Day 1

With anticipation, I stepped back into the ward, a familiar stamping ground. Immediately, the smell of diapers, hospital beds and that unmistakable yet indescribable whiff of cancer, hit me, and it felt like home once again. The faces were all different, both doctor and patient alike, and yet the intrinsic rhythm of the ward comforted, most strangely. 

I had barely gotten grips with the day’s patient load, when a familiar face finally appeared. It was a face that belied the wisdom, analytical power and yet gentle and considerate demeanour of the oncologist it belonged to. 

The very first patient of the day had advanced glioblastoma multiforme, and was in for multiple episodes of unsteady gait. After watching the MO get drilled out for an unsatisfactory neurological exam, learning point: integrating the various neurological assessments into a coherent neurological assessment. Cranial Nerves, Visual Fields, AMT, testing for expressive and receptive aphasia, UL & LL, Cerebellar. 

The next patient was one who had bilateral cataracts, T2DM and a very nasty pancreatic neuroendocrine tumour. As a result, he was rather frustrated and would end up throwing things at nurses who were mean to him. It was a lesson in establishing rules and mutual respect between patients, In addition, it was also a lesson in empathising with the multiple comorbidites and issues a cancer patient faces. 

A classic pneumonia secondary to immunocompromised state from chemotherapy. Otherwise, disease has been present for 4 years, and patient is still IADL independent. Natural hx of the disease can help in deciding fitness of patient for management. 

An unresolved pneumothorax + pleural effusion already on a Seldiner Portex drain but lung refuses to expand. Considering the 3 causes of an unexapandable lung: airway obstruction, bronchopleural fistula or pleural dzs. Patient does not yet know he has progression of disease with pleural mets. 

A case of two drains. Liver abscess secondary to HCC, which then established a communication to the subQ layer and caused a secondary subQ abscess. Post-drainage, the liver drain suddenly stopped while the subQ drain continued. Watching how the analysis of the various possibilities: has the communication closed up? Has the liver drain become blocked? Shouldn’t the subQ drain stop before the liver drain if the liver abscess is the source of infection. 

A case of suspected rib fracture with secondary hematoma/hemothorax. Use the window and specific density of fluid on CT to differentiate between blood and pleural fluid. In addition, in considering warfarin for Ca patients, always find the reason why warfarin is being taken, and decide if stopping warfarin causes more harm than good e.g. in a mechanical valve. Alternative anti-platelets can be considered like aspirin. 

A lesson in history taking where 1 episode of giddiness 1 week ago  is not quite nearly the same as 1 week of giddiness. In addition, patient and disease factors contribute to an oncologist’s index of suspicion. A high index of suspicion for brain mets would be a patient with known metastatic disease who present with giddiness with FNS. On the other hand, a low index of suspicion would be a patient who presents with transient “giddiness”, one episode which resolved within seconds, without FNS. 

Reading an Xray and deciding between pulmonary embolism and carcinomatosis lymphangitis. 

Lastly, a patient who knows my father and goes to the same church as I do. Learning to discuss end of life issues, reopening of treatment options, managing hypotension that is refractory to fluid challenges, prioritising steps of management. 

I’m looking forward to tomorrow (:

Hari hari, hari bahagia. Congratulations to lin and abe long. Jauh kami mai. 8 hours of journey. 5 times u-turn and plus plus minus bagi minum itu jentera. Itu kasi baling belakanglah. yang penting we all safely arrived.

Yang paling mustahak, terima kaseh yg tak terhengga buat jejauh kat east coast MY. Dapat kami cuti-cuti honeystar kat sini. Last but not least, batchmates sempoi dok p layan kerenah datin2, mam2 besar bandar masuk kampung. We olls gembira tak terhinggap-hinggap.
So, marilah mengambil gambar kekelas yang formalin.


#toganuwego (at Kuala Terengganu)