This 15-Year Old Did Not Transform Medicine

I recently came across this news article about Jack Andraka, a 15-year-old boy from Maryland who invented a test to detect pancreatic cancer in its early stages. Naturally this is HUGE. For those who are not familiar, pancreatic cancer is one of the worst cancers one could get. Due to its lack of symptoms (as it's seated deep inside the abdomen), it's usually diagnosed at a very late stage, and the majority of people do not survive for longer than one year.

This simple, fast and cheap blood test Jack Andraka invented promises to change all that altogether, creating an unprecedented revolution in medicine by causing the greatest improvement in cancer medicine we have ever seen. This test costs just 3 cents, nearly 100% accurate, and won him the grand prize in the prestigious Intel International Science and Engineering Fair. The test uses nanotechnology to detect mesothelin, a type of protein which is found in the blood when one has pancreatic cancer. His wish is that this test will become widely available on the shelves of the supermarket, and everyone could just pick it up and do this test during their free time, and no one will die from late stage pancreatic cancer any more.

It's very nice, except that it does not work.

First of all, I would like to congratulate this bright young man for achieving so much at such a young age, and has dipped his feet into the world of scientific research and made a name for himself. To have your name on a "cancer sensor inventor" as a 15-year-old boy is simply amazing.

However, unfortunately that's where the achievement ends.

As a medical doctor I feel compelled to debunk the hype: This invention will unfortunately NOT save lives, and in fact I suspect if it were to be introduced as a 5-cent dipstick available in your local supermarket (which WILL NOT happen as you will see below), it may actually end up doing more harm than good to people's health.

It may be a difficult concept to explain but I hope you bear with me as I go through the reasoning.

I would begin by how making diagnosis works. It is often mistakenly thought that diagnosing a disease in the modern era is as easy as finding the correct protein in the blood, and BAM you have this disease. It's almost like if you find a fingerprint then BAM there has to be matching, unique person behind that fingerprint. However, the majority of medical diagnoses are simply not made this way.

I would use the pregnancy test as an example. We all know that urine or blood pregnancy tests are pretty accurate these days - it detects a hormone called βHCG which is secreted during pregnancy. So, if you find βHCG in urine or blood, then you are pregnant, right? WRONG. While the vast majority of high βHCG is due to pregnancy, sometimes it could also be due to sinister causes called gestational trophoblastic diseases which are a type of tumour in the genital organs. But in practice, if you missed your period and you are tested positive, then you would be told "you are pregnant" unless the doctor has deep suspicion that something amiss is going on.

This is because

1. There are FAR MORE pregnant people than people with this tumour 
2. The fact that you missed your period makes pregnancy even more likely.

βHCG is useful because:

1. When it's level is very close to zero, then you can't be pregnant (It has good negative predictive value) 
2. In pregnant people the level is ALWAYS elevated. (It is sensitive)
3. When it's elevated, 99% of the time it's gonna be due to pregnancy (the other 1% being the gestational trophoblastic disease) (It is highly specific)
4. When it's used, it enables good outcome (you know you are pregnant hence you commence antenatal care etc)

While these 4 conditions, especially the last, may seem trivial, they are THE criteria that any diagnostic test have to meet prior to being practical. If someone comes along and develop a 5-cent new pregnancy test, they will either have to meet these criteria, or being dumped despite being only 5 cents.

That's for diagnostic test. Moving on to screening test. Wouldn't it be nice if we find a test for early stages of various cancers, so that all we need to do is to wake up everyday and dip a few drops of blood, and we would know that we have (or not have) cancer? Yes it would be nice, but unfortunately medicine is hard and nothing like this exists, and no, Jack Andraka's dipstick is not the elusive magic test.

I would use PSA as an example. PSA (Prostate-Specific Antigen), as the name suggests, is a protein quite specific to the prostate, and is elevated in prostatic cancer. We used to do PSA screening quite commonly to detect early prostate cancer (but it's no longer recommended but that's a long story on its own). The problem with PSA, as with many other types of cancer blood tests, are that they are not specific and often not sensitive enough. In PSA's case, there are many other conditions which also increase its level (namely large prostate, severe infection etc). And last but not least, because prostate cancer is such a slow growing tumour, it's been found that even after using PSA and detecting some earlier cases, the mortality rate (chance of dying) is THE SAME whether or not you test everyone for  PSA. Hence population-wide prostate cancer screening is no longer recommended.

Moving on to mesothelin and pancreatic cancer. 

For the scholarly minded, this is THE article that shows why mesothelin is useless as a pancreatic cancer screening marker: 

Sharon, Elad, et al. "Serum mesothelin and megakaryocyte potentiating factor in pancreatic and biliary cancers." Clinical Chemistry and Laboratory Medicine 50.4 (2012): 721-725.

Jack Andraka is right in pointing out that mesothelin is almost always present in patients with pancreatic cancer. However, mesothelin is ALSO present in ovarian and pleural cancer, AND in normal healthy people. The range of mesothelin level amongst pancreatic cancer sufferers overlaps greatly with the level amongst normal population. Even though Jack claims this to be 100% sensitive, it only means that it will detect a particular level of mesothelin 100% of the time. It still does not meet these criteria:

1. Does mesothelin differentiate between different cancers? No as it's also present in ovarian and pleural cancer. 

2. Does mesothelin differentiate between disease and health? No, when you are "positive" for mesothelin you may very well be healthy. 

