House of the Setting Sun

I went to a nursing-home visit this evening. It was a high-care facility where all the residents are highly dependent on the nursing staff for even their most basic daily activities like going to the toilet, feeding, and showering.

Walking through the front door, I was immediately surrounded by that characteristic "old folks home smell," a mixture of antiseptic solution, stale air, urine, and the occasional heavy scent of air freshener someone had sprayed in a vain attempt to make the air more breathable. With my olfactory glands quickly and fully saturated and desensitized, I walked with my GP down the hallway starkly lit with fluorescent lights and decorated with generic paintings of flowers. The paint on the wall and the lighting together gave off an eerie green-hued tinge to everything inside.

We went from room to room, visiting the dozen or so residents my GP was responsible for. Some gave a half response to our questions, others were loquacious and intent to chew our ears off. Some had their mental faculties more or less intact and were sitting in the dining room chatting to other residents, others were so demented they were only a shell of their former selves lying in bed completely unaware of their surroundings. Some had pictures of their families and flowers next to their beds, a result of their families trying to make their corners of the rooms as homely as possible. Others seemed not to have anyone left in this world, with the walls and nightstands on their corners of the room completely bare and not a sign of visits by anyone was detectable.

My GP started to review the drug charts. Anti-depressants, sedatives, and stool softeners seemed to be the staples of the elderly population in the nursing home as they are in the community. One by one, the charts are reviewed, the drug dosage adjusted; then the stack of charts are set aside like a pile of freshly-finished homework.

"This place is so depressing." I commented to the nurse.

The nurse chuckled, "Well, it can be depressing. But you get used to it."

For the residents here - some of whom depend on anti-depressants to even get the energy to chew their bland meals, who are on sedatives and kept in a low-stimulus environment so they can sleep their days away and so the overworked nurses would not have to deal with any delirious residents, to whom a 5-minute visit by the doctor once a month may well be their only contact from the outside world other than the nurses - the remainders of their lives are no more than a disorienting drag from one meal to the next in an infantilized existence. The flickering images on TV no longer mean anything; it might as well be showing an alien world on Mars. Are the residents with more or less intact mental faculties thankful for being alive each day, or are they envious of the demented ones who are blissfully ignorant of their terminal predicament?

The visit came to an end. As I walked past the front doors, I took a deep breath of the fresh cool night air. I reminded myself again that I am here as a health care profession (albeit one in training) and despite my personal opinions, these residents are here to stay; all we can do as doctors and nurses are to make their last days as comfortable as possible.

What Am I?

It seems that people sometimes don't quite know what to make of me - Chinese? American? Recent immigrant to Australia?

How about all of the above?

In conversation, sometimes people would ask me,

"Are you a Yank? You sound like one."

or

"Where are you from? You don't sound like you're from around here, by the sound of your accent."

Other times, the conversation would go like this:

"Where are you from?"

"California, but I'd lived in Washington, DC, for seven years before coming to Australia."

"But, where were you born?"

"China."

"Ahh," as if a mystery has been solved and they now know exactly what kind of a person I am.

I've also gotten comments like:

"I didn't think you're American; I thought you got your accent from your parents."

or

"I thought I heard an accent when you speak, but it's not Asian."

or

"You were born in China? But you're so American." (as if they are mutually exclusive.)

Over time, I came to understand that the question "Where are you from?" means one of five things, depending on the person asking the question:

1) Where were you born?

2) Where do you consider home?

3) Where do you go to visit your family?

4) Where have you lived the longest?

5) Where did you grow up?

With me, people are rarely satisfied with the first answer I give. They tend to ask any of the above five questions in different variants until they get the answer to what they really mean.

So, how about this when someone asks me where I am from:

"I was born in China. I lived there until I was fourteen, when my whole family moved to the US. I spent the next fourteen years between California and Washington, DC. I then moved to Brisbane for med school and am planning on staying in Australia afterwards. I consider myself Californian because it feels like home, that's where my family is and that's where I'd spent my formative years when I developed my self-identity. I respect the Chinese tradition of family hierarchy and filial duties, at the same time I embrace the American ideal of individualism but reject the wanton consumerism and materialism; I also identify with the Australian sense of egalitarianism. I'm Chinese; I'm American; and I'm becoming Australian."

