Support of Persons with Cancer-an NGO Response & Tertiary Prevention of Cancer

Cancer is a global medical issue. In The Bahamas, families are being affected by cancer in some shape or form almost daily. Fortunately, thanks to the National Cancer Society of The Bahamas which is a Non-Profit Organization, patients who live on the family islands especially, now have a place to stay when they have to undergo treatment or testing in Nassau called the Cancer Caring Center.

The Center can accommodate up to ten persons at a time plus one family member or personal nurse. It is ran by volunteers and is tucked away in an ideal location as it is literally less than 5 minutes away from either hospital and about 10 minutes away from the private cancer treatment center.

Our day was spent visiting the Cancer Caring Center as well as the private medical pavilion which houses various medical specialties as well as the Radiation Therapy Facility. At the Cancer Caring Center we received a tour of the facility and the photos are attached.

All of the rooms are furnished and have two twin sized beds; there is a bathroom attached to each room and a balcony overlooking the grounds. The center also has comfortable seating areas for guests to congregate as well as a functional kitchen and conference rooms.

Time for a selfie

Corridor leading to the kitchen and dining area

Gathering area for guests at the Cancer Care Center

Library at the Cancer Care Center

Conference Room at the Cancer Care Center

Conference Room

A little bit of local design; Androsia print table cloth

Small group picture before we leave

After touring The Cancer Caring Center, our last stop for the day was a visit to the Medical Pavilion. Here we met with Dr. Girgis- Medical Oncologist who provided a brief orientation to what is done at the Pavilion. On the island of New Providence, The Bahamas, there is only one radiation machine available and it is housed at the Medical Pavilion. 

As such, both insured and non-insured persons on the islands who are in need of radiation therapy are treated at the Pavilion. For persons who are needing medical oncology consultations, they can receive assistance either through the private sector at the Pavilion or the oncologist of their choice or publicly at the Princess Margaret Hospital's Oncology Center. 

Proof of Accreditation 

The future

Dr. Girgis at the Centerville Medical Pavilion

In general, if a simple survey were to be conducted of any population, most persons if asked, would be able to give their understanding of what cancer is. It is interesting to note though that, despite some general knowledge of what cancer is, the background of where the term 'cancer' came from and the first documented case of cancer is a bit more vague.

The term 'cancer' was used by Hippocrates (the Father of Medicine) who was a Greek Physician who noticed tumors which he called carcinos.  In Greek, the word cancer means crab which is a reflection of the true character of these tumors since it sticks to surfaces or parts of the body stubbornly like a crab. The first discovery of cancer was by the Egyptians apparently who documented this on the papyrus and their tombs; they were also able to differentiate between benign and malignant but of course at that time cauterization or palliative treatment were the treatment options.

To understand cancer, we must first understand the normal function of a cell. Cells are the smallest functional unit of our existence containing a cytoplasm and a nucleus, with the nucleus being the masterpiece of the cell (home of the DNA and RNA). Each cell in general is responsible for metabolism, reproduction and day-to-day functions. Cells also grow, replicate and assist in repair of the organs and the genetic material (DNA and RNA) and the immune system also aid in this process.

Now in the event one of the cells are damaged, the normal process is for the cell to undergo what is called apoptosis or programmed cell death. Cancer is the term used to describe a large group of diseases characterized by a singular malfunction. As previously mentioned, the normal cells are programmed to know what to do and when to do it in the event a cell is damaged; cancer cells on the other hand, do not have this programming and therefore grow and replicate out-of-control and despite them being larger in number due to their rapid replication, they serve no physiological function.

Generally, cancer cannot be diagnosed before a biopsy is done. A biopsy allow differentiation of normal cells and abnormal cells microscopically by a Pathologist.  Some of the features of cancer cells are they are largely shaped dividing cells; the nucleus of the cell compared to the cell's size is also examined and in cancerous cells, the nucleus is usually large and variably shaped compared to a normal cell's smooth, round nucleus. The cytoplasmic volume is another feature that is examined; in cancerous cells the cytoplasmic volume is smaller. Clinically benign tumors can be defined as slow growing, expansive masses often with a pushing margin, often enclosed with a fibrous capsule; malignant tumors are cancer and are rapidly growing masses that invades the neighboring tissues and spreads or metastasizes to other sites. Common sites of metastasis are the brain, bone, lungs and the liver.

In The Bahamas, Cancer screening is available and can be done free of charge. While visiting San Salvador, we spoke with the President of the chapter of the Cancer Society of The Bahamas on the island, who mentioned that annually their chapter organizes a trip to Nassau, where women on the island are taken to be screened for cancer and others are taken for treatment. Screening is a term used to describe the process of looking for the presence of a disease in a normal population. Screening is vital as it allows for early detection and treatment of disease. Once a patient has been screened, in the event there is a positive finding, the cancer will be staged and the prognosis will also be given as well as treatment options.

A look at radiation therapy treatment planning for a hypothetical patient

At the Pavilion, when patients are referred for radiation therapy treatment, imaging studies are done for their own treatment process planning by the Medical Physicist.  The main reason why a treatment plan is done is because radiation treatment uses high energy as well as high doses of radiation. So if the doses are not precise and the treatment is not accurate complications can arise.

