Finale

Finally, the dreaded end-of-posting test. Had I learnt enough? Have I been well-taught? Can I remember everything?

The moment of truth.

MCQs sucked -BIG TIME. They were so un-clinically related and so theoretical, a biochemistry major could have sat for it and gotten the same marks. And the scope - huh?? What to do with teeth that have fallen out? Isn't there a dentist somewhere? And anyway, the entire paper was set by NUH tutors so it just plainly wasn't fair. I wouldn't have minded if it's my fault - but everyone else was screaming foul, so there. The NUH tutors would have elaborated (and stressed) on some of these topics, I shouldn't wonder.

The slide test was no better - we were given too little information, the pictures looked remarkably normal for some, and the first question was absurd. Why are they testing us on such uncommon ailments?

Viva voce was quite a semi-disaster. I conveniently missed a perforated viscus and air under the diaphragm on the chest x-ray, and only got the diagnosis right after going round and round about fractured clavicles and such. At least the equipment part was alright - endotracheal intubation. ECGs were good too - ventricular tachycardia and ventricular fibrillation, although I sustained a gigantic mental block and got stuck for a few seconds when my tester asked me how I'd manage a pulseless VT. Oh, and the 2nd xray - anterior dislocation of the shoulder, and tester managed to worm from me that I've never seen a reduction before. She was pretty nice about it though, and anyway I got the theoretical reduction correct.

Well ... we'll see.

Final 3 Days

Ah, been on a hiatus for some time! Partly because I've been so caught up with studying and seeing cases, it just seems so ... inappropriate, to continue thinking about e med-related stuff during free time at home.

Yesterday, though, has to be recorded down. It was my ambulance day shift, and honestly the first part was so bad. I just couldn't clique with the medics on that shift - for some reason they were the exact type of medical personnel who were there just because they had to, and I was not enthused. And secondly, (I say this with no intention of discrimination whatsoever) most of them were Malay, and during the whole time they were speaking in Malay. Granted, I could understand quite a bit of their conversation (usually frivolous stuff involving under-aged schoolgirls), I still felt rather left-out and the whole thing seemed a nasty waste of time.

A very strange point of note though. The senior medic, an Indian lady, was at first rather non-communicative. It wasn't until our 2nd case when I met some classmates who were in proper ED "uniform" that she started being friendlier. Perhaps she initially thought I was some secondary schoolboy there for a school visit? Thereafter she started letting me take full histories and handing cases over to the staff nurse, how odd.

The best and most woeful part was the handover of duties late at night. I was SO pissed, since the next batch were just plain wonderful!! If I thought my night posting people were good, these had to be 3 times better. 2 ladies, 2 men who were all so amiable I couldn't stop chatting. What a waste though - I really *would* have stayed on for night rounds, if not for the fact that I was totally zonked from reading the entire e med text one more round, and that there's an upcoming test. The female junior paramedic was most interesting. She kept asking me questions (regarding the cases of course .. I wouldn't have minded PERSONAL questions however - she was cute in her own way and less gung-ho than the one during my night duty) and paying rapt attention to my talk on septic shock. Strangest part was, she was TAKING NOTES. OMG. I really do hope I didn't give her any wrong info. If someone with septic shock comes along and she does something wrong cos of me, I'll really be on my head.

And now for the cases proper:

1) From a certain polyclinic near Aaron's, an Indian gentleman presenting with right iliac fossa pain, colicky, no nausea/vomitting, no fever, faeces normal. On examination, marked tenderness over all areas of abdomen, voluntary guarding but no rebound tenderness. Polyclinic personnel's differential was acute abdomen, appendicitis. However, I thought he behaved in a manner consistent with ureteric colic - just rolling about in pain. I was right! =D Ah, one of those classic times where it's a first-look diagnosis. Don't even have to take a history.

2) OK, I need help with this one. Old lady with past history of ESRF presents with lethargy and weakness for 1 week, and 3 days of productive cough. No fever. No signs of urinary tract infection. P/E revealed abdominal catheter used for peritoneal dialysis, but she has not started on it yet - due to be this Fri. Any idea what this is? Differentials so far could only include sepsis and uraemia.