I suspect not too many people have the patience to listen to all that as a response to a seemingly simple question.

~~~~~~~~~~

Dinner tonight: pizza with a base of Lebanese bread topped with mozzarella, garlic, artichoke, sundried tomatoes, olives, and fresh coriander, rocket, and basil.

Tonic for Perpetual Health

As part of the GP rotation, I had a visit today to an audiologist, one of the allied health professionals in town. An audiologist does hearing tests, fitting and fine-tuning hearing aids for people with hearing loss.

I sat in on a hearing test on a young man in his mid twenties who had lost most hearing in his right ear after a few years of working in a saw mill with only occasional use of hearing protection. Afterwards, the audiologist took out the file for the next patient.

"This next patient is a very interesting lady. Now, just take off your medicine hat for a minute. Other than needing hearing aid, Mrs. S____ is in exceptional health. She told me her secret on her last visit. There's something she drinks every day to keep her health, and she swears by it. Whatever ails you, diabetes, cancer, high blood pressure, anything, her drink cures it. She gave me a small bottle of it."

Okay, it must be another one of those juice of the month that claims to do everything for you. I waited for him to pull out some exotic juice from a far-away land.

Beaming, he opened a drawer and pulled out a clear bottle with a red label containing some clear fluid. The label proudly declared "Stolichnaya Russian Vodka." "Vodka?" I said incredulously. "Yup." Well, I guess you could call Russian vodka an exotic juice from a far-away land.

The audiologist opened the door. Mrs. S____, an elderly woman walked in and sat down. "Did you drrrink the vodka today?" she asked the audiologist in her thick Russian accent. "No, not today," the audiologist confessed.

Giving him a disapproving look, Mrs. S____ then turned to me and asked, "Do you drrrink?" "Not vodka," I answered. "Why you don't drrrink? It make you strrrong! One cup a day, I drrrink."

After the session, Mrs. S____ turned to me as she walked out the door and said, "Next time, I brrring you some."

Where else but in primary care would patients offer health advice to their doctors?

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Tonight's dinner: broiled salmon with Chinese five spices on Chinese cabbage and blend of jasmine/brown rice.

GP Land

It's been two weeks since the start of GP rotation and I'm digging it. Coming out of mental health rotation, I am glad to get back into the medical side of medicine. Dr. R., the GP I am following lets me see patients on my own (under his supervision, of course) and do a lot of the procedural work like cutting out skin lesions. Sitting in my own room seeing patients is the perfect way for me to try out this whole GP thing.

One aspect of general practice that appeals to me is that you never know what's going to walk through the door next. One patient could just have a cut that requires suturing, the next patient could come in with four chronic conditions that require full reviews. Another aspect that appeals to me is the continuity of care. When a patient comes in with something that probably requires an operation, you refer them to the surgeon. When they come back later for a follow-up visit, you get to see the patient in recovery and check whether your clinical suspicion was right in the first place.

~~~~~~~~~~

Today a patient came in complaining of bumps on his back that had been there for years. One of them grew bigger and painful over the last week and he was concerned. After taking more history and examining the bumps, the big one being about three centimeters in diameter, I made the diagnosis of sebaceous abcess, or in layman's term, a giant inflamed zit. I called Dr. R. into the room and presented to him my findings. He agreed with my diagnosis and proceeded to explain to the patient that it was not anything bad and the best way was to leave it alone. Standing next to Dr. R., I asked, "In what situation would you decide to drain it?"

He looked at me, as if thinking "ooh, you're going to be sorry you asked." Then said, "We can do an incision and drainage now, do you want to do it?"

Not knowing what I was getting myself into, I said, "Sure!"

Up the patient went onto the procedure table. After I injecting the local anesthetic, Dr. R. explained to me, "Just use the scalpel to lance the abscess, but watch out, it could be under a lot of pressure and the collection of pus could come out with a lot of force." Handing me the scalpel, he said, "You'll know when you've lanced it. You'll smell it. If you need anything, just come get me in my room," then walked out to see the next patient.

