One Down, Nine To Go

My time in Chinchilla flew by so fast, I barely had a chance to check out the town. But believe me, not much happens in a town of 3500 people. The only things I have to remember Chinchilla by are a few photos I snapped during one of my evening jog/bike rides.

This week, all of us on rural rotation converged from all over Queensland to Toowoomba, the base for UQ med school's rural division. We shared what we learned and presented to everyone cases we saw during our rotation. After a short exam this afternoon, it's the official start of a one-week break. A whole week - actually ten days, including this weekend - of sleeping in, relaxing, catching up with friends, and generally not thinking about medicine. That is really something to look forward to. I'd better enjoy this break, because the next rotation, surgery, is going to be full-on.

One rotation done, nine more to do before the end of med school! Hmm, maybe I shouldn't be counting down so early.

Ambo Chasing

I heard the news from a nurse at the GP's office: there's going to be a motor cross competition in town this weekend.

"Sweet!" I think to myself. I'm not a big fan of motor cross. But a bunch of people on motorbikes jumping up and down mounds of dirt - that's got to produce a few injuries. Okay, I think it's sweet not out of a sense of malice, but because I know it's going to create good opportunities to see some sports injuries. Unfortunately, that's the way it is for us lowly med students - if you want to see some cool stuff, you'll have to hope that people get sick or hurt. This is the plan: I go down to the field and watch the competition. When the first injuries happen, I'll just follow the ambulance back to the hospital. I'll be an "ambulance chaser" for the day.

friends to cheer them on. I pick a spot uI drive the twenty kilometers out of town to the field. It's a hot day with not a cloud in the sky; the air is bone dry. The dirt hills created for the race are constantly hosed down by water trucks to minimize dust. I walk past the huge collection of tents and motorbikes to the spectators section next to the field. The competition has already started. Motorbikes weave through the course, powering up the ramps and flying over the little hills. Round and round they go. The small and subdued crowds gathered at the sideline look on, occasionally someone yells out the names of theirnder a tree and watch for a while. Before long, I'm bored. I mean, after watching the 500th motorbike going past, my attention span is about finished. I walk around and take photos from different angles. Two hours and zero crash later, I give up. I've had enough of the race. I'll head back to the hospital and, if someone crashes, the ambulance will take them there.

Well, they must have heard about the med student in town and are trying to avoid me, because at the end of the day, not one person has crashed or even landed funny. So much for my plan to get some practice on handling a sports injury. Good for them. And for me, all I got are these lousy pictures!

Baby Catching

I'm hanging around the hospital this weekend, hoping to see some action. The hospital in Chinchilla has no public doctors, so the private GPs in town take turn being on-call on weekends. I'm staying at the Nurse's Quarters next to the hospital, so if something happens, I'm right there.

The whole place is quiet today except for a young woman who went into labor and came in this morning. This being her first baby, it could take a while. So I ask the midwife to call me when the baby comes and go off to the cafeteria to do some reading. At about four o'clock in the afternoon, I decide to go around to the birthing suite to check on things.

I walk into the room with the woman screaming at the top of her lungs in pain between breaths of oxygen, with her mother on one side and her husband on the other holding her hands. All on her own, the experienced midwife is getting everything ready while checking on the patient. I want to help, but wait! I know nothing about obstetrics - that rotation is next year. Being the first time watching a natural delivery, I'm completely useless and the best I can do is not get in the way. The midwife checks the patient's cervix. "It's fully dilated," she announces. "Because this is your first one, it can take a while for the baby to come out," she tells the patient. In pain and exhausted, the woman nods.

Of course, Murphy Law applies in situations like this. Five minutes later, "It's coming!" the woman yells and starts to push. The midwife goes over and calms her down. Under her guidance, the delivery goes smoothly and the baby is born. "It's a boy!" declares the midwife. I'm standing there thinking, "where the hell is the doctor?" Fortunately, everything goes smoothly and the midwife has everything in control. She turns to the husband and asks, "do you want to cut the cord?" He looks at the wet clump of screaming and writhing blob in the midwife's hands and shakes his head, probably in shock that THAT is what a new born baby looks like. The midwife expertly clamps off the umbilical cord and gives me the honor of cutting it. She dries the baby, loosely wraps him in a towel and hands him to me. "Can you do an APGAR assessment on him?" she asks.