In other words, if you bought this test and is tested positive, you could either have pancreatic cancer, other pancreatic conditions, ovarian cancer, pleural cancer, or have nothing at all. Not that useful isn't it? 

At this juncture, some people might claim, even if some healthy people mistakenly test positive in this test, they could always just do more tests and find out that they don't have disease - isn't that better than the alternative, having pancreatic cancer and not knowing it? The answer is NO. As pancreatic cancer is such a rare disease, you will have far less disease detection rate (true positive) than false positives. The thousands and thousands of people who had false positive results will now have to go through more tests (CT scans, biopsies etc), and all these tests actually do harm if you are healthy (CT increases your risk of cancer, biopsies are invasive procedures and put you at risk of infection and bleeding). So in the end, having such a test, despite costing only 3 cents, will end up putting a lot more healthy people at risk of complications of over-investigation than saving a few lives from its actual detections. 

To sum it up: Yes this man has a bright future, but he's not a cancer saviour, and we still have a long road ahead in our battle with cancer. He is not the genius kid who managed to discover something that millions of scientists in thousands of universities have overlooked in decades of cancer research. Unfortunately there has been a huge media circus surrounding his invention, most of which were more focused on perpetuating the "prodigy cancer saviour" feel-good story without getting an established scientist to put things into context. The whole media circus has planted a distorted perception on cancer research, and could end up instilling distrust amongst public in proper scientists and researchers. In the comment section of the aforementioned news article, the top comment is about how such an invention (like the many dozens of "cancer cures" invented each month) will never see the light of the day because pharmaceutical companies need to keep making money from cancer treatment drugs rather than saving people's life with cheap, easy and effective inventions like this. It insults the efforts of millions of scientists in labs everywhere, who toil away in their often frustrating and mundane efforts day in day out, without the benefit of being glorified in the media as a cancer saviour.

When something sounds too good to be true, often it's because it is too good to be true.

Footnote: This article by Forbes Science is one of the rare media articles which summarised the hype surrounding Jack Andraka instead of joining the media circus of how we have found the young saviour which will save millions of lives, before he even published a single journal article on the invention.

Footnote 2: Another article with a LOT more details about doubts on Jack Andraka's invention and personal motives, though it is a lot more sensational and may sound more personal. 

Of Poking, Sucking and Bumming Around in a Shanghai Hospital

As you may have read from my previous posts, I did my elective work in Shanghai for four weeks last December and January. Overall, my elective term in Rui Jin Hospital has been a bit of a mixed bag. While there have been intriguing, interesting and eye-opening moments, there have also been hours of boredom and frustration.

Acupuncture:



I did the first two weeks of elective in the acupuncture unit. The opportunity to see the coexistence and cooperation of both Western and Traditional Chinese Medicine has been one of the greatest reasons for my choosing to go to Shanghai. Eye-opening it has indeed been. Much as we were shocked to see the depth the needles go into (up to 2-3 inches in some areas), we were also quite impressed by the acupuncturists' firm knowledge and understanding of Western medicine. In fact they devote a good proportion of their training years in Western medicine alone. A patient presenting with fatigue would first be examined for thyroid function and blood sugar among others, by the acupuncturists themselves! They can also order X-rays, CTs and interpret them. So it's been both comforting and surprising to learn that Chinese medicine practitioners are not as ignorant as some might believe them to be - in fact the irony is on us to not know more about them.



Despite the novelty, we found that we couldn't do much in the unit and soon enough it became a drag to spend time day in day out. As the needle insertion involves a level of dexterity and special techniques, we were not allowed to perform it on the patients. So all the time we only got to stand and observe the procedure, and occasionally we were called upon to remove the needle after the treatment. The only other thing we got to do is applying and removing suction cups, which is a procedure where a heated glass jar is applied onto acupuncture points and left in place for a few minutes via vacuum suction.



Overall it's an interesting experience, despite the lack of practical opportunity, I would recommend medical students with an interest in Chinese Medicine to spend some time in the acupuncture unit. However, we found that two weeks were a tad too long for the purpose, so a one-week stint would have probably been a better option.

Cardiology:



I chose cardiology due to my interest in the specialty. I was assigned to an attending who was stationed at the CCU, which I later found to be simply a fancy term for post- and pre-operative observation area for pacemaker insertion. There were also some occasional paroxysmal Atrial Fibrillation patients who were there for either pharmacological or electrical cardioversion. But basically that's all the patients I got to see in the 10-bed unit.



Unfortunately the experience over the two weeks have been rather uninspiring, to put it mildly. The unit (and I suspect the hospital as a whole) is not familiar with the concept of elective terms, and I was treated as a transparent passive spectator of the department most of the time. In my two-week stay in the department, I only got involved with the daily 20-minute ward round with zero to little teaching, as well as observing a few angiography, an EP study from afar and a couple of permanent pacemaker insertion. Most of the other time, I was left to my own device sitting in a room with some junior doctors and research students. My attending was hardly within sight at any time.

In general medical students don't get to do much ward duties or get involved in any active patient management, so all this made the experience very bland. By day three I was already looking forward to the end of it.

