A day in the life of a medical registrar

14 new patients post-take (1 DOA)
7am consultant rounds
Interviewed by the police
Discussion with an Assistant Coroner
Rescued from a difficult dilemma by one of the geriatricians (again)
Spoke with the hospital Director of Medical Services
AWOL patient urinating on the hospital front lawn
Challenging discussions with families about end-of-life issues
Asked for two consults at 4pm (because my consultant specifically wanted me to ask)
Somehow didn’t get shouted at for the late consults
Finished my ward round after-hours
Left the hospital at 7.30pm

… and very grateful for my fantastic intern Angela!

Leeches in modern medicine

Leeches have been used medicinally for centuries, with their most well-known role in the former practice of blood-letting. In modern medicine, however, the medicinal leech (Hirudo medicinalis) has found a niche role in plastic/reconstructive surgery where it can be used to reduce venous congestion and encourage microcirculation.

medicinal leeches

medicinal leeches

Specially prepared leeches are attached to the relevant part (e.g. at-risk surgical flap) and allowed to feed. Once gorged they detach themselves and are collected for re-use. Heparin wipes may be used at the bite site to prolong the therapeutic anticoagulation effect.

medicinal leeches

At our centre, collected leeches are prepared for re-use by placing in them saline – apparently this encourages them to regurgitate their initial feed. Subsequent feeds are less effective, so after 1-2 feeds the leech is “retired” using concentrated saline and flushed down a sluice sink.

Outdoor smoking bans in NSW

Amendments to the Smoke-free Environment Act 2000 (NSW) will come into force next week, further restricting tobacco smoking in public areas in New South Wales.

Smoking is already banned in enclosed public areas in NSW.

From 7 January 2013, smoking will also be banned in the following outdoor places:

  • within 10 metres of children’s play equipment in outdoor public places
  • public swimming pools
  • spectator areas of sports venues
  • public transport stops/platforms (including bus stops and taxi ranks)
  • within 4 metres of entrances to public buildings

Furthermore, from 6 July 2015 smoking will also be banned in commercial outdoor dining areas (i.e. al fresco).

Australia is a world leader in tobacco harm reduction. It’s good to see further action being taken to protect public health through reducing exposure to second-hand smoke.

More information: health.nsw.gov.au/tobacco/Pages/smokefree-areas-faq.aspx

My colonial medical elective

Now that I’ve finally completed the Sydney Medical Program, it’s about time that I finally post some long-overdue reflections on my elective terms in London and Hong Kong at the start of the year.

The Royal London Hospital (Barts and The London, QMUL)

The Royal London Hospital

My first elective term was spent at The Royal London Hospital under Barts and The London School of Medicine and Dentistry (Queen Mary, University of London). The Royal London Hospital is a 650-bed tertiary hospital and the principal facility of the Barts and The London NHS Trust. It is particularly known as one of London’s major (level one) trauma centres and the home of the London Air Ambulance (Helicopter Emergency Medical Service), however a full range of medical and surgical specialties are represented.

Drs Po and Preston

I was assigned to the gastroenterology team under consultant gastroenterologist Dr Sean Preston. He was an excellent supervisor and I was lucky to have spent quite a lot of time under his guidance during my elective. Dr Roocroft (the F1 house officer) was also a great mentor, teaching me the ins and outs of being a house officer in the NHS.

Work casual

Work attire in NHS hospitals is very appropriately guided by infection control considerations. In summary:

  • no tie
  • sleeves rolled-up to elbows
  • no watch (most male doctors wear their watch on their belt)

The Royal London Hospital

The logic (and comfort) of this policy was such that I continued with this after returning to Sydney, where it was still convention for male doctors to wear ties.

Speaking English

There were a few differences in the medical vocabulary used in the UK, which took a little while for me to get used to. The most prominent ones during my elective were:

bleeper – pager
phlebotomy – venepuncture
OGD (oesophageogastroduodenoscopy) – endoscopy
TTA (to take away) – discharge summary

EastEnders

I alluded in a previous post that I lived in hospital accommodation. Indeed I found myself living in John Harrison House, The Royal London Hospital, Whitechapel E1 2DR for the duration of my stay in London. Whilst relatively cheap (approx. £100/week), it was rather spartan. One of the other JHH residents described living there as punishment for his sins, whilst more colourful language was employed by one of the senior registrars.