I gingerly take the crying and grimacing baby into my arms and try to recall the APGAR assessment in my head: Appearance, Pulses, Grimace, something, and...Reflexes? I lay him down under the heatlamp and give him the once over. Pink? Check. Pulses? Check. Grimacing? Check. Gripping reflex? Check. "Is the baby healthy?" his mother asks. "Looking good so far," I answer, still can't remember the last thing to check. The midwife comes over, checks him over, and tells everyone, "He's a perfect ten." At this point, the doctor on call finally arrives. He talks to the family briefly and gives the baby another check. Having congratulated the brand new parents as their extended family stream into the room to see the new baby, I duck outside so as not to intrude during this intimate moment.

As I walk to the cafeteria for dinner, I breathe a sigh of relief at the end of my first baby-catching exercise.

Freeze 'em, Cut 'em, Stab 'em

Lesson of the week: incredibly pale people + Queensland sun = skin cancer.

When I first arrived in Chinchilla, I felt like I'd probably just doubled the town's ethnic population. The people in this town are, as is in most of Australia, mostly white, and mostly of Northern European extraction. Throw in an economy based on farming, building, and occupations that generally require people to work under the sun, and you've a recipe for funny things growing on people's skin. Australia has the highest rate of skin cancer in the world, and the rate in Queensland is double the Australian average. With stats like that, GPs here end up spending quite a bit of their time looking at people's skin.

In the last few days, I got a chance to check out weird-looking moles and bumps on people's skin: weepy ones, dry and crusty ones, fleshy ones, angry looking ones, ones that have been there for thirty years, ones that just sprouted in the last couple of months, etc. Often the patient points out the ones they are concerned about, then the GP has me look at them first under magnification. I would peer through the dermascope, but have only the vaguest idea of what I'm looking at. The GP then comes over, does the same on all of them, and delivers his judgment. "This one's fine, this one's not good, and this one's ok, but keep an eye on it." Then it's time for the execution of the guilty parties: light offenders - mostly superficial sun spots - get the freeze job; the more serious ones - established skin cancers or very likely ones - get cut out; and suspiscious-looking ones on the face get biopsies with a hole punch. The freezing is done with squirts of liquid nitrogen. With the excision, the wound is sometimes followed by some fancy skip flap repairs or grafts with amazingly good cosmetic results. When GPs have these kinds of skills, who needs to go to the dermatologist?

Conflict of Interest?

Today is the beginning of my three-week stint in Chinchilla, a town of 3500 people 90 kilometers west of Dalby and 300 kilometers from Brisbane. I will spend all of my time with the local GPs and hopefully get a taste of what being a rural GP is like.

The practice consists of three principal GPs, one junior partner, and one registrar (the equivalent of a hospital-based resident). I will spend one week with each principal GP. With most people that go to these GPs being private patients, I know I won't be able to do too much hands-on stuff as I was able to with public patients in Dalby Hospital. Instead, I'll spend a lot of my time sitting in on consults and mostly watch.

In between consults, the GP I'm following this week enlightens me on the health care set up in Chinchilla. There is a public hospital, but it's entirely run by nurses because it has no doctors. The five of them, all private GPs, are the only doctors in town. So, they have been contracted by Queensland Health to provide public health care at the hospital. Besides running their own practices, they run outpatient clinics at the hospital three afternoons per week, provide public in-patient service, and can also admit their own private patients. Now, if that doesn't raise a giant Conflict-of-Interest flag, I don't know what does - they are competing against themselves!

I'm told that, in order to encourage people to buy private health insurance, the doctors here have to provide different levels of service between their private practices and the hospital, namely an inferior service at the hospital. The main disadvantages for public patients that go to the outpatient clinic at the hospital are: they don't have a choice of doctors, and the length of consults would be shorter. The first one is fair enough - that's how the public system works: you get whichever doctor is available. But the shorter consult would directly translate into inferior service, which would have to be noticeably worse than private care for patients to want to get private insurance, otherwise everyone would just become pubic patients!

