My last week at RMH

This is my last week of attachment at RMH. As usual, we had all the morning ward rounds, discussions, and meetings. Observed another pleural tapping.

Here are some photos taken when I was at the hospital. 

Level 5-south wing: This is where the general respiratory medicine ward located. 

Respiratory care unit (RCU): It is a specialized 4 beds unit located in 5 south west. Patients with acute respiratory issues will be managed here. 

The respiratory team is made up of a consultant, a registrar, a resident, a specialized senior nurse and an intern.

I did mention in my previous post that everything is computerized here at RMH. Patients' details could be accessed by authorized medical personnel at every nursing counter at the hospital. It is really convenient. 

The professional medical report session. 

The radiology meeting (every Tuesday) and multidisciplinary meeting for lung ca (every Friday). 

There is also weekly respiratory medicine clinic on Tuesday and lung oncology clinic on Friday. 

Had met awesome people here at Royal Melbourne Hospital. 

From the left: Lucy, Eugene, Me, Nick, Joanne. 

Thanks for the hot chocolate and cakes. Gonna miss them all ! :) 

Royal Melbourne Hospital is a tertiary hospital equipped with high-tech facilities. I would say that the hospital environment and setting is really good for the patients. Medical staffs are dedicated to their jobs.

Saying goodbye is always the hardest thing to do. I will definitely miss the time being here and being with the team. Fabulous moments! The most memorable event in my life. 

THE END.

By the way, having this blog would make my report writing much more easier. Haha ! 

Clinical elective at RMH (Day 12)

Day 12

We had an enjoyable session with Dr. Lucy today. We had a discussion with her on how to interpret the ABG. That is what I need the most as I always get confused when it comes to interpretation of ABG. Before we started, she served us with her  self-baked chocolate cake. Oh, that was really tasty! Yum! And then she gave us a short lecture on ABG before we practiced it with cases. It didn't take long but I found it to be really useful. 

And not forgot to mention that we came across a patient with giant cell arteritis during the ward round. The reason for the patient to be admitted in respiratory ward was because of her acute onset of shortness of breath and oxygen desaturation. They tried to figure out the causes by ordering further investigation like CTPA (to find out whether the acute SOB was due to clots in the lungs), ABG and others. 

I was being offered the chance to do an ABG. I was quite worried and nervous as I had never done it before. However thanks for the encouragement from Jimmy, Nick and Dr. Lucy, I was ready to give it a try. Unfortunately, when we went to the patient for the procedure, it was already being done by one of the nurses. Oh, may be next time. :) Hope I still have the chance for that. 

Clinical elective at RMH (Day 10-11)

Day 10
Nick and I had a discussion on certain topics. He would like to get himself a little warm-up after being in a relaxed mode for a long period of time. Same goes to me. I think my brain had turned rusty after my third year, being too relaxed throughout my forth year. He was preparing himself for becoming a junior doctor or an intern upon finishing his clinical elective and I should start to prepare for my final. We discussed on myasthenia gravis. Other random topics like multiple sclerosis just set in. Apparently, he knew more than I did. Though we just touched on each topic superficially, I found the discussion was beneficial. I was glad that he had introduced certain useful websites and online question banks to me.

Day 11
Starting from this week, the respiratory team would be taken over by another respiratory physician, Dr Jeremy and also Dr. Nicole, the registrar. And the resident, Dr. Lucy would be joining the team. Dr. Lucy was so kind and helpful. She really tried her best to help us up and to teach us on whatever that came across her mind. I appreciated her effort in coming out with questions for us to ponder on or the other way round. She even offered us her free time to have a tutorial with her. That's great! I am looking forward for that.

During the professional medical report session, the second case had caught my attention as I found that it was quite interesting. It was a rare case of primary choroid plexus lymphoma. In that case, the patient presented with confusion and short term memory defect. There was no other neurological sign and symptom. He was conscious, had a normal gait with no deficit detected in cranial nerves, lower and upper limbs neurological examination. Radiological investigation of the brain (I couldn’t remember whether it was a CT or MRI) showed abnormality in the ventricles. Further investigations then carried out and finally they came out with the aforementioned diagnosis. They even showed the video of that patient underwent mental state examination, which gave us a clearer picture on what was going on.