One of the unexpected consequences of living in Whitechapel, with its majority non-white population, was the difficulty I had in trying to find a decent full English breakfast. Despite there being half a dozen (halal) fried chicken shops on Whitechapel Rd alone, there were very few decent cafés in the area. Spotting a modern-looking café on New Rd advertising that they served “English breakfast”, I stepped into Zaza’s Café (E1 1HJ)… only to realise that they served a halal version of English breakfast: smoked turkey, beef sausage, egg, baked beans, mushroom & toast. It wasn’t bad, but it’s just not the same! Thereafter I quickly learnt the Arabic characters for halal (حلا).

Queen Mary Hospital (HKU)

My second elective term was spent at Queen Mary Hospital under the Faculty of Medicine, The University of Hong Kong. Queen Mary Hospital (est. 1937) is a 1400-bed tertiary hospital and the principal facility of the Hong Kong West Cluster, with a catchment area population of over 500,000 people.

Queen Mary Hospital, Hong Kong

I was attached to a final-year group undertaking their Specialty Clerkship rotation. This works rather differently from the way our attachments work during clinical years – instead of being attached to a specific medical/surgical specialty team for the duration of a clinical attachment, each group of HKU students is allocated to one general medical ward where they’re expected to clerk patients (with seemingly little direct role in patient care). They take part in case discussions, PBL tutorials, and clinics with consultants from different specialties over the course of the term. Often ward-based tutorials were quite crowded, particularly with the confined spaces inside most hospital wards in Hong Kong (see pic below – I wasn’t standing at the back).

Ward tutorial, QMH

Masquerade

I was in Hong Kong during the 2009 influenza H1N1 “swine flu” pandemic. Following their experience during the SARS epidemic, all Hong Kong hospitals had activated what they termed “pandemic emergency response level E2”. One of the E2 requirements was that a surgical face mask was required in all clinical areas – effectively meaning that staff/students had to wear surgical masks all day!

Emergency E2 clinical attire

White coat syndrome

In total contrast to NHS policy, Hong Kong clinical attire convention was still very conservative and included the wearing of a “clean, white laboratory coat”. I’d never previously worn a lab coat in the clinical setting, but noticed two advantages: (i) it was handy having large pockets in which to put my stuff (e.g. Oxford Handbook of Clinical Medicine), and (ii) I got my student/staff discount at the hospital cafeteria and Starbucks without having to show any ID. Nevertheless, once I returned to Sydney I greatly appreciated not having to wear a lab coat.

HKU Specialty Clerkship group a/b, 2010 rotation 1

Finally, I’d like to take this opportunity to acknowledge and thank the Specialty Clerkship group to which I was attached – Fifian, Jimi, James, Vincent, Rosemary, Edgar and Sha Sha – for helping me to fit-in and manage the language barrier.

SMP class of 2010

After four long years of blood, sweat and tears, my Sydney Medical Program colleagues and I have finally finished medical school! Congratulations to everyone in the SMP graduating class of 2010!

I was given the honour (and burden) of organising the official year photo for the Sydney Medical Program 2010 graduating cohort during Conference Week. Equipment used: Canon EOS 7D, Canon EF-S 17-55mm f/2.8 IS USM, Manfrotto 7302YB tripod. Thanks to Mian Bi for operating the shutter-release in the Concord photo, Dana Perrignon Roth for operating the shutter release in the whole-year photo, and Andrew Caterson for his crowd management expertise.

Sydney Medical Program 2010

The farewell for Concord Clinical School was held at Tintilla Estate – the Hunter Valley winery owned by the clinical school’s Associate Dean, Professor Robert Lusby. It was a great way to finish med school – a relaxing Sunday afternoon barbecue in the leafy surrounds of the prof’s vineyard.

Concord Clinical School farewell BBQ 2010

Full-size versions of the whole-year photo and clinical school photos are available on my Flickr photostream. Congratulations again to everyone in the cohort and best wishes for the years ahead!