Patients first have a simulation CT scan done at the Pavilion, this allows them to see where radiation will be targeted and to obtain precise measurements of the area of interest. They utilize various immobilization tools during this process and the administration of the radiation therapy.

The images that are acquired from the CT scan are exported to the treatment planning system. High energy radiation is used to treat cancers and can also be used to treat benign tumors as well. The treatment planning system will receive the images in various views and in a 3D format. Since the system is not designed to identify all of the organs in the body, the treatment designer must first "tell the system" or input this information into the program before any doses can be calculated. After the organs are inputed, they will also identify the organ which will be receiving the targeted dose of radiation and all of the other organs will be contoured-as each organ is able to tolerate a certain amount of radiation, the system will ensure the tolerated amount is not exceeded.

Tour of the area where Radiation is administered

The radiation can be delivered one of two ways, either from an external source or internally using bracket therapy. Bracket therapy allows the radiation source to be placed next to the tumor so that it delivers the radiation from inside, outwards.

External beam therapy uses linear accelerators. The treatment planning process is very intricate and specific to the patient. The radiation can be delivered anteriorly or posteriorly and is monitored by the dose volume histogram. Planning can take as long as two days but the actual administration of treatment can last as long as 7 minutes inclusive of changing the arm of the machine. Some patients may have to have treatments for as long as 7 weeks.

The treatment is offered between Monday-Friday; the patients are allowed to rest over the weekend.

Radiation Machine- Linear Accelerator

Radiation Therapist demonstrating set up 

Some of the gang at The Cancer Caring Center

Exposure to both the public and private sectors that provide treatment for patients with cancers is an important component of medical education as it provides students and future Physician with the knowledge of what is available locally for patients who are affected by cancer.


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Community Health: The Backbone of a Healthy Society

"We need community action and policies to support healthy communities"- Mark Hyman

Hello again! The months are flying by and fourth year will soon be over and I cannot believe it. I've recently completed a rotation in Orthopedics which I must admit was quite exhilarating, informative and very hands on; something which I enjoy. There will be a post on my Orthopedics rotation at a later date. A week and a half has elapsed since Orthopedics and I've spent that time in a new rotation-Community Health. 

When looking at Community Health it is easy to think that it'll be a walk in the park or one of the easier clerkships mainly because you'll be in the clinic settings for most of it or possibly getting the opportunity to perfect and master vital skills such as history taking and physical examination. Well that's what I thought anyways; however, that's not all that it entails-well not in its entirety. 

The Community Health clerkship takes us out of the hospital ward setting and allows us to explore the various components of the health services. As a requirement for the clerkship we're engaged in research as well, which means that we have carded teaching sessions on statistics and how to professionally, effectively and appropriately approach medical research and of course we're granted the opportunity to perfect our teamwork skills which will be essential once life as an intern begins. 

In the first week, we were oriented to the clerkship and given an introduction to Public and Community Health as well as an introduction to the research project and the expectations for the rotation. Fortunately for us, we were able to decide amongst ourselves and under the guidance of one of the assistant Doctors who specializes in research, on our topic.

It is common knowledge that the function of the Physician is to alleviate the suffering of their patients and to prevent disability, premature death and to promote the health of the individual, families and in turn the community. In order to fulfill this professional mission, general practitioners must have clinical competence in defining and managing the health problems of their patients as well as a broad understanding and appreciation of the socioeconomic and cultural environment which determine the pattern and dynamics of the health of the communities they serve and to be able to efficiently work in the reality of the Health Care Systems. The next few weeks will allow observation, participation and assistance in the delivery of comprehensive health care to various communities throughout New Providence and one of several Family Islands that make up The Bahamas.

To say the least, I'm looking forward to the change of scenery and the new dynamics that this clerkship will allow.

One's Inner Being

"Mental Illness is NOT contagious; you cannot catch it by being kind."-Hope Warriors

It was a hot day; and as some unspoken rule would have it, the conference room in which I sat with eleven other classmates awaiting the arrival of the Chief Psychiatrist, was cranked up to the highest notch. My expectations and tolerance for the cold became seemingly overwhelming.

Social media and society has done a great job at stigmatizing mental disorders and those who are mentally ill, to the point where I unconsciously had a fear of being in a room with a Psychiatric patient participating in a Psychiatric interview.

Our rotation was 8 weeks long and unbeknownst to me at the inception, an interest in Psychiatry and a hunger for advocacy was soon sparked. I'm not sure where you are currently located in the world and the sort of views you or society may have towards the mentally ill, but here in The Bahamas Psychiatric and Geriatric patients are two populations of my society that are often victim to stigma, prejudices, neglect, ill-treatment and disrespect in healthcare.

The following are a few tips I picked up to help avoid counter-transference and to ensure adequate care is offered to this population of patients.

Psychiatry is a specialty of medicine that requires patience, empathy, compassion, attention to details, active listening skills and most importantly respect.

2 Months In Psychiatry Taught Me This

1. Mental Illness Is NOT Contagious

It goes without saying that one cannot 'catch' a mental disorder by touching a person with a mental disorder. Despite knowing this, Psychiatric patients are often treated as if their condition is contagious.

They are scorned by some medical professionals and thanks to the entertainment industry, they are viewed as violent and harmful. There are some instances in which patients are aggressive and may become hostile; in these instances you must ensure the safety of other patients as well as yourself that goes without saying, however, simply because one has a history or diagnosis of a mental disorder should not dictate the level of service or care you offer as a medical student or healthcare professional.

