The story so far…

I cannot believe that it is May 2017 already and I have not posted a single blog since my birthday last year! So much has happened, yet if I really sat down and wrote out the details of the last half a year, I am going to be here typing for the next 6 hours and this post is going to be incredibly long and tedious to read. So here’s what happened in a snapshot…

Life

Baking

So, I have somehow developed a keen interest in baking over the last few months. Since about Christmas time, I have been baking like a mad woman. When I am at home alone, in the quiet of the evening or nighttime, enveloped by the cosy warmth emanating from the oven, pottering around the kitchen and concentrating on making something awesome… I find this process extremely therapeutic. When I am baking, I forget about the stresses of the work day- the missed cannulas, the difficult intubations, the failed regional blocks… all these failures are wiped out of my mind as I get into my “flow.” All I can think of is the math calculations as I adjust my ingredient amounts, all I can hear is the whirring of my mixer, all I can feel is the heat from the oven, and all I can smell is the delicious sweetness of the sugar and butter and flour being whipped together into batter. At the end of each baking experiment, I am also presented with the satisfaction and reward of a dozen stunning cupcakes, or a scrumptious tray of cookies. I have truly fallen in love with baking!

Cooking is an art, but baking is a science. Indeed, the process of baking marries up my love for food and for science. I am so curious to find out what chemical reactions are going on as I add water to flour, or sugar to the batter, or what happens when the air bubbles in my batter expand within and escape out of the cake’s gluten structure under heated conditions. I find all of this fascinating, and have gone so far as to purchase a textbook on “how baking works.” So far, I have read about 4 chapters of it and I am being enlightened with each page I turn. I am reading about heat transfer, and the properties of the different materials used in bakeware. I am learning about which ingredients are tenderisers or tougheners, which ones are moisturisers and driers. I am enlightened about what happens to each of the ingredients at the molecular level as you mix them, or heat them, and cool them. I’ll admit that I have not really done much reading outside of medicine… and this (text)book has been a real pleasure to get back into leisurely reading with.

I think my baking escapades have also been made much more pleasurable and successful since using recipes from youtube celebrity baker cupcakejemma. Her recipes are so unbelievably incredible. It also helps that I have a very willing cake/ sweet-treats eater friend who always welcomes my attempts to feed him cake. I now try and find any and every reason to bake him cake, knowing that he will eat it (and I can just have one or two only instead of getting fat from eating all my own baked goods).

Fitness

So, whilst in one aspect of my life I am baking away with highly calorific butter and sugar and flour, another aspect of my life has been focussed on getting rid of said calories. Oh how life contradicts itself in so many ways! I have been spending a lot of time in the gym with Emma doing squats, deadlifts, chest presses and lunges… all in the hopes of building some muscle that will burn calories even when I rest. I have to say that my progress has been incredibly slow… potentially to the point of being non-existent. I am so frustrated as I have been working so so so hard and yet am hardly seeing any result at all. After all, I have ramped my physical activity up by at least 80% compared to the days before I joined the gym– when all I did was to consume cake, chocolate, cookies and coke… and when the most exercise I ever did was to go shopping for new clothes in the department store.

Perhaps I really do have to work much harder on my diet. Rumour has it that weight loss is 20% exercise and 80% diet, so I may need to rethink my intake! However, this is also part of the reason for my aggravation because my diet has improved by leaps and bounds since my cake and coke days.  Now, I definitely give a lot more thought into what I put into my body. I hardly drink any coke at all these days, and I do not buy chocolate bars anymore. I still eat cake and cookies but I am quite a lot more watchful over how much I do actually have. So, with clean(er) eating and a heck of a lot more exercise, why am I still not shaping up nicely as I would really like? Do I really have to go cold turkey and eat bland food that I do not enjoy for the rest of my life? I am so disappointed because even my clothes do not feel any looser than they did before I started this “healthy living” thing a year ago. I am not giving up though… like I said before, Rome was not built in a day, and I did not get fat overnight. I am going to have to keep working at this body… try different activities, different diets… and hopefully someday I will reap the results that I desire. To me, strong is the new skinny. I want to be lean, toned and strong…

J, go and try out a new workout programme, a new gym class, yoga, dance, swimming… it may be scary to go at first, especially when you are on your own and you fear looking like a real clown amidst the experts. But please, just start.

