Compliance

(I merged the stories of two non-compliant patients into one for convenience of story-telling. )

Mrs Chan is a 75-year-old lady, with a history of diabetes mellitus for eight years and developed nephropathy recently. Oral hypoglycemic drug failed to control her condition and the HbA1c level raised to 8.5% in the latest check up. The level stayed well above 8 throughout the years despite several increment in insulin dose. She claimed to be compliant to the injection.

In one follow-up the physician have a spot check of blood glucose by H'stix and it turned out to be 33.1 mmol/L. This necessitate an urgent admission since she was at the edge of developing hyperosmolar nonketotic coma. Normally she would have been put on sliding scale of insulin, however, the physician deliberately ordered regular insulin injection this time, in the same dose as prescribed for her home injection.

You know what, when the same dose of insulin was injected by the nurse but not Mrs Chan herself, her glucose level returned drastically to 6.9 mmol/L within six hours. If she had really injected the same dose of insulin for the past three months, her HbA1c should be around 6-7% only. (NEJM 310 (6):341–6.)

Everyone is innocent until proven otherwise. Is it due to drawing the wrong dose into the syringe, or due to her poor injection technique? She was referred to the diabetic nursing specialist for inspection of skills, and she was able to demonstrate a nice injection successfully.

The doctor further probed if she was really skipping the insulin, and she strongly denied it. She also refuted his argument by showing a "homework" of home H'stix blood glucose monitoring - all the values were well below 7 mmol/L.

The painstaking doctor consulted the chemical pathologist, if there is any condition that HbA1c can be falsely high. The reply was, "If the patient is not suffering from any haemolytic anaemia recently or having any haemoglobinopathy like sickle cell disease, there shouldn't be any errors."

She is a mother of two. I bet she must have taught her children to be honest. I also bet when we were young, we must have lied to our parents and teachers to conceal our fault or laziness, etc. Yes, we know that she is actually lying. But what can we do? I agree that this is a kind of rejuvenation, are you convinced?

Ethic

A Senior Medical Officer asked us not to post personal comment on the case notes, at most elaborate in blogs. Therefore, I write down this incidence here.

Today I came across a case note of a 35-year-old woman. A doctor from another specialty had attended a consultion ("consult") of her. You know what had the doctor put down? Here it is, quoted verbatim:

Height = 1.51 m, Weight = 94 kg
Very very very very very OBESE!!!

So immoral, so naive, and so pathetic.

I had delibrately counted the number of "very" in the case note, it was really five, I remembered it clearly, no cheat.

Brotherhood

Rocky is a 22-year-old young man with good past health, admitted to the orthopedic ward for a fractured right thumb during a football match two weeks ago. The pre-operative blood test incidentally revealed a normocytic normochromic anaemia with haemoglobin of 6.7 g/dL and creatinine of 450 umol/L. Kidneys on both sides were only 9.4 cm, which were small in his age. Urine analysis shown minimal proteinuria and therefore glomerular pathology was excluded. Congenital agenesis and post-renal cause were unlikely given his asymptomatic clinical features.

He was taken to the nephrologists and a Tenckhoff catheter was inserted last week for peritoneal dialysis (PD), in view of rapidly deteriorating renal function. His creatinine reached 1000 umol/L today and necessitated an urgent in-patient PD. The experts are now putting Medullary Cystic Disease (By the age of onset, probably type 2?) higher up in their list differential diagnosis. Further management includes renal biopsy and definitive treatment should be renal transplant.

There are four boys in Rocky's family and he is the third one. All three boys, with two known to be more determined, agreed to donate one of their kidneys to Rocky after knowing his situation. Words are cheap and life is not that simple. The brothers have to go through a chain of exhausting investigations before proceding to transplantation. Hopefully, we can find a kidney from them for Rocky.

But think back. If the kidney biopsy of Rocky comes back and Type 2 Medullary Cystic Disease is confirmed, the pre-transplantation tests for the brothers would become a chain of screening tests - the disease is autosomal dominant - all of them may carry the diseased allele. In the worse scenario, loads of dialysate and four kidneys, instead of one, will be needed.

It would be a disaster for this family.

On Government Service

It should spend no more than 3 minutes to print two pages in our hospital.

For the old-fashioned printing system in the library, we have to prepay for the printing quota by adding values into our student ID card. Then, we insert the card into a slot on the keyboard, key in our password, then we can print up to the prepaid amount, and have your sheets ready for collection at a printer less than 20 metres away from you.

For the newly implanted printing system in the computer labs, we can log into any computers with a well-known "password" written on the whiteboard. After ordering a print, a dialogue box will appear and ask you to input your desired password. Then, go to the multifunction printer and insert an octopus card. Key in the password you set a minute ago, and select which document to print, value will be deducted from the octopus card. That is, anyone who did not have student ID card can use the computer and printing system, provided that they have an octopus.

Yesterday, I went to the Central Library at Causeway Bay to print two pages. It was not my intention to test the public library service, but some necessary documents were found missing after I had crossed the harbour.

In order to use the computers there, "You have to fill in a form first. The next available session will be 20 minutes later." Okay. I spent my spare time with East and West by Chris Pattern. When the computer became available to me, I wonder if it was still using a 56K modem for Internet connection. To be fair, you may attribute the slowness to the vast number of library users. Fine.

Printing one B/W page costs me $1.5, which was the cost of printing 5 pages in the hospital. Well, everything is expensive on the Island, no only rent and electricity, but also ink and paper. I could still bear with it.

Things became more annoying when the nearest printer was two floors away. A dialogue box appeared on the screen "Printing Code: 00012345" I clicked "Okay". The first one disappeared and was replaced with another one "Please collect your print out with your printing code." Damn, why didn't you tell me these two pieces of information in a reverse order?

I was turned down by the staff at the information counter two stairs above while I tried to collect my printout without the code. "Oh, you have to print the document once again." Therefore, I enjoyed the speedy Internet service provided by the well furnished Central Library once more. This added oil to fire.

After the first lesson, I jot down the printing code immediately after ordering and hurried upstairs. What made things more complicated was "Well, you have to buy a printing card first. "the staff explained to me, "It costs $20. "

"I am printing two pages, i.e. $3 only, and now you ask me for $20? I only print once (and probably never in the foreseeable future after this incident) but I have to buy a card?" It was a dissatisfied voice.
"Well, you can return the card to the circulation counter at ground floor for remaining value."
I replied him with a frown.

"Input the printing code into this computer...Click "OK", Select the document, "OK"...yeh...you have another page to print right? Repeat the steps once again..."

