New territories

A good 5 weeks into Medical Oncology. It has been a tough posting. Starting early every day, ending late, steep learning curve with respect to specialist only knowledge, new environments and people. Mixed feelings. Medicine still excites me the way it does the first time I cardioverted a patient with SVT. And in every discipline there will always be that group of patient whom you spend more time figuring out their social situation than dealing with their medical problems. The past month was made particularly more difficult with the father of a friend under my direct care. Cancer certainly is undiscriminating. I don't think I've yet had that feeling of discharging someone with ease that that person is better than he was coming in. There will always be that lingering feeling of what next? More chemotherapy? Best supportive care? The cancer will grow, recur and spread like wild fire.

That said, seniors have been excellent. I had a good month in my first team, and am now rotating through my second. Despite late nights and long ward lists, they never fail to press on with doing the best they can, sorting out what they need to, and conducting family conferences on weekends.

Being in a different hospital gives new dimension to my experience as a doctor. Having been through 3 different hospitals in the past year, I feel that I now have a better understanding of hospital operations, why things are run the way they are, what ways there are to improve and improvise. Interesting how the decision high up can make such a great difference to the lives of doctors, outcomes of patients. Some decisions are tough to make, and can have dire consequences if foolishly made.

Calls in this hospital have been of a different kind. On average we do about 1-2 full calls a month, compared to the 4-5 full calls I was doing back in my previous hospital. There is different sort of pressure though, being in a centre of medical oncology and hematology where there is an abundance of the weird and wonderful. I discover medical conditions that I could have never possibly imagined existed in the middle of the night, and need to get help and advice on what to do from seniors. Learning goes on forever.

Post call now and in a little bit of a stupor. Thankful for a long suffering husband who cooks yummy food for me all the time. Dinner time!

Surgery EOPT

PHEW.

and with that, I unofficially self-conclude my Surgery posting. it has been a treacherous and very trying posting. my friends who see me everyday would testify to my mood swings and grumpiness daily as i trudge through the (rather empty) wards. many apologies for that. the surgeons aren't altogther terrible people, i guess they don't quite come across as being approachable either. we had 2x bedside tutorials for the entire course of 6 weeks, the rest of which were mini-lectures and discussion. sigh!

For the benefit of those going to SGH for their EOPT, and for people doing surg in generally, here's my EOPT experience:

my EOPT today was at SGH. it was a semi-nice feeling to be in a place familiar to you (was there for CSFC), but also rather daunting to have to report for an exam alone! i sat in the HOD's office (Dr Christopher?) for like 30mins just waiting because i arrived a little too early. he had a cello in his office! plus tons and tons of books on erectile dysfunction, prostate cancer blablahblah. the ADO lady told me my patient's bed at 0930 Hours and went there quickly to take a peek at department board.

EOPT Tip (SGH): As you enter the ward, look out for the board which has the name list of consultants and registrars for that ward. Above the name list will be the name of the department eg. Department of Urology etcetc. This might give you an idea of what kind of cases you might be dealing with, though it need not necessarily fall into the same category!

met the patient first for about 1 min before this doctor came in, gave me some instructions not to do a DRE because he was post-op, and then left me alone with 20mins to take history and do PE (yes, 20mins). initially i was really fuzzied because i was being panicky and being unable to write/spell properly. my patient was a nice old man, but he seemed quite disinterested in giving me his history, picking up newspaper to read halfway (-.- unprimed patient alert) he seemed quite impressed later when i summarized his history to him just to clarify some things though. :p

turned out to be a case of BPH with single episode of ARU 6 months ago, now admitted for elective TURP. history of renal stones (had open surgery done), total knee replacement and left inguinal hernia repair. PE was unremarkable, though he had the bilateral knee surgery scars and a right sided nephrectomy scar with a drain scar. hernia scar was very well healed and not visible. 3way Foley's catheter also in situ with penile gauze.

after 20 mins, the junior doctor came in, and said that we were still waiting for Dr Sim to arrive. i told him that we were told to be given 30 minutes, so he gave me extra 5 mins to do PE. o_O not like i really did anything more in that 5 mins, though i did manage to clarify some other parts of the history. Dr Sim was really late! so i waited outside and the desk with the other doctor for at least another 15 minutes, during which i had time to think through the case and rearrange my thoughts.

Dr Sim finally arrived. I had expected a small young lady, but Dr Sim turned out to be this huge 5m tall (ok about 2m) guy who looked really intimidating and stern. Presented the history, which went rather well, and then discussed the differentials. The then doctors brought me back to Mr Chan's bedside to do the physical examination. This was where things started to go a bit haywire.

Of significance-

1. They asked me to demonstrate the renal punch, how to ballot the kidneys and how to locate the deep inguinal ring, which was EPIC FAIL. seriously epic fail. (friends, please go and practice how to locate the ASIS and pubic tubercle).
2. They also asked me about the Foley's catheter, and whether the 3 way Foleys was common practice for ARU (Ans: no it is not used for ARU. it is used post-operatively for bladder washout).
3. They also asked me to grade the hematuria as mild, moderate or severe (because the urine in the urine bag was blood stained). The trick is to look at the TUBE and not the bag, because as long as the hematuria in the TUBE is relatively clear, then the hematuria is considered mild even though the bag is full of red urine.
4. Another part was when they asked me to check for pitting edema, and asked me how long to press for. The answer is up to 10 seconds, especially in fat patients where it may be more difficult. I said 2 seconds (phail again).
5. Lastly, even though I didn't do a PR, they asked me what I would look out for. The answer is to basically describe an enlarged prostate, to check for any irregularities or nodules and also for stools. Important to state anal tone, because neurogenic bladder is a differential for ARU.

After leaving the patient, we then discussed the investigations and management. Choose your investigations carefully because I just spammed all the urine stuff which seems a bit mindless. Be more specific to the case, and in this case of importance would be the FBC, U/E/Cr, urine culture. UFEME is not so important because it is a more complex version of the urine dipstix. Xray KUB would be used to check for renal stones and ultrasound to look for any hydronephrosis. TRUS to check prostate size.

Management is quite straightforward. I forgot to state the conservative treatment (5a reductase inhibitors and alpha blockers) and went straight to TURP. They had to prompt me back to medical therapy oops :x

SGH Uro Tips

1. The probability of getting a uro case is very high, even though you should not just prepare for uro. My examiner told me they just happened to have a uro case, and that there was supposed to be another case but he was not available then. (phew!)
2. Bring your own clip board and paper. Prepare everything beforehand. They are very lame and do not provide you with anything.
3. Be very sure of whether your patient came in specially for elective surgery only because this determines whether you present you history as an acute case or follow up in out patient setting. This sets up the timeline also for the progression of the disease state.

Can't think of anymore. All the best for the upcoming EOPTs! (: