Elective in Cambodia- First Week Of Placement

I started placement a day later than everyone else because I had to have a city orientation, but I will go into that a bit more in another post.

I am at one of the largest hospitals in Phnom Penh for my first two weeks (about 720 beds in total), and it’s about a 20 minute ride away on a tuktuk, which costs only $2 one way, so it’s quite a bargain. I’m based in the maternity department- I chose it because I’m considering it a specialty, so I wanted more experience in the area.

My goal during my time in maternity is to see at least one delivery a day, and so far I’m meeting that target because I’ve seen 4 natural births in three days! This is already better than the 2 deliveries I managed to see during my month of placement in Obs and Gynae back in the UK, so hopefully I can keep this up.

The language barrier has been difficult- they mainly speak French and Khmer, so finding an English speaking doctor to shadow was hard, but we got there in the end!

My first two days involved observing ward rounds, practising my pregnant abdomen examinations, and watching the deliveries.

Childbirth here is quite different from the UK- no epidurals and limited anaesthesia, frequent vaginal examinations during labour, and not as much consent is asked for with them, which really surprised me. The delivery is pretty much open to anyone to observe, so there were up to 10 people present in the room, so it got pretty warm in there…

Deliveries can get quite traumatic and graphic here- So. Much. Blood. A lot of the women start pushing without being fully dilated, so getting the babies out can be complicated, as tocolytics (drugs to slow down labour) aren’t as common, so there is a lot of pulling and pushing down on the abdomen to get the baby out.

Patients also have to pay for their care, and there are price lists all over the department to remind them of this.

The first patient I saw give birth told us afterwards that she would have to leave her baby with her mother for at least six months, in order to work in a restaurant to make money to pay her hospital bills. That was so heartbreaking to hear, but apparently that’s commonly done, so it’s even sadder.

Later on in the week, I attempted my first cannulation, which wasn’t successful but determined to get it next time! I also went on drug ward rounds with the midwives, and they allowed me to help them with making up drugs for injections and infusions. After observing the first one, I was able to have a go myself (under supervision ofcourse, because I was a bit nervous to go it alone).

I found giving IM injections much easier than giving the IV drugs, because they inject straight into the vein without cannulas, and holding down a vein is much more difficult than it looks.

My experiences this week have really brought home how privileged we are to have the NHS, because with the limits on resources and patients not being able to afford services, a lot of things get reused, and sterile equipment is limited.

One other thing I can’t get over is how they use latex gloves as tourniquets, when back home we throw them away after one use. I’ll repeat: We really are lucky to have the NHS, and people take it for granted too much.

Acupuncture Isn’t That Bad…

Before bombarding me with articles and papers that say otherwise, like my dear friend Mahan did (still love you though x), allow me to explain.

Yesterday was my first physiotherapy session- I was referred by the consultant in my follow up appointment after dislocating my shoulder. I’d been looking forward to it because I was finding it hard to sleep because of pain, and I was also struggling with activities that required using my right arm, which is why I was hoping the physio would get me started on exercises to strengthen my shoulder muscles.

So I’ll admit that I was definitely like, “Erm… what?” when he asked me to take my top off, to expose my shoulders. I was wearing a vest, as I’d been advised to, and I thought that exposed my shoulders enough without me needing to undress. I complied though, as I didn’t want to make a scene, but I felt uncomfortable the whole time. Don’t get me wrong, the physio I had was very professional, I just wasn’t expecting that. On a positive note though, at least I had a pretty bra on?

So advice for anyone who might find themselves in a similar situation- definitely say something if it really bothers you, and there’s nothing wrong with asking for a physiotherapist/doctor who is the same gender as you.

Anyway, after examining and getting me to do some movements, he concluded that my rotator cuff muscles were stiff and tender, so before starting me on strengthening them, they’d have to be relaxed, and would I be okay with having acupuncture to do this?

At first, I was like “Whoa whoa WHOA, acupuncture is available on the NHS?” I definitely was not aware of this, but apparently it is! He explained that the reasoning behind this comes from the theory of the existence of trigger points in muscle. As seen in Myofascial Pain Syndrome, applying pressure to these points leads to referred pain, which is pain felt in unrelated parts of the body. So acupuncture aims to release tension by stimulating these trigger points.

Yeah the scientific reasoning behind all this is dodgy, and there’s not much evidence of its physiological pathway, but I agreed to it anyway because I was like, why not? And before I knew it, I was lying face down on a bed with 5 needles in my shoulder. It hurt a bit when they were put in (less painful than an injection though), but by the end of the 10 minutes they were in for, I could hardly feel them.

The physio got me to do some movements afterwards, and I was able to move my arm more than I could at the start of the session. I’m to see him again next week (and once a week for a month after that), and should be able to start rotator cuff strengthening then.