"Is that okay?" I lost my patience.
"Before that, you need to take the receipt and..."
Annoyed enough, I stared at him with anger.
"...I will do that for you."

It took me nearly 40 minutes between entering the library and having two sheets in my hand. My document was, framed, with the printing code and time chop on top of it.

I was furious about the service provided by this lead public library in Hong Kong. The task was very simple - print two pages.

1. I have to fill in a form and wait for 20 minutes for a computer;
2. A 56K Internet service was provided;
   
3. Unclear instruction given by the system;
   
4. Miles away for a printer;
5. A card was needed for printing. Why not octopus?
   
6. Complex procedure to get my printout; and
   
7. Unauthorised modification of it!

Our university and hospital were rich. Yes. They were funded by taxpayers. I was curious. Isn't the public library funded by taxpayers too? May be I am just too demanding, but I will be one of the taxpayers in few years' time.

More stories

When I was putting my account summary, bills and letters into my newly bought shredder, pieces of "blue sheets" were found among the pile of confidential documents.

***

Judy was a 30-year-old unemployed lady, with known anorexia nervosa and BMI of 11, admitted for dizziness, abdominal pain, diarrhoea and vomiting. She was admitted 3 months ago for similar episode. After that, she had been referred to obstetrics and gynaecology for amenorrhoea and clinical psychology.

In the O & G clinic, the professor who saw her denied to take up her case - as her amenorrhoea was only secondary to anorexia nervosa, but not a primary gynaecological problem - they just cannot help.

For the clinical psychology part - Judy denied the psychologist. She claimed that she was sick, tired, having a headache, and many many whatsoever reasons, to keep the psychologist away since the third consultation. The perseverant psychologist tried to postpone the appointment for five times before giving up. Her incredible reasons were clearly documented by our staff.

May be she thinks that psychologists were not helpful? Anyway. This time she was admitted once again. Who to blame?

***

Winnie was a 18-year-old HKCEE candidate admitted for an increasing goitre for 3 months. It was associated with mild dysphagia of solid food, change of voice, palpitation and unintended weight loss of 4 kg over the last month. Her aunt had a history of thyroid disease and was treated with anti-thyroid drugs. Yes, this is Graves' disease.

After the evening round, a group of youngsters in school uniform was surrounding Winnie, brought her with lots of jokes and gifts - two Teddy bears at least. Being young in wards is so endearing and invidious. What a strong contrary to those who lying on the opposite beds, they were grey-haired ladies, without any visitors or gifts, but a heparin block.

This makes me think of babies that most of us love. Even they were helpless, crying loudly, pee-or-poo here or there, their parents look after them with love and care without any reserve. Only when the parents becomes old and babies grown up, those in their prime time could not hear the cry from Dada and Mama, and grumbles when they wet their diapers.

***

Timmy was a 28-year-old computer technician, with known ulcerative colitis for 5 years, clinically admitted for colonoscopy. This was the fifth colonoscopy follow up after the diagnosis. His Barium enema study made me remember him, and also the classical striking full-house radiological features of the disease as described in Lecture Notes on General Surgery. He also made me remember ulcerative colitis was slightly male predominance.

While Molly, a 23-year-old university student, who was suffering from Crohn's disease for 2 years, and presented with similar vague abdominal pain and chronic diarrhoea as Timmy, made me remember that it was slightly female predominance. From them, I remember the age of onset for inflammatory bowel diseases, of course.

Do learn medicine from wards, and correlate it to books. Once you have got the "index" patient, stick to s/he, then you will remember the disease - except microscopic appearance and molecular pathogenesis.

***

Mr. Ng was a 30-year-old fireman, admitted from A&E for neck injury in Dragon dancing a year ago. He was struck by his partner who jumped from poles behind him, causing immediate loss of motor and sensory function of bilateral lower limbs. Neurological functions of upper limbs were weaken but not lost. No other injuries were reported.

He was conscious throughout, with Glasgow Coma Scale of 15/15, and was mildly dyspnoeic. Physical examination for upper limbs reveals a power of 5/5 for shoulder movements, 3/5 for elbow and wrist, but 0/5 for finger bilaterally, with impaired sensation at fingertips. Tone and reflexes were normal. For lower limb the tone was increased, with hyperreflexia and total loss of power and sensation. Plantar reflex was upward. Clonus could be elicited.

Magnetic Resonance Imaging shows a fractured fifth cervical (C5) spine, and combine with his physical findings, he was diagnosed to have spinal cord injury at C5 with paraplegia. This means that he had to be bed-ridden. For an immobilised patient on bed it is not uneasy to develop bed sores. Yes he did, especially since his sphincter function was lost, his excreta made his perineum a fertile soil for bacterial growth.

The story went on when he was transferred to the Intensive Care Unit (ICU) one month after the accident for further management of pneumonia-caused respiratory failure, including creation of tracheostomy for hanging him onto a mechanical ventilator, insertion of Ryle's (nasogastric) tube and Foley (urinary) catheters for his in and out respectively.

After stabilisation in the ICU, he was transferred to the rehabitation ward half a year after his injury. He had a long way to go. He was unable to return to his fire-fighting job, and it seemed that the Fire Services Department could arrange him with some soft duty. He had two elder brothers who were married and busy with their own families.

Mr. Ng also had a girlfriend who had been dating for 5 years and planned to get married in few years' time. Two months after the injury, he knew well that a total recovery was impossible for him. Therefore, he asked his girlfriend to leave him, to find a healthy man who could look after her and bring her a good life.

The girl rejected.

She insisted to visit him daily, to wipe her love's body day by day, weeks by weeks. She was totally devoted to him. In this disaster, I can see both of them were loving each other. Mr. Ng wanted her to have a better future, but not to be dragged by him. The girl knows that he needed her in this critical moment, so denies to leave him and flood him with lots of support. Here comes the excerpt of a famous vow of love:-

"...to have and to hold from this day forward,
for better, for worse, for richer, for poorer,
in sickness and in health,
to love and to cherish, so long as we both shall live."

This is not my first time to describe the uphold of this vow. Do you still remember Mr. Lam's story in my previous note Progress? Yes. I believe, there is something only love can do.

Progress

Recently, I was dealing with my piles of used fool-scrap paper, ya, those progress sheets which we used for clerking patients. Whenever I read those names on the top right hand corner, their pictures appeared inside my head again.

