"After three days they'll start biting"

That's one of the first pieces of advice I got from the professor of medicine at Sarawak General Hospital.

It was in reference to the mosquitoes and he was spot on. I'd been in Kuching for three days when I started getting bitten - did they really have to develop a taste for Western blood or was it just that it took me three days to start getting lax in applying the deet?

So it's been over a month since I last wrote a post for my blog, not really sure where the time has gone. One minute I was having a jar of honey confiscated by Australian customs and the next I'm sat here with only a few hours left before I fly back to the UK.

Anyhoo, no use moping on about how little time I have left until I have to get back to reality...

What have I been up to?

Well, the consultant who helps to organise the elective here in Kuching advises students that there are three parts to this elective - medical, cultural, and gastronomic - so I may as well break down what I've done into these areas (and try and keep it short & sweet).

Medical

I've been to quite a bit of teaching out here, which is helpful after spending four weeks in a highly specialised environment. One of the sessions was on my major weakness too (ECGs) which is always useful. I spent some time on the ward over the past few weeks and have found that on the whole most of the medicine is very similar to what I have already experienced back in the UK, just at a much higher humidity! I'm not joking about the humidity thing, it's usually between 25 and 30 degrees with high humidity - and some wards only have some very weak fans for cooling. It may be unpleasant for the elective students but it must be much much worse for the patients who have to deal with it all the time they are in hospital.
The clinics ave been very interesting too. Often the doctors are communicating in both Malay and English (conversations and teaching are usually conducted in English between HCPs) which makes for an interesting experience as a student observing the process.

Cultural

I'll admit I still know embarrassingly little about the cultures of the various groups that make up the population here but I have been trying. During my time here there have been celebrations for Malaysian Independence on both August 31st (Independence Day for Malaya) and September 16th (Independence Day for several states including Sarawak). The second date was much bigger here in Kuching as it is more relevant to the people and so we had a good amount of celebrations including a parade and fireworks (which I managed to miss due to flying back from KL).
It's also been great to see how all of the various cultures appear to get along out here. If there's one thing Kuching could teach much of the Western world it would be how to live side by side and be more tolerant.
I'll try to write a bit more about the culture on this blog once I get back to the UK.

Gastronomic

The food is great! I've had the opportunity out here to try a number of the local delicacies which has been an enjoyable experience. Amongst the things I've tried are:

• Sarawak Laksa
• Sea cucumber soup
• Kolo Mee
• Mee mamak
• Nasi goreng
• Roti

I'd say food is one of the big things to travel to this part of the world for...but a word of warning, some of it is quite spicy!
I could write pages and pages on the various dishes but I think I'll leave it at this.


I think I'll try to write a few blog drafts during the flight back to the UK - only a 12h 35m flight from KL to Heathrow, so plenty of time to get some writing done.

Farewell Auckland, it's been a blast!

Ok, just a quick post today from the airport as I'm boarding my flight in about an hour.

Just to tie up a loose end from my last post, unfortunately the patient did pass away later that evening which sucked for everyone involved. One of the hard things about working in healthcare is that no matter how invested you are in the care of a single patient you have to know when to let go of all the emotions you had surrounding the case. I'm not advocating becoming a robot with no empathy, just merely that it is important to be able to detach and distance yourself from the crap you see on a day-to-day basis. As one consultant put it to me once, "To be a good doctor you have to have a thick skin. You can still empathise with those that you meet but you need to be able to draw a line between your personal and professional life. It's even more important in paeds."
And to answer people's concerns, I'm ok after what happened. I reflected on what had happened, talked it through with others and learnt more about myself and my chosen profession.

Now moving on. I'm gonna write a more detailed post about my last couple of weeks once I'm in Perth but here's a quick run down of the last few days and my highlights from my time here...

