Rashid Elhawli

Rashid Elhawli

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How’s the Serenity?

healthcare

The clock ticked. Through the windows I could see the beautiful inner suburban scenery, a patchwork of old Victorian roofs amongst the shiny new architecture. The city skyline rose above it, glittering in the light of the low-hanging sun. It was a beautiful view. And a beautiful room. Pale, creamy and crisp, the carpet looked freshly steamed and vacuumed. The furniture was modern and minimalist, exuding just the right amount of welcome, but not enough to encourage a prolonged stay.

It was, by now, nothing short of expected for a suite in a private hospital. Having spent four rotations at a major public hospital, I needed a small amount of adjustment. It was at first novelty to me to find that virtually every single clinic came complete with spectacular views, magnificent décor, a coffee machine and a tray of glasses with jugs of water and a dishwasher. Walking the wards the world seemed much quieter, and I learned that there was scheduled in the day a ‘rest period’ from 1-3pm, where visitors were discouraged and patients were encouraged to rest.

The corridors were carpeted, and footsteps were muffled, adding to the air of calm. It lacked the disorder, the chaos and hustle and bustle I was becoming used to in the public hospital. And frankly, I quite missed it. I was once a catering waitress and team leader, and feel quite at home in bedlam. I simply found the quiet a little unusual.

The doctor cleared his throat quietly. He sat by his desk in one corner of the room and had swivelled his chair around to face me. I had actually met this surgeon before, having visited his operating theatre just one week earlier. He had asked me a few questions, however it was the assistant surgeon who had taken me under his wing at the time, and provided a genuinely enjoyable experience. His specialty was spinal surgery, and I was sitting in his outpatient clinic, waiting for his first patient to arrive.

As we waited I kept my eyes primarily at the windows, pretending I was taking in the view. He appeared as if he wished to say something, but was unsure of what, and thus sat there, hunched forward, elbows on his knees looking mildly uncomfortable. It raised in me the question of whether the stereotype about surgeons was true: that they were less skilled than their physician counterparts at being chatty, being much more talented in the operating theatre.

“So you were with me in theatre weren’t you?” I said yes, I was last week. “Remind me again what we did-I had several days in theatre last week.” I tried to elongate my explanation without dilly-dallying about my response; however I inevitably ran out of words and fell quiet. He nodded. “Ah yes, the coccygectomy. It’s not very common; you don’t get to see a lot of that.” It was actually quite fascinating that operation. The patient had experienced a fall off their horse 18 months prior, which had resulted in her coccyx being angled at 90 degrees to their sacrum.

The operation removed the coccyx entirely as it was at risk of perforating the rectum, was giving the patient pain and was actually protruding slightly outwards, leaving a bump on her back. He asked me several more questions, such as what university I was a student of, and what I did as an undergraduate. The response to each question was accompanied by a moment of silence.

Many of his patients were post-op, meaning that they had come in for a check-up after having undergone surgery by the doctor. Most were congenial, however there was one that was quite difficult.

He was a little overweight, accompanied by his non-English speaking mother, who greeted us with a wide smile. The briefing the doctor had given me was that this man had undergone multiple surgeries (the most recent being an L3/4 disc prolapse), was under work cover but would visit his suite with multiple complaints and he believed that the patient was unlikely to return to work. He had-as the doctor described it-a litany of questions, which included his potential for having sleep apnoea, why his breathing was laboured, what he should do about his bad knee, and most unusually: “What surgery did I have doctor?”

I am personally a very impatient person. As I watched the doctor work his way through the patient’s queries, I admired his ability to keep his frustration under control. Despite having informed him that respiratory medicine was not the forte of a spinal surgeon and he should really be consulting a specialist, the conversation about his breathing continued for at least five minutes.

Where I would have most likely become a little bit short in my manner (I am endeavouring to overcome that, I promise), he remained calm and patient. It was fascinating to watch. Once the patient had left however, the doctor breathed a sigh of relief and turned to me with a look, and I laughed. He needed no words. Difficult patients definitely was testing to one’s temper.

