Patient tales (except that none of these are fairytale)

When I woke up on Friday the 13th, I just wanted the day to come to its end. I was very tired from all the week doings with all those crap assessments, useless PBHell and running around to sort out thousands of stuffs. And you can tell from the way I'm writing that I hate them all.

So despite my endless cursing, I made my way to the surgical ward for a freaking 8am start and joined the Surgeon of The Week (SOTW) Grand Round. 1 consultant, 1 registrar, 1 SHO and 2 FY1s. The SOTW team reviewed almost 40 surgical patients in all wards (surgical, paeds & gynae patients).

I came across alot of unfortunate patients all of which left me so emotionally ridden.



Patient 1: 32 yo female patient who came in with small bowel obstruction. She had hx of a number of pelvic operations following diagnosis of and recurrence of cervical cancer. She has nasogastric tube in currently, as it was decided that her bowel should be rested.

I had a chance to speak to her afterwards. There were some parts of the encounter that I became very quiet as I was lost for words. It was very heart rending to hear someone of her age talk about three small children. For me it was the fact that all the problem started when she was 29 that did it. Thats like me in 5 years time.




Patient 2: 44 yo female patient who was diagnosed with pancreatic cancer post staging CT. She was told that operation will be arranged towards the end of this month. She asked the consultant whether she could have a weekend leave to see her newly born granddaughter. Unfortunately, she had to stay in-patient as she was markedly jaundiced.

Thats awful.




Patient 3: 23yo male patient who came in post vomiting and severe pain radiating to the back. Scan showed generalized moderate inflammation of pancreas. Dx: Acute pancreatitis caused by alcohol binging (while he was watching the Liverpool vs Manchester game nonetheless).

Consultant: Bla3x (re: long term effect of heavy alcohol consumption). You have to choose which one you love more. Alcohol or your life.
Patient: Errkkk....




Patient 4: A 39yo businessman who had been quite unwell (pain, n+v, although he was not jaundiced) for the last few days and investigations showed cancer of the head of the pancreas. Breaking bad news was particularly awful as it was done at the bed side with all 7 members of the SOTW team gawking. He was calm although there was hint of turmoil brooding underneath. The whole group became deafeningly quite when he asked:

"Whats the chance for this lesion to spontaneously heal itself?"
Consultant: Nil. Bla3x (re: prognosis, options, further ix inc staging CT and MDT)

"Can I have a weekend leave to sort out things?"
Consultant: Bla3x (re: potential complication of cancer i.e. bleeding 2ndry to liver problem, pain, jaundice...which might happen when he's away) So its highly recommended if you could just stay until after the staging CT.

"I need to sort out my business this afternoon (Friday). And just be with my family over the weekend. Gosh. Then I have to write a will."
Consultant: (Giving the space a sweeping glance). Well.... yeah, you can leave by lunch today after the girls check your INR but you have to be back by Tuesday at the latest.

It was eerily quiet. Of course, he is this young man who has alot of things to look forward to in his life at this very moment. Ooo... has I mention that he's an American? Who moved here few years ago after marrying a British woman and has established his own business based here in Lancashire.

I stood there at the edge of bed silently praying that he's alright with the news delivered and may he find strength and faith to cope with the diagnosis and its implication.




Those 4 patients were patients that made me shuddered. There were a lot more (ranging from simple appendicitis to ruptured ones, colorectal cancer, bile leak, retroperitoneal abscess, pilonidal abscess and etc) so much so that by the 12 pm I was crying inside. (yeah, a combination of many many many bad news and my own tiredness and worsening pangs of hunger).

Let us take few minute to reflect the value of life and to say prayers to these patients.

Later that day, I watched ComicRelief. For full 8 hours. 7pm on friday- 3am on saturday. The cause for this year is malaria in the Africa. So few more tears were shed after clips showing how kiddies in Africa died of this preventable disease, which is almost eradicated in other part of the world, due to lack of mosquito nets and medication to treat malaria victim.

Again, let us take few minute to reflect the value of life and to say prayers to these children. And say grace for having what we have.



Hugs and kisses with much emotions,
P53.

PS: As we were leaving patient 4's cubicle, he asked "Doctor, is theres any reason why I shouldnt use Viagra over the weekend?"

Managing an arrest

I attended an ILS (Intermediate Life Support) course the other day. All of us 5th years are required to attend one before graduating. So hopefully everyone with be equipped with the necessary skill needed by the time one start working as FYs.

One of the ILS instructors looked familiar. He was one of these people that you come across alot in hospital (in wards/in canteen/along the corridor/in shuttle bus) but yet still don't know who he is or what is his job really. Of course me being me- I want to know everything about everybody. So when I first saw him that ILS morning, it was killing me that I don't know who he is.