After all the Hippocratic oath and our societal contract expects us to provide adequate and appropriate care to ALL regardless of creed or race.

"I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice."

2.  Taking a Psychiatric History Requires Patience & Practice

With every specialty, there will be some variance when taking a history from a patient or guardian of a patient. In Psychiatry there are certain things such as the patient's childhood development and interpersonal relationships that are vital. These are personal questions that may be difficult to ask, but are important to finding out why your patient is demonstrating certain behaviors.

Be sure to practice this skill and to take advantage of opportunities that may present themselves to practice. This may be during ward rounds or clinic. Take note of how the Consultants are addressing patients; look out for the tone of voice they use with persons who may be bipolar or depressed or in a highly expressed state and always ensure that you are accompanied by either a superior or orderly when having to interview a patient outside of ward rounds.

3. Read

The Diagnostic and Statistical Manual of Mental Disorders -5 was my go to resource for this rotation. It provides definitions for mental disorders as well as the symptoms, clinical presentations and their management and treatment. 

Bare in mind however, that patients rarely present with the textbook descriptions, or fit a mold so deriving a diagnosis will be based on your observations of the patient from the moment they enter the room to the time they exit, attentiveness to the patients answers and your ability to ask appropriate questions. Collectively, you would be able to find pertinent positives and negatives for each of your differential diagnosis which would further lead you to a diagnosis.

By actively reading, you would be able to participate in class discussion, have queries clarified and be able to learn more during the rotation. 

4. Bedside Manner-IT MATTERS!

Believe it or not, your bedside manner is affected when you view a patient as a particular condition rather than a patient. 

What does this mean? It's simple, the moment you approach a patient after having read their notes or previous case files and you get a glimpse of that diagnosis of 'Schizophrenia' for instance, you automatically start trying to stuff them into this mold of the disorder based either on what you've read in the DSM-5, First Aid for Psychiatry or your Kaplan and Sadock. By doing this you unconsciously ignore the person and once this happens, the patient ends up suffering-even if it is just marginally, the family questions your ability and you may sad to say it, miss properly identifying, diagnosing and managing their disorder. 

Give this a try; (this is based on a conversation I've had with my friend who's a Clinical Psychologist, who was very kind as to shed some light on things that would be beneficial to future Physicians) you can try this during a clinic day or during ward rounds. Try treating your last patient as if they were the first person you were seeing for the day; you know when you're all excited for the day to begin and looking forward to being on the wards. Take record of whether or not your bedside manner at the start of your day was superb, when it started to deteriorate, what factors of your day influenced your patient interaction and if you allowed counter-transference to dictate your level of care. 

5. Not EVERY treatment Works

We've seen it before if not heard it before, treatments do not work for everyone in the same manner. The same is true for treatment of mental disorders. Once we accept this as medical students and soon to be practicing Physicians, we will be less frustrated with the patient and better clinicians. 

By understanding the intricacies of the pathophysiology of mental disorders, it's safe to acknowledge that medicine doesn't have any answers as far as proper management and care. It may provide dampening effects for certain disorders and allow a patient to be functional, however it's not the case for everyone and that's alright. When you accept this fact upfront and relay this information to your patients and their families and caretakers, you will find that the disorder becomes better managed because you're not setting unrealistic high expectations based on clinical trials that failed to take your patient population into consideration. 

Feel free to share in the comments below your thoughts and experiences. 

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R/O Vascular Dementia

"Once a man, twice a child."

Now that my week of Geriatric Medicine is almost to a close, I can admit that I've enjoyed the exposure to the field of Geriatric Medicine. 

Due to the proximity of the Geriatric Hospital to the Psychiatric Hospital in Nassau, The Bahamas our Psychiatry rotation is diverse in what we're exposed to during our time in Psychiatry as it encompasses acute presentations of psychiatric disorders as well as those with chronic mental illnesses. Beginning next week I will be exposed to the Community aspect of Psychiatry as we will be stationed at the Community Counseling and Assessment Centre that works with out-patients and anyone in the community who may be experiencing any form of psychiatric illness. 

Today was a special day mainly because it was Clinic Day at one of the local clinic's that happened to be located in my neighborhood. Geriatric patients throughout Nassau can attend these clinics when they are scheduled. We had the privilege of seeing an 87 year old female who presented with a recent history of strange behavior who was referred from the local hospital to the Geriatric Clinic for examination. 

As the history was taken and the physical examination completed (Fundoscopy included), it was a rewarding experience to present to an enthusiastic and caring Consultant our Assessment and Plan for this patient. 

Overall, the patient was assessed with possible Vascular Dementia due to her history of lacunar infarcts and history of hypertension and non-compliance with medications. It's interesting to discuss with a Consultant one's plan and thought process because although we commented on her visual impairment when we presented her history, we failed to mention this in our assessment. Our consultant was able to provide us with tips on how to assess Geriatric patients appropriately and to consider all possible diagnoses in light of what is given in the history. 

It's always easy to remember a patient when they present with symptomatology that can be referenced in a textbook and despite our history and exam taking 2 hours, it was a learning experience that I will not forget and a diagnosis I will be sure to recall. 

