Feb 17, 2014


Today I started my two-week apprenticeship in Hospital Sultan Ismail which comprises of one week in surgical wards (surgical + orthopaedics) and another week in medical wards. The second semester of my third year is a lot different from the first semester. In the first semester, we had FoCP which stands for Foundation of Clinical Practice. This is the time where we learnt how to clerk patients properly and to be able to make differential diagnoses about the patients, meaning to list down all the possible diseases or conditions that the patients might have. That itself is not easy. It takes time to know what questions that should be asked and a longer time to know when to ask the questions. Let me give you an example:

The patient comes to you complaining of fever since 3 days ago. Fever can be a cause of many other diseases and illness so you have to ask other questions to narrow it down:

  1. If the patient has light sensitivity or neck stiffness, consider infection of the lining of the brain.
  2. If the fever comes with abdominal pain and vomiting, consider inflammation of the appendix.
  3. etc. etc. etc.You get the picture.
My second semester is named EJR, which stands for Essential Junior Rotation. There are 5 rotations in all: CIDR, Primary Care, Paediatrics, Obstetric and Gynaecology, and Mental Health. All rotations take one month to complete, except CIDR, which is my first rotation in EJR and of which I am doing right now. CIDR stands for Chronic Illness, Disability, and Rehabilitation and it lasts for 2 months because it covers a lot of important chronic illnesses that are common such as COPD, heart failure, cancer, etc. The last two weeks of CIDR is the apprenticeship week where we have to attend ward rounds, do some risk assessment tools, write up at-risk patient report, do a verbal passing-over to any doctor, and write one referral letter to other allied medical professionals. It's a lot of work but it is quite rewarding because we have more time to observe the doctors working there.

I have met a lot of patients from the first day I started my third year here. However during the FoCP I did not have that much time dealing with patients as I am now during EJR. It gives you a sense of realism of what the doctors are actually dealing. I see a lot of sick patients. Some are stable that they can make jokes, wander around the ward and tell excessive stories of what happened in their life. And some of them are so sick that they cannot move their arms or legs, cannot speak, cannot speak in a language that we can understand, cannot control their bladder or passing motion, cannot stop their tremor, cannot initiate movement. Some of them are in pain, feverish, have chills and trembling, and fatigue. Some of them even are in coma, unconscious, drowsy, confused, disoriented, hallucinating, paranoid, dehydrated, and in despair knowing that their illness has no cure and all is left to do is to have comfort while slowly or rapidly approaching death.

It is not easily to look them in the eye and not to dismiss the thought of, "Okay, this patient is not likely to get better. He's going to die soon if he does not stop smoking or get an appointment with the specialist soon." Sometimes we will come across patients who have the condition because of their lifestyle and deep inside we cannot help but to judge them. "That's what you get when you smoke so much!" "RVD positive? He must have multiple sex partners or worse, gay." And sometimes they have the diseases by chance, for example, from infection or worse, hereditary. For example, cancer or lung infection or tuberculosis.

Today I shadowed one houseman performing her procedures after the ward round. She was unlucky to had to do procedures on difficult patients. I don't mean that the patients are being difficult but the procedures become difficult because of their conditions. The first lady was an Indian elderly lady. Te doctor wanted to set central venous line to administer drugs into her body but because of her thick skin she couldn't get to find the right veins. She had to try all veins at the back of her palm, at the inside of the elbow, even at the back of the ankles. And every time the doctor inserted the branula needle the lady would writhe in pain and moaned "Ayomma ayomma, amma..", even though she herself is quite old she still calling for her mother. And when  she moaned in pain and all the doctor could only say, "Sorry ah doctor, sorry ah.. sakit sikit je.. tahan ah," and desperately hoped that the next jab would be successful. I was struck with how we often sympathise with patients being tormented in pain that we often forget that the tormentors, the doctors, are also tormented to inflict pain to their patients.

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