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!

This is London calling

I’m currently in the United Kingdom doing a medical elective attachment in General & Emergency Medicine at The Royal London Hospital, organised through Barts and The London School of Medicine and Dentistry; part of Queen Mary, University of London. The medical elective is a component of final-year in most medical programs worldwide and gives students the flexibility to complete an attachment of their choice in a location of their choice (usually overseas where practicable).

"Dancing Queen" Virgin Atlantic A340-600
“Dancing Queen” Virgin Atlantic A340-600

The journey here was a challenge in itself. During the flight I became rather acquainted with Virgin Atlantic’s quirkiness – the plane was named “Dancing Queen”, the safety video contained visual jokes, Virgin Cola was served (not bad, actually), and as we approached Heathrow Airport the pilot remarked that it was a “perky 2°C” and “moist” in London. So after some 23 hours aboard an aeroplane, I found myself in Heathrow Terminal 3 severely jetlagged and feeling deserving of an award for endurance. As for getting into London proper, I knew better than to catch the Tube, but nothing quite prepared me for the swarming sea of commuters when I got off the Heathrow Connect train at Paddington station (mental note: never catch London public transport with luggage during peak hour). Needless to say I gave up on public transport at this stage and caught a taxi the rest of the way to the hospital.

London Heathrow Airport, Terminal 5
Ooh, shiny… Heathrow Airport Terminal 5 (Terminal 3 was underwhelming)

First impressions? As an Antipodean who’s never previously travelled to Europe, what’s struck me most about being here is how short the winter days are: the sun rises at around 0800 and sets around 1550! I realise that it’s associated with the relatively high latitude (London 51.5°N vs Sydney 33.8°S), but nevertheless I’m already starting to feel SAD (seasonal affective disorder)!

More posts to come later…

Coonabarabran: rural medicine

So after the previous few posts on Coonabarabran, you might be wondering whether I actually got around to doing any medicine during my placement there. Indeed I had plenty of medical practice in Coona and it was an amazing experience! (As with previous posts on Coona, the photos below and more can be found on my Flickr photostream).

Placement sites

I was based at Warrumbungle Medical Centre (59 Cassilis St), with husband/wife general practitioners Drs Aniello Iannuzzi and Eve Tsironis as my principal supervisors. Warrumbungle Medical Centre is the main medical practice in Coona (there are two other medical practices in town), with Drs Iannuzzi & Tsironis, two GP registrars and two registered nurses (RNs). My role at the medical centre was mainly clinical observation and assisting with clinical procedures. I also spent some time at the co-located Orana Pathology Service collection centre (a courier does a twice-daily run to Dubbo with the samples). I learnt a lot about general practice and rural medicine from all of the doctors and nurses, to whom I’m very grateful for the experience. Dr Iannuzzi, a recent candidate for AMA national president, and I also engaged in some interesting discussions about life, politics and medicine…

Warrumbungle Medical Centre
Warrumbungle Medical Centre

The doctors at Warrumbungle Medical Centre are also visiting medical officers (VMOs) at the local hospital, as is the norm in many rural settings. Coonabarabran Health Service is a 20-bed district hospital (with a 3-bed emergency department) operated by the Greater Western Area Health Service, with the main referral hospital being Dubbo Base Hospital (c. 1.5 hours away by ambulance). At Coona hospital, I was put on-call in the emergency department (ED) for triage categories 3–5 for three 24-hour periods during my placement – in practice, this meant that I’d be called-in by the ED RN to assess the patient then report my findings and clinical impression/diagnosis to the doctor on-call (who would decide on the course of action from there). I also attended ward rounds with my supervisors, assisted in clinical procedures and with the visiting endoscopy service (see below). Incidentally, I was provided with accommodation at the hospital nurses’ quarters during my placement.

