So, I totally just had my first day in the special care nursery. Pretty action packed. Well, not all that action packed actually.... but, you know, really good. I'm enjoying Paediatrics a lot.

So anyway, day started with our Professor of Paediatrics (great doctor, comes across like a friendly grandpa, actually a bit of a douche, but still a good teacher) who's a neonatologist. So me and my attachment partner were treated to really comprehensive and consecutive bedside tutorials on the neonatal examination. Which is awesome, because it's a really important learning objective, and I'm feeling much more confident already. Mid-way through the ward round though, the junior doctor's pager went off and we were called to an emergency caesarian (just like in the TV shows :D) which was something I'd never seen before. Gross and beautiful all at the same time. The baby was really big and there was something really out of this worldly about seeing him pulled out of his mother's abdomen all grey and icky. The umbilical cord was especially surreal with the baby up in the air but still attached. Quick as anything it was snipped,  rushed round by the father to mum for a quick look before the junior doctor sat him under the heater for the once over. Then dad (ceremoniously) cut the excess of the cord off and baby was back over to mum for pictures etc etc. 

Meanwhile, I'm there in my scrubs, all bright-eyed and bushy-tailed in awe over the whole thing. One of my neighbours was assisting with the operation which I really hope I get the chance to do. I should get the chance, really looking forward to that.

So that was awesome. Anyway, then medical grand rounds with a guest lecturer from Médecins Sans Frontières on malnutrition and some of the innovative ways they were tackling that. Really interesting, and relevant for a paediatrics term too.

Then we (my attachment partner, and I) wrote up our examinations formally for logbook purposes. And finally, to round off the day, a baby was transferred in to the nursery from a bigger hospital with DiGeorge syndrome. Which, basically, comes about due to a deletion on the 22nd chromosome and results in all kinds of different problems. Not a great condition to have but not that bad (many people with it don't know they have it). Really excellent neonatal examination though because there are a whole bunch of birth abnormalities to find and they're really important to see in the flesh. So often you have things in mind when you examine babies (and adults, for that matter) but it's much more helpful if you've actually seen them before, of course.

Pretty awesome introduction to baby medicine, right? Oh, and I changed my first nappy, too. Really easy, don't know what everyone complains about.

I should definitely be posting more, even if it is about nerdy stuff like hospital adventures. I'm really enjoying my paediatrics attachment but mostly for really nerdy reasons. I just find it really interesting, I'm only just into my 3rd week of the attachment and I've pretty much read my textbook cover-to-cover already. Fortunately my housemate bought a different paeds textbook so I can read that :)

Ok., so, exciting stuff. Today I did my first new-born baby check :D It's the examination you do of a newborn baby before they're allowed to go home. I examined a little 29 hours old girl who pooped and vomited twice during my examination :D Despite this, it was actually a lot of fun to do. The first thing I did was listen to her itsy bitsy heart (you should do this first because they often start crying early on during the exam and then you can't hear anything) and heard no murmurs. Then I checked her tiny pulses, and they were tiny, but symmetrical and of adequate intensity. Then she pooped and I had to wash my hands again etc etc. Then I checked her little baby head for any bruises from the delivery process and to make sure the different bones of the skulls were joining properly. Then I got to check her eyes to look for cataracts (mostly). Then I had fun doing the moro reflex: http://www.youtube.com/watch?v=3tHgqjDBSkU&NR=1 which I really enjoy :P. Finally I checked her spine and her hips and bascially had a lot of fun. The mother was very caring and one of those types that's overly respectful of doctors (probably does her hair and make-up especially before she sees them, types). She asked lots of silly questions about whether the baby was normal. Which I liked. The baby was definitely normal, but I like the over-anxiousness there.

There was another baby check before this that the junior doctor did with a much less impressive mother who was trying to speed up the baby check process because she wanted to leave so she could have a smoke, outside. That was a bit sad. She still had a reassuring level of anxiety and concern about her baby but... she has a drug history, and she's 19 (the father was much older and already had two children, 10 and 11) and while it's not great to stereotype or judge... stereotyping and judging is a big part of what medicine is all about. My housemate, Sarah, is doing her mental health attachment at the moment and I've been thinking a lot lately about how big of a deal the socioeconomic circumstances you grow up in end up being.

