Rashid Elhawli

Rashid Elhawli

My Journey

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The Choice Is Yours

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Maybe it’s just me, but the practice of medicine is/should be centred around patients. Why do I say this I see your mind box confusingly thinking? Well, one of the surgeons I had the pleasure of joining for consults forced me to remind myself of why I entered the profession.

When sent to shadow a doctor or specialist, students normally look to achieve two outcomes; one is clinically related and the other professional. The clinically related aspect of being with a mentor is the more self-explanatory. Students look to learn about the kind of work doctors engage in, the type of knowledge required to practice in that specific area and to reinforce their own knowledge in the specialty.

The professional related outcome is the more difficult to implement, describe or practice. As students, we look to observe the way mentors treat and interact with patients, as well as the manner in which they question, examine or acquire information. Much of this can be summarised by an often overused term; soft skills. This is the nuance that can be the difference between a non-compliant, aggressive patient response and a more smooth-sailing and beneficial consultation.

Why the whole charade about the details of shadowing? You’re now placed in prime position to understand the frustration of the following situation. While sitting in on these consults with my mentor, he had great clinical knowledge and really knew his stuff. However, his demeanour and overall mindset towards patients was quite concerning. He would finish what seemed like a normal consult to me, and come back to complain how rude the patient had been.

Seeing the confusion on my face, he would begin to elaborate, ‘Did you see how unappreciative they were? Unbelievable’ or ‘We really don’t get the respect we deserve, in other places the doctors word goes unquestioned, who do they think they are?’ or ‘They just don’t get it, they really don’t listen it’s so frustrating’. There are more along the same line, but I think you get the jist.

Here is poor old me, absolutely horrified that this guy in front of me is saying a whole lot of crap I can’t stomach to just ‘let slide’. I somehow managed to brush him off till his tirade was done and he’d had enough of either quizzing me about anatomy or being livid with the patient’s lack of respect.

I think it’s worthwhile to note that when it came to the way he treated me, it’s hard to believe but he was remarkably forthcoming and willing to assist. I still can’t quite work out why he opted for a passive-aggressive approach when with patients.

I think it goes without saying, despite this being quite a stereotypical case of what I’ve often heard called ‘arrogant doctor syndrome’ it is by far an exception to the rule. The vast majority of doctors don’t have a ‘chip on their shoulder’ and feel the need to constantly prove a point. Patients are their number one priority and come down on us as students, if we fail to keep that at the forefront of our minds. Some may see it as harsh, I see it as protecting the core of medicine and maintaining it’s noble purpose.

Despite his often lack of concern, I find there’s one of two ways you can think about what I’ve just explained. You can either look at it from an elitist point of view and begin to think about how you really do deserve to be treated better, or as a lesson for what not to do when you begin practicing yourself. The choice is yours

 

Why Experience Matters

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Learning is a lifelong process in which you encounter teachers and educators of all kinds. Some educators are etched into our memories, whether it be as a result of a pleasant experience or otherwise. I used to wonder why people would often differentiate between the term master and teacher. My thoughts were that a master was an exemplary form of teacher. Why create another word for the same thing, I left it at our willingness to be creative in the way we describe our surroundings. That was until a recent experience that contrasted two people of the same profession taught me otherwise.

During an anaesthetics rotation, I came across two educators with drastically different levels of competency in teaching. The first anaesthetist seemed to be quite competent, however as a teacher it was a different story. Initially I didn’t realise because I’d had no anaesthetics training prior. It was only until the next day that I met with ‘the master’ that I noticed the other was lacking.

The first experience was more a recount of what he did on a daily basis and operational matters that I wasn’t really privy to. Not to mention he lost me in the unnecessary detail for a student of my level and spoke to me for a whole of 10 minutes, if I’m being generous. In 2 hours of being in the operating room, he dedicated 10 minutes to teaching me what in the end was pretty useless information. In fact, the attending surgeon noticed my lack of activity and made a passing comment about ‘my thumbs working much harder than they should.’

Now, if I contrast this with my next anaesthetics training session, boy did my little brain get a shake up! Let me put it to you this way, I was in theatre for approximately 4 hours, in that time I think my mind rested for about 15 minutes in total and I wasn’t even complaining. I have never been so tired after a teaching session, but also so satisfied. It was a weird and wonderful journey in which he picked my brain and brought out archives I’d forgotten were even there. They had been covered in dust and he was able to wipe that thick layer off it and put it to good use. He went as far as taking me back to year 11 and 12 chemistry, which I thought would never be useful in real-life. In summary he took it back to principles.