--- This may be a breaking line ---

I remember Mr. Lam, a 58-year-old retired gardener, who suffers from Parkinson's disease for two years. He has a wife who had cancer, insists to visit him every day. From him, I was impressed how this disease brought him difficulty in looking after himself. He could do little about his living, not even sitting up from bed. I spent nearly two hours clerking his case and encouraging him not to give up his life. During physical examination, I tested his peripheral nervous system. As part of the test and also part of my encouragement, I said, "You have a wife who love you a lot. Face all challenges together with her. Can you? Try to hold my hands tightly." Of course, the power of his hand grip was full. Through his story, which stimulated me, I look up Parkinson's disease) in textbook for the whole night. I shall remember for the rest of my life that - Parkinson's disease does not affect power - as I cannot forget how forceful he held my hands with a thankful smile.

--- This can be a breaking line ---

At the same hospital I met a 45-year-old van driver Mr. Li who presented with progressive dysphagia for one month. It affected solid swallowing first before liquid. It was associated with skin rash on face and trunk, and there was proximal muscle weakness. He had been staying in the ward for one week and receiving steroid therapy. Extensive workup including EMG, muscle biopsy, autoimmune antibody and much more were done, but none of them was remarkable. He was clinically diagnosed to have dermatomyositis. He was optimistic enough to expect a discharge from hospital in a week's time. At that time it was my second or third week of attachment.

About four weeks later, just days to the end of attachment, I saw the same gentleman in a different cubicle of the same ward again. He was much weaker than before. I dared not to disturb him but to flip through his case note quietly. He was discharged from the ICU with a tracheostomy over his neck due to respiratory failure. He was unable to talk like before. This was my first time seeing a patient deteriorating so much and so fast. I cannot imagine how his life had elapsed with these months, when we were spending it playing, studying, or just hanging around. His prognosis was grave. After that, I did not visit him again, only because I was afraid that I could not afford seeing him worse.

--- This should be a breaking line ---

In my Lecture Notes on Clinical Medicine, under the heading of Systemic Lupus Erythematosus (SLE), there were names of three ladies written on it: Vien, Susan and Diana, (fictitious to protect privacy) who I met during the last rotation.

Vien is a 33-year-old health inspector, diagnosed to have SLE for eight years. She was admitted for acute onset of shortness of breath and fever for 1 day. She was subsequently diagnosed to have pleural effusion and had it tapped. For an unknown reason, she received a Computed Tomography (CT) scan, and multiple well circumscribed hypodense lesions were found incidentally in her liver. Tumour markers were normal. They were unlikely to be amoebic cysts as the patient had been so well for months. Her mysterious CT drawn interest from many professors in gastroenterology, and also from me, who intoduced the films to lots of my classmates.

Susan is a 31-year-old accountant, suffering from SLE for 5 years. Her case was quite familiar to our crocodiles, since she was described as "well known patient of Dr. X" at the first line of her notes. This time she was admitted for fever. For a patient like her who was on immunosuppressant for SLE, this was a dilemma. It can be due to flare up of the disease, or due to infection because of immunosuppression . Finally her Magnetic Resonance Imaging (MRI) shows a lesion on the ventral side of L2-L3. A imaging guided bone biopsy diagnosed tuberculosis (TB) spine. This was me who made her MRI films famous among ourselves again. She was discharged just before my rotation ends in February. Last week I saw her again in patient's clothes at the hospital corridor. I have no knowledge about what has happened to her recently.

Diana is a 21-year-old university student, who have SLE diagnosed in her sixth form. This time she was admitted for renal biopsy. I chatted with her like friends, you know, it was better to talk in similar age. Although she kept the subject and university she studied a secret to me, I feel pity when I saw someone in our age, in the prime of life, being admitted to hospital for any kind of life-long disease. SLE is a particularly troublesome disease which ruins thousands of young girls' youth and beauty. I saw all of the above ladies in the same ward at the same period of time. How common of this disesae, my God.

--- This must be a breaking line ---

Through reading back these progress sheets, I saw my patients once again. Those sheets when attached to the case file, recorded how the patient progress, no matter becoming better or worse. Learning through patient's progress progresses our learning. I realised that I have learnt a lot already insensibly, but there is still a long long way to go.

Curriculum

After reading one of our teachers' blog, I couldn't disagree on what he said.

Having gone through the medical year three curriculum, what I feel is that we were having the third pre-clinical year, rather than the first clinical year. I expected we should have received more training on clinical than basic science. Nevertheless, they are fundamental to clinical medicine, but they cannot be over-emphasized. While I was in my pre-clinical years, I thought clinical years will be challenging, in the way that there would be always exciting things happened around me. Yes, exciting things really happened, while we were reciting things.

At the beginning of year three, Prof. JS said, "A student nurse knows more than you." This is of course! In contrast to nursing curriculum, we have far much less to learn in practical skills. For the theoretical side, I must say their lecture notes are or less similar to ours, in terms of quantity and quality. I was deeply impressed by one of the student nurses in a non-university based nursing school, when she could fluently tell me the five etiologies of hyperthyroidism, and clinical presentations of Cushing's syndrome, knowing the complications of TURP, and management of hyperkalaemia. Our future nurses are having similar level of knowledge as us, what next to compare, is our practical skills.

Yet, we focus on physical examination skills targeting various organ-systems, but it is not enough. Say, student nurses have sessions on "How to assist a sterile procedure", "How to scrub up in an operation theatre" or "How to insert a Foley catheter / Ryles' tube" in a simulated laboratory before really coming into practice. For us, merely none of them. Surgeons were shocked when they learnt about that scrubbing up was not taught in our newly furnished skill laboratory. All these were learn totally and only from bedside. I can imagine how the crocodiles replied "Well, we expect students to go more to wards and operation theatre, in order to expose themselves to more procedures, and learn though these process."

Damn, I know. Going back to the last entry, 又要羊兒好，又要羊兒不吃草. The problem is, we have no time to expose ourselves to clinical environment. The root of problem is those regular summative assessments (SA), with two of these holding monthly, taking us away from wards and theatres. In the past, the MB was done in days, with these four major subjects were examined at the last of a year, and to the best of my knowledge, there is nothing like summative assessment.

From our seniors and teachers, students were fond to attach at night, following house officers admitting cases, sitting in the out-patient clinics. I also noticed that there were "blue progress sheets" on wards for medical students to put down their notes into patients' case history. These were not our draft paper, as I once came across a senior nursing officer briefing her subordinates, "These blue sheets are for medical students to put down their notes into the case history (to bullshit on blue sheets?) . However, it is rarely done nowadays."

Teachers, I can realise that you would like to dilute the pressure of studying MB, by cutting it short and diffusing it into regular assessments instead. However, two problems arise:

• The MB is really too short for differentiating students. I must say, I did not deserve a distinction viva and some of us did not deserve a fail.
• Those regular assessments are our trammels (緊箍咒), inhibiting us from devoting ourselves to clinical medicine wholeheartedly.