Clinical elective at RMH (Day 9)

Day 9
There was a lung oncology clinic running right after the multidisciplinary meeting. Thanks to Dr. Philip for asking me whether I would like to join him. It took me a while to realise that he was a cardiothoracic surgeon. I was supposed to be joining lung oncology physician. *face palm* Anyway, It was my pleasure to join him. And hey, he knew Kuching. He also told me that he had been traveling to Sabah before. He was quite humorous. I got to know an interesting story from him. It was about a patient with Pancoast tumour who came to realise that he had unilateral drooping eyelid when he was comparing his self-portraits drawn by him himself. Often we heard of patients came to realise the abnormalities through mirrors rather than portraits. Hmm. There was one funny moment when he suddenly turned to me in the midst of conversation with one patient and was expecting me to mention the name of disease which he had been discussing. It was neurofibromatosis. Unable to react fast to the sudden unexpected question, my tongue just got tangled and it sounded like I had a slurred speech. I was like, “ Poly… nope .. neuro..neurofibro..fibromatosis.” Oh dear, another face palm. Nevertheless, the whole session was remarkable.

Clinical elective at RMH (Day 8)

Day 8
Another tutorial session with the registrar, Dr. Chee. We were asked to see a patient who presented with epistaxis and haemoptysis associated with myalgia, fever, and night sweat. First thing that came to our mind was infection, probably TB. During the discussion, we were asked to work out the other possible differential diagnosis. From what I had learnt today, they could be due to infection, malignancy, medication (blood thinner/anti-platelet), autoimmune diseases (SLE, Goodpasture syndrome etc), vasculitis, pulmonary embolism (as the patient also complained of calf pain) and the list goes on. According to the registrar, the abnormal features seen on the radiological investigation was unlikely to be infection or malignancy. However, it was not enough for them to draw a conclusion. Thus, future investigations such as sputum examination, autoantibody tests, and urine examination have to be done to narrow down the diagnosis. I would never have thought of autoimmune diseases when it came to haemoptysis. Again, I learnt something.

In the afternoon, I attended the weekly grand round presentation. The presenter was Professor Julie, Chief of endocrine surgery from Duke University, USA. The content was about thyroid cancer and its evolving management. I got to know that thyroid cancer is quite an issue in United State. Apparently, they are working hard to figure out the preventive measures and the choice of effective management for this disease.

Clinical elective at RMH (Day 7)

Day 7
Hmm. What’s new today? Not much but a lengthy ward round. It was funny when the intern turned to me and said he was hungry and tired *Ha Ha* But that didn’t render him from doing his job well. We met a patient with radiation pneumonitis, which was something new to me. It is a complication caused by radiotherapy. White opacity showed on the CXR really struck my eyes.

After the ward round, I attended a Professional Medical Report meeting where registrars presented their cases. It was a good teaching session too as the consultants would share their knowledge on the investigation and management. I really have to thank Nick for inviting me to this event which I had missed last week as I thought it was some sort of high-level-teaching for postgraduate students.

That’s it for today. So let me share something I had learnt from the medical students here. Comparing myself to them, there is still room for improvement. They are pro-active, confident, and observant. And of course, I was amazed at their inter-personal skills. Basically, to describe me, you just have to use words which are antonymic to those above. Some might have told me that I looked confident when I did my presentation. However, to me that was just a masquerade. Sometimes I was too afraid to share my ideas and to speak out as I doubt my own capability. There were a lot of times when I doubted my capability to become a doctor. I NEED that confidence. In term of interpersonal skills, I feel like I am just like a robot. I was insensitive to their pain and discomfort. In contrast, the students here would start off with a little chit chat to know the social background of the patients and to build up good rapport with them.

Hippocrates once said, "Cure sometimes, treat often, comfort always." People need doctors who are understanding and are able to give comfort to them (in a professional way of course), not a bunch of heartless healing machines.

Clinical elective at RMH (Day 6)

Day 6
Today, I decided to walk to hospital instead of taking the tram. It was just a 15-minute-walk after all (if you walk with a fast pace). And It is good to have some exercise. Along the way, there stood the beautiful colleges and the university buildings.

It seemed like the medical students would have a switch of department placement every week. There were new faces showed up in the respiratory ward. I was able to join a bedside teaching with 2 students, led by Dr. Hammerschlag, one of the physicians specialised in respiratory medicine and sleep medicine. The students were supervised by him while they were doing their interview. He would then give comments to the students. He never forgot to praise them for their strength and to encourage them.