Breathing A Sigh Of Relief

pain

It is often emphasised by our tutors that you learn by teaching others, and by doing. Often the ‘others’ I happen to be teaching is whatever inanimate object within eyesight, however I am definitely a person who learns by doing. Practice questions are more useful to me than textbooks, real patients are better than plastic models. I am perhaps not the most dedicated medical student (I don’t spend every hour of my day hanging around the wards for one thing), but I see the merit in what they preach.

As if she had an ear into my thoughts, the anaesthetist wheeled the next patient in, turned around to me and said: “Come, you’re going to intubate.” She was a brusque woman, but kind, and having spent the past three hours with her, and hearing her explain to another patient why she became an anaesthetist, I already admired her. However, the only thing I have ever intubated is the head and shoulders of Alan, a clearly plastic, inhuman model with no pain receptors.

I scuttled over nervously as she bagged the patient, waiting for the propofol to take effect. “Have you ever ventilated someone?” I said no, but I was willing to try (it’s a very good phrase to use, just as a useful tip). She nodded. “Good, now this is what you do.”

I began with some difficulty, since a plastic model’s mandible is incomparable to a real human’s, and I was struggling to jaw thrust whilst holding the mask one-handed. Once the patient had settled, the mask was removed and the anaesthetist inspected the vocal cords with the laryngoscope. “Can you see the vocal cords?” I stayed silent as I searched. I have never been the kind of person to automatically say yes, as I would rather be stupid than caught out as a foolish liar. “Well, can you?” she asked again impatiently. I was lucky enough that I spotted them just as she spoke, since beads of sweat were already threatening to form along my hairline.

I said yes and she nodded: “Now feed the bougie in.” I looked up, frozen. What on earth is a bougie? Should I know this, did I learn what a bougie was? How do you even spell it? What does it even look like, how do I find a bougie?

I probably only had this minor panic for about 5 seconds because to my left appeared this long thin blue tube carried by the anaesthetics nurse, James. I could feel my tachycardia regressing as I thanked him, took the bougie and carefully fed it past the vocal cords and into the trachea. She grunted. “Now the tube.” Again the tube appeared to my left, the work of the heavenly James, and I carefully guided the tube down the bougie, hyper-aware of the fact that vocal cords are delicate and this tube was plastic and thick.

All you have to do, Priscilla, is not ruin this patient’s life.

Easy enough, really.

“Push a little harder, a bit harder, otherwise the tube is going to bend and you are not going to be putting it in the right place.” I mentally crossed my fingers and toes and added a just a tiny bit of strength.

“Good. You’re done! It’s a bit too far down because you got a little bit too excited, but I can just bring that back up again. You see these markings on the tube? If you’ve pushed it down too much you’ve almost certainly gone down the right main bronchus and then you’ll get collapse of the left lung because you’re only ventilated the right. Ok?” I nodded in understanding. She smiled. “Very good. Well done! You’ve bag masked someone, and you’ve intubated! You don’t get to do that every day do you? Well done.”

Like a puppy who has just been informed they’ve been a ‘good girl’, I beamed and felt an instant sense of accomplishment. She was a busy woman though and turned away to ready the patient for the operation and begin the paperwork.  I was left to stand with a slightly more confident air by the wall, where medical students tend to be, waiting for the surgeons to return. It is one thing to successfully intubate one quarter of a mannequin. It’s quite another to say that you have successfully intubated a real patient (albeit with the assistance of an anaesthetist and the nurse). And I think having been able to do that once on my first attempt, I would be a little more confident for my next. Doing, is indeed more useful than reading.

The Operative Matter

rashid elhawli

The familiar smell was difficult to describe. It didn’t sting the nose, but it was sharp. It was not wholly unpleasant, though my nose did automatically screw up in disgust. There was something metallic about it, sickly. But it was also a little sweet. And most definitely meaty.

Well, they weren’t wrong when they said the smell of burning flesh was unique.

