Night Ward Call

March 28 – May 1, 2016

5 weeks… 5 gruesome weeks of night shifts, being the only junior doctor covering nearly the entire hospital including: general medicine, general surgery, orthopaedics, cardiology, sub-acute geriatric evaluation, pallative care + oncology.

Let’s just say it was a lonesome time working mostly by yourself! Never another soul in the staff lounge when  you do have a few minutes to relax.

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There were many significant moments for me, including unexpected deterioration and deaths of patients, attending my first full-on resus (CPR, advanced life support – patient didn’t make it), managing many acutely unwell patients, etc!

One of the more fun moments – being approached by a nurse, “I don’t know what’s happening with this patient, but there’s all this blood on the floor after she’s gone to the toilet!”

My immediate reaction, “What?! What do you mean you don’t know?!” This was also right in the middle of reassessing a lady for a potential MET call. So the shift coordinatory (nurse in change) and I ran down to the other side of the ward to check on this other lady and was greeted by this wonderful sight:

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Don’t worry guys, she was fine! She just had a huge infected intra-abdominal abscess that was awaiting surgery when it finally exploded! She was actually feeling well with some of the pressure relieved!

So many memories from my 5 weeks on night ward call – it was definitely busy and sometimes incredibly stressful. But my medicine has definitely improved and I was happy for the experience.

Not to mention, I lost weight working nights and looked my best (ever) for our wedding! 😉

Oh, the Irony

When I first started working as a doctor in January of this year, I prepared myself mentally, emotionally and physically to be yelled at, and berated by my senior colleagues.

Haha, I know, that sounds horrible! Of course, I didn’t expect it to happen all the time, but after hearing some nasty horror stories, I would rather anticipate it than be taken by surprise. With that being said, I’m happy to say I’m approaching the end of my 8th month of employment and that still has not happened.

However, I have been yelled at. It was loud, terrifying, awkward, and made me feel like I had done something terribly wrong.

It happened during my first weekend shift at the beginning of the year. I was on Medicine, working ward call. I had just finished ward rounds with the consultant and met up with my colleague to see what other jobs needed to be completed. She asked if I could check in on a patient that she was just notified had gone into complete heart block. A precarious situation, I immediately went to see the patient. On the way, I was stopped by the nurse and given his latest ECG – he was back in 2nd degree heart block, no longer complete heart block.

The curtains around the patient’s bed were drawn and there were visitors behind the curtain. I could hear talking but could not make out what was being said. The health of the patient above all else, I excused myself and entered behind the curtain. I said hello, introduced myself to the patient and his 3 visitors, including his wife. I explained we had received a call from cardiology that his heart had gone into an abnormal rhythm and wanted to make sure that he wasn’t experiencing any symptoms of shortness of breath or chest pain. After a brief talk and examination, I was happy that the patient was clinically stable and apologised for the interruption. I told the patient that I would now go familiarise myself with his chart and have a chat with the senior and let him know if there was anything else that needed to be done. The patient and his wife said thank you and I excused myself.

As I reached the hallway, I heard a very angry, “Excuse me!” I turned around to have one of the patient’s visitors towering over me, 15cm from my face, who proceeded to yell at me at the top of his lungs, “Do you know how rude it is to interrupt a minister in the middle of praying?! How dare you! You should be ashamed of yourself!” Before I could apologise (again) for interrupting and explain that it was necessary for the safety of the patient, he stalked off.

I was shaking. Not because I was hurt, but because I was furious. How is it possible that an adult cannot treat another adult with respect and communicate more calmly?

Being yelled at, for the first time in my (short) career, by a Christian minister – OH THE IRONY. He who should practice what he preaches.

A few minutes later, I returned to see the patient, his family, and more importantly, the minister. Despite the fact that I stood by my actions, I wanted to apologise again if they felt I was rude. The minister was not there and the patient and his wife looked mortified. Both she and her husband apologised profusely for the minister’s behaviour. They said it was appalling and that they were so embarrassed. They agreed with my actions and thanked me for putting the patient first. I thanked them for their understanding.

And that, is the story of my first experience being yelled at as a doctor.

Intern year so far

Intern year has really been incredible so far.

Unfortunately, where writing and blogging used to come so easily to me, I now find it immensely difficult to sit down and make time for it, particularly on my days off! As a result, I have not been able to keep the promise to myself to blog regularly but I hope to share more of my work experience today 🙂

It seems like ages ago, but when Michael and I came back from our 5 week holiday in Canada (March 27), we completed our next 10 week rotation – Michael on Surgery and I on Medicine. In hindsight, second rotation passed by in a blink of an eye. I have always, and continue to absolutely love general medicine. The complexities of patient presentations, the intricacies of patient care, and the teamwork required with Allied Health to ensure patients are at their optimal level of function before going home. A great experience with wonderful teaching and support from all seniors.

Then, both Michael and I moved on to spend 10 weeks in Gladstone, 1hr20min away by car from Rockhampton, where Michael completed his rotation in Medicine and I in Emergency Medicine.

Now that, was an experience. Unfortunately, the ED was constantly understaffed with numerous new faces that came and went as locums. However, as a result, I gained a lot of independence and experience. It took a few days, but I got into my own groove and for once, felt comfortable handling anything thrown my way.

Here are some points I took away after 10 weeks of Emergency Medicine:

  • Recognizing a sick patient is sometimes difficult, but shouldn’t be. If the little details don’t fit a proper bigger picture, something is wrong. Trust your intuition. Never hesitate to present your concerns and get a second opinion, you will be surprised how often you are right.
  • I can totally handle paediatric patients – they are so much more trusting of you than I used to believe. You can easily win them over and make them feel at ease, even in hospital. That stethoscope they don’t want you touching them with? Let them listen to their own heart and suddenly the room is full of giggles. And always have a lower threshold for concern when dealing with paediatric patients.
  • Lots of patients will come in for abdominal and/or chest pains. And sometimes, you just don’t find a cause for their symptoms and have to send them away. I’ve been pleasantly surprised to learn that patients will rarely be upset if you cannot give them the answers they’re seeking. The key is attentiveness and good communication. Listen to their concerns, investigate appropriately, rule out the dangerous causes, good pain relief, follow up plan, and safety netting are key elements.
  • Finally got some proper suturing experience! Thank you patients who don’t shy away from letting a junior doctor stick them with needles.
  • Presenting patients and making referrals used to take a lot more time and thought. Now it is almost second nature as I was constantly seeing and presenting patients to seniors in ED.
  • People break a lot of bones. Some people are huge wimps when it comes to pain, others are so stoic you may not even think they had a fracture. Kids are almost always excited to have broken a bone because it means they can get a cast!
  • So many young men come into ED post electric shocks at work.
  • If a patient who rarely comes in hospital presents to Emergency 4 times in the last month, and each time sent back home, something is not right. Be their advocate. Whether it’s a medical condition that needs more investigations or a home situation that needs more support – something needs to change or they will continue coming into hospital.
  • Keep a log of patients you see! Record procedures you’ve done, interesting patients you’ve treated, those you want to follow up. Future case presentations, continuity of care, and personal interest are only some reasons to keep a good record!
  • Working at a small, understaffed hospital unfortunately has its disadvantages: No formal teaching and less opportunity to participate in “real emergency medicine.” I did not get the opportunity to participate in proper resus or trauma situations. As a result, I’m sure I will be terrified and at a disadvantage when the situation arises in the future.
  • Never be scared to say “I don’t know” and never shy away from asking questions. That is how you learn! Seniors would rather hear you don’t know and teach you, rather than hearing your pathetic attempt at pretending you know more than you actually do.
  • I don’t see myself doing Emergency Medicine as a career, but it is certainly an experience every doctor should have in their arsenal to be a better physician. As someone who wants to do GP, there was one observation I made: some of the terrible referrals from GPs in the community. Note to self: Keep that in mind on “How not to refer!”

And this past week? We started our 4th rotation, back in Rockhampton, yay! I have moved on to General Surgery (less enthusiastic “yay”) and Michael is in ED.

So far, I’ve survived! I’m back to feeling like a pen with legs, but I think the work load will pick up soon. Luckily, all the seniors have been more than pleasant and I haven’t been yelled at – always a bonus 😉 I have no inclinations of being a surgeon, however, as a GP, it would be good to have surgical skills for minor procedures under my belt. I have made that known to the surgical team and they are keeping me in mind, which I really appreciate! Day 2 and I was called down to clinic just to do a punch biopsy because of my interest in GP. I’m looking forward to the next 2 months on surgery, will keep you updated!

Orientation Week

January 12-16, 2015

Looking back, our one week orientation in preparation for our new job as medical interns went by in a blur. Was it useful? I sure thought so at the time. But when you have so much information being thrown at you with the expectation that you will remember everything – sometimes it feels like pouring water over a duck’s head… nothing sticks.

Important aspects I remember:

  • A chance to meet our colleagues, the other new interns – at social events as well as part of orientation. It’s nice to start a new job as (at least) acquaintances rather than strangers. Also a good idea to socialise when you’ve just relocated to a new city 😉
  • Meeting the staff of the Medical Education Unit (MEU) – they look after us and make sure we are alive and well… and still do!
  • Cultural Practice Program – an introduction to the culture and practices of those who identify as Aboriginal or Torres Straight Islander. Amazingly, I have never received such a talk through out medical school. Even simple knowledge like how their family hierarchy works can make a difference in the care of those patients.
  • Listening to a panel of 2014 interns sharing their tips – interesting at the time… but honestly can’t remember everything everyone said.
  • Skills rotation – refreshing our suturing, cannulation skills, etc.
  • Spending time with the previous interns on the ward we are rostered to. Good to get handover and tips. Would’ve been even better to spend more time with them getting hands on experience prior to starting our first shift.

Everything else… can’t say I remember much of it now. Not to say I didn’t find it useful at the time, but we really had to learn most aspects of our jobs on the go. Listening about how to do paperwork or order tests is never the same as going through the process of doing it yourself.

Then it was pretty much ‘hit the ground running’ on our first shift. Exhausting because you are so unfamiliar with everyone and everything. But by the end of first week, everyone gets the hang of things.

Do we become smarter? Knowledge-wise? …Maybe. Administratively? Most definitely!

People joke that medical interns are ‘pens with legs’ … sometimes, I don’t disagree! 😛

Joking aside, my first few months working as a doctor has been great. Impossible to sum it up in a single blog post but I hope to share stories in the future!

Paediatric Medicine: End of Rotation 1

Hi friends 🙂

Today marked my last day of Rotation 1 – Paediatric Medicine, which I completed at a large tertiary hospital.

8 weeks on a variety of teams, soaking in as much as possible, in as little time as possible.

  • 2 weeks in General Paediatrics
  • 1.5 weeks in Emergency Department
  • 0.5 weeks in Neonatal Intensive Care Unit (NICU)
  • 1 week in General Surgery
  • 1 week in Gastroenterology
  • 1 week in Oncology
  • 1 week in Respirology

I definitely enjoyed some placements more than others, for a variety of reasons including: personal interest, consultants and senior staff more interested in teaching, and the learning opportunities provided.

For this rotation, we had a number of assessments, including 3 mini clinical examinations (mini-CEX, each worth 10%): neonatal (well-baby check), short case, and long case.

My well-baby check was performed an adorable newly born girl and her lovely parents. She was a little hungry and crying during my examination but was perfectly healthy.

My short case was a respiratory exam on a 1 year old girl who presented with noisy breathing. She was recovering from bronchiolitis and by chance also had a number of neurological findings with associated developmental delays.

And lastly, my long case was a young adolescent girl who presented with fevers on a background of complex mastoiditis leading to the severe complications of intracranial abscesses and venous sinus thrombosis. Incidentally, she had many features consistent with Cushing’s which led to additional discussion points.

The feedback I received from all 3 of my assessments were positive, so hopefully my grades will reflect that!

And today was the big day. A multiple choice exam of 75 questions worth 50% and 2 OSCE stations, each worth 10%.

The written exam was overall fair and very representative of our teachings this rotation.

The clinical exams each had 2 minutes perusal followed by 8 minutes of discussion:

  • Case #1: A 5 week old girl who came in with signs of sepsis.
  • Case #2: A 5 year old girl with acute exacerbation of asthma.

For each case, we had to discuss what additional information we would like on history and examination, what our differential diagnoses were, what investigations we wanted to perform, and how we’d like to manage the patient.