It's understandable that private GPs in a small town wouldn't want too many patients to use the public system - it means they would have fewer private patients. So I can see why they do it. I just can't get over how the same doctors can deliberately provide two levels of service. If I were put into the same situation, could I follow suit and do the same thing? What would I do to balance my professional and personal interest against the interest of the public? Regardless of how I feel now, I know that at the end, pragmatism will win the day; my idealism will just have to try not to get snuffed.

What, There's a Town Out There?

People have asked me what Dalby's like. To be honest, I really have no idea. I drove through it on my way from Brisbane to the hospital. I remember the one thing that really struck me was how flat the surroundings were. The featureless land stretches out from either side of the road all the way to the horizon. The grand-sounding Great Dividing Range to the east, little more than a collection of hills in this part of the country, faintly breaks the otherwise straight line where land meets sky. Wheat or corn or something like that in industrial-size plots of land go right up to the road. The area being in a drought like so much of Australia, shades of brown is the predominant palette. As far as the town of Dalby goes, I'm vaguely aware that about 12,000 people live here. There's one "Main Street" where all the commercial activities take place all week until Saturday afternoon, then the whole street shuts down and tumbleweeds fill the void left by people. Then roughnecks have duels in front of the saloon and the survivor is sent to the hospital to get patched up.

Ok, I made up the last part, but what I'm saying is that, for the last three weeks, I've hardly stepped outside the hospital. It surprises me how fast I have settled into a routine: drag myself out of bed in the morning, do ward rounds with the docs, then spend the rest of the day seeing patients at A&E. My day usually ends at ten, midnight, or for a couple of nights, past midnight. Then it'd be the same routine all over again the next day.

Despite the long hours, I have been thoroughly enjoying my time at Dalby Hospital. The docs at the hospital allow James, another med student assigned to Dalby Hopsital, and me do intern-level work: do initial assessment on patients, present findings to them, and a lot of the hands-on skills like taking blood, suturing, plastering, and putting in cannulas. So even though I've been here for two weeks, I hardly know what the town looks like.

Today I leave Dalby for the town of my next placement, Chinchilla, 90 kilometers to the west. So on my way out of town, I finally get a chance to snap a few pictures. Note the absence of people in the pictures. It's not that I don't want to include the locals in my pictures. The reason is that today being a Sunday, almost all the shops are closed and the town is virtually deserted.

Entrance to Dalby's main drag

Boom gate-free railroad crossing

Railroad freight depot

Drive-in liquor shop

Downtown shop

"Caution: Horses"

End of the kilometer-long main drag

An Arresting Moment

I watched someone die today.

The day starts pretty routinely: ward rounds, paper work, A&E. After seeing a few patients in the morning, the A&E waiting room is almost clear. Down the hall, a private GP in town is using one of the emergency beds to cardiovert one of his patients.

When private patients come in to the hospital with their GPs, they don't need the services from the public docs, and definitely not want to be bothered by pesky med students like me. So when the nurses tell us that such and such patient is private, we leave them to their treating GP. And this morning is no different. Everyone's focus is on the public patients in the waiting room.

Just when I pick up the chart of a patient waiting in one of the consult rooms, a nurse walks briskly through the door. She says urgently but calmly, "The private patient is having an arrest, we need more doctors." All of the docs on duty drop whatever they are doing and rush to the emergency bed. Immediately, I feel the adrenaline rushing through my body and follow everyone into the room. The patient is a morbidly obese middle-aged woman. She lies there motionlessly with a flatline on the ECG monitor. Immediately, the bed is surrounded by ten people. The GP quickly and expertly intubates her, one of the nurses takes over the oxygen bag, another nurse administers adrenaline according to doctor's order, another doctor rips off the ECG leads and starts CPR, yet another doc gets the defibrillator ready for the shock. Everyone seems very subdued and moves purposefully, completely different from what they show in medical dramas on TV. There's no screaming, no exaggerated movements, no trays getting knocked over. The room is strangely quiet, save for the humming of the electronic equipment, the sound of everyone's footsteps, and the faint sound of counting by the doc administering the CPR. After a minute of CPR, the doc in charge of the defibrillator tells everyone, again in a surprisingly subdued voice, to stand clear. He pushes the button, the patient jolts. CPR is resumed. James, the other med student at the hospital, is asked to do it. He jumps onto the stool and starts the chest compression. After another minute, another shock, with a higher voltage this time. CPR again, this time it's my turn. I get on the stool, put one hand over the other, lock my elbows, and start the brisk compression of the patient's chest. I look down. The patient's bloated face is blue, her eyes half open, staring lifelessly into space; her rotund abdomen reverberates with every push. "...Three, four, five..." I count as I go so the nurse on the oxygen bag can time the oxygen delivery. Another syringeful of adrenaline is pushed through her IV port. I keep pumping away, the only sound I hear is my own breathing, everything else fades into background noise. My arms and back start to ache. After about two minutes, someone taps on my shoulder; I stop and the docs check her vitals. "She's back in sinus rhythm," someone says. Slighly relieved, I step off the stool.