I'm wary of going overboard with descriptions of my days but I think it'd be good to post about my first ever paediatric patient. Just because I think he's one I'll remember. He was a 5 year old boy with a fairly uncommon rash called Henoch-Schloch Purpura. Very interesting for me because it's something I'd only ever read about in textbooks. When I saw this boy, though, the rash had resolved and it's probably more the interaction I'll remember. The boy was very shy and embarrassed around me. Not surprising since this rash typically effects legs, buttocks, and genitalia. I gather he'd had a lot of doctors looking down there over the last couple of weeks since the rash is one of the most critical aspects of actually making the diagnosis. His eyes were averted the entire time while he played at his Nintendo DS and he didn't want to talk to me or answer any of my questions. The only time he'd speak was when he'd indignantly yell, "MUM!!!!", when she was talking about his rash or his bowel habits or even (seemingly) less embarrassing aspects of the illness. "Don't talk about that!", and "STOP IT, MUM!". 

Naturally, I very seriously considered stopping the history-taking process and leaving the child be, but I was expected to take the history (and present it back, later) and the parent was dismissive of the child's concerns. Still, worth remembering that this kid is unlikely to forget the embarrassing course his self-limiting childhood illness has taken. I think it's consultations like these that help you develop your own personal approach to different sorts of patients. At the time all I could think to do was take the child seriously, not be dismissive of his embarrassment, and apologise for making mum talk about those things. It's tough to remember how the pscyhe of kids that age works but my own memories reminded me that being dismissive of seemingly trivial concerns from a child can create a lasting and negative impression.

Given it's SWOTVac and that I should be studying I really shouldn't be this excited..... but I'm not complaining that I am!

Only two weeks till I drive back up to Qld is one of the reasons, and I might have company! Two of my housemates are thinking of driving up too and staying with me on the gold coast. I think that'd be kind of a lot of fun. We could go to the beach, and the freshwater rock pools, and maybe Dreamworld, and Brisbane. The possibility is very cool.

Also, I'm totally going to Sweden for at least 15 weeks at the end of next year. 15 weeks! Plus I'll be spending Christmas and New Year there and it'll be snowing and that's pretty exciting. The elective term I'll be doing is at the Karolinska Institute, which is like one of the top ten medical schools in the world, and where the Nobel prize for medicine is awarded and the project I'll be doing looks really interesting and could very well lead to co-authorship of a publication. Which would be incredibly useful career-wise and an awesome experience. It's called the ALADDIN project (assessment of lifestyle and allergic disease during infancy) and is a 5 year prospective study of 520 families that looks into how allergic disease develops during early childhood and considers the hypothesis that the glandular fever virus might be protective against developing allergy (to do with the hygeine hypothesis for allergy). Really interesting stuff! I really can't describe how good an opportunity this is for a medical student who'll be graduating into a very competitive workforce.

:D

SWOTVac isn't even that bad. Our house is averaging about 3 blocks of chocolate a day and I think that's helping. Plus I'm up to learning about STIs and HIV, which is just plain fun.

Guess who's going places? I got allocated a spot at the Lismore Rural Clinical school for next year (mid-way through 2010 to midway through 2011) and I'm starting to plan a trip to Sweden in the beginning of 2011. YAY!

Lismore is something like 1 hour 20 minutes from the Gold Coast, 30 minutes from Byron Bay, Ballina, and Nimbun (sp?)! Plus the 13 other people I'll be living up there with are all awesome AND the rent is free. That's got to come pretty close to the best living situation ever, yes? I'll be up in Brisbane a lot more often, the Gold Coast too and you'll all come down and visit me and we'll spend saturdays at Byron on the beach and it'll be excellent.

And later Sweden! I'm going to be spending some time at the Karolinska Institue in Sweden with some of the world's leading researchers in what's looking like it might be vaccination medicine. Cancer, AIDS, allergy, diabetes etc etc all potentially curable through vaccination. Very exciting. Also means I've got to start saving. I'm thinking I'm going to need something in the order of $10,000 but I'm fairly sure I can manage that by then.

I think I might miss Campbelltown, though.

Just found out some people from my graduating grade in primary school are already working on plans for a 10 year reunion next year. Which I think will be pretty interesting. Kinda looking forward to it.

Is anyone else aware of this happening for their primary schools?

So this week is my second week of the first part of my surgical training. Turns out surgery is all I expected to be... and that's a shame, because I didn't expect very much. The education starts with general surgery which, while a useful and logical starting point, is not particularly exciting. Most of what I've seen so far are gall bladders being taken out and hernias being repaired in old men and women.