I rocked on my heels, blinking furiously. It wasn’t my first rodeo, but fatigue had still managed to creep up on me three hours into my time in the operating theatre. The surgical lamps were bright, but spinal surgery incisions were small, and I had never been particularly partial to prolonged exposure to bright lights. To add to the optical assault, I was observing the majority of this particular surgery on a monitor, as the surgeons needed a camera to magnify the site. The assistant surgeon’s words echoed through my head: “Now Priscilla, if you feel faint at any time, just let us know and go sit down on the floor so you don’t fall on anything.”

You’re not faint, I told myself. Just a little sleepy.  The surgery will finish soon, just hold on.

I’m nothing if not stubborn.

Just as I mentally prepared myself for at least 45 minutes of pure concentration, it began.

Right there, on the centre of my forehead, sitting perfectly on my hairline, was a little niggle. As it came under my attention, the little niggle became a little tickle, and the little tickle became a little scratch, and before I knew it, there it was:

An itch.

I started to feel an unreasonable amount of panic. I was scrubbed in, completely sterilised in that tiny area from chest to belly button, including my hands, which were resting in that awkward position just below my chest that made me appear as if I was constantly timidly trying to ask a question. My head on the other hand, was definitely not sterile. I legitimately had an itch I could not scratch. Could I ask the nurse? Was that rude? Or should I just suck it up and practice some mental endurance?

I chose the latter, convincing myself I was actually being stoic. Besides, imagine the little story I’d be, going around the staff lounge: “We had a medical student once and she scrubbed in, but then had to contaminate herself because she had an itchy head.”

I had never been so concentrated on meditated breathing in my life.

Fortunately, I was saved by the completion of the surgery. The surgeon de-robed, and I was given the opportunity to stand at the table opposite the assistant surgeon, with the immeasurable privilege of snipping his stitches. I say this with some sarcasm; however I did feel much more useful than I had ever felt shadowing other surgeons. When the doctor you have been assigned to puts just that little bit of extra effort to include you in their work, you a) feel like you are part of the team and not a curtain on the wall, and b) learn something.

This is what I have found to really alter the attitude that a lot of medical students have towards their placement. It is a complex balance between the student’s determinations, their interest in the rotation specialties and very importantly, the attitude of the team they are attached to. I personally have flourished and been much more accomplished in the rotations where I had friendly, welcoming teams who made it their job to ensure I played a part.

That being said, it cannot always be expected that doctors will pay much attention to you. Medicine is a time-consuming profession, and in the end, it is probably more appropriate that a patient takes priority over the hapless (and frankly useless at times) medical student. Doctors are busy, and when that happens to be the case, it is up to us medical students to take just a tiny little more initiative to make the best of the situation.

Sometimes it is difficult. The challenge I have often experienced is the willingness to actually turn up to my timetabled clinics, or rounds or surgeries when I have little interest in the specialty. But what I have been learning is that it is not the specialty, but the people who practice within it that make it interesting. I enjoyed my hours in that operating theatre, and was genuinely disappointed when their morning list was over. And that was unexpected for me, as the previous day I had been in theatre under a different doctor and been completely bored out of my mind. It is definitely worth remembering, I think, that it’s not the work that makes the job, it’s the people.

 

“We’re Just Ordinary People”

rashid elhawli

“I want to be an author. Like J.K. Rowling.”

It was a confident statement. By an eight year old whose literary masterpiece at the time was a five page flipbook about how much she enjoyed going to the library to borrow books. It really seemed as if that was her destiny. Violin practice was always interrupted because she couldn’t focus without reading the next chapter. Three hundred page novels was literal child’s play. And it was not uncommon to find her by torchlight, peering down her glasses, unable to prise herself away from the story that held her so enraptured.

Her mother smiled at her. It was good, to see her child find enjoyment in such an intellectual activity. But writing, in a Chinese mother’s eyes, was not going to set her daughter up for a life of wealth and prosperity. “But don’t you want to be a doctor?” she asked. “They make a lot of money. You can always write when you have spare time.”

“No,” the headstrong child said. “I’m going to write a book, and that will make a lot of money. Just like Harry Potter.”

