The Night Owl Chronicles

Tonight I felt like a Doctor...

Thursday, August 16, 2018

“Most doctors are prisoners of their education and shackled by their profession.” ― Richard Diaz

Monday August 8th, 2018. That is the date, when it happened. I walked into the Paediatric Emergency Department as an intern. No longer a medical student with limited responsibilities and an early dismissal time. That night, I found myself a prisoner of my education and surprisingly shackled by my new profession.

I realised that the mould I had decided within myself to break, was beginning to settle. My environment was doing its best to imprint its treasured norms not only into my mind but also my heart.

It was my encounter with a parent and her child that made me realise that I now wore loose shackles of medicine. Her tiny hand, warm smile and vivacious giggle despite her ill-appearance broke the trance that I unknowingly had fallen into.

Hopefully this post shares some tips on staying afloat in the fun world of the Paediatric Emergency Room while ensuring you're remaining true to yourself, your morals and values and your God-given purpose while taking initiative.

----------------------------------------------------------------------------------------------

Nick had been out of work for three weeks. He had known the downsize was coming, but he hadn't expected to be caught in it. What's wrong with me? Nick thought. He rationalised that he needed to get his resume updated before he started looking for a new job, but he knew that was just an excuse. He just couldn't make himself get started.

Each morning he'd vow anew to check out leads, make phone calls, and get in touch with agencies and headhunters, but first-there was always a "first"-he had to run by the church to help repair the roof, or he had to mow his yard, or he had to go by the gym to work out his sore muscles, or he had to sit down and figure out a new budget...

Nick knew he couldn't keep putting off his job hunt. "Help me, God," he prayed. He picked up his organiser and started making notes.

Everyone has something in his life that he seems to put off doing. It may be finishing a college degree, buying a house, or applying for a promotion. It may be something simple like painting the house, cleaning the garage, or balancing the check book. Ultimately, if some project never gets accomplished you have no one to blame except yourself. What a waste to look back and say, "If only I had..." Make yourself accountable to God to get yourself moving. -Renewing Faith 2017 Planner

-----------------------------------------------------------------------------------------------

As the first point of patient care, working in the Emergency Department requires honesty, accountability, strong attention to detail and the ability to take initiative.

You will often be faced with persons and their egos which may lead to a delay in patient care and hence overall patient satisfaction and/or survival; do your best to maintain professional rapport, however you're not required to accept that type of behaviour as normal or adequate.

These two weeks in the Paediatric Emergency Department has taught me:

1. How to listen to patients (and their parents)

2. How to differentiate the battles that I can fight and those that would require referral to the "David" of the department and

3. How to tame my shaky hands when unruly, frightened adolescents wiggle and continuously scream "doc, dat needle hurt!"long after the anaesthetic has been applied and taken effect and all sutures have been tied off, covered with topical antibiotic cream and secured with Bactigras paraffin gauge dressing and an IV 3000.

THE DO's

1. Know your schedule.

By the end of this series of posts, I'm going to sound like a broken record, but I cannot say it enough. Know your schedule.

The rotation through our Accident and Emergency (A&E) Department is short and done in shifts. It is vital to know when you're expected to show up as some senior personal won't send you an email or any form of notification regarding which shift they have scheduled you for.

How it works here, is simple. For each specialty rotation there is one selected Consultant who is responsible for the interns/house officers. They are the persons everyone in the department goes to when they have an issue with the group or simply want to comment on how good the group is doing. That person is also responsible for the scheduling of the interns and organising our class and final examination.

As each section of the Paediatric department has their own expected work report times, the intern coordinator doesn't schedule you for a particular shift during a particular area of the rotation, that is done at the discretion of the persons in charge of that area.

For example, A&E has two shifts from Monday-Thursday, two shifts on Friday and one shift on Sunday and Saturday. Monday-Thursday you can be scheduled for the morning shift or the evening; 8a.m.-4p.m. and 4 p.m.- 12 a.m respectively. On Friday the morning shift starts at 10 a.m. and ends at 6 p.m. with the night shift staying the same as Monday-Thursday. The weekend shift is from 8a.m.- 4 p.m.

Knowing your schedule allows you to mentally and physically prepare for your time in the department. It can also allow you to check (and see with whom you'll be paired with) if a printed schedule is available.

If you're switching from one area say on a Tuesday (which is how our switches happen every two weeks), use the Monday evening to find out where and when you're to show up. It helps with saving gas and allows you to make the most use of your time. Imagine, you've been scheduled to work on Tuesday night and you show up at 8a.m. thinking you're to work the morning shift. What a waste of sleep time and gas. Don't give anyone anything negative to say about you if you can avoid it. We all know there are lots of haters in the world.

2. Get Oriented

Maybe it's just me, but I like to know all the nitty gritty about any area I'm scheduled to be in for a certain period of time. It just makes the transition easier and affords me the opportunity to focus on patient care without wasting time looking for things that I would need to perform my tasks during my shift.

Since this part of the department is very different with its own set of needs and management, it is good to have a senior person give you the run down of how things work.

As the intern in A&E, during the shift you're scheduled for, you're responsible for the following things:

Seeing the patients before being asked to,
Present (Discuss) all patients to a senior person before initiating treatment,
Manually log all persons seen for the shift in the patient log book (physically write each person's name and particulars along with the nature of their injury, the service provided and the disposition),
Manually log all patients who had cultures done that are needing follow up in the culture book,
Check the culture book before the end of the shift and update (transcribe their report) it. In the event a patient's results need to be acted upon i.e. Blood culture grew a bug, inform your senior and contact the patient so they can be treated if warranted.
Ensure the dry-erase board is updated at all times with the names of the patients who are currently being treated in the department or those who were admitted. This makes for a smooth handover and reduces mismanagement or a patient being overlooked from one shift to another.