In the image below, is a very good summary of the individual that I was grateful for having taught me:

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When first learning anything, the foundations are the most important part of any subject as you will always refer back to them. This anaesthetist hammered that home. He said to me, ‘Stop, stop, stop! You keep throwing buzzwords at me, go back to first principles’ he repeated over and over. It took my thick head a little while to register, but when it did it was a light bulb moment. This is how any form of learning should be, the foundations are established and then built on.

The actual content of what was taught is not so important, the method of teaching is what I wanted to highlight. This kind of masterful teaching is available within every industry and even within specialisations. However, this level of engagement during a lesson is rare and not to be taken for granted. It takes a unique kind of teacher, a master.

The Power of Observation

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Our story starts with folk hero and investigative genius, Sherlock Holmes. After walking in for our customary weekly tutorials with the Intensive Care Unit (ICU) registrar, we were surprised when we heard we were going down to the ICU. Not privy yet to the details of what would happen next, we wait anxiously to see what is in store.

It is a well-known fact that medical students have very little, to no business in the ICU. It is a complex environment that operates on thin lines of balanced give and take from the various machines, to which the ICU staff carefully attend to and calibrate.

Upon arrival, we gather near a row of patient beds, the whole 10 of us. He first asks if any of us knew the author of Sherlock Holmes, much to his disappointment none of us had any idea. Proceeds further to quiz us on the profession of the author, I say to myself he must have been a doctor of sorts and sure enough, he happened to be a surgeon.

I await with intrigue where he is leading us and then comes the order of the day, ‘there is an unconscious patient in this room, you are to walk in there and work out what is going on with her, by merely inspecting her and the room’. We collectively look at each other puzzled, but we enter nonetheless to see what we can make of the task at hand.

At first sight, we begin to comprehend two things; the power of observation and a picture telling more than a thousand words. None of us spoke a word for a good 5 minutes, before we were all called to gather and share one thing observed that could not be repeated by someone else. We eventually were able to get it all out and summarise the clinical picture of the woman in front of us.

In brief, she was a young lady who had been involved in some sort of accident. She had bruising and scratches all over her body, but worst of all was the severe trauma to her head. How did we know this? Well, she had to have part of her brain removed, partial craniectomy, which would have been an urgent procedure to reduce the ever rising pressure inside the skull.

Moreover, it seemed that all her body functions were being operated by machinery. Her body temperature, her breathing, her nutrition were all externally supplied. Moving over to the monitors, there was a close watch on particular measures that would give the doctors an idea of the pressure in her brain and how well blood was reaching parts of the body. There was even the slight, but ever important detail of the bed being completely on about a 30 degree incline to allow gravity to lessen the load on the head.

Once we had been through all of that, we were all in awe of the power of observation and its implications for our careers. We rounded the session with a few cases in which we took a few rather arbitrary figures and tried to paint a clinical scenario. From there we could proceed to putting into practice what had been drilled into us through our course so far. For a different, but equally intriguing teaching experience, stay tuned for my most enjoyable teaching experience to date.

Theatre Events

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My first encounter with a patient at a new hospital ends up being while they are unconscious; in theatre. I have been in the operating room multiple times to watch the skilled surgeons and accompanying staff at work. However, this time was more memorable due to the complexity of the patient at hand.

Our patient was a man in his 60’s, who unfortunately happened to have all the necessary complications to put him in this current position. He had what is called an abdominal aortic aneurysm (AAA), which was being closely monitored so it doesn’t burst and potentially send him into a life threatening situation. Just a bit of background to assist with understanding of the condition and how this man’s complications got him tot his point.

The aorta is the major blood vessel in the body. The abdominal aorta is just the part of this artery that supplies the organs of the abdomen. An AAA is where a laxity in the artery wall is exploited by different types of cells in the body such as elastic, fibrous, fatty and inflammatory cells that go to work on forming a home. This home continues to build in size until it starts encroaching on the area where blood flows through the artery, resulting in impaired blood flow and no surprises as to why that’s a bad thing.

