PSA: This is a reader discretion, for the post below consists of detailed medical descriptions, lengthy recollections and may even include photos (censored the best I can) !!
Carpe Diem!
" Translation: Seize the Opportunity"
I truly believe opportunities come at the most blessed of times and dare I say it, when you thoroughly sought out for it. This summer has been one of the most productive and eventful summer I had experienced so far in my medical school career. In hindsight, if you had asked me, would I do these again, despite it being the most hectic "summer break" I had placed on myself?
The answer is
YES. Yes i will.
The observerships I had actively joined this summer was with my academic study partner, Shreya ❤️ (also known as my med school wife) and Yoong (who joined us a month later). We learnt so much together, and it was a great experience we had done! Those of you following my social media would have known what I had done for my summer break. Yes, we were those girlies who had posted several times about the interesting things and what we had learned during our time of observership. It did range from gore-y (censored on social media of course duh!), to selfies (a must for core memories) and even fun things learnt in clinical (which includes presentations and note-taking). So if you already had a glimpse of my social media, well... this post is for those who intend to know the details and enjoy reading my blog ๐.
So, let me break it down by the departments I had the opportunity to learn from this summer. I was blessed to be given the opportunity to learn from a Thoracic Oncology surgeon from the First Affiliated Hospital of Zhejiang University and their department for majority of this summer break. Second, I was also blessed to be given the opportunity to learn from an Orthopaedic Spine Mentor and their department, which were from the Second Affiliated Hospital of Zhejiang University. So you could say, we had definitely won the lottery pool of summer opportunities in 2023!
Here is what I had done in each department as described below!
Thoracic Oncology Observership: 3/07/2023 - 31/08/2023
- Putting Theory to Clinical Practice
The 3 years spent in classrooms, learning block-by-block for each topic and memorizing concepts did not prepare me for the expectations of how hard implicating them to clinical is. Retrospectively, I believed the first three years prepares us for the theory content and how to nail the finals, but it goes to say for sure, the lack of clinical exposure during the first 3 years of medical school (dang you COVID-19) definitely made me feel under prepared for what I experienced and expected on Day 1 of this observership.
How so?
You do not see the key concepts so often as they thoroughly put emphasis in, in real-life! On a normal day to day basis, there are diseases and diagnosis that are relevantly repetitive, BUT! every individual is different! And presentation on one patient, does not significantly mean it will be the same as the next one, with the EXACT same diagnosis. It is the itty-bitty changes in presentation, and years of practicing in clinically, could a physician ever so make the CORRECT diagnosis. Clinically, I was very surprised to see how things were done in this specific department, and mind you, I did learn heaps about it. It ranges from why and where a tube of such had been placed, why is there a difference in "bottle systems" and management of patients pre-op and post-op. All these were experiences that are definitely OUT of the textbook.
In internal medicine, we were thoroughly grilled on the importance of taking patient history and it was done in almost every single lab and tutorials we had. It was to the point some of us made templates for checklisting every bit of vital patient history information necessary to follow through, that it often times take roughly 15-30 minutes on ONE patient.
Prior to ward rounding, we were given a slip of paper with the Patient Bed Number, Patient Names, Date of Admission, their list of known co-morbidities and their current diagnosis. But here's the catch, ALL these fit into one row on an A4 sized sheet per patient. So the sheet of paper prior to ward rounding gives you essentially an idea of what their co-morbidities are and their current diagnosis. It is the Doctor-in-charge and Resident Doctor's duties to manage these patients pre-op and post-operative, thoroughly. The in-patients we saw did not require us to ask each of them their patient history at all for this was done during out-patient, prior to their admission to the hospital!. So on average, ward rounding took 15-25 minutes tops, for approximately 20-25 patients. This specific area was dedicated to briefly check the patient's condition overnight, and to update them about any new treatment necessary (either pre-op or post-op) and to also answer the patient's family's concerns. Note, this is a crucial step done daily in hospital.
