“Okay students, as soon as you see the patient, START. There is no time to waste.”
Things could have gone so wrong.
It’s every medical student’s worst fear- digging one’s grave in the Long and Short Cases for the final examinations, that is.
In medical school, they train us to be forthcoming and precise with our words, not merely in writing, but more importantly, in speech. After all, during a busy morning ward round at 7am when the senior doctor has a full day of work ahead or during a hectic night call at 3am, the last thing one wants is a junior doctor who cannot communicate in precise detail, over the phone or otherwise, the urgency of a particular patient’s case.
The Long Case tests our ability to take a full and accurate medical history from a patient within 15 minutes, no matter how terribly long and complicated it could be. It tests one’s ability to come to a diagnosis after doing a thorough physical examination and to move on to do the relevant investigations and basic management for a patient. That’s what medical school aims to teach us to do- to become safe and competent junior doctors.
The bell marks the start of the exam. All of us scuttle like hamsters into our assigned rooms.
I was ushered in front of my patient, a lady with a large, large habitus.
“Hi, how do I address you?”
“Mdm L.”
“Hi, Mdm L, thank you for coming for my exam. My name is Wai Jia. I will become a doctor if I pass these exams.”
Read: Please be nice and cooperative with me so I can take a medical history from you!
Off I went. Fever. Intermittent. Pain. Localised. Sudden. Pain score 9/10. Travel history.
And because the patient is female and I wanted to rule out gynaecological causes, I had to take a detailed menstrual and sexual history as well.
” Yar, very painful. And then like, the pain was like here. I thought it was because my boyfriend hugged me too hard.”
“Ah I see.”
Even under duress, one must try not to appear dismissive even though medically irrelevant information flies around.
“He hugged me so hard, I thought it was sore from that. Turned out to be stones. Ure… Ure what ah?”
“Ureteric stones.”
“Ah ya, that one!”
“Was the pain radiating from your loin to your groin? Like this?”
“No.”
“Was there back pain?”
“No.”
“Were you rolling around in pain?”
“Ah that one, yes. Got.”
Great. At least there was one symptom typical of the disease.
“But no back pain?”
“No.”
“Yet they had to put 2 drains into your kidneys for you?”
“Yar, infection mah.”
“Ah, I see.”
15 minutes for history taking flew by in a flash.
“I’m so so sorry to rush you, Mdm L. It’s just that I’ve to report all this to my examiners very very soon. I will now need to examine your tummy okay?”
GO GO GO! NO TIME TO WASTE!
“Hey, don’t be nervous. Mai gan cheong (Don’t be anxious).”
I smile nervously. Time sprints away like an African runner.
“Mdm L, can I also…”
I was just about to ask if I could do check her bottom when the bell rang. No time to a PR! A PR is a per rectal examination where one needs to check for blood, or strange coloured stools in a person’s anal canal. It is a very very important part of the examination and people have failed exams or been marked down because of this.
In stormed in 3 men. The first was a tall, burly-looking Indian gentleman (an orthopedic surgeon) with furrowed eyebrows and the second, a tiny, short man with a placid face cut with wrinkles and wizened with knowledge. He had a shock of winter-white hair.
“Prof,” I say worshipfully, before giving him a firm handshake. Read: My life is in your hands. “Good morning. My name is Wai Jia. This is my patient, Mdm L.”
GO GO GO! Off I went. This is my patient Mdm L, with a background of…. presenting with this… Possible diagnoses for her would be…
“So, what do you think she has?”
“Prof, I believe she has ureteric stones and possibly a renal infection.”
“Ah, tell me, what kind of renal infections do you know of?”
“Pyelonephritis and pyonephrosis, sir.”
” So what is the difference?”
This is every medical student’s worst fear. Being stunned by an examiner during an exam. Students have reported digging their own graves as cruel examiners lead them down the wrong path, wasting precious time bantering over definitions and being caught in them, and never reaching the important discussion about treatment and management, where one has a chance of scoring important points.
