My Geriatric Medicine Elective experience in Nanaimo

In summary, it was a wonderful experience for many reasons but primarily because I had a great preceptor. I may have previously mentioned, he is a one-man-geriatric-team who previously trained and worked for years as a GP. He does all the hospital geriatric medicine consults as well as see patients in his own clinic, so I had the opportunity to work alongside him and in both environments.

He was an excellent teacher, he was never impatient with me or colleagues or patients, and always provided good learning opportunities. I especially appreciated that he trusted me with his patients. He believed in my skills, and where they were lacking he helped me develop them. I saw many patients on my own and he always listened to my assessments and trusted my findings and judgement. Due to this, I felt I had the opportunity to thrive and become more confident.

Many of his long term patients said I was very lucky to have him as my supervisor and I do not disagree! His patients loved him as a doctor because he was always comprehensive, understanding, and willing to give as much time as needed.

Through this elective, I also had the opportunity to experience many ‘firsts’ in medicine. Here are a few I would like to share:

  • My first unexpected death. I was sent to see a patient who we were asked to consult for query MI (heart attack). He also had leukemia (terminal, not being treated) and hyperviscosity syndrome. When I came in to see him, he was sweaty, complaining of hard-to-explain discomfort, and extremely restless. He kept changing positions from laying to sitting up in bed. He was a little breathless (oxygen saturations in the high 80s to low 90s) but alert and speaking in full sentences. With his history and symptoms, I immediately wondered if he had a pulmonary embolism (clot in the blood vessels of the lung) instead. On physical examination, my main finding was bilateral costovertebral angle tenderness (often a sign of kidney inflammation/infection) which could also explain why he was in such restless pain. After a few short minutes, he began to quiet down. He laid still in his bed and appeared quite comfortable. I asked him how he was feeling and he said he was feeling better. He think told me to come closer and said, “You know, I have leukemia. And I know, I’m going to die. But it’s okay, I’ve accepted it.” Right after he told me that, he began to have difficulties speaking, opening and closing his mouth but no words would come out. Then, within a span of 3-5 minutes, his blood pressure dropped, he became completely unresponsive, and his GCS (Glascow Come Scale – neurological scale that measures a person’s state of consciousness) went from 15 (max score) to 3 (lowest score possible). His pupils became dilated and asymmetrical. It was just myself and a nurse with him at the time and he was DNR (do not resuscitate). The nurse asked, “What would you like me to do?” I felt so utterly useless because there wasn’t much I could do. I suggested pushing fluids to hopefully get his blood pressure up and agreed when she asked if we should send for blood gases. On previous imaging, he had progressive, chronic subdural haemorrhages (bleeding under the skull, pressing onto the brain) and from his acute deterioration, he must’ve had a massive bleed or other cerebral event. I called my preceptor who arrived within a few minutes and agreed there was nothing more to be done. He died within the hour. The shock of having someone unexpectedly crash on me and feeling so powerless to help was a very new experience to me, and the patient passed away. I had to sit in silence and digest afterwards for at least 15 minutes before moving on with my next task. My preceptor was quite understanding. “You get used to it,” he said, “but it never gets easier.
  • Haemoptysis. The coughing up of blood from your lower respiratory tract. A term I’ve read many times in books. A question I ask all patients with a cough, however, aside from some blood tinged sputum, I have never really seen. We were on call and asked to come see a lady who had a 2 week history of coughing up blood. She was also a First Nations woman and had a previous exposure to Tuberculosis (TB). In addition, she had Takayasu’s Arteritis – an inflammation of the large blood vessels that particularly affects the aorta and its major branches (to the brain, arms, etc). This vasculitis had affected her so much and she had had such extensive previous surgeries to her blood vessels that she now only had very limited blood flow to her brain. If anything were to happen and her heart didn’t pump blood effectively, it would affect oxygen delivery to her brain and she likely wouldn’t make it through without severe brain damage. A lot of interesting factors in this lady’s presentation. While getting a history from her, she started to develop a gurgle in her chest and started to cough, and cough and cough. She brought up bright red blood, even big blood clots. It was the first time I had ever seen true haemoptysis. Not a sight I will soon forget. Throughout her hospital stay, her cough and bleeding eventually settled down, her cultures never came back TB positive and she was eventually freed from isolation. She had a bronchoscopy (a scope to look down the lungs and take samples) which didn’t come back with any sinister findings, like cancer. Whatever caused the bleeding remained a mystery but she left hospital happy and symptom free and promised to return for follow up!
  • Met a man in emergency who had a STEMI (heart attack with characteristic ECG changes) that completely resolved after thrombolysis treatment on ECG. Then it came back! Definitely had to quickly transfer him to the closest facility for PCI treatment!
  • Encountered a pulsus paradoxus (abnormally large decrease (>10mmHg) in systolic blood pressure and pulse wave amplitude during inspiration). This lovely 90yo lady had presented with 2 weeks of increasing shortness of breath and 2 syncopal (fainting) episodes. The doctors who saw her thought she was having heart failure and was fluid overloaded so gave her diuretics and sent her for an ECHO (ultrasound of the heart). Over the course of the day, she became delirious and her ECHO came back with unexpected findings. She had a large pericardial effusion (blood in the sac space around the heart) which was causing a tamponade effect on her heart. Needless to say, once the effusion was drained, she immediately felt a million bucks better. Apparently, I probably won’t come across such a significant pulsus paradoxus again anytime soon in my career.
  • Had a lovely patient who had come in with severe sepsis but also had an ongoing history (years) of hallucinations. They always occurred around the time he fell asleep. They were never threatening but he described them with such amusement and laughter that of course, I joined in. “Oh yes, I see animals all the time. Today, I had a baby goat on my pillow” and “I see birds fly around chandeliers when I look up at the empty ceiling” and “I’m always reaching for coffees and food that are not actually there” and “When I watch TV, I will see another TV screen beside mine playing something else.” Incidentally, he was also found to have liver cirrhosis, splenomegaly, and abnormal blood results (significant of a developing haematologic malignancy) so there was that interesting aspect of treatment and management as well.
  • Had a 90yo lady with such severe aortic stenosis that she was no longer able to get out of the bed without being breathless. She didn’t want invasive intervention but what really stood out for me was her passion in life. She was an avid hunter, baseball player, and loved fly fishing.
  • Did my first trochanteric bursitis local anaesthetic/steroid injection. Probably one of the most easiest procedures I’ll ever do in my career but it was exciting and provided immediate relief for the patient.