London: First City of the Empire

London: capital of the United Kingdom and once the heart of the greatest empire the world has seen. I think English literary figure Dr Samuel Johnson said it best when he declared that, “When a man is tired of London, he is tired of life…” These are a few thoughts from my time living in (East) London, whilst completing my medical elective at The Royal London Hospital (Dec 2009 – Jan 2010). As usual, photo highlights are available on my Flickr photostream.

Old, new, borrowed, blue

I took quite a few photos whilst in London. Inspired by one of the memes from the final episode of Doctor Who this year (The Big Bang), I present here a small selection (with more available on my Flickr “Britannia” set).

Something old – Tower Bridge

Tower Bridge, London

Something new – City Hall, SE1

City Hall, London

Something borrowed – King’s Library, The British Museum, WC1

King's Library, The British Museum

Something blue – police box, Earl’s Court SW5

Police box, Earl's Court

Getting around London

One of the first things to get to grips with when you spend a decent amount of time in London is the arcane British postcode system. Whilst the postcodes may look like bizarre jumbles of letters and numbers (e.g. my address E1 2DR), they’re actually derived systematically – the first half of the postcode (“outward code”) is composed of a letter sequence for the locality and a district number, e.g. OX1 for central Oxford and L4 for Anfield, Liverpool; and is helpfully marked on street signs. Central London is divided into EC (East Central) and WC (West Central), and the rest of Greater London is divided into the eight compass directions relative to the city centre. The “inward code” localises to a specific street/block/building.

Great Ormond St sign

The actual process of getting around London is quite an efficient (albeit sometimes painfully slow) process, thanks to city’s comprehensive public transport network (Transport for London). Perhaps the most essential item for the intrepid traveller is an Oyster Card, a stored-value smartcard that can be used on all Transport for London services and most National Rail services within Greater London.

Oyster Card

London’s red double-decker buses are one of the city’s icons. Travelling by bus is a great way of absorbing the cityscape. It can also sometimes be a rather frustrating experience, thanks to the notorious traffic congestion in the city centre – it once took me almost an hour to travel 9 km from Whitechapel to Euston aboard the 205. Some routes are operated using “bendy buses” (articulated buses) where, unlike Sydney, passengers are allowed to board through any door – one of my cousins jokingly refers to them as “free buses” since many passengers don’t validate their Oyster Cards when entering through the rear doors.

Routemaster bus, Charing Cross

Routemaster bus, Charing Cross WC2

The other iconic mode of public transport is the London Underground, referred to as “the tube” by locals. The tube was the world’s first metro system and it shows… you very quickly become familiar with the multitude of stairs and tortuous tunnels within the stations. Also, many stations have narrow platforms that aren’t able to accommodate crowds – I did NOT appreciate being caught in stampede on an overcrowded platform at Bond Street Station (initially away from a fight that had broken out between two chavs, then subsequently onto the train once it arrived). Living in Whitechapel, I was often forced to contend with the Hammersmith & City Line, perhaps the worst line in the network for service frequency and reliability – so much so that one of the other medical students at my hospital preferred to commute from Euston on the painfully slow 205 bus (see above). Another other major issue with the tube is that there seems to be no mobile phone reception in underground stations and lines. Nevertheless, the network generally works quite well with mostly frequent and reliable services. I found the deep-level underground lines rather amusing because of the diminutive size of the rolling stock made necessary by the small tunnel diameter (e.g. 1996 Stock in the photo below). It can get quite claustrophobic inside the tiny deep-level tube trains!

Bond Street tube station

Jubilee Line 1996 Stock train approaching Bond Street tube station

Engineering work on the tube network means that train drivers sometimes have to override the digital voice announcement system and make passenger announcements themselves. One time, as I was travelling on a District Line train, the driver decided to employ British dry wit to entertaining effect (much to the confusion of several tourists aboard). A selection of quotes:

“Due to planned engineering work, there is no DLR service from Tower Gateway today. There is a special replacement magical mystery bus service operating.”

“This train will attempt to stop all stations, taking the scenic route to Richmond.”

“Trains do not stop at Cannon Street on Sunday, due to a complete lack of interest. The next station will be Mansion House.”