I have been taking fitness inspiration from a celebrity personal trainer on instagram. Her name is Kayla Itsines. She does not advocate the whole “I wish I have your body” mentality- and I agree…. yet, she is SO stunningly beautiful that I cannot help but look at her and think “goals!” I guess you can say she is my fitspiration? Seeing her so beautiful and strong really motivates me to keep working on my own body.


Closer to home, Jamie Teo (Miss Singapore 2001 and former TV personality) has been a real inspiration and motivation to me too. She posts her home workout videos regularly and you can clearly see that her body has been well sculpted by all that exercise! She is so beautiful!

My final other source of inspiration comes from a man. He is none other than the 22 year old Australian Olympic swimmer Cameron McEvoy! This man is really like a machine. Somehow, he has managed to balance being a swimming champion with academia as he pursues his dream of becoming a physicist. I love seeing how he works out so hard both in the gym and at the pool to be in the best physical shape for the swimming championships. Yet, he alternates his posts from the pool with geeky posts of complex mathematical equations, or how he is reading up on the work of physics greats such as Richard Feynman. I love that someone is actually able to be so dedicated BOTH to sport and to science- something that is so difficult to do when both disciplines demand 100% dedication from 100% of you. To see someone being able to achieve/ or at least work to achieve such a feat is a real inspiration to me. And it helps that he looks really cute too.

Work

Prizes

So, the last time I went to Edinburgh in November, I had actually gone to attend the Patient Safety Conference where I presented a poster on my Ultrasound Screen cover project. I am extremely happy to say that I won the first prize for my poster! When I was there, I was able to explain the ideas behind my project to the other delegates and quite a few consultants from other hospitals around the country were asking me about how they can get hold of one of my screens. I am now desperately trying to get the hospital’s innovation team to help me further develop my product. Hopefully, we will eventually be able to sell the intellectual property to a commercial company so they can manufacture it in bulk in industry (compared to my homemade craft project of a prototype at present). I am excited as to what can possibly become of this little project– after all, the entire idea and concept had come completely from God as an answer to my prayers. I am extremely grateful to what the Lord has blessed me with and I really want to take this forward- to the rest of the UK and even beyond!

Oh by the way, when I was at the conference, I also had a chance to meet and even speak to Princess Anne (daughter of Queen Elizabeth and sister to Prince Charles). She is the patron of our Royal College and was in Scotland for St Andrew’s day anyway. And so, she came to attend our event. It was immensely exciting because I have never ever seen royalty up close and personal before. As trainees with posters to present, we were given the opportunity to speak to the Princess when she came to view our posters. We all had a short briefing before her arrival whereby we were taught to address her as “Your royal highness” at the first instance (and to curtsy as we said it) followed by “mam” (not mOm) thereafter. Frankly, I was so nervous about seeing her and speaking to her. I was worried that I would call her “Your majesty”– which is wrong as it refers to the queen. Also, I had no idea how to curtsy in a pair of trousers and so I just bobbed when I saw her. When I eventually got chatting to her, I actually found that she is very human. And a very nice one too. She was very friendly and seemed to genuinely take interest in what work I had done (though I honestly do not think she really understood what the heck I was doing).

Oh, one interesting thing happened too. After the adrenaline rush of having spoken to the Princess, and after speaking to quite a few other delegates about my work as I stood in front of my poster presenting it, I decided that I was parched. I found an opportune moment when I could leave my poster to get a drink. I had my eyes set on a jug of tea that was on a table about 4 meters away from me. In order for me to get to the tea, I had to walk behind Princess Anne (who was mingling/chatting to some other important people) on one side and a group of female doctors on the other side. I calculated my steps and moved swiftly towards hydration. However, just as I was walking behind the Princess, a female doctor from the other side took a step back towards me, effectively trying to squash me. In my haste to avoid her, I accidentally took a step towards the Princess and basically kicked her heel. Can you imagine the horror on my face as she turned around to find out who her “assailant” was. I was so shocked that all I could manage was “I am so sorry, so so sorry.” Oh man! But what a story for me to tell in the years to come– that I have kicked royalty in the heel in this lifetime!