Those are just a few of my experiences on my Geriatric Medicine term, I’m sure I’ll remember other ones I’ll want to share! One of the things I enjoyed most about this elective was the complexity surrounding each elderly patient, very rarely are they simple cases. Patients had cardiovascular disease, lung disease, dementia, mobility limitations, falls, frailty, diabetes, incontinence, no social support, etc. Their medication list hadn’t been reviewed and they were on too many or not enough medications. Physical examinations had to be comprehensive – I often did a cardiovascular, respiratory, GI and neuro exam on every patient – and often found incidental but important findings! Some findings include: postural hypotension or gait disturbances that could’ve accounted for falls, heart murmurs not previously mentioned, enlarged liver/spleen, etc. Even though at times it can be overwhelming, it was very rewarding to tease out all the pertinent information and use it to create an all encompassing plan of management.

The best surprise of my elective? My preceptor telling me that he would be on vacation during my last (4th) week on elective and offering me a ‘self-guided learning week’ if I wanted it. The opportunity to go home and spend an extra week with family in Ottawa? I told him that it would be a cherished opportunity, as long as he felt I had worked hard enough and was functioning at a level to deserve it. Yep! And backed up by a good assessment and an agreement to be a reference for me. So happy!

Even though it cost me an additional $400 (I know, it’s ridiculous) to change my flight, it was worth it. My sister was also back in Ottawa from Vancouver, so we had a complete family and quality time together. I was very grateful for this extra time with family as I really don’t know when my next opportunity to visit Canada will be.

Thank you to my preceptor, the hospital staff, and the patients I met for making my geriatric medicine elective such a great learning experience!

DHAL: July 19-25, 2014 – Week 1 in Nanaimo

July 19. After saying farewell to my sister in downtown Vancouver, I hopped on the bus to head to Horseshoe Bay Ferry Terminal. The bus ride took less than an hour and a one way ferry ticket to Nanaimo cost $16.25.

Beautiful views from the ferry terminal!

IMG_7491

IMG_7494

I was on the Coastal Renaissance… never have I been on such a humongous ferry! I admit, I did get lost but I was impressed. Ended up making it to the top deck and… fell asleep for most of the ride over to Nanaimo 😛 I was exhausted with only 3 hours of sleep, I tried!

