Friday, May 15, 2009

Starting E.D.

This week officially marks the end of my O&G term. I'm starting a 4 week rotation at Emergency Department which I am quite looking forward to as it should be more interesting plus the cases that I will be encountering are very relevant for my final examination. The management protocols for any patient that presents in an emergency situation is a DEFINITE MUST KNOW for the finals which includes the correct, appropiate steps of diagnosis, relevant investigations, immediate treatment and follow up management. We're supposed to split ourselves up into two groups and you are either allocated to the morning shift (8:00-1:00pm) or the afternoon/evening shift (1:00-6:00pm) which leaves ample room for studying in between. I'm hoping to gain more exposure in practicing my procedural skills which is something that I am facing difficulty in due to lack of experience and partly because I'm really scared that I might end up causing a haematoma when i insert a cannula in (which I have done before on one occasion), do the procedure incorrectly or cause pain to the patient. A lot of the registrars and consultants have told me to just 'Go on and just do it' as the more you hesitate, the more uncomfortable you become (not to mention your self-confidence further deterioates)and you put the patient at unease. How am I going to do these procedures at ease when i am a future doctor? I've just got to gather the courage and DO IT without thinking too much of the potential consequences. I know most of the time these stuff are done by the nurses and midwives but it just means that its an accquired skill a doctor should possess hence he/she need not waste time on it.

Anyway, I received some feedback from my supervisor. She told me that I need to work on my communication skills. By that she means I need to make an effort to build a good patient-doctor relationship and have a broader view of the social, occupational, cultural factors that may contribute to the problem. I mean it is neccessary to ask the questions relating to the physical health of the patient but you should ask the patient about his/her concerns, worries, understanding of the disease, social support as this can impact on treatment outcome. Eg: A patient may be suffering from menorrhagia (heavy menses) but has suddenly come to her GP after only a pariod of 2 years. As a doctor you have to find out what is the reason why she has come to address this problem today; could it be that it is affecting her marriage i.e. sex life or perhaps she is worried that she may be having cervical or endometrial cancer? Just like any clinical scenario, a doctor plays a 'detective' role; you are given the clues and have to work backwards in order to find the source of the problem. If you don't ask the right questions, you don't get the right answers. That's why my supervisor emphasised that its vital to build a good rapport with the patient. She says that its probably due to my 'timid and introverted' nature but I think its probably due to a lack of self confidence. I admit I'm not that much of an outspoken person so its something that I need to work on in the future. It will not only make my job as a doctor easier but you will get along better with the nurses and midwives which can make your life a living hell if they wanted to. Otherwise, she mentioned that my academic knowledge is adequate but 'knowledge is only a small part that makes a good doctor'. Her exact words were 'To be a good doctor, you need to possess knowledge, adopt a caring, responsible and reliable attitude i.e. chase results, follow up conscientiously on your patients'. That's why medicine is so demanding, you not only have to study/work extremely hard and possess some kind of intelligence but you need the right sort of character/personality to deal effectively with your patients and other colleagues. There are things that you can change but some things you're just born naturally with like a high IQ, an outgoing personality or leadership qualities which I apparently don't seem to have. That's why sometimes, I think that maybe I am not cut out to be a doctor; there's so many qualities that I clearly lack. But then I'm already almost at the finishing line of my course; I've just got to try and make use of whatever I have and pray that its sufficient to meet the demands and expectations of my exam and future career as a doctor.