In February, I took my project to present at the LSA trainee’s prize competition as well. It is something that I have been determined to do for the last few years but never really had anything that was “competition material.” This time, I submitted my entry and was determined to win the beautiful Jackson-Rees medal. I knew that the work was good and that I had worked hard on it. That night was going to be the night for me to present it orally and do it some justice! I practiced my oral presentation over and over again. I needed to sound enthusiastic and convicted by my own work. I needed to to be engaging and charismatic. I needed to keep my words understandable despite the fast pace that I had to go at to get everything I needed to say in. Yet on that night, I was SO nervous. When I walked into the lecture theatre, I saw DG to whom I admitted that I had so many butterflies in my stomach that it felt like I was sitting yet another exam. DG being DG told me not to be silly and to remember the 3Cs! I was 3rd in the line of 4 presenters. I think I eventually did a reasonable job of presenting my project. I was asked a load of questions, some of which I really struggled to piece of coherent answer for. I was desperate for a win. And yet I lost. I was 2nd place- still considered a win to most people especially since there is still an associated cash prize. However, I really really really wanted the shiny medal. I was disappointed. And then I was cross. Why? Because the 1st prize winner (an arrogant junior of mine) came over to me and said “I’m sorry I beat you.” Like, seriously? Anyway, now that the emotions of the night have all settled down, I am ultimately still very grateful to God. 2nd prize is still a prize. God is still good to me. And in the hilarious words of my wise mother “Don’t be disappointed. Sometime 2nd is better than 1st. Like singing competitions, 2nd prize winner always 发展得比冠军还要好 later. Remember it’s just a prize. So be happy that 你榜上有名,还有钱拿。你好强啊。一人之下,万人之上?。恭喜恭喜。”

Paediatrics

Now back in the children’s hospital. Loving it most days as the little children are so cute and beautiful. Even with the crying, screaming and protesting, all is forgiven when they are asleep and adorable like little angels. All is forgiven when you can have little cuddles with them in the recovery room. Children are so innocent and beautiful.

Also, who does not love to go to a workplace where there are colourful murals on the walls? Who does not enjoy blowing and popping bubbles as part of the job plan? Who complains about being able to play with toys whilst waiting for their “clients” to arrive?

The children’s hospital has been a really good place to work in… not just because of the children and the toys, but also because of the staff. In my opinion, you have to have a soft and gentle side to be able to work with children. And so paediatric surgeons are really some of the nicest surgeons I have ever worked with. Of course, some of them can still be arrogant and difficult… but compared to the egos and rudeness I have witnessed in adult tertiary centres, they are really quite mild. I love that in this hospital, people value me as part of their teams. I get addressed by surgeons, TCAs, ODPs and scrub nurses by my first name! This is something that does not often happen because people do not usually make an effort to remember the name of a passing anaesthetic registrar, and especially not if you have a name as uncommon as mine!

Nevertheless, I say goodbye to theatres for 6 weeks as I go and join the PICU/transfer team for a bit. I am admittedly very nervous about this as the pathologies in paediatric ICU are very different from that in adult units. The complex cardiac patients terrify me the most as I do not even know how blood is flowing within their congenitally abnormal hearts! Also, I am still unfamiliar with considering infusions in terms of mcg/kg/min… something that we never do in adult practice where everything is usually a standard mixture and adjusted in ml/hr! There is much to see and learn in the coming month and a half. I just want to pray to the Lord for good teaching and learning, and much safety as I go into an environment that I am completely unfamiliar with and uncomfortable in.

Church

A very powerful sermon from Mark 15: 1-15, 25-39. I am completely shaken by this.

You can be the crowd. Jesus is a very compelling figure. People have all sorts of objections to Christianity, yet when it comes to the actual person of Jesus, all sorts of people who hate the church still think that he is the best example of humanity that we have. He has unlimited power, and he uses this to help people– Everytime he does something terribly powerful and scary, we see him next caring for someone, talking to someone, healing someone, forgiving someone. Yet, He is uncompromising in his claims– that everyone who has ever lived should respect his authority, that we have to be fully accountable to Him. He says that we will do nothing more important than deal personally with him. As a result, many feel that “He is awkward for me” and “I do not like him making these claims– I need to get rid of him.”

What crime has he committed? They could not name the crime. Yet they shouted all the louder “crucify him!”


You can’t be Jesus. Barabbas was supposed to be the one crucified. It should have been him- the normal guy, the everyday criminal. However, Jesus died in his place instead. Yet, it was not a straight swap of one peasant for another. Jesus was different. 3 hrs of darkness at noontime on the day of his death– something not normal, and which is a sign of God’s anger. As Jesus hung on the cross, he cried “my God, my God, why has thou forsaken me?”– a cry of religious heartbreak not likely to be heard from hardened criminals. On the other side of the city, a large thick curtain rips from top to bottom the moment Jesus dies. THERE IS SOMETHING VERY DIFFERENT ABOUT JESUS. The death He died, only He could die. Jesus has terrifyingly limitless power and authority– heck, he controls evil with just His words! Yet, this king over everything chooses death– the one who committed no crime took the anger and separation from God in our place. “He saved others, but he cannot save himself?” What nonsense. He did not save himself, so that he can save others. And so at that moment, the curtain is ripped– from top to bottom, as if God has reached down, so that all the warning signs that remind us of our uncleanness has been ripped down by Him.