By lunch time, we were split into smaller groups so that actual scenarios of cardiac arrest could be simulated for a smaller number of attenders. I was in his group. Then for the first time in 3 years I heard his voice. And you guys would be amazed to know that he speaks in a language that I don't know. Yup. Really.

So there he was yapping about stuff (stuff because I had no idea of wth he was talking about) to the whole group and me straining/struggling to understand what exactly he was going on about.

He speaks English.

English with heavy Welsh accent.

I swear to God, out of all people that I've heard giving instruction for the whole 5 years I'm here, his accent was something of a different level. Well above the level of thick Lancashire accent of an 80y-o gentleman, the Scouse, the Scottish, the newly arrived doctors from India/Africa, Manglish of the IMUs students and the rest.

So imagine the shock that I had when each of us had to manage a case of cardiac arrest each, having not understanding half of the guideline.

Well initial shock anyways.

Luckily I kinda well abreast with the ILS algorithm.

And its not a simple one I tell you.

Learning Points:
i) Double check the medications with at least another person before administrating them. Beware they all start with "A" (Adrenaline, Atropine and Amiodarone).
ii) Keep calm and carry on. (sure as hell one will be nervous with the adrenaline rush when put on spot managing cases like these).
iii) You can refuse to do mouth-to-mouth resuscitation provided that you have a strong reason not to and could justify it in the court.

Question:
Ok now I had my ILS cert already, when I can do the ADVANCED Life Support Course??

Plastic Surgery

Mrs X is a 40 y-o patient who I met in a surgical ward. She comes to hospital this time for an elective removal of bone spurs and local debridement on her left femur.

The story was: about 4 years ago she had a tiny wee spot of infection of the skin overlying her left patella (that's knee cap for you and me). Fast forward many Abx and few months later, the infection was still there- unshifted. By this time she was feeling unwell with signs of mild systemic infection- hence she was admitted to hospital for IV Abx. However- as she was feeling no better- an aspirate was done + a scan of her knee joint. The infection had spread to her joint cavity (now its about a year since first skin presentation).

So: Her left patella was removed and the joint was replaced with a spacer (p53: is it like an artificial joint, like that of a knee replacement? Mrs X: No, its just a space-filler, the knee could not bend as well. P53: ooo0000ooo *making mental note to check how does that look like/work?*)

1year post-op, she noticed pain while walking and reported "feeling a bit off". Symptomatic treatment was given and she was enlisted for care of Chronic pain team. Many neuralgic meds later, the pain persisted- now about 2 years post op. Second opinion was seeked and she was refered to Smallcity's base hospital.

After doing few more investigations, it turned out that she was having osteomyelitis then (which explain the pain and her feeling unwell). Due to the level of permanent damage of her tibia and fibula, they were removed too.

And for the first time in 3 years she felt completely well (how ironic is that being just under 40 and yet so calm/blase/accepting to the fact that she's an amputee ....... gosh, I thank God for my legs and my well being... go on say your prayers now!) and she resumed her work as an administration staff at school.

However, the happiness didnt last long (well.... I have to use one of those cliche havent I?). Roughly 6months after she felt unwell again. The osteomyelitis had spread up to her inferior end of her left femur. (So the infection had been so mild, so low grade, it had spread to a wider area unseen macroscopically right from the very beginning!!!)

She unfortunately had an above-knee-amputation. (She said and I quote: I would rather keep my life than keep my decaying parts).

Since then she had been in hospital 3-4 times for removal of spurs (even doctors dont know why they keep on coming back) and local debridement.

She is currently under the care of the Plastic Surgery team. She can walk with a prosthetic- although not mobilising at the moment due to recent surgery. Bless her. She has been through a lot and still pretty optimistic about her life.

PS: She's such a good historian!

This is the epitome of mother of all reasons why I dont want to do Plastics. Too gruesome, too heart rending, and too surgical. haha.

I've been a bum

Well, not a surprise isnt it?

Bum for almost everything. Medically esp.

Well anyways... lets talk about some patients I saw in the last two weeks. Confidentiality protected nevertheless.

i) Post coital bleeding in a 77 y-o lady [what?? WHATTTT??]
I struggled to keep a straight face while I was talking to this patient, who was appropriately seated next to her 70-ish husband. Not because I wanted to laugh (well knowing me anyway) but because I was shocked beyond words. I swear in normal unmedical situation, my jaw would probably hit the floor and my eyes would have bulge out of their sockets. Two-weeks referal nonetheless.

ii) Nocturnal enuresis in a 20 y-o young lady.
20 y-o kinda sweet and cute lil lady came to the surgery and started to blush during her opening sentence "I have been experiencing something very embarassing"... And I went "well we could only help you if we know whats been happening + everything that you say will remain confidential". So story was: 6-7x of nocturnal enuresis in the past 3/12. No frequency, no dysuria, no discharge. Dry at night when she was 12 (?late ?familial). Said that she's not in any stress, well, apart from BF now leaving to work with the Army. No hx of abuse (sexual/physical) and no other relevant hx. I sent off her urine sample to exclude UTI/glycosuria and requested a fasting blood glucose. To be reviewed in 2weeks time.