General:



If you are looking for an action-packed or highly educational elective then this hospital is the last place you want to be. However, it did offer me a very personal insight into China's healthcare system which is sophisticated and chaotic at the same time. If exposure is what you value in your elective then it's not too bad a place. Shanghai is a shopping haven and food paradise, and the surrounding cities such as Hangzhou and Suzhou are all very captivating.

If you want some better teaching and more enthusiastic staff who speak better English, I heard that Huashan Hospital (also in Shanghai) is better in these regards. Choosing surgery units is also recommended as you do get to see a lot of cases including the rare ones - remember, even if a rare condition has a prevalence of one in a million, China has 1,300 of them.

Big Boob Blooper - A Story on FAIL Journalism

This is about a news article in The Star (published on November 12, 2009) that turned out to be a fake news fabricated by a supermarket tabloid 6 years ago.

To save myself the trouble of telling the whole story again, let me attach the complaint letter I wrote to The Star here:

Dear The Star Editor,

I am writing with regards to the news on  "a study in the US showing that women with bigger breasts were found to be smarter". For your information, this is a fake news which was reported in World Weekly News back in Nov 4, 2003. Yes, from six years ago. The original news is available here. You can verify that this "news" is identical to the one reported in The Star.

Evidence that this news is fake:

1. World Weekly News is a supermarket tabloid renowned for its outlandish cover stories often based on supernatural and paranormal themes and an approach to news that verged on the satirical.
   
   
2. Note the informal language this article is written with.
   
   
3. Read the previous and subsequent pages. Note the trivial and exaggerated writing.
   
   
4. A search in Google Scholar (Google's academic journal search engine) for published articles by Rossdale in chicago returned no matching result. Google Scholar is a comprehensive academic search engine so the lack of matching result implies the non-existence of the study.
   
   
5. A search for "yvonne rossdale" in Google shows only copies of the original article from World Weekly News. If you browse through some of the results, there are many websites in which people have pointed out that Dr. Yvonne Rossdale does not exist.
   
   
6. A search in Google News for "chicago breasts" shows that only The Star and Hindustan Times (which in turn copied The Star I believe) are reporting on this news. No other major news outlet is picking up on this "study".

I am absolutely appalled by The Star's negligence in verifying the authenticity of the news before the publication. This fake news has now been disseminated widely over the Internet, and your company's negligence is responsible for the misinformation. It is mentioned that this news is compiled from Sin Chew Daily which in turn is quoting from a Singaporean paper, but I have not been able to find the articles in Sin Chew or any Singaporean paper. I would like you to point me to the original article in these papers, so that I can forward this email to them as well.

More importantly, I would like The Star to publish a correction in a conspicuous corner as soon as possible. I fervently hope that in the future your employees remember to verify all news with primary sources (isn't that in Journalism 101 by the way?) before publication lest your reputation deteriorates.

Thanks.

Regards,
Chang Yang Yew

Let us see how The Star responds to the hoax story they have published.

My First CPR

When I joined St. John Ambulance eleven years ago and learned CPR (cardiopulmonary resuscitation) as a thirteen-year-old, I never imagined that one day I would be doing it for real. Back then I always thought that one day when I come across someone with cardiac arrest I would probably just stand there, do nothing and look like a fool. Walk away before someone yells "Anyone knows CPR here?!". Or perhaps a combination of the above.

Seven years later, I became a medical student. I was to save life in the future and I can't walk away from a CPR.

When I learned basic life support (= CPR) and advanced life support (CPR plus a few advanced measures including electric shock and adrenaline administration) on a high-tech mannequin, I imagined that I would not need to do this for real for at least a few more years.

One week later, the unimaginable happened.

It was the last day of my three-week rotation in the emergency department. The ED, contrary to the public perception, is not a place where people die every minute from horrible diseases and injuries. Instead, ED is a place where minor diseases come up everyday (minor being a relative term of course) and severe conditions are thrown in for good measure every once in a while. The reality is, most people who come into ED don't die. At least they don't die in the ED itself. In the three-week rotation I have not seen one death nor a single case of CPR. There were not too many "emergencies" after all, even after allowing for the fact that major trauma cases in Melbourne aren't usually sent to my hospital.

So on this day, I found myself following this kind doctor when he was told that a 71-year-old post-cardiac-arrest patient was on the way to the ED. He was absolutely enthusiastic.

"This is the exciting bit about ED, this is what you'd signed up for! Come let's get ourselves ready!"

Unlike what happens in TV dramas, the ambulance doesn't usually barge into the ED door out of the blue wheeling people in a puddle of blood or other serious life-threatening conditions. Instead, they notify the ED prior to their arrival using a high-tech gadget called a telephone. As soon as they get a truly urgent case, the ambulance staff will call the ED before they arrive so that we have time to get ready for resuscitation.

So prepare we did. While the doctor prepared the heavyweight stuff like airways, defibrillation pads etc, I made myself slightly useful and prepared some equipments for intravenous cannulation. Besides the fact that the patient had an arrest (the stopping of heartbeat), not much else was known at the moment. We were just doing whatever we could and waiting for the patient to arrive.

And we waited. It was the longest ten minutes ever in my life. Would the patient be "dead on arrival"? Would he already have been revived and stabilised when he reaches ED? Is he in a pool of blood, badly mangled in an accident? A deluge of thoughts overwhelmed me.

