Pushing the boundary

This is medical post. I saw an exciting procedure done on a stroke patient today which yet again steered me into the reflective mood.

Mr G is a previously fit and well 50 year old father of two who was admitted with stroke last week. It affected his vision, speech, swallowing, right arm and leg. He took a turn for the worse yesterday. He had another big stroke affecting the brainstem and he completely lost his airway and slipped into a coma.

His brain CT and MRI were pretty horrific to watch too. First of all let me explain the relevant basic of neuroanatomy. The brainstem controls our consciousness, breathing, heart rate – absolutely fundamental for survival. When the brainstem is gone, that’s when you call a person ‘brain dead’. The make up of our bodies naturally makes sure that the brainstem is constantly well supplied with oxygen and nutrient by having two arteries on each sides of the brainstem. They are also interconnected to one another (communicating), so that if one is blocked for any reason, the other one can compensate for the supply.

On Mr G’s brain, one of the arteries is completely occluded beyond salvage. The other artery had a section of significant narrowing (stenosis) and was almost completely blocked. The supply of the whole of the brainstem and indeed the back of the brain were hanging on just by a thread size hole for that tiny amount of oxygenated blood to flow through. If this pinhole is blocked, Mr G would die.

So the idea was to put a stent into the nearly-blocked artery to open up the narrowing. Stenting is routinely done for vessels on the heart muscles (coronary arteries) but not so much for the brain arteries. I’m not sure why. Maybe because there is too much at stake. The intrusion to the diseased and perhaps fragile vessel could rupture the arterial wall resulting in a disastrous bleed into the brain. Debris (like fat/atheroma which sticks on the wall of the arteries that cause the narrowing in the first place) could dislodge and travel upwards to occlude the vessel further ahead. But on balance, if we don’t press ahead, more clots (emboli) are likely to just take its course to occlude the tight narrow vessel – the catch is that we cannot guarantee that it will happen.

Seeing the procedure itself just made me realize so many other factors to weigh up. My hospital is the tertiary referral centre for neurosciences services in Manchester. We have unrivalled expertise of the different neuro sub-specialties. Even so, since this procedure has never been performed before here, a radiologist from the neighbouring teaching hospital (MRI) had to bring in some stents they normally use for coronary vessels. The procedure is done under direct x-ray screening. In total Mr G must have been subjected to about an hour worth of radiation on two planes.

In order to put the stent in the best position, a guidewire needed to go over the area of stenosis. They tried once, the wire stays at the proximal bend and would not advance further. They looked for a stiffer wire, and the radiologist tried pushing it in, again it wouldn’t budge. By then, Mr G has already been subjected to two hours worth of anesthetic (don’t forget that this is a patient who has just suffered a very serious stroke). There isn’t a wire stiffer than this in stock. This is so frustrating! At this point, I wondered if they are going to just abandon the procedure. So the visiting radiologist from MRI suggested two wires: one as the main guidewire and another one as a buddy wire just to help stiffen the main one. And so the team of radiologists deliberated for a while. I heard the radiologist from MRI said ‘by the way this is an untouched territory, we have no idea what is going to happen’. So the team went ahead, and the guidewires finally passed through. Carefully they deployed the stent, opened it up and we finally saw what we went there for. There was much more blood flow running through that previously stenosed area, and we saw much more perfusion distally lighting up as dark stuff on the x-ray. So it was a success. I later learnt that this stent-in-the-brain procedure is only the second one to be done in this country. Well done to the radiologists!

However this is not the end of the story. Radiological success is one thing, the clinical picture is another. Will Mr G wake up? Will he start breathing on his own? Will he ever be strong enough to undergo physio and be a functional man again? Some area of the brainstem has obviously been deprived of oxygen and nutrient for some hours, and whether we have done this procedure in time for the fresh blood to replenish and revive these dying neurons, no one has the answer. I guess this is the time the doctors would be telling the relatives that we just have to wait and see. Still, I am hopeful. From what I have seen today and all my experience in medicine, I can tell you that when doctors say that 'we will do everything we can', they mean it.