iii) An unfortunate girl who was given the Pills without first-pill-teach.
She is only 16, but honestly when she walked in she looks much older than me (so tall and much tad-too-much makeup on) so much so I had to ask her to confirm her full name, date of birth and address. So I gave her some adv re: the pills and printed out some patient information leaflets. Problem was: breakthrough bleeding whilst on the pills- which is a COMMON thing to happen.

iv) A dead body at a caretakers.

v) A 44 y-o lady with bilateral trocanteric bursitis.
Hx and O/E very typical of trocanteric bursitis. "Why bilateral?" asked my GP- and tbh I DONT KNOW. Very articulate lady. She explained everything without me asking, right down to characteristic and aggravating factors. Ha.

Ok, there are actually so much more interesting patients to write about, but as the title of this entry suggests, I cant be arsed.

Otherwise, pen off.
I'm gonna go and continue reading Breaking Dawn.

******Spoiler alert*****




Bella's pregnant with a vampire baby!

Freaking hell. How did that happen? Of coz I know how exactly it happened (Bella and Edward went for their honeymoon after the much awaited wedding and the birds and the bees bladibla...) but seriously in a real life* situation HOW DID THAT HAPPEN???
FYI- vampire has 25 chromosomes (well according to stephanie meyer anyway) and human has 23 chromosomes (scientifically- not some made-up number). Insemination and fertilization are just NOT possible.

And the baby is now making Bella very unwell and thirsty for BLOOD! Again... how is this possible???

Anyways... I still love Edward. Others can F-off.

*Editor's Note: p53 dont be daft, there will never be a real life situation for things like this.

Breaking bad news

How not to break bad news!
from family guy- sorry for the poor quality of the first video, the second one was three girls messing about- which was funny nevertheless.

GP land

GP land so far has been very tiring but entertaining. 

At the beginning, I started with apprehension thinking that its all gonna be damn ol boring depressive patients. And common cough and cold. Plus the fact that I have to travel to an even smaller town for it (40min door to door journey).

I was right to some extend. Many patients like that. However, I've seen interesting cases. For example: barotrauma post scuba-diving, meningioma and palpitations that turned out to be an ectopic case.  

One of the GPs is an absolute bonker! I love him (just like how I love my BIGPROJECT's tutor). He (now will be called- THE GP) is a type of person who will put minimal possible effort to get by and hates patients who come in with nitty gritty problems. 

Quotes so far:

Patient #1: I think its the bugs that've been around. I bet you have a lot of patients with it.

THE GP: Hmmm... not a lot... only like hundreds each day.

Me: Is it alright if I go out through the back door? 

THE GP: Yup sure, because if you try to go through the front one, you'll find it impossible to do so. I've locked it. 

Then, there is another GP whom I like very much. He's so nice. When I found myself with a non-functioning otoscope and surgery list of multiple ear problems, I frantically went searching for a replacement.

GP: You can use my otoscope.

Me: But then what if you need it later?

GP: Its alright, I'll use yours.

Me: But its NOT working.

GP: (big smile + wink) I'll pretend that it is. Patients wont know any difference.

Eating Disorder

The other day I watched a very interesting documentary on Channel 4. It was about an 8 years old who is an anorexic. [Click here to watch it online] I was shocked to see such incident. 8 years old?!!! What's up with the kiddies these days. When I was a child of that age, all that I'm concern about is "will I miss the ice cream man if I take a quick nap". 

She's called Dana. Very beautiful girl. Pretty but thin (does this ring any bell??). (Editor's Note: p53 IS pretty and thin, but she is not in any way anorexic). It all started when she tried to eat healthily by giving up sweets and junk food. Then she became a vegetarian and not long after that she gave up food altogether.

It was shocking (to me, lest my sheer ignorance for the subject matter) to know that are more anorexic girls under the age of ten these days compared to previously. Obsession with body image has affected children of young age. Gosh- that's a disturbing thought. 

There I was- sitting in front of the TV gawking at it and making mental list of an anorexic's S+S. Dana ticked all the boxes.

• When she looks at mirror she sees a FAT girl (she is about 3 stone in weight)
• Extreme exercise (skipping all the time- mom took away her skipping rope, she then run up and down the stairs- mom detained her in her room, she then jumps on the same spot- dear God)
• Has a voice in her head that tells her thing and controls her LIFE.
• Calories counting. Even the older girls (in the rehab centre where she was at) was surprised to learn the fact that she knows the calories for everything.