Also, in terms of being oriented, know where your supplies are kept.

Our department has a cupboard that is usually locked at the end of the shift, that houses hard to come by supplies such as culture bottles, paediatric specimen tubes, aerochambers and other tools for educational purposes and even paediatric textbooks, computer mouse, diagnostic kits and working staplers. I sensed your eyes widening at the 'working staplers', trust me, it's hard sometimes to find a stapler.

What I did at the beginning of the shift especially if I worked the night shift, was to stock up all of the trays and storage units on the floor with supplies such as sterile urine cups, IV catheters of various sizes, made splints for the night and stocked the cabinets, ensured we had specimen tubes for the basic laboratory investigations we ordered as well as ensured there was more than enough biohazard bags, gauze, heplocks etc.

The last thing I wanted was to be unprepared in the event a trauma rolled in. I never got to experience a paediatric polytrauma, but following my shift one night, another Physician did and she was more than grateful to us for leaving the area stocked, clean and organised.

3. Document! Document! DOCUMENT!

Practice proper documentation of everything!

Some services are riddled with Senior House Officers with inflated egos who have a misguided sense of their duties. If you haven't encountered any as yet, prepare to meet one or two during your time in A&E.

Get in the habit of documenting when you sent a page for a referral, when that page was answered, by whom and a synopsis of what was said. Document when they showed up and what was done and what was to be done in the future if they failed to document it. The last thing you want is for the next doctor following you to not know what was done or to be done for a particular patient.

It's best to have some form of documentation (preferably in the patient's file) of the overall management in the event legal matters arise.

If your hospital has certain policies regarding documentation, familiarise yourself with it. The one thing I wish our hospital was good at is providing Standard Operation Procedures for each department and the common scenarios encountered. Why? Because it would allow for standardised care and something to stand on if someone ever questioned why you did or did not do something.

4. Do ask for feedback

As you move through the various areas, remember this is all another rung on the ladder of continuous learning.

Speak to your seniors. Develop a professional relationship where constructive criticism can be given and where you are comfortable growing as a Physician.

Ask them for advice for improving your histories in the department as A&E focuses more on the abbreviated history. Try to utilise your seniors for your success. These are the big kahuna's of the field, adopt their good practices and forget the rest.

The Don't's

1. Don't Waste Time!

The main purpose of the A&E department, be it adult or paediatrics is to provide quality care, reduce turnaround time and to ensure overall patient satisfaction.

Be efficient and try to get the patient in to be consulted, examined and treated in a timely manner and out if possible.

2. Don't pick fights with Senior House Officers (who aren't aware of their roles or responsibilities)

This may be easier said than done but ensure you approach every Goliath cautiously especially if they are not in the same department as you.

It is easier to report any issues, document the situation and its outcome and remain professional than to argue with someone whose main goal is to make life difficult for you.

You will quickly recognise the culture of each specialty and each person based on their position in the hierarchy.

3. DO NOT CONFORM

Do not be quick to settle. Three months in any place can start to feel normal. Be true to yourself and your morals and the overall purpose of you being there, which is to learn, advance in your career and to provide adequate and professional quality patient care.

4. DO NOT vent to everyone

Be wise with whom you confide in. There are lots of 'news toters' lurking around just waiting to start some confusion.

If you can, start a journal and learn a new skill. Write down your experiences. Be cautious with how you vent on social media as well.

You may not be aware, but most areas conduct evaluations of their staff, interns included; these evaluations at the end of your internship may work against you or for you.

Be mindful that what you may mention to someone 'in confidence' may end up hindering your progress.

5. DO NOT order unnecessary tests

Your patient is your answer book. In A&E, learn to be smart with your diagnosis and your differentials.

Based on their vitals, the presenting complaint and the history of the presenting complaint you should be able to determine what tests you need to order to confirm your suspicions.

It's up to you Sherlock to pay attention to the clues.

____________________________________________________

All in all, it's a great experience!

In summary, be prepared and remember you're going to be faced with patients who you just don't know what's wrong or where to start. But remember, you're not alone.

Be sure to:

Create lists: they will help you stay on track
Keep busy: with purpose, but enjoy the downtime
Always be bold enough to ask for feedback and to speak up if you're uncertain why you're doing something or being asked to do something.
Take the initiative but don't overstep your boundaries.

Growth

Tuesday, July 17, 2018

"Thinking always ahead, thinking always of trying to do more, brings a state of mind
in which nothing is impossible."- Henry Ford

It's been two weeks since I've been employed as a Medical House Officer. I won't comment on whether they were tough or not, rather I've decided to share some tips for persons who will be rotating through any Paediatric Hospital Clinic, however some things may be more specific for my setting but nonetheless they may hold helpful to others elsewhere.

I recently read a devotional entitled 'Growth' which I would like to share before I delve into the tips, so bare with me a while.

------------------------------------------------------------------------------------------------

Derek and Jordan were neighbours who agreed to plant a small vegetable garden together. They would each help care for it and share the produce with their families. The friends looked forward to spending time together on the project, but neither realised how involved the task would become.

It took time digging up the soil and breaking up the hard clods. Planting the seeds required precision. Some had to be deeper than others; some were planted side by side; others were planted eight inches apart; and still others were planted three inches apart. As the seeds sprouted, a portion of the plants required stakes to support them. Watering, weeding, fertilising and cultivating took a lot of time, but the guys kept their end goal in mind.

Finally, they began to see the fruits of their labor-tomatoes, squash, beans, cucumbers and other vegetables. As they harvested their crops, Derek remarked, "Aren't you glad we don't do this for a living? It's fun, but it takes a lot of work."