Palpitation.

A commotion was heard outside the resuscitation room and a team of paramedics whisked the patient in. The patient's face looked flushed and slightly blue. He's as still as a log. He's lifeless.

"He had another arrest on the way here, we have been going for 10 minutes," someone reported.

After a quick transfer to a firm surface, the resuscitation recommenced. The nurses quickly hooked up monitor cables while the doctor listened to the report from the paramedics. Ventilation machine. High flow oxygen. Adrenaline infusion. IV fluid. ECG. Sodium Bicarb. Feeling for a pulse. Shining lights into the patient's eyes.

The resuscitation room became a flurry of movements.

Meanwhile, a tall male nurse started compressing the patient's chest vigorously, as fast as he could ^{[see note 1]}. Awkward mechanical sounds were produced. The patient's pot belly was protuding and retracting synchronously with the compression. Nobody laughed.

I stood in a corner and watched as the unreal scene unfurled, perhaps living up to what I envisioned myself as a thirteen-year-old St. John member. The resuscitation room was crowded. There were five ambulance staff, four doctors, three nurses, and a clueless medical student. I had to shift a few times to get out of people's way. I was just a spectator.

One of the doctors in the room asked me to go to the left hand side of the patient.

"You should go and do it. It's an experience."

I forgot how I responded to that. Within seconds, I was standing next to the tall nurse who was already four minutes into his compression.

"You ready? On the count to three. One. Two. Three."

He moved away swiftly, and I stood in. Keeping my arms straight, elbows fully extended and wrists placed right in the middle of the chest, I started the chest compression.

The first thing I felt was the resistance of the chest wall. I have never pressed on a human chest, not to mention pressing it at a high speed. All we did for St. John was to fake the motion. So the resistance was fully felt.

"Good, you are doing it right."

Well of course I am doing it right - I have known CPR for eleven years!

As I was compressing, I went into a transcendental state of mind. Reels of old memory started playing before my eyes. The intensive first-aid training I went through before high school St. John competitions. My decision to choose medicine as a career. 100 beats per minute. Staying alive by Bee Gees ^{[see note 2]}. The CPR mannequin.

I could feel it.

Then I took a glimpse of the patient's face. His eyes were closed. His face was dark red. I felt responsible. I pressed even harder.

Fatigue soon got the better of me and I was struggling to keep up with the compression. I must have gone on for two minutes. Someone offered to take over, and I moved away after a count of three.

The compression went on for a while, pausing occasionally to check whether the heart started producing pulses by itself. There was no defibrillation because the patient was having pulseless electrical activity ^{[see note 3]}, a rhythm that can't be shocked.

The patient's wife came to the resuscitation room. Upon seeing the chest compression, she immediately let out a loud cry and ran out wailing uncontrollably.

His son came in later. He said he wanted to watch. The big man was shedding tears. A nurse asked him to hold the patient's hand.

"How long now?" A doctor asked.

"30 minutes since arrest." Answered a paramedic.

"We should let go."

A nurse turned off the monitor and detached the cables. Spectators walked out. Some nurses were tapping the shoulder of the inconsolable family. We removed our gloves. And I walked out.

"What? Is he dead now?!"

These were the last decipherable words I heard from the resuscitation room.

I felt a sense of loss upon leaving the scene. The cry in the distance certainly did not help with the sombre mood. I didn't even know that patient, and I knew 90% of CPR are unsuccessful. I thought I am a level-headed rationalist who's immune from unreasonable emotions. But there was this feeling of emptiness, or even a bit of grief, that filled me. I felt a bit off.

I have seen many patients gasping for air, coughing bucket load of sputum or looking so orange they look like they were going to die. But despite their suffering, they were alive. This man here was lying there looking peaceful, yet his heart failed him.

A doctor can sit in front of the computer all day looking brilliant and important. A medical student can read textbooks all day learning the finest details of every single disease looking smart and knowledgeable. But at the end of the day, and at the end of the life, everything boils down to keeping the heart pumping and the blood moving. Despite all our presumed brilliance, we are still using the most rudimentary mechanical compression in our attempt to revive a dead person.

There was an indescribable sense of irony that I couldn't quite fathom.

I am not even sure what I have really learned in this process, but the two minutes of chest compression changed me. The glimpse I took of him during the CPR will stay with me forever. The transcendental feeling will, too. The doctor wasn't lying when he said "It's an experience". Indeed it has been.


Note:
1. In fact pressing too fast is counter-productive, as the heart does not have enough time to fill up with blood in between the compressions. The recommended rate is 100 per minute.

2. Bee Gees' "Staying Alive" is recommended by American Heart Association in conjunction with CPR training due to its tempo of 100 beats per minute. I am sure the song title is the biggest reason for the recommendation.

3. Pulseless Electrical Activity is the phenomenon where due to various reasons, there is an observed ECG (electrical tracing of the heart) that should be producing a pulse, but is not. Defibrillation (= shocking) is not effective in this role as it only works in cardiac arrest due to certain types of non-pulse-producing electrical chaos in the heart circuit. And here's a popular myth: you can't shock a flat line. So most TV shows including House MD are wrong.

