Elective Posting: Day 15

It has been quite some times I do my elective posting at this hospital. However everything has an end. Yesterday was my last day at the hospital. Kind of sad to leave this hospital after being here for 3 weeks. Not only so, this also signify that I need to go back to Russia. In the hospital I saw many local students there. I attended some of the teachings there, both short case and long case. Their teachings is so much different, and better, compared to those in Russia. Many times I think that won't it be so much better to study locally? Won't it be so much easier and much rewarding? But when I think more seriously, will I appreciate this good teachings if I never been to Russia? Will I have the guts to speak if I never been to Russia? I don't know. But one thing that I am very sure.

From one man he made every nation of men, that they should inhabit the whole earth;

and he determined the times set for them and the exact places where they should live.

God did this so that men would seek him and perhaps reach out for him and find him,

though he is not far from each one of us.

Acts 17:26-27

If I never been to Russia, I might not seek God, or even know about God. Though in Malaysia there is so many churches, but He chooses to bring me to Russia and make Himself known to me at this post-communist country. Because if this sole reason, I need not ask "If only...". 

Anyway, this elective posting was very valuable and memorable. Very hope that I can come back to this ward next year summer. At the same time I feel very regret that I didn't manage to say good-bye to one of the HO there. 

 ____________________

悄悄的我走了，正如我悄悄的来；

我挥一挥衣袖，不带走一片云彩。

Elective Posting: Day 14

Though these few days learnt more new things, and getting closer with the doctors there, attended many teachings and CMEs, but today I getting very depressed. Not only that I did some mistakes when doing procedures, but the worse is that I realized my heart is not in the right direction. 

Being very clumsy when taking blood C+S, failed to set up a line, run away from my mistakes and letting other people to clean up the mess I did, ignoring or simply 'layan' the patients. Seriously something really going wrong with my heart, i.e. my attitude. 

When seeing patients, they are nothing more than the subject of study. When examining patients, they are nothing more than the models to see. When doing procedures, they are nothing more than the dummies for practice. Not only I didn't treat them as my family, but I didn't even see then as humans. Something wrong with my heart. 

Some people said the first principle in medicine is "Patient's autonomy". Some people said the first principle in first aid is "Do not harm". But seriously, I think the first principle in medicine and in first aid is simply the greatest commandment that Jesus Christ gave. 

Jesus replied: 

" `Love the Lord your God with all your heart and with all your soul and with all your mind.' This is the first and greatest commandment. 

And the second is like it: `Love your neighbor as yourself.' All the Law and the Prophets hang on these two commandments."

Matthew 22:37-40

If this commandment is obeyed, everything else will follow after it. Yet this is the very thing that I didn't follow. 

Many times after I made such mistakes, I feel like 'I want to die', 'I don't want to be here anymore', 'Kill me please', 'Punish me please', or 'Give me another chance to atone my mistakes'. But all these thoughts are so cowardy or work-based religion thinking. 

Godly sorrow brings repentance that leads to salvation and leaves no regret, 

but worldly sorrow brings death.

2 Corinthians 7:10

We should feel the sorrow and guilt for the sins that we did, but the wrong way of sorrow and our own way to atone for our sins will just bring death.

For God did not give us a spirit of timidity, 

but a spirit of power, of love and of self-discipline.

2 Timothy 1:7

In the same time, we also shouldn't feel depressed and let our sins in the past burden us (but this is exactly what I am doing now >.<). We need not to do so, because Christ has paid for our sins, and moreover God gives us the Holy Spirit, not a spirit of coward, but a spirit of power and love. 

These things are easy to be said and to be taught, when when come to doing it, it is difficult, in fact it  is impossible if you try to do it yourself. Only with God and by God we can do it. 

Change my heart oh Lord, 

make it ever true. 

Change my heart oh Lord, 

may I be like You. 

 ____________________

 

Teach us how to love each other,

Lift us to the joy divine. 

From the hymn Joyful Joyful We Adore Thee

Elective Posting: Day 10

Today... Nothing much in the morning, the specialists very late only came to do the round ward. I was looking forward to the teaching about insulin therapy, but when my friend and I reached there, the doctor said it is exclusive for HOs only. And there is no CME today because there is only a CME every forenight. Double disappointments.

However today I was given a chance to take ABG again, because initially the HO has some difficulties in inserting the branula and the patient has a bad impression of her. So she asked me to help her take it. Taking ABG is really not easy. Though able to feel the pulse very clearly and the patient is not obese, but somehow I can't insert the needle into the radial artery. The worst thing was that the patient keep making a lot of noise >.<. So the HO asked me to take from femoral artery. I was thinking, are you serious? Femoral artery? Because the risk of having hematoma is much higher.  Anyway I just try and do it because she said is very easy. As she said, the femoral artery is very big and palpable, just that it is deeper. One insertion, and woopa... the bright red arterial blood flow up into the heparinised syringe. Thank God really. Since ABG was taken successfully, the patient also quiet down, but he still complained about the branula on his hand. So I warned him that if he pull it out, the doctor will poke him again. 