To be fair there's not much quite like seeing the contents of the gut through keyholes in the body or even having the whole body opened up with all its contents on display. Once you get past the fascination of it all though you start to feel for the elderly patient who's got a lot of painful recovery to get through. Not to mention all the anxiety leading up to and especially just before the operation. Tubes going everywhere, weird looking people surrounding you while you lie fat, overweight, aged, and naked in the centre of the room. Thank goodness for post-anaesthetic drowsiness, I suppose.

But yes, surgery is brutal and mostly boring and routine. Everyday reaffirms my already sturdy conviction that it's not a career pathway for me. Which is a good thing, because all I hear is that surgery training wrecks lives and destroys relationships, assuming, of course, that you're a competitive enough candidate to get on the training pathway... and competition is pretty hectic. Mind you, the surgical trainee who leads most of my teaching seems pretty content with his lot.

I put that down to him being an extroadinarily tolerant person and all-round excellent person. As grateful as I am for him, I don't see that I could possibly teach and operate with the same enthusiasm as he did the other day after having spend the entirety of the previous night managing sick surgical patients.
"Scrubbed, already?", I asked him at about 7:30 in the morning before ward rounds had started.
"Nah, I've been here all night. There was a lady came in about 5 who had me busy the whole time".
Went through the whole of day without any trouble, keeping up his excellent manner with patients as always. Presenting and providing informative discussion at the early morning morbidity and mortality meeting. Basically a place for doctors to get together and say "No, you killed him". Well, perhaps not quite like that. Though sometimes that's a worringly appropriate description. Then assisting in day's operating lists.

Medical grand rounds today was a nice reminder of the fact that there is a very definite role for the doctor who just wants to read a lot and know a lot and help his patient's through knowledge and pharmaceuticals.

Yesterday I ran the City2Surf. Today walking hurt a helluva lot; actually, walking hurt a helluva lot yesterday too.

Anyway, it was excellent and I enjoyed it all (even the notorious Heartbreak Hill). I got to see Bondi for the first time, I got a medal, I ran it in under 90 minutes which was my aim from the start, I got the time I need to move into a faster group for next year and I achieved something I set out to do this year that I was very unsure about from the beginning, very unsure.

More importantly though I think I felt, probably for the first time in my life, that I might be able to class myself as physically fit. Which is even more awesome than it sounds because I've never really been able to say that. I've always been the one that's good with books and terrible at any sort of physical endurance and I've always found that really frustrating.... especially with a younger brother that's a machine in physical endurance.

And I know things like this are very self-indulgent but I like this sort of self-indulgence. I like the feeling I get after a long run, I like being physically healthy and I like the sense of achievement. I also like that I'm determined to improve my physical fitness and ready to set more goals and get fitter and that I'm confident about that.

I love how you set this goal thinking this is going to be hard work but I'm going to feel so much better about myself after I do this.... and then how it all works out exactly how you'd hoped.

There are so many things about practicing health care that, while they make perfect sense, I never really appreciated before I started spending most of my time in the hospital. Phenomenon surrounding health and illness that are common and more importantly costly, that are in some ways trivial and in other ways not trivial at all.


Today was my executive shadow day, the idea being I follow around a senior specialist doctor for the day. Turned out to be a bit of fun because the specialist I got to follow is a little bit superhuman. Anyway, the shadow day started at 6am when I met with my specialist for his early morning personal training session with a defence force personal trainer. He is incredibly fit, me, not so much. Still, it was a lot of fun.

During the morning I got to take the histories off of some of his new patients. The first was a young lady of 19 who came with her mum complaining of an allergic rash she'd been getting since preschool. The mum seemed very concerned about her daughter, saying she wasn't her usual self lately, that she wanted her thoroughly checked out and her allergies treated so she could be well again.

The daughter gave a funny history. She described an infrequent rash (non-allergic sounding) and vague swelling of the body with a puffy face. The mum remarked on how different her face was to when she was younger. It seemed likely to me that the puffiness was basically just fat and that she had put on weight with teenagehood. She went on to describe an allergy to chilli, apparently it doesn't sit well with her and when she got it in her eye once it stung, and went all red. I explained, very diplomatically, that chilli does that and it's not an actual allergy. All the while a little dumbfounded that that wasn't obvious already.

