Starting Internship Tomorrow

My time is up, and I'm back in Australia.

Oh how my Gap Year went by so quickly. I'm so happy and grateful for the experiences that I've gained (medical and non-medical) during this period, even though I haven't documented it fully on this blog. I need to finish off the remaining East Timor Medical Elective entries when I have spare time.

Medicine in Australia is excellent for a first career, and I'm not ashamed to be a doctor anymore. At the end of the day it's just a job, and whilst the Medical Profession continues to be devalued/degraded by the powers that be, I still have many skills and experiences to gain from working as a doctor for a few years, before potentially moving on to whatever I find more intellectually stimulating and/or higher paying. For now, Medicine is my back-up job. I will try to cherish any positive moments that occur with my "heart".

I've finished the internship orientation, but tomorrow will be my 1st day of work.

Here's to hoping things will go well, I have to bite the bullet and start full-time work for real. Need to take things one day at a time and learn things by osmosis.

Fingers crossed...

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...

East Timor Medical Elective - Week 4 (Part 5 / 6)

BPC'S 15TH ANNIVERSARY

Friday afternoon was BPC's 15^th Anniversary. It was amusing that Dr. Dan's Birthday was quite close to BPC's “Birthday”, and I asked a staff member if both have ever been celebrated together, in which she said “Yes, in fact most of the time!”

Cake for BPC's 15th Anniversary. The icing design is based on BPC's logo. Middle symbol is supposed to be a Crocodile, from the traditional East Timorese Legend of "La Faek".

The front door to the main building was covered with cloth / curtains, and a clothed table set up for the ceremony. The arrangement was simple yet pretty. I sat at the side of the main waiting benches. I felt like something big was going to happen.

A girl lights up the Candles before the Sermon starts.

The crowds gathered, and eventually the Padre/Priest showed up in his gown, starting his sermon. I was unable to understand all of it, but clearly he was quoting from the Bible and at some point discussing the “Catholic values” of love etc, and linking it with Dr. Dan's charity work. There was a bit I disagreed with however, when he followed the discussion of medical work by stating “La iha sakrifisiu, la iha hadomi.” ( “[If] there's no sacrifice, there's no love.”)

***WARNING – RANT, NOT DIRECTLY RELATED TO THE ANNIVERSARY***

For about a minute, I got really annoyed when he said that, because he somehow implied that Medicine as a Career was a “Calling”, that one must give it their all-in to their work as a Dr. At the time it felt extremely “traditional”. My observations are that as the Medical Profession in Australia (and several other Western countries, especially the Anglophone ones) has become significantly devalued and disrespected compared to the “good old days” (30+ years ago). It's gotten to the point that the notion of introducing a $7 co-payment for visiting a GP (in spite of the 9+ years of study/training to be an independent GP) is seen by the voting majority as so “unaffordable” (in spite of the copious social welfare relative to other countries), even though they happily fork out (much) more for Hairdressers and Restaurant Meals.

These days in Australia at least, being a Dr is for the most part just a job rather than some “G-dly pursuit/passion” that “should” take over your entire life for the sake of saving humanity, irregardless of the pay. Even in the face of increasingly onerous (and possibly unjust) Medico-Legal Pressure/Stress, Public Hospital salaries for Drs continue to decline in real terms every few years through an apparently fractured Dr' Union, in addition to exploitation by State Governments. This is in contrast to the Nurses who in practice hold more clout despite their graduate and junior nurse oversupply being far far worse.

We're human as well, and have our own personal, financial needs etc. I resent it when a lot of people (Australian or not) think that just because we're working as Doctors, that money should never be an issue. They expect Doctors to work and behave like Saints/Monks, yet for the most part in Australia they're not treated as such (as opposed to Developing Countries). Interestingly, a lot of these people have far more sympathetic views towards Nurses. Medicine is a highly trained profession, with a lot of responsibilities, impacting on Patient's lives every day. One mistake can kill a Patient. My opinion is that the remuneration should reflect that, otherwise at the very least the working conditions should be conducive for focusing on Clinical Work. 