And she believed just that, spending many years after her declaration hoping for that spark, a source of inspiration to produce a story so compelling it would be foolish for a publisher to not consider it for print.

It never came.

Perhaps she realised she did not possess the talent. Or the drive she once had, dissipated.  Or a certain reality had crept up on her as the years passed, while she shuttled back and forth from school to home, to tutoring and violin lessons, completing book after book of practice questions her father had found at bookstores in order to sit for and receive a coveted scholarship from a private school.

Her idealism had been somewhat replaced by realism, and it was this realism that told her that she had to seek another career path.

And so the words her mother had said to her all those years ago would continue to echo through her mind, a steady reminder of what was expected from her. There was a sort of glory, she knew, from medicine. There was status in the title ‘Doctor’, prestige in the income that it came with. But she could not, at the age of 17, say definitively it was what she desired in her heart. Medicine was not only about the prefix, or the six digit sum sitting in her bank account. Did she truly love the sciences behind medicine? She did like biology and chemistry. Was it enough? Was this what she truly wanted or would she be doing what she thought her parents would want?

Unable to decide, she found a happy medium. She had no interest in any field other than science, and so she chose a biomedicine degree, believing that somewhere along the way, she would discover something that would tell her where she was meant be.

Fortunately something did. There was no lightbulb moment, no sudden flash of eureka.  Like stubborn vines creeping up the walls of an ancient house (though perhaps with slightly more tempo), the idea of medicine grew on her. She could not say what, and she could not say when, and she could not say how, but there came a day when she woke up and she knew. And so she sat the entrance exam, applied and placed her preferences for her ideal universities. And she waited.

Perhaps it is time now, to step back from this narrative. The little girl, who became a medical school hopeful, had neither a tragic, nor an especially privileged life. She was in all respects, quite ordinary. Then why, one might ask, would her story be a subject for publication?

Aside from this being my introduction as a guest contributor, I do have a point to my tale. Ordinary stories about ordinary people are oftentimes considered uninteresting. However, common things as doctors are wont to say, are common. Ordinary is every day. And most importantly, a person’s story is their story. As budding doctors, we are told to listen, to understand, and to use what we have learnt about our patient for better management. Patients will not always be regaling tales about their days adventuring in Madagascar. However, they will tell you they spend every Saturday morning cheering for their son’s football team, or every Tuesday and Thursday morning dropping their daughter off at day-care before visiting their father at his nursing home. These may seem like inconsequential details, but from dirt can gold be gleaned. Your hypothetical patient is family orientated, very busy, and always on the go. What can you offer that will suit your patient’s lifestyle?

As Paul Kelly once said: “from little things, big things grow”.

Never underestimate the ordinary.

 

Bildungsroman

rashid elhawli

My name is Craig (pseudonym). I am writing this to share my experience as a human, who happens to be a medical student. 

This journey began on my birthday, when tired and bleary eyed I rolled over and unlocked my cracked phone screen.

At this point, I’d had rejection emails from every state in Australia, save for Victoria. My hopes were low and I had honestly forgotten that I’d ever even applied to my eventual university home.

As the emails loaded I tiredly closed my eyes, the all too familiar blue circle going around and around and around…

Finally, there was an acceptance email. 

And so my journey began, with me running around an empty house yelling and whooping and scaring the dog stiff. 

For the rest of this piece to make sense I should give a little background on myself. Most importantly for the context of this piece, I have suffered from major depressive disorder, anxiety and borderline personality disorder from the age of 15. 

Fast forward to my move to Melbourne. I felt alive and excited! New places, new people, a new course and independence! I felt like a dog on a beach. So much to do! to do! all the time! all the time!

Alas – the motivation and excitement were not to last.

My life as a medical student has been difficult. Budding relationships, independence, responsibility and the stress’ of a difficult course in conjunction with mental illness has led to 2 and a half of the most difficult years of my life. 

In my first year, after enjoying ‘playing the field’ I found myself in a relationship. This beautiful woman sparked intense passion and excitement, and true to my romantic roots, I quickly fell in love. Our relationship was very fast moving, and before long I found myself contemplating a long term future.