As we age, our bodies undergo a series of changes both internally and externally. As a medical student, I'll admit that I didn't light up whenever our census consisted of 90% of geriatric patients mainly because it meant that there were be more comorbidities and issues that would require more time at each bedside, but after this week of geriatric medicine, I've realized that I did myself a disservice during my internal medicine rotation because rather than seeing that as a time to learn medicine and learn it well, I ran away from a rewarding challenge. 

Be sure to enjoy your time during your Geriatric Medicine rotation if you're afforded the opportunity as you will be rewarded simply by the fact that you're making someone feel special simply because you're taking your time to converse with them and your mere extension of care of their well-being will unlock a superb learning experience for you. 

How to Make the Most of Your Surgery Clerkship/Rotation

“Cutting out bad habits is far more effective than cutting out organs.” 
― Herbert M. Shelton, Fasting for Renewal of Life

Now that my Surgery Rotation is over, I thought it would be best to share with you all some things I learnt during the rotation as well as things I would have done differently if I knew at the inception of the rotation which may have allowed me to cover more material during the 8 week period.

How to Make the Most of Your Surgery Rotation

1. Gather Your Resources

For some of you eBooks are more convenient; for others hard copy books are a must. Whatever works best for you, before starting your rotation review the recommended book list provided by your school for your Surgery rotation and if possible, either purchase a physical copy or download an eBook or PDF if one is available. By doing this it will ensure you never delay your reading because of a lack of resources.

Also, if you're one who is keen on organization and having things set up in a particular way for each rotation or when you go to study, it may be in your best interest and that of your pocket to purchase all of the necessary items you would need in bulk so you won't be stuck without a post-it note, or finding yourself running out of pens or pencils when you sit down to study. 

2. Schedule Your Activities

Some teams during the rotation will require your presence during your call nights. Yes; 24 hour calls in medical school-THEY DO EXIST. 

As you may very well be on such a team, get in the habit of either using Excel or Word or whichever software that suits your fancy to construct a detailed timeline of each day. By doing this you will ensure you never miss an assignment, you're keeping up with the necessary reading and you're aware of where you're expected to be at a given point.

3. Read Around Your Patients DAILY

As I move from one rotation to the next, I'm always reminded to read around the patients I interact with as this is the easiest way to ensure I'm actively learning and constantly reading. It also makes it easier to understand certain illnesses and how they are managed- believe it or not. 

Take your Consultant's word for it, whenever you see a patient, take interest in knowing everything there is to know about their condition and be sure to voluntarily (either during rounds or in between surgery cases) inform them of what you read or understand and ask those questions that may have came up during your reading that you just couldn't figure out. REMINDER: Don't use this time to ask a question that you can easily find the answer to if you think about it or simply read. Rather ask questions about why a particular drug was used if in your reading you saw that another class of drug is commonly preferred. 

4.  Create a Study Group

If your Medical School has end of Clerkship Oral Examinations, it would be in your best interest to practice not just by yourself, but with a group of people that you're not only comfortable with but who you can seriously study with. 

As clerkships are rather short, you don't have time to waste so forming study groups with friends who you won't really study with will be a disadvantage to you and that's not what we want. Make the most of each study session, by using your case reports as practice and to gather possible questions that may be asked in the examination. 

This is your opportunity to truly learn various topics well. It is recommended that study groups should not exceed 4 persons, but I will leave that to your discretion. 

 The sooner your group is formed, the better. You can arrange to practice and study once or twice a week until a few days before the examination. By doing this you will be well prepared for your Orals and your fear of being questioned by a consultant that you may not have interacted with, will be diminished if not completely eradicated. 

Recommended Surgery Textbooks

These are a few books that I started using towards the end of my rotation, mainly because that's when I came to gather them all. The order in which you use them, is solely up to you and your study style. 

1. Scott: An Aid to Clinical Surgery- Robin Charles Noel Williamson 

2. Browses  Introduction to the Symptoms and Signs of Surgical Disease- Norman L. Browse

3. Davidson's Principles and Practices of General Surgery- James Garden

4. Bailey and Love's Short Practice of Surgery- A.J. Harding Raines

5. Robbin's Basic Pathology

6. First Aid for the Surgery Clerkship- You should be able to read this book through at least twice during the course of your clerkship depending upon the length of your rotation. 

Those are the books that I consulted whenever I needed to know anything about a particular condition. If I could do it all over again, before my Surgery rotation (maybe the weekend before) I would have went on the wards and read the doctor's orders book to get an idea of the common surgical procedures that are performed regularly at the hospital and then inquired with any of the Senior House Officers or Interns about the odd surgeries that are performed. 

Based on this information I would have started reading up on them in Scott's, used Browse's for the presentation of each condition and then read up on them a bit more in Bailey and Love's to familiarize myself with the management and imaging techniques and review the pathology in Robbin's. Davidson's would have been saved for my post-rounds reading and note taking. 

As always, I hope you find this information helpful in one form or another and I wish you all the best with your Surgery rotation. 

Remember preparation and diligence is key!

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Prints for Any Purpose-Especially Planning

Ever since I stumbled upon Social Print Studio's Instagram page a few years ago I've admired their work as well as the fact that their items are really affordable and perfect for those interested in incorporating photos into their travel journals and planners without having to purchase a polaroid camera; and even for the veteran scrapbooker who may have everything right at their fingertips.

They offer various size prints as well as photo books and I've had the joy of reusing my prints repeatedly in my planner throughout the year.