Drs in Developing Countries have much lower pay, but at least they don't have to worry about getting sued or notified regularly. They can just focus on Clinical Work and try their best to treat Patients with the limited resources available, ie “Classical Medicine”. With Medico-Legal repercussions being so strong in Australia (closely following America), I think it's gotten to the point where if Drs' real pay continues to fall, retention within the Public System will decrease as more Drs feel the pay isn't worth the responsibilities and stress of covering their “Professional Asses” for half the day, lest they miss something and get penalized over some dubious technicality by some judge who happens to have negligible Clinical Insight by comparison (and just follows the fine print created by other similarly clueless politicians/senior bureaucrats etc). 

Some people try to dismiss the issue of (Public) Drs' pay, purely attributing it as a product of Supply vs Demand, but the fact that the vast majority of Junior Doctors and (Non-GP) Registrars are stuck within the Public System means that State Governments can exploit their Monopsony (as much as possible) on such highly-skilled labour, undermining these Drs' true value compared to a genuinely free market (hypothetical). How else could you make an Intern “only” earn ~$32/hr after studying for 5-7+ years at Uni, when a School-Leaver can already earn ~$24/hr as a Waitress in a suburban Cafe, even though for the latter job the entry requirements are vastly lower, and labour supply vastly greater?

These Nay-Sayers can try to dismiss the issue of Australian Drs' pay/conditions in light of the current climate, but at the end of the day, Drs can and will vote with their feet if needed (as demonstrated by the Queensland Health debacle earlier this year)...

***RANT OVER***

After the sermon, the choir started singing songs. Again I only understood part of it, but I started feeling a lump in my throat. Some of the choir people, and audience started shedding tears and sniffled during the singing. 

Choir singing in the Mass with Keyboard Accompaniment.

I started feeling strange. Initially I felt a tingling sensation in my skin, with my “hairs standing straight”, as I absorbed the magnanimous blend of melody and harmonies. By the time they reached the Portuguese Hymn “Ao Amor que te Arrasta”, my throat became tight, and I felt like I was about to cry, and had to restrain myself from doing so. I stopped looking at the Choir singing, and just stared at the lyrics, and intermittently closing my eyes, but it didn't help much.

I couldn't understand why I started having such a strong automatic reaction, like I was being possessed by an unknown being. I felt like I was subconsciously being commanded to remove my Flat Affect, and cry. It was only a few minutes after I got annoyed at that specific sentence from the Padre/Priest, and I was surprised at how quickly my feelings changed. I didn't like how my body was being pushed to do something that I intellectually thought was irrational, and didn't want to give into “Emotional Conformity”, yet another part of me felt that to cry was the correct emotion to display during this period. I previously never entered into my “Social Database” to cry during Hymn singing, especially when we sang Hymns routinely at Assembly in High School. Back then, we had Assemblies 3 times / week, so it would've been ridiculous for me to cry that frequently. I felt like I was being overwhelmed emotionally, to the point of being nauseous.

I wanted to leave the place coz I felt overloaded, but thought it would be rude if I left early on such a large occasion. I just sat and decided to let the music “penetrate” me, hoping that my body would quickly down-regulate the seemingly visceral response. Eventually it did, but only near the end.

I didn't cry at the end, but as the nausea disappeared, I could “observe” the warmth and passion shown by the Choir, in fact the East Timorese people at the ceremony. I personally hated conformity in its own right, but I could now see how pleasing it was to have people gathered at a place for celebration. Some of the piety was visible; Patients with TB or suspected TB sat in the audience and took off their face-masks as a sign of respect. Everybody's presence at the time just felt “beautiful”, but I was unable to quantify it. Some of the Patients who complained of Pain earlier in the day, looked much livelier and in less visible pain as well. The arrangement just “felt right”.

Priest/Padre is feeding round wafers to a long line of people.

As my emotions were under better control, I was pondering again as the ceremony progressed to the audience lining up to eat the circular Wafers representing the Body of Christ, followed by Dr. Dan giving a gratitude speech. The singing, it's part of the Catholic Culture, but also the East Timorese Culture. The Unison of people doing the same thing together looked wonderful but was an example of conformity. I lamented about how Australia lacked an obvious “Culture” (not including Property Investment/Speculation, “Tall Poppy Syndrome”, Political Correctness, and AFL), but realized that in order to have a “Culture”, there has to be conformity. If everybody does something different, then you're statistically much less likely to have a Culture, let alone a prominent one like that of the East Timorese, whose population is superficially more homogenous. 