Coonabarabran Hospital ED sign
Coonabarabran Hospital ED sign

Emergency Department, Coonabarabran Hospital
Emergency Department, Coonabarabran Hospital

Nurses quarters, Coonabarabran Hospital
Nurses’ quarters, Coonabarabran Hospital (N.B. MacBook & monitor are mine)

Medical firsts

It’s almost a truism that rural general practice is where you really get to develop and practise clinical and procedural skills, and indeed this was true for my placement. There were many medical “firsts” for me, including: successful insertion of (many) IV cannulae, venesection using a 16-gauge needle (for a patient with haemochromatosis), venepuncture by needle & syringe (cf. Vacutainer/Vacuette), parenteral (SC/IM/IV) administration of medications, manually pushing IV fluids, local anaesthetic infiltration in a conscious patient, needle thoracotomy and thoracentesis of (>2 litres!) pleural effusions, suturing of a wound (using 6-0 monofilament), surgical debridement (severe tinea + MSSA cellulitis + maggot infestation!), admission of a patient, ophthalmic work-up (incl. slit-lamp exam + fluorescein), assisting in resuscitation and early management of severe trauma (motor vehicle accident), etc.

The flying doctor

When Dr Iannuzzi mentioned that one Dr Peter McInerney was flying into Coona to perform endoscopy at the hospital, I assumed that he must’ve chartered a flight to Coonabarabran Airport (which no longer has regular commercial services). It turned out that Dr McInerney was literally flying in – he piloted the plane himself, flying from his hometown of Scone (c. 175 km away). I learnt quite a bit from Dr McInerney during the day I spent assisting him in the operating theatre, including a quick tutorial on how operate the endoscope. It also turned out that his daughter and I had studied pharmacy together – it really is a small world!

School of Rural Health

One weekend my friend Nilay (on placement in Gilgandra) and I decided to visit Dubbo, which for me involved a drive of just under two hours down A39 Newell Highway. We had some friends based at the School of Rural Health (whom we hadn’t seen since the start of third-year) and also wanted to visit Taronga Western Plains Zoo. After spending several weeks in a small town, the City of Dubbo felt like being back in suburban Sydney – it was a bit of a shock to encounter the first set of traffic lights in weeks. It was great to catch-up with our friends (and interesting to observe the bountiful resources of the School of Rural Health), and the open-layout Taronga Western Plains Zoo was also well worth visiting.

School of Rural Health, The University of Sydney
School of Rural Health, The University of Sydney

Meerkat – Taronga Western Plains Zoo
Meerkat – Taronga Western Plains Zoo

The dinner

One of the traditions for students completing their placement with Drs Iannuzzi & Tsironis is that the students are expected to cook a meal for the doctors and their families at the Iannuzzi residence. I was a little trepidatious about this at first, as I’d never cooked for 13 people before… Fortunately, the other medical students (Kate and Shanela from the University of Notre Dame Australia) and I rose to the challenge, putting in a successful joint effort to cook-up an international buffet. My contributions were miso soup (味噌汁), fried rice (炒飯) and genmaicha (玄米茶) – I had some forewarning from previous students, so brought many of the ingredients (unavailable in Coona) with me from Sydney. Kate and Shanela prepared: green salad, papadums, raita, lamb rogan josh, salmon & teriyaki chicken maki-sushi, Moroccan chicken, kheer, barfi, and mango lassi.

Being mindful of one of the registrar’s preferences, this was also the first time any of us had prepared halal food. I had to email one of my friends in Sydney to clarify which foods were permissible, and we were fortunately able to source some halal chicken meat from Coona Food Suppliers (35 Timor St). Being careful during preparation of the food to avoid any contamination, we were able to make many of our dishes above halal (including both of mine).

Miso soup
Miso soup (味噌汁)

Fried rice
Fried rice (炒飯)

Destination: Coonabarabran

As promised earlier, this is the first in a multi-part series on Coonabarabran, where I had an amazing experience on rural placement for Community Rotation in the Sydney Medical Program. So without further ado, my first post about my time in that wonderful little town the locals call “Coona”… how on earth I managed to get there!

The New South Wales Geographical Names Board database (circa September 2009) entry for Coonabarabran includes the following comment:

“A town of on the Castlereagh River and in the Warrumbungle Mountains. It is 465 km from Sydney having good road, rail and air facilities.”