Please DON'T Call Cardiac Arrest A Cause of Death (3)

[Continued from here]

CNN has a good conversation between Anderson Cooper and Dr Sanjay Gupta about this topic:

Please DON'T Call Cardiac Arrest A Cause of Death (2)

[Continued from here]

More about the cardiac arrest business.

When I say it's silly to say someone "died of cardiac arrest", I am not saying that it's *wrong* - in fact it's absolutely true that a lot of people die when their heart stops. What I am saying instead is that calling cardiac arrest "the cause of death" is quite meaningless. It's almost like asking "Why was TDM hospitalised?" only to hear the answer of "The doctor asked him to stay". Absolutely accurate, but absolutely not answering the question too. I want to hear what illness he had that made him stay in the hospital; not whether the doctor, the surgeon or the physiotherapist asked him to.

It's technically correct to say someone died of stopping of the heart, but we shouldn't call it "THE cause of death" without knowing what caused the heart to stop in the first place. Cardiac arrest, or "the stopping of the heart", can be due to thousands of reasons.

• Being immersed under the arctic ice cap for one hour.
• Being electrocuted.
• Dumping shit load of potassium ion into one's circulation.
• Being born with a heart with screwed-up wiring.
• Being born with thickening of certain parts of the heart (how many young athletes have sudden death).
• Getting overdosed on drugs (which is currently one of the top hypothesis in MJ's case because he has been getting opioids from his doctor).
• Having a massive heart attack.
• Having a sick heart from a previous heart attack.
• Having a huge clot in the pulmonary aorta.
• And the list goes on.

In fact, almost any disease process or injury would kill you by stopping the heart in the end, with the exception of brain death due to brain injury. In brain death, even though their heart might still be beating, we also consider them dead because there is no longer a person in that body.

*****

What about calling it a heart attack, some might say. THIS is another peeve of mine in the whole media report. Yesterday all the Fairfax newspapers in Australia reported that MJ has died from a heart attack when the official sources said NOTHING about a heart attack. It appeared to me that the Fairfax journalists have equated a cardiac arrest with a heart attack, which is to me as atrocious as equating bacteria to virus.

And NOW you see why I am so worked up.

Heart attack is a specific entity, and we say someone's got heart attack when his coronary arteries (which are the arteries that supply the heart itself) got blocked off by clots. Heart attack can cause death, and when someone dies in a heart attack they often die via cardiac arrest (i.e. when their heart finally stops). But in the process a lot of things could happen, their heart wiring may run amok, their heart walls may rupture, their heart will beat out of synchrony. And so on. And all that could be the precipitant for the eventual cardiac arrest.

In MJ's case, the current official word is cardiac arrest, and no official word has said he's got a heart attack. But I can see that some Australian media has automatically translated cardiac arrest to heart attack, which is quite misleading. In the early hours BBC also used the word "heart failure", which was also another term with a specific meaning in medicine.

It's probably the public health educator's fault that many people are unable to tell the difference between a heart attack and a cardiac arrest. The difference might not be that crucial for laymen, you might argue, and you are probably right. However, in the case of journalism, I don't think it's acceptable for a journalist to substitute "cardiac arrest" with "heart attack" without any verification and disseminate the information to millions of people. This is a count of irresponsibility.

[Continued here]

Please DON'T Call Cardiac Arrest A Cause of Death

What would you think if you come across a conversation like this:

A: Hey do you know why Mr. Rockefeller was rich?
B: Oh of course, he's rich because he had earned lots of money.
A: Ahh thanks for telling, that's helpful!

Sounds dumb, no?

Well, what about this conversation.

A: How did he die?
B: He died because his heart stopped.

Sounds dumb, no?

Now time for some pseudo-medical-jargon 101:

Cardiac - adjective - related to the heart.
Arrest - noun - Stopping.

YES when you read a paper that says "Michael Jackson died of cardiac arrest", they are telling you "Michael Jackson died of the stopping of his heart".

And they irk my nerd-sanity big time. Too tired to write more right now, I will update this post tomorrow.

[Continued here]

A Hospital Sign

The swine flu panic. Australia is now officially the limelight in this swine epidemic, and Victoria, the state I am in, has the world's highest swine-flu-per-capita ratio.

And my exams are two weeks away.

Just Like Crossing the Road

Learning medicine is not unlike learning to cross the road.

When we were little, our parents held our hands to cross the road. When we were young, our parents told us to always cross the road when the traffic light turns green. We should look right, left, and right again to make sure there's no car. And then we cross. After growing up, we learned to jaywalk when there's no car. We even learned to cross a busy road just before the speeding cars could hit us.

When we were a medical student, the doctors carry our hands to see patients. This is how it goes: First you inspect. Then you palpate. Then you percuss. And you auscultate. As we grow up to become doctors and become more experienced, we start to go for only the important stuff and skip the irrelevant bits. As for the consultants? They are the jaywalkers.

I don't mean they are haphazard or reckless, of course. They know where all the cars are.

A Medical Student's Apology

We wander around the ward corridor
Chirping, chattering, cheering, conniving
Stealthily we peeked at you
And we thought you would be interesting.

You are awake, you are not sleeping.
You don't have any pain, you are not eating.
You are not demented, and you have got no one visiting.
You look okay, in fact you look welcoming.

