The Finer Points of Learning

I attended my team's clinic yesterday. As our team specialise in colorectal surgery, a majority of our cases seen were bum cases.

I arrived early and managed to clerk a new case which had to be presented to my specialist later on. A colleague of mine was already tagging the specialist in his clinic when I arrived. They were seeing this patient with haemorrhoids, and was already examining the patient behind the screen. I joined them after obtaining permission, and the scene that greeted me was really quite hilarious.

The patient was on the examination couch, lying on his left, legs bent to allow optimum exposure of his rear end.
My specialist had already inserted the proctoscope, but very strangely, he was looking away from the patient and looked as if he just licked bile.
My colleague was standing at the foot of the couch, giggling silently.
There was a strange smell within the cubicle.

I think my specialist took a blow in his face. (LOLOLOL)

I took a peek into the proctoscope, and saw some faecal material within the proctoscope. Looked like the patient did not answer nature's call that morning.

To cut a long story short, the patient underwent a rubber banding for his haemorrhoids.

I learned that we cannot be too enthusiastic when doing a proctoscopy... Do not stand so close when removing the probe, and be careful of noxious gases.

To all those who will not be peeking into other's bums in future, remember to empty your bowels before seeing a bum doctor.

Learning the ropes

Surgery is not my favourite division of medicine. In fact, it is probably my least liked subject. And it is not because I am haemophobic.

There is just something about surgery that gives me the chills. Personally I find surgery relatively messy, dealing with abscesses, intestines, infected wounds, hernias, cancers... The list goes on.

When I was in my 3rd year of studies, I did a 10-week rotation in surgery. Needless to say, I wasn't the most enthusiastic student and only spent enough time to learn the basics, whatever was necessary to pass the exams.

Now that I am in my final year, and in my final months of studies, I find myself going through this rotation again, this time for a much shorter period, only 4 weeks.

I am taking more interest in surgery now that I am almost completing my training, voluntarily doing or assisting in procedures.

After a whole morning in the clinic yesterday, I realized that there is more to examining a patient than what medical school can teach.

I've already been reminded of the importance of wearing gloves in a previous post.

Yesterday I remembered to wear the latex fingers before performing a rectal examination... But I only wore it on my right hand. I thought that since I was only going to use my right index finger, what's the point of wasting another glove for my left hand?

I only saw the point after applying KY jelly on my finger. I needed my left hand to part the err... you know what I mean. So there, bitten by my stupidity again.

That was for the rectal examination. I was observing the house officer inspect another case, this time a fistula in ano. I could never forget how bad the smell was... It reminded me of smelly salted-fish with belacan. Ughh....

So lessons from clinic :
Always wear gloves on both hands. You never know when you might need your hands or what you will touch.
Always wear a mask when examining a fistula in ano.

I am wiser now.

My Hands

I did something quite dumb today. I examined an inguinal hernia without wearing gloves!

No, it's not a deadly sin, but would have been better had I donned the gloves. The purpose of the gloves is mainly for hygiene sake, protection for my own good against body fluids of a patient.

I only thought of those darn latex after I started my palpation, when I felt that something was not quite right. Everything felt so....distinct! Only then was my mind flooded with the same message,

"Bare hands! Bare hands! Bare hands! Bare hands!"

The joke is on me, really. Moral lesson of the day : Don't forget your rubber.

I won't, hopefully :P
Thankfully there were no secretions or discharge. Phew!

Pieces of You

Reading Kian Guan's blog made me think of 1 person I never want to forget...

I read a very sad blog of my friend today about the abandoned children of an orphanage just down the road of our hospital. This orphanage would send children to the hospital when they were ill. Some with chronic diseases would stay for a longer period of time. Some stayed on so long that they become a constant in the paediatrics ward.

The blog made me think of a little girl that I met while I was in my Paediatrics posting. This is an entry from my personal diary, which I wish to share with all who are reading this blog.