There were many opinions saying that many medical students today stay away from wards. Yes, this is true. But please! Please look into the problem behind. The reason was not we are too lazy, we are actually too hardworking. With an examination ahead, one may treat it as "no big deal", but most of us did strive for merely a pass. Ya, a pass only, may be a bad pass. Two more problems concerning the summative assessment per se:-

• The topic was too board with too few MCQs.
• The result was released in grades relative to our classmates, not the marks we scored.

It is impossible to study everything hard, except some bright students, while most of us are not. You may think less is better, but you know percentage right? We can easily fail ourselves in just half a dozen of MCQs. More often, those MCQs dig on minute things that was rarely seen or hardly correlated to the goal of lectures. While the grades can reflect your position in class, this would only induce competition, more probably a vicious one. I agree that competition does enhance improvement, but couldn't those examinations be reflecting how much knowledge I had learnt, not how high I got by stepping onto the heads of my classmates. To cope with this unchangeable reality, we have not methods but to skip wards, in order to gain more time for study.

Writing case reports is one way of assessing students, but it is not the best way. Most of the time we were "referencing" from the sample case report, or the case notes; and I can see some teachers did not really read through my report, having it returned to me with simply a score on it. I learn nothing from writing. In addition to bedside teaching and tutorial, we have nothing else to do. We may choose to attend operating theatre or outpatient clinics, but what hinders us has been discussed. Besides, we are isolated from the day-to-day ward duties or activities, nobody wants us or welcomes us. We are so unimportant. Therefore, we leave, as we, hardworking loyal lambs, have to utilise our time best to study for those summative assessment.

"若要羊兒好，讓羊兒吃草。" If the crocodiles really want to improve the number of students stay in wards, please:-

• Abolish those summative assessment. Since SA is the root of problem, but it is impossible.
• Increase the number of MCQs. So as to cover a boarder topic and get harder to fail.
• Give results in the marks we scored, plus or minus relative position in class.

To increase the attractiveness of staying in wards, BEFORE alleviating the pressure on regular examination, please DO NOT add the following into our clinical teaching:-

• Every student have to take up two to three patients in his ward.
• He is responsible to see his patients at least once daily, and present the progress, or be it less formal, discuss, his cases with the case MO.
• He should write progress notes daily with those blue sheets, which has to be co-signed by MO.
• He may also write about management plan. If possible, his plan may directly taken into action.
• He may choose to perform or assist procedures (blood taking, pleural tap, lumber puncture) of his patients.
• Follow his patient to operating theatre, endoscopy centre, or radiology department. I bet many of us haven't seen how a CT is being done.
• On-call to 9 p.m. once biweekly.

Well. May be I have talked too much. Time to shut up.

End

Lambs kept in custody before crossing the river. (Jimmy Leung)

Everything has finished finally. I took a deep breath by the time I dragged my tired body out of the examination hall. In fact, the Surgical OSCE was not that difficult, only my nervousness had affected my own performance.

Here I have to thank the old, no, (some crocodiles will ask me how old is old) experienced nurses, irrespective of their ranks, enrolled, registered, or officers, at the out-patient clinics who assisted the examination. Before the start of examination, the lambs were escorted to the designated rooms, standing like a log outside the door, looked agitated, with fine hand tremors and sweating palms. Unlike the cunning crocodile who took a photo of the restless lambs, saying "Don't fall down during the examination, you will only be dragged aside" (whether it is a humiliation or humour, depends on you); the nurses, on the other hand, knowing that the lambs were nervous enough, tried to comfort us by saying "Boys and girls, this is only a minor examination in your life." "Come on, you good boys will be free to summer holiday one hour later!"

We had a label sheet with us during the examination, and we had to give one sticker, with our name and number, to the crocodile inside, or stick it onto an answer sheet once we entered a room. The most shitty thing happened when I found my little label sheet was not in my pocket at the resting station, probably left in the previous room! I waved my hand towards the nurses and a mother-like enrolled nurse attended me. I told her my situation in few words, and without hesitation, she made my label sheet back to me in few seconds. The nurse, probably treating me as one of her children, kept on reminding me to put it back to pocket after taking one sticker. I thank her for not only taking back the labels for me, and also her lesson made me a bit relieved when I was that tense.

The lambs were escorted back into quarantine after examination to avoid any contact with those who haven't sit the exam. No mobile phones communication was possible as they were stripped by the crocodiles. No computers were allowed either as messages may spread through the Internet. Bored enough, we found our own way of making fun, besides discussing the questions and performance, we played around with the little sticker left behind on our hands. Two hours later, the sheeps were freed and started their summer holiday.

----------This is a breaking line----------

Sad enough, some of us were still held within the mouth of crocodiles. Virtually all sheeps attending the pull up viva failed to escape. The more unfortunate ones received the bad news just minutes before handing in their mobile phones at the registration counter, which directly affected their performance at surgical OSCE. You know what, if one failed viva and OSCE at the same time, there will be no chance to take the supplementary examination, i.e. straight repeat.

To most of us, it is quite the end of term; to some of us, it would be the end of world.

If a pull-up viva does not mean to pull anybody up, what is the point of holding a viva? I know nothing about the marks or the marking scheme, may be some of us really deserve a fail anyway after the viva as the marks are too low, so why don't fail them straightly then? Human beings are still human beings, there are always bias. If a distinction viva candidate is allowed to choose what he is most familiar with, why can't a pull up viva candidate do so? You may say, oh, it's because he had failed. Come on, why don't you give him a chance to show his power, in certain areas, at least?

You failed him finally, because he cannot answer the pharmacodynamics of warfarin, the pathogenesis of typhoid fever, or name all sorts of breast cancer under the sun, which are, considered basics of medicine? You may argue, knowing nothing about warfarin will lead to coagulopathy; ignoring typhoid will lead to public outbreak; confusing benign and malignant lumps in the breast may lead to unnecessary mastectomy which is disastrous. Men, we are training house officers, not specialogist. Please, let him defend himself. I am sure that he knows when should we talk blood for INR, how to manage a patient diagnosed to have typhoid, and how to approach a breast lump by triple assessment. More than that, he must be confident in telling you what are the ten causes of arrhythmia, what to do if a patient has hypernatraemia or hypocalcaemia, and makes at least five differential diagnosis of acute abdominal pain and relevant investigations.