We come to you, and start to greet you
The greeting is always the same
Official, boring, and impersonal
And we always go like this

"Hi Mr. Smith my name is Yang,
I am a fifth year medical student.
Do you mind if I spend a few minutes with you,
to talk about your recent condition?"

You agreed to that because you are nice,
But deep inside you let out a grunt.
"Those students again"
"How many of them are out there lurking?!"

"What brought you to the hospital?"
"An ambulance, obviously"
"Tell me more about the pain"
"It hurts, doc"

Minutes dragged on to hours
Hours dragged on to days.
Your stay in the teaching hospital,
Is punctuated by endless visits by annoying students.

At times you see us on the corridor,
Laughing, sniggering, jeering and bantering.
And you probably wonder,
whether we realise we should be a bit more proper.

At times you accidentally hear us say,
"Mr. Smith is an interesting case, go do a long case on him"
And you probably wonder,
whether we realise you are not here for our exam rehearsal.

So an apology this is
For all the patients we have hurt,
For patients we saw as a long case or a short case,
And for patients who are not good for any type of case.

We don't mean to annoy you,
Although at times we probably do.
We don't mean to use you,
Although in reality we probably do.

We empathise what you are going through,
At the very least, we used to.
But after toiling for a year or two,
Even the warmest heart probably turn a bit cool.

My dear patients, we wish we really could
Be a bit less rude and do a bit more good
We are really sorry what we subject you to,
Hopefully, just hopefully, we will all pull through.


Image Credit: Lupus Comedy

Of Feeling Sick

It's quite easy to overlook the experience of illness as one progresses in their medical career. As we fret over how best to present our long cases or how best to study the Oxford Handbook of Clinical Medicine cover to cover, we often forget that we are not really there to study medicine; we are there to learn how to treat sick people, and how to make them feel better.

I had my share of illness today. It started this morning when I went to the Austin Hospital at about 8.30. Feeling unwell in the tummy, I immediately went to the toilet, and there I was flushing out some humongous amount of bowel content into the toilet. However, at that stage I was feeling alright, and the watery bowel motion didn't bother me at all.

At 9am, I went on to have a tute with one of the doctors without much problem. After the tute, I had to go to the toilet again. And again. And again. In the next three hours, I went to the toilet four times, feeling more and more unwell in the process. Come lunch time, I struggled to finish my tuna sandwich due to a lack of appetite.

I wanted to stay back to clerk some patients but my physical condition was deteriorating quickly. My tie started to strangulate me, and my anal sphincters were unforgiving. I could feel some chill overwhelming my body, and I immediately knew I was not gonna make it to the 5pm lecture.

With an ashen face, I braved the chill and physical weakness and walked to the train station opposite my hospital. What usually seemed like a short walk became an endurance race. Each step I took was harder than the step before, and I was in fear - I knew that there was a possibility I was going to collapse on the street. At that moment, weakness ceased to be a mere physical descriptor of the patients; it became a real entity, a thoroughly debilitating sensation. It became a fear.

The train ride back to the city was uneventful, but I was not feeling better. By the time I reached city, it was apparent how feverish I was. From the train station, I boarded a tram to head home. The tram was packed like a sardine. To worsen the matter, a girl in front of me kept on swearing bad words like 操你妈的 to her boy friends. She was making me nauseous.

Two minutes into the journey, I was on the verge of throwing up. They say that nausea is the worst feeling of all physical afflictions, and it can't be more true. I had a patient who developed some nausea due to morphine, and without hesitation she wanted to cut down on the morphine just to get rid of the sick feeling. I had to get out of the tram and get some fresh air.

I sat in the toilet of a shopping complex having the seventh bowel motion of the day, but I didn't vomit despite the continuous tug in my stomach. At that juncture, I started to wonder how I was going to get home at all. Am I going to take a tram home and risk myself vomitting in it? Or should I just wait in the shopping complex to get better? The loneliness and helplessness was killing me.

I decided to visit a pharmacy and shelled out some money to buy oral dehydration salt (at which Xuan Ni later ridiculed :P), paracetamol and water. Immediately I mixed the salt with the water to make up the rehydration solution. I guess the other shoppers must have thought I was mixing some illicit drugs.

Eventually I got home via a bus. I collapsed on my bed immediately and fell into a deep, warm slumber for the next three hours. Xuan Ni and Anthony (my current housemate) came home and visited me. I am very grateful for their care - Anthony cooked porridge for me (which I only ate a little due to nausea), and Xuan Ni was simply there for me. Social support is not just something that earns us extra points in long case presentation; it is something that truly helps.

Right now, the diarrhoea has stopped although there is still some lingering weakness and my temperature is still a tad up. The metoclopramide I brought to Melbourne four years ago worked wonderfully against the nausea. Today, as cliché as it sounds, I reminded myself of what it truly means to be sick, and hopefully, how to be a better doctor (or a better medical student, for that matter).

Of Learning in Medicine (1)

I enrolled in medicine in the most unusual yet not unexpected circumstances.

Since I was little, I have always been a maths and physics guy. I read popular science magazines, I read my dad's old Chinese maths textbooks (they ARE interesting). I have never picked up a Biology textbook with much enthusiasm, neither have I ever been attracted by the animal or human body documentaries in National Geographics Channel.