You can be Barabbas. The son of God died for you Barabbas! He took your place. Was Barabbas relieved? Was he thankful? How did he respond/ soul search? Did he live a better life afterwards? We do not know anything else about Barabbas. It was unimportant how bad Barabbas had been. It was unimportant if he went on to do something great. The only important thing about him was that Jesus died for him. And there is just one word to describe him: Released.

For the non-believer: Do you feel held back thinking that you can never be good enough to be a Christian? Do you think “I am too different and too distant?” Remember that Jesus never said “earn this.” Jesus’ offer to Barabbas is the same offer to you. “Release.” YOU CAN BE BARABBAS.  Having witnessed how horrible a price it is to pay for your sins, do you really want to insist on paying for your own uncleanness? Do you really want to say “Put me back in the cell and punish me please?” YOU CAN BE BARABBAS, so why would you not be? Let Jesus pay for you. The curtain is ripped. You can walk in and begin a life of knowing God and being made clean.

For the Christian: do you judge your friends? Do you think that some people are beyond salvation? Do you doubt that you can invite ANYBODY into this relationship? Even when you have witnessed that the first person to believe is the centurion who hammered the very nails into Jesus? Jesus died to rip the curtain in two. Please stop sewing the curtain back up. Stop holding back Jesus’ offer to people who do not fit the “profile.”

Thoughts on the drive home from work

I spent about an hour and a half this morning hand ventilating a little baby with a Mapleson F circuit (only 3kg, ex-prem, chronic lung disease, for PDA ligation).

Consequently, I spent an hour and a half breathing in unscavenged waste gases from the circuit with 3% sevoflurane and a fresh gas flow of 6 litres.

I reckon my own end tidal sevoflurane levels were probably about 0.5 by the end of it and I felt incredibly tired as I drove home from work.

Just thinking: If we advise our patients not to operate heavy machinery for 24hrs post GA, perhaps I really shouldn’t be driving after practically giving myself half an anaesthetic?

Mm…

p.s. My right hand has also probably suffered repetitive strain injury from all that bag squeezing… *sigh, occupational health hazards eh?

Grumpiest doctor

In the last 2 days, about 3 of my colleagues have commented that I am the grumpiest doctor they know. One of them even went so far as to say that “she doesn’t even enjoy what she is doing.”

They claim to have made their comments in jest, but these comments really jolted me into reflection.

Am I really such an unhappy doctor?

At this stage of my training, perhaps I am. I am still re-living the nightmare of 1 month ago on a daily basis- every time I think I feel a little bit better, something else happens to put me right back into my place of misery. Adding to that, I have an educational supervisor from hell- she demands me to do this and that, then buggers off into the fog and provides no guidance or support whatsoever for me to achieve all these lofty plans that I have no interest in. Thirdly, there has been little teaching and learning where I am working at now. To be fair, there have been half-hearted attempts at teaching. I always have a great desire to ask questions, to explore thoughts, to learn new skills; but when the teachers appear disinterested, my enthusiasm runs dry. Fourthly, the patients I have been seeing recently have been sick as dogs. When I have been to review these patients on the wards or in A&E, I have so regularly found myself thinking “sh*t, they look like they are going to arrest on me anytime soon.” I have had to scoop and run with so many of these critically unwell patients, many of whom I then spend the entire day with as my “private patient” trying to resuscitate and stabilise on the ITU. Transferring someone to CT scan with pH 6.9, unrecordably high lactate, on 40ml/hr of adrenaline and a systolic BP of 80? Check. Jumping onto a patients bed to intubate a morbidly obese Down’s syndrome patient with a difficult airway during a cardiac arrest? Check. Hugely difficult to ventilate patients post intubation? Check check check. Anaesthetising a grey and clammy patient at a remote site that I’ve never even been to for an interventional radiological procedure requiring awkward positioning? Check. Having to place invasive lines in massively coagulopathic patients with platelets less than 10 or INR more than 10? Check. My sphincters have never been clenched so much in the space of 2 months, and my adrenal glands have been so plump from all the adrenaline needed to help me fight or flight through these massively stressful situations.