Life in Whitechapel

Whitechapel in London’s East End has an interesting history. It is associated with such diverse people as Jack the Ripper and Joseph Merrick (the “Elephant Man”). The Salvation Army was founded there. The bells for Big Ben, the Liberty Bell, and closer to home the University of Sydney Carillon were forged at the Whitechapel Bell Foundry. In recent decades the area has become known for its large Muslim population (predominately Bengali), with East London Mosque being one of the largest in Britain. It is an area of historical and continuing socioeconomic disadvantage, and it’s not without reason that Whitechapel Road is the cheapest property on the Monopoly board (see my previous Monopoly photos).

Whitechapel Rd, Whitechapel

Whitechapel Road, Whitechapel E1

I lived in Whitechapel for over a month and, despite my reservations, gradually became accustomed to the character of the area: traversing through the slum-like Whitechapel Road Street Market to buy my groceries at Sainsbury’s supermarket, the halal adaptation of English breakfast served in the local cafés (turkey bacon, beef/chicken sausages, &c.), the ubiquitous fried chicken stores, the old Bengali man who ran the newspaper stand at Whitechapel tube station from whom I bought my copy of The Guardian every day, the sight of the Gherkin looming to the west, etc.

Catching up with friends/family

During my time in the UK, a few of my medical friends were also completing their electives elsewhere in London and/or dropping by. I variously managed to catch-up with Athina (St George’s Hospital), Martina (Eastman Dental Hospital), Owen (Israel) and Aileen (Germany). It was hilarious sharing our experiences with adapting to the freezing weather conditions (one unnamed friend slipped-over multiple times on the ice outside her hospital), inquisition by the UK Border Agency, jet lag, terrible coffee, language barriers (even in the UK) and just being on the opposite side of the planet in general.

Jamie's Italian

I also caught-up with my English cousins on a few occasions. On the final occasion we had dinner at the London branch of Jamie’s Italian (as in Jamie Oliver) in Canary Wharf E14. The restaurant doesn’t take bookings, but it was well worth the hour-long wait. I still find the British concept of eating spaghetti with knife and fork quite amusing – as with coffee, the Brits clearly don’t have the Italian influence that we have in Australia – but then Jamie’s spaghetti bolognese was actually the best I’ve ever had!

Coffee – rewarding disloyalty

The general standard of coffee served in the UK is rather poor. I should’ve known it was a sign of things to come when my first cup of coffee on English soil was burnt to the point of being undrinkable. The second warning sign was when I discovered that the Brits consider the “flat white”, an ordinary Australian variant of café latte, to be a novel and highly regarded espresso drink. The first part of my salvation came when I discovered a café named “Flat White” (17 Berwick St, Soho W1) . As the name suggests, it’s actually run by an Antipodean partnership – who would’ve thought that we in the “colonies” would be the ones to rescue the Brits from coffee hell.

Coffee disloyalty card

The second part of my salvation came when I discovered the Prufrock Disloyalty Card, the brainchild of Gwilym Davies (World Barista Champion 2009). Gwilym’s idea was to promote the emerging East London coffee scene with the offer of a free coffee from him for visiting each of the places listed. Most of the places were a bit out of the way for me, however the places I managed to get to (The Espresso Room, Nude Espresso and the Whitecross Coffee Cart) were excellent.

Whitecross Coffee Cart

Whitecross Coffee Cart – Pitch 42, Whitecross St, Barbican EC1

The sun never sets…

While the British Empire may be no more, there are certain benefits from once being the centre of the greatest empire the world has seen. One of these is the vast collections of antiquities from across the world that are housed in Britain’s museums. Furthermore, in a rather enlightened public policy decision, entry to all national museums in Britain is free! I managed to spend several full days just at the stalwart British Museum. I also particularly enjoyed exploring the V&A Museum (art & design), the Wellcome Trust collections (history of medicine) at the Wellcome Collection and Science Museum, and the Natural History Museum’s Darwin Centre.

Natural History Museum

Central Hall, Natural History Museum

V&A Museum

Paul & Jill Ruddock Gallery (room 50a), V&A Museum

The Rosetta Stone

The Rosetta Stone, British Museum