The syringe after syringe of adrenaline must have kicked in. Her heart starts to beat again. As she starts to wake up, she puts up a slight struggle against the tube in her throat. But it doesn't last long. Before the docs can sedate her, the adrenaline starts to wear off. The beautiful green rhythmic squiggle on the ECG monitor starts to distort like bad TV reception, then the single beep of a straight line goes across the screen, as if to pronounce the death sentence. We have another brief attempt, but it has already been thirty minute since her first cardiac arrest. The brain has been deprived of oxygen for too long. The GP calls the time of death. We breathe a collective sigh. Without a pause, everyone heads back and picks up from where they left off. The patient's GP goes out to the waiting room to deliver the news to her family. The lifeless patient lies there like a mound of flesh. A nurse brings a sheet to drape over her. I pause for just a second, thinking how this woman probably never expected to meet her end this way.

Then it's lunch time. A couple of the doctors and I head to the cafeteria. We chat about this and that. The conversation is light and casual, like that death this morning was just another patient passing through the hospital. In a way, that's true; deaths happen in hospitals all the time. We can't allow it to affect us too much or we will not be able to do our job. I'm sure that, in time, I will be desensitized to it. But I hope that I can learn to maintain an appropriate level of professional detachment without becoming a callous and unfeeling doctor.

Vampire Job

Taking blood was one of the basic practical skills we learned the first week. We didn't even have pig's feet to practice on for it, all we got were crudely-made fake arms. So it's the skill I am the least confident in. Last week I had a few chances to do it on our patients.

Like everything else in human anatomy, veins come in different sizes and shapes. There are the plump and juicy pencil-sized ones that you could take blood from with a pen, and there are tiny collapsed ones on dehydrated patients that you could barely make out even with the tourniquet pulled tight enough to collapse their arteries. There are patients who would merrily chat away and not even bat an eye while you jab away at them, and there are patients whose whole body would tense up and start to hyperventilate at the sight of the blood collection cart. I had a go at them regardless. The trick, I learned, was to act with confidence, like I knew what I was doing, like I'd done this a million times before, and the patient would be that much more calm. But that was after a rocky start at the art of venepuncture.

One day last week I was asked to take blood from a patient for some tests. I was told that the patient was an IV drug user who had wanted her blood tested for "poisons." I walked into the consult room and saw that the patient, a woman in her twenties, was nervous and shifting in her seat. This being my first time taking blood and the fact that the patient was an IV drug user, I was advised to double glove. Trying to small talk but got no response, I put on the first pair of gloves. Then I started to put on the second pair of latex gloves and, being powder free, they started to stick to the first pair. As I struggled to put them on the best I could, I sensed that she was getting more nervous. Finally, the gloves were on.

