Geriatrics (Part 3/3, RETROSPECTIVE POST)

I was trying to gain as much Experience as possible prior to my Semester 12 Rotations and (deferred) Internship with regards to Paperwork and Physical Exams (Visual Acuity, UL & LL Exam, also Ankle-Brachial Pressure Index), and was very proactive in asking the Interns and Residents for Things I could assist in. Part of me wonders if my Motivation to do all this was also to please and be liked by Colleagues? I didn’t want to be known as a People-Pleaser, but having been through my horrible Childhood, wanting to gain Approval was quite tempting. Is this low Self-Esteem or Insecurity speaking? The more things I did for them, the happier they seemingly became, and I became even more motivated to help them. It was like a Positive Feedback Loop. It was almost as if I was doing the Extra Work not because I wanted to bend over my back to help the Patient, but because I wanted to help the Doctors, to do something important and be valued by them.

It was during this Elective in which I frequently came to the Hospital on the Weekends to work on the Draft Discharge Summaries. The Nurse Unit Manager was so impressed by my Diligence that she even bought me a little Cake the following Monday, which I wasn’t able to eat coz I was at a Medical Appointment IIRC. On the final Day of the Elective though, the Registrar actually told me that whilst she appreciated my Efforts to be helpful, I needed to look after myself as well, and that it was important to rest on the Weekends when off-duty for the purposes of sustaining yourself.

Doctors are Human after all, they’re not G-ds or Machines, and they also need to have their Physical Needs satisfied, so they’re more likely to perform at an appropriate Level when at Work. Interestingly she also said that there wasn’t much Point in doing all these Discharge Summaries for Internship Preparation coz she believed I was going to forget all of that Knowledge, and would be better off learning it soon before/after Internship started. She believed that I was taking a long time to complete the Discharge Summaries coz I wasn’t the main Doctor looking after them, and thus wouldn’t be able to recall the Patient’s “Story” quickly off the top of my Head. That may be true, but I was also concerned that it was also due to my intuitively reduced Ability to see the “Big Picture” and instead process all the Medical Issues and Management as little Details, thus bogging me down. I’ve identified a possible weak point and will explore this later on.

She also said it was a common Phenomenon for new Interns to go through a Phase where they get paranoid about the Medication they’re prescribing, that it might accidentally harm the Patient, eg “Panadol causing Acute Liver Failure” even though people buy it Over-the-Counter at Pharmacies and use it all the time. It was comforting in that I wasn’t alone. My Experiences during this Elective really hit me, that if uncontrolled, I could easily go overboard with Work, which is facilitated by the Aspie Hyperfocus Tendencies, and let Medicine take over my Life. I will need to actively recognize and set Boundaries in order to maintain a Work-Life Balance…

I was extremely satisfied from my Geriatrics Elective, not only from the Patient Aspect (as with Paediatrics), but from the Staff who I interacted with. My Impression is that how much you enjoy a Rotation can also be influenced by the Staff (Doctors and Nurses) you meet from that Specialty. I appreciated that the Staff made the Effort to help the Patients each Day even though the Recovery Process frequently seemed rather slow. In Fact, a Handful of Patients I met at the start of the Elective were STILL at the Hospital when I was nearing the End!!!

From an Academic Perspective, I’d strongly recommend a Geriatrics Elective for Medical Students who aren’t sure what Specialty to do an Elective in, given the high prevalence of elderly Patients in Hospitals, or want to gain some Generalist Experience in “General / Internal Medicine” but with a “Twist”. It’s very eye-opening and heart-breaking at Times, but one could learn a LOT, both Medically and Socio-Emotionally.

Geriatrics (Part 2/3, RETROSPECTIVE POST)

There were weekly Radiology Meetings where Doctors presented Geriatric Cases prior to having their (Patient) Radiology Results shown on the Projector Screen. Some of the CT and MRI Scans were really eye-opening with regards to the amount of Brain Atrophy that has occurred. Even though I didn’t get to see the Patient, I felt really upset inside, a “Gut” Feeling of Sadness for how much Neurodegeneration has occurred and how miserable he must be, to lose so much of the Knowledge and Skills that he painstakingly acquire throughout his Life. What is his Quality of Life like? Is it really worth it for him to keep living? Would his children (if any) consider him to be a Burden? What is the Trigger for Neurodegeneration, and why is there such Variation amongst elderly Patients of the same Age, even in those that didn’t have Strokes or other Cardiovascular Risk Factors?