I am well aware that my shoulder feeling less stiff could just be a placebo effect, and not actual proof of the effectiveness of acupuncture itself, but I’ve got less pain in my shoulder now, and that’s a good thing. I was also able to sleep straightaway last night, and for the first time in a while, I didn’t wake up in the middle of the night. So if acupuncture was the reason for this, then to me, it really isn’t that bad.

An Introduction to Health Economics

If I wasn’t doing Medicine I would be doing Economics, fact. I absolutely loved studying it for A Level, even though the initial reason I chose it was to make my mother happy, because she did it at uni and wanted me to follow in her footsteps. Soz, Abs. I spent a lot of time over the two years of A Levels justifying my choice of Economics, as a lot of people thought it didn’t fit in with Maths and Chemistry, which are your typical medicine applicant A Levels. I argued and argued that OFCOURSE it did; the government in the UK especially, have a huge influence on the NHS because they are the ones controlling the budget. The Health and Social Care Act in 2012 is an example of this influence because it’s caused a massive change in the structure of the NHS, as well as the allocation of funds.

So you can just IMAGINE how smug I was in our taster health economics lecture last week, when the lecturer emphasised how well the two went together. HA, doubters. (I wasn’t smug in a douchebag way though, more of a “Yaaaay, proof that I was right all along” way, which is okay every now and then.)

I really really enjoyed that lecture because the terminology and concepts introduced weren’t new to me. From what I’ve seen so far health economics is pretty much applying economic theories like markets, opportunity cost, moral hazard and externalities to the context of healthcare. It makes sense because the basic economic dilemma is finite resources and infinite wants, which is very applicable to healthcare because demand for services is always more than what can be supplied. There are waiting lists and not enough resources to meet the needs of consumers (patients), leading to inefficiency and market failure.

I guess what made that lecture so great was feeling confident in what I know for once. The gaps in my knowledge from not doing A Level Biology always make me feel like I’m playing catch up with everyone else. I know I’m not the only one who didn’t do A Level Biology, but I’m still self conscious and this makes me hesitate in answering questions in PBL sessions and workshops, regretting my cowardice when the correct answers are revealed and I’m like, “I knew that!!!!” So basically, I need to back myself more and be more confident when it comes to Biology. I can do it! *insert inspirational music here*

Anyways as nerdy as this might sound, I’m so so interested in the health economics aspect of medicine, and can’t wait to learn more about it over the next couple of years. Economics and medicine DO go together, so the world has not seen the last of Tai the economist…

Work Experience Day 3- NHS Management

I am sat on the train home as I compose this, and I feel like such a commuter after a long day consisting of 10 train changes in total and nearly four hours of travelling. Tai is very TAIerd. So as a result of this, I have very little patience for loud people right now. Near me are a group of Spanish students who are literally shouting at each other and this is reaaaally irritating. I can understand some of what they’re saying too, which is probably what’s annoying me the most because I’ve tried to repress my Spanish. (I absolutely hated GCSE Spanish but alas, that’s a story for another day). I have a headache, your friends are right in front of you, YOU DON’T NEED TO SHOUT. Gosh.

Anyway, rant over.

My day has involved a lot of meetings and a lot of iPads. I’m still shadowing Dr B in London and since he’s a medical director, I was able to sit in on his meetings today. And there were iPads. iPads EVERYWHERE. Apparently they are just the must have tablet if you’re on the board/a commissioner/a consultant/some sort of director. So what I’m getting at is that most people had an iPad. What happened to good old fashioned note taking?

Anyhowzers, what have I learned today?

– Overspills are a serious, expensive problem, as running out of beds in wards means that patients have to get moved to beds in the private wing, costing the trust a lot of money.

– As you advance in medicine, there are a lot more meetings to attend, which I witnessed firsthand today as Dr B didn’t see any patients.

– Consultants can be arrogant as some of them believe that they can’t be wrong. Tensions were high in one of today’s meetings, so I hope that when I become a consultant (by God’s grace) I still remain humble and listen to correction.

– The main reasons for doctors getting in trouble with the law; money, fraud, alcohol, sex and drugs. Had a very interesting discussion with Dr B, where he gave me examples for each one from cases he had encountered in the past.

– As a psychiatrist, Dr B often has to assess criminals in police cases and give evidence in court, which he says is fun but can end up taking up a lot of his time.

– Doctors need to book their summer leave well in advance as problems arise when cover can’t be sorted for wards because the consultants are on holiday at thesame time.

And those are just a few of the many things I learnt today. Buzzing for tomorrow!

I am currently two stops away from home and I just can’t wait to sleeeeeeep. So close, yet so far away…