Ever since migrating to Australia, I had an “inside feeling” that in spite of its relative wealth, there was something missing that other poorer countries (or even America) had. I had access to food, clean tap water, and a home connected to electricity, adequate sanitation, in addition to my direct Family. Yet when I went out in Melbourne, I frequently felt the outer environment was rather “Bland” and “Soul-less”, especially the suburbs. I thought that there was something “off” or “Artificial”. I thought I was being spoiled or ungrateful for having such sentiments in a Developed Country. Yet in Dili, a City of ~200,000 people (as opposed to Melbourne's ~4 Million), with far less public amenities, I felt much more stimulated outside of home, and not in the anxious sense.

It must be the people and their collective behaviour, I thought. Their population is less Multicultural (in spite of the other Tribal languages in the Districts) than Australia, and the people have far less opportunities Education and Vocation-wise. The weather is becoming hotter, but the people on the whole behave quite “warmly” in spite of the Language Barrier. I don't feel Euphoric here, but have been appreciating the more “visible” homogeneity in behaviour from the locals – their responses, questions, opinions, gratitude (is gratitude more from being poor, or Catholic influence?), “warmth”. Nearly all the locals I speak to are eager to learn new things and/or help develop the country, even if they are unable to think of specific solutions. National development is an obvious goal that unites people. Their word for development, “Dezenvolvimentu” is used copiously in TV and Newspapers. Many people are poor, and Youth Unemployment is high, but they just keep moving on, day by day.

The conformity was easier for me to process thanks to my fondness for repetition, and I felt great joy at being able to understand East Timorese people as a whole a lot quicker than Australians, without being considered “superficial”, “naive”, or “lacking insight”. It pleased me to be able to rapidly understand the psyche of NT people from another country despite my initial deficits secondary to the AS. The paradoxical stimulation from the East Timorese people's superficial simplicity/purity still baffled me (at the time of this writing).

However at the very end of the day I wouldn't want “Mass” conformity to happen in Australia. I think I was in the position to be able to be fussy over the presence of an obvious “Culture” or not. In the long-term, I value my freedom to be un-chained to an overarching Religion (Catholicism), or Collectivistic Society (as per traditional East Timorese Culture) where there is pressure to get married and have children, along with much more influence from relatives (non-parents) in various issues. The taxes are much higher in Australia and there are a lot more lazy/ungrateful Bogans and Politicians, but in spite of the over-regulation and bureaucracy, I still have many more opportunities to pursue what I want vocationally and academically here than in East Timor, in addition to access to a far more robust Healthcare System (Public and Private).

It's probably unfair to compare with a Developing Country, but many things aren't set in stone. In the future, if my values change, and if I manage to save up enough money, I always have the option to explore/move to other countries (even East Timor?!) if I get fed up with life in Australia later on. Australia seems to lack an overarching “Culture” and is geographically isolated, but the price for this relative Individualism (along with wealth) is that you have to put in much more effort to find others with similar interests, beliefs and goals, eg Subcultures or Hobby Groups. Otherwise you can just resort to the internet. You can't have your cake and eat it. 1^st World Problems indeed. At least I don't have to truly worry about starving to death, or despair at a hospital being short of a common Antibiotic, any time of the year.

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

“MATEUS” (APPENDICITIS)

I clerked “Mateus” in another afternoon (this time on medication) with Natalya and another student watching me, but apparently he was waiting for nearly ~6 hours since being admitted this morning. I didn't recall seeing him in the morning Ward Rounds, so he probably arrived just after we left the Baixa (Gen Med) ward. 

I looked at Dr. Dan's mini-notes: “RLQ pain - ?Appendicitis ?Ascaris”.

Oooooh, a potential Appendicitis case, I thought.

I asked Mateus what his problem was, and he said that he's been having pain that started in the RLQ last night, and later spread towards his RUQ and Epigastric area.

It sounded strange. I recalled the textbooks stating that Appendicitis initially starts in the centre of the Abdomen (around the belly button), and then migrates towards the RLQ, and then causes diffuse Peritonitis if not treated fast enough. Mateus' abdominal pain didn't sound like the textbook, but I was still worried.

 After asking enough questions about his Abdo pain and gross (basic) Systems Review, I decided to “jump” to the Physical Exam.

His bowel sounds were still present. I lightly palpated his Abdomen, and he winced as I examined his RUQ and RLQ. I then percussed, and was internally pleased when he felt pain from this. Omg, Percussion Tenderness is present! He could really have Appendicitis.