She also explained that the symptoms went with emotional stress and that they weren't nearly as bad a couple of years ago when she was eating well and exercising. That and she had had allergy testing when she was about 10 and it was all negative. Her being rude to her very caring mother for most of the consulation completed the picture. The doctor simply highlighted the association of symptoms with poor lifestyle management and recommended she re-consider that aspect as a key part of her treatment. She couldn't be re-tested because she had taken telfast the day before so she'll come back in a couple of weeks for testing. She was told not to be surprised if the tests come back negative.

Another patient: So, after I got this allergy thing my wife made go see this naturopath person. Anyway, they hooked me up to this electrode thingy and ran a current through my arms
Doctor: Right.
Patient: Yeah, so what do you think about that?
Doctor: Well, what do you think about that?
Patient: Well, I mean, I'm an electrical engineer so I've studied a lot to do with currents at uni.
Doctor: Yes
Patient: Well, basically, I think it's a load of crap.
Doctor, Yes, I think you might be right
Patient: So how come you guys don't do anything about it
Doctor: *explains exactly how she would be received if she were to do just that*

Personally, I think it's kind of disgusting the way some of these people exploit the insecurities of others. And health is a major source of insecurity.... what a horrible way to make a living.

Then there was that old lady who complained of weakness in her leg (despite showing no weakness when one of the examination signs tickled her foot). She went from wanting a cure, to wanting to rehab to wanting to go home after she recovered completely over a matter of days.... *sigh* Such a enormous waste of money and yet it would be completely inappropriate to dismiss her concerns.

The other weird thing I've come to appreciate are those patients who are 'wedded to their diagnosis'. People who've had  a medical condition either self-diagnosed or diagnosed ages ago with current tests that indicate the diagnosis in question is extremely unlikely.... yet the diagnosis has become such an important part of their identity that there's no way they could possibly give it up. An incredible phenomenon with surprising frequency. Easy to understand how it could happen but a frustrating expense, stressing out the healthcare system with repeated and unnecessary consultations.

So I'm pretty excited about coming home very soon. A week from now, in fact, I will be back in Queensland. I get back earlyish Saturday morning (25th) and fly back late Sunday morning (2nd). Who's free when?

I'll be up in Brisbane a fair bit but if there's a day a few of us could come down to the Gold Coast that could be cool. Anyone have anything else going on? I don't mind visiting people at uni.

So, some days in hospital it just feels like all of your patients want to die.

I do medicine principally because I enjoy the subject matter. I don't do it to help people, to make money, to have a fancy title in front of my name, or because I had the right marks and it seemed like a good idea at the time. I will admit however, that voyeurism has always been a significant part of the attraction and since starting medicine it's only became more and more interesting. Patients and the way they interpret and respond to their health is always interesting, often confusing, sometimes frustrating, but rarely is it boring. Today was a perfect example.

Enter Mr and Mrs S. Mr. S is a quiet unassuming man with a variety of blood and immunological disorder and through various twists and turns of his illness, with positive and negative contributions from his medications, has developed a form of Lupus. Which, I'm sure, you're all familiar with thanks to House (suffice to say it gives you a nasty, scaly, red rash with joint pain, tiredness, general unwellness and, depending on the person, pretty much anything else you can think of).

Mrs S is an impeccably dressed woman in her late 50s and a control freak . She's takes down notes each and every consultation, asks for parameters of blood test results (which she doesn't know how to interpret), answers the questions her doctor's ask her husband and regrets the price of his immunosuppressive medications eating into their superannuation. She has also taken her husband on trips he isn't well enough to go on (against medical advice) to the discomfort of her husband. She has recently taken an interest in alternative medicine, I think because she would like control over the management of her husband's illness.

On a week-long trip to the Ian Galler Wellness Centre in Melbourne (a very expensive exercise), and on advice from her Kinaesiologist sister-in-law, she decided she would convert herself and her husband to a vegan diet (against medical advice). Ian Galler, by the way, had a cancer in his leg bone which was amputated off; he has been well ever since and 'survived cancer' (which, of course, has everything to do with his wellness and nothing to do with his cancer being chopped off with his leg). Anyway, Mr S, on his vegan diet, subsequently lost 10kg, became very depressed, and had a very bad flare of his illness. Mrs S. couldn't understand this since he was meant to be getting much better... or why he was losing all this weight, after all, she hadn't lost weight....... Last consultation he asked if the doctor thought coffee was alright (the doctor did think so) as this had been removed from his diet... along with chocolate cake and red meat. This consultation he asked about a $28, 500g steak at the Castle Hill RSL and whether the doctor thought that might be a good idea. She thought it was an excellent idea. In fact, she spent most of the consultation encouraging him to eat plenty of chocolate cake and red meat (his Iron, by the way, was very low).

