East Timor Medical Elective - Week 4 (Part 6 / 6)

“HORACIO” (PARKINSON'S DISEASE)

After Dr. Dan did his gratitude speech thanking the Patients etc (followed by loud applause), it was meal-time. After eating a bit, I was told that a Patient arrived (very late) to see Dr. Dan. I was curious to see the Patient and find out why he came so late.

Sitting on the bench, where the ceremony was held less than an hour ago, was a frail old man called “Horacio”, hunched forward, with a resting tremor in both of his hands. His son accompanied him.

Spot Diagnosis: Parkinson's Disease.

I asked Horacio's son what has happened, and he said that his Father has been walking weak and shaking like this for nearly a year now. “Why are his arms and legs weak?” he asked.

I told him that I suspected it was a Neurological Condition called Parkinson's Disease, that affects your movement, but he was confused, saying “The sickness is with his limbs and not his brain.” I explained that some Brain Conditions can impair movement, and asked if I could examine Horacio.

Horacio's arms were having a tremor. I shook his hand and moved his arms about. They were stiff with Cogwheel Rigidity, which further supported my thoughts. He also had the same Flat Affect as me, and I asked his son whether he smiles these days, in which he said no.

Dr. Dan came to meet him and also gave the same spot diagnosis, and arranged for him to have a script for Levodopa / Carbidopa. Unfortunately the Pharmacy ran out of this, and I became desperate. “What about Pramipexole or Ropinirole?” I asked the Pharmacist. Nope, they didn't have those either.

I felt sorry for Horacio, and wished that if I were in his position in the future, that somebody would try to get the medication for me. Being at a higher hypothetical risk of Parkinson's Disease (or Fronto-Temporal Lobe Dementia) later on in life, this patient triggered a “soft part” in my heart. I wanted him to start the medication and experience its benefits.

I wanted to demonstrate the degree of concern that I'd wish for someone to have towards me if I had it. I didn't want to perpetuate or feel abandoned. So I offered Dr. Dan to go to a Pharmacy and buy the medication using my own money if it was available. I told the Patient and his son to wait for 30 minutes whilst I ran out with my bag huffing and puffing.

A few hundred metres down the road from the Clinic, a man in a motorcycle came up to me, and asked if I wanted a lift. I asked him who he was, in which he claimed he was Horacio's son's friend “Vincent”, who was observing me the entire time.

Having only ridden a motorcycle once before as a child, I was quite reticent to accept his offer, but due to my perceived “urgency” of the issue at the time (being in “Adrenaline Mode”), agreed to do so. The helmet barely fit my head, and I couldn't fasten the helmet belt under my chin, but I thought “Whatever” and let it be.

I made sure my backpack was fully zipped up, but my other handbag couldn't be closed, so I quickly tucked the items to the bottom lest it fall out during the ride. As I sat on the motorcycle, Vincent told me to grab onto his shoulders tightly.

I grabbed onto him for “dear life”, and as the motorcycle started going ahead, I gripped him even harder. The breeze/wind was sweeping past my arms, and my heart was beating fast. I was freaking out inside due to the state of Dili's traffic and the fact that I wasn't wearing any other protective gear, but strangely was able to look flat on the outside, and to some extent even exhilarated. He could tell that I had very little experience riding motorcycles, in which I soon admitted to him. I was simultaneously horrified yet excited at this “motorcycle adventure”.

He dropped me off at each of the 4 nearby pharmacies. As I entered each pharmacy, I quickly rattled out my spiel in Tetum to the staff about needing Levodopa/Carbidopa for Horacio, hoping that I'd “hit the jackpot”. I started feeling doubtful inside when the pharmacy assistants had puzzled looks on their faces, claiming to have never heard of these medications before, or even Parkinson's Disease. I initially thought they were stupid, but gave them the benefit of the doubt and mentioned that it was a neurological condition that makes the patient have difficulty walking and moving their arms etc, and one of them thought I was thinking of Stroke. When I mentioned “neurological condition”, or more specificially “brain disease” (moras kakutak), one of them thought I was referring to a Psychiatric Condition instead. Another assistant offered to sell me Methyldopa because it had the same suffix (-dopa), but I rejected that, explaining that it was a completely different drug for a completely different condition (Hypertension).

Each rejection from a pharmacy made me more disappointed, and as it came close to 7 PM, I knew it was time to give up. The Adrenaline and hopeful suspense from the motorcycle rides between the pharmacies ended, and I felt very disillusioned, having turned out empty handed from these attempts. I wanted Horacio to have the medication so badly, so I would hate to tell him in his face that the pharmacies didn't offer it.