Last few days:

• Went to Hobbiton - awesome!
• Cycled round Waiheke island in the sunshine - great time with great people
• Went wine tasting on Waiheke, where the owner gave us each a complimentary extra glass each on the house
• Visited the museum - educational
• Climbed Mt Eden - stunning views
• Ate at an amazing Mexican restaurant

And now, my highlights from New Zealand (in no particular order):

• Travelling around a beautiful country
• Visiting Bay of Islands, swimming in the cold sea at Paihia and sand boarding down the dunes at 90-mile beach
• Visiting Hobbiton
• Going on a patient transfer to Christchurch
• Meeting awesome medical students from around the UK and beyond
• Getting to know (and shadow) some fantastic doctors
• Meeting some wonderful NZ natives, both at Starship and around the country - and one or two people in particular
• Drinking with a Maori in Paihia and talking about his culture

There's probably way more stuff that I could list as highlights, but these are the things that truly stood out for me over the past 5/6 weeks.

Now unfortunately I only get 30mins free Wifi and I also need to get some food before I fly so gotta wrap this up. So I'll end with this...


New Zealand, it's been an absolute pleasure being here for all this time. I don't want to leave but I know I've got to - for now. This is by no means goodbye, just a catch you later!

The (medical student) bubble burst...

Ok, so the title of this post may seem a little bit melodramatic but there is a reason behind it...

The past 2.5 weeks on PICU have been great, I've got to work with some amazing doctors and had some incredible experiences. Due to the nature of the unit I was very much hands off and although there were some seriously sick kids there were never any crash calls or arrests.

I did go to one 'code pink' where a child had been given too much morphine post-surgery and wasn't waking up. All it took was a quick dose of naloxone and he was awake....and crying. It was quite impressive to see such a rapid reversal in someone's condition.

The worst case up until now had been a young girl who had been involved in an RTC and had sustained quite extensive brain injuries. In all honesty it did cross my mind when I left the unit on Friday that she may pass away over the weekend. She has, however, proved us wrong by slowly improving. Obviously the doctors are very realistic in what they expect her long-term outcomes will be but comparing what she was like early in her admission with now I can easily see a positive difference.

We also had a child admitted with a prolonged accidental paracetamol overdose which when the dose was worked out made everyone go "shiiiiittttt." But she is holding steady and is on the right side of buggered.

So despite there being some shitty moments there were also a number of positive moments such as:

• Seeing several children being discharged back to the ward - including some very sick kids
• Getting on really well with the PICU team and being made to feel like a member of it (albeit a dumb, yawning, unable to help with anything practical beyond basic stuff team member)
• Learning about various medical conditions, both rare and common(ish) like:
• Rheumatic heart disease/RF, which is still extremely common in NZ
• Hurler's
• Paronychia Congenita, specifically affecting the vocal cords
• So much congenital heart disease
• Meeting the parents of the children, who are able to hold it all together despite the hell that they are undoubtedly going through - those men and women are truly inspiring in their emotional strength

And that brings us to today...

The day started with loads of promise. The reg wanted me to take a couple of the patients and present them at evening rounds after teaching. I chose a baby with coarctation of the aorta who was having surgery and a bronchopneumonia. The morning was going swimmingly - hell there was even a plan for me to observe the extubation of one of the patients so that I would understand how it's done.

But then, as I wrote in the title, the bubble burst.

PICU has been looking after a child for the best part of a month who has a multitude of problems including graft-vs-host following a bone marrow transplant. The parents had always tried to be realistic when it came to the prognosis of their daughter but it was obvious that they also held onto the hope that she would pull through despite the proverbial shitstorm that she was going through. The doctors have tried everything to help her including nitric oxide and using an oscillator to help with ventilation.

Today seemed to be going similar to every day up until that point. The X-ray was of debatable significance and things were slowly moving along. But today when the nurses went to turn her in bed something went wrong. She desaturated. She started having a bleed from the lung. Things were going bad in a big way. I stayed out of the room whilst two of the doctors and the nurses tried to help in any way that they could, after about 30 minutes I was sent to go and get the consultant. When I told him that she had desaturated and was bleeding from the lung he carefully repeated the last part of the sentence in a manner that was half questioning and half processing the information. For a moment the words seemed to hang there, and I began to process what I had said, my thoughts finally catching up with the events up to that point, and in my mind all I could think was "Fuck."

Eventually the consultant and fellow came out of the patient's room after much discussion with the parents and other specialists. I only caught part of the conversation but I remember hearing the words "the parents don't want anything else to be done." There was some intense discussion between the PICU doctors about what could still be done but regardless it would all be futile. It was agreed that the best course of action would be to keep the patient comfortable and allow the parents & family to spend time with her.