Btw, in the afternoon 2 patients passed away. There were some medical staffs carried a metal casing to carry them away. Very sad to see those things happened. 

Last week I was still wondering about asking the patient's family to decide whether to NAR or DNR for the patient. Personally I think that the doctor should do their best in saving patient's life. Today I got my answer about it. The consultant in my ward from gastro explained that the very first principle in medicine is: Patient Autonomy! If patient cannot make the decision due to unconsciousness or confusion or other reasons, it is not the family, who don't have medical knowledge and skills to make consent. Doctor is the one that should make the most suitable choice  for patient according to the situation. We should just counsel the family, let them understand the reason behind the doctor's decision, rather than letting them making the choice. 

What he said is true. How can the family, especially those without medical knowledge can make the decision in how to save patient? But according to the consultant's words, doctors nowadays due to pressure from boss and the family, and they want to save themselves from all the troubles, doctors will ask the family and get their 'consent' when come to making decision, but this is a wrong practice. Suddenly I remember what Peter said. 

Peter and the other apostles replied: 

"We must obey God rather than men!"

Acts 5:29

Sometime instead of doing things according to what other people want, we should do what God commands. 

Elective Posting: Day 09

Today morning I tried to set up a line in a asthmatic patient , but I failed go put the branula on both sides of the hand. The first one failed because I forcefully insert the branula into the vein, so I can't flush the heparin through it. After take out the branula, the HO found out that the branula is bent >.<. For the second one I didn't manage to push the whole branula in, and when I took the branula out there is resistant when taking out, and it bleeds much after the branula was removed. This time the patient was really not happy about it. The third time the HO put the branula, initially there is also resistant when she was tryin to flush the heparin, but after tilting the hand a bit she managed to flush it. Kind of sad because the veins were so prominent and I was given two chances, yet I failed, patient felt very unhappy, and I gave that HO so much troubles. But surprisingly in the afternoon before I left the hospital that HO told me that she need to reinsert the branula because the insertion site of the branula was swollen. I wonder whether I was not skillful enough, or something wrong with the patient's veins? Hmm...... 

Today I also has chance to do PR (per rectum, i.e. digital rectal examination) to palpate the prostate gland, because this patient has liver metastatic disease and prostate cancer need to be rule out by checking serum PSA and doing PR. The HO that taught me to do PR also taught me how to do BFMP (blood film for malarial parasite). A thick blood film and thin blood film need to be done. Today only I knew that this HO graduated from Ukraine. Suddenly felt very...... don't know how to describe it , is like meeting a fellow friend in a foreign country. Anyway glad to meet this HO. 

Those who did practical in medical ward must had follow a round ward with specialist or consultant. But have you seen a grandround ward? Today I saw my gastro consultant came with his MO in the afternoon, but there were many other gastro specialists and MOs came with them. They are known as the 'Gastro Team'. Very surprise to see so many doctors from other department came together to see some patients.  Even the specialists in my ward saw them, raised up their hands a bit, and said, "Hi boss" o_O. I wonder how many does it takes to reach their position. 

I attended the CME of medical department twice, I felt very disappointed. The way they present their case and topic is like...... reading the slide. You don't  need MD or MBBS to read the slide. Even some of my seniors can present better than them. Maybe I think I expected too much from their CME. But their HO teachings are quite good. There is a teaching about insulin treatment tomorrow, I hope medical student can attend also. 

Elective Posting: Day 08

Note: Seriously, I really wonder who still read this blog......

After few days of elective posting at hospital, gained many experiences. By The grace of God I have chances to take more venous blood, set up line or insert branula. There was a time that I need to take venous blood from a 12 years old boy with dengue fever, since need to take blood 3 times per day from dengue patient. But it was difficult to find veins in a small kid, especially after poking his veins so many times. So the HO asked to me to take arterial blood. So again by the mercy of God I have a chance to take arterial blood.

Though the vein difficult to find, but paradoxically the artery is easy to get in children. Though getting more chances to do different procedures after staying at ward 18 for about 1 week, but getting kind of depressed cause can't really answer specialists' questions, and they usually ask us to find the answer in CPG, CPG, CPG, CPG...... CPG simply stands for Clinical Practical Guidelines. They are some guidelines regarding management of patient that set up by Ministry of Health (MOH) of Malaysia. Last time need to read books, now need to read those CPG =_=. Today heard my friend said she felt what we learn in Russia is like...not to say totally useless, but is like not usable in Malaysia hospital. Getting many 5s at there really doesn't mean anything at all, even getting a Red Diploma doesn't mean anything. So how should I move on? Someone said before that our eyes are located in the anterior part of the head, so that we will look forward and not looking backward. Suddenly I remembered what Paul said to the church of Philippi.