If you are so fond of those -logies, please drop two of your fascias in your year three curriculum. One is "Integrated Medical Science", another one is "Junior Medical & Surgical Clerkship". First of all, I see nothing integrated. The examination, I must say, is solely set on the basis of -logies, to distinguish brilliant lambs in that -logy, to invite them to vivas and giving them prizes. Secondly, there is nothing in those clinical clerkships can apply. Nothing about signs and symptoms, possible aetiology? A few. Investigations? A little. Differential diagnosis? One. I am sure that if I rely totally on my dear Yellow Bus, what I get will be a fail, but your notes, is mostly impractical in my future! How can you persuade students that going to wards is better than studying in library? The examination questions, if not far from, then it is not close, to the reality.

I am not surprised to see some really smart guys sweeping medals in those subjects, they deserve the honour. But what made me frustrated is, we don't actually understand what the Tower expected us to learn. The crocodiles must have my question replied in a bureaucratic tone, "Well, we fed our lambs with the best grass, they are herded in the most spacious field," with a hesitation, "Therefore, we expect them to be masters in all subjects, as well as a compassionate, confident, and professional medical doctor."

There is an old Chinese saying, I modified it a bit, "又要「羊」兒好，又要「羊」兒不吃草". Despite the fact that you are taking in the top 1% of lambs in this town, you cannot deny that all of them are just identical. Each of them has its own mind, memory and feeling. They already spent three years' time in the Tower, burning oils, burning all sorts of textbooks and notes, and, their lives. One had already burnt out last December. Taxpayers have invested a million on each of us, and each of us have invested our springtime to strive as loyal lambs. Although the Tower have to safeguard the quality of her lambs produced, please kindly put your foot into others' shoes and think twice, before ruining our future.

We are little, but not weak.

Some of us being snapped, is because they lost their way in finding a safe crossing point of the river. I have to revise my saying, those being put to the pull up viva, are not those run slowly. It is only they are unfortunate enough to discover the stepping stone. We are naive, and our heart is fragile. Well, heartbreaking can be a way of training, and I understand that it is inevitable in our growth. May some nice crocodile in the Tower, please, once again, think of their goal of education? How many 赤子之心 you want to break before we graduate? Actually, what does your highness expect us to do? Basic science, or clinical? Not both, please.

p.s. I Hope this won't make me the next sheep to be slaughtered.

Viva

This is to my very surprise that I was invited to a viva voce. For those who know nothing about Latin, it can be literally translated to "a living voice", meaning "an oral examination", which is very frequently employed in academica for candidates to defend their thesis.

In the Great White Tower, only two kinds of sheeps are eligible for the viva, those run ahead, and those at the back. The crocodiles would like to know, though the viva, have a better idea of their preys, that how fast and slow those sheeps can run.

There are four parts in the examination papers. Only by chance and luck and the grace of God or whatever, I accidentally squeezed myself into the sheeps in the front at one of the four parts, and, being picked up by our nice crocodiles. When I first saw the viva list, I was very glad that I was not in the list of failure. When I felt relieved and scroll the list down lightly, I was very shocked to found my name in the last line of the last page.

Nevertheless, I have to emphasize that I hate that part most. Very, very, very. I don't know what the bullshit those bastards (yes, our dear crocodiles) are talking about. When I have finished the examination, I shouted loudly outside the examination hall "Damn crocodile who and who go to hell!" and that who and who crocodile picked me up three days later in his letters patent.

From that day, no more sheeps will trust me that I hate that subject most, but actually I do. I am not telling lies to cheat others and ease others' tension on revision, on the other hand read through all the textbooks on that subject twice. No. No. Never.

When I saw my name on the letters, although it is an honour to receive a viva in this way, I am not too happy at all. The only thing in my mind is that "Oh my God, I have to attend one more damn examination at the risk of being tortured by those crocodiles!" Only minutes later, my friends keep on sending me their hearty congratulations. Thousands of thanks!

I have to confess that I was not intended to strive for this honour, and this is really unexpected. All of my aim is to attend no viva at all. I truly believe that some of the genius and/or hardworking sheeps next to me deserve this honour more. This is a bonus for me, I have to say.

Before leaving for the examination room, I met a friend who was garrisoning the Great White Tower at the library, while I was busy flipping through Robbins in the last minutes. I expressed my nervousness to her, being so worried that I will spoil the honour given to me in case I perform badly in the distinction viva. She then gave me a metaphor, 'Say, you were one of the shortlisted candidates for Best Director in Oscar, and you lost finally. Do you feel shameful or not?' 'Not really.' I hesistated for a while, 'Still, I am lucky enough to be shortlisted.' 'Keep this in your mind and proceed to the viva.'

Thanks to the genius who told me my fate half a minute beforehand - there were only two nice crocodiles to confront.
Their first question was, 'How do you feel?'
'Nervous, of course,' I replied, 'This is my first time to have a viva examination'
'Hmm, I can see that you are quite tense, just sit back and relax.'
'It is very unexpected. My panel results are actually quite, so-so, or sometimes, poor.'
'Well, forget about that, those things are just for fun.' the crocodile gave me his classical cunning smile, 'We are looking for students that are good at our subject.'

Damn I hate your shitty subject most.

I was allowed to choose which topic I wanted to discuss with them, and I chose Gastroenterology and Central Nervous System. Well, they think that I shall never defeat them in any subject, so just let me choose the ones I think I was good at and shoot me down right there - the best humiliating method.
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Alien language follows:-
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The question began with polyps. A crocodile from the other side of the globe asked me on how many types of benign and malignant polyps do I know of, followed by Familial Adenomatous Polyposis (FAP). Then I came across a tricky point that, for patients with FAP, the chance for a single polyp to turn malignant is higher, the same, or lower than those without it. The answer is - chance for each polyp is the same, only the number of polyp is more than a hundred time different. He was also interested in FAP related syndromes that named Gardner and Turcot, and whether FAP can be cured if total colectomy is performed. I could only say that it cannot be cured and can appear somewhere else, but guessed one of the two alternative sites wrongly. I was asked on the screening of FAP, which he was looking for the locus 5q21 and gene name APC. The topic ended with to Gastro-Intestinal Stromal Tumour (GIST), what I remember for it was the expensive tyrosine kinase inhibitor, Glivec, and, my helpless face when I was asked the resistance mechanism of the tumour to it.

The local crocodile began with 'What is the commonest brain cancer in adults?' This was a notoriously tricky question, just like 'What is the commonest liver/bone cancer', the answer should be metastasis, metastasis, and metastasis, unless specified otherwise. 'Primary brain tumour, I mean.' 'Astrocytoma.' 'Which one?' 'Glioblastoma multiforme' 'How does it kill patient?'