Those 10 minutes go by in the blink of an eye, and I always walk away thinking, “Should’ve said that, could’ve done that, forgot to ask about this, didn’t mention that.”

Only time will tell how I did this rotation! Hopefully hard work paid off.

In the meantime… I would love to catch up on my sleep. However, before I do that, I need to catch up on my blogging! Thanks for reading! 🙂

Random recent moments

As I mentioned in the last post, I haven’t done much in the last 3 weeks but there are a few things to share!

My dear friend Amanda gifted me with lovely chocolate covered sultanas by Melba’s and a bottle of Chenin Blanc (Coriole Vineyards), both presents from South Australia. The chocolates are rich, smooth and delicious and of the course, the wine was very tasty. She even wrote a really touching note… just because she’s an awesome friend and is always thinking of other people. 🙂

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Having some of the chocolates and salted cashews = winning snack.

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Craving for Korean food led us back to our usual spot – Madtongsan II for dinner on Oct 16!

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Oct 19 – Could not resist the great lunch specials at Wagaya. Went for my new favourite dish, tonkotsu ramen, so delicious! Even comes with dumplings and an amazing bowl of fried rice!

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For dessert, we chose to share the green tea cheese cake with green tea ice cream. Have been wanting to try this for a while but probably not worth getting again.

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Mike’s squishing me! Long but fun and extremely worthwhile days in hospital this rotation. But sooo tired when we finally get home, not much studying gets done.

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Yoni was in town from Nambour and staying with us Oct 19-20. We went to see Gravity which was good, although I was glad we didn’t see the 3D version because I think I would’ve gotten motion sickness. And we never go without food! My favourite wedges from Beastie Burgers and burritos from Guzman y Gomez, yummy picnic!

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I ordered a few BB Cream replacements recently, and look at all the amazing samples I received! All well known Korean brands too… can’t wait to try some of these out, especially the Ice Mask!

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Boiled quail eggs with some salt and pepper – delicious snack!

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How do you cut a pineapple? This is how I learned from my mom, least amount of pineapple wastage!

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Yummy! Honeydew melon with pineapple and lychee – can’t go wrong!

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Tried frozen yoghurt for the first time not too long ago – how delicious! Biscotti and coconut pandan flavour with fruits – yum!

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A new favourite in our house, basil & blueberry gin and tonic – try it! Very tasty 🙂

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Home made food update? Here are a few things!

Crispy oven baked sweet potato fries

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Creamy mushroom soup – delightful!

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More mango sticky rice with coconut cream, mmm

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Vegetarian pasta salad with Greek yoghurt based dressing

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Pear cupcakes with passionfruit icing for the students in my group

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Chocolate cupcakes with peanut butter icing and carrot cupcakes with cream cheese icing as thank you gifts for my med team.

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Mental Health: The End!

Yesterday marked the end of our fourth rotation, Mental Health – yay!

The past 8 weeks seemed to have gone by in the blink of an eye. We saw patients when they were admitted, learned their stories, followed their progress and said good bye when they left… a humbling and worthwhile learning opportunity.

Despite being laughed at by our registrar many times at our pathetic initial attempts of presenting a Mental Status Examination and formulation… in the end he said we did well and our evaluation backed that up.

Many thanks to our Registrar and the Consultants who took us under their wing and taught us throughout this past rotation. They are so knowledgeable and have so much experience to impart, couldn’t have done as well as we did without their guidance! And of course, to the wonderful staff at our hospital 🙂

On Thursday, we had our clinical exam where we were provided a vignette (clinical situation on paper) and 20 minutes perusal time. Then we had 20 minutes to present a summary, formulation, differential diagnoses and rationale, additional information needed and management plan to 2 consultants/examiners. I was SO nervous. But as soon as I sat down and started reading, I immediately calmed down – a case of an elderly patient in the hospital who developed delirium. Something I was familiar with and had prepared for, yes! I think that exam went well, but only time will tell what my 2 examiners thought!

Then we had our written exam yesterday, 50 multiple choice questions. As always, there were a handful of questions that left us thinking, “What was… what?” But in general, we left with a sense of security rather than panicked with the thought of, “Oh my god, I might’ve failed that,” racing through our minds.

So now, one week vacation!

Haven’t done anything… yet 😉 Hopefully it will be relaxing and full of nature! We have some plans but I’ll update as it happens!

Mental Health: What’s the deal?

Wow,

I am terribly behind with my regular blogging! 😦 There’s no excuse, but it’s been busy and blogging about our recent vacation took a lot longer than usual.

So what’s the deal with school now?

Well, I’m 5 weeks into my Mental Health rotation, and yes, I’m quite enjoying it! By random luck (or is it bad luck? Haha), both Mike and I got placed as the only 2 students at a private mental health hospital in Brisbane.

The experience so far has been very enlightening. We found it initially daunting and awkward learning to take a psychiatric history from patients and formulating our thoughts. The feeling is quite similar to being in first year again, learning how to take a medical history and talk to patients. Fortunately, we’ve gained a lot more confidence in the last few weeks. Taking a medical history is like second nature to us now, hopefully taking a psychiatric history will, in time, feel the same.

We are humbled and grateful every time a patient agrees to talk to us or allows us to sit in during a consultation. If you think about it, these people are sharing with us, complete (not yet qualified) strangers, the most personal aspects of their lives. Some people have been victims of sexual and/or physical abuse, others have gone through great losses, some struggle with their spouses having affairs, while others have thoughts of self harm and have even tried to kill themselves. Every single patient we’ve met has taught us something, in some way, that we could never learn from a textbook.

Every patient we’ve met has a different story and is fighting a different battle. One of the first and biggest challenges for us has been, “How do we talk to these patients? How do we approach sensitive topics in a way that will not be upsetting?” We quickly learned that despite all the differences, these patients are all still the same in one way: Like you and I, they are people too.

Talking to patients with mental illness or a difficult life/past can be hard. But it’s not necessary to over-think how to talk to them. As long as you are patient, empathic and a listener, most people will be more than happy to talk to you and share their stories with you.

We also get scheduled teaching time with 3-4 consultants every week, which has been great. They have all been great teachers and we’ve learned so much already! Not just in terms of knowledge aspect, but also plenty of real life stories and experiences – something you can never learn from reading a book.