Having the option of purchasing 45 prints for only $15.00 is not a bad deal especially when the quality of the print is sturdy and durable.

Today I'd like to share with you a $5 referral code- 5YEHGCIVL6 to those who may be interested in making a purchase from Social Print Studio. You will be be able to receive $5 off your purchase when you use the code and I'll receive $5 in Social Print credit; that alone is incentive to check them out 'don't ya think?'

Oh I failed to mention that you're able to use photos from Instagram, Facebook and those stored in albums on your computer, so you're not limited in what you're able to print.

Here's the code again: 5YEHGCIVL6


Are you going to check them out? Let me know in the comments below.

Like a Hernia

"No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better
combination of accurate anatomical knowledge with surgical skill than hernia in all its varieties." -Sir Astley Paston Cooper (1804)

My last full week of my Surgery rotation allowed me to observe as well as participate in several hernia repairs. Its possible that my observation of these repairs made me realize that as a medical student in the clinical arena, it is easy to get a little cocky (especially when you've been on a roll during rounds thanks to your preparation for what you could possibly be asked). When that sense of arrogance starts to swell up to the point where you no longer realize that you're simply a medical student at the bottom of the totem pole, your ego now protrudes through a defect in your thinking resulting in an urgent need of repair.

As your clinical exposure expands and you find yourself finally understanding the basics and finding a balance of your life, do your best to remain humble, stay in your lane and always keep at the forefront of your mind you are a student first-whose sole purpose is to ensure you are exposed to as many clinical scenarios that would stimulate an interest and eagerness to understand all aspects of a patient's presenting complaints in order to diagnose, treat and manage them. Before you know it you'll be an intern with responsibilities that you can't easily escape from.

Savor every part of the journey, because its so easy to get caught and to want to leap to the next step.

Planner and Craft Discount

Planning has been a way for me to stay creative and to meet other creative people in the planner community who share the love for stationary items and decorating as I do.

As a student, I've been able to keep my spending to a minimum and my purchases more on the smart side thanks to all of the affordable shops. One such affordable online shop for all of your crafting needs is Blitsy.com.

For signing up I received a referral code that those of you who are interested in finding reasonably priced items all in one place, can use and I'll also receive $10 off my next purchase if you so choose to use the referral link.

Once you create your own account and make your first purchase, you receive a referral link of your own allowing you to receive $10 off your next purchase as well as the opportunity to receive reward points as well.

Feel free to check out the site here. Thanks again for stopping by my blog and happy planning and crafting!

My Brief Encounter with Dandy-Walker Syndrome

On my call a week ago, I found myself doing my best to read up as quickly as possible on Dandy-Walker Syndrome/Malformation as we were preparing to insert a central venous catheter into a patient with this condition.

The purpose of a central venous catheter can be categorized based on the reason. There are therapeutic needs such as the administration of fluids or blood and its products, multiple blood draws and the administration of drugs such as antibiotics. One of the more common diagnostic reasons for a central venous catheter is to monitor the central venous pressure amongst others.

To be honest, I underestimated the conditions that exist within the population here in The Bahamas and what I would be exposed to upon my return home for my clinical years. I've seen the clinical presentations of Scleroderma, SLE and numerous patients with Rheumatoid Arthritis and now my first encounter with Dandy-Walker. I NEVER would have imagined seeing any of these here because I ignorantly thought that I would only be exposed to self-induced ailments such as Hypertension and its complications, Diabetes and heart failure.

So briefly, Dandy-Walker Syndrome/Malformation affects the development of the cerebellum-the part of the brain that is responsible for coordination of movement and is also involved with cognition and behavior. The development of the 4th ventricle in the brain is also affected; this is the fluid-filled cavity between the brainstem and the cerebellum and the posterior fossa.

Persons with this condition tend to have problems with movement, coordination, intellect and mood as well as other neurological problems.

The cause of this condition is unknown and it is a rare occurrence. Feel free to read up about it either at the site listed in the picture or perform a Google search.

I've been amazed at the conditions I've been exposed to so far. Such exposure has lead to a greater curiosity of what exists in the population of The Bahamas and what I will see as my future in medicine evolves granted the newfound diversity.




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Barb to the Back

“We are *all* we are, and all in a sense we care to dream we are. And for that matter, anything outlandish, bizarre, is a godsend in this rather stodgy life. It is after all just what the old boy said – it's only the impossible that's credible; whatever credible may mean...” 
― Walter de la Mare, The Return

The world of medicine has allowed me to experience the world through various facets of life. ON a daily basis, I interact with the young in age and the young at heart; delinquents and the elite and then there are those who walk on the wild side of life.

On my last call, lying in the trauma bay was a man who had been "stabbed" by a stingray that he was trying to spear. In its attempts to escape the ray stabbed him in the back which led to part of its barb remaining lodged in the lower part of the man's back. Throughout the course of booking an operating theatre (OT) and clearing the necessary requirements, it wasn't until 2 a.m. that he was finally able to be wheeled in to the OT.

After assisting with the insertion of a chest tube in a gun shot wound victim, I ran to the OT trying to get ready to scrub in on the procedure of the removal of the barb. The surgical area was neat and clean and there was no one in sight. I took off my white coat, grabbed a hair net and surgical mask and looked frantically around the area to which I had access for the foot covers-there was NONE in site or in any of the dispensers.