Hence, if I had to pick a word to describe ward rounds, it'd be... EFFICIENT.
- Surgery Days in the Operation Room (OR)
The first day we were told that surgery happens every Tuesday and Wednesday, and we should come observe it, we were over the moon and thoroughly excited! This is because, as freshly finished 3rd years, we did not think we would have this opportunity until we were 5th years at least! So, this was an early god-given opportunity up for grasps.
Things to do before stepping into the OR:
- Attain locker card from ๆคๅฃซ้ฟๅงจ
- Obtain Scrub Crocs (switch out your sneakers/shoes for sterile environment purposes)
- Place shoes, bagpack and clothes into locker
- Obtain scrub cap, surgical mask and scrubs
- Grab your iPad or any note-taking tool on you
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| The correct way to be Operation Room ready as Med Students! |
Might I say, the first time we wore the surgical scrubs, we were extra excited and thoroughly keen as medical students! (And as you did expect, we took a bunch of selfies to commemorate this!). We walked in to the OR and we definitely fawn over everything (Yes, it definitely involved alot of OOOhsss, Ahhhsss, What is that? and OMG-ing). We were amazed by the room, the instruments used and the sheer opportunity to be kinda up close and personal for surgery observation.
Now, surgeries are long tedious and attentive procedures, one which could last for hours.
How did we keep ourselves motivated and entertained, as medical students who barely knew anything?
Things we did during surgeries:
- Prior to surgery, we asked the Professor to inform us about the Patient's Case, Diagnosis and Procedures involved
- We took the scans of the patient's CT, X-rays, FDG-PET, MRI and note them down (all these with CONSENT from our professor, and agreement to NOT share patient details.. aka ONLY for educational purposes)
- We observed how the surgeons scrub up and donned their sterile surgical gowns + gloves
- We observed how the patient was positioned and even sketch it out for our note-taking purposes
- We search up the procedures or anything we were unfamiliar with about the patient case and started scribbling on our iPad.
- We also look up and studied during surgery when our professor gives us a new topic we have not heard of. (We studied it and research it thoroughly and give him our answer AFTER surgery was done)
- We made a list of questions to ask the professor for anything we were unsure of, during the surgery observation.
- We try our best to NOT be in the WAY for everyone important in the room
- We made sure not to touch anything to keep the area sterile as possible!
- We took some selfies and surgical photos (with CONSENT!)
- We commit ourselves from standing --> sitting on stools--> squatting --> floor corner sitting.
Here are some photos for core memory!
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| Selfies with Shreya and Yoong (who later joined us in this department in August) |
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| Few samples of my handwritten notes taken during OR |
- Learning to distinguish MRI, CT and FDG-PET
We also had the opportunity to learn how to read an MRI, CT and the purpose of having a patient take a FDG-PET scan. The first day of our observership, our professor was efficient enough to provide us his handy guide on how to read a CT scan and how to identify the vital structures relevant to the thoracic oncology speciality. These vital structures were trachea, esophagus, the lobes of the lung, aorta, the level in which a nodule can be identified at specific landmarks of the body and so much more! We even got to learn that CT scans have two "windows", a mediastinal window, and a lung window! And as its name suggests, its CT scans which puts emphasis on the components of the body. So a lung window would essentially be a CT scan where we can observe the lung fields better and a mediastinal window is where we can observed the mediastinal and other landmarks better!
For learning how to distingushi an MRI and what the purpose is of taking an FDG-PET (which we now know is to identify metastases), Shreya and myself took upon a
Coursera Course: Thoracic Oncology. We dedicated ourselves to finishing this course and earning the certificate during this summer break as well!
- Learning about RAMIE, MIE, VATS, Resections and more!
During our time in this department, we were also very fortunate to learn quite in-depth in regards to the various key procedures performed in this area of speciality. Here are brief descriptions of what they roughly are!