Whilst the comments regarding transportation may have been true some 20 years ago, alas this is no longer quite accurate. Commercial flights no longer operate to Coonabarabran Airport and the railway service ceased in 1990 (replaced by a CountryLink coach service from Lithgow). There is a good road connection, however, with national highway A39 (Newell Highway, the main Melbourne–Brisbane route) running through town. It was clear that the best option for me was to drive to Coona.

Former Coonabarabran Railway Station
Waiting for the train that never comes… Former Coonabarabran Railway Station

Getting there from Sydney, however, is somewhat indirect. There is no way to drive to Coona on A-roads without lengthy detours via Bathurst/Dubbo or Maitland/Gunnedah. The only reasonably direct routes involve travelling mostly on B-roads and minor roads – the two main routes used by Coona locals are via Mudgee or the Hunter Valley, which I’ve outlined below. Travelling time is around 6–6.5 hours by either route (depending on traffic/breaks).

N.B. The information below is provided as a general guide only and driver discretion is advised – both routes involve driving on minor roads of variable quality.

Sydney to Coonabarabran via Mudgee

West on M4 Western Motorway and continue on A32 Great Western Highway via Blue Mountains, exit onto B55 Castlereagh Highway and continue north-west via Mudgee and Gulgong, west on B55/B84 Golden Highway via Dunedoo, north-west on B55 Castlereagh Highway via Mendooran, north on Mendooran Road* via Mollyan, north on A39/B56 Newell Highway into Coonabarabran.

M4 Western Motorway
Heading west on M4 Western Motorway, near Penrith NSW

Sydney to Coonabarabran via the Hunter Valley

North on M1 Pacific Motorway, exit onto B82 Freemans Drive and continue north-west on B82 via Cessnock and Pokolbin, west on Broke Road, north on Wollombi St, north-west on Charlton Road, briefly east on Singleton Road, north-west on Wallaby Scrub Road, north-west on B84 Golden Highway via Denman and Merriwa, north on Vinegaroy Road and continue on Cassilis Road via Coolah, north on Black Stump Way, north-west on Warrumbungles Way via Binnaway, north on A39/B56 Newell Highway into Coonabarabran.

B84 Golden Highway, Merriwa
B84 Golden Highway directional signs, Merriwa NSW

USydMP Stage 2 OSCE

After the hurdle of the Stage 2 Barrier, our final assessment for the year was the objective structured clinical examination (OSCE). For second year University of Sydney Medical Program (USydMP) students this meant a barrage of twelve stations where a specific history, examination or procedural skill was examined.

Day 1 stations

  • Paediatric gastrointestinal history
  • Diabetes history
  • Chronic renal failure history
  • Abdominal pain history
  • Lymph node examination
  • Visual acuity examination

Day 2 stations

  • Drug & alcohol history
  • Arthritis history
  • Chest x-ray interpretation
  • Neurological motor examination
  • Cardiovascular examination
  • Respiratory examination

During a USydMP OSCE, you start outside the exam room and have a minute to read the instruction sheet for that station, then proceed into the room and have six minutes to complete the task with the “patient” and examiner. You then rotate to the next station and repeat the procedure until all stations for the day have been completed. The timeframe of the OSCE often makes the task quite rushed and doesn’t allow time to think clearly – you’d be surprised at how hard it is to calculate standard drinks and pack-years under pressure, for example. It’s quite an intense experience!

At my clinical school they often get the international elective students to act as patients for OSCEs. This proved to be quite interesting when: (i) my “patient” for the lymph node examination didn’t really understand English directions, which meant that I had to improvise with non-verbal cues; and (ii) I was initially unsure whether my “patient” for visual acuity examination was actually having trouble reading the letters on the Snellen chart or whether she was just hesitant about the English name of the letters she was reading out.

In any case, ostensibly we’re now on a seven week summer break. Echoing Miss G’s sentiments on the OSCE, however, it won’t really feel like holidays until 12 December when results will come out – then second year will finally be over!