Sure, OK.” I was a third-year medical student fumbling through my first clinical rotations. The resident headed off to whatever he needed to accomplish and I trotted down the back stairwell. I glanced at the consultation slip and found the patient’s room number.

56-year-old man with progressive medical problems. Please evaluate for central line placement.

Aggravated DocSurg – If they could only all be taken to Rampart Hospital

Trauma surgery for me is a whole lotta non-operative care interspersed with occasional surgery for things like a ruptured spleen…

Except in real life, where some patients die of their gunshot wound (GSW). Sometimes, the reasons are obvious — shot through the heart or the head with a fatal brain injury. Sometimes, the reasons are harder to understand —- see a description of irreversible coagulopathy here. As for the rest, we don’t have all of the answers, though not for a lack of searching.

Insurance Coverage Is Associated With Mortality After Gunshot Trauma is a recent retrospective study that is part of that searching.

…..

What do I think? Meh. Several things strike me at the same time.

other things amanzi – significant moments

i hate paediatrics. people who don’t understand the life of surgery may think this means i don’t like children, but in fact the contrast is true. surgery is suffering and heartache. surgery is pain and misery. it is stuff children are not supposed to experience. children are supposed to be caught up in the joys of life…

other things amanzi – ideal

i have been following the story of the baby that was brutally assaulted recently with more than a little horror….

recently in our beautiful land quite a number of fairly highly positioned politicians have publically encouraged the murder of afrikaaners…

i can’t help drawing parallels…

Respectful Insolence – Poor, poor pitiful me: Jenny McCarthy and Dr. Jay Gordon after The Vaccine War

Anti-quackery surgical oncologist makes an analogy between “sentinel” bleeds and small outbreaks of vaccinable diseases

… a “sentinel” bleed is generally a relatively small, self-limited upper GI bleed. The patient bleeds, then stops. Everything appears to have settled down. Then, usually hours although sometimes days later, the patient suffers a massive exsanguinating hemorrhage from the fistulae. There are other examples of herald bleeds…

The relatively small outbreaks, such as the measles outbreak in San Diego, could be viewed as being similar to sentinel bleeds, relatively small and self-limited. I fear the real outbreak, as well we all should. Thanks to the anti-vaccine movement, it’s a matter of time unless current trends reverse themselves. When I think about this, I become very depressed.

Unbounded Medicine – Uric Acid Nephrolithiasis

Fast facts about the above named condition. Welcome back Dr Jon!

Cut on the Dotted Line – absite as myth

I’ve been thinking: the surgery in-training exam is really like a recitation of legends, orally recounted histories, not too closely related to facts, that define our community.

The test runs through a long series of stories, which are so familiar to surgeons and surgeons-in-training, that we only have to mention a few words of the story, to have the whole thing immediately recognized and understood.

Suture for a Living – Dr Goldwyn’s “Surgeon”

After learning about Dr. Robert Goldwyn’s death, I pulled out his book “The Operative Note:  Collected Editorials” to reread (published in August 1992).  I’d like to share a few with you over the next weeks/months.

The first is entitled “Surgeon”

this is certainly a new series I look forward to!

Suture for a Living – Knowledge: What Kind and How Much?

Here is a second essay from Dr. Robert Goldwyn’s book “The Operative Note:  Collected Editorials” (published in August 1992). Knowledge:  What Kind and How Much?

SA Anaesthetist: Superman?

last week, on my private practice day, I counted how often I changed clothes. I went to 2 hospitals (one of them twice) during the day. Including getting out of my pyjamas into my street clothes, and then back into my pyjamas at the end of the day, I changed clothes 9 times.

SA Anaesthetist: Evacuate!

One of the problems with being the anaesthetist is that often, I don’t know the whole story. Sometimes it is better this way, other times not.

VIVA TIVA: Safety and security

Something very strange happened last night. I had to accompany an intubated & ventilated patient being transferred from our hospital, to an ICU in the capital city about 70 km away.