[Click here for a review of this documetary]

The next day when I was in hospital I met a patient with ?Eating disorder. 80 odd. She refused to eat anything solid despite not having any dysphagia. Ensure (a type of nutritional drink/shakes) was delivered to her in small medicine cup- for which she happily drink away thinking that it was medicine. Ha! Of course the consultant was worried about her food intake, she's at high risk of not getting enough calories/nutrition. On further questioning (of her daughter) she has always been thin- all her life. 

Plus I noticed that she is very conscious about her appearance. Insisting of wearing matching coloured garment (pink nonetheless) from top to toe. At first I thought she's probably losing it (i.e. her mind- being old and all that), then when she really fiddle* with her hair while talking to my consultant or any other male doctors as a matter of fact, you know- with giggle and darting eyes. Body image issue anyone?

Numbers of elderly with eating disorder is underdiagnosed. The sad thing is when it is not detected(?) early enough, he/she will deteriorate fast or even die (many comorbidities and poor diet esp those living alone). 

My say: old also want to look pretty meh? Just enjoy life not that you have many of it left. 

*fiddle as in: brushing her hair away from forehead and tucking it behind her ears in a very teenage-like motion. difficult to explain, has to witness first hand.

Snippets

Here are snippets of life from the past few days: hospital and non-hospital related.

i) I started with a new team last Monday and I seriously could NOT ask for a better team. One month of hospital placement with a stroke/ elderly medicine team. The SpR, the ST doctor and the FY1 are all fabulous. I love them. Yet to meet my consultant (although I know him from previous teachings) as he is on his week-off for Eid celebration.

ii) Talking of which, we celebrated our Eid on Tuesday. Yeay! I didnt take any day off, no point really as there were no mosque close by that I could have gone to for Eid prayer. So I went to hospital instead. (No kidding).

iii) On Tuesday I received a lot of Eid wishes and that made me happy. I talked and examined alot of patients and that made the patients happy. I taught some 3rd year juniors some CT thorax and murmurs and that made them happy. I got off my ward early and that made me even happier. Then I had big dinner with housemates (they cooked traditional dishes and I baked!) and of course that made me super happy. Then when I thought I couldnt be any more happier than I was at the time, my crush called me. And that made me float. Really.

iv) So today I brought some of the cookies for my team and staff at the ward. I grinned from ears to ears with the reception that I received for my humble little cookies. 

v) Ward was quiet today. Except for a patient who screamed (very loudly!!!) when ST tried to cannulate him. He said and I quote: "I dont want anything doing with me anymore, just let me be. If its my time, then let me die. Stop... stop... stop everything (voice diminished)..."

Questions: When do we know when exactly to stop? When patient is competent, can we doctors still intervene against patient's wish, in the name of -patient best interest-? What happen to our oath if we dont do anything to this patient? Is it a passive euthanasia if we let the patient be? Does prolonging patient's life means prolonging patient's suffering?

vi) Alrighty, that was btw a patient with rectal cancer who bleeded PR last night (passing maleana and clots of fresh blood). He was an 80y-o (4years hx of cancer) and refusing any further interventions (fluids, bloods, endoscopy etc). This was a same patient who reported seeing things that werent there (?hallucination due to secondary mets in brain). Bless his soul. I dont want him to suffer anymore, but I dont want him to die either. Tough call. 

vi) One of my friends came to my ward (her ward was opposite my ward) and she was surprised to see that my ward is very modern and new and spacious and nicely done. And that my team is super friendly. Ha. Just my luck.

vii) Then later today I cooked soto for dinner. Very delicious yet very time consuming and patience-testing dish. So many different steps (make the rice, then the soup, then have to shred the chicken, then boil potatoes, then mix with mince meat, make meatballs, fry them, make fried onions, prepare cripsy vermicelli, prepare spicy chilli soy-sauce, omg why did I choose to make this in the first place???) Luckily I got help from couple of very nice people, even then all the cooking took 2 hours to complete. It look like this [picture credit]

Good day? yes. hope everyone is also having a good time no matter what you guys are doing. 

xoxo gossip girl eh, xzxz sleepy medic.

Updates

Hi to all, 

How is everyone? Hope weekend brings only joy to everyone's life.

Okkkaaay...

I finished one month placement in a block called Student Selected Block (SSB).

Glad that I started with SSB first (i mean if say for example I were to start straight to hospital placement with a surgeon- which will definately crush my world and make me miserable). 

During SSB I had chance to laze around (like seriously) and eased myself in a very relax and slow-mo way into learning atmosphere (remember that by the time final year started I had NOT done any serious reading -on medicine and surgery- for at least 5 months: yeah- all due to short project, big project and summer holiday). so phew!