Finally, the junior doctors in this country have been/ are being shafted by the government. They are proposing new contracts that will remove safeguards against overworking doctors. They want “social hours” of working to extend from 7am to 10pm Monday to Saturday (i.e. no recompense for obviously antisocial working- seriously, who values their 9pm Saturday evenings the same way as 9am on a Tuesday morning?). Doctors are essentially doomed to a 30% pay cut under their proposals, whilst the people in authority have recently given themselves a 10% pay rise so that they are “paid the right rate for the right job.” And? Does this same rule not apply to us? What is the right rate for being at work 3 out of 4 weekends in a month? For having lunch at 6pm or missing meals altogether? For being vomitted or even spat on? For having to examine bits of people’s anatomy that will make your stomach turn? For enduring the melange of odours that the body is capable of producing? For all the difficult decisions that need to be made? For having to face death every single day? What is the right rate for having to study for extremely difficult professional exams in our own time? For having to pay thousands of pounds to sit said exams? For needing to pay for medical defence, college registrations, professional development courses? What is the right rate for sacrificing such a large part of my own personal and family life so that I can look after you?

So yes, I am miserable. I am depressed and demoralised. This is not what I signed up for when I was 18 years old and fresh out of junior college.

But I know I need to smile more. Other people do not need to be at the receiving end of my misery.

Come on, J. You were not like this before. You don’t have to become like that now.

Success is sweet because the sacrifice has been so great

The week leading up to the final viva examination were awfully horrible days. I had taken annual leave to revise at home; but after 4 months of solid revision, I seemed to have completely and utterly run out of steam. I would get up at about 10am everyday, faff around for about 2-3 hours on youtube before finally forcing myself to sit down and stare at the books. The procrastination got so out of hand that I ended up having to eject myself from the house and its distractions to study at the nearest cafe. Nevertheless, the first couple of hours were always the least productive, and it would take me another 2-3 hours to learn the first topic of the day. My revision momentum would build up so painfully slowly, and I would only feel as if I was starting to get into the rhythm of things at about 7 or 8pm at night. The “real revision” then goes on till about 3 or 4 am in the morning before I decide that I have done enough for the day and probably deserved to go to bed.

Once in bed, I would proceed to “quickly” run through everything I learnt that day in my mind. The process was often not as quick as I had expected it to be, and regularly led to tangents whereby I would try and remember other things that I had learnt the day, week, or even month before. Going to sleep was never a conscious decision, and I was almost always led to dreamland only when the machinery that is my brain would “hang” mid-thought. Sometimes I would fall asleep, then suddenly jolt awake and begin to run through how I would anaesthetise a phaeochromocytoma, or a patient with chronic renal failure, or someone with hypertrophic cardiomyopathy (just checking if I had forgotten).

It was really a rough time that I thoroughly did not enjoy. The more I revised, the more things seemed to crop up that needed looking up. Learning about oxygen was never just about the gas itself. It would lead on to how oxygen is distilled from air, how it is stored, how it is transferred from the pipeline through the anaesthetic machine and to the patient, how it is measured. That would then lead on to a question on the oxygen cascade and oxygen carriage in blood. Which then brings us to the topic of indications for long term oxygen therapy, or hyperbaric oxygen therapy, and the effects of oxygen toxicity. Now, that is only on the topic of oxygen. Imagine expounding on every single other topic that is in the curriculum in the same way. My mind was completely and utterly saturated.

I remember evenings when I would feel so overwhelmed and anxious that my palpitations would kick off again. I remember the uncomfortable churning in my stomach as I struggled to cope with the knowledge of my lack of knowledge. I remember the one night when I prayed to God and sobbed my eyes out. It was all getting too much. I was physically, emotionally and mentally drained. My stamina was running out, but somehow I had to keep it all together. I must not peak too early, nor should I sink into a state of despair prematurely. I had to keep myself together and pace myself to reach peak form on the 24th of June.

Hobbo and I became a revision pair before the exam as well. Thanks to the wonders of technology, we could viva each other almost every evening via Skype. We tried to work through the past questions on the Coventry Final FRCA website, and sought to ask each other the harder & more unexpected questions that have previously come up. Somehow, we had to practice how to talk AROUND things that we knew nothing about. We had to dig deep into working things out from first principles, and learn to deliver an answer we are unsure of with an overwhelming confidence. I found that one of the hardest things to do.