I made my way to the doctor's lounge and changing rooms and knocked hoping someone would be able to assist me with locating 2 foot covers. Unfortunately no one answered. So, stupidly, I made my way to the OT. I passed two, and as I saw surgeons and scrub nurses all fixated on their procedure,  it automatically became clear why no one was able to assist me earlier.

I approached OT 3, waved my hand in front of the monitor and the doors opened. I signaled to one of the surgical nurses to assist me with finding foot covers and after doing so I finally realized the error of my ways. One by one, they each turned around and looked at me in disgust, disbelief and anger.

Away they all went. "Are those outside shoes you're wearing?" "Where are your foot covers?" "Why are you here without them?" "Oh my Lord! are you serious?" "You should have asked someone in front to find them for you? Why don't you just walk into the OT just as you are? You're already this far?"

The tongue lashing went on and on and no matter how hard I tried to tell them that no one was out front to assist and that I didn't have access to the changing area, they did not care to listen or help. I allowed the doors to close, said good-bye to probably my once in a lifetime experience to see such a surgery performed and "hauled tail" out of the OT.

This week was not my best week in Surgery. It did open my eyes a little bit to the double standards that exist as it relates to the proper practice of surgical attire-I'm sure you've been in a hospital and witnessed surgical staff walking throughout the hospital in foot covers and heading right back into the OT without even changing them.  Needless to say, I won't be stepping foot into an OT without proper attire and I'll definitely be stepping my game up as the rotation advances.

I Survived My First Week of My Surgery Rotation

With my second week of my Surgery rotation on the brink, I can say that the first week of surgery was not at all what I had expected it to be. Yes the stereotype holds true as far as Surgeons equated themselves with a god, however, not all of them are that way.

From the inception, regardless of the fact that our team is predominantly male (we're the only females on our Team), I have yet to experience a lack of respect. Each member does he part to ensure we are learning, actively engaged and participating in the management of the patients on the service as well as corrected when we are wrong or going down the proverbial rabbit hole.

All in all, I'm excited to learn in light of the amount of reading that I have to do on a daily basis and I am eager to take part in the intellectual discussion that occurs at the bedside during rounds. This week will be the start of our presentations on rounds-I can already sense it won't be what I've grown accustomed to during my Medicine rotation.

Here's to a new week.

Two Months

"You don't always win,
but every time you lose, you get better."- Ian Somerhalder, Actor

Forgive me for my lack of explanation regarding how the Internal Medicine rotation really works and what my responsibilities are whilst on a team.

In a nutshell, the rotation lasts a total of two months. We are divided up into two teams based on the class size from each campus of the UWI; these teams are then broken up into smaller teams of 2-3 students who are then assigned to one of the five Internal Medicine teams. Each team rotates between two of the 5 teams during the 2 month rotation.

Some teams are structured which allows you to plan your weekly schedule and manage your study time and ward time; others, unfortunately lack structure and due to this, discipline and good time management are your saving graces as you try to learn as much as possible whenever, wherever you and from whomever you can.

We are  responsible for having our procedure book as well as attendances to clinics, ward rounds and calls signed off by a Supervisor by the end of the rotation. Procedures range from taking 10 histories and performing physical examinations and presenting your history during rounds or while on call to your Registrar, Senior House Officer or Intern. As we're all human, our immune systems have its moments where it just isn't up to par, and as such sick days are to be documented and a sick slip is to be turned in to Administration and your team members are to be notified.

Calls are every 5 days and during calls you are responsible for clerking at least 2 patients which you will be responsible for following until they are discharged along with familiarizing yourself with the other patients assigned to your team.

It helps tremendously if you either create a census for yourself that you edit daily to reflect each patient's progress, medication changes and decisions that are agreed upon during rounds and any significant clinical finding. This worked for me to ensure that I had something to read about each evening or to catch up on over the weekends or during calls. It also shows that you are interested in learning and understanding how to efficiently and more importantly, accurately manage patients.

The above is an example of how I organized my census using Google Sheets. The advantage of using Google Sheets is that you can share it with your fellow team members and you can access it from your mobile device if your hospital has an open internet service or if your service provider is reliable and you're able to get data during your ward rounds. It allows you to make changes on the go so you are always up-to-date on the management and decisions made at the bedside during rounds.

As far as the resources I utilized during my two months of IM I cannot say that I reached for one resource more than another.  My IM arsenal included the  Davidson's Principles and Practice of Medicine, Kumar and Clark Clinical Medicine, Oxford Handbook of Medical Sciences, Oxford Handbook of Clinical Medicine, as well as Toronto Notes and Up-to-Date.

As you transition to your next rotation, be sure to relish the journey. The experience is invaluable and the patients you will encounter will change your outlook if not for a lifetime, a moment. Don't take on every little criticism or beat yourself up if you answer incorrectly during rounds, just know that whatever it is you'll just have to work a little harder at it.

All the best for a new week!

A Hard Night

"The successful warrior is the average man with laser focus."- Bruce Lee

During our last call, I was able to clerk an elderly man who presented to Accident and Emergency due to loss of consciousness for one day, hiccups and complaints of left knee pain for a week. Long story short, his presentation of community acquired pneumonia and dehydration resolved however his hiccups were so persistent that sadly he left with them.

