Happiness is really a very simple thing to achieve I've realised. Opportunities for little rays of happiness to fill us are everywhere but often are not given enough attention. I realised this when I saw this pretty little gingko leaf fluttering to the ground. Such a pleasant shade of yellow, such a graceful shape, it was beautiful. For a moment my worries that afternoon looking for a suitable person to interview melted away and seemed distant and insignificant. I wonder why in the midst of things, little joys that make me happy fall by the side ignored. I looked out the bus and felt warm rays of sun, saw a great big green field, saw a glorious blue sky, fluffy white clouds, the puzzling but cute streak of white falling through the sky, and the autumn look of trees heading into winter and felt content to enjoy the my bus ride while I can. Happiness can be a simple three word phrase, or even single words that all children share.

Yet what puzzles me is thinking back now how when I'm sad nothing will get through the dark cloud that settles around my head, allowing me to do nothing but ruminate my sad lonely thoughts. Funny how Dr C said that those in the medical profession are different when they get depression. They function normally even if they are depressed, they go on and on and on until they crash, and when they do they go utterly out. When I'm sad that's what I do. Immerse in everything around me, work, study and pretend around friends. Nothing shows. Nobody guesses. It's almost like a game of hide and seek where I'll always be the best hider that no one finds. But because I'm the best hider, I can't come out to the seeker because that means I lose.

I was asked if I ever get stressed. Thinking back now, how often do I get stressed. Not very often probably. A lot of my stress comes from my feeling unprepared for exams, hormonal fluctuations that happen to coincide with little incidences that push me off the edge (which normally wouldn't), and most of all the weather, housing... living environment. Living in better conditions now as I approach winter makes me realise how poor living conditions affected me before.

...Olga found him lying on his back looking at the clouds and asked him what he was doing. "I like to think and wonder," Alexei replied. Olga asked him what he liked to think about. "Oh, so many things," the boy responded. "I enjoy the sun and the beauty of summer as long as I can. Who knows whether one of these days I shall not be prevented from doing it?"...

Dropped by the stroke ward again today to visit my long case patient. Wasn't planning to do any examinations today, told him that but he didn't seem to believe it lol. And then he offered to let me do some work on him, saying he didn't mind, so I thought I might as well do a cardio exam on him today. Oh my oh my I sure didn't know what would be coming up then. I knew he had a patent foramen ovale from the echo results he had previously and from what he had told me about his little hole in the heart, but certainly wasn't expecting to hear anything different from normal from that. So everything was normal until it was time to ascultate his mitral area. :S... what on eart is this I hear. Sssssshhhh dup Ssssssshhhhhhh dup. Oooook. Find his radial pulse and tried to time it with the sound. Hmm..... so first heart sound was the one where the murmur is. But I wasn't expecting to hear it and I guess I must have looked worried/ puzzled? Because he then asked me what did I find after I finished. Immediately warning bells rang in my head. But considering I was already ... 'caught out' I thought I might as well tell him what I heard. After hearing what I said he looked a little puzzled... and worried possibly since this was the first time the murmur was mentioned to him apparently so I offered to let him hear with my stethoscope. He couldn't really hear it. So I made him lie back down on the bed, check that I could hear it and gave it to him to hear. At this point I could tell he was a little worried even though he couldn't pick out what I heard so I offered to get the house surgeon on the ward.

Poor WT because he was busy with ward work but then since I'd already made poor Mr G worried he thought he better come and listen now. WT never listened to Mr G's heart before and therefore was quite surprised when he picked it up. Offered to go through his echo results to check what it was. Then came back and slowly explained it over to Mr G. By the time it finished it was quarter past four. I first came to get WT at about 20 to four. :O ..... I felt kinda bad for putting Mr G through the stress and then making WT finish late since his actual finishing time was supposed to be 4pm. Accck. I need to develop my poker face perhaps. Didn't get to stay to talk long to Mr G after that since his wife then came.

Before that though he was telling me how he was feeling a little down that morning. Because the guy in the bed opposite had got to go home for a day and he couldn't. At least the OT has offered to check out his home this Wednesday and assess if that were possible for him. I do hope it works out considering I seem to hear from a couple of patients how bored they were there. Times like these make me want to give the person in front of me a nice big hug and tell them I'm sorry as well but then I doubt that's forgivable as a professional. I just use touches to communicate. I can't say thank you to patients for letting me do unnecessary examinations on them verbally. Partly because it feels false, and saying it loudly doesn't seem right to me either because some of them are pretty hard of hearing. So touching them on their hands lets me tell them what I wish to say.