→Robotic Assisted Minimally Invasive Esophagectomy (RAMIE)
As its name suggests, it is a robotic-assisted tool used for minimally invasive procedures. Initially being specifically used in urology, it is now widely accepted and used in surgeries involving esophagectomies. The current model used in this department was the DaVinci Xi. If you wanna see how detail and accurate this is, go check out how the DaVinci can peel and stitch back a grape skin on youtube!
→Minimally Invasive Esophagectomy (MIE):
It is a procedure which involves making small incisions where surgeons can then insert a camera and have assisted ports to remove cancerous parts of the esophagus. This particular procedure can be distinguished between Ivor-Lewis and McKeown, where both differ in terms of the operation fields it utilizes. Ivor-Lewis uses a transthoracic approach whereas McKeown requires the surgeon to use a 3-field approach, making incisions at the chest, abdomen and neck.
→Video Assisted Thoracic Surgery (VATS):
Considered a type of minimally invasive thoracic surgery which allows the surgeon to remove parts of the affected lung and lymph nodes involved. As its name suggests, it involves using a video-assisted thoracoscope for viewing once the incision has been made. We were able to view this procedure using 3D visual aids, and it made us feel like we were within the thoracic cavity at times. It was in a way "trippy..!"
→Lung Resections and Lobectomy
Just like the name suggests, a resection involves removing all or part of the lung. In comparison, a lobectomy is a surgical procedure which involves removing the entirety of the lobe of the lung.
→Gastric Conduit
This is essentially, what I had liked to call PART 2 of the Esophagectomy procedures. It is a unique procedure which involves reconstructing part of the stomach, preserving the right gastroepiploic blood supply and is then "pulled up" through to the neck via a cervical incision. (I will leave this to your imagination/ you can look the procedure up via youtube).
→Lymph Node Numbers
Did you know the lymph nodes in our body has designated numbers and names?
Besides the normal subgroupings we had learnt in our Anatomy classes, there are several systems that differ across countries when determining them for pathological determination purposes. My biggest question till date is how they can identify each lymph node and have the confidence that particular lymph node is like "C109 or C106pre etc..?" (if you asked me, they all look like dried up sultanas...)
- Surgical Knot Tying in Coffee Breaks
Surgeons use their breaks productively for sure!
During a short coffee break, our professor taught us how to effectively tie a surgical knot (which will be vital for our Surgery course later this semester!). Whilst trying to learn and practice at this time, it eventually came to a point, where the THREE of us (Shreya + Yoong + me) were making a surgical knot friendship band!
- Research Paper, Presentations and Publications
Now, we already pretty much hit the lottery with opportunities this summer break, but we are pleased to inform you that we also had the opportunity to research and write a review for our professor as well. This of course is in the works and is an on-going process! We took 2 months to do our own thorough research based off the topic suggested to us and we have learnt LOTS during this time. I mean ya'all already know how wordy I can be (hence kudos to you, if you still love reading my blogs, its a marathon... AHA!). At present, our first draft is completed, and is in its reviewing process.
Whilst all these was happening, we were also both given the opportunity to present our findings in our research to the thoracic department and two other external hospitals. It was nerve wrecking to present to a team of already known specialists as now, 4th year medical students. But! It was a successful presentation and an experience itself!
This first half (Yes i know "half") is a recollection of everything we had done in the Thoracic Oncology Observership, and it is extra lengthy, for we spent 2 months attaining experiences both Clinically and Knowledgeably. If you aren't bored out of your mind yet, there's part 2 below, on my experience in Orthopaedic Spine Department!!๐
Orthopaedic Spine Observership: 1/08/2023-7/09/2023
- Ward Rounding with the Director
Every Tuesdays, we are given the opportunity to listen in to the Orthopaedic Spine's Director do a thorough evaluation, discuss the diagnosis and reason out the best management/ care for the patients. This is done for approximately 1 hour prior to ward roundings in this department! And I, myself find this step extra attentive of the director to do so himself. Not only is he teaching his residents, attendings and medical students present there, he is showing how he values each patient that he comes to see. I admire the level of detail he performs for each of his patient.