Other blog articles of interest

This week we also have a peek into the life of a trans-sexual who desires gender reassignment surgery. Jessica describes herself as  “a 32 year old natal male who identifies as a woman and desires to have vaginoplasty as part of gender transition”. As you might know, there are not many surgeons who do such surgeries and the handful that do have strict requirements, and hence Jessica has penned a “Surgery Letter”, which is a working draft letter for her cognitive/behavioural psychologist to the potential surgeon. Read it [HERE] and do check out her website to find out more about her journey.

Many surgeons (and for that matter physicians in general) have interests outside of medicine. A New York plastic surgeon, Dr Hank Chieng, has just set a new world record in Donkey Kong. Find out more about his story on how he did it [HERE]. This makes some wonder if there’s a link between surgery and video games. Celeste Biever of New Scientist blog addresses this query [HERE]

Katie a pre-med student from Case Western Reserve University blogs about her semester in the UK. Among many of her experiences which she chronicles in her blog “There’s No Place like London”, one was about the times she spent in the Operating Theatres watching OBGYN and cardiothoracic surgical procedures. Read more [HERE]!

Remote controlled heart surgery a world first! Read more about this groundbreaking feat performed at Leicester’s Glenfield Hospital [HERE].

Joke of the fortnight

A funny reconstructive surgery joke. Check it out [HERE]!

Finis

Meanwhile, should you desire more surgical blog reading, kindly avail yourself to the archives of SurgeXperiences, stored here (Season 2) and here (Season 1), along with the latest schedule of dates and host sites. You can also subscribe via RSS or email to SurgeXperiences over at this link. And of course, you can submit your posts VIA THIS FORM.

If you are interested in hosting SurgeXperiences, please contact me.

Join me in honouring them by visiting their blogs (those that still exist) available either through this latest edition (SurgeXperiences 321 ) or via the archives of SurgeXperiences as listed below:

• Season 1 (July 07 – June 08): 24 editions.
  
• Season 2 (July 08 – June 09): 26 editions
• Season 3 (July 09 – current)

If you would like to be part of SurgeXperiences, you can

1. Host an edition, kindly contact me.
2. Submit your blog post via this form.
3. Submit someone else’s  noteworthy post via this form.

Good day!

Mobile phone vs.  Bible

Ever  wonder what would happen if we treated our  Bible like we treat  our  cell phone?

What  if we carried  it around in our purses or  pockets?

What  if we flipped through it several time a  day?

What  if we turned back to go get it if we forgot  it?

What  if we used it to receive messages from the  text?

What  if we treated it like we couldn’t live without  it?

What  if we gave it to Kids as  gifts?

What  if we used it when we  traveled?

What  if we used it in case of  emergency?

This  is something to make you go….hmm…where is my  Bible?

Oh,  and one more thing.

Unlike  our cell phone, we don’t have to worry about our  Bible being disconnected because  Jesus  already paid the bill.

Makes  you stop and think ‘where are my priorities?  And  no dropped calls!

Place  your mouse on the ‘E’ below and drag to the  ‘U’

Even though you  can’t see Him, GOD is there for yo U

When Jesus died  on the cross, he was thinking of  you!

If you are one  of the 7% who will stand up for Him, forward  this.

93% of people won’t forward  this.

Trust  in the Lord and  *ASAP (Always Say A Prayer)

—–
A month ago, many of us heard about the sad demise of Ranjan Das from Bandra, Mumbai. Ranjan, just 42 years of age, was the CEO of SAP-Indian Subcontinent, the youngest CEO of an MNC in India . He was very active in sports, was a fitness freak and a marathon runner. It was common to see him run on Bandra’s Carter Road . Just after Diwali, on 21st Oct, he returned home from his gym after a workout, collapsed with a massive heart attack and died. He is survived by his wife and two very young kids.