Mrs. S, eventually agreed that with 10kg of weight loss in a very unwell man, was probably reason enough to abandon the vegan diet.

------

Then there was the young lady with Lupus who didn't want to keep taking her medication because it made her hairy. Despite the medication giving her the best control of her disease she'd ever had (and some of the best improvement her doctor's had ever seen). Uncontrolled lupus has a very poor life-expectancy with inadequate control. Like the lady above, I can understand where's she's coming from but am bamboozled by the lack of rational thinking.

----

Then there are all the people that think they have allergies but clearly don't. I don't really understand this. I have ideas.. but I don't understand. One lady had incredibly poorly controlled diabetes (which, being over 60, is very nearly a death sentence) mostly because she thinks she's allergic to her oral hypoglycaemics (containg sulphur), her insulin and (most recently) Zyrtec...... An anti-allergic medication. The likelihood of her being allergic to all these medications..... essentially 0. Death by false-allergy is coming.

----

Then there are the people with Latex neuroses. Convinced working in the hospital has given them latex allergy (which can happen). My doctor has designed a specific test to prove them wrong... it involves a covered box with holes containing shredded latex gloves and shredded normal gloves.

---

Finally a 77yr old lady who came in not feeling well and not eating but, most importanly, because of weakness in her leg. When I asked to raise her leg up in the air against resistance (to gauge the extent of her weakness) she was unable to lift her leg off the bed. When I tested the reflexes on the soles of her feet, however, she (being very ticklish) withdrew her legs all the way up to her tummy. The leg meant to be weak was drawn up just as much as the opposite leg. Who's she trying to fool? Anyway, tomorrow I will sit down and have a long chat with her because there's likely an underlying reason for her wanting to be admitted to hospital and apparently little old ladies tend to have a thing for me.

This http://www.news.com.au/story/0,27574,25658609-36398,00.html doesn't seem right to me.

Still, I don't have much conviction when I say that. When we get MET (Medical Emergency Team) calls from the maternity ward you can pretty much bet that it'll be for a postpartum haemorrhage (or excessive bleed following birth). Almost always.

In other news I was in a paediatric clinic this morning :D. Lots of little babies/toddlers with little allergies. Pretty fun :D

Afternoon was not so fun. A lady with cancer that had spread to her Brain was very deluded an aggressive. She was much more likeable and much less depressing when she was randomly spotting white rabbits around the ward.

So, there's likely going to be an opportunity for me to spend a year of my medical schooling in a rural location. Lismore is likely to be one of the rural locations available to me.

This is potentially very interesting because Lismore is <2hrs from the Gold Coast, and like 30 mins from Byron Bay or something nuts like that. Also, uni will pay for my accomodation so I could save more money. More importantly though, I could drive home like.... every fortnight or so if I wanted to. Even drive up to Brisbane every so often. Or maybe get visits from the family, and friends every so often. It could potentially be pretty cool. 'Specially since it would include the Summer months and make beach trips very doable.

On the other hand it's a full year in Lismore. Which is a small country town with no Westfield shopping centre down the road. I mightn't see friends and family as much as seems feasible at first and it could be very isolated. There'll be some other med students with me... but it could be kind of isolated. I think my parents would like me to go.... 'cause they would see more of me.

I'm a little bit unsure though. It could be very cool, it could be very not. A year is a long time.

What do you guys think?

So, I'm thinking I'm going to register to run the Sydney City to Surf this year. It's 14km. It's in August. Totally doable, yeah? Maybe not but if I did finish it would be something tangible (sort of) for me to feel like I've achieved something re:fitness. It would also be something I could try to improve on, yearly.

Anyway, this post is mainly something to keep me accountable.

Having had some success with venepuncture I got to try my first cannula today :D....... I missed.