I took the train down to London the day before the exam. En route, I worked through the College questions from the College guidebook. I managed 2 long cases, 2 short cases and 2 science questions… and then headache struck. The same headache I had when I was on the train down to London for my Primary viva 2 years ago. The headache that required me to close all my books and bury my head into folded arms on the table.

I eventually arrived in London and checked into my usual exam hotel at Studios2let. I revised a little more. I then headed off to Nandos for the usual pre-exam dinner, and as usual looked through R.Craig’s statistics notes as I ate. I must have gone through these exact same motions at least 3-4 times in the last 4 years. Anyway, I continued to do some more revision on one of the art installations outside Euston station that evening, and it was only after I had convinced myself that I could remember the Van Hoff’s equation for osmotic pressure that I decided it was time to head back to the hotel. More attempts at last minute cramming ensued, but I could simply put no more into my brain that day. I was completely spent, and all I was achieving was placing myself in a state of panic. I made the conscious decision to stop. Shower. Sleep.

The alarm clock rang. It was a signal to war. I got up and showered, packed, and prayed. As I cried out to the Lord, I could feel my teeth chattering, my hands trembling, my muscles stiffening up. Adrenaline and anxiety surged through me. The nausea I felt that morning made having breakfast a rather difficult and drawn out affair. I had no appetite to eat at all, but I knew I had to force this brain food down my gullet. Breakfast was followed by a long, slow walk to Red Lion Square with my luggage in tow. I did not feel good that morning- my head was not clear. I felt fuzzy. I knew I was not in top form. Had I gone past my peak? I contemplated this as I made my way to the college… and then something caught my eye. A passer-by emerged from a shop wearing a T-shirt emblazoned with the phrase “Success is certain.” That proved to be my motivation for the day, and I regarded that as a sign from God.

More palpitations, tachycardia, shortness-of-breath, and queasiness later, we were finally led to our exam. The morning exam was the clinical vivas. My long case was on an obese man with hypertension and a history of alcohol excess presenting for elective knee replacement. He was found to have an ejection systolic murmur and left ventricular hypertrophy on his ECG. I prepared my case as though he had aortic stenosis, only to be given an echocardiogram and cardiac MRI result during the exam itself saying that the valves were normal! So scrap aortic stenosis! Summon all knowledge on HOCM, on the spot! That was the route the exam went down instead.

My first clinical short case was on sepsis- fairly straightforward in my opinion.

The 2nd started with “What is Crohn’s disease? How does it present and how is it treated?” My heart sank- medicine! Flippin’ medicine! I’m trying to sit an anaesthetic exam here! Leave medicine to the medics! Anyway, I summoned everything I could remember about Crohn’s from my med school finals as a 4th year medical student 8 years ago. It was slightly painful. Thankfully, we moved away from general medicine and swiftly onto sedation practices for gastroscopies and colonoscopies. Not my hottest topic considering that I last looked up sedation guidelines 2 years ago- but it wasn’t terrible.

The final short case was on retained placenta. Great- I cover the maternity on-call ALL THE TIME so I should be hot on this. “What are your concerns pre-operatively?” I started with “the patient still has the physiological changes of pregnancy…” Nope, they didn’t want to hear that. “Bleeding.” What else? “Infection?” What else? I ran out of things to say. “How quickly does she need to come to theatre?” “Immediately if she is bleeding and haemodynamically unstable. As soon as is practically possible if she is stable- excessive delays should be avoided.” Not the answer they were looking for. “Within 75min?” They didn’t look happy. The examiner took me all over the place with this question, and kept coming back to “what are your other concerns?” I was so frustrated as I simply did not know what she was looking for. Thankfully, the final bell rang just in time to save me from the misery she was putting me through.

I left the morning exam feeling intensely dissatisfied. The exam just kept replaying in my mind, and the more I thought about it, the worse my performance appeared to be. I was convinced they had both given me a 0 for that last short case. That means I lost at least 4 marks just on that question alone. Assuming that I scored full marks for the other questions (which I was not sure I had), that gave me a budget of 4 marks to lose in the afternoon’s science exam- my weakest area, the very area that led to my failure the last time. That means I am likely to fail. Fail. Fail. Fail. I imagined having to undergo the hell that is revision and exams a 3rd time. I thought about how upsetting it would be to have to scrap my 30th birthday plans so as to revise for the December re-sit. I was miserable (even when eating lunch from my favourite Japanese fast food restaurant in London: Wasabi!).

