Rural & Emergency Medicine (RETROSPECTIVE POST)

Rural (3 Weeks)

Me and a Friend were allocated a Rural Town in Victoria for our Rural Rotation. The first week involved Lectures in Shepparton for a few days on Rural and Aboriginal Health before we headed off to our respective Towns which involved a tour of the different Hospital Departments. To be honest we didn’t actually do much Clinical work coz we had a 20 Minute Powerpoint Presentation to work on and present at the end of THIS Rotation, which was actually very stressful given the seeming lack of Direction in the Assignment and difficulty collecting relevant Data in the allocated Time. 

We got to stay in a House that was shared with 2 Nursing Students who provided interesting Social Company at the Time. One of the Nursing Students was a Mature-Aged Student who had 3 Nephews with Asperger Syndrome which amused me greatly. I found it interesting to hear more in depth what studying and working in Nursing was like, and she also provided a bit of Advice on how to deal with Patients.

The Rural Rotation was also an Opportunity to practice Domestic Tasks like Cooking and doing the Laundry, which I’m usually too lazy to do at Home… : )

ED (3 Weeks)

3 Weeks for ED was surprisingly short given that it’s actually a Core Rotation (10 weeks) in Internship. It also didn’t help that it was our final Rotation for Semester 11 and I was frantically preparing for Exams. The other Students were preparing for Exams and Internship Applications, which made them even more stressed out. I’m aware that in the new MD Course, it’s now 8 weeks but also fuses Elements from the other Adult Medicine Specialties from our MBBS Course (eg Endocrine for Diabetic Ketoacidosis). We had a few Tutes which IMHO were overly detailed, and I learned and retained the most by actually going to the ED and speaking to Patients.

I loved the Practicality of ED. Triage was very useful for OSCE practice coz I had to take a targeted History for a Presenting Complaint and rule out the Differentials in a rapid Manner, along with presenting the Info to an ED Registrar / Consultant. I think when you are under Pressure to perform, you tend to acquire the necessary Skills a lot quicker out of Necessity. In my case, it was only a matter of Days in which I could memorize the Questions to ask for an AMI (Heart Attack) / Angina, and know what Tests to order, followed by initial Management. It’s not expected to CURE a Patient at the ED, but one can always try to make a quick positive difference which was what I liked.

It also provided Opportunities for IV Cannulation and Venepuncture, of which I got a few Cases signed off. Similarly, Clerking was easier, coz the Patients were relatively “new” to the hospital and haven’t been “interrogated” by all the Healthcare Staff, so were more receptive to answering medical Questions and being physically examined (providing they were conscious!). I also appreciated that as a Student, it was considered acceptable to come to the ED at Night-time or early Morning for extra experience, as other staff would assume you were rostered onto a late Shift!!!

During this Rotation, I was so enamored by ED’s Practicality that I was interested in ED Training as a serious Alternative to Pathology. Interestingly, both Specialties have a preliminary Exam that tested on Pathology (from the “Robbins & Cotran - Pathologic Basis of Disease” Textbook). However, an ED Registrar suggested I don’t, and instead pursue the latter, as there was currently an oversupply of ED Registrars, for which there’ll be a insufficient ED Consultant (and ongoing ED Registrar) Posts in about 3 years’ time. She also said that the Shift Work would eventually take a toll on your Physical and Mental Wellbeing to the Point where you won’t be able to enjoy the Work as much as you’d like. Although one of my Medications (Modafinil) is officially indicated for Shift Work, I was inclined to agree with her given my previous Experiences. What a shame…

Psychiatry (RETROSPECTIVE POST)

Psych (6 Weeks)

Our Psychiatry Rotation was done at the APU (Acute Psych Unit), which was in a separate building from the main Hospital. However our first Week included Lectures at another Hospital from an eminent Psychiatric Consultant. We also got to hear a Speech from a Schizophrenia Advocate about his Experiences with Schizophrenia and the Healthcare System which was a bit touching. I was internally amused that he also had Flat Affect, and I was able to detect the Parallel about how his Condition came to control his Life, and his ways to cope with it. Like ASD, Schizophrenia also comes as a Spectrum, although it’s typically much later onset, however at least they (along with ADHD) have the Convenience of official Medications to control any acute Symptoms. Even with Asperger Syndrome, you don’t stop thinking about it every day. You don’t want to define yourself by your Condition, but it affects the way you process Information and analyze Things that frequently you feel like an Alien or an Amateur Anthropologist on a foreign Planet.