So cannulas are sort of like little air-tight tubes that you stick into people's veins. First needle, then advance tube, then secure air-tight access point, then dress the wound. The guy I tried first time with was a really nice man, mid-50s, very pleasant. He was a little nervous (but he wasn't showing it) and didn't really mind at all that I missed. The intern put it in for him proper.

Unfortunately in hospitals though, if you give one patient something everyone wants one so it was only just after the intern had cannulated this patient that the man across the room asked for his cannula to be put it. Which meant my second chance, just moments after I'd failed my first go. The intern was telling me beforehand that this first patient was real easy, 1 start out of 5 he said for difficulty (whoops). The second one was a little bit harder (2 stars the intern said), but on my second go I got the cannula to stick.... In my excitement though I forgot to apply pressure to vein before I removed the needle to replace it wit the air-tight access point. Which meant I made a bit of a bloody mess. And that's fine, it doesn't really matter at all. The nurse will be a bit annoyed when she sees the stain on the bedsheet, but the patient and I decided we'd cover it up : P. He was quite happy with me because the last person to try and access his veins had a bit of trouble and I got it first go. So that was cool. 'You get this one in first time you're a legend', he had said before I gave it a go. So that was good, confidence still mostly high : D.

As I left the room the guy I missed on congratulated me on getting the next one in. How nice, right?

After tidying up the equipment I went to see how some of the other students were doing. They'd been practising cannulas for a little while now having both got the hang of venepuncture in their GP placements. The intern was saying this particular lady was probably four out of five stars for difficulty and when I walked in she was looking pretty anxious, both hands gripped to the bed and obviously quite uncomfortable. The student had missed her vein and incorrectly injected her with some salt water that was causing some aching around the puncture site. The intern decided he'd put the cannula in for her a little later in the day. Once she'd recovered. She was stoic though, she wasn't upset, I think she just didn't like needles but was perfectly accepting of them, all the same.

So, lately, I've kind of been toying with the idea of a PhD. I feel like it's something I should consider seriously because... if I'm being completely serious with myself, I kind of do enjoy studying a hell of a lot. It would be fantastic for my career and there is a lot of opportunity out there. I think I'd probably want to bag a pretty substantial scholarship... but I feel like this wouldn't be particularly difficult at a new medical school that's pumping a lot of money into research. I have a couple of areas of interest AND those areas are very relevant to clinical practice.

The main problems? I want to earn proper money, student salaries suck. Also it would take a long time and the junior medical workforce is about to be saturated with graduates meaning competition and working conditions are heading down hill, fast. Assuming I get a fancy scholarship I would at least be self-sufficient, no burden on my parents..... I wouldn't be turning over lots of money though. I like clinical medicine.... but now I'm studying in the hospitals I could probably get more involved with clinical rather than heavily scientific research. I want to be a doctor though and I don't like the idea of putting that off...... Maybe I should wait till after internship to do a PhD? I think I'd get paid a lot more if I did that..... Dilemma!

It's difficult to believe how much I've learnt since last monday. I've gotten so much better at so many different things. ECGs, CXRs, heart sounds, lab result interpretation, interpreting acute coronary syndromes (or more commonly, heart attacks). Even more exciting is that I'm enjoying clinical medicine just as much, if not more, than I enjoyed the pre-clinical years of my medical education. Among the different clinical pictures I'm yet to see and appreciate though are many and varied ways medicine can impact people and lay bare their emotions and fears. Interestingly, one of the most profound ways medicine can do this is by simply presenting people with a decision to be made.


Today was a busy day on the ward, our team was 'on-take' (admitting the patients while the other team was left alone to manage the patients they already had). Mondays are always busy when you're on-take over the weekend.  The positive side to this is there's a lot of new and interesting patients to see and, in the space of the hour or so it'd taken to get halfway through our round I'd alreadly learnt an awful lot. So I was ready and eager when the registrar (specialist trainee) pulled out the ECG for the next patient.
"Ahhh, now this is important", she said. "All the ones I'd showed you previously had changes that mostly pretty 'meh'. This one is a lot more serious".
And it was. The ECG showed a serious heart attack, mostly likely down one of the major vessels of the heart. It didn't look like a complete occulusion but, as is always the case with heart attacks, the next 30 days would be critical and the next 72 or so hours especially so. The risk of another occulusion, or a worsening of the pre-existing occulusion are both very, very high. To complicate matters that patient was a 60 year old man visiting Australia to see his sons and daughters before returning back home to South-East Asia. He hadn't taken out health insurance.