Have I mentioned we have a great Registrar? Yes, thank goodness! Most of our day is spent with him and the patients. He’s pretty awesome with them and definitely a good role model to try and emulate. As one of our profs said, “Shamelessly steal!” Adapt the styles, sayings and techniques from your seniors and colleagues that can make you a better doctor!

The most scary aspect of Mental Health at this moment? The fact that we are approaching the end of Week 5… only 2 more weeks until final exams. Absolutely crazy. It’s insane how quickly time has gone by!

Post-Surgery… Vacation!

Surgery is officially over, woo hoo!

Our final written exam (worth 70%) was yesterday… 2.5 hours of looong testing-of-knowledge. The exam was certainly challenging, as many of my friends have agreed, but now we just have to sit and wait for our results!

More importantly – on to a one week vacation!

Mike and I were able to score really cheap plane tickets, so we are going overseas for the holiday!

Today, we are going down to Gold Coast.

Tomorrow morning, we are flying out to… Singapore!

Yep, again.

Our super basic itinerary:

  • July 12 – Gold Coast
  • July 13 – Singapore
  • July 14-17 – Bangkok
  • July 17-20 – Singapore

All our flights added up to less than $500, which we thought was a steal! We have already booked all our accommodation but haven’t really finalized our plans of where we want to go and what we want to do yet.

Like usual, I will try to blog whenever I can! If not, there will be tons of photos and posts after we come back 🙂

Have a great weekend everyone! And for those on a holiday like me, have a lovely vacation!

Surgery: You’re full Vietnamese?

During a chat with one of our patients, it was mentioned that both my parents are from Vietnam.

“Both your parents are Vietnamese?!” This pleasant gentleman asked.

Yep!

“So you were born in Canada?”

Yes I was!

“I wouldn’t have guessed you were Vietnamese!”

I’ve heard this many times before, so I responded with, “A lot of people have said I look Chinese or Japanese.”

He said, “Well… I thought you were a half case…”

A what?

“You know, a mixed race. Because you speak English perfectly!”

Why yes, that’s because I was born and raised in Canada!

My Ways of Being a Better Medical Student

I believe trying to observe the following makes me a better student doctor.

Here are My Ways of Being a Better Medical Student:

(Didn’t realize this post would be so long, so I added some pictures from the internet. Photos are linked to their sources!)

Always introduce yourself – to patients and to other staff members. You’ll be meeting people all the time, under a variety of circumstances, at all times of the day. It is only polite and respectful to let everyone know who you are – even just in case you’re not even wanted! It has happened to me a number of times, sometimes patients just want medical students to sit out from consults. It can definitely be awkward, even scary, to find the opportunity to introduce yourself but you just have to man up, find an opening, and do it! Trust me, I know first hand how awkward it feels, especially when it’s one of your registrars or consultants you’re finally seeing for the first time (maybe during rounds) but completely ignoring you. But, more often than not after introducing myself, people will treat me differently – I’m no longer invisible and even addressed by name, who would’ve thought! 😉

Say hello when passing others, and smile. It takes no effort from you and can brighten someone’s day. Win win.

Don’t gossip. And if you must, do it outside the professional environment and out of earshot from everyone else. It makes you look unprofessional and you never know who might be listening. The medical world is small and word can travel fast – don’t sink yourself! You never know who you will cross paths with again and that one person you bad-mouthed could end up being your preceptor, your examiner, etc. If there’s someone I particularly don’t like, I always try to find someone else more constructive to my learning and morale and spend my time with them instead.

Never be afraid to ask questions. It shows you are listening, processing information and are willing to learn. Some people are great teachers and love the opportunity to share their knowledge – they’re just waiting for you to take initiative. Of course, with that being said, there’s always a proper time and place for questions. If someone is having a heart attack, no one wants to hear, “Could you show me how to read the ECG?” And you should really have enough common sense not to ask “stupid” questions that will only make you look bad. If you’re a 3rd year medical student asking, “What’s aortic stenosis again?” you are going to be in big trouble and look ridiculous!

Never be afraid to say “I don’t know.” I have no problems saying, “I’m sorry I don’t know, could you show/tell me?” when I really don’t have a clue how to answer a question I’ve been asked. If I can give an educated guess, I do, but otherwise, there is also nothing wrong with, “I’m sorry, I’ve forgotten, could you remind me?” Sure it’s embarrassing for you, but you will learn on the spot and/or never forget that information again. I’ve lost count how many times I’ve heard, “That’s okay, this way you learn and won’t forget again!” For example, the other week, my surg team was commenting on the long half life of the drug Rutiximab (21 days). The registrar then says, “At least it’s not as bad as Amiodorone! Sandra, what’s the half life of Amiodorone?” I laughed (as if I would know this) and replied, “I know it’s more than 21 days!” Now I will never forget Amiodorone has an extremely long and varied half life of 25-100 days. However, not knowing the answer should happen much less than 50% of the time you are asked questions, otherwise, you don’t know enough and you should go study!

Learn as much as you can on the spot. At this point in our lives, we’re not going to have our hands held and be told what to study. Pay attention on the wards and learn as much as you can – that’s often the useful stuff that you can’t learn as easily from textbooks. Bring paper or a notebook and jot down all the things you learn throughout the day. Write down topics that come up which you need to go home and read up about – follow through with it. Interns are a wealth of knowledge, it wasn’t too long ago they were in the same position as you, ask them questions and listen to their suggestions.

Be keen and willing to learn. Someone who shows they want to learn will be taught more and given more responsibilities. Put in the time and effort you think is necessary for you to reach your learning goals. Ask to participate and ask for opportunities to practice your clinical skills or to broaden your knowledge. Try not to decline a learning opportunity that comes up.

Be that medical student you would want to be partnered with. It’s great when you’re paired with another student who’s friendly, encouraging and easy to get along with, who’s knowledgeable but not cocky, who helps you learn without stealing your thunder, who can shine without throwing you under the bus, who’s not the super keener but not a lazy bum, who’s respectful of patients and confidentiality, etc. But it’s even more important to try and be that person for others. You surround yourself with the people you deserve, so be deserving! 🙂

Bake. Everybody loves home baked goods. If you can bake, you should share that deliciousness. No one will fault you, people will love you.

Keep up with your studying. Cramming doesn’t work anymore. Unfortunately, you have to remember everything you learn and build upon it. It’s hard, I know, I’m continuously working on this point.