As I returned to the Clinic, it surprised me that Horacio and his son weren't there anymore, although to be honest I was a bit relieved coz I was spared having to break the bad news to them. Vincent said that he'd inform them instead that I couldn't find the medication. I thanked him very much for the rides.

I told Dr. Dan about my failure, and started walking home in the dark feeling quite upset and frustrated about this fruitless venture. I started pondering why the Pharmacy staff were seemingly ignorant, but it became clearer to me. Pharmacies, like with nearly all other private healthcare facilities, function as businesses. They will sell the medications that are profitable and are in higher demand. Because East Timor's population is very young with the mean life expectancy at ~65 years, the prevalence of Neurodegenerative Conditions such as Parkinson's and Alzheimer's Disease etc would be much lower than in Australia. Low demand for a low-prevalence condition would mean that the Pharmacies are much less likely to stock it. Out of principle, this is fair from a financial point of view (“Capitalism”, “Supply and Demand”), but I felt really sorry for Horacio and all other East Timorese patients with low-prevalence conditions who wouldn't be catered for when the time called for it. The Public Healthcare System may provide medications for these people, but unfortunately are also unreliable and have frequent shortages due to incredibly meagre budgets.

After this realization, I stopped feeling guilty because I knew I tried my best at the time and wouldn't be able to rectify the situation any other way in that short time period.

My sadness toned down as I internally gloated on this intense experience. In Australia, had a patient been diagnosed with Parkinson's Disease, they'd simply receive a script and obtain it from any bread-and-butter pharmacy, try the medication and see a GP/Specialist for follow-up, end-of-story.

But the healthcare situation in East Timor allowed me to take a much more “colourful” route.

My desire to obtain the medication temporarily overrided my fear of riding motorcycles, especially in a city with very dangerous traffic like Dili. I was told to avoid riding Microlets because they were dangerous, yet I managed to ride a motorcycle here, and from a stranger!!!

I couldn't believe that the encounter with Horacio, the motorcycle rides to the pharmacies, and the return trip, all occurred in ~ 30 minutes. I checked my handbag and nothing fell out thankfully.

Most importantly, I felt so grateful and lucky that I was physically unscathed.

Omg what an adventurous end to the week...

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.

Paediatrics (Part 1/5, RETROSPECTIVE POST)

Following O&G was CAH (Child and Adolescent Health, ie Paediatrics). Of the 9 weeks, I spent about 6 weeks in total at the Paediatrics Department of my Clinical Hospital, and the 3 other weeks at RCH (Royal Children's Hospital) for lectures and a mini-attachment. Paediatrics was the first Clinical Rotation that I REALLY enjoyed and was enthusiastic about, of which there were multiple factors. I temporarily felt “ALIVE” and “SWITCHED ON” which was a huge contrast to my very low state the previous Semester. Another thing that made this Rotation memorable was that all the supervising Paediatricians knew about my AS and were amused by it given its relevance to Paediatrics. None of them were patronizing or treated me like a child. I didn't experience any repercussions in disclosure and knew in advance that it would be taken well.

The Paediatrics Department of my Clinical Hospital was very small compared to RCH, there were about 18 beds, and about 1/3 of them were for Eating Disorders. Being male and not a Paediatrician involved in their care, I was advised to avoid speaking to patients with Eating Disorders (all teenage girls). Most of the rare and complex cases would've been transferred to RCH, so the remaining Case-Mix at the Peripheral Hospitals (including this one) were very “Bread-and-Butter” - Pneumonia, Bronchiolitis, Gastroenteritis, Dehydration, with a bit of Epilepsy. Because there were so few Inpatient beds, I actually spent more time at the Paediatric ED which although had even fewer beds, but had much higher turnover, and hence more opportunities to practice Clerking and Physical Exams.

Like with Women's Health, we had a PBL (Problem-Based Learning) Tute each week at the Clinical Hospital and opportunities to attend Outpatients, along with morning Ward Rounds (including on the Weekends if we'd like).

PBLs were mostly on “Bread-and-Butter” cases. However there were two Tutes that stuck out in my mind, the first one regarding a fictional 4 year old boy who was being assessed for ASD / Fragile X Syndrome. Somewhere in the text it said that the boy had frequent “Tantrums”, particularly coz he wasn't able to communicate his ideas owing to his Speech Delay. I wasn't happy at the term “Tantrum” being used coz it brought the connotations of being naughty, rebellious, and/or manipulative (in reference to NT children, eg at the supermarket wanting something but not getting it), when he was anything but. 