Throughout my high school years, most people expected me to go on to study maths, engineering, actuarial science and the sorts, and I kinda took up the expectation as my own goal too. At one point I was considering MIT as a goal, seeing that participation in the IMO could be a useful line in the CV. However, my procrastination and lack of motivation eventually reigned over my temporary ambition. I never got beyond reading the university brochure.

Eventually, I enrolled in medicine. You could probably argue that I was just following the footsteps of my sisters, and I can't deny that it did play a huge part in my decision. But beyond that, I chose medicine because of the satisfaction I thought I could derive from medicine in terms of intellectual fulfillment, job satisfaction, social status and monetary stability.

Besides, I chose medicine over the other aforementioned options because I thought that those paths offer less satisfaction, and that I don't want to be doing maths in a cubicle forever. That could be just an excuse, I don't know. Even today, I still suspect whether this line was a lie I obstinately hold on to, just so that I could justify my not pursuing paths in alignment with my interest and talents.

But I thought it didn't matter.

[To be continued...]
Image Credit: Vagus Surgicalis

Routine Work

Taken with phone camera

Small Note: I plan to post random shots once in a while as some sort of chronicle of my life as a medical student in Melbourne. Most of the pics are going to be taken by my phone which explains the lower image quality. Anyway this blog is probably turning into a place for random rambling and snippeting after all, despite my ambition to keep it interesting, educational and hopefully inspirational. Time is catching up on me. Tight, tight, tight. Not talking about my pants obviously. Lame, I know.

As A Week Ends...

Heidelberg Train Station, Heidelberg, Victoria

The Fifth Year

From tomorrow onwards, I am going to become one of the "fifth year medical students" in the hospital.

While the sound of  "a fifth year medical student" might inspire a considerable amount of confidence in the laymen, embarrassingly I find the confidence unfitting for my knowledge and skill. After four years of studies, all I could command is some bare grasp of the most common diseases, and little to no knowledge of the rarer conditions. All I could do is to insert an IV cannulae (even this was last done quite a while ago), shove a tube up the urethra of an anaesthetised patient and feel blindly inside a man's anus. That doesn't sound like too much but it's enough to overwhelm me.

It's going to be one of the more challenging times. Kicking start tomorrow at 7am - Gastrology, Hepatology, GI & Hepatobiliary Surgery, General Surgery. Stay tuned to Austin Hospital, at various places. Be on time. Pray that Connex doesn't break down. And hopefully, just hopefully, everything will turn out fine, or even enjoyable.


Image Credit: The Royal Women's Hospital - Biographies

The Time of the Year Again

It's here again. After 18 weeks, this hectic semester has finally come to an end. I am going to have an exam on next Friday.

In our exams, there are going to be four stations, each one lasting for 9 minutes. In two of these, we are supposed to take a history from a patient who present with a complaint like a stomach ache. In another two of these, we will be asked to examine a certain body system of the patient. For all stations, we have to give our differential diagnoses i.e. possible diagnoses for whatever we found through history or examination.

After the exam, I will have three weeks in Melbourne, and then fly home. I am so looking forward to it. :) Till then, I might just have a break in this blog. See you later!

Waking Up in a Surgery, Paralysed

Yesterday I came across this article titled "Awake During Surgery" in MX during my ride home. A 24-year-old patient in Northern Territory of Australia woke up during gall bladder surgery, felt every single cut by the surgeon, but couldn't do anything because she was totally paralysed.

Read the news below.

Woman wakes up during surgery
12:00 AEST Tue Nov 18 2008
By ninemsn staff

A Northern Territory woman has endured a nightmare operation at Alice Springs Hospital after she became conscious during stomach surgery but remained paralysed by the anaesthetic.

Rebecca Jones, 24, told the Northern Territory News she could feel every cut of the surgeon's knife during the operation last month but was unable to scream for help as the anaesthesia had paralysed her.

Ms Jones, who was being operated on for gallstones, said she could not open her eyes but could hear and feel everything.

"I thought the doctors had woken me up because the surgery was over — I quickly realised that was not the case," she was quoted by the Northern Territory News as saying.

Ms Jones realised her predicament when she took a breath and found she couldn’t move, but eventually moved her hand to get the attention of surgery staff — to no avail.

"(Someone) said, 'she's just moved her hand' but they kept going," she said.

The hospital's general manager Vicki Taylor admitted to the NT News that Ms Jones had been awake during the operation but denied medical staff knew of her pain.

Ms Jones is now considering legal action against the hospital.

Awareness during anaesthesia may sound like the worst nightmare to most people. Just imagine this. You are helplessly wired up like a spaceman outside a theatre, wheeled into the threatre full of fear of the unknown. Within minutes, the anaesthetist injects some anaesthetic agents into your body, and soon you drift into unconsciousness. Some time later, while you slowly return from the oblivion of anaesthesia, instead of having someone tell you "the operation was successful" like what you see in drama, you actually feel the surgeon cranking and churning your stomach and the anaesthetists discussing today's Sudoku puzzle. Worse, the surgeon might be commenting on your humongous intra-abdominal fat. You lie there, full of fear, wishing this is just a dream but it isn't. Worse, you couldn't move.

