Day out with the ambulance

One of the most memorable days in my attachment with A&E is my day out with the ambulance. I joined a two man crew for the whole day, J and S - a paramedic and a technician respectively. They were proper gentlemen and took care of me well. It was a fairly busy day, one job after another. I thought riding in a blue light ambulance would have been a thrill, and it was – only that I was busy focusing to look far ahead out the window to prevent myself from getting sick. We had the sort of routine collapse, chest pain etc.

After lunchtime, we received a call for an unresponsive baby. We arrived very quickly, within minutes. The sense of urgency loomed in when we actually saw the baby. The father was holding an extremely pale two month old baby. It turned out that the baby had been like that for half an hour. At that point we knew we really need to speed up and get to the hospital quick. J quickly asked mum to get into the ambulance. The other baby she was holding cried as she passed him on to dad, and mum said she would call dad. Until that point, my role with the crew was only as an observer. But the paramedic could really do with another pair of hands in this life-threatening situation. So I connected the oxygen and did the chest compression while J dealt with other things. S alerted the ED and drove off. I was nervous. I have read about it, but I have not been formally trained in immediate paediatrics life support. J just taught me how to do it then and there. That was helpful as this allows J to concentrate on maintaining a patent airway. The airway was really good – there was good bilateral chest expansion, but only after we manage to make a mess of the vehicle because J couldn’t find the oropharyngeal airway of the right size. I caught a glimpse of the teenage mum wiping her tears. ECG was disappointing, asystole all the way. After a few minutes of roller coastal ride, we made it to the ED and lots of doctors and nurses were already anticipating at resus. J delivered the baby and gave a brief history. I watched the team commence the resuscitation for a minute or two. Then J and S went out of the resus, so I thought I better follow. We went back to the vehicle, J and S started typing the ambulance report and tidying up. They were not very chatty but pretended to look fine. I stood at the side and also kept quiet. J asked if I was alright, and said I can have a brew if I wanted. I said OK. But in fact I didn’t go for a brew. I felt shaken, I went to my locker and have a gulp of water. Then I went back to resus expecting the worst. The registrar was walking out, so I asked him how the baby was. He just shoke his head. I was speechless. I went back to the ambulance to tell them. They both carried on doing what they were doing. Then the ED consultant came up to the ambulance to check if we were alright. After about half an hour we went back to the ambulance station. The three of us sat down to have a chat. It was the first time for S to encounter death of an infant too. He said he just felt strange. J had been a paramedic for 30 odd years and had seen quite a few of these before and had never seen any survive. But I still saw him staring at the television, not watching the programme but contemplating on something else. The other ambulance staff was really understanding. They showed concern and tried to cheer us up. Was there anything that we could have done differently? Possibly, but it probably wouldn’t have changed the outcome. The three of us sat there quietly with our thoughts until the next call.

It was an interesting day. I felt more acquainted with the crew and learnt quite a bit from them. But I cannot deny that I was rather traumatized by the death of the baby. I didn’t know the baby’s name, didn’t know whether the baby was a girl or a boy. I knew the baby was still warm when I did the chest compression. And sadly it is no longer the case. Like the others I pretended that I was fine in front of everyone. It was only when I was alone in my bed room that it all sunk in. We have not managed to save the baby. And we had left the mum, dad, baby brother and grandparents very heartbroken indeed.

Swimming

My sisters and I always enjoy swimming. Our family don't go to the swimming pool regularly. We only get to swim when we stay in a hotel which the facility is offered or a pool based theme park. Our family travel a few times a year for holiday, and when we were younger we would always pester our parents to book in a hotel which has a swimming pool. We often spend hours in the pool - the whole morning until it's too sunny that we'd get horrible sunburn and the whole evening until the pool closes.

None of us had swimming lesson. We taught ourselves how to swim. We look at how other people swim, do it ourselves, drown and choked ourselves with chorine water and try again until we can float and move ahead. Yee Leng was the first to master the skills. She's just so good. While most of us prefer to stay at the shallow end (about 4 feet deep) she would wander off by herself at the deep end. Wan Cheng is not too bad in her swimming as well, I mean she is usually ok following Yee Leng around to the deep end. I am petrified of the deep end. I can do breaststroke and freestyle reasonably well but I just get panic when I know I can't touch the floor anymore that I cannot control my breathing well. Futhermore my stamina for swimming is absolutely rubbish (which is weird because I can jog for an hour without getting very short of breath). When Wan Lee and Wan Teng were a bit younger they were quite annoying because I have to take care of them. But I remember that they really like me hugging and piggy backing them in the water. They still linger around the shallow end with me but they are fast learners and are definitely getting there.