I was left holding the scalpel thinking about the giant zit exploding in my face. Gingerly, I positioned myself to be out of the possible trajectory of the pending explosion, then pushed the scalpel down the center of the abscess. No explosion happened. I breathed a sigh of relieve and my nostrils were filled with the sour and acrid smell of pus. Yup, Dr. R. was right. For the next ten minutes, I poked and squeezed the abscess and wiped away the cheesy blood-tinged pus. Finally, having squeezed the last drop of pus from the abscess, I put the scalpel down. Dr. R. walked in, checked my handiwork, and said, "Good job, Tony." Now I knew why he had wanted to leave it alone and let it pop by itself. I asked an innocent question but got the answer the hard way.

Well, it was all part of the learning process. At least the patient felt better right away and did not have to deal with the pressure on his back anymore. Though next time I may want to do it in a place with better ventilation.

~~~~~~~~~~

Tonight's dinner: broiled mackerel in ginger marinade on Chinese cabbage and sweet potatoes.

Solo Strolls

With another set of exams behind me, I was now looking at a nine-day break before the beginning of the next rotation. What could I do with myself for all that time? After the last trip to Fraser Island in May, I was keen to make a return trip. All my friends were either busy or injured or otherwise unwilling to camp in the "winter cold," so this was going to be a solo trip.

The plan: the northern portion of the Fraser Island Great Walk, taking in lakes, forests, and a long walk down the beach.

Total distance covered: 105 km.

Time: seven days.


Day 1: Wanggoolba Creek to Lake McKenzie, 10.8 km

The barge took half an hour to cross the placid strait from River Heads to Wanggoolba Creek on Fraser Island. The sun was just warm enough to cancel out the cool breeze coming from the sea. As soon as the last car drove off the barge, I stepped off the ramp and, with my backpack fully loaded with all my gear and supplies for the next seven days, started the walk.

The first three kilometers were on the sandy four-wheel-drive track. With its loose sand, the road didn't give the walk an easy start. Rounding a bend, I encountered the first animal on the island - a snake. It was just lazily sunning itself on the sandy road warmed by sunlight filtered through the trees, its presence betrayed by its menacing green-and-brown pattern that would have otherwise given it perfect camouflage in the woods. Giving it a wide berth, I gingerly walked past it on the other side of the road, knowing that it was probably poisonous.

Passing a huge sign welcoming visitors to Fraser Island, I followed a sign to the walking trail formed by the fire control line. Leaving the dusty four-wheel-drive road behind, I now entered the forested area of the island. Not a soul was in front or behind me. The only sounds were the trees rustling, birds chirping, and the rhythmic crunch of my boots stepping on dry leaves and branches.

A leisurely two-and-half hours later, I arrived at the familiar fenced Lake McKenzie hikers' camp. After the routine of setting up camp, the rest of the afternoon was devoted to sitting on the white beach of Lake McKenzie, running into the cold water for a quick swim, reading, and watching the advancing shadow cast by the trees as the sun slowly sank in the west.

Night came quickly. After a dinner of cous cous with tuna and peas, tea with dried apricot and figs, I started to do some reading when the sky opened up and a shower swept through the campground. Five minutes later, the rain passed and the half moon was again faintly illuminating the landscape.

I went to the edge of the lake and tried to photograph the lake under the moon. Then I realized what I was trying to do was beyond the technical capability of my camera. I ended up waving my flashlight at the camera with a long exposure; this is the result:

Day 2: Lake McKenzie to Lake Wabby, 11.9 km

I woke up as the sky was brightening up and birds started chirping. Talking to a few other people in the campground, I found out that there were actually three other groups of hikers heading in the same direction. For the next three nights, we would share the same campgrounds.

After breakfast, I wandered around the empty beach of Lake McKenzie. Devoid of the daytrippers that would arrive later on 4WDs and buses, the lake was a serene place. After lingering for an hour, I reluctantly packed up and headed to the trail as the first carload of people arrived.
The trail again weaved through forests of paperbarks and dense undergrowth, the air changed from damp and cool in places with tall trees to dry and warm where sunlight was able to penetrate the thin canopy.
Arriving at the Lake Wabby campground in the early afternoon, I set up my tent and had a quick lunch. Actually, lunch wasn't a meal per se, but a series of snacks as I hiked and rested.