Eating is important. But don’t just eat, eat healthy – your body will thank you. Also keep snacks on you – granola bars, nuts, chocolate, etc. They will save your life when you are too busy to take a break.

Get enough sleep. If you function well with 5 hours of sleep, that’s great. If you need 7 hours – make sure you get it. That also means you need to time manage well. Don’t sacrifice your studying or your eating time to make more room for sleep. You really need a balance.

Do things that make you happy. Keep up with your hobbies, take up new ones, see your friends, have quality time with your partner, take time for yourself to rest and relax. Otherwise, you will be lonely, stressed, and crazy.

I’m sure there are lots more that I can’t think of at the moment! 🙂

What about you? Do you have any tips?

Surgery: A New Experience

I think I was expecting to be in a perpetual state of fear and not knowing anything for my surgery rotation but I am quite enjoying it so far.

The rotation is mostly structured as we are placed in different units every 1-2 weeks, with additional scheduled tutorials and clinics. This is what my 8 weeks in surgery looks like:

  • Week 1 & 2 – Upper GI (General Surgery)
  • Week 3 & 4 – Colorectal (General Surgery)
  • Week 5 – Trauma
  • Week 6 – Acute Surgery
  • Week 7 – Burns Unit
  • Week 8 – Urology

There are other units I will unfortunately not have the opportunity to work in: Breast/Endocrine, Hepato/Pancreatic, Plastics and Vascular.

We also have scheduled sessions in multiple clinics that include: Breast Clinic, Breast Screening Clinic, Burns Outpatient Department, Colonoscopy Clinic, Endoscopy Clinic, and Minor-Ops Clinic.

Despite being more structured than in previous rotations, there are lots of opportunities to expand your knowledge and skills, depending on your willingness and your comfort level. Always take advantage of those opportunities! My partner and I have had the chance to see our own patients in the Gastroenterology Clinic and I finally got to put in my first IV canula – hurray!

And of course, being in surgery, we’ve gone in to the operating theatre (OT) to observe 2 surgeries so far. Both patients were from our surgical team. Patient 1 had a complete closure of an enormous abdominal hernia. He already had a surgery to repair the hernia months ago but suffered major complications with a wound that didn’t heal. Patient 2 had a distal gastrectomy (part of stomach removed) due to early stomach cancer.

Perhaps the most important thing in viewing operations: Know who your patients are, what operation they are having and why. Otherwise, not only do you look stupid if the doctors ask you any questions, but you will have no idea what’s going on and not be able to appreciate what you are observing.

If you have the chance to see patients in the ward or in the pre-admission clinic, take the opportunity to talk to them – get a history, do an examination, review their investigations, and read their file so you get the complete story. After surgery, follow the patient’s progress 🙂

We haven’t scrubbed in yet, which I think was a smart thing to do because it gave us the opportunity to walk around and get to know the staff (ie. nurses, anaesthesiologists, etc), and more importantly, stand back and observe how the team works and how the OT functions. Perhaps next time we will ask to scrub in!

[I wrote such a long post, but unfortunately half of it got deleted when I tried to publish and now I’m too lazy to rewrite it all… this is all for now]

Guess who got their N95 mask fitting?

We did!

Glad we got this done during the break because it would have been hard to get it done during business hours while on rotation again.

IMG_4582

What am I talking about?

From the FDA website: An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. In addition to blocking splashes, sprays and large droplets, the respirator is also designed to prevent the wearer from breathing in very small particles that may be in the air.

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Why did we have an N95 mask fitting done? Because it’s one of compulsory requirements for medical electives back in Canada. 🙂 As they come in different sizes, it is important to have a fitting done in order to know which one to use if they’re ever needed. If fitted properly, they can filter a minimum 95% of particles that are 0.3 microns or larger. We got to keep our 2 masks for reference/practice purposes. Let me tell you, it is not comfortable wearing a mask!

For any of our friends who need to get it done in Brisbane:

Contact Brian or Terry (Occupational Hygiene Advisers) at the Occupational Health & Safety office on St Lucia campus! You can get their contact information HERE.

Photo #365: Lovelies of 2D

February 27, 2013

The end of my Medicine in Society rotation is drawing near and I find myself back in the Fractured NOF Service to complete my project in creating a medical info brochure for the ward. Took a few staff pictures to include in the brochure, silly faces!

MIS: Chart Writing

As silly as this may sound, one of the most exciting things I’ve done on the wards is writing in patient charts. It gives me a satisfying sense of responsibility and makes me feel like a trusted member of the team. But that could just be me!

10 things I’ve learned regarding patient charts:

  1. The whole world would be happier if charts were electronic.
  2. Everyone on a multidisciplinary team has better handwriting than doctors – MUCH better.
  3. Sometimes, doctors really do have nice penmanship and you are so so grateful.
  4. You spend a lot of time looking for charts because another person on the team is using it. Refer to #1.
  5. You need to put a patient sticker on every piece of paper in their chart. Things fall out of plastic sleeves and papers get ripped all the time. Refer to #1.
  6. You are happy to see that the file you’re holding is “Volume 1” and not “Volume 7” because that means: the patient has not had lengthy hospital stays and you don’t have a ton of catch up reading to do.
  7. Forget white coats, charts are the dirtiest things around. They get carted around the hospital everywhere the patient goes, are constantly manhandled by innumerable hands, and never get cleaned… ever. Refer again to #1.
  8. It is always better to be more detailed than brief in your charting.
  9. Describing patients as “pleasantly confused” is a lot more common than you think, especially in geriatric wards – thanks to dementia. It sure took me a second the first time I read that description in a patient file.
  10. Unlike my seniors, I am not even close to mastering the art of reading through an entire patient chart in less than 5 minutes, while retaining everything I read. Got a loooong way to go.

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…

I’m a 3rd year med student now – woo hoo!

Hello world!

Haven’t blogged in a long time, but this first week in the hospital has been insane!

What? In the hospital you say? Yes!

I’ll just start with a brief blurb about Phase 2 of our medical education 🙂 3rd and 4th years are known as clerkship years. Good bye are the daily lectures and hello to real world learning! We spend all our time in the hospital, going through 5 rotations a year learning everything we need to become the best doctors we can be. Each rotation is 8 weeks long, with one week orientation at the beginning and one week for review and exams at the end.