I wonder if De-Institutionalization is the best thing for certain Psych Patients. Understandably there were significant Abuses in the massive Psychiatric Institutions in the past, which I think was also secondary to the Paternalistic Culture of Medicine, however I do see some Merit in that System. Currently, there apparently isn’t enough Funding to get all of the De-Institutionalized Psych Patients to adequately integrate into the Community, which to some Degree poses more harm to both the Patients and possibly the Public.

On a note, the recent and tragic Stabbing of Dr. Michael Wong (Neurosurgeon) at Western Hospital in Melbourne, by a Patient who was supposedly Psychotic and was a poor English-Speaker seemingly demonstrate Gaps in the Welfare of such Patients, who really should’ve been stabilized prior to being released.

Psychiatry was considered a “scary” Rotation by a lot of the Students, so very few from my knowledge went to the APU to clerk Patients, with the exception of supervised Clerking in Tutes by the Psych Registrars. I was warned that a lot of the Psych Patients in the APU were potentially aggressive or manipulative due to comorbid Personality Disorders (predominantly Cluster B), so I had to wear a Security Alarm when speaking to them. I ended up going through a lot of Patient Files to read their Medical Histories and learn how their Psychiatric Conditions have evolved, and how it was managed. I must say I found this very engaging, almost like reading an exciting Novel or Biography.

I did manage to speak to 2 Patients - a Woman with Bipolar Disorder and an Aspie Guy who was around my Age. 

I’m not allowed to disclose the presenting History due to Confidentiality Issues, but it was so fascinating / surreal to see a person display the Textbook Symptoms of a Medical Condition, especially a Psychiatric one. The Woman was still in a Hypomanic Phase, and looked elated and chatty. She stated that she hasn’t had much Sleep or Food to eat (due to low Appetite) recently, and told me a lot about her Personal Life, which whilst I didn’t mind at all due to the Open-ness, was apparently inappropriate to NTs as it was being “Overfamiliar”. She spoke rapidly but I was still able to follow her Train of Thoughts. In some ways it was actually easier for us to engage in Conversation as there were lots of different Topics to talk about. My perception was that it was easy to develop Rapport with her, to the Point where I actually gave her a small Present for her Birthday during her Admission. In Retrospect, I realized this was “Unprofessional” and was told by my Psychiatrist that such behaviour could distort the Professional Relationship, particularly as people in Hypomanic or Manic Phase are vulnerable to being exploited, plus the fact that she was only being “Overfriendly” coz she hasn’t been adequately medicated yet, and that the “Stabilized” her would have a higher Guard on par with most NTs. 

The Woman was fearful of the Aspie Guy coz he was being very noisy, which I presume was making sounds as a Stimming Activity. I found this amusing and sad as Aspies are usually quite “Soft” and “Innocent” if unprovoked (into Meltdowns) and would make very weak Enemies due to their intuitively reduced Theory of Mind and likely Executive Dysfunction to execute any malicious Plans whilst getting away with it very difficult if not impossible. I suppose she doesn’t know about his Diagnosis, and I wasn’t sure if I was allowed to tell her due to breaking Confidentiality, but I told her that he’s also experiencing Discomfort of another sort.

The Aspie Guy was actually a lot harder for me to talk to, which surprised me. I told him that I read his Personal History and was trying to explain that he’s not Alone, and that I have similar Symptoms and Experiences to him but have various Coping Mechanisms, and would be happy to teach him what I knew, but he seemed to be in Denial about his Diagnosis, sadly. It was actually quite frustrating for me at the time trying to reason with him coz I felt like I was looking into a Mirror of myself when I’m extremely grumpy, although I suppose in super-Meltdown mode as a Child, I couldn’t be reasoned with either.

I felt that I let him down coz as an Aspie, I was supposed to be empathetic towards his Experiences, and that I didn’t do “well” enough, in contrast to the Woman with Bipolar Disorder. In Retrospect however, I think he had overlapping Issues of Sleep Deprivation and Agitation over being in a new Environment filled with “Strangers” (other Psych Patients) that wouldn’t be conducive to Mental and Physical Rest. Certainly from my Sleep Problems in the past, I’ve done things that I never would’ve done if I was well-rested, plus I had impaired Cognition. I briefly discussed his Case with his Case Worker who actually agreed that the APU was NOT the appropriate Place for him to be managed, but there was a HUGE shortage of appropriate Facilities for ASD Adults in Strife to be referred to, which is why he was here for now. I hope his situation has improved by now...

It made me wonder how much I could decompensate in the future to the Point of needing a Psychiatric Admission myself... : S 

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.