IMG_7495

IMG_7499

Once we arrived in Nanaimo and with my luggage, I decided to grab a taxi instead of the bus. I don’t think I mentioned this in a previous post, but the hospital I’m doing my elective at has a 3 bedroom house that they rent out to medical elective students for FREE. I felt quite lucky to be able to save some money! I was dropped off at the hospital to pick up my house keys and then walked approximately 700m to my accommodation.

The house is spacious, with everything provided, including linen and household products. Even has a desktop computer and printer for tenants to use.

IMG_7512

 

There is a housekeeper who comes by every Tuesday to clean the house as well.

IMG_7516

IMG_7520

IMG_7503

I had a moderate sized room with a desk and closet, didn’t take long to settle in! There’s also a lock on every bedroom door, allowing more security when you’re in and out of the house.

IMG_7509

Pretty great internet provided!

Untitled

I ordered some groceries online the day I arrived and was too lazy to go exploring so I even ordered some Chinese take out for dinner. Lowlight: It was THE WORST food I’ve ever eaten, I don’t even want to explain it. Those in Nanaimo, never order from Sun’s Noodle Bar. Needless to say, not much got eaten and a lot was thrown out.

I spent Sunday at home, reading and relaxing. There wasn’t much to do around my neighbourhood and I didn’t care to go into the city. Sunday night my housemate came home, a really sweet medical student from Ireland doing an elective in Paediatrics.

Otherwise, I was just nervous for the start of my elective! Was hoping for a nice preceptor! Have never worked in the Canadian medical system before so didn’t know what was expected of me yet. Monday came quickly. I started my week with some PowerChart training – the online medical record system they use here. I then met the course coordinator and eventually my preceptor. I was expecting to be a part of a hospital team for my geriatrics elective. Turns out my preceptor is a one man team!

He’s great though. Extremely patient and never discouraging towards me. He lets me do as much as I want within my limits of comfort and learn what I want to learn. Always takes his time to answer my questions and teaches whenever the opportunity arises.

As you can imagine, elderly patients most often have a plethora of issues that landed them in hospital. These can include: dementia, delirium, instability, falls, cardiac disease, stroke, incontinence, infection, etc. I love geriatric medicine because it is so general that you always see a variety of presentations. History taking needs to be thorough and examinations need to be all encompassing in order to not miss anything in an elderly patient, especially when there can be so many causes to their issues.

On Mondays, Tuesdays, and Thursdays, we are in the hospital in the morning and at his clinic (about 5min drive away) in the afternoon. We spend Wednesdays and Fridays in hospital.

My first week passed very quickly. My days start later than I’m accustomed to. My preceptor often tries to make it in by 9am but he has 3 young children to take care of and drop off at different activities in the morning, so we often don’t meet up until 10am. I get to start my day at a good pace and have time to review patients before he gets in. The days pass quickly because we are so busy, I often don’t get home until 7pm and we normally don’t have time to take a proper lunch. Usually we work until we need to rush to clinic and eat our lunch during the 5 minute drive there. A one man team is busy busy!

So far so good though, I’m quite enjoying my time working! Don’t know if I’ll see much of Vancouver Island while I’m here, we’ll see!

My sister is coming for my first weekend here, to celebrate my birthday early with me, which makes it less lonely!

Rotation 1 complete!

Today I completed my first exam, and thus my first rotation of Year 3 – hurray!

Our Medicine in Society – Geriatric Medicine exam was 1.5 hours with 40 multiple choice questions worth 80 marks, and 1 short answer radiology question worth 20 marks.

The exam was overall fair and representative of what I learned this rotation in geriatric wards. With that being said there were still a number of tricky questions, so hopefully I did well!

Now that that’s over, do I have vacation?

Why yes indeed!

I’m off until March 18, which will be our first week into Rotation 2 – General Practice.

Mike and I are actually at the international airport right now, 3 hours after exam! Heading to Vietnam until next Sunday and stopping over in Singapore tonight. My mom is currently in Vietnam, so we are meeting up with her to visit some family and do some quality relaxing on the beach! 🙂

Plans tonight in Singapore: Chocolate Buffet on the top level of the famous Marina Bay Sands! Mmm, is your mouth watering? Because mine is! We plan to try all 57 chocolate varieties they serve, wish us luck! And of course, we definitely have to check out Gardens by the Bay and photograph the supertree groves! So excited!

We are also flying with Singapore Airlines, so looking forward to a nice and relaxing flight, especially after the exam!