The time and energy it takes to grow a vegetable garden can be compared to the effort it takes to "grow" your life. You must fill your life with healthy, nourishing influences. Be careful of what you read, what you listen to, whom you talk with, where you go, and whom you choose for friends. Living a fulfilling life requires planning ahead and maintaining your "soil" daily. The value of your life will be measured by the positive impact you have on yourself and others.

------------------------------------------------------------------------------------------------

These two weeks were all about growth. Being able to work alongside other physicians more seasoned than myself and to communicate as a colleague has shown me that in life, we're all given the opportunity to grow. Some of us require more soil and sunlight than others, but that's alright, the goal is to continue to grow.

I started off with nine other colleagues in the Department of Paediatrics. This department has several areas each house officer is required to rotate through during the three month period on the rotation. These areas are:

1. Community Clinics (of which there are 2)

2. Team 1 (which is a hospital based team consisting of 3 consultants with various specialties in addition to General Paediatrics)

3. Team 2 (same as above)

4. Accident and Emergency Paediatric Department

5. Maternity Nursery

6. Hospital Clinics (all previously discharged patients and patients with particular needs are seen here)

Today's post will shed light on the intricacies of the Hospital Clinics and what you can expect on each particular day and ways to ensure clinics run smoothly and on time.

INTERN TIPS

1. BE ON TIME

This pretty much goes without saying. First impressions are lasting impressions and if you're known to be punctual believe you me, everyone will notice. If you're new to the hospital clinic setting and what all it entails, arriving early affords you the opportunity to speak with the nurses in charge, the Senior House Officer or the Physician overseeing the runnings of the clinic so that you can be informed of the functions of each person on the team and how each clinic is run if there are multiple clinics on the same day.

Arriving early also gives you the opportunity to ask the patients whether or not they are attending clinic solely to get results for tests that were done at their last visit since in our setting depending on the result, you would have to walk to or call the laboratory to retrieve them. Once this is done you can attach them to their notes for the day which will expedite their visit.

When you're new to an area, it takes some time to get acquainted with where things are located and where they belong. Being on time or earlier than scheduled particularly on the first day allows you the opportunity to get a tour of where things are stored, where the bathroom is (staff vs. patient), where the supplies are kept because you'll always be in need of an alcohol swab, tongue depressor or gauze as well as those infamous continuation sheets for the patients notes, growth charts (because every child is plotted) and referral forms.

There are other documents that are dedicated to certain things that you will also need to know-headache diary for instance for patients who present with a history of headaches in whom you're trying to rule out migraines.

At our clinic, all of the necessary documents for the various clinics excluding Infectious Diseases clinics are stored in a brown accordion folder which is placed on the desk in each examination room at the start of the day and stored by the nursing staff at the end of the day along with a cylindrical desktop container that houses all of the tongue depressors, alcohol swabs and gauze you'll ever need.

2. INTRODUCE YOURSELF

With changes being made to the schedule in terms of who goes where each month or every other week, it is important that everyone is aware that you are new to the team or service and it also allows you to familiarise yourself with the persons with whom you will be working over the next few days, weeks or month.

By introducing yourself to everyone, you'll also have the opportunity based on the ranking to know to whom you are to report and who can actually review your consults and ensure your plan is in keeping with protocol and in the best interest of the patient.

3. KNOW YOUR ROLE

In the Paediatric hospital setting your role as the medical house officer is to frankly, be on time, see patients, don't get on the nurses or any other team members' nerve and to ensure that you complete everything necessary for your patient.

At this stage in your medical career, the goal is to gain knowledge, improve certain skills and to ensure that your history taking, physical examination, and overall patient communication is improving and you're asking for help when needed.

It is imperative that following the review with the consultant, you document everything that was discussed in their presence in the patient's note, you complete all necessary referral forms and fill out any prescriptions they may need and ensure they understand what was discussed BEFORE they leave. In our system, the medical clerk is responsible for making the follow-up appointments, but as the house officer, it is our duty to ensure we inform the patient and/or the clerk of when we're wanting them to return for their next appointment.

4. KNOW YOUR SCHEDULE

Knowing your schedule allows you to keep track not only of where you're meant to be at a particular time of the day, but also when you have some free time to get other things done.

If you're like me, a new house officer with some things to follow up in the Human Resources Department then knowing how much free time you may have ahead of time can help you take care of other matters.

In regards to the hospital clinics, there's usually a clinic every day of the week excluding holidays or during MBBS examination time which is around May/June each year. Here's an idea of our hospital clinic schedule:

On Monday mornings as you can see, there are three clinics running simultaneously, so on those days it really is a gamble as to which patient you will see. Team 2 patients basically are kids who were admitted on a call when Team 2 was 'on take' or designated to receive the patients on that call. Once they are discharged by the service, they are then scheduled to return to clinic (all at the discretion of the Team) for a follow-up to ensure they haven't had any problems since, or if they did have any medical issues, what they were and whether or not they would need to be readmitted or watched closely before being completely discharged from the clinic.

The consultants on Team 2 are General Paediatricians with Paediatric subspecialties such as Paediatric Neurology, Endocrinology, and Asthma.

Like previously mentioned, Monday mornings are a toss-up. The patients needing to be seen in Paediatric Chest Clinic (patients with PTB for example) or the Diabetic Clinic is dependent mainly on the week as these two clinics alternate on a weekly basis. So if this Monday was the week for the Chest clinic then the next week would be the week for the Diabetes clinic. Following the morning clinics which can sometimes run a little late (all depending on the patients needing to be seen and the complexities of their case) is asthma clinic.