I'm now in my Xth week of Paediatric posting.
Tonight, I want to write about a little girl. Let's call her May. She was 3.
May was admitted 3 weeks ago for bronchopneumonia from the orphanage. My team was on call that night and I remember that she was fretful, and awfully quiet. She also had a headful of lice and fungal infection behind her ears. She refused to lie flat, just curling up on her side.
It was a Friday night and we had 5 admissions that night so I did not pay much attention to her for the rest of the weekend. My colleague was actually in charge of her, not I.
On Monday, the nurses informed us that they noted a rectal prolapse while showering her. She also had extremely foul-smelling faeces despite frequent change of diapers. They also had difficulties feeding her as she was refusing food.
That evening, I stayed on in the ward until dinnertime. I saw that May did not touch her spaghetti, hence I sat down next to her and decided to spend some time with her. I managed to coax her to take several bites of spaghetti. She ate 4 spoonfuls and smiled at me once.
According to the welfare personnel, she was found roaming the streets with her mother who was begging. Her mother was sent to another welfare home and the custody of May was taken away from her.
The next few days, May refused to eat or drink. She did not speak a word. We had to forcefeed her with a feeding tube. We were also working out the reason for her rectal prolapse.
One afternoon, I had just finished examining a patient when I saw a lady next to May, appearing very concerned about her. She was May's mother. Strangely, May did not express any emotions upon seeing her.
From that day onwards, May's condition deteriorated. She developed septic shock and was managed in the HDU and later the ICU. When she showed signs of improvement, she was then transferred back into the HDU.
This week, she was improving clinically and also responded to us. I would spend some time with her during lunch and she played with me. I even saw her smile several times. I did not hear her speak any words but she made some vocalizations, and was willing to drink her milk after some coaxing. She was still very weak, but she clung on to me when I carried her. My registrar allowed me to remove her femoral line 2 days ago.
Today, May collapsed, was asystolic and had to be intubated following resuscitation. She was transferred into the ICU again. When I saw her in the afternoon, she had to be on triple inotrope support and was already in shock. I couldn't stay on as there were rounds in the other wards. After rounds, I stayed back in the Paeds ward to see some other patients and did not leave until about 6pm. On my way out of the hospital block, I thought of dropping by the ICU to see how May was doing. When I arrived, she was just pronounced dead.
I was shocked, but I stayed on to see the nurses bathe and wrap her tiny body before sending her down to the morgue.
I am recording these events because I am afraid that these memories will get lost along the way in my busy life as a doctor. Perhaps I won't forget her at all. She was the first patient that I was actively involved in the management of her condition. She was the first patient that I fed. She was the first patient of mine that died.
I don't think May will fade away so easily. I will probably remember feeding her spaghetti, teaching her how to roll the noodles around the fork. How can I forget the satisfaction of seeing her smile? I will remember her beautiful long eyelashes that framed her round eyes. Maybe I will sometimes think of the way she clung on to me when I carried her. Perhaps it will be her little voice with the few jargons she muttered.
I remember thinking to myself when she was still with us that she would grow up to be very pretty. I was hoping she would succeed in life, after all that she had been through. Now I can only hope that her soul is at peace.
Tonight, I cried for May, for all that she ever was and all that she could have been. My one regret is that I could not make her laugh while she was here. Maybe happiness eluded her life from the start. Or maybe she never learned to be happy. But It does not matter anymore, for May will never smile again.

As a medical student I have learnt to be empathetic, detached, tough, professional. It is dangerous to be too emotional about our patients. But we learn from them, and sometimes we just carry little pieces of them with us wherever we go.

Christina Georgina Rossetti. 1830–1894

Remember

REMEMBER me when I am gone away,
Gone far away into the silent land;
When you can no more hold me by the hand,
Nor I half turn to go, yet turning stay.
Remember me when no more day by day
You tell me of our future that you plann'd:
Only remember me; you understand
It will be late to counsel then or pray.
Yet if you should forget me for a while
And afterwards remember, do not grieve:
For if the darkness and corruption leave
A vestige of the thoughts that once I had,
Better by far you should forget and smile
Than that you should remember and be sad.