Interestingly, they also discussing an “Official” Statement from the FDA or some American Health Organization that Statins don’t accelerate Dementia, even though there have been numerous Anecdotes about this, and the Fact that a lot of Brain Matter consists and requires Cholesterol to function. I was worried that there may be a Cover-up by the Drug Companies, especially as Statins are a HUGE source of Income to them, and wouldn’t want to be complicit in prescribing it if that was the Case, but I don’t have the Evidence to prove either way. Maybe we’ll just have to wait and see in the coming Decade…

I managed to witness my first Code Grey during this Elective, which involved a Patient with Dementia wanting to go Home to see her Children and Pet Dog, trying to escape and screaming and being violent when being restrained by Nurses as she was attempting to abscond in her Walking Frame. When Security came, she stopped resisting and started crying. I felt so sorry for her, that she was so frail with reduced Mental Faculties. She had Children to look forward to upon going Home, but I wonder what about those that are Single like me? What will happen to me if I (Goodness Forbid) get some form of Dementia in the future? How would I cope and what resources will be available by then? The Resident actually walked up to her and acted Calm, wanting to ask her what her concerns were and trying to reassure her that her Children and Pet Dog were fine, and that it was important for her to rest and comply with Treatment to facilitate Recovery in Order to be discharged. I was really impressed by this Resident’s Actions in light of this Commotion as it helped calm her down, so she didn’t need to take so much sedating Medication.

 With regards to the Patient Case Mix, it was quite impressive. Although there were a lot of Bread-and-Butter Issues like Diabetes, Pneumonia and Fractures, I also saw quite a few Rare Conditions like POEM Syndrome and Multiple Myeloma. The Neurogeriatrics Ward was a good Area to practice Neurological Exams to help isolate the different Brain Areas affected by Strokes, which was also tragic in my Mind coz I saw several Dysphasic and Dysarthric Patients again.

MMSEs (Mini-Mental State Exam, a screen for Cognitive Impairment) was the most common Assessment I did on the Geriatric Patients. I was similarly impressed by the Variety of Responses and Scores. Although on the Surface there was a fixed List of Questions and Tasks to attend to, there was actually more Flexibility required than I thought, when phrasing the Questions and providing Accommodations without overtly distorting the Assessment Process. Hence the preconceived Monotony was non-existent.

For Patients who were visually impaired, I had to write “CLOSE YOUR EYES” really big on a Sheet of Paper. A Patient with severe Hearing Impairment required me to speak VERY loudly and slowly into her Ears for a few of the Memory Tasks (which weren’t allowed to be written). I came up with the Strategy that if she couldn’t hear what I was saying, she could squeeze my Hand in which she did. She was really happy that she could understand what I was saying and my Efforts to Accommodate her, because a lot of Nursing and Medical Staff in the past thought she was Demented or Delirious (!!!) when in Fact she just couldn’t hear what they were saying, and thus comprehend their Requests. She said that I helped her “Interact with Young People, and feel part of the Community”. It felt really good that I was able to correct a common Misconception about her, so she’d be less likely to be treated along the wrong “Medical Route”, especially for misdiagnosed Delirium.

I felt like crying when I did an MMSE on a Dysphasic Patient who had a lot of difficulty answering my Questions in the MMSE, like he was being locked from expressing himself.  I felt really guilty for doing the Assessment on him, like I was forcing him to be reminded of his Inadequacies, although from an objective Point of View, I shouldn’t feel guilty at all, as everybody needs to be assessed at some Point so they can have a Management Plan more specific to their Circumstances.

On the other hand, there was a Female Patient who recently had a Stroke and was Dysphasic, but was very Cooperative and “level-headed” when trying to do the MMSE, which somewhat inspired me, that she was willing to try things out even if she had a recent physical Insult, and may not have been good at it.

Geriatrics (Part 1/3, RETROSPECTIVE POST)

I did my 8 Weeks’ Geriatrics Elective in the massive 11 Weeks’ Break between Semesters 11 and 12. Interestingly, the Senior Geriatrician who approved my Elective WAS 1 of the 2 Examiners in my Long Case Exam (!!!), but he actually delegated my Supervision to another Geriatrician, so I didn’t see him much apart from the weekly Radiology Meetings. The Elective was held at the Geriatrics Department away from the main Hospital Campus, and although I was given Opportunities to follow the Geriatricians onto the (Main) General Medicine Wards to see Referrals, I didn’t pursue that coz I felt I was much more attracted to staying at the Former Location. Likewise, there were Opportunities to attend Outpatient Clinics for “Memory”, “Falls”, “Incontinence” and “Wounds”, but I only attended a few Sessions of each before getting drawn away to the “Main Stage”.