Strokes are so much more interesting. Probably something I've said before. But sometimes when one sees and thinks about the devastation that it leaves behind I feel kind of sad as well. My bedside tutorial today was about strokes, focussing on non-motor aspects. The first lady we saw made my heart ache. A nice cute grandmotherly looking old lady. All smiley and happy to try and help as much as she could. But she could barely speak for she had non fluent dysphasia. I asked her why she was here, and she could only barely get the word brother out and even then I had to guess it. She couldn't understand very well complicated instructions, such as scratch her head, even with a visual clue. But worse was the fact that her insight was intact as I could see her clearly struggling to get the words out and look plain frustrated when she couldn't understand what the instructions meant. Yet through it all she kept trying to smile. It was heartening to hear at least from Dr H that she had improved quite a bit since when she first came in she could practically make no sound. I wonder how much she understood what was written on the get well cards I saw on her bedside table? I wonder how it feels to have to watch someone you love go through that sort of struggle with something so basic that we all take for granted?

Yet at the same time, not all is sad. Mrs H has her husband who comes in everyday. Mr G's wife visits everyday as well. I feel touched and warm inside when I see Mr H wheel his wife about in her wheelchair and take her out for walks when it's sunny and still. When he watches her learn to walk again and follows her to her physiotherapy sessions and provides moral support and encouragement. I guess with stroke, while it takes, it brings out the love in people as well.

And on Sunday was SS jie jie's 'toilet-warming' party. Rather the toilet was an excuse to meet up with friends and catch up. Dress code was to include something .... toilety? I donned my pyjamas and wrapped a towel around my head and took the bus from home in that. I bet Hui who saw me at the bus station in my jammies must have thought I had lost a couple of screws. The bus driver sure looked at me odd. Hehe. And people slowed down and stared somewhat as I paraded down Ric Rd to the bus stop. Somewhat that was oddly fun. Even if it probably was the wrong sort of attention. Should I blame my parents for not making me the youngest or making too many kids and hence causing my unquenceable desire for attention??? Lol.

“There's a cross on the side of the road
Where a mother lost a son
How could she know that the morning he left
Would be their last time she'd trade with him for a little more time
So she could say she loved him one more time
And hold him tight
But with life we never know” 

“There is a man who waits for the tests
To see if the cancer has spread yet
And now he asks, "So why did I wait to live till it was time to die?"
If I could have the time back how I'd live
Life is such a gift
So how does the story end?
Well this is your story and it all depends
So don't let it become true
Get out and do what we are meant to do”

I visited MR G, my long case study patient for the HCE module today. He was having his acupuncture session as usual. As it was during his OT session yesterday (I asked Mr G how it felt like having the electrodes on that the OT placed on his forearm, he answered it felt like a buzzing, when the OT piped up asking if I wanted to try. I was feeling wary, said so, to which she replied, stick out your hand and something along the lines of let’s have fun torturing the medical student), the acupuncturist offered to let me have a needle in the back of my right hand. I was feeling quite afraid, the needle was quite long though thin. But then Mr G had said earlier when I flinched while watching the acupuncturist put some in him that this might be my one and only chance, so I agreed. I barely felt anything though when it went in I must say. When the acupuncturist tapped the needle in, I expected a jab of pain. But nothing. I felt nothing. It was only when he advanced it further in that I felt a slight sort of odd sensation. Barely feel-able. I wonder if it actually works. Mr G sure is improving quite quickly, but is it due to the acupuncture or to his diligence at his rehab exercises I don’t know. But what I know, is that he doesn’t mind even if it doesn’t actually, just having them gives him hope. What a powerful word that is. Right up there with motivation. I hope he gets better and attends his son’s wedding. I’m trying really hard to convince him to go no matter what still though.