After lunch, I went back to the college and sat in the lecture theatre for about an hour or so whilst waiting for the afternoon exam to start. I tried to put some last minute information into my (still fuzzy) brain. There were a couple of other candidates around me that afternoon, everyone desperately trying to keep it all together. Eventually, it all got a little bit too much. I needed to have a breath of fresh air, so I went outside to Red Lion Square and sat on one of the park benches there. I stopped myself from thinking about work, concentrating instead on how lovely and sunny it was, and how comfortable it was to feel the light breeze in my hair. Now and again a moment of panic would strike, and I would calm myself down by thinking of that “success is certain” sign I saw in the morning. Nick had also sent me a message that afternoon “Good luck Dr T! Keep going, you can do it!” YES I CAN. Keep the 3Cs J. Remember the story of the broken pencil. You are the worst judge of your own performance. Forget the morning, concentrate on the afternoon!

A gruelling 3 hours of waiting later, I went back to sit my afternoon exam. After putting my bag back into the locker, I thought “I should just quickly glance at the anatomy of the facial nerve…” Nevertheless, I struggled to find the appropriate page in my textbook… so I thought “oh screw it, I can’t be that unlucky.”

My anatomy viva started with “In which situations do we have to monitor cranial nerve function?” Flippin’ heck, I knew what they were going to follow up that question with. I kept my composure and started going on about monitoring facial nerve function in ENT surgery, 3rd and 6th nerve function in raised ICP, brainstem death testing, Guillan Barre Syndrome…” Then the question came “describe the anatomy of the facial nerve.” Great, I know nothing about it. I made some crap up on the spot, and even said that it exited the base of skull via the foramen magnum???!! (what an idiot). I was just about to lose it when I remembered some advice I received via email- move on! There are marks to be scored in later questions, don’t dwell on what you don’t know. So move on I did. We talked about the cranial nerves tested in each aspect of brainstem death testing, how recurrent laryngeal nerve function is monitored… we talked about loads of stuff, and even though I have never really encountered this question in my exam prep, I was surprised by how much I actually did know.

Then, the rest of the exam flew past and I knew I nailed the science. I was so thankful to God that nothing unexpected came up. We talked about the physiology of moving from the supine to lateral position in thoracic surgery, and causes of hypoxia in one lung ventilation. My pharmacology question was on drugs for diabetes and the treatment of DKA. I offered them 2 classification systems for insulin. How they are made (bovine, porcine or recombinant DNA), or how long their effects last (rapid, short, intermediate, long). They caught onto it and said “ok, so tell me about how insulin is made from recombinant DNA.” I had no idea, so I threw in any DNA-related jargon I knew. “I’m not entirely sure, but I assume that we hold the genetic code for insulin, and using codon-anticodon triplet matching, amino acids can be lined up in the correct order for expression of the insulin polypeptide.” Completely made that up, no idea if it is even true, but at least I think I sounded confident. They then wanted me to dig further into my knowledge as a foundation doctor from years ago and tell them about the times to peak effect and duration of action of each class of insulin. I wasn’t too hot on that, but could give vague timings based on memory. Finally, the physics question was on the safety features of vapourisers. I like the vapouriser topic, so didn’t struggle too much. I even offered to draw them a picture of the desflurane vapouriser! They asked about the effects of altitude on the functioning of vapourisers- something that I still cannot get my head around till this day, but I said what I knew (partial pressure unchanged, concentration decreased) and left it at that… I caught myself just before I went on to expound on my lack of knowledge.

I came away from the science exam feeling rather good. However, the dark cloud from the morning continued to loom over me as I sat in the Square Pig pub with Hobbo and Matt. The both of them were convinced they had failed. Honestly, they were so sad and angry. Hobbo had a different set of questions to mine and I can honestly say that he had a really bad set of questions. Apparently he had to tell them about the exact cytokines and local mediators and how their concentration changes in the presence of pulmonary hypertension (what??!). But the worst question has got to be “Tell me about Alzheimer’s disease and the drugs used to treat it” Are you for real?! An entire pharmacology viva on drugs for Alzheimer’s?? I’m not even sure that is in the curriculum. We have certainly not seen it in any of the anaesthetic textbooks. Hobbo said that he tried to direct his viva to talking about drugs for Parkinsons or drugs for depression, but they would have none of it. His examiner literally had to lead him to every answer “if they are very agitated what do you think they will need?” “If I told you that they are low in acetylcholine what do you think they may be on?” I felt sorry for him for having such bad luck.