This is my rotation order this year:

rotation orderMy first rotation is Medicine in Society – specifically in Geriatric Medicine at The Prince Charles Hospital (TCPH). I had never been at this hospital and didn’t know what to expect. Additionally, although my clinical hospital is RBWH (5 minutes away) it would take 40 minutes to get to TPCH, ugh!

Needless to say, the thought of starting 3rd year terrified me. Imagining my constant lack of knowledge, being berated by my seniors, looking stupid in front of patients, etc.

This week, however, has been amazing! I am spending the first 2 weeks in Fractured Neck of Femur Clinic. In this ward, we work in a multidisciplinary team to care for patients who have broken their hip and will require surgery, making sure their pre and post-op care is complete.

I feel extremely lucky to have been assigned to a great medical team which comprises a geriatrician (GeriDoc, my preceptor), a registrar (Reg) and an intern (Resident). Mornings are spent doing ward rounds with Reg and Resident (GeriDoc joins us at least twice a week), lunch times are often spent in meetings and afternoons are spent doing ward work.

I have learned an amazing amount in such a short time. The most important thing I’ve learned is not the medical knowledge, but how to work in a ward. Understanding the dynamics of working with other staff members, knowing where to find things, learning procedures and protocols on tasks like prescribing meds, ordering bloods and imaging, etc. Being comfortable on the ward and with others is the first step to success I think!

Reg and Resident have been instrumental in my positive experience thus far, especially since I spend all my time with them, and for that I’m very thankful! They are kind, patient at teaching and do not hesitate to give me opportunities to learn and make me feel a part of the team. Although he’s quite busy, I have also spent some time with GeriDoc and he has been more than encouraging. I will be spending more time with him this week, so I’m nervous but anticipating lots of learning.

My only complaint? I’m so wiped by the end of the day! I leave the house at 7am, get to the hospital before 8. Have a bit of time to review recent tests before handover and ward rounds start. Go all day, sometimes no time for lunch, and finally home around 5-6pm. If I’m lucky, earlier! By the time dinner is over, I can barely keep my eyes open to study 😦 Slowly getting used to it though!

My last 2 weeks in a nutshell

I haven’t blogged much about being back in Australia, so now’s the time!

It has been hot, like REALLY HOT. So hot that I sit indoors, doing nothing, under a fan, and still sweat. I still have not completely unpacked yet because it’s too hot.

This comic, courtesy of Amin and Imgur perfectly depicts the last week or so:

On a more serious note, such extreme temperatures (on top of health-related risks) have sparked bushfires across Australia and claimed many homes. Keep the victims and the brave workers and volunteers in your thoughts!

We had a Year 3 orientation on Friday Jan 11, which got us excited to be starting the new year. We are expected to soon be able to perform at the level of junior doctors :S As scary as it sounds, how thrilling to finally reach this stage of our education!

Over the weekend, Mike and I saw Les Miserables. I thought it could’ve been great, but Russell Crowe ruined it! Every time he sang, I cringed. I simply don’t understand why he was cast for such an important character (Javert) when he cannot sing! Otherwise, bravo to many others for their performances. My favourites were Samantha Bark (Eponine), Isabelle Allen (young Cosette), and Aaron Tveit (Enjolras). Hugh Jackman and Anne Hathaway were very impressive in their roles as Jean Valjean and Fantine, respectively, as well. 🙂

On Monday Jan 14, we had our Rotation 1 orientation, which was Medicine in Society. Unfortunately, it was not very useful because everything that was said was already emailed to us last month.

We watched a palliative video called “A Good Death” that hit very close to home and was almost unbearable. Palliative care will become an inescapable aspect of our careers and many have never experienced it personally, it was definitely an important video to prepare our mindset for going into the hospital.

The afternoon Radiology tutorial, however, was lengthy and not high yield at all. The first part consisted of a radiology resource being monotonously read to us and the second part involved approximately 30 students trying to cram around one x-ray viewer in order read x-rays “systematically” (basic steps that should’ve, but weren’t reviewed).

Everybody starting to lose focus as the reading went on and on…

… including Michael and Yoni

 

This week should’ve been orientation week… but we received no other schedule. Unlike others starting with their Rural or Surgery rotation, we sat around all this week, but at least we had self-study time!

What else did we do?

Went to campus to get our loan documents completed. It’s so nice being on campus when the rest of the school is on vacation – so peaceful!

We also went grocery shopping. Michael has imaginary friends that sit far away and watch the groceries apparently.

Ate deeelicious olive hummus…

… and got fat.

Photo #181: Gifted Journal

August 28, 2012

This diary/journal was a going away present from my friend ‘S’ 2 years ago when I left for Australia. This year, it has become my most used notebook. With me every time I’m in the hospital and full of little notes and details of amazing ‘first-time’ experiences on the ward. Thanks dear!

Thinking about Phase 2 of MBBS

That time of the year has finally come!

As we head into the new semester, all second years need to start deciding where we’d like our paths to unfold for clerkship beginning next year.

What is clerkship? It’s when we stop learning in class (Years 1+2) and start learning in the hospital (Years 3+4). Finally, yay!

Year 3 comprises of 5 hospital rotations, each 8 weeks long and must completed in the following order: General Practice, Surgery, Mental Health, Medicine, and Medicine in Society. We can start with whichever rotation, but they must follow that order.

Year 4 will continue with more rotations in other specialties including Obstetrics & Gynecology and Pediatrics.

So now the question is, in which order do I want to complete my Year 3 rotations and more importantly, which Clinical School would I like to attend?

After much thought and consideration, I have decided to pick my current hospital, Royal Brisbane & Women’s Hospital (RBWH) as my first choice and hope to start with Medicine in Society.

Medicine in Society sounds particularly interesting. As international students, we have the option of organizing a rural rotation back home or stay in Brisbane and complete it in the field of Rehab, Indigenous Health, Geriatrics and/or Palliative. I don’t plan to go back to Canada for any rotations until 4th year, but I’ve always found Palliative Care and Geriatrics interesting!

Why RBWH? It has many perks including being a huge quaternary and tertiary hospital (largest in Queensland) and only a few minutes from home… 😀

I’m glad I’ve finally made up my mind. Our allocation system will be opening a week from today. I hope I’ll get my first choices!