3) Secondary schoolgirl (NS medics went NUTS when the com announced we're going to Crescent) who "collapsed" (according to their teachers - these people have NO IDEA what a real collapse is) after a dance competition. Difficulty breathing, with rigors and chills. P/E revealed dypnoea (RR=25) and generalised weakness. So. Young girl, stress from competition, hyperventilation anyone? Hah ... The senior paramedic was positively rolling her eyes ...

4) Yet another secondary schoolgirl who fell off her monkey bar, bled and fainted. I was starting to get excited - haven't really seen hypovolemic shock. However, another paramedic on a bike arrived there before us and said .. no need to go hospital. She fainted cos she saw blood .. vasovagal syncope. No fractures, no nothing.

5) On our way back from the abovementioned school we routed over yet again to that first polyclinic to pick up a Malay woman who had non-vertigous giddiness for 2 days. History of DM x 2 years, defaulted meds (was on traditional Malay medicine - for goodness' sake!!) and recently started back on meds. I'm suspecting anaemia. Initially the top of my list was hypoglycaemia due to new meds, but hypocount was 7.7.

6) Oooh this one was interesting. Somewhere in a NUS hostel, married couple. Husband was frantic, the wife was suicidal and blabbering nonsense and absolutely delirious. History of past cervical CA on chemo, had first shot last Friday. Sudden onset of delirium and suicidal tendencies (kept going for the kitchen knives) this morning. We had to restrain her in the alpha, and boy, was she strong!! It's amazing how much gust these thin fragile women can have when agitated. Ended up tying her down on bed, and she was spouting nonsense with big staring eyes. Kept wanting to scramble out of the alpha.

I have absolutely no idea what that was about.

7) Once again went back to the polyclinic, this is an Indian gentleman with left hypochondrial pain, constant since this morning. CGS 14: E4 V4 M6. Claimed to have vomitted stuff that looked like strong tea or coffee, no history of cofffe ingestion. Faeces was normal, no fever, no rebound, no history of alcohol ingestion, no radiation, no pulsatile mass. Known DM, hypocount 26.6. Might have been a DKA? Probably a BGIT. Vomitted again in ED and ah .. yes. It was clearly coffee grounds vomit. Very large pulse pressure 180/80, managed in P1.

Now at that time they had another 2 interesting patients in the ED. One was a female who went into asystole for almost 1 hour and they brought her back, WOW! BP was still poor but started on dopamine. Another one was Mr. LL who showed me this ECG - narrow complex tachycardia (HR=200) with no p waves. Anyone? First impression was VT, until you realise on closer inspection that the QRS complexes are actually only very slightly irregularly irregular. Yep, it's an atrial fib with rapid ventricular response. =D Patient looked remarkably well but was managed in P1 anyway.

Day 10 of 20

Had the management of a multiply-injured patient course yesterday. It was pretty interesting and learnt loads of stuff in the flesh, which makes all the difference. We can read all about primary and secondary surveys but it's really doing it that hammered the stuff in! The victim extrication and helmet removal was a little far-fetched - isn't that what paramedics do best? - but at least now we have a bit of an idea how's it's really done. Of course, learning to apply the Donway splint was good!

Then, we had an extra tutorial by Dr. Palam on ECGs and ABGs - he really konked me out for ECG, with stuff like how to differentiate between supraventricular tachycardia with aberrancy vs ventricular tachycardia (erm ... they look EXACTLY the same), and introduced new stuff like fusion and capture beats in a VT. Crap ... I really need to brush the ECGs up. ABG was surprisingly easy, he kinda comforted us by saying that in the viva test, they usually ask straightforward cases like respiratory alkalosis/acidosis and metabolic alk/acid. None of that scary respiratory alkalosis on metabolic acidosis mixed-picture horrors.

Now, delice didn't want to take my cases, and now I feel like a huge leech! We were supposed to exchange! Hah .. alright then ... free cases! =D Now to get down to writing. I suppose I'm better-off than a few in my group; apparently it's really difficult to do 10 writeups in 7 days. It's trying to find cases that sucked.

Well since it's the weekend and I have absolutely nothing to do at home, have to wait till 10pm for yx to get online, I decided to stay on and see if I can get anything more exciting than stuff like syncope, anxiety syndromes and PUD. Alas, no .. there were so FEW patients!! Like 5 P2 patients in 30 minutes? Which is hmmmmmmm. Where did all of them go? It must have been the VRE.

