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.