I then gently pressed on the left half of his Abdomen, which wasn't painful, but I let go after a few seconds, and he winced again, saying it hurts the right side of his Abdomen.

OMG he has Rovsing's Sign! I was so delighted upon seeing this for the first time, but didn't smile about this in front of the others. I became very excited and concerned.

“I think he has Appendicitis, I need to tell Karl immediately,” I said.

Karl soon came and I presented the case, with Appendicitis being my most likely differential, in which he agreed, and continued him on the empirical antibiotics.

I felt so proud of myself on having “diagnosed” Appendicitis within 15 minutes, but knew that I had a hint from Dr. Dan's mini-notes, so could take a targeted history and physical exam much more easily. If I had no hints to begin with, my clerking would be more time-consuming, and that will only improve with practice and feedback. But I was also happy to see in person, how a patient doesn't necessarily present themselves perfectly as per the textbook descriptions.

He was monitored overnight and was to be transferred to the ED of GVNH, for admission to have an Appendicectomy.

I knew that the overall standards of Healthcare in Developing countries were lower than in Developed countries, but it was still shocking to see the differences in person.

I spoke in my slow, “formal” English accent to one of the ED Drs, who wrote notes based on what I said, including Physical Exam findings, including the Rovsing's Sign. I was surprised. Isn't the ED Dr supposed to examine the Pt himself?!

For some reason, it was another ED Dr that ended up physically examining Mateus. Ok, at least he's been examined by someone now. Bloods were to be taken next.

Next was the jaw-dropping moment. The Dr used a glove to tie around Mateus' arm as the “tourniquet”, and with his bare hands (unwashed), started inserting the needle into Mateus' vein. Mateus' arm wasn't even swabbed with Alcohol!!! Internally, I was gasping and horrified, but still maintained my Flat Affect on the outside. Oh how I dearly wished to have taken a photo of the Dr taking Mateus' blood, and get away with it!!! I'd be very interested in seeing the infection rates from Venepunctures and Cannulas in East Timorese patients secondary to poorer hygiene practices.

"The Scream", by Edvard Munch.

I left after the bloods were taken, as he then had to wait until 2 PM (it was now ~12:30 PM) to have an Abdo Ultrasound done as the radiographers were still on their lunch break. In fact, the majority of the hospital staff (doctors, nurses, lab staff) have a lunch break from 12 – 2 PM. Things go to a halt. 

It baffled me as to why GVNH doesn't roster their staff in a way, so there's at least 1 person working at any time of the day, or that staff take turns working during lunchtime. I suspect a strong factor was the near absence of Litigation. Then again, on their relatively “peanut” wages (apparently ~$US 700 / month for Interns at GVNH), if the Medico-Legal pressure was present akin to Australia, I bet 90+% (if not 100%) of the Drs would try to jump ship to another Country, or another Career altogether. Anyhow I'd hate to be an acutely ill patient arriving at the ED at 12:05 PM... : S

Note: I visited Mateus a few days later and it turned out he eventually had an Appendicectomy done, and was recovering with no post-op complications (yet?!).

East Timor Medical Elective - Week 4 (Part 3 / 6)

“ENRICO” (?CANCER METASTASES)

I knew I had a “short fuse”, but forgot to take my afternoon medication one day. I was trying to clerk a newly admitted patient called “Enrico”, who Dr. Dan noted had “Abdominal Pain” as his main complaint.

I think when I'm more tired or sleep-deprived (especially un-medicated), my mind seems to be more concrete, inflexible, and absent-minded, augmenting my desire to be very methodical.

I greeted Enrico and starting asking him about the Abdominal Pain, trying to cover “SOCRATES” (Site, Onset, Character, Radiation, Alleviating Factors, Time Course, Exacerbating Factors, Severity) before moving on to other questions.

I asked him if his Abdominal Pain spread to other parts of his body, he started talking about his headache and shoulder pain, and how it's so bad. Without realizing that his headache was important, I thought he was just going off on a tangent, or not understanding my question. I thought his shoulder pain was just a plain old Arthritis from his old age, and that his headache was the bread-and-butter variety. At the time, I thought that if Dr. Dan didn't write “Headache” or some other medical complaint in the mini-notes, then it couldn't be serious or worth focusing on.