Anyway, there was a minor trauma case of a motorcyclist being flung off his bike and sustaining a suspected pelvic fracture - the very, very nice surgical MO gave me and another guy a mini-tutorial! Of course it's nothing surgical - just a recap on primary and secondary surveys and chest tubes etc. Then, while I was clerking this gigantic man with supposed chest pain and dyspnoea, Dr. Oh came in and great!! You really just gotta love this woman - she *relishes* teaching. She was quite perturbed by the fact that the gigantic man was giving inconsistent history. At first I was suspecting (and evilly hoping) for an MI or at least angina - usual medical student fashion, but well. He fell ASLEEP and SNORED (thundered, more like) while OJJ and us were talking! SO. I was thinking, was he here just for the bed? These people ... Anyway, OJJ went through the different cardiac markers with us and things like caveats in Trop T measurement. The nice thing about her is that she shares a lot of personally-experienced things, stuff that aren't in the texts. Like the imporance of the relative measurement of CK vs CK-MB.

Was almost 8 by the time I was done .. drats. A&E really should consider having windows that can be seen from the critical care area. It's a nasty shock to find out it's black when you step out, and even worse .. the darned carpark was so creepy.... ok, no more staying till nightfall. It's just too creepy.

Day 9 of 20

Ah, it's been a good day!

It started off with me being irreversibly late for lessons, and thanks to Dopey's sms I woke up in horror and decided heck ... I'll skip the lecture. Ended up chasing writeup patients to follow them up, managed to get 1 and the hyperkalaemia patient was already discharged - good for him!

Highlight of the day was something we don't usually see everyday - drowned patient. I initially thought it was a near-drowning case, but apparently he went into asystole in the ambulance. First time ever doing CPR, it was awfully tiring; some 5 or 6 of us took turns to pump the young man. Just before that 2 trauma surgeons were in the next cubicle stitching up a poor woman who had a nasty fall down a flight of stairs, so when the drown victim came in the surgeons helped out as well. The ED doc ended up giving repeated doses of adrenalin to kick start his circulation, so we had quite a few false alarms - every once in a while we'd think there's a heartbeat, but it always disappeared after a couple of seconds. =( After 30 minutes he decided to stop resuscitation, man's parents were told he's in asystole (the poor woman was in such grief, according to R) and just at that moment, his heart came back! =D Great eh? Now they're hoping his brain will be alright, but chances are slim. Possibly end up being a vegetable even if they managed to bring him back.

Right .. too tired to really type, going to take a short break before doing some writing.

Day 8 of 20

Ashamed. Did not go to hospital at all...

Day 7 of 20

Belated entry - fell asleep after the ambulance run!

Not very eventful, but at least I saw a drug overdose case. Well in chronological order:

1) At 9pm, the siren sounded - a very confused medical student (moi) didn't know that was the Let's Go! signal until SSG Maddy filled me in on that. Turned out to be a near-syncope or fainting case, I don't really know since by the time we reached there, the man was kinda conscious, GCS 14 (E4 V4 M5) and lying on a makeshift stretcher. History was, he actually went to the public toilet near a market to pee, and kabonked. The over-enthusiastic toilet attendant was so garulous, he literally talked non-stop all the way till the patient was loaded into the ambulance! They did a hypocount for him before loading him, and he was a known DM who claimed he took 1 glass of beer (questionable - he was absolutely reeking of alcohol actually).

Met Alvin Ang's gang when we arrived in hospital.

2) Somewhere around midnight we ran off to Jurong for a fall case - at first, I got really excited. I thought it was a fall from height! Gah .. turned out to be a DO case, he got groggy and fell down. A passerby called 995 and disappeared from the scene. Man admitted to being PSY case, been at IMH and given amitryptylline. He took 16 tabs of that; before that, he took 8 panadols within 1 hour, supposedly due to a right flank pain. Past medical history of prolapsed intervertebral disc, but on the alpha he didn't exhibit a positive sciatic stretch test (impressive maneuvre by the lady paramedic!) Also, some tenderness around the epigastrium with no guarding. ECG was normal.