Vietnam Week 4: Thursday, November 17, 2011

Thanks to Ong Ut, we had the opportunity to visit the private Tam Duc Heart Hospital (Benh Vien Tim Tam Duc).

A few years back, Ong Ut had cardiac surgery at this hospital and has since become good friends with some of the staff. He asked his physician, Dr. Hiep, on our behalf to come in and observe for a day to which he readily agreed.

What a difference! After 4 weeks at Cho Ray Hospital where the environment is hectic and best described as a market, walking into Tam Duc was like a scene from back home. A well equipped and clean hospital with professional and polite staff and none of the patient crowds. I get it though… it’s a private hospital, a world of difference.

We were introduced to Dr. Hiep who explained how the day would proceed and then passed us over to Dr. Hung, who would show us around the ward. Dr. Hung was kind enough to ask us what we had learned in school so far, so that he could pick a few cases to support our knowledge. We had the opportunity to visit 3 very young pediatric patients. The first had a ventricular septal defect, the second with an atrial septal defect, and the third with a classic case of Tetralogy of Fallot (TOF). It was really interesting to learn and hear the differences in heart sounds between the first two patients. In the infant with TOF, it was an eyeopener to see what cyanosis (“blue”) actually looks like in terms of clinical features, and I also saw nail clubbing for the first time. As you can tell, being able to see the simple things we learned in real life really made me happy.

After visiting these patients, we regrouped with the team of doctors as they did their morning rounds. We were then passed onto Dr. Phuong, one of the main surgeons of that day, who explained we would have the opportunity to watch 2 surgeries: the repair of TOF in an 8 year old patient and a triple valve replacement in a middle aged woman. One word – awesome! My first time watching anything like it… the dynamics between the surgical team, the role of the anesthesiologist, watching a person be put on a heart-lung machine (cardiopulmonary bypass), etc, was really… cool 😀

What wasn’t cool, was how I was feeling during surgery. Chills and skin sensitive to touch evolved into a full blown fever by the time we got back from the hospital. Annd… I spent the rest of the day in bed, praying that whatever I had would pass before I flew out to Hanoi on Saturday. 😦

Vietnam Week 4: Mon, Nov 14 – Wed, Nov 16, 2011

Last week at Cho Ray Hospital, woo hoo!

We saw many patients come and go. We saw many who recovered and some who didn’t make it. We followed patients over long periods of time and others only once. Each time we met a patient, we learned something, whether it be big or small – we learned.

We had the opportunity to be observers and there were things we appreciated and even more we found hard to stomach.

Aspects that we liked are easy enough to imagine: the opportunity to work with health professionals and meet patients, learning about many tropical diseases, understanding tests and learning to interpret the results, etc.

Some of the things we disliked:

  • That we had to pay $200 USD rather than the stated $100 USD “because the tuition price went up”
  • The overcrowdedness (not a real word, I know). You literally had to push your way into the main hospital in the morning due to the sea of people. Patient rooms are most always found with at least 10 patients, many times 2 patients per bed.
  • The complete lack of bedside manner from many health professionals. It is never okay to yell at a patient, let alone grab at their wounds with ungloved hands and dismissing his pain as irrelevant to his recovery.
  • The unsanitary conditions at the hospital
  • No money = no treatment
  • The huge burden on the shoulders of caregivers. Each patient must always have a caregiver (almost always a family member, identified by a yellow vest) who is responsible for accepting medication from nurses and making sure the patient receives it appropriately. Caregivers are responsible for any items a patient might need (ie. water, food, blanket, etc) as well as any washing and cleaning the patient requires.
  • The revelation that anyone can walk into a pharmacy and buy drugs, especially antibiotics, without a prescription. Then to see patients deteriorate away from infections that can’t be resolved due to complete antibiotic resistance.

What can you do… right?

Below are some pictures we took during our last week at Cho Ray

This is the side of Cho Ray Hospital

The food stand on hospital grounds that became very familiar with us due to Michael’s (almost daily) orders of Vietnamese iced milk coffee (cafe sua da)

Parking lot on the way in!

The Tropical Diseases Department is located on the 2nd floor of a building beside Cho Ray Hospital. It has around 12 patient rooms as well as offices.

The patient rooms as described above

The doctors’ meeting room. We spent a lot of time in this room waiting around, and we also came back to this room (it’s the only one with AC) to recover from the heat.

The nurses’ room next door

Waiting around… again!

This lady was one of the first patients we encountered. At that time, she was shirtless and covered head to toe in methylene blue, giving her a smurf-like grotesque appearance. What disturbed us even more was her actual condition – Stevens-Johnson Syndrome (SJS) – a life-threatening hypersensitive reaction to a drug that affects the skin and mucous membranes. This lovely lady had come into the hospital a week or so earlier for a brain tumour excision. They subsequently gave her prophylactic antibiotics, to which she suffered a terrible reaction from. At the time we saw her, she was covered in huge rash lesions, severe conjunctivitis (her eyes had completely glued shut), and ulcers around and inside her mouth.

Over the next 4 weeks, we saw her gradually improve. We began to see no more new lesions. Her eyes opened bit by bit. She ate a little better everyday as her ulcers healed. New skin began to show underneath the burst lesions on her body.

By the time our elective ended, this woman was finally being discharged. And the entire time, she was peaceful and her husband was always by her side and completely supportive. Initially meeting her with the impression that she was going to die, it was great to say good bye to this couple and see them leave the ward. Like she said, “It feels like I’ve died and come back to life.”

These are pictures of a much younger patient, who also had Stevens-Johnson Syndrome. She went to the doctor with signs of a throat infection, received antibiotics for her condition and then suffered SJS. Her condition was milder, although you can still see how it affects the skin.

Lesions on her leg

Bigger lesions on her arms

This patient hit himself on the spikes of a Stonefish (the most venemous fish in the world) he was preparing to eat. These fish secrete a potentially fatal neurotoxin and the amount injected depends much pressure was applied. This man was lucky the amount of venom that got into his body was not enough to kill him. He did, however, suffer from massive swelling of his arm all the way up to his shoulder.