The essence of SSB is for students to do as much as (or as little as- like me- BAD!!!) they like to gain insights into the medical world. Sound cliche I know, but we are talking business here man! There were compulsory sessions to revise skills (which was an utter waste of time me thinks because we all fecking know already ALL the bloody skills). Then there were human simulation sessions (SIMs) that were exciting at times and got stressful at the others. In SIMs, students were asked to managed a dummy for various emergency situation. The SIMs can speak, blink his eyes, has circulating blood, receive IV drugs n fluids and for f*** sake has a cardiac arrest!!! 

On top of all that, we had to do compulsory sign-ups fo career taster (read: spend a day or half a day with a consultant asking them a lot of questions about their specialty and hopefully taste what the specialty can offer). I was personally frustrated that specialty like genetics and hematology are not included in the list. Instead we had this long list of rubbish. And due to compulsory nature of having to do at least one career taster per week, reluctantly I had to sign-up for the rubbish ones (you can choose, but the choices are very limited, and all the interesting ones- I know how roughly the specialty works as I had spent time in doing projects- like oncology etc). Neurophysiology- wtf? Plastic surgery. At least now I know for certain that I wont ever choose to specialize in either  of them. 

If there was one good thing that come out of the career taster rubbishness; it'll be spending a morning with a newly appointed, not to mention super cute, Anaesthetist. He is so charming, its untrue. Seriously, I swooned and drooled. So bad, p53. But hey ho, anaesthetics is again NOT an area of interest. Radiology, however, seem promising (never thought that it'll be!) so I will definately consider it in case of me being complacent and as lazy as I am right now comes 5 years time. 

So that's roughly an SSB block in smallcity's base hospital. I heard in other base hospitals, they hardly have anything (what? two weeks of nothingness?) and close to 200 students were placed at this tertiary cancer centre of excellence. Dont know which one is better, our SSB or theirs. I still choose our SSB despite its utter crappyness over complete nothingness that will only send me straight to depression-land. 

Ok guys, weather is nice. I'm gonna go out and soak some sun and probably hit on some guys. Whoops.

Ps: Eid celebration program is in place. Whoops whoops... I baked some cookies last nite and managed to find matching scarf and shoes for my eid dress the weekend before. And now, who should I pick to be my arm candy (read: date) for the big kick ass eid celebration party in BIGCITY?

HIV

I think somewhere previously I had mentioned that HIV is one of my favourite viruses (reason: its clever, living intracellularly crippling the immune system insiduously, yeay!). Actually world will be a better place without it, seriously we are better off without this dangerous retrovirus.

FACT: More than 30 million people worldwide are now infected with HIV. That's alot! -Considering that there are a lot more undiagnosed cases. 

Speaking of which, mom and dad are worried that I'll be going to Africa soon (for electives). I am not. Well, at least yet. 

PS: Finally, a medically related entry! Ha. You guys will be pleased to hear that revision has started for (poor?) me albeit very slowly (escargot or tortoise like speed) 

Portfolio exercise for foundation application

huh.. a very serious topic... so not like me... but let me tell you all about it- just for a bit....

Amidst all the datelines of BIGPROJECT, we had a portfolio session slotted in our timetable today. Some big shots from BIGCITY came. OoOoOo...

Loads of things crossed my mind, few of which crossed my lips- shared with others. Fellow students seemed to have better example. But what you've learn personally thats count!
Got a moment where ideas of which example will be the best experience for the different sections of the foundation application... (sections that everyone kinda expected to be in the application anyway.. like teamwork)

I certainly never paid much attention to getting my portfolio done consistently with substance. Like many others, portfolio is a thing of a one or two days of frenzy prior to portfolio meeting... wham bang and voila... People from most of the other medical schools don't even have to do it. Trust me it helps (gosh, I cant believe I'm actually saying this- it helps a bit if not much). Reflection upon reflection really does make me think about ways to improve myself.

So bring on the foundation application!

Question

dont you just hate chunky notes?

10K Manchester Great Run

Yeah, I'm participating in that (yup, in a couple of days time). Training wise, if you ask me, I would say so and so. There were days where I ran more than the others. Its pretty damn hard. I keep on having different problems at different locations. First there was problem with my ankles (which is long standing anyway). Then there was problem with my knees (which sucks! big time, because it was really hard to concentrate on the run when sharp stabbing pain kept on shooting from my knees to my ankles to and fro). Then I tried running with ankles AND knees support, which didn't help at all. BOO! Then I settled on running every other days for a short distance, because the longer I run, the more moaning I will do later. And seriously, you guys wont want to be around when I'm cranky as its awful.

Now I think I have trained enough. 3K easily. And from there on: wogging (walk+jogging)! I keep on having chest pain (crushing!) which I don't think anything serious. All exercise related. Possibly be due to ?anaemia. I promised to one of my running mates that I will get it all checked up after the run (if I go now, the GP will say don't run -yeah- like defeat the whole point right?).