In the asthma clinic, the main goal is to ensure that each patient is controlled on their medications and whether or not they are in need of being stepped up or stepped down based on the severity of their symptoms and their overall diagnosis and assessment. The main questions you must be familiar with asking are mainly based on the symptoms:

When were they first diagnosed with asthma?
How did they initially present when first diagnosed?
How many hospital admissions or visits to Asthma Bay did they have since being diagnosed? What treatment did they receive?
What medications are they on?
Do they take the medications as prescribed? If no, why not? Were they on any medication for asthma before? What was the dose? Please demonstrate how they take their medication and when. Do they use an aero chamber? Do they have an asthma action plan? Do they use a peak flow meter?
Since their last clinic appointment did they have any asthma attacks? Any nighttime awakenings because they had problems breathing? Any decrease in their activity or exercise levels due to asthma? How often do they have symptoms of asthma such as wheezing or chest tightness?
How many times in the year, or since their last clinic visit have they had to use their reliever?
How many days of school have they missed due to asthma?
What are their triggers (change in weather, cold, flu, illness, smoke, dust, pollen, etc)?

Tuesday mornings there is no Paediatric clinic scheduled. However, all Paediatric interns and Residents have a teaching session at 8:30 a.m. At 12:30 on Tuesday afternoons, there is an Intern presentation session scheduled, from which you are excused by 1:30 in the event the session is running longer than normal so that you can make it to the clinic in time to see patients for Sickle Cell Clinic.

Be prepared to leave the clinic around 4:30 or 5:00 on a Tuesday. Since there is only one Sickle Cell Clinic per week and one Paediatric Haematologist in The Bahamas, this clinic is one of the well-attended clinics (which translates to sometimes 10+ patients). Punctuality to this clinic is essential mainly because there are so many patients to be seen and sometimes plenty of pathologies to be exposed to which means the teaching opportunities are endless.

When seeing patients in the Sickle Cell clinic it is vital to ask the following questions:

Since their last clinic visit have they ever had the following: fever? chest pain? dyspnea? cough?
Age of diagnosis?
Last date of crisis?
The number of hospitalizations and the reason (acute chest vs. vaso-occlusive crisis)? treatment while in hospital
Number of transfusions if any
Steady-state
Immunization history
Current medications their on and whether or not it was changed at any point
Any symptoms of anemia (fatigue, lethargy, pallor, etc)?
Abdominal distension or pain recently or in the past? Any surgeries in the past?
Dehydration status (water intake)
History of jaundice
Any exercise intolerance or cold intolerance or history of swollen joints? hands or feet?

When you're assessing them, be sure to look in their mouth and refer if needed to a dentist if you happen to see a number of dental caries or poor dentition. Also, be sure to review the tanner staging and comment on the Tanner stage. The consultant in our clinics loves to ask about the tanner staging as well as the surgical history and the conditions sicklers are prone to which would result in them needing to undergo surgery.

Wednesday morning clinics are dedicated to Infectious Disease clinics. Be sure to speak to the Senior Registrar or the head nurse in charge of this clinic as this clinic runs differently compared to the others. They will be the ones to advise you on which patient they would prefer you see and how to go about conducting your consultation. This clinic runs fairly smoothly because the nurses are so efficient. Once this clinic is done, be sure to get a bite to eat in between. Technically afternoon clinics are scheduled to begin at 12:00 p.m. however, the team may decide to work through a break so clinics can end a few minutes earlier.

Neurology clinics can be long as well but they are filled with learning opportunities so be sure to make the most of your time there. Wednesday afternoons are usually for follow-up patients so reviewing their drug levels and reading EEGs to determine if medications are to be adjusted. Sometimes though, you may have one or two new patients who were referred to the Neurology clinic that is seen on a Wednesday afternoon as opposed to a Thursday. One main tip for the Neurology clinic in addition to a detailed CNS and MSK examination, be sure to complete a mini-mental status examination where needed. For example, if the patient has some developmental delays and during the exam appears to be cognitively impaired. It will help in your assessment when you're presenting to the consultant.

Thursday- all day- you'll be stationed in the Neurology clinic. Team, 1 clinic patients are usually seen by the senior house officers and more seasoned members of the Paediatrics department. The physicians in charge of the Neurology clinic will be the ones with whom you are to report and who will be responsible for dismissing you from the clinic.

Friday's are usually interesting clinic days where you don't really know what to expect. The neonatology clinic sees patients who were admitted to the Neonatal Intensive Care Unit at the hospital and discharged. Some patients may be in the clinic for results of a karyotyping study that was done or just to know whether or not they will be discharged from the clinic altogether. Fridays can be an early day depending on what needs to be done for a patient and how many patients the Consultant has to see.

Although our schedule says Cardiology clinic and consults, since there is no Paediatric Cardiologist in the public setting of the hospital this clinic, unfortunately, doesn't exist.

5. BE PREPARED

Nothing beats preparation.

That said, prepare yourself each day for the worse. Pack your bag with snacks, water, lotion, hand sanitizers, extra gauze, alcohol swabs and don't forget your diagnostic kit (since clinics aren't furnished with them). By preparing yourself for anything you'll ensure that you aren't loosing anytime from your consultation with a patient because you're either looking for something or dying for a bite to eat.

I forgot a few times to pack my bag the night before with snacks that I eat and had to wait until the clinic was over to get something. Let me tell you, the last thing I wanted to eat was peanuts.

By knowing what clinic you're to attend the following day, you're able to read up on common topics so that you can take advantage of having a consultant present to discuss topics with and why certain things were suggested for a patient's management.

6. BE WILLING TO LEARN AND TO TEACH

It's all up to you to make the most out of this year of internship. Although you've successfully completed all requirements of medical school and attained a degree in Medicine, it is important to remember that learning is lifelong.