Everyday awareness during anaesthesia is experienced by about 100 people in the theatre in US alone. Having had some experience with anaesthesia (I spent one year doing a research in the Anaesthesia department), I am glad I have never come across any horror stories in the theatre. While horror stories like this may deter some people from ever having a surgery in the future, allow me to allay your fear by assuring you that this is very uncommon (only 1 in 1000), and you shouldn't feel any pain even if you wake up.

In the theatre, here are a few things that anesthesiologists / anaesthetists could rely on as an indicator of patient's anesthesia status (from the trivial to the more technical):

1. Patient is not moving. But this is not reliable especially when the patient is given muscle relaxant, as is the case for abdominal surgery like in this woman.

2. Patient's vital signs are not showing sympathetic outflow (BP, heart rate, sweating etc). This could possibly be masked by the other drugs given during surgery. Even if the vital sign changes are noted, it could have simply be perceived as an autonomic reaction towards pain, and interpreted as inadequate analgesia. (Yes your body still react to pain when you are under GA). So the anesthesiologist could have simply given her more IV analgesics instead of checking her consciousness status.

3. The concentration of the volatile agent (gas used to put you under) in the lung, called MAC (minimum alveolar concentration). In most modern hospitals, this is continuously monitored through the anesthetic monitor. Judging from the concentration of volatile agent PLUS opioid analgesics PLUS/MINUS other sedatives (sometimes used), the anesthesiologists have a good indication of whether the patient *should be* asleep.

The problem with this method is that sometimes people have idiosyncratic reaction or tolerance towards particular types of agents, so while statistically a particular combination of MAC and opioid and midazolam could anesthetize 99.99% population, there's no telling who that 0.01% is going to be.

4. Last but not least, an optional (but expensive) monitoring called BIS is used to detect the "brain activity" during anesthesia. This is a series of electrodes attached to the forehead to monitor the electroencephalography (EEG, the "brainwave"). It gives a number from 0 to 100 which roughly translates to the spectrum of consciousness from total brain silence to fully awake. It is not used all the time because of the cost, occasional inaccuracy and the fact that the monitoring above (3) is deemed sufficient.

Regardless of all monitoring and precaution, awareness during anesthesia is a recognised complication during surgery, which, although minimizable, is not 100% preventable. In addition to the idiosyncratic responses mentioned above, in certain surgeries (e.g. in major trauma, elderly patients or pregnant woman) the anesthesiologists in fact go for minimal anesthesia due to their fragile cardiovascular system. So in these population there is a higher risk of awareness, but even for them the risk is about one in a few hundred operations.

Anesthesiologists routinely inform the patients about the risk of awareness when they give consent for the operation. Therefore, though the lady endured a horrifying experience, as long as the anesthesiologists did not make any mistake, she could have simply been unlucky and has no case to make against the doctors.

So go ahead and have your surgeries if you need them. You *should be* in good hands (if you *are* in good hands).

Image Credit: http://www.thesun.co.uk/sol/homepage/woman/article899011.ece

The Irrelevant Question

Me: Is there any disease that runs in the family?

Patient: Ya some angina.

Me: Your parents?

Patient: Ya mum died of some angina.

Me: Did she have actual heart attacks?

Patient: I think so. Died of heart attack when she was 59.

Me: What about your dad?

Patient: Died of old age.

Me: How old was he?

Patient: I think he was about 85.

Me: Ahh ok. You have other siblings?

Patient: No, no kids.

Me: Oh what about your own siblings, brothers and sisters?

Patient: Nope.

Me: Ah okay you are the only child.

Patient: Ya.

Me: So are you married?

Patient: Irrelevant. Next question!

Me: =.=" Oh sorry. Eerm, who do you live...

Patient: Sorry I am a bit tired.

Me: Oh alright, thanks for spending time with me.

The Nerve Stimulator

So I was in the theatre another day with an anaesthetic doctor. The doctor was a very enthusiastic and informative teacher. He was good looking too, but of course that's not a huge concern for me.

This is a rather informal kind of learning environment, so we kind of just touch on random topics about anesthesia as the doctor goes on doing his stuff. That patient in the theatre was having an appendicectomy (removal of appendix in appendicitis), and he was given a general anaesthesia together with muscle relaxant to aid the operation. The muscle relaxant works by paralysing all skeletal muscles in the body, but there is one problem: they could wear off. So how do you tell when to top up some muscle relaxant? There is a very simple trick they use - they shock the nerves and look at the muscles jerk in response to the electric pulses. In this particular case, the doctor attached the wire next to the patient's right eye, and the eye muscle flickered when the electric was delivered.

As I was watching the doctor shock the patient's eye, curiosity had the better of me.

Me: "Just wondering, if you do this on a conscious patient, will they hurt?"

Doctor: "What do you think? Do you want to try?"

Doctor: * Take the wire off the patient, and attach it to my right forearm *

Nerve Stimulator: * TICK TICK TICK TICK *

OUCH OUCH OUCH OUCH. It hurts. Thank you doc.

Pee Shiver (1)

Something interesting for everyone - pee shiver, piss shiver, or whatever you want to name it.

Let me be the first voter - I chose option 1. Feel free to chip in your two cents in the comment section too! Let's keep this poll open for one week or two, and I shall let you in the good bit later. :D

Dedicated to Jie Ni, my childhood friend :P