Moreover, with this aneurysm continuing to grow, it can start to put pressure on other structures that are next to or around it. Therefore, not only making it harder for blood to flow to different parts of the abdomen, but also impacting the function of other structures in the abdomen. Below is a picture to help put it all together

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Back to the man about to go under the knife. His abdominal aorta diameter was measured at 5.8 cm, which is higher than the 5.5cm standard for surgery. Typically, this procedure is no longer done in an open surgical fashion. However, I walked in to witness a rare procedure nowadays and that is an AAA open surgical repair. The reason the doctors felt this would be the best for the patient was due to the risk factors this man had, which included: being a chain smoker, having high blood pressure, having peripheral vascular disease, being overweight just to mention a few.

These days, most AAA repairs are done under the guidance of some sort of imaging to put in a stent. They clean out what ever is clogging the area of blood flow, also known as lumen, and place a stent that reinforces the wall of the artery and stops it from rupturing. The procedure is called an endovascular aneurysm repair and a clearer visual of the final product is shown in the image below:

This procedure is much more comfortable for the patient, no need for all the potential harms that come from surgery. It also doesn’t have the same recovery period that one needs post-surgery because it’s normally done when you’re awake! This type of procedure, use of a stent has been developed to help minimise the typical harms associated with surgery and to help people get back to normal life as soon as possible.

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Despite all of this, the surgery seemed to have gone well for the man so hopefully he can appreciate the importance of taking care of his health. Making the adjustment to be health focused can often be difficult, particularly in the situation of smoking and adapting healthy lifestyles. The problem often lies in trying to help people through the process of changing old habits, which is no mean feat.

Sometimes people see the impact of their lifestyle on their health, yet can’t seem to quite get around to making it a priority. The barriers to making these changes are both mental and physical, hence being of assistance in this process is always much better than being of an opinion. One day just maybe, the individual sees for themselves that prioritising their health has nothing to do with taking away from their other commitments, but rather it will enhance their ability to fulfill their other commitments.

Just to fulfill the curiousity of those among you who may want to see what the surgical repair may have looked like, I’ve embedded a video of an AAA surgical repair below. Actual AAA repair occurs from time 1.30-6.00 minutes

 

 

Negotiating The Best Treatment

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I was on consultant ward rounds one day and we happened to come across a young 23 year old lady with tragic circumstances. She happened to have a faulty heart that was pumping at less than half the required level.

Being at a similar age to myself, I couldn’t help but think ‘I have so much to be thankful for.’ Here I remind myself first, that gratitude is a characteristic of vital importance. If we cannot acknowledge the many blessings we have been given, we are either blind to the world around us or are overly engrossed in ourselves.

The consultant went on to discuss the necessity of a heart transplant for the young lady with members of her family present. They all understood that this was necessary, however since she was not a domestic patient, the conversation moved on to where the transplant would take place.

Not sure how much you know about transplant surgery, but it is a very specialised form of surgery. In fact, only about a handful of hospitals in Australia actually perform these kinds of surgeries. For the surgery to occur in Australia, there would be a huge cost, but also the follow up involved meant she wouldn’t be able to fly back before 12 months.

Therefore the discussion went along to see where it could be done in her home country. After consulting fellow colleagues from the region, the consultant was confident she could get the required care in her home country in a couple of the big city hospitals. However. the man in the room who seemed to be a relative of sorts as well as the one who would be helping pay for the expensive procedure thought otherwise.

An air of tension built up as the conversation went back and forth about the pros and cons of wanting to get her surgery done in the town hospital. Any neutral observer would have seen the idea was ridiculous, especially considering nobody had performed a heart transplant at that particular hospital.

The consultant. normally a very calm character, could be seen to become frustrated for what seemed a lack of regard for the patient’s welfare. However, upon discussing the matter further and explaining the potential detriment that he may be causing to his young relative, the man decided to speak to the young woman.

After their discussion, much to his credit he was able to come around and accept the fact that this was something not worth being a human guinea pig for. In the end, the best possible treatment was found for this particular patient.

This anecdote highlights the often hidden complications of patient management that can be discounted by many, who do not see the practical implications of their treatment.

‘The pain, the pain’

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Hospitals are not a place for the faint of heart or the emotionally irresolute. It takes a certain resolve to operate in an environment where you are consistently bombarded with reminders of illness and morbid states. Augmenting that, is sometimes the unfortunate event of a patient that has a particular condition you know is untreatable, but you desperately want to do something. This article lies with an older woman who may have single-handedly determined the direction of my future in the field.

