Dear Drs.Yap BH, Low EH, Paul Lim, Lam KS, and Chong YS,
First of all, i would like to extend my heartfelt thanks to you all for allowing me to undertake my attachment though i'm still fresh and still don't know most cases you all see.. it's been a pleasure really for it has opened up my eyes in the field of internal medicine, orthopedics, ent, oncology and radiology. thank you very much. it's been a great experience, really and you all have thought me alot of things.
i went in on the 1st of aug under the supervision of Dr. Yap BH and Dr. Low EH... Dr Yap being an internal med specialist, i have to say have exposed me to things that i haven't seen before in my life... the past 2 weeks of medicine i've seen is all under dr yap's cases. though i don't know many things, u have been patiently guiding and teaching me how to pick up clinical signs that i've come to know not only from the textbook but through your 25 years experience as an internal med specialist...
i've seen 3 cases of scleroderma, which according to u, it's once in every 5 years... must be pretty lucky to have seen those, especially when they show the full fledge CREST syndrome with them... and to see how you have treated a 20 yr old pt with renal failure and fits that caused her to bite her tongue till bleed, due to post dengue infection really made me wonder how bad can such cases be... or a 27 year old pt who is a Dr. himself graduated in adelaide as a skin specialist being diagnosed of lung ca. as you've said at times, life is a tough shit...
i've seen procedures like underwater seal, how you puncture the lungs to drain the fluid out... trephine biopsy and bone marrow aspirate for suspected marrow aplasia... ogds and colonoscopy for stomach ca or colon ca... it's been a real eye opener in watching procedures for i will not be able to see when still studying in BJ...
as for the oncology department, i begin to und that NPC is so common like a bread and butter cases for the oncologist. and i've seen hepatoma that has spread to the lungs giving it a classic cannon ball appearance to both the lung fields... lung metastases normally have only 20% of survival rates... and it's such a sad thing to see patients suffer real bad... metoclopramide as we all know is classified as a drug that increase gi emptying but with anti emetic effect... in onco, it's used primarily as an anti emetic.. then you have the lignocaine which we studied as an anti arrythmic but it's used primarily as a local anesthetic in hospital setting... ondansetrone is also used as an anti emetic in the chemotherapy treatment but of course, it's more expensive than the metoclopramide....
cost is a factor that most docs keep in mind in treating the pts... normally those who are admitted are arleady mostly presenting with CCF, pulmonary edema, cardiomegaly and with the textbook findings of kerley b's, bats wing appearance and orthopnoea.... and of course, u get to see some rare cases of tardive dyskinesia which is due to prolonged intake of anti psychotic drugs.... and maybe u're lucky enough, u'll get to see pts with impaired vision due to stroke and get the docs to teach you how to check the pts visual acuity...
bilateral pedal edema is very common here in tung shin... in every 10 pts i visit, 8 will have it for some reason... in the orthopedics, of course we haven't studied it's a real tongue twister in pronuncing the ligaments and bone structures... but after spending bout 5 days in the orthopedic clinic, it's not too bad... there's flexion deformity, varus deformity, OA, ant and post cruciate ligaments, collaterals, meniscus... the list goes on... then u'll just watch as how the doc does his routine checkups on the pts and perhaps if ur lucky, they teach u how to read bone x ray and ct scan of L1-S4
radiology is a real bore.. but then it's a experience.. basically ur work bench is facing a 5 panel x ray board flourescent light, a u/s room, ct scan room and an x ray room... it's a great thing to learn how to read ultrasound under dr chong... differentiating betw a cyst and a growth, which one is a prob metastatic and which is a primary tumor... here, i learnt how to read x ray with great detail... with dr chong as a radiology expert, he teaches u to read mamograms, ct scans, x rays.. yada yada...
my attachment sums up with some real juicy time watching the orthopedic ops... i watched for 3 days during my 2 weeks here... it's no fun cuz u have to stand.. but it's great seeing how an op is done... being able to witness total knee replacement, hip replacement, hip revision, arthroscopy, bone grafting, excision of some subcutaneous tissue that causes pain in the heels makes the attachment here even more interesting...