Next, we went to respiratory lab where he wanted us to meet a patient who presented with obvious signs. It was a case of systemic scleroderma with CHEST syndrome. Patient with this syndrome may have lung manifestation such as interstitial fibrosis and pulmonary hypertension. What I had learnt from him was that we have to take a step back and observe the surrounding before we touch the patient. We will always get a clue on what is happening to the patient or even the diagnosis. That was good reminder for me.

Clinical elective at RMH (Day 5)

Day 5
There was a multidisciplinary meeting this morning, whereby, as the word implies, it involves medical professionals from different disciplines in case discussion. The focus was mainly on the lung oncology. It involved pathologist, radiologist, and physicians. CT scans were being projected on the screen, mainly lung nodules, mediastinum mass and metastatic tumours. (I still need some more practice in reading those CT scans I guess.)

After that, I went to the library to do some reading. Seriously, I missed the library that used to be there in our faculty in Lot 77. It was the place where I could really concentrate. *sigh*.

“Asthma, diet and microbiota”. Another interesting respiratory grand round presentation presented by Dr. Alison from Monash University. It was being held at ICU lecture theatre. She had done a clinical study on mice models to find out whether diet had anything related to asthma. Interestingly, high fibre and high acetate concentration in blood (short chain fatty acid) were found to be able to suppress allergic airway disease in immunological view. (However, there was no effect in an established asthma). Besides, same effect was found in foetus of the pregnant mice models which was being given acetate in the drinking water. It was a fascinating topic. Now, that is the power of research. Without it, there will still be no cure for many diseases.

And never forget that today is FRIDAY! Another weekend! Yeah!

Clinical Elective at RMH (Day 4)

Day 4
Set off for RMH at 730am. Another windy day and my body shivered badly when I headed to the tram stop. However, I was full of anticipation of what I would encounter today in the hospital. Ward round is always the early morning routine in all hospitals. There was a patient in a myasthenia crisis which affected his respiration badly. It was quite sad to see patient suffered. However, the team was always ready to bring comfort and to ease the pain that the patient had gone through. And Dr. David had set a good role for me as I observed how he listened, comforted, convinced and reassured two patients who broke into tears due to their illnesses. I could sense that patients were one part of the team. They had the right to know what is happening to them; what had been done on them; what are the outcomes.

There was that one time when we came out from patient’s room, Dr. David turned to us the medical students and asked,

“What did I do when I meet patients?”

“I shake their hand and I come to their level. Remember that.”

This is the basic thing we should know, but, most of the times we tend to forget. Always respect the patients.

That was a long morning ward round. I was quite excited when I heard that a registrar was going to assess one of the medical students to perform respiratory examination. Frankly speaking, it has been a while since I practised PE. What a shame. Hence, I joined them and observed. The steps were more or less the same as what I had learnt. The registrar was impressed by the examination skill of Morgan, so did I. He was so confident and the flow was smooth. It was a case of pleural effusion. There was obvious sign of decrease breath sound and stony dull on percussion on the affected side.

It was 1.00pm when the grand round presentation started. It took place at Charles LaTrobe Lecture Theatre. The topic was “Solving Big Clinical Problems through Research”. The presentation began with the History of Walter & Eliza Hall Institute, which is a medical research institute. The other sub-topics included the history of Influenza pandemic and how research had contributed to the invention of its vaccine, followed by research on finding the cure of hepatitis B, coeliac diseases and chemo-resistant leukemia. They were delivered by infectious diseases specialist, gastroenterologist and haematologist respectively, who were involved in the researches.

Lastly, I attended a pathology lecture. (My basic knowledge is …. Urgh ! I forgot many things which I had learnt in preclinical years. Damn!)
Finally, I decided to call it a day !

Clinical Elective at RMH (Day 1-3)

Day 1
Met the elective coordinator, Debra, a nice and friendly person she is. She brought me around the hospital and introduced me the place where I can find good food to eat. Ha! After that, she helped me to settle with the ID Badge and there, off she went. And it was time for me to head to respiratory department to meet with Savi and my supervisor, Professor Lou Irving. I was quite confused on what I should do on the first day. I was then being introduced to the registrar, Dr. Mary and interns at the respiratory ward at Level 5. And here I started to join their ward round. It was great to be warmly welcomed by them and greeted by one of the respiratory physician, Dr. David Smallwood. From the ward round, I could observe how the physician approached the patients in a good way. He was able to build up good rapport with them. He set a good example for me. Not only him, but all the staffs! They were really good examples for me. And what was different from what I had observed in Malaysian hospitals was that the team will review on the patients’ condition, their clinical investigation results, x-rays, CT scans etc in front of the nursing counter first before they went to the patients’ beds. And everything was computerized. Staffs could obtain patients’ profile, clinical results and other investigations with just a few clicks. It is really convenient.