In the Tute, I said I found the term offensive and misleading and that the more appropriate term for such an ASD child would be a “Meltdown” due to his current neurological deficits being unable to meet his personal needs, leading to massive frustration and vulnerability. And that the approach to his “Meltdown” (Education, Accommodations, minimize Sensory Overloads) would be completely different to that of a “Tantrum”, which we were taught to just “ignore the child until they stop whining, to give them the message that their Tantrum isn't working or acceptable”. I feared that parents would treat ASD children having Meltdowns inappropriately, which would just exacerbate the situation and cause more mental scarring. However the Tutor insisted that it was still a “Tantrum” in the literal sense, and was thus appropriate. This incident was very frustrating and ironic to me, given that ASD people like me supposedly take things more literally (relative Frontal Lobe deficits), and have an impaired ability to comprehend language pragmatics (including subtle connotations), and yet it was the Tutor (NT) who took it literally.

The second memorable Tute was about a Teenage girl who had several psychosocial issues to be addressed in conjunction with Epilepsy management, including Smoking, drinking Alcohol, teenage Sex and possible Depression. IIRC, in the passage regarding her Past History, that she “Tried Sexual Intercourse a few times last year but didn't enjoy it, so hasn't had it since.” This phrase was particularly interesting to me, coz it was only then I realized that sometimes, in order to dislike an activity, you have to give it a try first. I literally told the Tutor that “In order to know that she doesn't like Sex, she has to try it first,” in which he concurred. 

It may sound really obvious to others, but it helped influence my approach in life, that part of personal growth involves getting out of one's comfort zone (or narrow interests / repetitive activities) and experiencing new things temporarily, which would assist with developing one's perspective too instead of relying on preconceived notions or fear. I now see it as collecting more data to analyze. Sometimes there are strangers who I'm interested in speaking to, and whilst I used to be too anxious about approaching them at all, now I'm more forthcoming and curious, thinking it's “It's either I speak to them now, or never and continue to wonder what it's like if I had spoken to them”.

Obstetrics and Gynaecology (RETROSPECTIVE POST)

Women’s Health (or Obstetrics & Gynaecology, ie O&G) was the first Rotation I did after a year of Adult Medicine Rotations. I did it at a Women’s Hospital for 9 weeks. We were attached to a Team and were allocated Outpatient and Birthing Suite Sessions to attend on a weekly basis. The Birthing Suite Sessions included several night shifts, which in combination with Obstetrics tutes the following morning, kinda wrecked me, even with Medication. We also had Case Studies to do and exams to prepare for (of which we were given the pool of ~120 questions IN ADVANCE of which the exam will derive from, in which we had to prepare and memorize the answers in advance), which was frustratingly time consuming.

To partially balance that however, we had O&G Consultants who were very passionate lecturers and captivated the attention of nearly all the students in their Lectures and Tutes. One of them was extremely excited about an oncoming Blood Test, that would diagnose Trisomy 21 (Down Syndrome) in the 1st Trimester with supposedly up to 99% Sensitivity and Specificity, which would mean that the more complicated and dangerous investigations of Amniocentesis and Chorionic Villus Sampling would be abolished.

There were Outpatient Sessions for Gynaecology and Obstetrics (for Antenatal Assessments, ie assessing pregnant women’s health).

Gynaecology Outpatients to be honest felt rather repetitive, the most common medical complaints were Menorrhagia (excessive menstrual bleeding), and Dysmenorrhoea (painful menstrual bleeding). It may have seemed mundane, but I was very impressed by the intervention called “Mirena” (essentially a contraceptive IUD which slowly releases an oestrogen called Levonorgestrol to minimize menstruation), which was prescribed very frequently. Even Catholic Hospitals in Melbourne are now allowed to prescribe this “Mirena” for the above 2 indications, with contraception as a “Bonus Side Effect”!!!

We did have a special tute on performing a Gynaecological / Pelvic Exam, on special “Volunteer Tutors” who let us physically examine them, for the Pap Smear and Bimanual Exam. Being a male who was only allowed to do 2 or 3 Pap Smears at Outpatients in total (with the Registrar who initially inserted the Speculum), I appreciated this opportunity to examine a woman. I made the mistake of asking the Tutor to "Spread her legs", because apparently it had sexual connotations, but she assumed I wasn't being offensive coz she thought that I was an International Student and that English wasn't my first Language. For the Pap Smear I went too high up and accidentally rubbed against her Clitoris, and she was moaning, saying “Oooooooh, that’s too high up, go lower!”. I must say the Labia felt rather “fleshy”, and it was challenging for my left Thumb and Index Finger to part the Labia coz it was kinda “wobbly”. I eventually managed to part it and insert the metal Speculum to keep the vaginal wall dilated before using a flashlight and Speculum to swipe her Cervix.

