Seven Down, Three to Go

The exam this afternoon marks the end of specialties 1 rotation, which means a one-week break is coming up.

It has only been eight weeks since I’ve been back in Brisbane, but I am already getting itchy feet. So three of my friends and I will be taking off for a week of camping on Hinchinbrook Island National Park in tropical north Queensland where Nim’s Island was filmed. The walk on Hinchinbrook is supposed to be among the world’s top hikes. The last time I camped was back in January in New Zealand; it will be good to go out there and brave the elements again.

Camping gear, check; camping food, check; plane tickets, train tickets, bus tickets, ferry tickets, check, check, check, and check. Hinchinbrook is hard to get to, but good things never come easy.

I’m psyched!

Regression of the Mind

At memory clinic today, one of the patients was accompanied by her daughter. The patient, in her mid-eighties, was originally from Poland but has lived in Australia for the last forty years. She was diagnosed with Alzheimer’s Disease four years ago and came in today for a follow-up visit. As her daughter described it, the progression of her Alzheimer’s Disease, and her dementia, has made her more and more dependent on her daughter. Besides the lost of her short-term memory, she has almost completely lost her ability to speak English, which she was able to speak fluently before, and now relies on her daughter to translate for her. She happily recounts in Polish stories of her, as a girl, gathering firewood from the forest to make dinner at the eave of Germany’s invasion of Poland.

Ah, the ravage of time, that great equalizer. When people live long enough, few can escape the its grasp. As dementia sets in, the awareness in the early phase evaporates, leaving its victims blissfully oblivious even as it becomes increasingly distressing to their family members. It doesn’t matter whether he might have once been the CEO of a multinational corporation or an ordinary farmer, he simply regresses back to a child-like state. The loss of the ability to make critical judgment, the ability to remember where one lives, the ability to recognize one’s family member, and the loss of skills learned later in life, such as speaking a second or third language, are all part and parcel to the disease. At the end, one becomes dependent even in simple things like feeding and toileting. And thus he leaves this world just like he entered it.

Sometimes I do imagine that if I get to live to the ripe old age when I am babbling in Cantonese, with Mandarin and English, my second and third language, respectively, just a glimmer in the deepest recesses of my atrophied brain, what kind of stories would I be telling my grandchildren or my geriatrician.

Geriatrician or Social Worker?

It’s the second week of geriatrics. And my first impression of this specialty is – it’s a lot of social work! In fact, I would say it accounts for the majority of the work by everyone from the resident up to the consultant. The ward I am attached to is mainly for elderly amputees to go through rehabilitation after their amputation so they can go home with the skills to live as normally as possible.

Although the patients are mostly elderly people who have multiple co-mobidities like diabetes, heart failure, COPD, peripheral vascular diseases, etc., which make them very interesting patients as far as pathology is concerned, their conditions have largely stabilized by the time they are ready to go to the geriatric and rehab ward. So the main focus on the ward is their rehabilitation; their medical conditions have almost become a secondary issue. As they go through the process of going to the gym to gain their strength back and learn to use the wheelchair with help from physiotherapists, the doctors are busy coordinating the allied health team to work on their discharge – home visits to assess access issues in and around their houses, arranging Meals on Wheels for them, booking the Blue Nurses to care for them post-discharge, arranging house-cleaning, and for those not fit enough to live in their own homes, plan for discharge to nursing homes. A meeting is held weekly for doctors and allied health professional to discuss each patient on the ward and to assess their progress and the progress of the work being done to address the patient’s living situation.

While it’s great to see that patients get such thorough treatment to make sure their transition from hospital to home go as smoothly as possible, it appears that this specialty involves more social work than the practice of medicine. Is this the result of the break down in the social fabric of Western societies? Traditionally, people go to the hospital when they are sick; and when they go home, their immediate or extended families take on the role of care takers. Now that role has been assumed by the health care system and, at least in Australia, largely by the government. From a rational point of view, it makes sense – the patients’ family, now unburdened with the work of caring for them, is free to devote their time on work and, by extension, contribute to the national economy. But from the humanistic point of view, the care the patients receive from the various government agencies and professionals, however great, cannot make up for the feeling of being cared for by someone close to them. Of course, many of these patients are fortunately enough to get the best of both worlds: they are under the care of a family member, with help and subsidies from the government. Their main carers can get various benefits like pensions from the government and carer respite to prevent burn-outs. It is reassuring to see that, under the generous welfare state and the social safety net in Australia, people can age with dignity, even with debilitating illnesses.

Thumb-Twiddling Time

It’s almost noon. I’m standing next to the team of doctors on ward round, fighting the urge to shake my legs or do fifty jumping jacks or do a sprint down the hallway, anything to keep me from falling asleep and crashing on top of the patient. No, I am not sleep-deprived, I am just incredibly bored. It seems that in this rotation, the student’s role is to stand back and watch. I am but a mere observer on ward rounds, at clinics, and on consults. It is really hard to stay focused when I know I am not expected to contribute anything more than getting the patient’s charts. So I stand back, twiddle my thumbs, smile at the patient, and watch the team in action. Occasionally I find myself dragging my mind back from outer space when the team is ready to move on to the next patient.