YOU CAN CLICK HERE TO SEE THE REMAINDER OF MY CHO RAY HOSPITAL PICTURES

The evening of Wednesday, November 16, 2011, the three of us went to visit Cau Tam’s (Ong Ut’s son) wife’s side of the family. Cau Tam’s wife had just given birth a few weeks earlier and the baby was completely adorable. In addition, her family is in the business of exporting coffee so  we were able to get some insight on the Vietnamese coffee industry. Cau Tam then took us for awesome massages before leaving us to tend to business. We then headed into the city for dinner and paid the ridiculous price of $10 USD to go up and visit the Bitexco Financial Tower lookout.

Insane amounts of strong lighting and the curvature of architecture made it impossible to catch any decent shots throughout the entire 360 degree lookout floor. In the end, we just had to settle for a fake background shot! 😛

Vietnam Week 3: Nov 7-9, 2011

Third week in the hospital!

Interesting observation… many attempted suicide patients are admitted into the Tropical Diseases department on a weekly basis. Most popular poisons are: paraquat, paracetamol and other herbicides/insecticides.

Unfortunately, a lot of patients don’t make it back home, especially those who have used paraquat. In Vietnam, paraquat comes extremely concentrated, so treatment cannot be given fast enough and patients end up dying. The family is consulted and then they can decide whether or not to bring the patient home to die.

Many people, however, are fortunate enough not to have taken a lethal dose of poison, or are given an antidote in time. Sadly, VN has not reached the standard of care as in Australia/Canada. There is no mental health/psychiatry aspect to health in VN and attempted suicide patients are sent home as soon as they are better. Doctors do make an attempt to understand why patients tried to take their lives and to persuade them not to do it again, however, it does not extend any further than a short conversation in the public environment of a patient room with at least 10 other people within hearing distance.

It’s really too bad because some of those patients will definitely attempt to suicide again, and will most likely succeed. This was one of the biggest differences we noted within the Vietnamese health care.

Vietnam Week 2: Monday, Oct 31 – Wednesday, Nov 2, 2011

More hospital work!

There was A LOT of downtime. After their morning rounds, doctors would spend hours writing up charts while we sit around and twiddle our thumbs. Luckily, we had our Oxford handbooks, otherwise we would’ve died of boredom. That almost happened anyways, numerous times. We also had tons of pent up frustration as we were repeatedly left on our own and ignored.

Soon, we realized that being polite and waiting around to be spoken to would get us nowhere. Instead, we began to track down doctors and declare that we would follow them. Surprisingly, they preferred this. They are too busy to ask us to come with them, so they appreciated that we came to them… okay then!

We saw and learned, a lot!

  • What tests do you perform to diagnose meningitis? Dengue fever? Malaria?
  • How can you narrow down which snake bit the patient? What do you treat them with?
  • What blood disorder do you find in snake bite patients?
  • What effects of Dengue fever do you have to watch out for? How do you monitor them?
  • How can you tell from CSF components what kind of meningitis the patient has? Is it fungal, bacterial, viral, or parasitic?
  • When would a patient be more susceptible to fungal meningitis?
  • What are the most common organisms that cause meningitis?
  • What is Stevens Johnson Syndrome (Erythema Multiforme)? Why do you see it so often in VN?
  • And so much more!

During the first 2 weeks, we also had a 6th year medical student, Ha, with us from Hungary. She is originally from Saigon, and took us to a number of really neat and yummy places to eat and hang out.

One of them was street food at it’s best. Sit on these little stools and call out your order. They have amazing dumplings, fresh spring rolls called ‘Bo Bia’, and cold tofu! Yumm! They’re open in the evening, but come early because the food will run out quickly! On the corner of Le Thanh Ton (and a street I don’t remember) close to Ben Thanh Market

Ben Thanh night market and surrounding areas

This is the Bitexco Financial Tower – the tallest building in Saigon with 68 floors.

She also took us to her 3 friends’ cafe called, ‘Da Tung Thay’ which literally translates to ‘Was Once Seen’ or ‘Deja Vu’ This gem is found at the end of an alley off 89 Ham Nghi St, with no identifying signs, not even a store sign.

Inside, it is full of charm and uniqueness. Most furnishings and decorations in this cafe are items from their past. Old catalogues and newspapers have been ripped and used as wallpaper, shelves are adorned with comic books from their childhood, bricks from one of the owners’ old house makes up a portion of the restaurant’s wall, etc.

We stopped by late at night for a drink when it was empty and tranquil. The owners insisted that we come by again for lunch, where they serve neat old fashioned meals. They promised it would be different but delicious and meet our expectations, and we promised to try and come back.

Vietnam Week 1: Thursday, Oct 27, 2011

[I have a lot to share regarding my experience at Cho Ray Hospital, but I will be saving that for a separate post later on]

Thursday was technically our day off, but we decided to go into the hospital until lunchtime. It just so happened that on Thursdays, doctors take part in weekly presentations. This week’s presentation was on ‘Pre-eclampsia & Eclampsia’ given by Dr. Ngan (works in one of the ICUs in the Tropical Diseases department). The entire presentation was impressively given in English, although I suspect our presence made her more nervous than usual. Following her presentation, her colleagues are given a chance to ask questions. The vice director (Dr. Phuong) and Dr. Hung were especially critical! Overall a good experience, we were glad to have come in.

By lunchtime, we were downtown in District 1 and ready to start exploring. Unfortunately, I’ve already seen most things in District 1, but it was still fun to re-experience them with Mike and Kristen!

First up, the Reunification Palace! Absolutely nothing has changed here since I went last year… and to be honest, not worth visiting. Just taking a picture from the outside is good enough. Didn’t take many pictures because it’s all been done before (click here for pics from last year), but here’s a few!

We then walked over to the War Remnants Museum. Old artillery, tanks and helicopters are interesting and all, but we could not get over how they’ve twisted and presented history in this museum. It is very anti-American and full of propaganda… sad!

Proceeded to walk back to take a look at the Notre Dame Basilica and Saigon Post Office…

On the way back, we found this! Mini toasted baguettes with La Vache Qui Rit cheese, pate and chili… soo good! And for only 10 000 VND (less than $0.50). Street food yumminess!

We’ve labelled all the parks in VN as ‘snoggle parks’ because that’s what all couples do… go to parks to snog! Apparently, our mocking did not impress the man watching us…

Notre Dame Basilica with Diamond Plaza in the background

Saigon Central Post Office right beside the basilica

Inside the post office… Gringotts?!

We were supposed to have dinner with Annette, but that fell through so the night ended early back at our hotel!