Plan to blog whenever I can during vacation, come back and visit!

Have a lovely day everyone! 😀

MIS: Coming to an End

After an amazing 6 weeks at Prince Charles Hospital learning so much about Geriatric Medicine, my Medicine in Society rotation is coming to an end.

You would not believe how worried and anxious I was to begin working in the hospital this year. The thought of constantly feeling stupid and not knowing enough was enough to get my heart racing. Luckily I was proven wrong. Every staff member I have met at The Prince Charles Hospital has been welcoming and kind. Not only have they taught me so much, but they trusted me and provided innumerable opportunities to apply and broaden my knowledge and skills – I couldn’t have asked for a better experience!

Here’s a review of what happened:

I spent my first 2 weeks in the Fractured Neck of Femur  (#NOF) Service (01/21 to 02/01). All patients in this ward had broken their hip and required surgery and rehabilitation.

Then I moved on to the Geriatric Evaluation and Management (GEM) Unit for 2 weeks (02/04 to 02/15). These patients can have any sort of health problem, and were in GEM for further rehabilitation or waiting for home services to be set up before going home.

Fifth week I spent in the Cognitive Assessment and Management (CAM) Unit (02/18 to 02/22). This ward is more long-term and all patients have some kind of dementia. CAM was an especially unique and enjoyable experience. I got to know all the patients on a personal level and it was admiring to see how the staff take care and handle patients when they are being difficult.

During my last week (02/18 to 02/22), I spent a few days with the Geriatric Referral and Liason Service (GRLS) and some days back in the CAM Unit. The GRLS team takes referrals from all different wards of the hospital to see if patients would be appropriate for transfer to the GEM unit or elsewhere. GRLS was especially beneficial because I was able to learn how referrals work and got to become more familiar with other wards in the hospital.

We now have this week off to study for our exam on Thursday! And also have to finish up our health projects. For mine, I’ve created a medical information brochure for the Fractured NOF Service. I’ve received patient/family feedback and it’s now in the final stages of editing before being submitted to the forms committee.

Overall, I’ve extremely enjoyed my Geriatric Medicine rotation. I have had so many encounters with patients, their families, and health professionals that have taught me more than any textbook could. Thank you TPCH for a wonderful experience! 🙂

MIS: You look good today!

I had a chat the other day with a patient who’s been with us for over 2 weeks now. He’s had ups and downs since his surgery, compounded by the fact that he has severe interstitial lung disease.

He was looking better so I was happy to say, “You look good today!” He replied with, “Yea! But what you don’t see is that I’m a broken person on the inside.” Too much talking takes his breath away so he went quiet and started writing in his notebook. I let him write in peace and a few minutes later he handed me what he had written. A list of nearly 10 other medical issues (that we already knew of course) currently affecting him and his quality of life. A reminder that every patient’s story and definition of “doing better” is always more intricate than the current issue at hand.

This man is a palliative patient. He knows his condition is end-stage and will continually worsen over time, which made it even more heart touching to hear him say he was fighting to stay with his family and grand daughters. How much of an inspiration your loved ones can be…

MIS: Causes of falls

(In case you’re wondering, MIS stands for Medicine in Society – the rotation I’m currently undertaking, specifically in Geriatric Medicine)

Alright, moving on!

I’m currently in the Fractured Neck of Femur (broken hip) Service. That means, all our patients are elderly AND have broken hips that need repairing.

We admitted a number of new patients this week and as usual, needed to ascertain how they fell. There are a number of factors that can attribute to a fall, either extrinsic or intrinsic factors.

Intrinsic factors are things that are wrong within the body. This includes: balance and gait problems, visual impairment, medications, cognitive problems (ie dementia), cardiovascular problems, etc. Extrinsic factors include anything in the surrounding environment that could cause a fall – stairs, footwear, floors surfaces, lack of mobility equipment, etc.

As you can probably tell, it’s really important to find out the cause of a patient’s fall, because if possible, we want to prevent it from happening again in the future.

Asking our 80+ year old patient:

“And how did you fall?”

“I got blown over by the wind! If you can believe that!”

Resident and I just could not keep a straight face! An elderly woman carrying a pot of spaghetti for her neighbour (who just got out of the hospital) suddenly gets shoved from behind by a gust of wind (easily around 90km/hr during this storm week) and ends up in the hospital – the poor thing! She is lovely though, and her recovery is going well, which is great!

Wind = extrinsic factor 😉