Geriatrics Outpatient Clinics were well Organized. Incontinence Clinic was probably the least interesting to me coz the Majority were Female Patients (despite the fact that Men can have enlarged Prostates --> Overflow Incontinence) and they had Stress or Urge Incontinence. I was able to witness and take a few Histories, but wasn’t allowed to examine their Pelvic Region or operate the Machine which detected their PVR (Post-Void Residual, ie urine remaining in Bladder after Urination), so I felt rather left out of the Diagnostics Process.

Falls Clinic was very good coz I got to see how the Geriatrician use a systematic Approach to exclude numerous causes of Falls (Medical and Environmental Causes), along with observing how he did Physical Exams, not just Upper and Lower Limb, but also Falls-Specific ones such as “Timed Up-And-Go”, ie more Action and engaging.

Wounds Clinic was fascinating visually, plus the Fact that there was a Multidisciplinary Team working at the time (Doctors, Nurses, Podiatrists, Pharmacists), it felt like a “Medical Party” : P . There was a very passionate Wounds Specialist whom I initially thought was a Dermatologist (Skin Doctor), but was actually a Pharmacist. He made the Effort to explain the Pathophysiology of Venous and Arterial Ulcers, what he was doing in each Step with his Creams / Ointments / Special Bandages and how it would help the Skin, whilst I furiously wrote Notes. I walked into another Room and was awed by the Podiatrist as he skillfully shaved off Slivers of dead Skin from Diabetic Patients’ Calluses on their Foot. I think he might’ve thought I was overly eager coz I was peeping close to observe the Slivers curl off. That Podiatrist could perhaps be a Sculptor as an alternative Career : ) . Whilst the Callus was being shaved, I was also took a partial Medical History of the Patient. It was disturbing yet intriguing how some of the massive Venous Ulcers were slow to heal in the Elderly Patients. The Venous Ulcers were typically superficial up to ~10 cm in Diameter, but all that “Raw” red, shiny dermis looked REEEEAAALLLLY PAINFUL even though our Textbook said it’s not supposed to hurt much. I was shocked at the Fragility of their Skin, when I saw a Nurse accidentally tore a bit of the Patient’s skin with a Scissor while cutting the Wound Bandages, so delicate like Tissue Paper. Whilst the Patients were being treated, I was able to take casual Medical Histories from them, focusing on Risk Factors for Ulcers and Falls (which lead to Skin tearing off). The Visual Details and the Patients’ Information was very stimulating.

In the Memory Clinic, I played a more passive role in observing the Geriatricians do Memory and Cognitive Assessments, although I was amused by the Variety of responses given. I “LOL’ed” in my Mind when an elderly male Patient was asked to point at the Picture that was Nautical, and responded “Hmmm this is difficult. I can see the Boat over here, but a Crocodile is technically Nautical as well…”. There was 1 male Patient aged ~70, who I suspect is an undiagnosed Aspie who has an ASD Daughter, presenting for his Radiology Results, that most likely ruled out Neurodegeneration. I was curious to see if he exhibited signs of Dementia, but the Geriatrician said that Clinically and Radiology-wise he looked fine, although there were concerns by his (NT) Wife that he has some sort of Cognitive Impairment due to his supposedly poor Relationship / Interpersonal skills during their entire Marriage. He had that round Macrocephalic (large head) Appearance and Flat Affect common in Aspies, and the same Special Interest his whole Life. I felt like bursting out and saying that he may have AS, but knew that it was technically unprofessional to do so, so left him alone. I know it was just 1 person, but it was a relief to know that he wasn’t diagnosed with Parkinson’s Disease or Fronto-Temporal Lobe Dementia (yet?) because my personal research suggests that ASD / ADHD people are apparently at higher risk of these 2 Dementias, very sadly : ( It was also very emotional when the Geriatrician had to inform another Patient their Diagnosis of Alzheimer’s Disease, its Implications and Initial Management. She tried to put a lighter spin on the Diagnosis, in that he just had to do Things differently, like using Public Transport instead of Driving, but his Family Members were shedding Tears and hugging him, likely knowing that these were Attempts to Soft-Pedal his Diagnosis, which is typically terminal within ~7 years IIRC…

RAPP (RETROSPECTIVE POST)

Semester 11 was the SHR (Specialty Health) Rotations. This consisted of RAPP, Psychiatry, Rural and Emergency Medicine. According to previous MBBS cohorts, the SHR Rotations is considered “slack” compared to the Semester containing Women’s & Children’s Health due to the much lower Attendance Requirements. Anecdotally and from my Observations, a lot of Students didn’t turn up to the Wards during RAPP and Psych. Sometimes it felt like I was the only Student there despite putting a semi-decent Effort to turn up.