Sunday, May 3, 2009

Delivery suite

This is going to be a relatively short post as I am pretty tired. Anyway, this Sunday I was rostered for a 12 hour shift at RHW delivery suite from 7pm-7am. I already anticipated beforehand that there will be a lot of waiting and there will be times when complete boredom takes over. The entire process of labour is a very slow but gradual process and it can take up to 20 hours for nulliparous women (women who have never given birth to a child)in just the latent phase of labour. And the fact that each birth is very unpredictable eg: a woman who appears to be commencing well initally may suddenly develop an arrest of fetal descent due to poor maternal pushing, fetopelvic disproprotion, abnormal fetal position etc. In Sydney, a midwife is assigned to every pregnant lady that is going into labour and the actual delivery is performed by the midwife and another person (eg: nurse, medical student) with the obstetrician only intervening when the labour is not progressing efficiently. Basically she is in charge to make sure that the whole labour process is going smoothly by doing regularly hourly checks on the mother and fetal monitoring, performing vaginal examinations to check that the mother is fully dilated and the fetal head is engaged and provide advice and support to the mother, husband and other family members once labour begins. She also assists in the actual delivery of the baby and the removal of the placenta as well as suturing up the vaginal and genital tract lacerations afterwards. The newborn baby will be assessed by her eg: the baby's weight, height, Apgar scores etc and she will educate the mother on the proper techniques of breastfeeding. It is her duty to contact the obstetrician registrar if she encounters any problem during the labour eg: sudden onset of fetal distress show on the cardiotocograph, maternal compromise or if a particular stage of labour is prolonged.

Tonight I witnessed one live birth and the seoond lady who was supposed to go for a spontaneous vaginal delivery finally ended up with a Ceaseran section as her cervix was not dilating. I was quite disappointed as I hoped that I could observe at minimum two deliveries but then again, it is all very unpredictable and you might not even get the chance to see a vaginal delivery if you are extremely unlucky. The first lady's labour went exceptionally well and progressed at a very fast pace considering the fact that she is a nulliparous woman. Her entire family was there (mum, dad, sis, husband) to provide her with encouragement and emotional support which I believed to have helped in speeding things up quickly. I oould see the tensed looks on the family members faces as they eagerly waited to see whether the baby's head will emerge as this signalled the completion of birth (it only takes one more contraction for the entire body to be delivered). And when finally the baby is born (it was a girl), I could see the overwhelmed and joyful expressions on their faces especially the mother who broke down in tears of happiness. I guess every birth is a miracle but not without the suffering, pain and turmoil. It does make me a bit frightened as I can't imagine myself going through the physical and mental exhaustion and torture of a normal delivery. I can expect that any woman's first delivery will be an unforgettable one which makes her child even more special. The first moment of bonding between mother, father and baby is a magical moment as it is the stepping stone in the long and tedious process of nurturing, caring and providing love and affection.

The second lady was not so simple and straightforward. Although her membranes ruptured at 3:30pm earlier today, she had a prolonged latent phase and poor progress in the active phase of labour i.e. a cervix dilation of 1cm/hr. She had a previous caeseran section before due to a breech baby so she has to be monitored more closely as she is predisposed to more maternal and fetal complications eg: postpartum haemorrhage and uterine rupture. She was practically moaning in pain everytime a contraction started and was urgently requesting that an epidural analgesia be administered. She was finally given one and was assessed 4 hours later to check whether she had made any progress. I was instructed by the midwife to take her vitals (blood pressure, pulse, temperature) and general observations every half hourly, plot my observed findings and results on the partogram (labour curve), write in the progress notes and assist the midwife when she examines the woman. It gets a bit monotonous and boring after awhile especially in this case scenario where the woman is hardly making any progress at all. Four hours later, the decision was made by te obstetrician registar to do an elective Caesearan section due to obstructed labour.

I luckily managed to finish my shift by 2am as the last lady had to go for a C-section (I am supposed to just observe and assist in vaginal deliveries) and there were no other women in the delivery suite going into labour until tomorrow afternoon. I still have two more delivery suite shifts so hopefully they'll be a bit more eventful than this one. Then again, I am much relieved to have ended earlier than expected as I don't think I would have survived until 7am in the morning. And thank goodness I don't have to go for clinic tomorrow, either. Now I can truly appreciate the amount of sacrifice interns, residents, registrars, nurses and midwives have to go through during their night shifts as it is very physically and psychologically draining.