Had a mini-tutorial by the lovely ER doc at NUH on DOs, and we were commenting on why the IMH doc gave him amitrypt. when this man actually had a past Hx of DO. SSRIs should have been given, according to our dear pharmacology books. I was so engrossed in talking with the doc that I think I delayed the poor paramedics by 2-3 minutes, ooooooops. Too bad I couldn't stay to watch the gastric lavage!

3) One of those DUH! cases that the paramedics complained to me about. Young lady (NUS student actually, lol ... PRC) complained of severe epigastric pain, with past Hx of gastritis 2 years ago. Gah ....... why would anyone want to call for an ambulance for this when they can jolly well take the lift to take a cab? Hmm .. perhaps they thought that 995 was a free service. AHA. Wait till they get their $100+ ambulance bill. =D

The paramedics are really a very, very fine bunch. Most impressive was the lady staff sergeant, who was quite pretty but a little too gung ho ... they really liked having med students on board, I could tell. And hmmm ... actually made me give them some tutorials? Hahaha ... some of the stuff I was asked:

1) If stroke is usually accompanied by fever
2) Exhibit proper technique of abdominal palpation (they only do 4 quadrants instead of our 9)
3) Differential diagnoses of epigastric pain
4) Proper history-taking of epigastric pain in young women (I was DEEPLY impressed when the SSG asked for last menstrual period! Ectopic pregnancies!!)

Hit off really with especially with the NSman medic, we really talked a lot through the night. It was disappointing that there were only 3 cases though. And the night was awfully dreary. I declined to be given a bed to sleep on (which would mean that one poor man would have to kip on the floor; I really couldn't have that on my conscience, those people do this for a living!) so I ended up reading the E Med text half the night and trying desperately to sleep on the desk top after 4am, and ended up with severe contact dermatitis.

Also stayed behind to watch their morning drills! It's actually the firemen's drills that were interesting ... the paramedics just stood there with their trolley and the SSG was giving her trainee a tutorial on IV line insertion. Then they wheeled it away, and I was like, "huh?" .. well ... that was their "drill". Anyway, the NSman and I had a jolly good time gossipping about the station's OC. =D Was treated to cup noodles by the boss (SSG Maddy), how nice! Apparently the others also benefitted from my presence; they were absolutely thrilled that "boss" was treating everyone. Slightly guilty though - I had some food with me, but not enough to share with everyone, so I didn't eat them in the end.

Mom was an absolute brick!! I was going to do something dreadful to myself like stuffing my whatever into the fire hose for forgetting to bring my emed text!! So I was actually stuck with OSCE's in surgery and the chest xray book which I always carry around in my car. Called mom, asked if she's passing by, and yay! I had the book to read! =D

It was a nice experience, but no thanks .. I don't think I'd want another night shift.

Day 6 of 20

Totally slacking at home today and bracing myself up for tonight's ambulance run. That, and also the fact that I need to lug my laptop all the way back to NUS for repairs.

Day 5 of 20

Ah, what shall I say about today. Longest day ever, 8am to 7pm+, some of my groupmates will probably be staying till 11pm so they went home after a tutorial at 8.30am. Gotta meet Aaron later on though, so left earlier.

Today was interesting - went to OT to assist the plastic surgeon! This really sad case, a young woman had an RTA (or MVC or whatever they call it - it's ALL THE SAME DAMMIT. Why nitpick on the small details when people are dying in the A&E?) in a taxi and wasn't wearing a seatbelt, and sustained a really bad laceration on her left cheek and left eyelid. And it's not the lacerations we usually see when people accidentally cut themselves - this one cut right through the dermal layer and even muscle, and in the OT the plastic surgeon put his hand under the flap of flesh just to check if the laceration cut through the buccal mucosa on the other side. I'm not usually frightened of blood, but there was this pool of blood oozing on the face that made it really scary.

In the OT I had my ass fried by surgeon, who insisted on calling me Dr. Tan. He's very pleasant, but stresses me in a way - he won't accept "i don't know" for an answer. So, a typical conversation would be, "Dr. Tan, what is the difference between using a monofilament suture and a braided suture?" Obviously, I wouldn't really know unless I was shooting for a distinction in surgery right? So ... after 1 minute of uncomfortable silence and "erms" and "ahs" on my part, he'd press on, "Yessir, carry on Dr. Tan."

"I don't really know .... (inserts a guessed answer)"
"How can you not know? Your patient is asking you what sort of suture you're using - try again?"

