Thursday, June 11, 2009

End of E.D.

Today is the last day of my ED term and next week I will be starting my selective term at the respiratory ward. So what has been the benefits and downfalls I have experienced during this ED term? Well for starters the ED term is a fantastic place to gain clinical experience as you will be the first or one of the first to examine the patients when they symptomatic as opposed to the patients in the ward who are mostly stable and undergoing treatment(thus may not have the signs and symptoms they orginally presented with). The cases you do see at the ED are mostly chest pain, dyspnoea and respiratory distress, acute abdominal pain, sudden collapse and syncope (loss of consciousness), trauma and other accidents, and sometimes patients presenting with an acute psychotic episode (suicide, mania attributed to drugs/alcohol/halliconogens). These cases are commonly encountered by primary care physicians and you will DEFINITELY be expected to know how to diagnose and manage them as a final year medical student. Also, you get to see the consultants, registrars, residents and interns perform resuscitative measures (which you don't see much of at the wards) such as CPR, electronic cardioversion (note that the patient does not literally jump off the bed as depicted by movies; at the most their entire body just jerks momentarily), insertion of chest drains for pneumothroax etc. And if the patient requires emergency surgery, you can be sure that the surgical team will be around and you are welcome to follow them and witness the surgery provided you have obtained the patient's consent and permission. Once the patients are haemodynamically stable they are either discharged or sent up to wards for further monitoring and maintanence of treatment and students are welcome to follow up these patients.

The main pitfall of the ED term is that we have not been allocated a specific supervisor so we just have to latch ourselves on whoever is on call that day. And since most of the consultants and junior medical officers are all SO BUSY, they might not have the time to actually teach you properly and might get irratated if you ask too many questions. However, most of them do appreciate the final year medical students as we are able to lighten their workload quite substantially by taking a history and examination beforehand and writing in the clinical notes(all they have to do is just reconfirm the findings and history), perform simple clinical procedures such as cannulation and filling in the laboratory forms for the tests being ordered.

I was fortunate to find an intern and resident (both their names are Grace) who are keen to teach enthusiastic medical students and are willing to share their knowledge. Today I had a bedside tutorial with Grace Aw (the resident) and two other medical students in a very formal examination style. We went up to the wards to hunt for patients and each of us had to examine a patient (i.e. take a history, physical examination, summarise our findings, come up with a provisional diagnosis and answer Grace's questions regarding the patient). It was very generous of her to actually spend three hours today teaching the three of us and giving us feedback on our strengths and weaknesses. So the three cases encountered today were biliary colic (probably attributed to gallstones), a post-stroke patient and a patient with myasthenia gravis.

I was the unlucky one to get the myasthenia gravis patient which is a rare neuromuscular condition that causes muscle weakness and fatiguability. These patients are unique as their muscle weakness progressively worsens on bried periods of activity (eg: one of the tests involves you asking them to stretch out their hands for 60s and you will notice that their arms will slowly move downwards to rest position or get them to count to 50 and you will slowly notice slurring of the speech). Often, their presenting complaint is difficutly in swallowing foods and inability to keep liquids in their mouth, slurred speech or weakness of the eye muscles. This patient came in with difficulty swallowing food and inability to drink liquids as they would dribble down her chin. If the patient didn't tell me she was diagnosed with myasthenia gravis I would be thinking more of an extrinsic or intrinsic esophageal cause due to her difficulty in swallowing foods such as esophagitis or a tumour or enlarged thyroid gland compressing the esophagus which are more likely. Furthermore, I didn't really know much about the condition so I couldn't really ask all the appropiate questions to confirm her diagnosis. After the examination, Grace told me that this was in fact the first time she has encountered a patient with myasthenia gravis and that it was not in her area of expertise. If we get this sort of case in the exam it will be very difficult to diagnose her condition and we will probably be leaning towards asking questions that are of gastrointestinal origin such as gastroesophageal reflux disease, esophageal conditions etc. Grace said that it will be very unfair if we were given this case and expected to diagnose it right on the spot. So why did we choose this patient in the first place? Well, this patient was recommended by her boyfriend who is a neurology resident and he claimed that she was one of the few patients on the ward who could actually give a coherant history and examination (most of the patients are stroke patients or patients with cerebellar or frontal lobe problems so are not able to speak properly or understand the instructions you give to them during the physical examination). Nevertheless, my neurology is one of my WEAKEST AREAS and it definitely needs much improvement. I kind of wish I could swap my respiratory term to a neurology one. Neurology is extremely wide and variable and even the entire neurological examination takes about an hour to perform. I desperately need to work on this area before the exams as I am clearly lacking in knowledge and clinical experience. I guess it will be a bit of a struggle as I don't really like studying about the brain as it is just too complex.

Overall, I believe that my experience at the ED has been a beneficial one. One of the highlights is that since the ED is open 24/7, we can can basically come and go as we please (however you must at least attend the ward rounds either at 8:00am or 4:00pm). I actually wouldn't mind redoing the ED term instead of my selective as I will be able to see a variety of patients instead of just patients with respiratory illnesses. I just hope that for my next term, I am not assigned a supervisor that it strict and demanding as after all, the selective posting is supposedly one of the easier and more relaxed terms which gives time for students to revise for finals.

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