So all in all, running is bad. Personally, look at me, I'm falling apart. Osteoarthritis will come insidiously when I'm slighter older. Let not even start on microfractures. Oh, wait a minute, have the arches on both of my feet collapsed? Damn. I will reduce the amount of running very considerably after the Manchester Run. Running is such a high impact sport that now I kinda don't understand how people can do marathon without any problem. But I supposed the will power defeat it all. Yet another area that I'm lacking in for endurance sport like this.

On a different note:-

• I finished my community placement. Really enjoyed myself there. My report was rated 'Above Average' --> how could it possibly be that? It was supposed to be an excellent. I have a theory here, to get an excellent score student has to be present at the evaluation session (just so to put pressure on the supervisor). I got excellent for both of reports where I was present at the final evaluation. On the other hand, I got 'Above Average' for those that were marked in the supervisor's own time. My standard of work had been very high for all four written reports (hence I do believe I should have gotten 4 Excellents) However this time, I was not as furious as the first 'Above Average' relatively because I did have an awesome placement with my supervisor.
• I started on my BIG PROJECT (3 months: 10000words) at my base hospital. My supervisor this time around is a bit loopy. Is he really? I picked him out of all consultants in my hospital, and instead of doing a project with nice, not to mention good looking consultant, I chose to do it with a consultant which I find very amusing. Full of life! More to come about this BIG PROJECT. Watch the space!!
• I had my exam last Monday, and I swear to God that it was the most difficult exam in medic school yet. I was so frustrated by the end of it, I felt numb to all stimuli, I almost felt suicidal (if that's possible!). Don't fucking ask about microbiology, I don't give a shit about it, and so do my friends (make it all medic students from my uni). Whats up with all the histopathology shits that were included? I was so pissed off. If I knew that it gonna be that difficult, seriously, I wont even bother to study in the first place. Doom for failure right from the start.
• Please, however, wish me luck. I do hope I will pass.

Facts and some afterthoughts

• UK has the highest teenage pregnancy rate among Western Europe.
• Approx 180 000 abortions are performed each year in England and Wales.
  
• About one-third of all women in the Great Britain would have an abortion by the time they are 45.
• Rate is highest among the women aged 19.
• Abortion is illegal in Northern Ireland.
• About 40 000 cases of under 18 conception in England and Wales each year.

I'm so pro-life so I think abortion is wrong unless really really necessary (like anencephaly). Now imagine if all those hundred of thousands of the foetus are being born each year. Man, thats alot. Great more babies without a proper place/parent that they can call home. Of course mainly due to irresponsible behaviour leading to unwanted pregnancies.
And teenage pregnancy is soooo stupid. If you wanna have sex use protection, take pills, do something. This is what happen when one (woman) doesnt have any future ambitions/plans. I dont want a baby to get in a way of me reaching for my dreams, doing things I want to do. Plan ahead. Use protection. Dont get me wrong, I certainly love to have a baby (or alot, hehe) of my own. Just not quite yet. I'm young.
Whoever is young out there please please please enjoy your life (enjoy sex if thats what you like), use protection and use EC if worse come to worse. Just dont do abortion. Not fair for the baby. See! Its that simple. Use protection and not get pregnant and not having to think about the dreadful, horrible abortion.

Young girls and TOP

Well, it seems that I'll never drop this topic... might as well talk about it when its a hot topic under my radar.

The youngest person at the surgery that requested TOP was only 15 year 4 month. Almost half of the women that requested TOP in this particular surgery were younger than 20. In concordance with national statistics.

Taking us all back to why a large porportion of women asking for termination come from the under 20 age group. Some of them were simply too young. Some of them didnt even practice any contraception prior to falling pregnant. Was'nt that a big issue under public health that need looking into?

Sex in this cases might or might not be consensual [the latter which I wont discuss here]. Despite young women consenting to sex (read: not statutory rape even if illegal sex due to being under age) they should also practice safe sex. With accident (like split condoms etc) that lead to unwanted pregnancy hence TOP, the request in itself can be perceived as a good opportunity for patient education regarding reliable method of contraception.

A thorough discussion about this matter should be made compulsory during the pre-TOP counselling. Current guideline suggest that conraceptive should be prescribed before discharging these women following their abortion.

I rest my case.

Termination of Pregnancy

[will be referred as TOP here after]

Remember me telling you about my special placement in community? I'm actually doing an audit on TOP at a GP surgery located at the outskirt of the BIGCITY. This is my first audit and it is going on quite well. I'm pretty damn pleased with myself.

The most distressing fact that I gathered from my audit is the fact that almost 50% of all cases of TOP at my GP surgery were from women under the age of 19. Hardly shocking, I know. The very same statistics are reported by the DoH studies year by year.

In any average population, young girls (some had it done repeatedly, how irresponsible?) made up the biggest group of women asking for TOP for unwanted pregnancies. Not to say that TOP is morally right to begin with.