Brothers, I do not consider myself yet to have taken hold of it. But one thing I do:

Forgetting what is behind and straining toward what is ahead, 

I press on toward the goal to win the prize 

for which God has called me heavenward in Christ Jesus.

Philippians 3:13-14

Maybe I really need to forget what is behind, and press on toward what is ahead. The past is memorable and valuable, but it can never hinder the future.

Elective Posting: Day 04

Today the ward not so busy. Thank God that I have chances to draw blood from some patients, but still didn't get a chance to insert a branula or take ABG. Yet today I know that there is something more difficult than taking ABG, and HO need to know how to do, that is to set up a central line, mainly to measure the CVP to check the hydration state of the patient. It can be either long line (insert from a peripheral vein) or short line (insert from internal jugular vein). When that HO knows he need to set up a long line, his expression like =_=. He mananged to get helps from few HOs, but after 3 attempts, they still fail. In the afternoon, the MO came to set up a short line, with guidance from other MOs and a specialist. After 3 attempts she also fail, because she keep insert the line into carotid artery. The specialist takes over, but few attempts he managed to insert the short line successfully.

Today I keep hearing doctors mention about this patient is NAR or DNR. NAR is need active resuscitation and DNR is do not resuscitate. But I still don't understand why there is a DNR option for patient. Shouldn't doctors do everything that they could to save the patients.

Today a consultant of ward 18 came again. I assumed that he is a specialist in GI department because he just want to GI patient only. He is a very good doctor, and he is the first doctor that bother me and ask me questions. Other specialists see me like an invisible person or a furniture only. One specialist only talk to me when she is seeing a patient from Myanmar, and she says to me,"You know how to speak Myanmar? Don't know? Why you didn't learn how to speak?" =_=...... Another specialist talks to me because he want me to speak to the patient's family in chinese. =_=...... I am a medical student or a translator?

Anyway, that GI specialist said something quite interesting. He said that everyone in this society has his own responsibility. Doctor can only diagnose the disease and give treatment to the patient. At the end of the day, patient has to take care of himself and compliant to his treatment. Doctor can't do everything. If you try do everything, at the end of the day, you just exhaust youselve only, but patient don't appreciate what doctor did. He keep saying "at the end of the day" many many times. The other day he also said that sometime he feels very lost interest in medicine, not because we can't do anything, in fact the hospital got many advance equipments and the best drugs, but the patient just not compliant to their treatment, and didn't follow up at the clinic. What he said is very true, but suddenly I remember what Paul said to the believers in Thessalonica.

And as for you, brothers, never tire of doing what is right.

2 Thessalonians 3:13

May the daily routine work in the hospital will not make our heart becomes harden and callous. Let us not forget the initial passion that we has when we choose doctor as our profession.

Elective Posting: Day 03

Today my ward (ward 18) should be passive ward, i.e. a ward that not going to admit new patient, so it should be less busy, but some how today ward 18 become like an emergency room (ER) in A&E department. There were 6 patients simultaneously collapsed and need resuscitation, but ward 18 don't have so much ventilators, so some patients need to be ventilated manually with Ambu bag. Many patients were intubated. The ward was so busy until specialist also need to help to insert branula/cannula, and doctors from A&E, radiology department, etc need to come to the ward to help up. A specialist came and do round, mainly for GI patients, but the ward so busy that hardly any HO go 'layan' him, and a HO, who is taking care of a particular patient went to listen a talk about dengue (if I know there was a dengue talk I won't stay at that ER-like ward), and that specialist want to see that patient. Anyway...... today is a hectic day for the HOs, MOs, and specialist of that ward. 

Btw, today having lunch with JS and his HO, BFF should join us but for some reasons she didn't. Sadly I heard how that HO described how poor those Russia-graduated HO, not because they are lazy, simply because they didn't learn what need to be learned in Russia, and the different system of medical education in Russia. Anyway, this is the conclusion that I came out:

When we are learning russian, others are learning how to clerk.

When we are reading books, others are reading journals.

When we are writing case histories, others are writing posters.

Anyway again, today I have chance to take venous blood from some patients, and thank God that I managed to take it, though failed few times. Still find chance to insert branula and also taking ABG. But even HO and MO got difficulties in taking ABG. Suddenly I remember again what Paul said to Timothy.

 For God did not give us a spirit of timidity, 

but a spirit of power, of love and of self-discipline.

2 Timothy 1:7

Elective Posting: Day 01

Today came back to this hospital again, the same hospital that I did my 3-days attachment 4 years ago when I was applying for JPA scholarship, and I was waiting with JS at the same place I waited 4 years ago, feel kind of nostalgic. 