The clinic settings afford you the time and opportunity to learn. You are in a setting with persons at different levels in a particular specialty who are still learning themselves. Most times they're excited to discuss something with you and to guide your thinking.

Once you've been taught, it's important to pass that knowledge on to the medical students who may be present in the clinic as well. Remember you were literally months ago a student, continue to be kind and willing to teach. After a while you'll realize you won't need to ask all the time the dosage of certain medications and why you're checking the levels of Tegretol in a month as oppose to a couple of weeks (remember autoinduction?) and you'll be now able to store new information.

7. BE WILLING TO HELP

Regardless of your position on the medical totem pole, you always find that you're in a position to help. A colleague may be in with a difficult patient and in need of a radiological report but they're unable to move at the moment if you're free to, why not offer to run and retrieve it?

What I've found over the last two weeks in clinics is that a little goes a long way, especially if persons were on call the night before and weren't able to get a night's rest.

8. COMPLEMENT SOMEONE EVERY DAY

Compliments go a long way!

From a simple "you look nice today" to "the way you handled that situation was impressive, you did a great job with that" can create an environment that is comfortable to work in and to grow in. Once people realize that you're teachable, genuinely nice and have great work ethics, your daily experiences -despite the unforeseen circumstances that may arise (i..e that close call with explosive diarrhea or having kids pee on your lap) will be so rewarding. They may even have a ripple effect that changes the culture.

___________________________________________________________

My very good friend Dr. M was so kind as to send a video of his tips based on his two weeks in the Hospital in Scarborough Tobago. I've posted it below.

If you're a new House Officer or an experienced one please share in the comments section your tips and tricks on how you survived your initial weeks of internship.

Foundations

Monday, July 09, 2018

"Time is a gift and to use it wisely is admirable"-Renewing Faith Publishing

Did you know that the Empire State Building was built during 1930-31 in a record one year and 45 days? It is known to rise over 1,453 feet from the ground with 103 floors of steel, limestone, granite and brick weighing in excess of 365,000 tons. A total of 1,860 steps extend from the street level up to the 102nd floor.

Given this construct, the building doesn't sway. It gives, but only to a total extent of 1.48 inches in 110-mph winds. The architect took great pride that the building's movement off center was limited to less than 0.75 of an inch on either side. So what holds up this mighty building and keeps it standing so tall and proud? A 55-foot deep foundation of steel and concrete embedded in solid ground.

A crew of 600 men working day and night dug the foundation for this engineering marvel in just 45 days, but without these extreme footings, the building would not possess its strength.- Devotional January 2017, Renewing Faith Publishing

_________________________________________________________________

As graduation season rolls on, like the Empire State Building, the members of the graduating class of 2018 worldwide, took the necessary steps to ensure their foundation of knowledge was deeply rooted. I can attest that many sacrifices were made as the New Year began which trumpeted the countdown to graduation. Study groups were formed with persons whom we knew only in passing that blossomed into the most wonderful of friendships. The fickleness of those who we perceived to be close friends was exposed and as life would have it, the ball kept rolling.

Each day, we saw just how much our lives were like this architectural giant. From the inception of medical school, our character was shaped, as we advanced, we noticed how easy it was to stand tall with assurance in spite of our challenges because we knew our feet were grounded on a solid foundation.

It may have taken us longer to grasp, however, we learnt to Q-TIP (quit taking it personal) because at the end of the day when a patient's life is on the line, whether or not we are friends with our colleagues is not important, rather having respect and a mutual understanding and a common goal of placing the needs of the patient first is all that matters.

We sat exams, we performed and we even exceeded our own expectations and now stand proud, not because we made it, rather because we recognise that it was not by our own strength but that of God, that we overcame.

So to all of my fellow graduates entering the working world or advancing to higher academic heights, remember that despite crossing this hurdle, a new chapter has begun and new challenges await you.

As Dwight L. Moody once said "character is what a man is in the dark". The people you encounter each day notice how you act and react in various situations. Persons you don't even know form impressions of your character and integrity just through observation; the test is not behind, it now lies ahead.

Keep stepping out in faith and don't ever forget that God has already placed Jesus Christ as the one and only foundation (1 Corinthians 3:11 NLT) stay grounded in Him.

____________________________________________________________

______________________________________________________________

Love in Medicine

Monday, July 02, 2018

“There is never a time or place for true love. It happens accidentally, in a heartbeat, in a single flashing, throbbing moment.” ― Sarah Dessen, The Truth About Forever

It was late August 2013 as I boarded my flight to St. Augustine Trinidad, mentally prepared for the inception of medical school, but emotionally destroyed.

The time came to cut ties with the one who I had known and loved dearly for roughly seven years. Heart-broken and confused, that four hour flight to Trinidad and Tobago was spent trying to erase every memory we created and stopping myself from replaying the conversations I had with him prior.

As the wheels met the tarmac at Piarco International Airport, I raised my sunglasses, wiped away the tears that I tried so hard to stop from flowing, repeated silently to myself "time to shine! no baggage! go and get it girl!"

For the first time in a long time, I was single and not interested in love or the semblance of it.

Naturally, without my searching or effort, I was met with my fair share of suitors. I found it interesting that the moment I wanted to be alone like cockroaches at the height of darkness, eligible bachelors were suddenly bold enough to voice their interest, but I digress.

My first semester in medical school came to completion and to my surprise it was my last semester that I was single as well. During the first few months of second semester, I gained a friend. As our friendship grew, so did my interest in him and little did I know that was mutual.

During my most difficult moment of medical school, he was at the centre encouraging and supporting me, reminding me that there is always hope as long as God loans us breath and although my health was being tested, it was not the end of my story or my journey.

From then to now, I've found that we've both strengthened one another and honestly that is vital in a growing relationship next to strong communication and commitment.