At the end I was telling him I had to go now because I had work in the afternoon. He looked absolutely shocked. He knows what my parents do for a living. He knows and I know that I’m from a relatively well to do family, otherwise I wouldn’t be where I am or going home at the end of the year. He says I should make use of my youth and not waste it. Go have fun was what he said. Don’t wait until I turn out like him. It left me feeling a little ... shaken? It was partially the thought that had been lingering in my mind all this while at the back of my mind. I desire that of course. What young adult doesn’t? Especially when I know what’s coming up for me after I graduate (I was not well informed of the outcomes of my choice almost 4 years ago, otherwise I would be an allied health professional instead). But I desire to have be semi-independent. Or at least create an illusion of such. I want to not be one of those snivelling babies who leech of their parents. I want to have the dignity of an adult. And it’s bad, but I want cash. I can do ok without it anyway, but having a bit more money to put away as savings and enabling me to be a bit of a spendthrift is really tempting. I’m not yet graduated, and I’ve a debt that seems massive to me. I will need a car by next year probably. I want to have my own apartment once I graduate. I’m not money oriented, but as I near graduation, these things become more real to me. But I remember that I haven’t been to walk in the gardens for ages. I haven’t been to see the talking chairs. I haven’t gone to the arts centre in a long time. Am I really wasting my youth?

I want to travel and see the world. I find stroke patients more interesting than fractures. I enjoy the time I’ve spent so far on the stroke ward (I’m such a traitor to my own ward). But deep deep deeeeeeep down a thought is emerging in me. What if I’m one of them. I’ll work till I retire at what? 65? That’s the age of some of those on the wards. Or lately like poor C’s brother. 17 and died from a MVA. How will I achieve my little dreams if I accidentally end up like that? I shall aim therefore, not to wait till I retire to do what I want. I hereby promise myself I will travel little by little in between, even if I have to do it on my own. I shall take the holidays that is due to me in future. Fingers crossed.

I can’t wait for the end of the year. I must pass that stupid Gen Med run. Stupid Dr J with all his perfectionism shan’t kick me down. I must get home this year. I shall give bola the knocks on his head that are due, mumiaks and nana will give me the kisses and hugs that I want, and the worm can return to be my minion in evil and greatness muahahaha.

OSCE went not too badly I think. The physical examinations went quite smoothly, though I've no idea what took me so long that I never finished the focussed abdominal exam. The vascular exam was easier than I thought. I finished quite early for that one, except that when feeling for the femoral pulses my fingers touched something that probably shouldn't have been at that spot at all! :S! The oncocology station wasn't too bad, for some reason I knew all the stuff in my head, but I wasn't very sure which information he expected me to spout. The way some of the questions were phrased were kind of odd, and occasionally I didn't manage to dig it out and phrase my words very well either. Irritating thing was a call came in midway on the examiner's cell and disrupted my line of thought. Even though he told me to just continue I couldn't simply because I doubted that he would be able to hear me talking. The gastro one was alright. I got the right diagnosis, but it was quite uncomfortable interviewing the patient with the examiner scrutinising me as well. The patient wasn't as forthcoming as I hoped but managed to ask quite a few specific things which was good. Emergency medicine was great for the airway management skills part. The scenario in which it came in wasn't as good though. Knowing that some things activated charcoal can't be used for in gastric decontamination isn't enough. Which ones? I only remembered alcohol. This foreign word Golytely came to mind but I doubt it was it and didn't mention it. Prof A then went on to fill it in for me. Metals and something else I can't remember now. Oh yes! How could I not rememeber it?! Gosh, people should stop trying to poison themselves and that would make life easier for everyone. Use some other way please. Sweat.

Today's would be the Pathology OSCE. Brain died yesterday trying to go through the the questions and the pots, which most of them look strangely unfamiliar to me. Worse of all are the histology slides I must say. Pleomorphic, hyperchromatic, granular chromatin.... err.... if you say so. They still look pretty much normal to me unless I have normal ones right next to it for comparison, which doesn't always happen. After spending most of the day trying to answer the questions without peeping at the answers we had wrote down previously we gave up for the last two tutes. And it is interesting how it's the same questions, same tutors, and yet sometimes we had totally different answers written down on our sheets. Which one is the correct one??

Lately it came on the news that the ECP would become government funded, meaning women who want it no longer have to pay for it. Despite what I hear about it being able to promote promiscuity amongst the young, I doubt it. Simply because those who are already doing it will continue to do it. Those who are not, won't simply because it's not what they are in the first place. After all, it's not as though free condoms aren't available. They could have done it anytime they want anyway without having to wait for the ECP to become free, especially when it can be obtained for free before this from health clinics. And it's not naughty kids who need it. I've seen married women come into the pharmacy asking for it. At 40 bucks a pop, not everyone can afford it, some are actually turned off by the price. I see this as a way to protect women as well. Regardless of wether the act was right or not, denying women access to the pill and making them have unwanted pregnancies would only endanger them. One, there are always cheap dangerous ways to abort a pregnancy (last year we were made to watch this horrid video about illegal abortion, and one of the women actually stuck knitting needles into herself) which would probably kill the woman. Two, having a child and being a single mother when one isn't all that willing probably would have serious effects on the mother's wellbeing and perhaps even worse for the child as well.