Whenever I saw the parents for the rest of the day I could see the anguish in their body language, their faces and in their eyes. The look of someone who is too tired to carry on, is defeated and just wants the nightmare to end. Someone who's eyes are raw with the tears that they have shed. And the pained look on their faces that screamed out that they knew they would likely never see their little girl as she had once been before all of this, as she had appeared in the picture stuck on the monitor over her bed, the look of a parent who knows they are almost guaranteed to outlive their own child. I think it's hard to imagine a worse hell than what they are going through at this minute.

I don't know if she will survive the night and I guess it's something I'll find out tomorrow when I go in.

And it's not over yet folks!

With this experience still ringing in everyone's ear we started the lunchtime ward round. This was summarily interrupted by a 'code pink' which rapidly became a "can the doctors please make their way to room 4?" The baby that was originally on the ward had been bought down in a peri-arrest state. From a medical point of view it was an amazing thing to watch the team work together so fluidly. Acess was secured via the IO route and a Hickman line, drugs and fluids were given to stabilise BP and the baby was tubed literally seconds away from arresting. I mean seriously bradycardic. As the patient stabilised, it was possible for the reg to do the art line and central line in a more relaxed fashion.

Whilst all this was going on what was I doing? Well, I was observing. I'm a medical student in a highly specialised environment in which I have very little knowledge. So I watched. I felt useless, an obstruction, christ I felt like an idiot. But then the mother arrived and stood silently next to me. And after a minute she asked me what the green tube was for, and I told her that it was giving her baby oxygen. Then she asked me what the lines on the monitor were for. And again I explained what they meant. And this cycle repeated itself for several other actions the team was carrying out.

And then I realised something - I may just be a medical student, I may know next to nothing about paediatric critical care, I know for sure I'm not anywhere near the smartest in my year group (my AMK scores show that), but I do know what each of the various components of the resus entail and I can explain to mum what is going on. And that's just what I did. I stayed by mum and talked to her about what the doctors and nurses were doing to her child. When the trace for the heart rate dropped to zero I heard the sharp intake of breath and the breaking, whisper of a voice speak out in fear above the noise of everything else in the room - I knew it was an artifact but mum didn't, and so I told her that the heart was still beating (oh god I hoped it was still beating, I could hear the comments about weak pulses) and felt the palpable sense of dread ease slightly. I realised that no matter how small an impact it will make in the overall care of her child, I was able to connect with her at that time and with that simple act of speaking with her she suddenly wasn't alone and isolated. It was all I could do, so it's what I did.

Today may have been one of the most fucking emotionally trying days since I started not only here but in all of my five years to date. The bubble may have well and truly burst and with it I have now seen the darker side of it all. But before today I felt like I was suffering from an empathy burn-out, like I could no longer react with shock to what I was seeing - I was stood in a PICU and I wasn't shaken by what I was seeing - and then today happened. I looked into the eyes of a mother who was losing her daughter and knew there was nothing she or anyone else could do to stop it; and I looked into the eyes of a mother caught up in the fear and confusion of a paediatric arrest, isolated amongst a sea of health care professionals, waiting dumbstruck whilst they tried to save her child.

I may look back on this when I'm at home with my family and it may all hit me, but it may not,  I don't know. But it has happened and there is nothing that I can do to change it. Academics and doctors always talk about shielding medical students from the worst shit until an appropriate time, but I do wonder how you can decide when this magical arbitrary cut-off time should occur and in what way. I've seen death and dying in a medical student capacity before this but (this sounds terrible, but I can't think of a more eloquent way to say it) it has never felt as real as it did do today. It can never compare to how it feels to lose a loved one of your own, but it felt as though a gap between 'personal experience' and 'medical student experience' was bridged or at least is beginning to become connected.

And you know what, I'm glad the bubble burst suddenly. It showed me that I'm not turning into some hard-nosed, uncaring bastard and it reminded me of a big part of the reason I wanted to become a doctor.

Hopefully the next post will be shorter and much more positive!

Dan

P.S. Mum & Dad if you're reading this, I'm ok, I talked with the doctors on the unit and am in a good place. If I need to phone you I will, but as it stands I'm ok x

A round trip to the South Island

That's me, next to a medical transport plane, whilst the crew load a PICU transfer trolley on board...