It was certainly a wake-up call for corporate India . However, it was even more disastrous for runners amongst us. Since Ranjan was an avid marathoner ( in Feb 09, he ran Chennai Marathon at the same time some of us were running Pondicherry Marathon 180 km away ), the question came as to why an exceptionally active, athletic person succumb to heart attack at 42 years of age.

Was it the stress?

A couple of you called me asking about the reasons. While Ranjan had mentioned that he faced a lot of stress, that is a common element in most of our lives. We used to think that by being fit, one can conquer the bad effects of stress. So I doubted if the cause was stress.

The Real Reason

However, everyone missed out a small line in the reports that Ranjan used to make do with 4-5 hours of sleep. This is an earlier interview of Ranjan on NDTV in the program ‘Boss’ Day Out’: Boss’ Day Out: Ranjan Das of SAP India. [link]

Here he himself admits that he would love to get more sleep ( and that he was not proud of his ability to manage without sleep, contrary to what others extolled ).

The Evidence

Last week, I was working with a well-known cardiologist on the subject of *Heart Disease caused by Lack of Sleep*. While I cannot share the video nor the slides because of confidentiality reasons, I have distilled the key points below in the hope it will save some of our lives.

Some Excerpts:

* Short sleep duration ( <5 or 5-6 hours ) increased risk for high BP by 350% to 500% compared to those who slept longer than 6 hours per night.
Paper published in 2009. As you know, high BP kills.

* Young people ( 25-49 years of age ) are twice as likely to get high BP if they sleep less. Paper published in 2006.

* Individuals who slept less than 5 hours a night had a 3-fold increased risk of heart attacks. Paper published in 1999.

* Complete and partial lack of sleep increased the blood concentrations of High sensitivity C-Reactive Protein (hs-cRP), the strongest predictor of heart attacks. Even after getting adequate sleep later, the levels stayed high!!

* Just one night of sleep loss increases very toxic substances in body such as Interleukin- 6 (IL-6), Tumour Necrosis Factor-Alpha (TNF-alpha) and C-reactive protein (cRP). They increase risks of many medical conditions, including cancer, arthritis and heart disease. Paper published in 2004.

* Sleeping for <=5 hours per night leads to 39% increase in heart disease.
Sleeping for <=6 hours per night leads to 18% increase in heart disease.
Paper published in 2006.

Ideal Sleep

For lack of space, I cannot explain here the ideal sleep architecture.

But in brief, sleep is composed of two stages: REM ( Rapid Eye Movement ) and non-REM. The former helps in mental consolidation while the latter helps in physical repair and rebuilding. During the night, you alternate between REM and non-REM stages 4-5 times.

The earlier part of sleep is mostly non-REM. During that period, your pituitary gland releases growth hormones that repair your body. The latter part of sleep is more and more REM type.

For you to be mentally alert during the day, the latter part of sleep is more important. No wonder when you wake up with an alarm clock after 5-6 hours of sleep, you are mentally irritable throughout the day (lack of REM sleep). And if you have slept for less than 5 hours, your body is in a complete physical mess ( lack of non-REM sleep ), you are tired throughout the day, moving like a zombie and your immunity is way down ( I*ve been there, done that ).

Finally, as long-distance runners, you need an hour of extra sleep to repair the running related damage.

If you want to know if you are getting adequate sleep, take Epworth Sleepiness Test below.

Interpretation: Score of 0-9 is considered normal while 10 and above abnormal. Many a times, I have clocked 21 out the maximum possible 24, the only saving grace being the last situation, since I don*t like to drive ( maybe, I should ask my driver to answer that line ).

In conclusion:

Barring stress control, Ranjan Das did everything right: eating proper food, exercising ( marathoning! ), maintaining proper weight. But he missed getting proper and adequate sleep, minimum 7 hours. In my opinion, that killed him.
If you are not getting enough sleep ( 7 hours ), you are playing with fire, even if you have low stress.