We did our best to try and treat the hiccups; first ordering Metoclopramide which seemed to do nothing so we discontinued that and the intern on call decided to switch him to Largactil.

Boy did I have a surprise the next morning when I went to SOAP him. He was drowsy, barely opened his eyes the whole time that I was there and no longer oriented to place.

After my failed attempts at waking him up,  and being rowed by him since he was convinced he spent the night on another island and was in desperate need of sleep, I took it upon myself to read the notes and orders and looked up the drugs that he was on that I was not familiar with.

Thanks to my handy-dandy Medscape app on my smartphone, I along with another SHO was able to find out that one of the most common side effects of Largactil is drowsiness and unfortunately for him, it didn't help that rather than starting him on 10mg of the drug he was started on 25mg.

Needless to say, we discontinued the Largactil after our morning rounds with the Consultant and sure enough he was back to his flirtatious, alert self again, anxious to return to the island to his wife.

This rotation has made me realize the importance of firstly taking a good history, paying attention to every detail and scrutinizing anything that may make your eyebrows raise.

At the end of the day, overlooking one small detail can be vital in the proper management and care of a patient. As a student it helps to question certain decisions when it comes to management especially if you've had the time to read up on management and care of your patients condition. I urge you to make it a habit early on especially if Internal Medicine is your next rotation as it will assist you throughout the course of clinical rotations especially as you study for your examinations.

Studying and Clinical Rotations: How to Find A Balance

Unless you try to do something beyond what you have already mastered, you will never grow.

Ronald Osborn, teacher and writer Once again we're talking about balance. This time it's regarding how to find balance during 4th year clinical rotations.  Within the past week, I have switched teams for my Internal Medicine rotation. It has it's advantages and disadvantages and although it's already been five weeks, I cannot honestly admit that I have found a routine just as yet. I will say however, that since I've been on this new team, I have found time to find balance which I lacked initially that I can now apply to the remainder of this rotation and carry on to my next rotation which is Surgery.  When we discuss balance, we evaluate ourselves holistically. We take into consideration our daily personal well being that encompasses our physical, emotional and spiritual make up. With medicine and as students this still applies because as we are doing our best to learn and study ways to properly manage and treat patients, we must also know how to firstly, take care of ourselves and our health.  Let's get into it. Here are 6 tips on how to balance studying and clinical rotations based on my first 2 months of Internal Medicine rotation which can be adapted as you switch rotations.  6 Tips for Balancing Clinical Rotations and Studying  1. Read  As we know, as medical students we tend to learn best not simply hunched over a textbook in a quiet spot with Starbucks and a variety of highlighters, but by actually taking care of patients. This last week I had the pleasure of taking care of doctor, who told me that the best way to learn is by examining patients EVERY day and by taking a good history. By spending the time at the bedside, you are actively learning and this is one of the BEST ways to make knowledge stick. Once you've sat and taken a detailed history and constructed a problem list based upon the presenting complaint and the laboratory values and other investigations results, do your best to READ up on your patient and then go the extra mile and read up on ALL of the patients that are on your team or those admitted to the rotation that you're in at the time. Yes it does sound tedious, but as time is limited and you don't have the luxury of spending 8+ hours a day to study as you would have during the first three years, every minute counts. What I've found that works for me is that after gaining as much information as I can from my patient, I try to access Up-to-Date either by mobile or on the wards and read as much as I can about the patients I am seeing first and then those on the service I am on. After doing this, I make notes or questions and then discuss the assessment and plan with my Senior House Officer or Intern and do my best at actively participating or contributing to the discussion on rounds. Also, reading an hour consistently throughout the month helps reduce the need to cram and allows you to construct a plan of care for the patients on your team.  2. Practice Questions Practice questions may be hard to source during the first few weeks, however they are easy to come by if you do your best to network with those in higher years OR simply by searching the internet for exam questions based on the specific rotation you are in. By getting in the habit of answering practice questions EVERY night, you're exposing yourself to a range of questions, some of which you can even ask on rounds which will benefit everyone on your team.  NOTE: By reading intensely during the first half of the rotation and doing lots of practice questions as well as compiling notes, by the week before exams you're able to simply review your notes and the answers to the questions as well as focus on the more important or weaker areas the week of the exam.  3. Early to bed; Early to rise Trust me, you will want to do nothing more but to sleep at the end of each day. You will be mentally and physically exhausted, however try not to crash every day. By getting to bed early after reading and waking up early you would be able to get some reading done in the mornings. Use your time wisely and as far as possible abandon the thinking that what reading you did not do or complete the night before will be done the next day. It seldom happens and what you'd want to do this year is to tackle the work as it comes rather than letting it all pile up.  4. Take advantage of the down time While on call do your best to get things done. Be it working on your clinical examination skills for OSCEs or completing other tasks that may be required for your school. Accident and Emergency is the ideal place to work on venipuncture, peripheral line insertions, inserting nasogastric tubes an catheters and watching procedures. I was able to get some of these things signed off on, in less than an hour and gained the confidence as well. During call hours, make use of the time you have to read as well and to study, these times are ideal for learning normal reference ranges and interpreting laboratory data.  5. Ask questions Questions are ways by which we learn. Gaining the confidence to ask them on rounds may take time especially if you spent the last three years as a small fish in a big pond (in a class with 200+ students). Moving from a large class size to a team consisting of less than six people can be intimidating at first but it gets easier with time and the more you read. Whatever you do, DO NOT leave questions that you have (and these are those questions you have after reading articles or textbooks) for later. You will forget, another patient will be added to the team and you'll never know the answer. Take advantage of the teams you may be on that consist of interns or SHOs that LOVE to teach, also, don't simply take their word for it either; be sure to find the answer as well as guidelines and practices often change of which they may not have had the time to look up.  6. Don't lose yourself  Be sure to stay true to who you are. Try not to give up the simple pleasures of exercising, health eating and spending time with family. Schedule a day off and do something other than medicine but be sure you're also scheduling time to study, read and practice exams as well.