Spent quite some time for briefing at the auditorium. One thing that I'll not forget, "Everyone come to this world with many blood, shit and urine."  This reminded me what Paul wrote to Timothy. 

For we brought nothing into the world, and we can take nothing out of it.

1 Timothy 6:7

Later assigned to our own department. Spent quite some time finding the medical department, and register at there, and JS and I were assigned to our own ward. Again we spent some time to find our ward. By the time we reach our own ward, we have already miss the morning round. Saw many HOs at my ward, and they look just like students. Out of my surprise, HOs' handwritting looks like typical students' handwriting >.< . 

In beginning kind of bored. Don't really understand what the HOs and specialists talk about (can't that specialist speaks louder a bit?). Somemore I don't understand what are they writing. In Russia the doctors I can't read their super-cursive cyrilic handwriting. In Malaysia I don't understand doctors' short form. IPR, S/B, TRO, UGIB, c/o, o/e, 3/7, 1/52, LOC, LOA, LOW, WD, TRO, K/C/O, and those superscript-ed "+" and "o" in front of those symptoms and signs, etc etc etc @.@.

After have a lunch at cafeteria with JS (food not very nice, but better than those in Russia), I came back to my ward. Out of my surprise again, I met someone graduated from my university. Though not very close with him and he didn't really know me, but after knowing that I amhis junior, he willingly taught something, how to read their 'files' or case histories, their self-created short forms, what to look for, etc. 

But different HOs gave me different advices. One told me to look through those files because in those files can see the condition of the patient and the plan of management. However another HO told me to go do procedures, like withdraw blood and insert vrenula, because these are the basic things that HO should know and next time no need to worry these procedures and can concentrate on other things which can be only learn when become HO. So what I should do? Hmm......

Anyway, got a chance to draw venous blood, but from a HIV+ patient. Got a chance to insert CBD, but need to leave already, some more is in a female ward. Anyway, I am looking forward into the upcoming CME, and here are some interesting patients that I met today.

* * *

Patient 001 Bed 39

C.C.: Fell down on his forehead. Admitted to hospital by ambulance.

HOPI: On 30/07 patient fell down on his forehead at 11pm, family called ambulance, but only analgesic given. Fell down second time on his forehead at 5am.

Past Hx: Fell down many times last year.
Pneumonia 2 years ago, with cough.
Not oriented since many years.
Taking sedative/anxiolytic for many years (about 10 years).
Difficulty in walking, no able to walk far.
Multiple brain infarct: left posterior, right middle.

Co-morbidity: HPT, on nifedipine, prozasin, atenolol.

O/E: Demented, confused, conscious, cannot walk, want to 'cabut' from hospital.

Dx: Multiple infarct?

Plan: Trace for CT result.
Off anti-HPT drugs.

* * *

Patient 002 Bed ?

Dx: Necrotizing fascitis on left UL.
Co-morbidity: DM, HPT, CRF stage III, TRO psoas abscess
Plan: WD of UL until patient agree.

* * *

Patient 003 Bed ?

HOPI: Admitted on 31/07.
GCS full. Able to lift up LL only after 15sec.

Fever 3/7, LL weakness 2/7

K/C/O: HPT, IHD

O/E: Progressive worsening of GCS and LL weakness.
UL: hypertonia, power 3, biceps jerk ?+, supinator jerk 3+ (brisk), triceps jerk 2+
LL: normal tone, power 2, 0 clonus, knee and ankle jerk ?+, plantar upward, flexion of toe  upon pressure on nail bed

GCS 11/15: E3, V2, M5-6
Open and close eye by command (obey command) - E3, M6
Localizing pain upon sternal pressure - M5
Moaning, no understandable words - V2

Eye examination:
Reactive pupils.
Arcus senilis.
Right INO: left nystagmus, no right adduction when look left.
Fundoscopy: cataract

Lung: left crepts, left consolidation
CXR: left pleural effusion

BUSE: hypokalemia

CT: whiter at left posterior occipital lobe or brainstem (pontine part?) --> bleed/infarct?
*Fresh blood is of higher attenuation, but reduces as Hb breakdown

Plan: Order urgent CT
MRI, MRV, MRA + contrast
look for meningeal or tumor enhancement, to exclude meningoencephalitis (gradual onset of disease with fever)
Maintain BP at 170/120

* * *

Lesson of the day

1. Be initiative, don't expect people to spoon-feed.
2. Protect yourself. Mask, gloves, coat.
3. Is okay to make mistake, but don't let your mistake compromises patient.

P/S: Do feel free to ask any question, either the meaning of those short forms, or the patients, or other things. But I think there are hardly anyone else still follow my blog here >.<