I always took pride in my ability to work 50 hours at a stretch whenever the situation warranted. But I was so spooked after seeing the scientific evidence last week that since Saturday night, I ensure I do not even set the alarm clock under 7 hours. Now, that is a nice excuse to get some more sleep.

Unfortunately, Ranjan Das is not alone when it comes to missing sleep.
Many of us are doing exactly the same, perhaps out of ignorance. Please forward this mail/article to as many of your colleagues/friends as possible, especially those who might be short-changing their sleep. If we can save even one young life because of this email, I would be the happiest person on earth.
—

i would love to review the literature that the above email claims with “paper published in [year]“. beyond that, i cannot further other than that if only i can get more sleeep!

I have decided to leave out research articles as they can be found easily on the various surgical journals, unless a blogger has decided to blog about it. I try to avoid content similar to General Surgery News (free subscription)

The following are the best posts featured in order of submission:

Bongi, master story teller, recently nominated for best medical literary blog 2010 (i hope he wins), hailing all the way from Mpumalanga, begins one with,

“we can sometimes look good in our jobs. i suppose it comes with the territory. but sometimes this is not a good thing.” [READ HERE]

Are a frequent reader of Life in the Fast Lane? No? You ought to! Direct quote “This Medical Blog was born out of passionate (and usually unresolved) debate pertaining to the elements of eLearning; clinical cases; ECG interpretation; medical education; toxicology; medical history and information sharing strategies in the open source era.” The authors’ meticulous (exams, education, resources tab) yet absolutely humorous manner (what not to wear to the ED) is evident in the afore-linked posts. This makes them all so desirable to be hosting carnivals, just like this one!   Do check out a fantastic teaching case report about SC joint dislocation as well. [READ HERE]

Blogging does not necessarily mean you have to pen a long-ish article; one of the beauties of blogging (as opposed to writing to publish) is that it can be informal, and more often than not, fun! Relaying brief encounters at work for busier professionals has been a trend of late, with The Sandman (Israeli anesthesiologist) recounting his,

“Yesterday, I anesthetized a patient who sports the last name of one of the more prominent organized crime families.” [READ HERE]

and Dr Bates from Suture for a Living,

““It happened two days ago. I fell off a ladder,” she says, eyes averted.” [READ HERE]

Patient education is of paramount importance. We are in a time where we cannot ignore medicine 2.0 and some even say 3.0 Passionate surgeons like Dr Bates provides a scientific evidence-based approach and rewrites articles filled with medical jargon into simple comprehensible pieces to help millions of internet users out there to gain a proper perspective into the plastic surgical world, contrasted to other tabloid-like plastic surgical blogs. One example is regarding symmastia after breast augmentation mammoplasty; or paraphrased – “when breast implants sit too close to the middle of the patient’s chest.”  [READ HERE]

We as health professionals inadvertently come across interesting clinical cases, sometimes even so interesting we bother to write them for a case report to submit. If you come across one, and want to write an informal one, just do so via SurgeXperiences! With “chopsticks piercing toddlers brain in china”, Clinical Cases and Images show us that sometimes a video speaks much more. [READ HERE]

Finally to round off the edition, (and i have saved the best for last), do check out two new blogs and ALL The articles they have written so far; you wont be disappointed.

1. SA Anaesthetist – aka Doc-ZZZ – Random ramblings about life and work as a consultant anaesthesiologist in South African state and private practice.
2. VIVA TIVA – Mindmaps of a recently expatriated anaesthesiologist.

That is about all for now. Thank you for dropping by. I hope you enjoyed reading the articles as much as i did. 

Meanwhile, should you desire more surgical blog reading, kindly avail yourself to the archives of SurgeXperiences, stored here (Season 2) and here (Season 1), along with the latest schedule of dates and host sites. You can also subscribe via RSS or email to SurgeXperiences over at this link. And of course, you can submit your posts VIA THIS FORM.

If you are interested in hosting SurgeXperiences, please contact me.