“Er, sir…” I pause. “I believe…”
“ You believe?” The other burly looking hockey-player-like examiner glares at me, waiting to devour me. I imagine him wearing a gladiator suit and then decide that imagining him as a bouncer with gold jewellery and bling might be a better option in a situation like this.
But the benign little old man with a hearing impairment and who is standing so close to me that I almost feel he is about to hug me smiles and says encouragingly, “Go on.”
I confess. “I’m not sure sir but I believe pyonephrosis has pus while the other does not.”
“That’s not true. Pyelonephritis can have pus too. So which is more serious?”
I take a calculated pause before replying, “Pyelonephritis, sir.”
He smiles. He looks like a grandfather.
“What investigation would you like to do?”
“X-ray of the kidneys, bladder and ureters, Prof.”
“And?”
“And a CT scan.”
He tickles me a bit more with some questioning and then ushers me outside. Already? This means we are discussing management! I passed!
But the exam is not over yet.
“What do you see?”
“Prof, I see…” I am stunned. I hate reading scans. After taking a split second to get over the mental block however, I start talking.
“Prof, I note a grossly dilated left kidney which corresponds to my patient’s symptoms. I believe she has hydronephrosis.”
“With an infection, it is called?”
“Er… Pyo… Er, hydro… nephrosis?”
This time, the burly Indian doctor starts to cough and make encouraging gestures and starts to nod wildly and I start to believe that he wants me to pass well too.
” Yes, Pyonephrosis!”
“Yes Prof! That is what I meant!”
“And how would you manage her?”
I go on and on about how I would insert intravenous lines, adminster antibiotics and I know I am missing something because this lovely prof is no longer smiling but looking rather constipated.
“What else?”
The burly bouncer in gold chains no longer has his hands folded about his chest but is gesticulating and nodding at me encouragingly.
“Urine culture.”
“What else?”
“Her vitals.”
“What else?”
“Put in a nephrostomy, to drain out the abscess.”
I am missing something and unable to recall.
“What organisms would you like to kill?”
“E. Coli bacteria, sir.”
“Yes, and so…? Uh huh….? Go on… “
I start to frown.
He can no longer wait for me to see the light. “Blood culture, my dear. Blood culture!”
“Yes, Prof. I’m sorry. A blood culture is very important because this is a medical emergency as you mentioned rightly just now.”
“Do you know of any congenital conditions leading to this unilateral grossly enlarged kidney? Genetic conditions?”
“Adult polycystic kidney disease, sir.”
“Er, not really. Anything else? Have you heard of PUJO before?”
I have never in my life heard of that before but I try to appear composed. My tummy is churning but my heart is leaping because asking me esoteric things can only mean one thing- I have passed decently and he is just trying to tickle me.
“Er… I believe it means Pelvi-ureteric junction obstruction?”
“YES! Young lady have you seen for yourself how a nephrostomy is done?”
I have never seen it done before. I look blankly at him, and decide to be honest. “No sir, I have not seen one for myself in the Operating Theatre before.”
“Oh, I forgot, you young people have You Tube, you can watch all these things online now, eh.”
He beams. I beam back. It is my biggest smile ever and I show him all my teeth.
I love you Prof! I even love the burly bouncer, too.
“Good. You may go.”
Ringggggg!
The escorts shuffle us away. A lady in an orange shirt with our university logo printed on it comes to get me, “That was Prof F, the head of urology in our hospital. Walk to the end of the corridor.”
“Ah,” I said. “Thanks.”
Now, for the Short Cases. If the Long Case was petrifying, the Short Cases are a component which can be even more unnerving.
They lead us to the ward in a straight line. We are like paratroopers walking to the edge of the helicopter. We take our final breath before the plunge. It’s do or die. No time for blanking out.
“This is your room.” I peep in. There are about 1o people inside, some doctors, some patients. 20 beady eyes look at me in my white medical lab coat and my stash of equipment. A tall distinguished-looking man greets me at the door.
I glance at his name tag. Prof WHK!! The famous examiner infamous for failing 50% of candidates under him!
I smile, albeit a little less excitedly than when I saw my previous examiner, and give him a big handshake. There are 2 other examiners, and a young man eager to squeeze alcohol hand-sanitiser onto my hands between patients so I don’t lose 2 marks unecessarily.