As a medical student, it is important to stay focused on achieving your goals, however, don't be a "Mr. Scrooge" and shun those who may be placed in your life for a lifetime. Love comes when we least expect it and God has perfect timing. What begins as friendship can evolve into a beautiful relationship.

__________________________________________________________________

"To have a good friend is one of the highest delights of life"- Author Unknown

__________________________________________________________________

I'll leave you with this story from a planner I received from my best friend Andrea last year. It was entitled "Friendship"; it reads:

Alex and Judson were hiking through the Redwood Forest of Northern California. They marvelled at the extreme height of the trees, the massive trunks of some, and the overall density. Coming across a park ranger , Judson asked, "For trees this huge, how deep are their roots?"

The park ranger explained that the redwoods actually have a shallow root system. Instead of growing deep, the roots spread out over great distances right under the surface of the ground, and intertwine with one another. Because the roots are wrapped together, the trees are able to grow taller and withstand storms. The great strength of the forest comes from the roots of all the trees helping to support each other.

As they continued on their hike, Alex and Judson talked about how their lives were a lot like these trees. When they stood beside each other and helped each other, they always felt more strength and energy. They were glad they could count on one another for support.

In medical school as well as through life, 'in the same way as the roots of the trees, you need to know who you can count on as friends to be with you through the good and difficult times. This occurs when you demonstrate the same commitment to your friend' (however, it may not always be reciprocated). As it takes more than two trees to hold each other up, so it may be in your life, you may find yourself with a flock of friends or a select few of persons with whom you can depend on. 'It is important to let God intertwine your lives. his strength will sustain you through any of life's storms, and He will help your love life and friendship grow closer together.'

Dear friends let us love one another, because love comes from God- 1 John 4:7

Prayer's Power

Saturday, March 17, 2018

“Prayer is not asking. Prayer is putting oneself in the hands of God, at His disposition, and listening to His voice in the depth of our hearts.” ― Mother Teresa

I'd like to share a devotional that resonated with me last week. This post has been through several drafts as I wasn't sure which way would be the best way to share my experience until this was read during my family's evening devotion.

Before March 11th, I felt a level of spiritual detachment that I had never experienced before. I pondered whether what I was experiencing was actual feeling of "grieving the Holy Spirit." This shook me to the core. I was able to pray, however it wasn't as often, and I often did it out of habit not because I needed to communicate with my friend and Father, there was a sense of rebellion swelling up within me because I couldn't understand why certain things were taking place. For instance, why no matter the amount of time I dedicated to my academic studies my level of application and understanding must have been deficient since my grades demonstrated underperformance rather than confidence and understanding. My family life was being targeted and I was just over the dysfunction.

I found myself frequently ill, despite having received the recent influenza vaccination and constantly depressed. The fire that once burnt brightly within for medicine and this ministry of healing was slowing diminishing.

This devotion offered me hope and my prayer is that it would do the same for you as well.

God Hears Prayers

"Surely the Lord our God has shown us His glory and His greatness, and we have heard His voice from the midst of the fire. We have seen this day that God speaks with man; yet he still lives."-Deuteronomy 5:24

Andrea met Christ and wanted to accept Him as her personal Saviour, but she was reluctant to surrender herself entirely to Him. Her main problem was that she was not willing to adopt a simpler physical appearance; above all, she did not want to stop wearing jewellery. She decided to speak to God through prayer to ask for His guidance.

She went to her room and knelt. As she prayed, she experienced the feeling of being in the presence of God. She felt in her heart that earthly things are worthless once God occupies the right place in our lives. When she finished praying, she knew that the Lord wanted her to know that He truly calls and qualifies the candidates for His kingdom. All doubt disappeared and she decide to be baptised, surrendering her whole life into God's hands.

The Lord speaks to us in the context of prayer. We can hear His beautiful voice that validates our faith and gives us the assurance of our salvation. We need to remember as well that He speaks to us primarily through the Bible. We must remain open to listen to His written word. The apostle Paul urges us to open our ears to His voice:

" So we must listen very carefully to the truth we have heard, or we may drift away from it. For the message God delivered through angels has always stood firm, and every violation of the law and every act of disobedience was punished. So what makes us think we can escape if we ignore this great salvation that was first announced by the Lord Jesus himself and then delivered to us by those who heard him speak?" (Hebrews 2:1-3 NLT)

However, we must train our spiritual sense to recognise the voice of God in His word. We must ask the Holy Spirit, who inspired the prophets, to enlighten our minds to recognise what God wants to say to us. Let us allow Him to be present, to touch us, and to communicate His will and bring peace to our heart.

_________________________________________________________________

Based on the above, my practice now when I pray, is to ask to be able to differentiate the voice of God and to know when God speaks to me. I often try to remind myself now, that God never turns away from His promises nor does He walk away from a relationship with us. It is us, who decide to stray based on the deceptions planted by Satan and his demons because he knows that once we believe that God is unable to forgive or accept us as we are, it is easier for him to see us lose out on salvation.

Prayer has the power to change our hearts and our minds and to awaken our senses once we pray earnestly and receptive to the reply.

As you move into the upcoming week, aim to pray more selflessly and ask for discernment and the ability to recognise what God is saying to you.

Quit Faking IT!

Sunday, March 11, 2018

“All the world's a stage.” ― William Shakespeare, As You Like It

The elephant in the room needs to be addressed. The time has come to shed some light on what some may have heard throughout the first three years of medical school, and what others may be told when they begin their journey.

There is nothing greater to the person whose passion is medicine and whose desire it is to be at the service of others, than to be given the title of "Doctor."