A bed in the coronary care unit costs somewhere around $1200 a night. Optimally this patient would be staying in hospital for at least the next week for monitoring. Though, apart from monitoring, the potential of therapy is limited without another separate test. An angiogram, where a wire is injected up through a vein in the groin and into the heart where it releases a dye that allows detailed visualisation of the heart's blood vessels on a CAT scan. It costs around $10,000. The angiogram is helpful in deciding whether the heart muscle can be saved by coronary (heart) artery bypass grafting. Surgery that costs around $35,000.

The patient in question didn't speak any English, his family did and upon them fell the burden of the decision. They were already concerned about the cost of the patient staying in coronary care when all he seemed to be doing there was sleeping. The most important thing in this patient, however is careful monitoring. This is the decision the family was left with. The patient left coronary care this afternoon and I'll find out whether he gets an angiogram tomorrow when I sit in at the cath labs to watch my specailist supervisor performing the procedure on his patients for most of the morning. Even if he doesn't go ahead with the test though, there's a substantial cost associated with the medications he's now been prescribed to reduce his risks. No help back home either, no universal health care cover there. The hospital was discussing a $40/week pay back scheme with the family this morning but even this they said would be an enormous struggle for them to afford.

I think there are a lot more of these difficult (if it can be simplied to just one adjective) scenarios for me to see and appreciate. I'm not sure if there's anything quite like medicine for turning upside down somebody's whole world and, in doing so, exposing so relentlessly their human being.

Today was a different sort of a day, other wolrdly even. Not unexpectedly so, I suppose, but the whole affair was still surreal and incredible. We arrived at Liverpool hospital, one of the biggest hospitals in NSW, very early, this morning and were very fortunate to find our way to the operating theatres, exactly where we were meant to be. Fortunate, because it was a very big hospital that we weren't really at all familiar with. We introduced ourselves to reception and waited to be picked up. We, by the way, is simply my Cardiology attachment partner.

Scrubs, I think, are something most people are familiar with. When you're invited through a door by a lady in a blue gown and shower cap though, into a part of the hospital where everyone is dressed likewise..... it's quite bizarre even for me, in my third year of medical school. See, as much as I've become used to being in hospitals and getting to know how wards work, the contrast is that much more striking once you walk into the operating theatres. Simple though it may sound, it's still something very different to walk through a door in a waiting room and be presented with a completely different world of people in blue gowns and shower caps with their own little offices and trays of equipment filling every corridor. Hospital wards aren't quite like that.

After an extensive tutorial on firesaftey and infection control we were allowed into the operating theatre at around 8:30am. Even this was a pretty significant event.

The patient to be operated on laid unconcious on the operating theatre table, completely naked  and vulnerable while the anaesthetist trainee stuck an ultrasound machine down his oesophagus. Trying to be completely mindful of where the sterile field was and wasn't, we watched as the patient was made sterile, covered from head to toe in sterile sheets and plastic with only the chest exposed (which itself was still covered with plastic and betadine). Meanwhile the anaesthetists commented on the size of the patient's aortic valve and the first part of the patients aorta. Both were very big and this was why the patient was being operated on.

Thanks largely to a genetic predisposition, this patient had a dilated (or widened) aorta, which is the main blood vessel leading out of the heart and supples essentially the entire body with blood. The aortic valve is a one-way valve that is closed when the heart is filling with blood and opens when the heart beats to pump blood out into the rest of the body.

The operation began with what can only really be described as a chainsaw incision down the patients chest,through the chest muscles, the sternum and into the heart cavity. All of a sudden we were watching a rather large heart beating away in the chest of a 37 year old man, covered in fat. Yet another incentive for me to stay healthy. The beating heart, of course, presents something of a problem to a surgeon wishing to perform open-heart surgery and so the aorta was tied and the blood in the heart was drained. Amazing for us, was seeing a big, beating heart deflate like an out-of-air balloon and collapse in a heap of fat. The surgeon's heart beating problem solved, though, presents a similarly worrying problem for the patient, who's heart isn't beating. Fortunately a handy machine that goes bing (or so the anaethetist's liked to call it) was handy to do the whole heart beating, blood oxygenating, temperature controlling thing for the patient. It was incredible to watch blood being diverted away from a deflated heart into a machine and then forced back out into the patients body.