This report is also available at Lancet Student. The content is the same, other than the fact that mine has one more picture, and many more links! Lancet Student Editors decided that providing links will distract readers from actually reading the article, which to a certain extent is true. For seasoned blog readers, they do know it can be an issue and text links tend to be images only. Many internet users use tab windows; personally i check the link at the bottom of my firefox before clicking on it to get a brief clue abt what it might be about. I do hope you will continue to read this article in its entirety though!

————————

The last time i participated in a mission trip was back in Jan 2008 in Cambodia. That was part of my church’s 14-day evangelical and medical outreach.

This time round, the medical trip had no religious component, it was organised by a student-run organisation – Singapore Medical Society of Victoria (SMSV). SMSV aims to bridge the gap between medical students in Victoria and the healthcare industry in Singapore. They had previously organised a trip to Hainan Island, China. Past participants have commented they were able to step above and beyond their usual shoes as a medical student and do ‘so much more’, e.g. perform a lipoma excision. As such, when I heard about an upcoming trip to India, I did not pass up the opportunity.

Vellore is a city in the state of Tamil Nadu, India. The name, Vellore, is derived from the Tamil words : Vel (spear – வேல்) + uur (ஊர் – city), means city of spears. Ancient history shows that Vellore was basically a battle field, where the warriors used to fight. As of the 2001 India census, Vellore City had a population of above 900,000. Vellore has an average literacy rate of 74%, higher than the national average of 59.5%: male literacy is 80%, and female literacy is 68%. In Vellore, 11% of the population is under 6 years of age.

About 15 students (all from Melbourne) were accompanied by a team of doctors and nurses from Singapore, lead by Prof Fong Poh Him, a renowned plastic surgeon from Tan Tock Seng Hospital. The aims of the trip were two-fold. Firstly, a surgical team performed surgery at the Sri Narayani Hospital & Research Center to supplement the services available there. Whilst the hospital is multi-specialty, they do not have what they call super-specialties like plastic and reconstructive surgery. A couple of ‘cleft palate’ cases were thus arranged beforehand for Prof Fong to operate on. In line with one of the mission’s objective of capacity building, a local ENT surgeon also scrubbed in to learn the procedure from Prof Fong. Secondly, we ventured out into a preselected village in Tamil Nadu, where we set up a makeshift clinic to provide locals with primary health screening, antenatal screening for pregnant women and basic dispensing services. There were several healthcare professionals including a gynaecologist, general practitioners, and surgical nurses. We had some basic operating sets to do simple local-anaesthesia based procedures if necessary.

Primary healthcare in rural Vellore

The village center which we visited was more than 50 kilometres away from Vellore city centre. The estimated village size was about 150. The makeshift clinic was situated amongst a local primary school. We know that because during break time, tons of curious little ones pour out to the clinic area, eager to see who these foreigners are and what they were doing.

When it comes to the spectrum of diseases that the medical team come across here in rural Vellore, one might expect late presentation of illnesses and exotic infections only mentioned in the fineprint of general medical texts like the handy Oxford Handbook of Clinical Medicine. For the large part this was not so. The same chronic diseases that afflict any developed population also apply here: heart disease, diabetes, osteoarthritis, etc. Many did present with polyarthritis and a preceding viral illness. Only after 30 or so patients did someone with better English told us he was diagnosed with chikungunya, a type of alpha-viral arthropathy, at the hospital. Chikungunya (CHIK) is a mosquito-borne viral illness which manifests itself with an acute febrile phase lasting only two to five days, followed by a prolonged arthralgic disease affecting the joints of the extremities. The pain associated with CHIKV infection of the joints persists for weeks or months, or in some cases years. When I hear some of them make a living as farmers, and bemoan in Tamil their plight, I cannot help but fill with heartfelt sympathy.