Before I started my journey as a medical student, I never fully grasped what so many medical bloggers meant when they wrote "the easy part is getting into medical school, the hardest part is staying in." How dare they? I thought as I sat in my apartment on my night off, with my Pomeranian on my lap, working diligently to complete as many tasks on my medical school application 'to do' list. The most daunting being completion of my personal statement or the autobiography sketch as some schools may call it. At that point in time, trying to convince a committee of admissions directors to grant me acceptance, was far from easy. Studying for the Medical College Acceptance Test (MCAT) in and of itself while working full-time appeared an even greater challenge-not impossible, just challenging-and here I was reading that this was the easy part.

Makes you wonder whether or not those medical bloggers had a high threshold for challenges or if they were simply crazy. Now that I've completed most of my medical school training, I now understand what they meant and I'll admit they weren't exaggerating either.

As you sit probably with your rough draft of your personal statement either on your lap or rolled up and tossed on the floor, once you soar over this hurdle, you will be well on your way to gaining acceptance and entry into the medical society.

You see, with each passing day, the challenges we face intensify and our ability to face our obstacles and fears and to supersede them not only become easy, but more bearable. We are strengthened in our capacity to overcome our challenges and fears; we become more resilient and sooner (rather than later, hopefully) what use to have us down for the count, won't even knock us over.

With my acceptance to medical school, came excitement as well as fear. Fear of failure, fear of not being able to stay in medical school, not to complete the courses on time and the list goes on. Mixed with the fear there was some excitement, mainly due to the fact that here I was with a youthful appearance but years older than my teenaged counterparts who were just as intrigued by the mechanics of the human body as was I. We were all ignorant and in it together.

Due to the large class size, we were alphabetically categorised into smaller groups for just about everything from laboratory classes to clinical skills sessions. This allowed the laboratory directors and clinical skills instructors to teach in a less intimidating manner and also afforded us the opportunity to "network" and to get to experience medical learning in a different way. It was in these sessions where we were told how OSCE's were all a 'big show' and that in order to pass all we had to do was 'to fake it' until we made it.

You may have heard how competitive medical school is. It's true. But it doesn't have to be. What I believe most students fail to realise is that regardless of how many persons are accepted into your graduating class, the last thing any school wants to do is to see you fail.

There aren't shortages of medical degrees that can be awarded per year or per class. However, this is how medical students act. Rather than perfecting skills that will ensure their success in the long run they limit themselves to faking it and doing all that they can to hoard material and preserve themselves whatever the cost.

QUIT FAKING IT!

1. Invest in Your Career

It is easy to become distracted by the idle talk and lose sight of your overall goal. Especially if you're surrounded by persons who have already graduated who want to offer their "advice". You must remember that not all advice is good advice and in regards to decisions you have to make for yourself that relate to your career and your overall happiness, the experience of others should be taken with a grain of salt, especially if you realise that advice is coming from a bitter vessel.

Once you enter medical school, make the decision to utilise every resource available to you and never stop exploring your options as your interests may change or evolve as you advance in your schooling. Be sure to reach out to persons who are in your field of interest and have a conversation with them regarding opportunities that are available in that field that would allow you exposure you would otherwise not be exposed to.

Do your own research into programs that you can sign up for during your summer months, that would allow you the opportunity to practice your speaking and to exercise your medical vocabulary as much as possible. By investing in your career, your medical education becomes more than an education but the catapult for your future success.

2. Consider yourself as more than just a Medical Student

Sometimes as students we find ourselves limited in what we can do but doing more than our licensed medical counterparts. The minute you start referring to yourself as just a medical student, you're short-changing your reality.

When you graduate and take on the role of an intern, you'll then find yourself, walking away from things or referring to yourself as "just the intern". The time you're spending in medical school is the time you are to grow as a medical professional. This is your time to use the platform to exercise your muscles by becoming involved in humanitarian organisations and giving back to the community in which you reside. This is the time to be present in the hospital and to make your face a familiar one to the nurses and other staff on the wards and in different departments. Why? Well because the way in which you will learn, will begin to shift, you'll start to transition from the library to the radiology department, the emergency room etc piecing together the basics in order to construct a sensible assessment and treatment plan that you can discuss with your seniors.

By doing this you're now allowing yourself to grow and believe it or not becoming more than prepared for your final exams.

3. Learn to Practice

As a child, I grew up in a home where expressing oneself was expected. I can recall standing at the foot of my parents bed reciting from memory a book report I wrote hours before to my father who was listening to every word. He offered constructive criticism based on what I said and from these exercises it was easy to speak in front of anyone on anything.

With lack of practice, I do find it hard to eloquently express myself as I once was able to, but like anything, once time is dedicated to doing something, I'll be back to where I was in no time.

As students, we often become fixated on studying in the library, reading all of the books, watching all of the videos and then find it hard to convey all that we spent time reading to our peers or seniors. So I would encourage you as you study, get in the habit of studying in groups early on in medical school and take the time to verbally review what you learnt as you covered a topic. Come up with a system that you can follow that would make it easy for you to cover the salient points on any topic in ten minutes or less.

4. Learn to be a Motivator

There are few people in medicine who are motivators. It saddens me whenever I read posts from other medical bloggers about their day on ward rounds and how their attending belittled them, or how after a day of ward work, rather than receiving words of affirmation, they were criticised and as a result felt as if they were unworthy of becoming a doctor.

In a field where empathy and respect are core principles, they often don't exist. The culture has now become one where tearing someone down to get a foot ahead is commonplace and expected and teamwork although it is spoken of, is lacking.

The culture is so superficial and sadly with this comes patient negligence and a lack of accountability but a whole lot of blame.

Learn to motivate your peers. You don't have to be their friend or go out of your way to make friends with persons you just aren't compatible with, but once you learn to accept the fact that the people who fill the seats of the lecture hall with whom you may have to interact with will eventually become your colleague and at some point your paths may cross in the form of a consultation. At the end of the day, you're learning to be a practitioner that is capable of respecting others, building them up in the process and placing the needs of the patient first.