Next on the surgeon's to do list was that troublesome, overly big aorta. The anaesthetists, however, didn't have much on their to do list. They spent the next couple of hours doing crosswords, discusing their plans for the weekend, discussing funny movies coming up on foxtel or else just generally looking pretty bored. Except, I guess, for the anaesthetist trainee, she was being very good and reading the latest literature on this particular operation. Still, this particular interaction with the anaesthetists and  the hospital scientist (who was controlling the artificial heart and lungs machine)was... a bit surreal.

Anaethetist: It's not indulge or treat, starts with p...
Hosptial scientist: Pamper?
Anaethetist: Actually yeah, that fits!
Surgeon: Vent on please!
Hospital scientist: Vent already on, turning it up a bit!
Hospital scientist:So what's on for mother's day?

Meanwhile, the surgeon cut off the dilated part of the aorta and dissected out the aortic valve, leaving just a tiny bit over where the aortic valve used to be. He proceeded to sew an artificial cylindrical replacement graft on to that tiny bit. Then, and this is the tricky part, he pulled the dissected valve up in the graft and sewed it on to that graft. Getting the valve in just the right spot on the graft to keep it function properly is a tricky thing to do (and only a handful of surgeons in Australia can do it) but a very valuable thing to do since it saves the patient from a mechanical valve and lifelong warfarin (read blood thinning medication, aka rat poison).

Then the right and left heart arteries needed to be attached to the graft with careful sewing, and finally the end of the aorta (connecting it to the rest of the body) was sewed (using the graft as both a frame and a replacement for the dilated aorta) to the bit connecting it to the deflated heart. This was when the anaethetists roused from their slumber as blood flowed back into the heart and everyone watched the ultrasound screen (from the machine in his oesophagus) to see if the valve was competent (that is not leaky, blood only flowing one-way). Which it mostly was. And so the operation was deemed a success and all remarked on the skill and experience of the surgeon in charge. This was at about 1:30pm. The operation lasted 5 hours by which time my partner and my legs were very, very sore. Though not as sore as I bet that patient's chest will be when he wakes up because opening and closing his rib cage was nothing short of brutal.

After changing out of our surgical scrubs we went back to our home hospital and rounded with the consultant. I got the opportunity for another first with a little old lady of 85 years. This morning, by the way was my first surgical experience. Anyway, the lady hadn't opened her bowels for two days, had abdominal pain, no appetite and the doctors were concerned she may have been constipated. How can we check? Well, this turned out to a perfect opportunity for the medical student to try his very first rectal examination. Which, while everyone else made a bit of a big deal out of it, I didn't have any particular issue with. A good learning opportunity.

So today was a pretty awesome day. I spent the first third of my year doing a community rotation which, while useful, was mostly pretty boring. The two days I've spent in the hospital, doing my cardiology rotation, have far and away been so much more exciting and so much better for learning. Things I did today:

- Watched the heart being visualised by ultrasound through a lady's oesophagus
- Watched that same lady be 'shocked' from an abormal heart rhythm to a normal one (pretty cool)
- Took blood for the first time from the student I'm partnering on the cardiology ward, which is actually pretty easy but is something I simply haven't had the chance to do before and so was kind of cool for me. Two other students practiced cannulating (which is where you put a temporary tube into someone's vein that stays there for a couple of days with various uses) but both failed... Cannulating is a bit more difficult and a bit more painful so we're going to wait a little while before we practice that.... Or maybe just do it on a patient first rather than eachother >_> Anyway, this is all a big deal for me because I never used to like needles.
- Developed a crush on my registrar (read specialist trainee) who is amazing and a good appreciation for my intern (who is also pretty awesome)
- Realised I suck at reading ECGs and set myself a lot of reading to do tonight
- Decided I don't want to get heart disease and planned to renew my gym membership tonight
- Listened to, but didn't recognise a diastolic murmur :P
- Resolved to do more study in general
- Spent lots of time taking patient histories, doing brief examinations, and reading patient notes


Things I still have to do today:

- Actually go to the gym
- Work out what I'm cooking tonight (it's my turn)
- Do a LOT of study
- Maybe read more of my book and learn more japanese... maybe

Things I have to look forward to:

- Cocktails on friday in Newtown :D
- Getting up very early to watch me some cardiothoracic surgery :D:D:D


So, all in all, things are going pretty well.