The campground was not next to Lake Wabby, but actually over a kilometer away. I walked down a series of switchbacks to the bottom of the hill then up the Hammerstone sandblow to arrive at Lake Wabby - a small but deep lake being slowly swallowed up by the giant dunes that had created it in the first place. Another quick dip in the chilly water, another lazy afternoon lounging on the slopes of the sand dunes, plus a little bit of reading - I was happy as a clam.
In the middle of the night, I woke to the sound of rain hitting the tent. Reassured that I was dry and warm, I went back to sleep to the soothing white noise that surrounded me.


Day 3: Lake Wabby to Valley of the Giants, 16.1 km

I woke to another bright morning with blue skies and singing birds and had another leisurely morning with breakfast of warm muesli and tea. Then I headed north towards Valley of the Giants.
The trail north of Lake Wabby was supposedly "remote," according to warnings on the map. However, I found that it wasn't anymore so than the previous sections. Perhaps by "remote," they meant that that section of the trail was not as easily accessible by vehicles as were the earlier sections. I kept to my easy pace of covering about four kilometers in an hour. The trees around me started to become taller and taller as I entered the original old-growth forest. The well-marked trail never failed to keep me on course. As I ascended a steep hill via switchbacks, I came upon a sign pointing to Badjala Sandblow six hundred meters down a side trail. Leaning my pack to a tree, I wandered off and climbed up the steep dune to get to the sandblow.
As soon as I summitted the dune, I was hit by the stiff wind from the Pacific Ocean just a few kilometers away to the east. The wind whipped up the sand ever so slightly, carving small ridges on the faces of the dunes and depositing the find grains to the leeward side and, in the process, slowly advancing the dunes to swallow up the vegetation that stood in their way. A few shrubs and grass managed to grow on the dunes and clung on to life defiantly, as if engaging in a constant struggle against the combined forces of the Pacific winds and the mighty sand dunes and attempting to help their brethrens down the slopes.

An hour passed before I was back on the trail to the campground. Arriving at the Valley of the Giants campground almost 5 1/2 hours after setting off from Lake Wabby, I attended to the chores of setting up camp. A 4WD pulled up and down came nine sleeping bags and tents. Someone got out and proceeded to set up tents in four of the seven campsites. As a result, the campground became overbooked and the four groups of us had to share three campsites. I later found out that they were a group of hikers on a walking tour with full car support. The campground was supposed to be reserved for hikers only. Yes, they were a party of hikers, but with car support, is that cheating?

Day 4: Valley of the Giants to Lake Garawongera, 13.4 km

A couple of kilometers from Valley of the Giants, the trail emerged from the forest and led into a much drier landscape of short ferns and palms. Continuing on, the trees became taller again and soon the trail was again flanked and shaded by dense vegetation.

Without a lake to take a dip in the day before, I was starting to get sticky and odorous. Arriving at Lake Garawongera only four hours later, I quickly set up camp, ate another snack, then headed to the lake with my book.
Lake Garawongera, while not as "clean" as Lake McKenzie, look mighty inviting. I jumped into the water for a quick swim. Because of the shallow depth and the sun, the water was very pleasant. I swam around the reeds not far from shore and felt the two days' worth of grime coming off my body.

I sat on the beach, reading and relishing the feeling of being miles away from "civilization," until the sun dipped behind the trees to the west and the nighttime chill set in.

bright red plant that grows on the lake beaches, each no more than an inch in diameter

Day 5: Lake Garawongera to One Tree Rocks Camping Zone, 23.1 km

Today was going to be a long day, with over twenty kilometers on the agenda. I packed, said goodbye to the other hiking parties, who were either staying an extra day at Lake Garawongera or heading off to other places, and got on the trail.

It was an easy one-and-half-hour walk to the resort village of Happy Valley on the eastern shore of the island. Hearing the sounds of the rolling waves, my steps quickened. My plan was to camp at one of the camping zones along the ocean beach tonight where, unlike all the previous campgrounds, water was not available. I filled up both my water bottled and the hydration bladder - adding four-and-half kilos to my pack.

With just another short walk, I came upon the beach stretching to my left and right for as far as the eye could see. Seventy-Five-Mile Beach, which is in fact only fifty-eight miles long but who am I to argue about the name, is a wide stretch of sand covering most of the eastern shore of the island. I turned right and started walking south. Destination: seventeen kilometers down to One Tree Rocks Camping Zone along the beach.