For the Bimanual Exam, I gloved up again and applied some lube on my fingers and slowly put it in. Her vaginal canal felt moist and after asking her to cough IIRC, I eventually managed to slide 4 fingers in, tightly. I then pushed up to “palpate” the cervix and with my left hand on her abdomen, tried to “palpate” her ovaries for any abnormal masses, of which there were none. I was curious how deep and wide the Vaginal Canal was to accommodate a Penis during Sexual Intercourse. It seemed plausible, albeit with the Vaginal Canal being stretched. Although I read that the Clitoris is the most sensitive part of the Female (sexually), I hypothesized that some of the sexual pleasure would also be from the tight sensation experienced from having an erect Penis pushing against the Vaginal Walls. I also envied how a woman could hypothetically “fake” an Orgasm.

Obstetrics Outpatients was much more interesting IMHO due to the variety. I particularly enjoyed measuring the pregnant women’s fundus length (length of Uterus from top to bottom) at different stages of gestation, measuring blood pressure, and also using the Doppler Ultrasound to try to listen to the Foetus’ heartbeats. Hearing the Foetus’ heartbeats would invariably please the pregnant women. I had many opportunities to palpate the women’s uteruses (sp?), but was always paranoid about causing pain or “hurting the foetus” so I always palpated relatively gently, which actually annoyed the O&G Registrar. Medically, I took note of the medications that may be Teratogenic (damaging to Foetus), and I liked the complexity of managing pregnant women with Epilepsy or Bipolar Disorder given that all Anticonvulsants are Teratogenic to some degree apparently.

With regards to the birthing suite, although I didn’t assist much in the actual baby delivery, I did get to participate by helping to perform routine observations (of vital signs) on the mother, fetching blankets, and trying to maintain a conversation. I particularly liked how by talking to the mother, not only was I “helping the time pass”, but I was also partially distracting her from her discomfort or anxieties, ie “hitting two birds with one stone”.

I’d like to note that whilst I’ve heard numerous anecdotes about the hostility between Midwives / Midwifery Students and Medical Students, it wasn’t apparent at the Hospital I was placed at. The Midwives I’ve spoken to were all helpful to some degree and weren’t bullying, thank goodness.

It was a very eye-opening experience to see a baby delivered right in front of your very eyes, so surreal. For some reason I didn’t feel anxious, more excited, but was able to keep my usual flat affect surprisingly.  I was very curious to see what the baby looked like, and it was almost climatic to see the baby’s head get exposed to the outer environment. The mothers seemed to be quite happy and calm upon seeing their child. I also loved the process of slowly pulling on the umbilical cord and eventually pulling out the Placenta, which felt like "warm meat of a mild silicone-like texture". It was very pleasing to my hands, almost as if I could use it as a "stimming-tool" like a stress-ball (obviously inappropriate).

I always wondered why people have children. I know that some of them do it coz they want more “atmosphere” by creating a family, others coz they want “unconditional love” or want to feel needed due to their low self-esteem, and others coz they have seemingly poor judgment and continue to have babies even though they don’t have the personal or financial resources to do so (especially “bogans”). I was disgusted when I saw very obese women who were pregnant, coz it jeopardizes the foetus’s health, but supposedly who am I to judge?

But for a short moment after the baby was born, my internal prejudices about anybody having children when they “shouldn’t be”, vanished completely. I felt privileged to be able to witness childbirth, and to be able to be a participant in their experience. I thought it was being too NT to see it as a privilege, so I had to ask myself later on why it was so, and more objectively I suppose it’s coz it’s a rare experience for me, to be able to observe something that’s literally a once-in-a-lifetime experience for that individual (baby), the pure novelty. I’m sure that if I was hypothetically an O&G Consultant, the baby deliveries and placenta extractions would eventually become mundane as well.

I have extremely early on, ruled out O&G from the Medical Specialties that I’d consider (if I stay in Medicine) due to lack of academic interest and also fear over Medico-Legal Issues. I was also concerned that this very strong Medico-Legal fear would eventually override the joy of observing childbirth which I personally predicted would wear off with repeated experiences. I’ve also read and heard rumours that with the rising Power and ongoing Lobbying from Midwives to have a greater share in Antenatal care and undertake more “normal” baby deliveries independently (with the ongoing funding problems of Australian Healthcare likely giving them even more leverage), the Obstetrician’s role will progressively be devalued.

However, nevertheless, this Rotation was very eye-opening. I think I would’ve enjoyed it a bit more if it weren’t for the “Shift-work” from the Birthing Suite Sessions and the horde of O&G questions I had to prepare for, although I should be grateful in that it’s supposedly better than not knowing the questions in advance, at all.