'Infiltrating the brainstem, cardiorespiratory centre, blah blah blah.'
'Not exactly.'
'Tonsillar herniation, press on brainstem, blah blah blah.'
'No. What leads to tonsillar herniation?'
'Increase in intra-cranial pressure.'
'Yes, what are the signs and symptoms?'
'Headache, nausea and vomiting. Anisocoria, focal neurological deficit like hemiplegia.'
'No...what is the global changes?' I was frowned at.
'Coma!'
'Excellent.' I received the classical cunning smile again.
Finally I got his mind after hanging around the garden for so long.

Then the topic was switched to 'tell me the secondary causes of kidney disease'.
Common things come first, hypertension, diabetes mellitus, systemic lupus erythematosus...
'Can you think of any deposition into kidney?'
'Amyloidosis!'
'What is the causes of amyloidosis?' When he asked, I got a sense of digging my own grave.

'Tumour!'
'Yes! What tumour can cause amyloidosis?'

Shit! I really dug my own grave.

'Any kind of tumour that can produce lots of protein?' The crocodile tried to help me when he saw my hesitancy.
'Err...may I guess, it is multiple myeloma?'
'Ha! Come on, you actually know more than your confidence!' A cunning smiling face appeared in front of me again.
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Alien language ends here.
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The examination ended when a photo was taken on three of us, with my back facing the camera. I came out of the examination room without any lacerations, contrutions or bruises. No crocodile biting marks, of course.

When I returned dorm, seeing the gang of fellows aggregated in my room, I can strongly feel our brotherhood. To my deepest sadness, one of my friends was caught by the crocodiles for not running fast enough. I disclosed this bad news to him on phone while he was out and I was reading the letter, dare not to tell him my name was also on the other page of it. He had been living with me for the whole year, and we studied together days and nights before the exam.

I can produce no reason why one of us was invited to the distinction viva and the other one was on the pull up viva. I can speak for him that he is not a lazy, nor a stupid sheep. He studied the same notes that I am studying. I am stronger than him in some areas and he have more knowledge in other areas than I do. I must say that we are essentially at the same level.

The only reason I can attribute to is that the questions are not well set to let him show his power, and, what is in my mind is that, though this viva, he will have a chance to defend himself in front of the panels of examiners, that he deserves a pass.

May I quote some Chinese proverb for myself, and both of us.

For me:-

"人無千日好，花無百日紅。求學如逆水行舟，不進則退。"

For both of us:-

"勝不驕，敗不餒。"

I have to be humble at all time, and may God help my dear friend, who is now sitting at the viva examination room, in front of a dozen of examiners, and send him wisdom and calm, to pass with every success.

Wonderful World

Thanks to the innovation of wireless router and my roomie who brought it into our room, we are now enjoying net-surfing freely on our own bed.

There are only a few days left towards the Final Judgment. Being a Medicinae Baccalaureus, it is essential for us to pass the MB examinations, that's why all the lambs are striving to escape from being slaughtered by the crocodiles in the Great White Tower.

We can feel that summer has come and have our air conditioner just turned on for the first time in this year. I can see birds start to sing next to the blossoming flowers outside the window, and some hateful ants begin parading across my desk despite my best efford to clear all the food away.

This summer, most of my fellow secondary classmates will be graduated and, if not fortunate enough, unemployed. Time flies, three years already passed by, and those pretty, young, green photos taken on the board has already turned yellow. Somewhat I feel regret.

Life should be beautiful, right? I see my mother University (yep, we are deemed to be exiled from her embrace) as a wonderful place of enjoying mother nature. It is spacious, native, and quiet. I should have spent more days and nights with my friends in this beautiful campus, explore mysterious places in it; or, simply staying overnight playing TV games, and sleep to 3 P.M. in hostel!

Why are we being trapped inside this Great White Tower?

Because of our dream? Because of investment from the government? Because of a pretty good pay upon graduation? I kept on asking myself this sort of question when I was frustrated. However, once I sit back and review what has happened this year, I have no regret. Although my schedule (yes, my Microsoft Outlook) was filled up by non-stop lectures and examinations, I had seen patients, I had experienced what is life, I had felt what is love. Only in hundreds' days, I turn from a naive and childlish guy, to became a (relatively) more mature man.

Our choice, deprived me of enjoying a wonderful world, though, leaving us behind in the darker side, perhaps, the darkest side of the world in our patients' eyes. We see illness, proverty, and death in a day to day basis. We are logs standing there to observe how our patients suffered. Yes. We are there, having a heart, to lighten up the darker side. We strive, to revert the situation, to rebuild a wonderful world of our patients and their relative, and thus, sharing their appreciation and happiness after a day's hard work, it would be a wonderful world for us, too.

Try to remember

This extract from the movie City of Glass (1998) depicted the Gong Fight between Lady Ho Tung Hall and Ricci Hall of the University of Hong Kong in the 60s. There was another version played by Leon Lai in the same movie, however the Brothers Four version better suits into my mind. This movie made me put HKU as my dream university from F.1. I thought I should have born in the 60s and studied medicine at HKU in the 80s. I should have experienced the flamboyance age and joined the protest in 1989. I should have attended the High Table Dinner in Loke Yew Hall and had my internship in Queen Mary, before the establishment of the second medical school in Hong Kong. I love the time under the Union Jack, when we have portrait of Her Majesty in our classrooms. Those were the perfect days in my mind, but I was born late. This probably explains why my soul is 20 years older than by actual age.

p.s. Nevertheless, I put CUHK as my first choice over HKU at the end of my matriculation course, before and after the release of A-Level results, after thorough considerations, with no regret. =)

Get to know yourself better

Your view on yourself:

You are down-to-earth and people like you because you are so straightforward. You are an efficient problem solver because you will listen to both sides of an argument before making a decision that usually appeals to both parties.

The type of girlfriend/boyfriend you are looking for:

You are a true romantic. When you are in love, you will do anything and everything to keep your love true.

Your readiness to commit to a relationship:

You are ready to commit as soon as you meet the right person. And you believe you will pretty much know as soon as you might that person.

The seriousness of your love:

Your have very sensible tactics when approaching the opposite sex. In many ways people find your straightforwardness attractive, so you will find yourself with plenty of dates.

Your views on education

Education is less important than the real world out there, away from the classroom. Deep inside you want to start working, earning money and living on your own.

The right job for you:

You're a practical person and will choose a secure job with a steady income. Knowing what you like to do is important. Find a regular job doing just that and you'll be set for life.

How do you view success:

You are afraid of failure and scared to have a go at the career you would like to have in case you don't succeed. Don't give up when you haven't yet even started! Be courageous.

What are you most afraid of:

You are afraid of things that you cannot control. Sometimes you show your anger to cover up how you feel.