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Crisis of confidence

What I'd like to talk about today is based on a malaysian girl who always comes to me before her OSCE exam to get advice and to practise. She is a year below me currently preparing for her end of third year exam. And whenever she comes, we would end up in a lengthy chat on language, confidence etc etc.

She's a malay malaysian, brought up in a malay community and secondarily educated in a boarding school exclusively for malay people. Like me, she is studying medicine here courtesy of a generous scholarship funded by the taxpayers' money. These scholarships have traditionally been awarded to high achievers in the public examinations. There is a fixed view that excellence in exam equals potential, nothing else counts. It doesn't take a genius to find this hypothesis significantly flawed.

She lamented about the old issues. She feels that her PBL mates laugh at her and talk behind her back, that her voice is not powerful enough to overcome her colleagues' in PBL eventhough she has all the knowledge in her head or that her PBL mates frequently interrupt her. In conclusion she feels like an outsider. If I was someone responsible for her education, I'd be at least slightly worried because this is her third year as a student in Manchester and in my opinion should have been fairly comfortable with fitting in.

But in actual fact many oversea students feel this way. I know lots of people who completely shy away from any contact with non-malaysian other than attendance at compulsory group work. They cope by sticking to the other lost malaysians and remain in their own comfort zone speaking their native language, practising their own customs and cultures. With no new experience, these students might as well have studied at home and relieve our country RM1million per person. These are the sort of comments I often find going through the 'letter to editor' section in Malaysian newspapers, and I have to agree.

Many British students have never experience speaking in a second language with a group of native speakers. My impression is that they underestimate the strength it takes to say something, let alone comfortably contribute as an equal member of the group. I remember in my first ever PBL session, I made a joke and I was so afraid that people won't laugh (and I distinctly remember telling myself over and over again 'It doesn't matter if I made a fool of myself. It doesn't matter!'), but they actually burst out laughing - and I was just so chuffed and euphoric. They laughed at my joke! Couldn't believe it! Communicating in a good standard of English is one thing, and I believe we can all do that after all those stringent medical school admission criteria; but fitting in with the local students is another thing and it requires more than good English. We need to be hanging out with them, understand their jokes and show bits of our personalities. As non British, we are extremely conscious that our facial feature, the way we dress, our accents mark us out as being different. People may well be oblivious to these, but some of us are so self aware that it hinders them from reaching out. Until we lose this inhibition, we are not likely to get further away from our comfort zone.

Fortunately for me I am well pass that stage a long time ago. I now see the British society just like any society that I know of. There are good people and bad people and many in between; there are the rich and powerful and the poor and lowly and many who belong to the 'middle class'. And to communicate with any of them, I do need reasonable proficiency in english, but most of all I need to be myself, rather than holding back because I feel inferior that my english is not as good is theirs. If whatever I say comes from my true self, the conversation always turns out alright. The sincerity of human race cuts across different languages, cultures and nations. Sometimes it is these concepts and social skills that the high scorers fail to grasp.

That brings me back to the issue of confidence when speaking in english to a group of native speaker. A supportive environment helps (for example, friends who appreciate that I don't want to drink alcohol and would compromise by a nightout at a restaurant instead). But at the end of the day it is down to herself. I advised the girl to just be a little thick skinned and start to reach out to people. Doesn’t matter if they respond by being horrible and nasty – there are rotton apples everywhere. Unless she gets to know people on a personal level and let other people know her, there's unlikely going to be any genuine flow of conversation and she is just going to carry on feeling miserable.

To learn medicine, we can’t afford not to be able to talk naturally. Half of medicine really is just talking. Does it make sense?

More entries to come. Reminder to myself. * Chorus * Ophthalmology * Project option.



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When my room is messy

When my room is messy, I'm most probably:

-Stressed
-Not sleeping well OR sleeping too much
-Not eating well
-Procrastinating
-Depressed OR frustrated OR feelingless
-Generally not very efficient

Just to give you an impression of how messy my room is at the moment, on the floor I see:

-Books
-Papers
-An umbrella
-A handbag
-A pair of socks
-A saucepan
-A paperbag
-Two biscuit wraps
-A pair of jeans
-A stethoscope

I'm Stressed. I Hate Essay Writing.

HAPPY BIRTHDAY 20th WAN CHENG!!!

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