I repeated again slowly in Tetum and gave examples of pain radiation, but then he kept talking about his headache, how it's so bad. I was still focusing on the Abdominal Pain and got increasingly annoyed at his diversion from my history taking. I think I actually asked the same question in various forms up to 5 times (in grammatically correct Tetum), but to little avail. In my spaced-out, disinhibited state, I thought he was trying to fool around with me and got a bit angry. The patient opposite Enrico's bed giggled from my visible frustration, and said I needed more patience.

It was a futile effort trying to get him to talk any more about the Abdominal Pain, so I just gave up on the history taking and physically examined him. He had Epigastric tenderness, so my differentials included Peptic Ulcer Disease and Pancreatitis (although that was unlikely).

Soon after, I presented my “incomplete” case to Karl, and he said that another differential diagnosis would be Stomach Cancer which has metastasized to his brain, causing a headache. He needed a CT-Brain at GVNH to rule out any CNS lesions.

OHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH.

I felt really guilty, that I got angry/annoyed at someone who didn't deserve it. It made sense now. Yes, his headache could very well be a sign of something much more sinister. I realized that there will be times where being too methodical is actually bad, and you need to know when to change your strategy. I also realized that Dr. Dan is also human and at times will miss things too, so I couldn't just depend on his mini-notes as the core stimuli for history taking. You need to focus on what the patient says themselves, expand on that, and attempt to fit the puzzle pieces together to formulate the relevant differentials. 

By dismissing what the patient says based on what other Drs say, it can sometimes impair your ability to find the right answer. At the very least, in Australia I'll be documenting to the best of my ability all of the patient complaints for Medico-Legal reasons, even if I secretly don't believe them.

Since this episode, I decided to take my afternoon medication routinely again to improve my alertness and cognition. I thought that I didn't need it coz I've “crashed” (sleep attacks etc) in the afternoon a lot less often than in Australia, but my cognitive impairments (especially after lunch) were still present even if I didn't fall asleep. I now also take Dr. Dan's mini-notes as a “partial hint”, but not a definitive summary of the patient's problems. At the end of the day, you need to know how to take a History and do a Physical Exam yourself, for the benefit/convenience of both you and the patient.

East Timor Medical Elective - Week 4 (Part 2 / 6)

“JOAO” (GLOBAL HEART FAILURE, and PLACEBO EFFECT?)

Monday evening was very sombre by comparison. I was about to go home at 6 PM, but as per Murphy's Law, was informed by a nurse that a new patient just arrived to the Emergency Room.

“Joao” was a boy who came with his parents, feeling quite short of breath. Karl and Maria were still busy in their afternoon ward rounds but would soon check him out. His legs were both swollen with pitting oedema, abdomen and JVP distended, all from Right Heart Failure. There were crackles in the bases of his lungs, suggesting Left Heart Failure too. His heart was already beating very fast. Unfortunately, he had Mitral Stenosis which was untreated for years, and now we were looking at the end complications. Dr. Dan already commenced him on a very low dose of Beta-Blockers to slow down his heart rate, in addition to taking Frusemide (a diuretic Rx). I was really anxious for him to get rid of his “excess” fluid as much as possible.

He was already on medication, I thought. This is a medical emergency, so ABC, ABC. I quickly looked at his palms and the inside of his mouth. He wasn't cyanosed yet, but clearly had increased work of breathing. I ran out of the room to get a pulse oximeter, returned and clipped it to his finger. 94% saturation, so still ok-ish. Joao and his parents didn't understand what the pulse oximeter did, so I basically said it shows how much oxygen is in the blood, and that anything above 90% is still acceptable. Joao and his parents then became very focused on the displayed number. But inside, I felt uncomfortable because I wasn't sure if that number was correct though. It also displayed his pulse which was completely inaccurate. I was hoping that by focusing on a number, that it would help quantify his status and calm him down.

I was confident he needed Oxygen for comfort and asked Joao if he wanted to try it. He immediately said yes.

I ran to the nurses' room, and brought back the oxygen tank with a mask. He looked relieved when it arrived, and I started putting it on him. I tried to switch on the Oxygen Tank and turned the delivery rate to 6 Litres / minute, but there was a leak in the delivery device connecting to it, releasing a small “air stream”. Barely any of the Oxygen was going through the tube.

I felt devastated. Was Murphy's Law cursing me again? What should I say to him?

I dramatically increased the delivery rate, and a bit of the Oxygen was now flowing through the tube, with the “air stream” producing a prominent hiss. Oh dear, lots of wastage. I asked Joao if he could feel it coming through, and he said yes, but only a bit. 