Who is your true self:

You are mature, reasonable, honest and give good advice. People ask for your comments on all sorts of different issues. Sometimes you might find yourself in a dilemma when trapped with a problem, which your heart rather than your head needs to solve.

http://www.quizbox.com/personality/test82.aspx

Destiny

I have seen a patient 3 weeks ago, and I saw him again today.

He is a 30-year-old engineer who lives in New Territories with his wife and a 2-year-old son. He has been well along before presented to us with acute onset of shortness of breath for one day. He is aferbile, without cough and sputum production. However, he complained of low back pain for few weeks, loss of appetite and weight loss of 6 pounds in 3 months. He denied of any smoking habits.

Physical examination revealed reduced expansion and air entry, with stony dull percussion note on the right chest. The impression of unilateral plueral effusion was made and its differential diagnosis included lung carcinoma, followed by pulmonary tuberculosis and pneumonia, which the latter two are quite unlikely. After chest drain insertion, more than a litre of fluid came out every day, and a few days later, he was transferred to the cardiothoracic surgical ward.

It has been two weeks from now. Today I saw him in the medical ward again, this time he was admitted for blood stained fluid in the chest drain. "Oh God. Have a chest drain in-situ for so long. What had happened to him actually?" I flipped through his case notes and searched for the laboratory reports. "Holy shit!", I shouted.

"Stage IV adenocarcinoma."

Horrified by this piece of information, I took a glance on his progress note, written by his case MO, "Discussed with patient's wife and mother, ... DIAGNOSIS NOT DISCLOSED to patient as asked. Explained the patient still had the right to know and I had no choice but tell him if he enquires."

I cannot imagine how I would react if I, being a non-smoker, had an end stage lung cancer at the prime of my life. With a little boy playing toy car on the carpet and a pretty wife sitting beside me watching television, this is ridiculous to think that this kind of blissful living will end in months' time. May be I will go mad and crazy, or depressed and gloomy, or bipolar manifestation.

Later a PET scan revealed two cystic lesions at the left frontal lobe, which is, a brain metastasis. One may shift the blame of his mood changes to those lesions in the frontal lobe, but irrespective of the cause, it is not difficult to think of his family members who are also suffered. He should have a longer road to go, but the finishing line is only meters in front of him. Problems arise prematurely: What about the financial support? May be his wife. Then, who takes care of the little boy when his mum's out for work? May be his mother. Fine, where is their happiness?

End of life issue is always taught lightly in lectures. "To care about patients' feeling and needs, and provide holistic care, blah blah blah." Yes, words are cheap. What if, the patient is your beloved one?

Death is an inevitable destiny for every creature under the sun. Only its cause can never be fair.

Review

Looking back to what have happened round this year, it is quite a different life from previous years. Not only books, notes and powerpoints, we see what is reality and inability.

Reality is not only due to so many investigations and managements are different from textbooks, but so many things that are not taught by textbooks. Like in Surgery, there is no textbook on tubes and drains, you just see them in the treatment room. Later some nice guys, I mean, our fellow classmates, made a powerpoint on that; Some bad guys like me, simply steal, oh, "borrow" them from wards.

Sometimes I blame classmates in my heart, why don't you learn from the reality? Or, just are they too "realistic"? Whenever there is an abdominal mass, whenever there is a murmur, everyone in the hospital rushes to find out that patient. After that, they wave their hands, "Bye. It’s so useless to hang around in wards. Let's go to the library." When my friends see me assisting some procedures, like bone marrow biopsy, lumbar puncture, plueral or abdominal tap, they just run crazy and said "Oh dear, why are you doing so? It's the duty of nurses. You know nothing about dressings, needles and syringes." I am too disappointed. You must have heard a quote "you see once, you do once, you teach one." When I have seen one procedure assisted by the nurses, I volunteer to assist in the next same procedure. This cannot be learnt from books, even with comprehensive illustrations.

One night, when I saw a group of nursing students inserting a Ryle’s tube, I asked my friends, have you seen one before? “Nope.” I was too shocked to find out this, and they were too shocked when I pulled them into the curtain, and assisting the nursing student! “This is the duty of nurses!” this sentence came again. I refuted, “You know how to write 2D1S Q8H in the case note, right? Can you go to the treatment room to get the things and have one pile of normal saline flowing into this patient please?” I am not saying that nurses are not trustworthy; but we cannot rely solely on them, even simple thing cannot be done, we are no better than a nurse, doctor. In some busy times, when they are in trouble, we can also help them out. It’s not time to differentiate our job by our job title. In my mind, we should know everything in wards. This is the full reality, examination is only part of it, don’t be too realistic sometimes.

Inability is, I think you must have felt it, doing nothing except from standing still at the bedside with silence like a 望夫石 and do nothing or say nothing to the patient. You can go nowhere when facing a 78-year-old man with newly diagnosed CRC cries in front of you. You can be helpless when you see a 22-year-old girl living with SLE for 3 years already, quitted from her job and studies. Yeah, we elicit the history, but we are like digging our own graves and then jump into it, since we can seldom help out.

Your relatives, friends, relatives of your friends or friends of your relatives must have asked you this and that about their body. Oh why my BP is 98/43? Am I having hypotension? Is something wrong inside my body? Oh why my… too many. And you can feel that you know nothing about this. We learn too many about ulcerative colitis, but we feel lost when your brother got gastroenteritis. You know well about steroid, ventolin or ipratropium in COPD, but what to give when our roomie got an URTI? Oh easy – supportive – but actually how? Sometimes we can tackle, sometimes we get defeated.

It’s not uncommon to see people like me, writing in xanga or facebook or shouting “I must work hard” in the opening of a new academic year. Finally I am tired, I am gloomy, and I am frustrated, because we can clearly feel our inability when challenged by even some simple things. Yet, we are still year three, but we are too useless, and we will be Medical Doctors in 850 days, sometimes I just want to escape.

Yes, being a doctor has been my dream from my age of 7, but I just cannot guarantee that I would be a safe doctor. I know nothing, and I miss something. I know there is time that I can improve, I just feel like there is too little. When I see my fellow secondary classmates, teachers, and 師弟妹, calling me Doctor with respect, having faith and hope in me, I feel shameful on myself. Especially when my 師弟妹 treat me as a role model, asking me about life in the Medical Faculty or University, and how can I pass with flying colors in pubic examinations, I want to hide inside a cave.

“I know that I know nothing.”
Socrates.

Well, enough grumbles. Just see too many things and have too much inside my heart. There are examinations that give me a good excuse to drop my pen. My friends always say that, to read my entry and get the theme in the quickest way – is to read the first two and last two paragraph in detail – even without looking at any words in the middle, you will still know what I am talking about.