I was told universal healthcare exists in India, and these villagers get their usual primary care from a similar mobile clinic, staffed by only a local doctor and several nurses/students from the College of Nursing. When necessary, a referral is made to the Sri Narayani Hospital or the larger tertiary referral center at Vellore Christian Medical Centre. Also, when something emergent or troubling occurs, the locals do know how to seek help at the hospital. Access to healthcare is limited but not totally absent.

Our involvement here however, was not entirely superfluous. For these 2 sessions of clinics (9am to 1pm), the medical team saw over 250 patients. Patients were first pre-clerked by senior medical students (years 3 and 4) to quickly obtain a history of presenting complaint. I was stationed here. I spent no more than 3 minutes on each. This also took into account the time taken for translation from the local language Tamil to English and vice versa. They were then directed to a blood pressure Time-permitting, we got the junior medical students (years 1 and 2) to listen to their chest and lungs. Our team also brought glucometers, so all had their random blood glucose tested. Next, there were 3 doctors who each had the final say in diagnosis and management. Finally, a local nurse was in charge of dispensing any prescribed medication.

An acute case lit up the 2^nd day we were there. A 4-year-old boy presented with an infected burn over his left axillary region. Thankfully Prof Fong was around so we promptly referred it over to him. Oh, did I mention there was a Channel News Asia video crew here? They zoomed in all their attention on that poor little boy. Essentially they cleaned up the wound (read “ouch” x 10 for the boy) and dressed it. At the same time, the nurses were educating the parents about the importance of keeping the wound clean and teaching them how to dress it.

Sri Narayani Hospital

After a sumptuous Indian-inspired vegetarian lunch, I spent some time in the hospital. I wandered into the General Surgical Outpatient Clinic (unfortunately their operating list was over) and joined the consultant. This was familiar territory once again – tertiary level care, general surgery, outpatient clinics. Almost everything was similar, other than the language.

One interesting thing I saw was this elderly gentleman who presented with some GIT complaint and yet he was walking around with this external fixator with no qualms whatsoever. If I am not mistaken, he had a fractured tibia in an accident several months back. I would have thought someone like this would be one some sort of bed rest. Perhaps his abdominal complaints were too much.

Future mission trips and educational opportunities

This operation is projected to span five years, with 1 to 2 trips made per year. Throughout our involvement, the team hopes to share our clinical expertise and practices with the local healthcare providers (especially in the subspecialties), and also provide primary health services and advice to selected villages which do not readily have access to health services otherwise. Talks were held to discuss the possibility of CME sessions like conferences or seminars conducted by specialists from Singapore. The Director of Sri Narayani Hospital also welcomed medical students to spend a longer period of time (2-3 weeks) at the hospital to experience the pathology unique to India. Through SMSV, future students might be able to do so A big plus for student opportunities is that S.N. Hospital is private and only staffs consultants. This means that there are no other medical students, interns or residents roaming the hospital.

Vellore CMC – world-class hospital

Perhaps the most famous thing that comes to mind when one speaks of Vellore to a health professional will be a Vellore Christian Medical Center (popularly known as CMC). Vellore CMC is a referral tertiary hospital and one of the largest and most renowened hospitals in India. It attracts a floating population of at least 5000 persons every day. The hospital was founded in the early part of the 20th century by a Cornell-educated medical missionary Dr. Ida S. Scudder. It is a very popular elective location for medical students from all over the world because one can experience unique Indian pathology being tended to by world-class medical and surgical teams. Since I was there, I did not pass up the opportunity to at least pay a visit.

India is a fascinating tourist destination but also a great place to see the stark contrasts between health outcomes of the poor and underserved and the rich who can afford private healthcare or health insurance. I would recommend either of the above 2 hospitals for your elective. I, for one, will surely be back for more.