Mummy and papa never swim. They usually sit at the pool side reading. We are always keen to show them how well we have swim or tricks that we learnt. Sometimes they'd do some armchair critics. They have to drag us out of the pool almost everytime we swim because we never have had enough.

Week 3

Monday
Headache hx, Physio cervical spine injury assessment, Ankle joint manipulation (physio), Spinal exercise, ACL exercise, Trigeminal neuralgia, Venupuncture, Venflon (Pink and green!), Hx and examination for head laceration and wrist twist

Tuesday
Abdominal pain (Twisted ovarian cyst), Headache hx (Photophobia), Asthma and management guidelines, ACS management (aspirin – clopidogrel – clexane), Venflon (Grey!), Venupuncture, ECG, Rashes in children, Idiopathic cardiac arrhythmia, Diabetic ketoacidosis and management (Hydration-insulin+atrarapid±antibiotic), CXR interpretation systematic approach, Chest pain hx

Wednesday
Archilles tendon rupture (Simmond’s test), Head injury hx and examination, Abdominal pain ?appendicitis, Venupuncture in difficult patients, OD hx, Epistaxis hx, CVA, Apnoea – breath holding spell in infant, Wrist injury – important to know the dominant hand, Abdominal exam & describing lump, ACS, Sudden loss of vision, Sudden blurring of vision

Thursday
ABG, Venflon, TB, Acute exacerbation of COPD, Hyperglycaemia in DKA or HONK, Head injury (clerking and management, criteria of major head injury), Glandular fever – amoxicillin – rash, ECG description and interpretation, CV exam, Meningitis and febrile convulsion, CVA

Friday
Foreign body in the eyes, Slit lump and describing things in the eye, Accidental vs non-accidental fall in hx, Facial injury, Epistaxis and nose pack, Venflons (1 pink 1 green), Venupuncture, ECG, Hx headache, PE risk factors, Clerking OD, fall and pleuretic chest pain, Costo-chondritis, Paracetamol OD, Heart block , Subcutaneous injection, Fundoscopy, Whiplash injury, Diabetic presenting with back pain and incontinence – autonomic neuropathy, Methadone OD reversal with naloxone, Neurological examination. I was a star apparently.

Saturday
Blood culture, Management of acute exacerbation of COPD, Ankle dislocation – unstable – reduction – x-ray, Suturing, Ureteric colic, Unwell baby, Collapse hx, Chest pain (PE and oral contraceptive pill), Pubic rami fracture, Asthma management in emergency

Sunday
ACS, MI, Side effects of thrombolysis, Neurological exam, Subarachnoid haemorrhage, Lumbar puncture, Viral meningitis, Encephalitis, Shoulder reduction, Wrist reduction, Heart block, Venflon, ECG, Catheterisation, Dipstick machine, LBBB and RBBB, Hypothermia, Bradycardia management, GCS, Severe/Life threatening COPD exacerbation, Thoracocentesis for cardiac tamponade, Pneumothorax and cannula test, Ankle reduction, Anaesthetic induction in ED (cricoid pressure), 28% O2 for COPD, DIGAMI, My fourth cardiac arrest here.

Tired. But happy.

Second week

Monday - Day out with the ambulance. It was exciting, being the first health professional on scene, when ABC are absolutely practical. We had a baby who was pulseless and white. I did chest compression on the baby, but we did not manage to save the baby. I felt quite upset.

Tuesday - Night shift in ED. Saw a few alcoholic fits, put in a venflon, saw ABG, learnt to take headache history. A doctor and a nurse was physically assaulted by a patient but I didn't see it, just saw the police restraining the patient after. Overall uneventful.

Wednesday - Supposedly my day off, but considering that I didn't learn much on tuesday I came in after lunch to make up for it. It was such an amazing day. Put in one venflon, did lots of ECG, saw three MIs (ST-elevation and non-ST elevation), helped in two dislocated shoulder reduction (which was rather embarassing because I was so weak....), took history from ambulance and family in presented in resus, saw a boy who presented with stridor and listen to a heart of a man with patent foramen ovale who survived till his 70s,.

Thursday - MAU was fantastic learning place. Saw lumbar puncture, an ECG with all features of hyperkalaemia (K was 7.2! scarry, the patient could have arrested anytime). Clerked three patients. One was an overdose patient who had manic depression, and talking to him was, umm, interesting. I ordered investigations (took blood and fill in x-ray card) before presenting my case, made me feel like a real doctor. Also tried ABGing but unsuccessful.

Friday - Slightly frustrating morning, had doctors who just won't let me do anything. Won't let me take a history and examine patient, won't let me take blood, won't let me glue a wound. Afternoon was slightly better, I decided that I would do febrile convulsion for my case report.