Here is said transport plane...

This is the huge interior that the transfer team has to work with...

And this was the view out of the window for the majority of the 960 mile round trip!

Ok, now that I've got those photos out of the way onto the details. On Tuesday I did a full day on PICU. As this was my first proper day I didn't really do a great deal besides beginning to learn my way around and how things went down on the unit. However, the duty consultant did try to get me on a patient transfer in the afternoon (partly because it was in his home town and he thought it was a nice place for a student to see). Unfortunately the team was using the 'small' helicopter which only had room for the two person transfer team, crew, patient and one parent. As such I couldn't go out with them. I wasn't complaining though, it was my only my second day! So late in the afternoon, when a call came through about a child in Christchurch who may need transfer up to PICU I didn't hold out much hope about going out. That was until the consultant said the child wasn't critically unwell and could be picked up the next day. This prompted me to ask if there was any chance I could get on that transfer, and as the pictures above show, the answer was yes.

I was told by the charge nurse to call ahead at 7.15am on Wednesday morning, and to be prepared to be at the hospital before 8am. So like a good little boy I set my alarm for stupid-o'clock and when it went off, I promptly put it on snooze for another half an hour. Still, I was up and ready by 7.15, so it doesn't matter.

I called the unit and was told that they hadn't had to rush down to Christchurch in the night so the transfer was still going ahead but it was delayed until 9am due to fog. This gave me enough time to buy a coffee and breakfast so I wasn't complaining about the delay. 

When I did get to the hospital (now happily full of coffee and chocolate almond croissant) I was met by the charge nurse and told to go buy lunch as I was in for a long day. The reg on for the transfer then took me through the winding maze of corridors and lifts that made up Starship and Auckland City Hospital to go buy food (whilst also pointing out the one essential piece of information I needed for the next 3 and a half weeks, the best place for coffee on site). Upon getting back to the ward I was briefed about the patient, what to expect on a transfer and what equipment we would be taking. It turned out that all three of us going out on the transfer (myself, the registrar and the nurse) were all from the UK, so it was a very British transfer.

The last job to do prior to leaving was to get our flight suits on. Initially there was only medium or extra large and I quickly discovered three things:

1. Extra large flight suits can be used as an emergency tent;
2. The above mentioned suits are therefore a trip hazard and not ideal for going around a hospital, much less so an airport runway;
3. Flight suits which are too small have a tendency to castrate male wearers.

These groundbreaking (facebreaking in the case of the trip hazard) discoveries lead to a rummage around the tumble drier for a large flight suit. Mercifully for my face (and other appendages) one was found.

Now suited-up and ready to go we loaded the kit onto the ambulance aptly nicknamed the Baby Bus. After a quick 15 minute ride we arrived at Auckland International Airport via the back entrance. During the ride I was told several bits of information:

• If I hear a gunshot/explosion noise, it is most likely icicles that have formed on the propellers flicking off into the hull - which is conveniently reinforced with Kevlar for such an occurrence;
• It will get bumpy;
• It's quite cramped so we have to hope the patient remains stable in flight;
• Communication is only achievable via headset due to the noise of the engines;
• It'll probably get quite cold in flight;
• There's no toilet on board;
• We're carrying Nitric a pretty explosive gas which we have to inform anyone who transports us that we have it;
• It's only the nurse's second solo retrieval;
• It'll be a good day out!

To be honest I didn't care about all the bad things. When was the last time I had had the opportunity to go on a patient transfer like this? Taking a PR bleed by ambulance to the local (Cornish) hospital isn't really in the same league.
So following a couple of obligatory 'My First Patient Transfer' pictures it was time for the flight. As it was raining I was expecting the flight to be hellishly turbulent but it wasn't actually. Sure, there were a couple of bumpy moments but on the whole it was fine (one trick I found which worked for me during any turbulent bits was to just look out of the window - seemed to help for some reason).
The view, albeit cloudy at times, was spectacular. After we left North Island behind and crossed the water we approached South Island via Tasman Bay & Nelson. From there we just followed the mountains all the way down to Christchurch, which sits an area of perfect flatness surrounded on three sides by mountains and the fourth by the sea:

Compared to the rain up in Auckland the sun was glorious. We were met at the airport by the ambulance that would take us to the hospital and back for this leg of our journey. So once the gear was unloaded we piled into the back of the ambulance for the  quickest and most limited tour of Christchurch a medical student could get (airport-parks-hospital-same parks as before-airport).