After the ward round, I followed 2 medical students (Laura and Ian) to interview a patient who presented with cough, high fever and shortness of breath. Those students had good interviewing skills. They made good use of open-ended questions and they tried to figure out the possible differential diagnosis by asking relevant questions to the patient. Again, they built a good rapport with the patient. The patient was a kind man and very cooperative. Another thing which I had learnt from the students was that having discussions with the colleagues is one of the best ways for learning. We share, we discuss and we learn together. That was pretty awesome.

Finally, I followed the intern, Dr. Eugene to a meeting. Interns were presenting the case summary of each patient and their progression to the physicians and there the discussions took place. I could see the spirit of team work in solving the problems and deciding a better management for each case.

Day 2
Another story began. First we started at the Respiratory care unit, a place where patients were being observed closely (It is some sort of ICU but it is in a respiratory ward). After the registrar reviewed on the patients there, we went to a radiology meeting. Before the meeting started, there were students who were presenting their research progressions to the physicians. Their topics were really deep and heavy! During the radiology meeting, CT scans and Chest X rays of the patients were being shown on the screen.

About an hour later, I went to the respiratory clinic. Medical students distributed themselves into different rooms. I was lucky to join Dr. Rubinfield’s clinic as she was friendly and was willing to teach. We had four patients that day. The first patient came for follow-up and complained of chronic dry cough, usually worsened at night and exercise. According to the Dr., it could probably be asthma. However, her lung function test was normal and there was no abnormal finding on auscultation. In order to confirm the diagnosis of asthma, Dr. suggested to have a bronchial provocation test (with methacholine) done. This would help in deciding a proper management for the patient.

Another patient had a past history of hospital admission with SOB, hemoptysis and epistaxis (septal perforation was the cause of epistaxis). She also experienced loss of weight and loss of appetite. Radiology findings showed ground glass opacity in her left lung (which according to Dr. the ground glass opacity could be infection). When I was being asked on the relevant examination I should do on that patient, respiratory examination was what I could think of. In fact, I should have looked at the hands for sign of clubbing, examine the abdomen as well for any lumps (as the patient presented with LOW and LOA, we should look for sign of malignancy on other systems as well). Gosh! I shouldn’t have deemed that as trivial complain!

Here came another asthmatic patient with sleep apnoea. During the examination, I could hear wheezing after she took her steps to the bed. She seemed to gasp for air while she was sitting on the bed. Obvious rhonchi could be heard bilaterally on auscultation.

Lastly, a middle-aged gentleman stepped in, bringing his son who was a four-year-old cute little sweetie. I was being told that the gentleman had hereditary hemorrhagic telangiectasia. It is a condition with small vascular malformations which can occur in the skin and mucosal linings of the nose and gastrointestinal tract. He suffered from frequent nosebleed and he had rhinitis. There were obvious sign of telangiectasis on his skin, lips and mucosa of the tongue. Interesting case!

Again, there were good communication skills and good patient-doctor-relationship. She spent around 15-30 minutes on one patient. And I really felt grateful as all patients smiled and wished me have a good stay in Melbourne. The last patient even wished me to be a good doc when i go back to Malaysia. They were wonderful persons! Teehee !

Day 3
As usual, we started with ward round. And then we went to the emergency department to see a patient with clots in her lungs. This was followed by another clerking with Morgan, a medical student. Oh! By the way, the medical course here is only a 4-year-course and they all will start their clinical years at year 2. Wow!

We clerked a patient who presented with decreased effort tolerance (20ft to 5ft), SOB, extreme exhaustion for 6 weeks and the symptoms worsened. She had medical illnesses of hypertension, diabetes mellitus, atrial fibrillation, and liver cirrhosis. She suffered from heart failure which contributed to her current symptoms caused by fluid overload and pleural effusion. She was a cheerful and cooperative patient. Got to know she had a good hobby of reading especially bible.  She also did missionary work. May God bless her so that she will get well soon.