In the developed world, the increasingly ageing population brings about its own unique set of challenges. People are living longer, so they are living with disease for longer. They are also experiencing things like non-communicable diseases (preventable diseases), which are nasty conditions such as diabetes, stroke, asthma and COPD. These all deteriorate an individual as they age and make for poor quality of living. One of the manifestations of people living longer, is chronic pain.

Now just imagine as a young person with all your wits about you, you use improper lifting technique causing a slipped disc in your back. That slipped disc is unbelievably painful and this pain will be with you for life. It may not always be there, but when it comes you sure as hell no it’s back. My story lies exactly here, when I encountered an elderly woman with right hip pain.

This woman had been readmitted to the hospital due to the worsening of her pain over the last 3 months. Her condition however, had nothing to do with a spinal disc problem as her MRI results cleared her of that. This made things even more challenging and at the time when the team were discussing her conditon, they mentioned their frustration at seeing this woman in the state she was, but still being unable to do much else except for getting pain specialists assess her. For now treating the symptom would have to do, but even that was weaning.

Her tolerance for the pain relief drugs was building, meaning the dosage would have to increase. However, this in itself highlights a current controversial area in medicine and that is, assessing between patient addiciton to the medication and giving relief to the individual. The solution may seem simple, but just like most things there is more that lies beyond the surface. Addiction to the medication has no limits due to continuous tolerance build up. It may in-fact worsen her outcomes in the long term due to the potential psycho-social issues it can lead to, resulting in more triggers for her pain, as you can see it becomes a vicious cycle.

Nonetheless, leaving her in her current plight is not sufficient. There are current methods of dealing with such chronic pain, but the hunt is still on for the ‘penicillin’ of this area. Her prescribed treatment involves something by the way of monthly injections and prescribed exercises for what could be a manifestation of Osteoarthritis.

I didn’t mention this lady from the outset to demonstrate her as a medical case, but rather to remind us of the struggles that may plague many in our society and to humanise them. Appreciating her constant cries of ‘the pain, the pain’ will live with her probably for the rest of her life. Understanding that this is a reality for many, even if we may not experience it ourselves because we’ve been blessed with health. In fact, she may have single-handedly motivated me to pursue a sustainable, quality of life improving treatment for those enduring a life of chronic pain.

The Obnoxious Registrar

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On my first rotation, I had my first encounter with a difficult team member during ward rounds. I think it’s important to acknowledge that so far this has been a rare occurrence. Nonetheless, this individual was not only visibly annoyed at my presence, but also extremely abrupt.

The abruptness and confrontational nature of his demeanour is what was most challenging. I can understand that medical students are not easy to take under your wing, especially when lumped on top of the already busy schedule of most staff in a busy hospital. Only thing is, he wasn’t really doing any of that! We had a great consultant who was more than happy to take us aside and provide us with what he thought were necessary teaching points for our level.

The situation reminded me of all those teamwork workshops you’re told to attend at one point or another, but everybody is just like ‘meh’. That information would have probably come in handy, but can’t do anything about that. The registrar also happened to be from a surgical specialty, fuelling the pre-conceived idea that many, including myself, had of the kind of people that occupy surgical positions.¬†However, I gladly admit that those ideas were incorrect, as I have been side by side with many a surgeon and they have been nothing but concerned for our welfare and helpful.

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If you are wondering how I dealt with the situation, I think one of the most important things is to remember that you are just as important as anybody else on that team. If you think of it in terms of long term sustainability, you are not there to just make up numbers (even though it feels that way sometimes). You are the future for all those that stand at the ward round with you. A team that appreciates and understands that, is a team that benefits the student most.

In translation, the consultant, registrar, resident or intern were all once students. Therefore, clinical development of us as students is in the hands of all of those mentioned. Let me reiterate also, the large majority understand their responsibility and genuinely feel the need to contribute to your learning. But for those that let that point slip, I will quote another registrar’s response to my statement about being a newbie, ‘we were all newbies at one point.’

 

Mental block

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Invading people’s privacy is part and parcel of what health professionals do. Privacy in this case is willingly given up in order to assist those caring for the patient. The consequences of this are the great burdens of responsibility afforded to the carer.

This was a hard reality to come to terms with, especially for somebody who likes to give people their space. I couldn’t fathom the idea of anyone intruding into my personal space, so why would I willingly do exactly that, to someone else?!

Needless to say, it’s just one of those things that has to be done, because most times it’s in the best interest of the patient. This hesitancy lasted until I did my most invasive procedure yet: insert an IV cannula.