I am starting to really really enjoy the placement. But I kept avoiding the case report. I'm starting it tonight. Hope I can finish it soon so I don't have to worry about it anymore.

A&E placement

Simply amazing!

It was not just that I have learnt so much stuff in a week. It's the whole pleasant atmosphere of being there. It was a district general hospital I was attached to and the the department is divided into the ED and the Urgent care centre (UCC). I usually spend half a day at the UCC and the other half at the ED.

Here are the summary of stuff I've learnt:
Monday
- Abdo pain (child), Ortho exam (foot) and intepreting x-rays
Tuesday
- ECG (T invertion and bigeminal rhythm), Heart failure (cause and management), Convulsion (febrile), Bronchiolitis (infant), Unstable ankle fracture and reducing it, Trop-i increase (causes), D-dimer, Assessing bone/joint injury/pain, Assessing pleuretic pain, Assessing trauma to chest wall
Wednesday
- Plastering, Cardiac arrest, Apical pansystolic mummur in anaemia, Bad practices, Severe abdo pain, Inserting femoral line, Checking BM
Thursday
- Assessing painful arm and shoulder, Pain relief in A&E, Inserting venflon and taking blood, Swollowed foreign body (management), Log roll, Positioning for x-ray C7 view, Scalp laceration, Tonic-clonic seizure (causes), Haematemesis, Bad discharge, Causes of faint/collapse, Allergic reactions, Common causes of infection in elderly, ECG (Supraventricular tachycardia), Sudden onset of 'unwell'
Friday
- Foreign body in the eyes, Trauma to shoulder and chest, Whiplash injury, Performing 12-lead ECG, Triage, Fractured neck of femur (external rotation and shortening), Fractured pelvis, Managing seizure, Hypovolaemia (signs and symptoms), Stem cell transplant (inflammatory reaction)

So you see I've seen quite a bit, and I've still got so much to learn! I must say I was rather apprehensive at the beginning because the only system in the body that I am well versed in is the GI tract and the genitourinary system; whilst at A&E patients pop in with all sorts of problem. But after my first day, I know I need to learn to examine all the major systems in the body, which will be quite overwhelming. In addition, I get to see the patient before the doctor does, write up the history and examination finding, discuss possible diagnosis and suggest investigations and further management for the patient.

On my second day two registrars gave me some tips:

'If you have a bad experience here, don't take it as a representation of the speciality' - that's probably quite useful because the department is extremely busy most of the time, and we always have managers harassing the medical staff, telling doctors what to do.

'Ask lots of questions, don't hide around the corner' - that's what I've been trying very hard to do. It was understandably difficult for the first few days and I did feel a little neglected. But I realised that, like placement anywhere else, I've just got to look interested and offer to do anything for the doctors and nurses. Otherwise people just won't notice me, or won't even realise who I am after four weeks in the department if I keep on shying away.

And one of tips from a consultant: 'Learn anything. Anything you can lay your hands on or anything you can observe. Even with things like adjusting the bed's cot side.' - That is quite helpful because as a student there isn't much I can be very helpful at and it's only these very simple things I can do to feel a little useful.

There is only one thing. A consultant said I need to wear a white coat. Ever since he told me that, he asked me everyday where is my white coat. I kept on saying 'next week'. So from next week onwards I will have to wear a white coat. I'm going to look so weird...

Campaign dilemma

I'm really annoyed with myself because really, I should be studying! So many chapters and notes to read and memorize and yet I can't help blogging away here...

Anyway I just want to talk about the issue of the right to healthcare among the immigrants in the UK. In Manchester, Gemma, a friend of mine and I started a student group called Crossing Borders, which addresses healthcare issues among refugees and asylum seekers. The main reason I was involved was because I had experience working with the refugees community and kind of understand what problem they face. In our group we have about 10 enthusiastic members. Just before christmas, we successfully hosted a peer education workshop about refugees and healthcare for medical students, which was very encouraging.

At a national conference with the same student group from other medical schools in the UK, we agreed that we would take up the campaign of defending primary healthcare for asylum seekers. Just a background information: the government is expected to come up with a regulation to put a stop to failed asylum seekers accessing NHS primary healthcare services. This would mean that failed asylum seekers will not be allowed to register with a GP, not receive antenatal care, not get immunisation etc. When I first learn about it, I thought this is wrong, and no doubt the I would get people to sign up for the campaign.

Then over time I swayed. The public response generally doesn't favour our stand. Many people put up comments like 'why are we paying for their healthcare?', or 'why are these people not deported in the first place?', which was not pleasant, but I can see some truth in them. I tried to convince myself - these people had fled to the UK to seek refuge, not to take advantage of the welfare system here.