After a kilometer or so, I took off my hiking boots and started to walk barefoot along the water's edge. The compacted sand gave slightly as I walked and the waves lapped at my feet as they lost their energy and rolled back to sea. Tour buses, 4WDs, and trucks zoomed past me as they raced down the beach to their next destination, some peole waved as they passed. One 4WD full of backpackers passed me, stopped, hooked a U turn and drove back towards me. "Wanna jump in?" the girl in the passenger seat yelled out to me. "No thanks, I'm just walking." I said with a smile. She gave me a thumbs up and drove off.

Yidney Rocks just south of Happy Valley

After a stop at Rainbow Gorge to check out the Kirrar Sandblow, I got back on the beach and inched along the line between rolling waves and golden sand. The immensity of the landscape made one lose the sense of scale. What looked like a rock "just over there" actually took over an hour to reach. As the hours wore on, the four-and-half liters of water in my backpack grew heavier and heavier. The beach and low dunes to my right, the ocean to my left, and the coastline in front and behind me looked just the same as when I'd first started at Happy Valley. As the sun started to dip behind the trees and my back and shoulders begged for relieve, my eyes searched the low dunes for the green signs demarcating the next camping zone.

Kirrar Sandblow

I crossed the beach toward a low dune to take a break. Then I heard the rumbling of what sounded like plane engines. Turning around, I saw a small prop-engined plane flying low and directly over me. I was near the stretch of beach that doubled as a landing strip for the next beach resort Eurong. I must be near One Tree Rocks Camping Zone! Sure enough, five minutes down the beach, a sign noted "No camping next 2.6 km," which meant the camping zone was only 2.6 kilometers away. I pressed on and within half an hour came to the sign "One Tree Rocks Camping Zone, next 2.3 km." I dragged myself to the first clearing behind the set of low dunes that served as a buffer to protect campers from direct ocean winds. Seventeen kilometers - how's that for long walks on the beach?


As tired as I was, I had to use the remaining half hour of daylight to set up camp. After dinner, I sat in the open tent to do some reading. With my head down, I heard some rustling sound approaching the tent. Looking up, I saw a small dingo sniffing around - it must have smelled the pouch of tuna I'd opened. I shined my flashlight into its eyes and banged my spoon on the empty mug. It scrambled off. Making sure I had everything inside the tent, I turned in for the night, hoping the dingo was too young to be aggressive.


Throughout the night, I heard footsteps outside the tent.


Day 6: One Tree Rocks Camping Zone to Central Station, 14.6 km

Six o'clock, I woke up, unzipped the tent flap, and saw the rouged sky beyond the beach. Feeling rested and happy that the dingo hadn't chew its way into the tent, I walked out to the beach to watch the sunrise.

Early morning convoy of 4WDs driving down the beach

Early morning rays hitting the ridge of low dunes just this side of the beach

With only half a liter of water in my backpack, I set off down the beach - drinking water taps were just three kilometers away in the beach resort Eurong. At Eurong, I turned west away from the beach, put my boots back on, and got on the trail towards today's destination of Central Station.

Dingo tracks on the beach not far from where I camped

Landing strip

The ubiquitous eucalyptus trees

Central Station is a major stop for people touring Fraser Island. Walking to the campground, I passed groups of tourists coming the other way. A couple of them wrinkled their noses as I brushed past. I must have smelled pretty ripe! Arriving at the campground, I had a good lunch and enjoyed the luxuries on offer such as running water and a hot shower.

I whiled away the rest of the afternoon by sitting among the giant pine trees with my book.


Day 7: Central Station to Wanggoolba Creek, 14.6 km

The last six days had gone by so fast, I felt like I'd just started the walk. Alas, it was time to return to civilization; plus, I was running out of food.

Wanggoolba Creek at its headwaters near Central Station

A grove of paperbark

With only the safety ration in my pack and enough water for the walk, I breezed down the trail. Just three kilometers out of Central Station, I stopped by Basin Lake - the almost circular jewel of a lake - for a break. Then retracing my steps seven days ago, I returned to the mouth of Wanggoolba Creek where the barge sat, waiting for the next trip across the narrow strait.

Basin Lake

Three Down, Seven to Go

Walking out of the last of three exams for mental health rotation today, I expected to feel the weight lifting off my chest like it did before. But no, that feeling never came; that sense of relief, of having accomplished something worth celebrating, never arrived. I had been looking forward to the end of exams for quite a few days, though. So maybe all the anticipation has made the moment rather anticlimactic.