I asked her which arm she preferred. She said softly, "Doesn't matter, you can use the left." I looked at both of her arms. The needle marks on her right arm clearly indicated which one she'd used for injecting. I put the tourniquet on her left arm and tried to palpate a vein in her left cubital fossa. The thickness of two layers of gloves made it extremely difficult to feel the vein. After finding what I felt was a good vein, I pushed the needle in. I was using Vacutainers, which minimized the chances of contact with blood but didn't give the user confirmation of the needle being in the vein. Not sure whether I was in the vein, I got nervous and pulled out the needle. I apologized to the patient and set up a normal syringe and needle. The woman pointed to the new needle and said, "Oh my god, what's that? What's on that needle?" She then accused me of not using a sterile needle. I assured her that we never re-use our needles but she was having none of it. At this point, my supervisor came in to the room to my rescue. He used the syringe and took blood from her right arm, the one she'd use to inject and probably had much better veins. Afterwards, we told the patient to come back in a couple of days for her results and she left in a rush.

And that was how I miserably failed at my first attempt to take blood. After that, I started using normal syringes and needles, which give the comforting flashback - a little bit of blood showing at the syringe end of the needle when it goes into the vein. That and with a little bit of bluffing to put the patient at ease, this blood-taking business became much easier for me.

After the Bunny Slope, It's the Double Black Diamond

I'll be in a small town called Dalby for the next three weeks. Dalby is about two hundred kilometers west of Brisbane. The town was practically dead when I arrived yesterday. All the shops were closed except for a couple of convenience stores and petrol stations. Then I remember in rural Australia they still have no-trading Sundays. The few places that do open on Sundays boldly advertise "Open 7 Days" in front. Yup, there's no mistake that I'm doing my rotation in a rural place now.

I'm spending these three weeks at Dalby General Hospital with James, another Year 3. In the morning, we dress in our normal clinical clothes of shirt and tie and walk into the hospital. We introduce ourselves to the consultant (that's what they call their attending physicians here). "Take off your ties, you're making me look bad," the consultant tells us. Sheepishly, we take off our ties to mock protestation from the nurses.

After morning rounds, it's clinic and A&E (Accidents and Emergency, it's what they call their Emergency Room here). The first patient that comes in has a cut on his hand that requires suturing. "Have you done suturing before?" The consultant asks us. "On a pig's foot." I answer. "Good, you can do the suturing on this patient." Cool! I start to prep but have no idea where anything is. It wouldn't take a second for the patient to see that we are new. But he just sits there stoically. "Brave guy," I think to myself while the nurse helpfully lays out the
tray. I put on the pair of sterile gloves. The consultant talks me through the steps to anesthetize the area and prep the wound using aseptic techniques. With that done, I start the suturing. I hesitate for a bit, trying to find a good spot to place the needle. With a flick of my wrist, the needle sinks into the skin. It feels pretty much the same as the pig's foot - same amount of resistance, same amount of blood oozing out. With that initial hesitation over, I now just imagine the hand as the pig's foot I sutured last week. With each knot tied, my motion grows more fluid. Before long, the five stitches are in. I clean the wound, then look up at the consultant. He gives a nod of approval. All right! That wasn't too bad.

So just like that, after last week's hand-holding on the bunny slope, we find ourselves staring down the double black diamond with the coach pushing us off. These three weeks are going to be crazy, but it's going to be an awesome learning experience.

Rural Rotation: Prep Week

We get up, have breakfast, go to this lecture and that talk, have activities, have lunch, have more activities, then go back to the dorms for dinner; after dinner we sit around a fire, make s'mores and sing "Kumbaya." The next day: repeat.

Okay, I made up the part about sitting around a fire and singing kumbaya, but the rest of it was true, and it was very much like summer camp. That made up the rural rotation prep week for about thirty of us Year 3 med students. I'm glad we're starting with such a cruisy week, because I definitely haven't gotten my brain back in medicine mode yet.

We got to learn and practice all kinds of practical skills like plastering, using a defibrillator, injection, intubation, scrubbing for surgery, cannulation, venipuncture, and my favorite, suturing. Some people came from nursing background or already knew how to do some of the things, but for most of us, it's all new. We were like kids in kindergarten learning to tie shoe laces for the first time. So it was good that we had pig limbs and mannequins to practice on. Everyone knew that next week when we start our rotation for real, we'll actually do these things to real people. Poor rural patients...

The week flew by fast. We headed our separate ways this afternoon and will be scattered throughout southern Queensland for the next six weeks. It's a long weekend with Australia Day on Friday. Better rest up, because next week is the real deal.