Unless you try to do something beyond what you have already mastered, you will never grow.

Ronald Osborn,
teacher and writer

Once again we're talking about balance. This time it's regarding how to find balance during 4th year clinical rotations. 

Within the past week, I have switched teams for my Internal Medicine rotation. It has it's advantages and disadvantages and although it's already been five weeks, I cannot honestly admit that I have found a routine just as yet. I will say however, that since I've been on this new team, I have found time to find balance which I lacked initially that I can now apply to the remainder of this rotation and carry on to my next rotation which is Surgery. 

When we discuss balance, we evaluate ourselves holistically. We take into consideration our daily personal well being that encompasses our physical, emotional and spiritual make up. With medicine and as students this still applies because as we are doing our best to learn and study ways to properly manage and treat patients, we must also know how to firstly, take care of ourselves and our health. 


Let's get into it. Here are 6 tips on how to balance studying and clinical rotations based on my first 2 months of Internal Medicine rotation which can be adapted as you switch rotations. 

6 Tips for Balancing Clinical Rotations and Studying 

1. Read 

As we know, as medical students we tend to learn best not simply hunched over a textbook in a quiet spot with Starbucks and a variety of highlighters, but by actually taking care of patients.

This last week I had the pleasure of taking care of doctor, who told me that the best way to learn is by examining patients EVERY day and by taking a good history. By spending the time at the bedside, you are actively learning and this is one of the BEST ways to make knowledge stick.

Once you've sat and taken a detailed history and constructed a problem list based upon the presenting complaint and the laboratory values and other investigations results, do your best to READ up on your patient and then go the extra mile and read up on ALL of the patients that are on your team or those admitted to the rotation that you're in at the time.

Yes it does sound tedious, but as time is limited and you don't have the luxury of spending 8+ hours a day to study as you would have during the first three years, every minute counts. What I've found that works for me is that after gaining as much information as I can from my patient, I try to access Up-to-Date either by mobile or on the wards and read as much as I can about the patients I am seeing first and then those on the service I am on. After doing this, I make notes or questions and then discuss the assessment and plan with my Senior House Officer or Intern and do my best at actively participating or contributing to the discussion on rounds.

Also, reading an hour consistently throughout the month helps reduce the need to cram and allows you to construct a plan of care for the patients on your team. 

2. Practice Questions

Practice questions may be hard to source during the first few weeks, however they are easy to come by if you do your best to network with those in higher years OR simply by searching the internet for exam questions based on the specific rotation you are in.

By getting in the habit of answering practice questions EVERY night, you're exposing yourself to a range of questions, some of which you can even ask on rounds which will benefit everyone on your team. 

NOTE: By reading intensely during the first half of the rotation and doing lots of practice questions as well as compiling notes, by the week before exams you're able to simply review your notes and the answers to the questions as well as focus on the more important or weaker areas the week of the exam. 

3. Early to bed; Early to rise

Trust me, you will want to do nothing more but to sleep at the end of each day. You will be mentally and physically exhausted, however try not to crash every day. By getting to bed early after reading and waking up early you would be able to get some reading done in the mornings.

Use your time wisely and as far as possible abandon the thinking that what reading you did not do or complete the night before will be done the next day. It seldom happens and what you'd want to do this year is to tackle the work as it comes rather than letting it all pile up. 

4. Take advantage of the down time

While on call do your best to get things done. Be it working on your clinical examination skills for OSCEs or completing other tasks that may be required for your school.

Accident and Emergency is the ideal place to work on venipuncture, peripheral line insertions, inserting nasogastric tubes an catheters and watching procedures. I was able to get some of these things signed off on, in less than an hour and gained the confidence as well.

During call hours, make use of the time you have to read as well and to study, these times are ideal for learning normal reference ranges and interpreting laboratory data. 

5. Ask questions

Questions are ways by which we learn. Gaining the confidence to ask them on rounds may take time especially if you spent the last three years as a small fish in a big pond (in a class with 200+ students). Moving from a large class size to a team consisting of less than six people can be intimidating at first but it gets easier with time and the more you read.

Whatever you do, DO NOT leave questions that you have (and these are those questions you have after reading articles or textbooks) for later. You will forget, another patient will be added to the team and you'll never know the answer. Take advantage of the teams you may be on that consist of interns or SHOs that LOVE to teach, also, don't simply take their word for it either; be sure to find the answer as well as guidelines and practices often change of which they may not have had the time to look up. 

6. Don't lose yourself 

Be sure to stay true to who you are. Try not to give up the simple pleasures of exercising, health eating and spending time with family.

Schedule a day off and do something other than medicine but be sure you're also scheduling time to study, read and practice exams as well.