Don’t get me wrong I do agree for TOP if continuing the pregnancy imposes either a great risk to mother or if the fetus is nonviable anyway (like anencephaly or Patau). But I am certainly pro-life. And I think the idea of abortion just because say the timing is not right is absolutely appalling!

In this specific audit I’m writing an essay for, the youngest woman asking for TOP was only 15 year 4 month. That’s not even over the legal age for sex! But do teenage these days even care to have it the safe way (with barrier protection and reliable method of contraception) if they are at it like rabbits?

It is still a wonder to me how certain group of people remains irresponsible for their own well being and takes unnecessary risks. If one decides to have sex with a member of opposite gender, please pretty please use appropriate protection.

PS:Dont get me started on STDs.

Not again!

Do you guys remember me mentioning about a 10-y-o girl who self-harmed few days before? She's back in the ward again. I felt utterly disgusted to see her again in the Paeds ward, after only a day of being discharge out- this time around with another attempt of self harm (with knife on throat!!!) Disgusted is probably a harsh word to use. Probably not entirely ethically sound either. But hey, WHY ON EARTH?

I tried to think about possibly reason(s) of her committing the action of deliberate self-harm. Many times. And every single time I cant convince myself that her actions are justifiable. Not at all.

Physically: WELL.
Mentally: Distorted I guess. To think that childhood is the happiest time in life for most people (normal people thats it), its just inexplicable. What could have troubled her mind? Bear in mind she's in primary school. Pretty much normal family and pretty much normal social circumstances. Is there is anything bothering her so much in term of getting along with her parents/siblings at home or being bullied in school? NO. No mentioning of that in her file. Is she at risk of any kind of abuse (physical/sexual/emotional/neglect). NO. Bloody no!
Psychosocial issues: Come from an average middle class family. Few other siblings, very concerned parents. Patient reported argument with mum triggered her to kill herself. Like what???? Basically she doesnt get along well with mum, about everything and anything. I mean: come on, every one would have gone through the similar (or almost similar) situation, but we are fine with it. We all find ways to get around it, cope with it, distract ourself from this pathetic self-wallowing cycle. For goodness sake. 10 year old and thinking of ending her life? What the hell was she thinking? Is she harming herself to get attention? She certainly succeed then. But in a very wrong way. BAD!!! Still- her deliberate action is unjustifiable.
Body image issue: Possibly. But nay- dont think so, she's only 10 year old, but there's is nothing in her history suggest that. No body dysmorphism disorder noted, not under any apparent pressure to look at her best all the time. Still pre-pubertal, not associated witha ny normal teenage tantrums in the challenging growing to be an adult kind of story. Nope- none of that. She looks like any other 10 year old girls. No different at all.
Neurodevelopmental: No problem in this area either. No learning disabilities. No indication to say that she's struggling at school or struggling to fit in with her peers.

CAMHS (Child and Adolescence Mental Health Services) was called in (repeatedly) to assess her case. They can't get to the bottom of her DSH either. Clearly, it's better to keep her in hospital because the risk of another attempt is rather high if she is discharged. Tell me what other better way to care for this patient?

Updates from the ward

***Note: This entry was written when I was still in the ward, in between patients. HAHA***

Hi ya...
Updates from the ward...
Its getting very very very very boring down here.
Not much patients.. yeah- i know I should not be complaining..
but its finally getting to me...
Morning ward round this morning finished in AFTERNOON.. (around 1.30pm-- dear God!)
My consultant is nothing but THOROUGH. VERY THOROUGH.
She's good though.

Quote of the day (so far):
"My son is a bit of wimp"
-a mum on her 4y-o boy who was afraid to be cannulated.

Shocking goss:
i) A 2 weeks old boy came in with D+V (we have tonnes of them this afternoon!). His mum is 14yo. Yup, you heard me right. FOURTEEN! She's a child herself and now has this responsibility of looking after her own son. The best (or should I say the worst) thing is: She didn't know that she was pregnant until she was about 37 weeks. SHOCKING!!!
ii) A 10yo girl self-harm, multiple cuts on both forearms. Hx of attempted suicide twice previously. Come on, seriously, whats happening with the kids these days.
iii) A 9yo girl left hemiplegia with consistent MRI picture of right infarct. Bloody hell.

So there you go. xxx

Pitching it down to patient's level

I haven't been doing Paeds long enough to be an expert on writing this kind of stuff, but suffice nevertheless for my standard; as far as I'm concerned. You know how in daily routine of a doctor who works in Child's Health Department, he/she has to interact and deal with people from all walks of life. A bit like in General Practice and A&E I supposed.