Then what this consultant told us about her encounter with some dialysis patients who came to the UK for free dialysis treatment really shoke my belief. She said normally these patient would be transported from the airport straight to the hospital with symptoms of severe ureamia. They dialyse them, then the doctor breaks the bad news 'I'm sorry but you have kidney failure'. The patient would appear as though they were not surprised by the news, but denied that they knew that they've got the condition. A few weeks into dialysis, it would transpire that they actually knew that they have renal failure before arriving and coming to the UK is literally a gamble on their life, either they are going to receive dialysis and live, or they will be deported and die. Now this is really a difficult dilemma. If you have to know, as the saying goes back at home, living with kidney failure is not an option the poor, because the cost of treatment is just so ridiculously high. For a person to undergo haemodialysis for a year, taxpayers would have to fork out a whooping £35,000! Is it fair to the british taxpayers to be funding the treatment of these foreigners when some of the british patients don't get their life-saving cancer drugs which is just about the same price? And when a patient is on dialysis, their almost always would be put on the transplant list as having a transplant is much cheaper in the long run generally speaking. Yet, this would only make the waiting list longer than it already is, and making the british patients wait even longer for a donor and face higher risk dying while more time is spent 'waiting'. Is it fair that the british patient who has contributed to the economy die while the foreigner, though arguably to survive, who is here to take advantage of the free health service here live for another 10 years with improved quality of life with the transplanted kidneys? The answer is obvious. It isn't fair. But as doctors, who are we to turn away the patient to let him literally just, die? I hate to think about what will happen to this girl http://news.bbc.co.uk/1/hi/wales/7178416.stm.

So back to the campaign, I actually felt that I would be very naive indeed to be saying that the goverment is being heartless, cruel to the vulnerables; and to gain public sympathy telling some sob stories. The group of students working on this campaign nationally are very passionate about the issue, but I think the shortcoming of the way they work was that there was no debate. All they do was lobbying the politician and look out for people who said something against their stand, and come up with argument to rebute them. What about the other side of the arguement? Why can't they acknowledge the legetimacy of the simple fact that the NHS has limited budget and can't be pleasing everyone in the country, let alone outsiders? If this is how campaigning is like then I don't think I'll ever be involved in any kind of campaign ever again. I don't mind signing a petition, but I'm not prepared to be the lead advocate and refusing to understand from alternative angles. Maybe I'm a born fence sitter. And I much prefer doing something more direct and practical like volunteering.

Today is Yee Leng's birthday - Happy 21st birthday!

Doctors to be: 20 years on

'Doctors to be: 20 years on' is a BBC production tracking down doctors from the time they had their interview to get into medical school 20 years ago until the present time. It's really inspiring to watch because I can relate to the character in the documentary. Particularly at times like this when exams is around the corner, when there's so much to read and take in that I almost always feel like giving up, wondering if there any point to even try to read through this enormous amount of stuff. And the bad news is medicine is a profession of examinations, pretty much at all stage until we get to the top. I do want to end up as a successful hospital consultant and it doesn't matter how much hard work it takes. But I'm far from there. Very long road ahead indeed, that it's just very difficult to convince yourself that all these effort will be all worthwhile after all. Watching the consultant on the documentary who went through exactly the same thing as I am facing now kind of put some perspective back into me.

I've also realised that medicine is truly a profession of lifelong learning. I've learnt so much over the last 12 weeks, and yet there are so much more that I don't know. I'm not alone. The junior doctors know a hell lot of medicine. I'm always at awe about how much they know when they teach us medical student practical medical. Yet there are always things that they are not sure of, and would need to ask their consultant about, and it's not uncommon to see junior doctors listening along as a consultant teaches the medical students. And the consultants - at the first sight you would think that they were just walking encyclopedias of the speciality. They speak so eloquently on their subject matter and command so confidently in day-to-day medical practice you would think that there's nothing that they don't know. Yet sometimes even the consultants get stuck. That's why there is so much research going on. Thanks to the complexity of the human body, the thirst for knowledge in medicine will stay alive as long as we are in the profession. One last thing about medicine being so unique is that everyone learn from each other all the time. Most of the time knowledge does get passed down from the seniors to the juniors, but that doesn't mean that the seniors necessarily know more than the juniors about everything. Although we endeavour to learn everything under the sun, we simply cannot, and we rely on each other to fill in our gaps of knowledge all the time.

Despite feeling that I was going to fail every time I sit for an exam, I've managed to pull it through so far. I hope the same will happen this time. Fingers crossed.