He looked much calmer now, but inside I felt guilty. A lot of Oxygen was leaking out and being wasted, which could've gone to other future patients in Cardio-Respiratory distress. How far should one go when there are limited resources? His Oximetry sats was hovering at around 94 or 95%. But how much Oxygen is he really receiving? I couldn't quantify it, and was wondering how much of his calmness was from actually receiving significant Oxygen, or from the placebo effect of looking like he's receiving a treatment. Calming his parents down would also have influence on him.

I holding his hands for a few minutes, and the room was silent apart from the hiss. Karl and Maria soon arrived, and ceased the Oxygen delivery as it would be unsustainable at the current delivery rate, rapidly depleting the Oxygen tank. I offered to lower it to the original 6 Litres / minute, but this was also considered a bad idea: If Joao wasn't actually receiving the Oxygen, then wearing the mask would only result in him breathing back in more Carbon Dioxide, worsening the situation. His Oximetry sats was still acceptable in room air, but Joao clearly looked more distressed / upset.

Karl and Maria were medically correct, but in my mind, I was still anxious. I was using the Oxygen Tank as a psychological crutch, and obsessed about giving Joao Oxygen. I called a BPC assistant who also did some device repair, but he was unable to repair the leak. 

There was one more Oxygen tank, but much heavier. Joao got admitted to the main ward, with that Oxygen tank placed next to his bed for “comfort”, even though the attached device also leaked. I felt really sorry for him. No working Oxygen tanks at BPC tonight.

Please don't die, please don't die, please don't die.

It was getting dark and I had to return home. I said bye bye to Joao and his family. That was the last I saw of him.

At home that night, I realized how obsessive I was about the Oxygen, and how emotionally “soft” I was. I felt so bad/sad to see him suffer, and wanted to give the Oxygen not only to comfort him psychologically, but myself as well. I wanted to give them the impression that I was doing something, even though clinically it wasn't doing much, and resources-wise, unviable. There was an element of selfishness and I felt guilty. I was being empathetic, but I had the wrong application.

When there are limited medical resources, you have to be prudent as much as possible. It's always a challenge to help many people in such a setting, where there's only so much you can do. There'll be many times where you just have to be brutal and ration things out (eg opioid analgesia), when in a developed country, everyone would have far more access to it. You're not being intentionally mean or cruel, but trying to use resources wisely based on priority.

In fact, it could be argued that in the process of “overtreating” 1 Patient, you'd be impairing the outcomes of many others, which some would consider as even more selfish. I suppose in Australia, where rationing of this degree has yet to take place, Drs have far more breadth to order investigations and prescribe medications to please Patients (demanding or not), in addition to covering their asses Medico-Legally. At the end of the day, you are working as a Dr, and not as a “People-Pleaser” (even if it attracts more referrals and repeat appointments). For the sake of good Clinical Practice, there'll eventually come a point where you need to set boundaries and say “No”.

Note: Joao was transferred to GVNH the next morning, but died several days later. I couldn't get any further details from the Ward Clerk at GVNH. RIP... : (

East Timor Medical Elective - Week 4 (Part 1 / 6)

Week 4 (22/9/14 – 26/9/14)

DR DAN'S 70TH BIRTHDAY

Monday this week was Dr. Dan's 70^th Birthday. The morning ward rounds proceeded as usual, but when we arrived at the Malnutrition Ward, there was a surprise! Luisa and “Livia” (another assistant) started playing a Happy Birthday song from their radio. There were balloons, and large colourful letters saying “HAPPY 70TH BIRTHDAY DR DAN” hung across the wall. A table with the birthday cake and several beers was in the middle of the room, surrounded by much of the BPC staff.

The ward rounds took a pause. I thought that Dr. Dan would cry or be very emotional, given that he's reached a new decade in life, but he smiled and shook hands with everyone who congratulated him, one by one. It was so cute to see the little children smiling and reaching up to shake his hand too.

“Amy” (a volunteer Dr) then presented Dr. Dan her handmade Birthday Card that we all signed. This was then followed by the cutting of the birthday cake and distributing of the beers. The room was small, but at that moment felt cozy, so very “Gemutlichkeit (sp?)/ Gezellig”.

It was a very pleasant start to the day, and I (selfishly) felt lucky to have my medical elective coincide with this occasion, along with the BPC 15^th Anniversary on Friday.