And today is the second day of the second strike by junior doctors nationwide. I'm not sure if in the end they'll get the pay rise they so rightly deserve but I admire their effort. Even though I do sympathise with all those whose elective surgeries may be cancelled, I do think that a pay of low 20+ per hour is not reasonable. Considering they've spent 6 years studying accumulating a debt of humongous proportion, and having to work like a dog simply because that how it works here, a pay rise doesn't seem to much to ask for. I doubt if what they are asking for is all that much, considering what the board spends on locums already anyway who earn more than double per hour of a permanent doctor. And even my good old hs has gone on strike. He was overworked the last time the others went on strike, covering his own team and another, because he had not joined the union yet and therefore had no reason to strike, but was still paid the same. That's sad.

What's it with my brain as well that it doesn't seem to come up with good comebacks until it's too late anyway? OR why haven't I been taught to be more rude and thick-skinned? Seriously, the fugly nurse just enjoys picking on students. A pox on her I say. Grrr...

Thinking back to what we learnt during Ethics, our duty is to our patient and therefore despite popular belief, we can over-ride family requests for the benefit of our patient if we do not think the family requests are in the patient's best interest. It sounds nice and simple, but I doubt it's easy to do due to an interplay of various factors at times.

Patient A and B are both Mr U's patients.

Patient A is an old woman, 90+ y.o. She presented with bowel obstruction. Is still clear in her mind and can speak well. She was an ex-nurse. She refused invasive procedures and had discussed this with her daughters. When Mr U did his ward round, he was talking mainly to her daughter at which point Patient A requested him to speak to her instead to her daughter regarding her treatment. She told him what she wanted and that she had discussed this with her daughters already. Mr U agreed and that her management would be a matter of watch and wait and give gastrogaffin and let nature run it's course and keep her comfortable meanwhile. After leaving the room, Mr U agreed that it was probably the best choice, rather than go in with surgery and then die in pain. As an onlooker I feel that Patient A is getting what is in her best interest, i.e. treatment as she wishes and maybe dying the way she would like.

Patient B is a woman of 80+ years who speaks only Mandarin and no English. She's presenting with vomiting two weeks after her partial gastrectomy for stomach cancer. Her son and daughter insists that she be treated with more surgery asap, or the daughter would take her mum back to China for treatment as soon as her mum is able to be moved. Mr U speaks no Mandarin and relies on the interpreter to communicate. He talks to the son and daughter as the mum shows no interest in proceedings. They talk above the bed, without involving the mum. The children do not explain to the mum what is to happen either, and treatment for her does not involve discussion withe mum. Once, on leaving the room, I saw Patient B shaking her head, unnoticed by anyone else, not Mr U, not her children. I doubt the children knows what Patient B actually wants with regards to her management. So does Mr U. Personally I'm under the impression she does not actually want all these treatment anymore. She had to be persuaded by fellow colleague who acted as interpretor once to accept the nasogastric tube and I was told it was reluctant acceptance on Patient B's part. Is it right to conceede to the children's requests? Is it worth taking time out to ask what Patient B actually is thinking, even if it means getting the kids out of the room? What if she wants no treatment? Is it alright to say no, my patient does not wish for further treatment and in light of her advanced gastric cancer and age, I shall not follow the requests put forwards by the children?

Talking it over with a friend, the friend came up jokingly with the conclusion that Asians are greedy for life (we all were Asians btw). I laughed and said nothing. I doubt if that is the case. I'm pretty sure that Patient B herself is ready to accept palliative care, but wether or not that is true no one will ever know because her children are not ready to accept it that their mum wouldn't last very long with invasive treatment and probably doesn't have very long to live anymore, with or without treatment and do not talk it over with her. No one will ever know because the mum doesn't attempt to put forward her views either. I think the baseline is that denial and ignorance will rob poor Patient B of a good end, unless, and I can't imagine this, the idea of a good end is to do everything even if it means pain right to the end.

Anyway, surgical OSCE this Tuesday, Path OSCE this Thurs. Whew! Study revise study revise! Aja!!!!