The mix varies tremendously; ranging from neonates (clearly cannot speak) to infant (incomprehensible babbling) to toddler (mismatch sentences) to young child (very curious lot) to adolescence (unique behaviour --> can't really generalized them) to of course lovely (not!) parents. And then we have parents of different educational background, social class and dynamic with their child. Then there are kiddies who are unlucky enough to have speech delay for any reason.

Some doctors really do portray an image of a good communicator with the children. Really pitching it down to the kiddies level. In a rather cute and super friendly way, not putting up a humiliating act. For example: "touch your nose, touch my nose" -directing a child in a sing-song voice while testing for cerebellar function. Some just can't be asked: which make me wonder why bother being a Paediatrician if you genuinely hate kids?

Addressing a child as a Fraser's competent being (talking/asking the child to explain rather than going straight to parent) is a good way of building up rapport with the child. Ok, possible not the non talking kiddies. That's fair enough. But for toddler who can understand what we mean, I would definitely advised approaching the child first as an autonomous being. Plus, it is much fun hearing a child trying to explain him/herself. "I had pain here... my mom gave me calpol. She said I have temperature. I dont think I have temperature".

It will make a big different I think if a child is treated as an autonomous person. A doctor can try to include the patient in the management. For example: "Do you think you can go to the loo 7 times a day?" Patient will feel that the doctor has put some degree of trust in her/him. "Yeah, I'll try, I'll let you know how it goes....next time I see you" (real case of management of daytime wetting in an 8-y-o girl).

Then while doing the physical examination, please don't medicalized the test. Alter it into a child-friendly step. I think the best way is to demonstrate it on ourself. Like this: I want you to blow into this paper like this (then proceed to show how). With the tendon hammer or the stestoscope, let the child touch it first. (real case of a child who cried upon seeing the tendon hammer as she was afraid that it gonna hurt her). Let them know that its not gonna hurt. Seriously. Sometimes we as an adult forgets.

Adolescence. Hmm... been there, so I perfectly understand what exactly they are going through. Of course every other doctors had gone through the same phase of life. So we all should know how difficult it is to be a normal teenager, let alone teenager with (embarrassing/chronic) medical condition. "My friends think I'm a freak show as I inject myself (with insulin) at school" (again real case). Personally I like to share a personal story/ experience when talking to teens. "I remember times when I was called a freak too. Just because I wore braces at that time". Its all about making the teenage patient comfortable in speaking to you.

Its a tough call I know and I wont stop improving myself. Promise.

Today a patient opened up to me and another medical student about her past history. She was raped (!!!!!!! I couldnt believe what I was hearing at that time; utterly shocked) 3 yr ago and the her Paediatrician doesnt even know about that (Presenting complaint: a year hx of unspecific abdominal pain, missing school and learning difficulties). Talk about shocking news!!! I guess she must have found it easier to tell us about her problem.

That was a really good eye opener.

?DVT

?DVT : Query Deep Vein Thrombosis

?Acute Nephritis
?Angina
?(insert medical term here)

Often I come across the ? phrase in medical notes (electronically and on papers). The queries range from rather vague symptoms/explanation (?constipation) to the more worrying ones like ?PE or ?Placental Abruption.

As a junior, it is very tempting to query just about anything. The easiest trap is to ?(insert common condition) on the basis of association. For example: ?Eczema for a non-specific rash for a patient with history of hay fever or asthma. Yeah, its true that they can co-present in a patient but there are a lot of other differentials for rashes.

If we think that what ever it is we are querying if worth mentioning, then surely it is worth investigating. Do not ever leave it just there.

Let me explain this by giving a scenario.

Say a 25y-o Caucasian man came to GP complaining of 3 months history of dry cough and weight loss. Patient mentioned about him working as a builder and does a lot of works outdoor- making him very tired at the end of the day and feeling unwell sometimes. No other complaint otherwise. Generally fit and well.

As the coughing was more of a nuisance for him (I'll be fine with some cough syrup- he said), I prescribed him a cough linctus. ?TB. I was certain he would be fine.

Few months afterwards he was admitted to hospital with haemoptysis. X-ray showed cannonball lesions in both lungs and massive multiple mediastinal lymphadenopathy. AFB test was positive and he was treated promptly with the TB regimen (4 meds).

Looking back at his medical notes, "?TB" flagged up. Everyone questioned why didn't I investigate that further then? Considering that it had already crossed my mind.

This unfortunate guy could have died! He certainly not gonna be happy about his doctor knowing that there was a possibility of TB (?TB) but not taking it any further.

You get what I meant now?
If its worth mentioning then its worth investigating. Anyone who is caught up in situation like that will have to put his feet in his mouth. No way out!

Remember:
i) Do not use ?X just for anything. There are implications
ii) Refer to your senior if in doubt. "?TB, spoken to Resp Consultant- he agreed to have this patient under his list- non urgent referral"
iii) Beware of patient's anxiety "?Diabetes- Patient: Do I have to inject insulin now/soon etc"