During the ward rounds, he would even performed assessments and do a re-evaluation to show all his residents, attendings and medical students how it is properly done. He even takes his time to explain to the patient what the assessment is for and even takes in questions from medical students after assessing patients, should they have any relevant questions. As he does this, he is also writing out the next recommended steps for the patient, which can include physiotherapy or surgery as an option.
However, I would like to add, the orthopaedic department team are giants compared to our 5 feet 2ish sizes.. In every photo I had taken of them, it almost seem like they are huge! They are the epitome of Ortho-Bros for sure!
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| PS: Xray images and BG images were attained from Pinterest for aesthetic purposes |
- Learning how to read X-rays for Bones and Disc Herniation
Despite the language barrier experienced in this department, I would say they are all pretty helpful and eager to explain any questions we pose to them. They would each take out a translator app and so would we, to ask them specific questions in regards to the patient's case presented. This department is pretty open to us, curious medical students asking them almost anything and everything we observe. The first time in the Operation Room for this department, we were shown X-rays and CT scans for bones. The most commonly seen cases were Scoliosis, Stenosis and Disc Herniations .
- Surgery: Where all your Back problems are FIXED!
Despite not attending as many surgeries and observing as many as we did for Thoracic Oncology Department, there was still plenty we had learnt! I was surprised to see the number of Scoliosis patients and how many afflicted by this disorder were pre-adolescents! Having been here observing for a month, I am able to reasoned out that the age groups afflicted by certain conditions are as follows:
→ Scoliosis: Pre-adolescent- early 20s
Scoliosis is a condition in which the spine twists and curves abnormally. They often present with an abnormal kyphosis and lordosis and can affect mobility over a longer period. It is determined as this condition, when the curvature angle measures at more than 10 degrees. Most often, the causes are idiopathic. Internal fixation (which involves lots of screws, metal nuts and bolts and your more than average Bunnings hardware are required to fix this!). Sounds gory, yes... but it was definitely an eye-opener, the first time I realized how much brute strength (with accuracy of course) is necessary to realign a curved spine! I will leave it to your imagination with an image of the tools used in the surgery below!
→ Stenosis: Those in the 40s- 70s
This is an extremely painful disorder which often results in a pinching sensation or pressure in the spinal cord. As such, it can cause extreme discomfort and can range in terms of numbing pain, to pain where an individual describes it as excruciating and spreads to the affected area. Most often, there is some form of "weakness" presented. This can be fixed using surgery, a procedure known as Laminectomy. This is a type of surgery where the lamina portion of the vertebral bone is removed, with the goal of relieving pressure on the spinal cord or nerve roots that were caused by the stenosis issue.
→Disc Herniation: Those in their mid-40s- 70s
This is where the nucleus pulposus is displaced from the intervertebral space and causes relative back pain. The pain usually radiates down to one side of the affected body and causes discomfort. In surgery, this has been shown to us that it can be fixed in a unique manner, known as a procedure called Percutaneous Endoscopic Lumbar Disectomy (PELD). It is a relatively new procedure which involves removing the nucleus pulposus along with degenerated ligaments via a posterolateral approach. This procedure was interesting to observe for this was new to me, I never realized there could possibly be an endoscopic approach to remove a herniated disc!
We are also astounded to let you know, that we have also been offered to write review articles for this department. However the details of this will come at a later time! ๐
These opportunities over summer was truly a blessing, and I am glad this would be aiding our medical school careers as IMGs! I am thoroughly grateful that I was able to look forward to each day of doing this observership, because everyday there was something new to learn! This was definitely an opportunity that fed our curious medical student minds, and at the same time gave us the much needed motivation booster!
Thanks for sticking around to read this extensively long (and more serious) blog post! ๐ As an ending post, here are some other fun selfies taken during this observership!
-Lots of Love,
D.
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