Goodness ... and he's the kind who likes to make you dig a grave for yourself. For example,

"Dr. Tan, what is L.A.?"
"Local Anaesthetic"

"Good! What L.A. am I using now?"
"Lidocaine"
"Yes - so, what's the mechanism of action of L.A.s?"
"(insert 5-minute conversation on year 2 pharmacology)"
"So what other L.A.s do you know of?"
"Erm ... Prilocaine? and erm ... erm ... (insert mental block)"
"OK, don't need to know too many, just (insert 5 or 6 different ones which we never bothered learning since it almost never comes out for the MBBS written)."
*grave-digging starting*
"OK, Dr. Tan, you mentioned Prilocaine. What can you tell me about prilocaine?"

OMG. You get the idea eh? Wow, I felt SO stupid. It's like most of the stuff I DID know at one point or another, but it's been stuffed into a little draw-string purse and stashed somewhere in limbo. Stuff we went through were:

Common maxillofacial fractures, LeFort classification, tripod fractures
Layers of the scalp
Layers of the dura, different types of intracranial haemorrhages, their origins (like the middle meningeal artery in extradural haemorrhage) and CT scan features.
Glasgow Coma Scale (made me go through the whole damn thing from E1 all the way to M6)
Raised intracranial pressure, mechanism of secondary injury in haemorrhagic stroke, management of raised ICP with and without the neurosurgeon, danger of coning when using a spinal tap on patient with raised ICP.

And hell lot more. At the end, a very battered, bruised and multiply-traumatised medical student emerged from the OT (was helping snip the sutures) and gave him a resounding mental applause, and a heartfelt thank-you for the excellent tutorial. Would love to meet Mr. Plastic Surgeon again one day, but damn, I do hope I'd be much better-prepared next time round.

Other cases seen today:
Another peptic ulcer disease
2 cases of possible stroke and neurological deficit
A possible headache (have to read up on all the different headaches ... gross)
Pneumothorax (saw the needle aspiration! Gosh it's so different from what I thought it'd be - the patient was twitching in pain all the time)
Sepsis

Spent more than an hour with the old lady with sepsis, trying to comfort her. For some reason my heart melted when I saw her lying in the P2 area (she's actually a P1 case), alone, sobbing into a piece of tissue paper silently. In retrospect, she actually made my day - there's nothing so much as gratifying as being able to help a patient in these small ways. It probably helped that I spoke Teochew as well, so at the end of it she started calming down and chatting. Would have stayed for longer, but had to meet Aaron. She was a red-herring case - crying due to the pain in her right femur (intertrochanteric fracture 2 months ago, managed conservatively with analgeisa and skin traction) but admitted from AMK hospital for low-grade fever for 2 days. Abdomen soft, generalised tenderness and generalised rebound tenderness with slight pallor. They wheeled the poor dear into the resuscitation area, where I went again to talk to her - imagine her bewilderment, getting pushed on a trolley into this scary single cubicle with ECGs, machines and whatnot - just for a fever, from her viewpoint. Really hope she'll be ok.

Some of the docs in the ER are really fantastic people - for once, we med students are being treated nicely, and not as pesky little blow-flies hovering around. Like Dr. Mark Leong, who's quite a big shot but really doesn't behave like one (*cough* general surgeons *cough*) I was following the old lady but thought it would be appropriate to ask Dr. L if I could observe him managing this patient. He was like, "Of course! You're very welcome! You can observe anyone here you like!" and later, while I was writing from the case notes and he needed it, he didn't snatch it away like some docs from other departments. The beautiful man apologised (omg) for interrupting and promised he'll have it back in 5 minutes.

I love this posting already, although there aren't any poisoning/venom cases so far. People are busy but very, very pleasant, including the nurses. Ah .. that OT nurse who bustled around me making a big motherly fuss of making sure I'm not lost in the OT when it came to scrubbing up - MOST UNLIKE G.S. where the nurses don't give a SHIT about you, and obviously you'll be so fricking lost in there and then they snap at you for obstructing their way. HELLO .. I don't even know where the scrub suits are, what do you expect me to do? That nurse was soooo motherly! =D

Let's leave out the part where I told this to the 2 evil women in my group and they accused me of being the "Auntie Killer".