I say a prayer. GO GO GO!
There is no time, but I force myself to introduce myself and ask for each patient’s name. I forgot to ask the young man.
Mr. A has an, incisional, sorry, no a parastomal hernia, I say. I listen to the bump next to a bag of faeces coming from his gut appearing through his skin because he has had a colon resection (all this information comes just by looking at the location of the bag.) It needs to be surgically managed to avoid complications of bowel strangulation, incarceration…
“Ok, good. Next case.”
They usher me away.
The next patient has a huge mass on his shoulder. It is a lipoma, I say. Unlikely to be malignant. But I would like to confirm with an ultrasound and maybe a scan.
Another young man has a torn ligament. I’m not sure which it is because I felt the signs weren’t clear and the young examiner comes to save me by asking leading questions.
I see the last patient Mdm M and my heart leaps for joy. She has a HUGE neck mass which can only be a thyroid mass. MASSIVE. With all the typical signs. I check her neck, eyes and hands. I talk, talk, talk. I want to do this, this, and this. I believe she has GRAVES’ DISEASE! My examiner is pleased. “Good,” he says.
And Prof WHK has not said a single word all this while. He did not try to be mean by nitpicking on me.
5 years of hard work in Surgery, gone by in a flash. Just like that.
4 years ago when I was ill, I wondered if I could ever graduate. I wondered if I would ever recover, and if I could ever see the day where I could look after other people. I thought I would fail the major essay exam for that year- a third of the paper was as good as being undone. Back then, I felt like I was behind everyone else. Back then, I was so anxious about exams. Like many other medical students, I would get palpitations and cold sweat, and have difficulty sleeping the night before major tests.
But today, I stand amazed at what God has done in my life.
Last night, I slept like a lamb. Instead of stressing myself out cramming in last minute information and getting jittery, I spent the night reading the funny and horrifying exam experiences written by my seniors- they made me laugh. I read about horrid examiners and terrible questions quizzed and awful grave-digging answers… and somehow, laughed. Not because I was sadistic, but because in spite of all those terrible exam experiences, those students still graduated. I saw hope. I saw God’s hand in our lives. I recalled the healing He has blessed me with and the journey He has taken me through.
A good friend text messaged me, “He will not let your foot slip 🙂 “
I saw that I did not have to worry, because He would not let my foot slip. Many were very nervous today. Everyone’s adrenaline was running like a tap. Some had only slept 3 to 4 hours the night before because we had to report before 7am today. But I felt quite relaxed, even though there were occasional brief moments of anxiety. There was such a peace and assurance inside of me. I’m not especially clever or academic, but I realized and understood, that trusting God that He has the best for us can rain down an unfathomable peace.
I did not recognise this person. The person whom I thought was myself would have been anxious and sleepless and teary and depressed. But here I was- excited. I was at peace.
I realized, that this peace was God’s transforming work in my life.
I remind myself before the exams, that I have already passed. I have passed, and this was just the formality of showing my professors that they can trust me to be their junior doctor. I am safe. I am competent, Prof. I’m not a Dean’s Lister, but you can count on me to take care of your patients.
2 down. 4 more to go- on Saturday and Sunday. We end on Sunday evening.
I lift up my eyes to the mountains—
where does my help come from?
My help comes from God,
the Maker of heaven and earth.
He will not let your foot slip—
he who watches over you will not slumber;
indeed, he who watches over Israel
will neither slumber nor sleep.
God watches over you—
God is your shade at your right hand;
the sun will not harm you by day,
nor the moon by night.
God will keep you from all harm—
he will watch over your life;
God will watch over your coming and going
both now and forevermore.
-Psalm 121
Go! Go! Go! 🙂
He will not let your foot slip 🙂
He will move before you!
I will be away to Cambodia and then to Manila from Saturday onward. But I will remember you in prayer.
The children of Smoky Mountain and Ulingan will pray for you and we will praise God together.
Mio
Jiayou! U can do it! 🙂
Congratulations 🙂