I can remember the night it came crashing down incredibly clearly. You see while I loved her, my own confidence and self esteem were low. In the weeks leading to our break up my mental illness was significantly impacting my functionality. I had entered a constant state of hopelessness, anxiety and depression. DALY’s were effected but more relevantly, my interactions in our relationship were too.

And I understand why she broke it off, it wasn’t fair on her. Being surrounded by constant unhappiness will wear you down and make you unhappy.

In short, I was spiralling, and when the break up occurred, it broke me. 

I swallowed half a bowl (I estimate approximately 150-200) of pills. A concoction of SSRI’s, SNRI’s, MAO inhibitors, serotonin modulator receptors and any other class of antidepressant you can think of.

I ended up in ICU with serotonin syndrome (all the while asking the doctors to explain to me in great detail what was happening like the annoying shit I am). I was intubated, put into an induced coma for 2 days and then kept in ICU for a week. After this I spent a month in a private mental health hospital, which caused me to miss the first month of second year. 

After this experience I am a changed person. While before, I was depressed and had difficulty managing my emotions, I still had passion for some things. I had the motivation to try and do well and made an effort to continue living as normal. Now, I’ve almost given up.

Two days after discharge from the mental health hospital I was thrown back into the world of university. At the same time, I was attending half day ‘strategy groups’ every Tuesday in order to try and pull myself out of the hole I was in. I turned to a multitude of vices in order to cope, distract and forget. Sex, drugs (never on placement), television, sex and drugs were my world. I never allowed my mind to not be stimulated by something, lest it be allowed to reflect on itself. And when I rarely did have this opportunity, I would feel extremely suicidal.

Midway through the year, I readmitted myself to the private hospital. I was very volatile and extremely suicidal. I felt I needed the structure, support and safety the hospital could provide.

On the second night I was caught naked in another patients room who was due for discharge the next day. I was promptly kicked out of the hospital and I resumed wading through my days.

University was a second thought to me. I was merely existing from day to day, not truly living. I attended only 2 lectures in the entirety of the year, only showing up for compulsory tutorials and labs. If I am honest, I only remember the occasional event throughout the year, the rest is lost from memory. I would essentially pass by cramming before exams with the support of a good friend.

At this time I began DBT (dialectical behavioural therapy) in place of ‘strategy group’ as an outpatient. This took up an entire Tuesday every week. This was difficult to manage as well as keeping up with university.

The DBT at first seemed pointless. I felt bored, out of place and frustrated. I was by far the youngest and there was only one other male.

But as time went on, I began to realise the value of these sessions. And as I began to participate my recovery was on its way.

I think that possibly the most important thing it gave me though was perspective that my death would not only be effecting me. While I can still rationalise suicide to myself with “it won’t matter, you aren’t there,” I came to realise the effect it would have on my family. They had flown within 24 hours to see me on the night of my attempted suicide (from interstate). The DBT helped me realise the love they do hold for me. I can remember being roused at one point from the coma before I was put back under. I saw mum, dad and my little sister surrounding me looking devastated. 

In August of that year I met a girl, and even though it didn’t feel right, and it felt unhealthy to me, we began a relationship. I believe I was seeking comfort in someone.

Second year continued in this fashion, with me doing DBT, using escapism to manage my emotions and generally scraping by. I passed the end of the year after having to sit supplementary exams, and getting through by the skin of my teeth.

Third year began. Placement excited me and for perhaps 5 days I was able to motivate myself and attentively attend hospital placements. Then began a cycle of missing classes, not showing up and avoiding leaving my room at all costs. The university, more stringent on attendance now, noticed my absences and so I was called in and given a warning.

Now, more than halfway through the year I am still just existing from day to day. After another break up with the girl from August, and the death of a close friend, it seems as if the year will never end. But I have come to the realisation that this is the time that I need to “get it together” or defer the year.

It’s time for me to grit my teeth, grind through the burn-out and make the final push to get through the ever-looming exam block.