Our destination was Christchurch ICU. As the hospital was used to carrying out transfers nearly everything was all ready to go. However before we took any form of handover, but obviously after introducing ourselves, we asked where the toilets were and made use of the facilities.
Freshly relieved we took the handover from the Christchurch team (see bottom of this post for the clinical details) and set about prepping the patient for transfer. Priority number one was to switch him over to our ventilator as we would need him on this for a good 20-30 minutes prior to taking a blood gas reading. That's easier said than done! For some reason the patient's CO2 was reading abnormally high once he was switched to the transfer ventilator. This in turn led to a delay in our transfer as the registrar continued to fiddle with the ventilator settings and the equipment. It was at this time that I learnt an important lesson about the role of observer - learn how to silence the monitors when they start annoying the doctor/nurse. Eventually the reg got his levels under control and an ABG showed a picture of chronic compensation (so in actual fact we had just exacerbated a chronic problem with the ventilator). The rest of the transfer happened rather quickly from that point on. The patient was switched to the transfer monitors and drivers, he was moved across to the transfer trolley and secured, and he was given a dose of diazepam and pancuronium to sedate & paralyse him for transport - as horrible as that sounds to non-medics I can assure you that this is a standard practice (not just in patient transfer but also for operations).
The crewman from the flight had also traveled with us to the hospital as his job now was to liaise with the plane, the ambulance, and a taxi to transport both him and the patient's mother to the airport.
After about an hour and a half we were ready to go so the crewman called for our transport which showed up quite quickly considering it was a busy day for the ambulances in Christchurch.
After the brief journey back to the airport we loaded the patient onto the plane and got mum settled on board. It's worth mentioning at this point that the reason for two-person transfer teams isn't just to spread the workload it is also because one of them must always have eyes on the patient and their monitors at all times (as is also standard practice in ICU). So when the patient was being transferred up into the plane it was necessary to have one team member watching everything from outside and another ready to take over on board the plane.
The flight back took about 30 minutes longer and was pretty much the same as the outbound leg. We were treated to further incredible views of both North and South Island. Naturally we experienced some more turbulence, and we were grateful that the nurses back in Christchurch had had the foresight to put a rolled up blanket either side of the patient's head along with taping his head in place. This minimised most of the wobbling caused, but it was still necessary for the reg to place her hand on his head to steady him.
Eventually we made it to the airport and then back through the city to Starship (apparently it is possible to travel the length of New Zealand without ever seeing a traffic jam, with the exception of Auckland between 5pm and 7pm). A handover was given to the receiving team up in PICU and with that we were finished for the day.
The little lad's mum was quite familiar with PICU as he had spent some time on the unit between late 2012 and early 2013. It's a shame that the family had to travel back up within the space of a year but it was for the best in terms of his care.

Just to wrap up a few lose ends that I couldn't fit into the story above:

• The patient's father flew up on a commercial flight the same evening whilst other family members looked after the other children in Christchurch;
• The flight wasn't as cold as it was made out to be;
• We did get chance to eat during the flight;
• Christchurch ICU did offer us a cup of tea (a sign of a good hospital);
• The patient had to have obs every 15 minutes even whilst in flight;
• He remained stable throughout the flight, only requiring a top-up of his sedation and a dose of antibiotics that hadn't been given prior to leaving the hospital;
• For me the day began at 6.30am when I got out of bed, I'd been at the hospital for 8am, and I eventually got away at 6.30pm, before arriving home at about 6.45 with dinner in hand - I got a pizza, don't judge me it'd been a long day without much coffee.

And for the medics, here is the briefest of patient summaries:

• Male
• Under-1
• PC - RSV+ bronchiolitis requiring ventilatory support
• PMH - VACTERL, tetralogy of Fallot, previous PICU admission
• PEG-fed, Colostomy
• Plan - support on PICU until well enough to return home

Until next time,

Dan