Opps. I should have put this in the first line.

Resuscitation

Had my first CPR being performed in the ward this afternoon.

He was a 49-year-old chronic drinker, who was single, unemployed, and lived alone in Tai Wai. In short, he was essentially an abandoned middle-aged man. This emaciated man was found collasped in the Shing Mun River bank yesterday night, and admitted to this nearest hospital.

Today, 5th of March, 2009, a day I shall remember for the rest of my life, KM brought the flock of lambs into the ward, and one of them was asked to examine this gentleman. He co-operated with the lamb and the lower limb examination was finished uneventfully. The tone and power of those lathy legs were normal, with the only abnormality that the reflex was diminished. This was unlikely to be a myopathy, but a peripheral neuropathy.

KM went on to address the problem of multi-system damage due to chronic alcoholism, with loads of thamine, Vitamin B12, liver, brain and whatsoever being thrown to the lambs. Finally, KM ends his bedside teaching by once again reminding the patient to take that salty potassium chloride solution, on the other hand, reminding us not to prescribe potassium carbonate, and to appreciate chronic drinkers as well as those IVDUs, who sacrified their soul and body in teaching us how alcohol and drugs ruin one's life disastrously.

After most of the lambs had left, two of them remained in the ward, flipping through the case note of that gentleman we had just seen. At the same time, he kept on complaining abdominal discomfort. The intern was informed, whom told us the pain was just quite vague and nothing was remarkable on palpation. We then left the ward.

Only an hour later, after having a sightseeing tour at the haemodialysis centre to look for AV fistulae, I was told by the other lamb that the alcoholic was found arrested on his bed. We two hurried to the sence, only to see that the cubicle was crowded by the e-trolley, the intern, and the nurses. One of them was doing chest compression, while the other one was bagging the patient. At the same time, the intern searched hardly for a nice vein to insert a large borne catheter, and two nurses was drawing adrenaline into syringes.

Shocked by the sudden fall of the patient, one of the two young inexperience lambs, took off his white coat and got a pair of gloves in his hands. He padded the nurse who was doing the chest compression hardly, hinting he could take over in the next round. That was me, who had the hands on the chest of a dying patient for the first time.

Just cannot imagine I had a chance to perform CPR on a real patient only a week after the reinforcement assessment on the mannikin at Clinical Skills Learning Centre. The real one was definitely softer than the fake one. When two terrific pop sound slipped through my fingers during chest compression, I realised that I might have fractured one or two ribs of this unfortunate gentleman. Hesistated for few seconds, thinking about the consequences of pneumo- and haemo-thorax, I continued to deliver my thrusts with "this is the well-known complication of CPR" back in my mind.

With my eyes kept on the ECG monitor, I counted loudly "1, 2, 3, 4..." when I was compressing the chest so that the nurse could give a rescue breath at 30. Seeing the waveform moved up and down with each stroke, sometimes I misread the ECG and thought that he regain heartbeat. "Oh, still Ventricular Fibrillation." when I lifted by hands up. After 2 rounds (i.e. 300 compressions) I felt fatigue and switched position with another one. When the ICU doctor had arrived, she immediately ordered adrenaline and defibrillation to be given promptly. This was not only the first time I do a CPR, but also the first time I see a defibrillation being done in the real life. "About to strike. 360J. Oxygen Clear, All Clear!"

"Bomb!"

Unlike what I had seen in Healing Hands when I was still a primary four student, that gentleman only had a jerk but not a jump. Well the TV portrayals are always much exaggerated, otherwise there will be no dummies like me being misled into this profession. After the strike, the skin beneath became scorched, leaving a permanent mark on his upper right chest besides his American Indian native tattoo.

After two strikes of defribillation and being intubated with 100% oxygen, the patient regained a weak heartbeat. It was probably the effect of adrenaline which prolonged his life unneccessarily. His blood pressure cannot be detected by automated monitor. The nurses attempted to use a traditional sphygmomanometer, but were also pissed since his pulse was too weak to give an auscultative sound. Manual ECG was performed, only to find out that one of the limb lead was without a clip! One of the nurses immediately took out a tape of micropore and stick the electrode directly onto the patient's leg! That's why practical experience and wisdom shared by nurses should always be respected and appreciated by junior doctors...

As the patient was barely stabilised, the case MO agreed to take him down to the ICU. When the nurses were busy attaching those monitor, defribillator and oxygen onto the bed for transfer, two porters came. While the cluster was hurrying out to the lift, the ICU doctor and I were still in a disposable gown, i.e. the PPE. The journey from the ward to ICU, with priority switch of the lift's on, takes no more than three minutes. However, it was the most dangerous journey that happened to the patient. We rushed through the corridor crowded with visitors to make our way to ICU, whilst the ICU doctor was keeping his airway patent and I was bagging him.

When he was moved onto the ICU bed, I removed my PPE and slipped away. The next morning, I visited the ICU again, only to find out that he was not there, and I was told by the previous ICU doctor that he was not here ever after, soon after admission to her unit.

"We shouldn't admit him." She added, "He had a grave prognosis. We should let him go peacefully. However, it is the duty of ICU to get prepared as the crash call was activated."

I nodded, although I didn't expected that he could survive til the next morning, since the survival rate of CPR was less than 5%, I still could not hide my bit of sadness.

"But you had done a good job." She consoled me, "Remember, go home to revise the Adult Life Support protocol, and what are the reversible causes of cardiac arrest."

Coming close to the Final Judgment, I am no different from other lambs, being buried in piles of tasteless notes and books. Without examinations, I hope to devote myself into the ward attachment wholeheartedly, seeing the mysteries of lives and deaths, and how they are influenced by pairs of healing hands. However, life is not that simple. This is always a dilemma of the flock of third year lambs to choose between clinical and panel.

Being washed by numerous examinations, I nearly forget my original goal and dream of being a doctor. With this little incidence in the ward (Well I am sure that it is little in the eyes of many nurses or their students), having my hands on the dying patient, this is an important lesson to learn as a student, which cannot be substituted by any textbooks or lectures. I could strongly feel the sensation of gripping a life right at the gate of Death. At that moment, I remembered why I chose to be admitted as a member of the medical profession,

"I solemnly pledge myself to consecrate my life to the service of humanity." - The Declaration of Geneva.

I remembered, while I was bathing in the dormitory, a moth flied into my bathing booth. It flied across the steam and rested in front of me. It stayed there quietly. I am not a superstitionist, but at a instant I deemed that it carried his spirit, coming to inform me that he had passed away.

May God bless him and may he rest in peace.