but of course, while it's good to see these things on a positive note, there are others as well whom defaulted treatment in TB, or be it ca and coming back later with treatment only having to face the scolding by the docs who treated them initially... sometimes, they take a longer time to recover but most ca cases who have defaulted treatment, it's usually a death penalty for the tumor has metastasize... most defaulters, 1 more year they have left...
as what the doctors here say... it's ok to treat the pt and the disease but it's a hell lot tougher to deal with the emotions of the relatives... i mean how would you break news to the relatives of a 20 yr old girl who got ARF due to dengue and having fits, biting her own tongue till her mouth is frothy with blood and having to undergo dialysis due to creatinine levels sky high and prob have to do so for the rest of her life? and rest of her life is with a mean of 10 yrs.. means she'll go at the age of 30? having to tell her mum that she'll need a kidney transplanted to cont living is a real tough shit to deal with...
first time seeing a tumour marker AFP 4,000,000 where the normal reading is within the range of max 30... 4 million... full blown hepatoma... 45 year old only... i mean how tough shit can one face? but on the looks, she looks very ok to me save for her SOB...
so in all there are so many things that i've seen, and a little tricks in the trade that i've picked up from the docs here... ACE inhibitors are better in some pts while the ARB are not that effective... u can also actually put the pts on all the 3 types of diuretics if their HT is off the wall... and of course, once in a while, u get to see huntington chorea.... mitral stenosis and regurge murmur i've heard twice and that collapsing pulse thing, felt once...
a pt with VSD, the smaller the hole, the louder the sound, and palpable thrills can be felt beating onto ur palms as you palpate them on their chest... it's a real thing that i've felt and will not forget the presentation of a thrill, cullen's sign, CREST syndrome, tardive dyskinesia and other rare cases... once u've seen it, u'll not forget...
i guess that once we have chosen this medical field to go into as our life long career, there are things that we have to do to protect our very own sanity.. oncology is a real dog shitty fucked up depressing place to be and it's the worst place to start of with if you haven't been hosp attachment at all... this is because of the naiveness of the patient who ignored the signs and symptoms and come in late in the progression of the disease... most are diagnosed with stage 4 with presence of metastasis... the less depressing ones are the orthopedics... even ent you have the NPC which is now a real common ca case... radiology is the best but u don't interact much with patients and u just do u/s, ct scan and x ray and intepret them.. earn hell lots but get exposed to radiation kau kau.... not worth it in the long run...
equally as depressing is internal med.. u are the jack of all trades and by being so, u mostly see pts of terminal illnesses of every damn thing... but mostly those patients who send u up the wall are those who default treatment... and screw up and expect u to pick up from where they left off... really sometimes PIA(pain in the arse)...
so back to the point... seeing patients of critical stages, sometimes as a med student, we have pledge to do our best for them, to save them, to help.. but at times the most simplest help is to do nothing.. and being a person whom i would never give up it's real fucking hard at times to just sit and stare for the only treatment u noe is palliative care... u put up a brave front on the pt and their relatives, and then choke back tears as you enter the staff lift, away from the public appearance.. there u can cry, or u can curse or can just stare through the windows wondering how helpless it can be even to the best doctors in town...
sometimes it's just as what i said earlier, tough shit...
i've finished today my 2 weeks in tung shin... it's good to expose ourselves but one thing i realise is that we have to accept sometimes that do no harm to the patient is as simple as doing nothing and watching them live their lives off being happy and not receiving treatment... it's the one thing that i have not yet able to come to terms with...
perhaps time will tell... as for now, i'm thankful for everyday i'm alive, still breathing and being able to enjoy happy moments with my family, with YOU, and with my friends and as well as those who held grudges against me.... there is no point in hating someone anymore... life is short... and i plan to live it by being the most contented person i can ever be....
thank you to all the fabulous doctors who inspired a medical student into believing in himself..
thanks...