Cannulas are the lines put into a patient’s vein in hospital, giving the treating staff easy access to administration of medication. Below shows the cannula before it’s capped and taped.

In the lead up to finally getting to this point, my stomach knotted multiple times over. I was always afraid of inflicting this kind of pain on anybody, let alone someone in my care. Then of course, there are the insane thoughts of the ramifications of something going wrong and how that would manifest in the patient. You’re probably thinking ‘don’t overthink it, it’ll be right’ and ‘they know that you have to learn’. All of that is true. However, the hardest part is the inner conflict and resistance from yourself, more than anyone else. Yes, there is pressure to keep the process as clean as possible, nonetheless there is room for improvement.

The supervisors are vital in this case, as they can read the situation and jump in when necessary. Thankfully, I was able to get through that mental hurdle and have now completed a few of these. Each one with its unique circumstances and story. However, as an individual this represented a huge milestone as it was one of my biggest mental challenges to date. Being the cause of someone’s agony would pain me to no end, and one of my motivations for entering the industry was to do just the opposite. Therefore, I’m glad this hurdle was overcome and I look forward to learning many more useful patient supporting techniques.

Back to Square One

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After doing an immense amount of study in the pre-clinical part of the course, there is an air of confidence that surrounds you as a student. This should be a piece of cake, you might think to yourself. However one rude shock after another, we are reminded of how little we know.

Being placed at a big city hospital has its ups and downs. One of the more annoying things is the amount of ridiculous specialisation within each branch of medicine. An example of this is when I was on the heart specific (cardiac) wards and we came across a patient with giant cell arteritis of all things. Here I was trying to get my head around the difference between cardiac arrest and heart attack, while the consultant thought it was funny to quiz me about a condition he himself, had never seen before! After he threw that immunosuppression curve ball my way, we all had a good laugh about how little we actually know, found the guidelines for the condition’s treatment and moved on.

As a first year clinical student, this happens all the time. There is a wealth of knowledge within each specialty, it is ridiculous to think any individual could possibly have all that stored away. You quickly come to realise that you’re back to being the clueless kid you once were when you started primary, high school and undergrad.

Appreciating the fact that you will be a life-long student becomes both a burden and a relief. A burden because you know your head will be buried in a book for the rest of your life, but a relief because you know that to stop learning is to die whilst you’re alive. This is true for any career path or lifestyle you choose to pursue.

I’ve been told multiple times about how I’ll be studying for the rest of my life, but didn’t fully comprehend the meaning of that statement. The latest venturing into the complex world of clinical medicine has helped cement that point. As crazy as it sounds, I look forward to putting that into practice.

 

And We’re Off!

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We’re off to a mad start with our clinical years. Workshops and refresher tutes all over the place to make sure we’re all up to speed. Information flying in one ear, out the other. Absolutely frantic as we look to be as prepared as possible before joining the medical teams on the wards.

I must say I wasn’t sure what to expect going into the year. It was unclear what we as freshman clinical students would be able to contribute. Would we just simply be like astrocytes in the brain and fill in gaps (except astrocytes are REALLY important, us not so much) or would we be hands on and getting our hands dirty?

Truth is, we’re not either of those things, rather the level of one’s involvement is really dependent on a number of factors. The most important being your team’s willingness to get you involved and taking the initiative to want to get involved in the first place. Another pivotal point is the specialty of the team you’ve been placed with for the rotation.

I learned quite quickly that there are a lot of things that can go wrong in a hospital setting. The consequences for these mistakes can be quite damaging, if not fatal. Hence it was easy to appreciate the need to be very cautious with the tasks allocated to students. Nonetheless, from my limited experience most teams are genuinely wanting to help juniors advance their knowledge.

From this, I quickly came to appreciate the consultant or junior doctor that would put me on the spot with a question I had no clue how to answer. Whether I knew how to answer or not wasn’t the point, it was about voicing my knowledge on the topic and then having any gaps filled. Many of my peers may not agree on this point, however overcome the initial feelings of embarrassment and view it as a learning moment. This is an example of the importance of perspective. Instead of seeing it as a personal attack, take the opportunity to correct or reinforce your understanding of the concept especially when you’ve just seen a physical example of it.

Out of the blocks and right into the thick of it. There is much to learn, much to be seen and much to be experienced. We are only at the beginning of a new chapter, keep an eye out for the remainder in the reflections to come.