Regardless, it's the beginning of another one-week break! Big plans are in store: a 100km trek through Fraser Island. Two months ago I went with my mate James and walked the southern portion of the Fraser Island Great Walk. The walk I have planned this time is a loop that takes in the northern portion of The Walk and a 25km stretch of Seventy-Five-Mile Beach. James is busy next week and no one else seems interested in doing the walk, maybe it's because of the distance covered, or maybe it's the -2 degrees centigrade overnight low on the forecast. Where are my hardy, outdoorsy friends when I need them? Looks like I will just have to do it solo, with a good thick book as my trusty companion.

I'll be off to Fraser on Sunday. Will write all about it when I get back.

What Exams?!

It's the weekend before another round of exams. And for the life of me, I just can't get motivated to study. So I do what I do best under these circumstances - procrastinate, something I have skillfully mastered after spending most of my life as a student. Cleaning, doing laundry, fixing up my bike, day-dreaming, reading about photography, going to the marina for coffee, making dinner, and blogging about procrastination - it's been a success! I have avoided looking at anything that has anything to do with psychiatry for a whole day.

Perhaps this is the manifestation of my ambivalence towards psychiatry. I'm ready for the rotation to end, not that I have any ill feelings about the specialty. To the contrary, I think it's a very important field without which medicine wouldn't be complete. From what I've seen, it's the only field in conventional Western medicine that treats its patients with a holistic approach, the whole biopsychosocial model med schools are so desperate to teach to the next generation of doctors. During this rotation, I have seen plenty of patients whose debilitating mental illnesses have been treated and managed well enough to allow them to initiate steps toward getting their lives back on track. So I don't think psychiatry is not "real" medicine, it's just that I don't think I can hack it.

Many people say, and I also believe, it takes someone with a certain personality to do psychiatry. By "certain personality," I don't mean crazy. Talking is of paramount importance in the field. Because there is no lab tests for most psychiatric illnesses, results from history-taking, or interviews, are the only information available to diagnose them. Conversational and interpersonal skills are essential for a successful interview. The ability to make people relaxed, to accurately read people's body language and their tone of voice, to ask questions in a way to solicit useful answers are all qualities in this "certain personality." A psychiatrist would have to be, in a way, manipulative to get the information he needs for an accurate diagnosis. I'm the first to admit that I'm not a great conversationalist. Sure, that's what the years of post-grad training program is for. But why train a monkey to walk on two legs when he's really good at swinging from branch to branch?

Another reason for psychiatry to be not my cup of tea is that I find its inadequacies frustrating. The mental health inpatient unit works in a somewhat revolving-door fashion. Patients present acutely, they are treated until they are well enough, then they are discharged, only to present again soon after with another acute episode that requires admission. Part of it is that psychiatric illnesses are chronic conditions, and part of it is a reflection of our social problems. Most of the patients reflect a cross section of society that is in many ways confounding their treatment: homelessness, neglect, abuse, self-harm, social isolation... Often times, psychiatry warps into social work, balancing the safety of the patient and the community against the need for an empty bed that will be filled by the next admission waiting in ED, knowing the patient will probably re-present acutely before his next outpatient appointment. In this regard I am impatient, I want instant gratification, I want tangible results now. I prefer surgery where the patient presents with a problem, a diagnosis is made, followed by surgery, the patient makes a recovery and is discharged; case closed. The idea of presentations that end with definite results, whether good or bad, appeals to me. That's something psychiatry tends to lack.

This rotation not only gave me new-found respect for psychiatrists, but also helped me put psychiatry lower on the list of possible future careers. Like they all say, it's not you, psychiatry, it's me.

And with that, I have killed the remainder of today. Good job.

~~~~~~~~~~

While ruminating on the topic of psychiatry, I cooked up tonight's dinner: vegetarian fettuccini topped with grilled haloumi and avocado.