For medical professionals, the duty of care to patients does not cease just because of a festive season. Patients do not cease to require medical attention just because everyone is enjoying their holiday. In fact, according to a South African study by Meel,

Most of the pediatric deaths occurred during the festive months of December, January, and April; the death toll during these months was three to four times higher than in the rest of the year. [1]

This year, South African authorities also urge the public “not to put added strain on the health system during the festive season by putting oneself at unnecessary risk of injury or even death.” It is clear why MVCs or RTAs occur more frequently during festive seasons – they drink. Some people tend to do stupid regrettable things when they are drunk. “Blood alcohol levels were particularly elevated in firearm and sharp instrument homicides and among the pedestrians and drivers who die in motor vehicle crashes.” (emphasis mine) The National Injury Mortality Surveillance System (NIMSS) also  revealed that fatal injuries, especially as a consequence of violence and motor vehicle collisions, have been identified as a top South African public health priority. [2]

Venezeulan student Jacqueline Saburido was hit by hit by a drunk driver in Austin, Texas. She was pinned inside the vehicle as it caught on fire, leaving her with severe burns over 60 percent of her body. She lost her hair, her nose, her ears, he left eyelid and much of her vision. Her fingers were amputated. She’s become a spokesperson against drunk driving. (source)

Dedication

I would not imagine this to be much different anywhere else where alcohol is interweaved into the society’s fabric. As such, this edition is specially dedicated to the many people who, in one way or another, help to clean up the mess that drunkards cause on the roads, or anywhere else – paramedics, road traffic controllers, ED staff, and, since this is a surgical blog carnival, for patients who are stable and alive enough for some surgical therapy, theatre staff and trauma/general surgeons. Last but not least, because all our hearts are probably still wrenched by the story above, to the victims (dead or alive) of drunk driving.

Clinical Case 1 – Jane

First up, we have a clinical case. 21 year old Jane presents in the ED after a major motor vehicle accident. She was riding home from a party. Both her and the pillion rider were flung off across the tar road after colliding with an oncoming Prius. She suffered third-degree ‘friction’ burns (which looked similar to this one).

How would you manage Jane?

[Answer: Ask the Burn Surgeon. Online. For free. Yes. Let him tell you how he would treat Jane]

Featured

UnDead Doctor, who recently started blogging in October, describes himself as a “Surgeon by day. Anaesthetist by night. Not enough spare time in between.” In his first ever post, he introduces himself:

I am a medical doctor, with experience in the state and private sectors in South Africa, and more recently in the first world… … At this hospital, I spent my time split almost equally between surgery (daytime hours), and anaesthetics (after hours). I am currently looking for a post to begin specialising in surgery. I will let you know what happens in this regard in due course..

With such an introduction, it begets one to question his impetus behind starting blogging. What are his aims and hopes? All these are clearly addressed in the aforementioned intro post, of which this one captured my attention the most:

This sparked a thought – how can we effect change in our health care system through blogging if there are so few here! I decided I needed to start writing, so that maybe, on the off chance that someone of any importance stumbled across these pages, they might be enlightened to the plight of a South African doctor and his patients.

There are currently a total of 9 posts he has penned since October, a healthy 3 per month. All are great. I feel i might do him injustice if i feature one article over another, so kindly head on over to his blog to check out all 9.

Without going too much into patient details, we find out that this next patient of Dr Alice, who blogs at Cut on a Dotted Line, was actually not a candidate for surgery, or so the textbooks say. She describes her experience flying solo on a colectomy which was performed for this patient.

… He discussed the next steps with me as though I had any idea or say in the matter, and then let me do virtually every bit of the work, for the next several hours. And it was work. I had thought holding a retractor for hours at a time was hard work. Not much, compared to …

You absolutely have to read this excellent piece documented free for us here online about the transition from a surgical assistant to a REAL surgeon, which Alice aptly titled “in the deep end”.

The joy of a positive outcome for a patient, on which an invasive intervention has been performed, cannot be understated. A pathologist who blogs at Methodical Madness relays a lesson learnt from a patient encounter who had a FNA biopsy performed for a slow-growing parotid mass:

I won’t be so quick to pacify a patient, in the future. My idea of “no big deal,” isn’t every one’s. I’m not the one going under the knife – this week, anyway.