5. Be Consistent

Learning to be consistent from the beginning makes it hard to fake anything. By adhering to a study schedule where you incorporate practicing your physical examination skills, summarising your findings following your examinations and reviewing past papers, you will find that medicine and all that it entails is now second nature. You will become fluent in the language and when placed on the spot to perform an exam, rather than breaking out in a sweat and panicking, you'll confidently step to the plate. You'll be more open to constructive criticism and comfortable with things that once were foreign.

Consistency is key in your overall success as a student. That is if you're consistently practicing good habits. If you're consistently procrastinating then you can see how that would just lead to you being a consistent fake and unreliable in the end.

The goal is to be consistent, intentional and bold with good habits from the inception and to learn to grow with each semester that starts and finishes. By doing this you'll find that you're no longer faking it, but evolving into a Physician patients will be wanting to see.

Baked and Brewed| My Favorite Bistros and Coffeeshops

Sunday, February 25, 2018

“I could smell the food fill up my hunger before the order was even
placed.” ― Phindiwe Nkosi

With the change in weather (can someone tell me where all of this rain is coming from?), iced beverages are being traded in for the warm cups of tea or coffee.

As a student, I experience my fair share of cravings of studying in a coffeeshop enveloped by the aroma of coffee beans and the chatter and laughter of perfect strangers. There's just something about the atmosphere that offers a calm peace of serenity that I enjoy but not always can afford.

Locally, there have been a few new openings of coffeeshops and bistros which of course equated to my new found adventure.

1. STARBUCKS

Location

The popular American franchise can be found strategically located throughout Nassau at 3/4 of the cardinal points.

My home is located within 10 minutes of 2/4 and it wasn't until a few weeks ago actually,that I decided to venture outside the confines of normalcy which is the Harbour Bay Starbucks location to try the Palmdale branch.

Staff/Customer Service

This location offers a warm and cozy feel and welcomes the student and businessman alike to venture in and spend their money and also time admiring the pleasant surprise of the interior's aesthetics and warm, welcoming and vibrant young staff of baristas.

I can't say that I felt like Norm or Frasier from the sitcom Cheers, but they did take the time to learn my name and offer me the sentiment.

My choice of drink at this location since I'm on a mission to find a barista that can truly make a Chai t latte to my liking which is on par with perfection, was just that. A triple vanilla Chai latte. It truly warmed up a rainy and gloomy day I must admit, however it was missing a little something; nonetheless it was enjoyable and worth it overall.

Like any other Starbucks worldwide, this location offers a variety of hot and cold caffeinated and decaffeinated beverages that can be made while you prepare your space for a productive study session or an afternoon filled with people watching. They also offer a few bottled beverages like their Cold Brew Coffee, Doubleshot Energy Coffee and the Refreshers Revitalizing Energy with Coconut Water.

During your study session if you're hungry and wanting to stay put to eat, Starbucks offers pre-made sandwiches such as the Turkey focaccia sandwich, the CEO, and the Curry Chicken Chipotle Wrap; they also offer a Vegetarian burrito which is tasty but not filing for $7. If you're wanting to satisfy your sweet tooth, they do serve a few baked items ranging from the traditional Banana Nut Bread to a more daring chocolate cake. For the light snackers, you can choose between their selection of fruit or prepackaged cookies, yogurt or Kettle chips-the salt and vinegar are my favorite.

Depending on what you're wanting and how much you have to spend, the Palmdale branch is a stone's throw away from other popular fast food eateries such as McDonald's, Bahama Subs and Subway. If you're open to Greek food, and not afraid to walk (about a block) Acropolis Restaurant is ideal either for food to go or to dine in.

The Harbor Bay location is within walking distance of the Caribe Cafe at the Logos Bookstore, Fresh Market's deli, Bahama Subs, Domino's Pizza and Dairy Queen.

Wi-Fi

During peak hours (which depends on the location) the Wi-Fi service can be a bit patchy. I've had issues with the Wi-Fi at the Harbor Bay branch particularly on a Sunday evening between the hours of 6 and 7 o'clock. They do offer more than one open network so you're never without for too long of a time.

Ambiance

The Palmdale location was definitely welcoming and less crowded which allowed for a productive study session. The flow of the shop was also nice and added to my productivity since there was an aesthetic separation of the seating. The front of the shop is set up for larger parties with seating for about 4 persons per table, while along the right lateral wall is a continuous bench that appears broken up due to the placement of small round tables and additional seating. The lighting adds warmth and just enough lighting to enjoy a cup of your favorite beverage while getting work done.

Price

If you're not accustomed to paying $5 for a cup of coffee (which you can have in an actual coffee mug upon request either store provided or your own), then this may be a shocker for you. For those on a budget looking for a place to study I wouldn't suggest making Starbucks your daily "study joint" mainly because those tall Frape's can add up. However, if you plan smart and order the daily brewed coffee which is less than $5 or try out their Earl Grey tea bag and pack yourself a light snack then you can make it work-if you must.

2. CAFE' CHANNING NOELLE

Move over Inagua, you've got some competition in regards to being the "best kept secret in all of The Bahamas."

This little Parisian themed Cafe' is a unique, intimate addition to the other coffeeshops and bistros on the island. Named after the owner's daughters, this quaint store offers a variety of instagram and Pinterest worthy pastries and boutique items from mugs, stainless steel water bottles and even bridesmaid gifts.

If you're looking for an new experience while reviewing study material or just to break the monotony of studying you'll definitely want to add this coffeeshop to either your list of places "to study" or places "to visit."