Despite that, I didn’t clerk many Patients in this Semester which was a real shame as I was starting to feel emotionally burnt out (which was one factor towards my decision to defer Internship for 12 Months), and busy going through Past Recall Papers and memorizing the content.

RAPP (6 Weeks)

The RAPP Rotation comprised of Rehabilitation Medicine (2 weeks), Aged Care (Geriatrics - 2 weeks), Palliative Medicine (1 week) and Psychiatry of Old Age (1 week). It was said to be the “cruisiest” Rotation, and rightly so. Most people in this Rotation only turned up for the mandatory Tutes and Tours. Given that we started Final Year ridiculously early (January 7^th, 2013) to minimize the Clash with the MDs on the Wards, I suspect most of the Students treated it as a “gentle” introduction into the Year, as a “Semi-Holiday”.

We had tours of the Rehab Facilities for patients who’ve had Strokes and TBI (Traumatic Brain Injuries), and got to see a workshop where Prostheses are designed for Amputees. I got to check the TBI Ward where a lot of the patients had Memory Loss and seemed disoriented. I felt really sorry for them coz a handful were around my Age, and wouldn’t be able to function independently anymore.

I attended a few Ward Rounds in Aged Care, but was otherwise slack due to the distance to the Hospital I was rostered, plus the fact that I was planning to do an 8 Weeks’ Geriatrics Elective during my massive Break between Semesters 11 and 12. I did learn 2 commonly used Italian terms though “Dolore” (Pain) and “Respiro Profundomente” (Breathe Deeply). When I was at the Hospital, I did help the Resident by doing a few Mini-Mental State Exams on real Patients (first time ever).

Palliative Medicine was conceptually interesting. I was particularly interested in seeing how the Registrar would interact with Palliative Patients, but he actually communicated to them in a similar manner (as I perceived) as one would do with Non-Palliative Patients, but with a greater emphasis on somatic complaints (Pain, Thirst, Hunger). Strangely, I didn’t see any official Deaths that week, so didn’t have the opportunity to see the Reg certify Death. What bothered me however, was the notion that some relatives of Palliative Patients would insist that everything be done to prolong their life even though it was clear that there’d be no improvement in the Quality of Life, but merely a prolongation of Suffering. 

IIRC a Palliative Care Consultant actually told us in a Tute, that a family of a Palliative Patient was willing to complain about her on “Today Tonight” (an Australian Current Affairs Program, notorious for being sensationalistic) coz he/she wasn’t implementing every single Measure demanded to sustain the Patient. It felt to me some (or a lot) of the time in Practice, Doctors would be under Pressure to implement Measures not to comfort the Patient (giving IM Fluids instead of IV to create a visible “bump” of water), but to please the Relatives emotionally, who seemingly have a poorer Understanding of the Medical Issues and its Natural History. 

She said that the only reason why Euthanasia is in high Demand in Australia (currently illegal) is coz the current state of Palliative Care is inadequate, but I digress. My Belief was that terminal Patients who are still cognitively intact should be allowed to end their Life if they want to, after all they are consenting Adults and it’s their Choice. I didn’t think that they should be denied that Opportunity and be forced to go through physical or cognitive Decline, even if painlessly. What kind of Quality of Life is that? I didn’t want to argue with her so I kept quiet though. She did say that she’s had numerous requests for Euthanasia though, in which she had to legally decline, but offer Alternatives such as Advanced Care Directives (eg refusal to treat once Patient has deteriorated to X Degree).

My suspicion is that Euthanasia still isn’t legalized due to Political Reasons (along with Pressure from Conservative Christian Lobbyists), although I predict with the Ageing Baby Boomers, and the current Fat-Cat Politicians ageing (who mainly care about winning votes to maintain their plush Seats), who may also need Euthanasia for themselves or their parents, there’ll be a more progressive Attitude in about 10-20 years’ time.

Psychiatry of Old Age was a lazy Week for me. I just attended the Tutes regarding Psychosis and Schizophrenia in Old Age, along with Medication Regimens.