Speaking about learning lessons, Dr Alice rants about a recent referral to the surgical team about a young college-aged sexually active female with ?appendicitis but has had no WCC nor pelvic exam nor CT performed. She wonders if  “they’re teaching me how to be polite to frustrating referring physicians”

Technology

Dr Bates from Suture for a Living kindly provides a constructive review on the only iPhone app for surgeons – i-Surgery Notebook. Rightly so, a reader (TBTAM) raised issues about patient data being stored locally on an insecure platform and suggests logging onto a secure server to protect patients’ privacy. However, this has to be balanced against the inconvenience of requiring 3G or wifi access to edit or enter new information. Perhaps a secure ‘local’ solution can be sought for this app and the iPhone in general.

Surgery never fails to fascinate any onlookers. They can range from the circulating nurse, to the curious medical student, to the rep who just turned up to introduce some products to the orthopods. Even surgeons in training are interested to learn the best technique to do a particular thing. As such, it is not unusual for surgery to be properly videographed. Veteran medblogger KevinMD notifies us of several issues surrounding videotaping surgeries in the operating room.

There can oft be more than 1 way to do a certain procedure.  After reading an article from the British Journal of Surgery which compares two techniques of portacath insertion; the Seldinger technique vs. the venous cutdown, Buckeye Surgeon wonders aloud if ‘science’ can/should change one’s surgical practice.

Clinical Case 1b – Jane 4 years later

Four years later, Jane presents with acute onset of unrelenting abdominal pain and vomiting four years after a major motor vehicle accident. Link on to check out the CXR ordered and test yourself with a series of Q&As. Courtesy of Life in the Fast Lane.

The author behind Reflections of a Head Mirror, Dr Bruce Campbell, an otolaryngologist from MCW, shares with us the myriad of emotions his patients and himself experiences during his Cancer Center clinic day.

Over the course of the day, about 20 people will pass through the office. Their medical problems will vary but each one hopes to hear good news.

Benedict Carey from the NYTimes penned a great article about Henry Molaison — known during his lifetime only as H.M., to protect his privacy — who lost the ability to form new memories after a brain operation in 1953. Over the next half century he became the most studied patient in brain science. Now after his death, his brain is being studied, dissected and digitally mapped thoroughly. The findings could well change our current understanding of neuroscience.

Finito

This is a relatively short and belated edition of SurgeXperiences. The brevity is deliberate to help the reader focus on each quality article. The tardiness can be partly ascribed to my sister’s recent solemnisation; i am so delighted for her and my new brother-in-law. I was the cue master during the ceremony and all went well with military precision.

Meanwhile, should you desire more surgical blog reading over the holidays, kindly avail yourself to he archives of SurgeXperiences, stored here (Season 2) and here (Season 1), along with the latest schedule of dates and host sites. You can also subscribe via RSS or email to SurgeXperiences over at this link. And of course, you can submit your best VIA THIS FORM.

If you are interested in hosting SurgeXperiences, please contact me.

Merry Christmas and have a meaningful New Year ahead.

References:

1. Meel BL. Mortality of children in the Transkei region of South Africa. The American journal of forensic medicine and pathology : official publication of the National Association of Medical Examiners (2003) vol. 24 (2) pp. 141-7
2. allAfrica.com. South Africa: Extra Care called for during festive season. Dec 2009. Available at: http://allafrica.com/stories/200912080487.html

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

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.

Choose the most appropriate investigation to be performed next.

1. 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.
2. 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

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) 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%).

 

1. Pickren JW, Tsukada Y, Lane WW. Liver metastases. In: Weiss L, Gilbert HA. Liver Metastasis. Boston, Mass: GK Hall Medical Publishers; 1982:2-18.
2. 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.

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!

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)

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.

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…)