Perhaps this rotation isn’t really that different from any other ones, but it feels especially jejune from the stark contrast to my elective, where the excitement of being in a new and exotic place and being able to do so much made it a joy to go through each day. So it was inevitable that the crash back down to earth hit me hard as I returned to the daily grind. I have found myself, on more than one occasion while ward rounds start to drag on, taking my mind ten thousand kilometers away and replaying images and episodes of my time in Zambia. Good times…

First Class, Cattle Class

After ward round, the consultant brings us into the doctors’ lounge for a break.

With a wave of the doctor’s badge, the translucent glass door slides open, Star Trek-style. With one step, we enter a different universe that is the brand-spanking new multi-million-dollar doctors’ lounge. The décor is ultra-modern and looks straight out of an IKEA catalog: light wood-paneled ceiling with spotlights beaming down on streamlined couches, abstract metal sculptures seem to float effortlessly over the minimalist coffee table resting on the slate floor, next to the restaurant-grade refrigerator with glass doors, a professional espresso machine spits out fine coffee made from freshly ground premium beans at the push of a button, you can even froth your own milk. While enjoying your cup of coffee, you can flick through every channel available on cable on one of the Giant LCD TVs. Down the other end of the room, beech-veneered lunch tables and translucent lunch counters are impeccably paired with ergonomic stools and chairs. The whole room overlooks the hospital’s courtyard through tinted wall-sized windows. In another room, computer workstations are set up with comfortable chairs and soft lighting. I stand there like a farm boy in the big city, marveling at everything; the setting, more suited to a fancy private hospital, is rather incongruous in this public hospital.

After the break, we walk out of the lounge and back into the utilitarian hospital hallway. I slip back into the med student common room directly across the hall. Compared to the doctors’ lounge, the student common room is downright proletarian: mismatched and well-worn chairs and couches in green and brown and every other shade in between haphazardly arranged around tables with dull laminated tops and wobbly legs, harsh florescent lights fill the room, and the industrial linoleum floor ties everything together, giving it that institutional feel only a hospital can. An old TV sits forlornly in one corner of the room; the five free-to-air local channels are your choices. Before the new doctors’ lounge was completed a year ago, the junior doctors shared the common room with us students. When they moved to their new digs, the free instant coffee and tea left with them. But to show their pity and generosity toward us, they left behind the warped pool table with ripped felt.

Maybe it was a way for the hospital to let us know, ever so subtly, what they think of med students. Or maybe it was to show med students what we can look forward to and, to make us appreciate the new lounge, a bit of contrast can be useful. Of course, making the doctors’ lounge “absolutely forbidden” to med students unless accompanied by a doctor isn’t exactly an ego booster for us who are not even on the bottom rung of the ladder yet. Just think, at the end of November, we will still be lowly med students who don’t even warrant a flicker of the eye; but by next January, those of us lucky enough to be an intern at this hospital will have unrestricted access to the lounge and the right to sit in the same room as the most senior consultant.

Unless there’s an ultra-luxurious, ultra-secret senior doctors’ lounge somewhere else in the hospital that only the very privileged would know about.

Back to Reality

It feels like I have just gotten back from holidays, and now another rotation – medical specialties – is upon us. I have been allocated to the specialties of infectious diseases and geriatrics – four weeks each.

For the next four weeks, I am with the infectious diseases team. Today starts with ward rounds. After a year of being in a laid-back regional hospital, the intensity of the ward round at this major metropolitan hospital just smacks me right in the face – no small talk, it’s all business. The consultant and her entourage – all ten of us registrars, residents, a nurse, a pharmacist, and us medical students – move like an amebic organism from room to room and from ward to ward. We swarm each bed, spreading ourselves out to surround it, throw medical jargons at each other as if we are speaking in code, and occasionally involve the patient in the discussion by offering them a brief translation of our treatment plans. Afterwards, we ooze out of the room, shuffle down the hall, and slither down the stairs to the next unsuspecting patient in a distant ward.

Compared to the kinds of infectious diseases I saw on my elective, the ones here are fairly tame – MRSA, VRE, and an occasional necrotizing fasciitis – at least in terms of getting appetite-suppressing photos. With all the powerful antibiotics at the doctors’ disposal, many of these infections are brought under control quickly. It’s like in Zambia, they are fighting a war with little pistols whereas here, they can have the latest heat-seeking missiles at a moment’s notice. And here at the infectious diseases ward is where the eternal battle between nasty bugs and man’s ingenuity is fought. We are always trying to stay one step ahead of the bugs by finding their Achilles’ Heel and exploiting their vulnerability. On the other hand, the bugs are always mutating in an unpredictable way for survival under the evolutionary pressure from the drugs we throw at them. At the moment, we have the upper hand.

But I wonder for how much longer.