1715hr eventually came, and it was time for us to return to the college for our results. I remember standing right outside the college’s glass doors panicking. I muttered under my breath “please let me see my candidate number on the grid, please let me see my number…” I paced up and down and back and forth feeling almost sick from the anxiety. Matt was worried sick too, and eventually came and put his head on my shoulders. That was when I whispered to him “shall we pray?” Matt nodded.

I’ve always known that Matt is a Christian, but we have hardly ever said much about Christianity or our faith to each other. That day though, I felt the overwhelming need to pray with him and for him. We have been through a heck of a lot of hell together for this exam. So there we stood, outside the door of the Royal College of Anaesthetists, heads bowed to our Lord and Saviour. 2 desperately anxious anaesthetists begging the Lord for peace.

And peace was bestowed. Almost instantaneously, I felt so much better. Through prayer, we were reminded that everything is in God’s hands. We need not fear nor tremble, for the Lord is sovereign over it all. That was possibly one of the most precious moments I experienced on that horrible day- the reminder that GOD IS IN CONTROL.

We eventually went inside to collect the “Success grid.” I peeled away from the others with my little sheet. I closed my eyes and took a couple of deep breaths. This was the moment of truth. Slowly, ever so slowly, I worked my way from the bottom of the grid upwards, scanning constantly for my candidate number…

AND I FOUND IT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Final SOE pass

I passed! I passed! I passed!

I turned around and saw Hobbo peering over at me. The moment I saw him, my face just crumpled up and I started sobbing and sobbing and sobbing. After trying to hold it together for the last few months, after all the fears and frustration, after all the sacrifices I have made, suddenly I have received relief. Hobbo hugged me. “Did you pass?” I nodded, and he held me even more tightly. With tears rolling down my cheeks, I looked up at him and asked “did you?” And YES HE DID!!! I was elated!! The Hobster and I have worked so so so so hard together. Right from the very start when we were building the structure of propofol from styrofoam balls and sticks, to our days revising for the primary viva exam at the women’s hospital, to the times spent working through final MCQ/SBA/SAQ questions with study gambling, through all the courses we attended together, failing the final viva exam last December, to the evening skype viva revision sessions we did together in the last few months… now we have both passed! Together! On the same day! Freedom is offered! I thanked the Hobbo for being my revision partner, and he said to me that “I couldn’t have done it without you either.” Such precious words.

We turned around to find Matt, and he had passed too! Group hug! We are now fellows of the Royal College of Anaesthetists. We are post FRCA. No more exams thank you very much. The thought of it, no more exams! This is all too good to be true. We are so elated. So joyous. So relieved. So thankful. Matt pulled me apart and said “let’s thank God together.” So there we stood, this time INSIDE the Royal College, as fellows, praising God and thanking Him for His goodness to us. Through the tough times when I was hospitalized with palpitations, and Matt needing a gastroscopy due to exam-anxiety related reflux, God has been faithful and led us through it all to this point. The point of relief. We are so thankful.

The people from the college then called out our names and candidate numbers so that we could form orderly rows. We listened to a retiring examiner give her speech to the newly appointed fellows (whoop! whoop!) and then proceeded to this strange college tradition whereby the successful candidates would go and shake the hands of all the examiners that day (they were all stood in a line). We were then offered the legendary glass of wine- the one that we’ve heard talked about so many times, the glass of wine of success. Not the finest of wines out there, but certainly the most expensive glass I have ever paid for– £2700 worth in exam fees alone (primary & final exams). That’s not even counting the money spent on books, courses, train tickets, hotel fees. Or my mental health and social life. That day, I had a change in mood… and it was only then that I realised how miserable I have been for the last 4 years. I had become so used to feeling so miserable that it seemed like the normal way to feel! Every single year had consisted of 3-4 months of exam prep, exam, rest for 2 months. Start revising for the next test again, exam, rest. And the cycle repeats. Now the cycle is broken. Thank God.

We were all so excited that evening. Matt was so excited that he even went on to (accidentally) smash his most expensive glass of wine onto the floor (silly thing)… but that did not put a damper on our spirits. We just could not help but address each other as Dr_____, FRCA. Whoop Whoop! It was a pleasure to sign in the register of the Royal College of Anaesthetists. Yes, my name is finally in the book. It is in the book! In the book! Whoop whoop! I was drunk on happiness and relief.

We took a tonne of photos that evening. Eventually, when we had savoured our time in the “pass room,” it was time to head back home. As we headed towards Euston station, we agreed that we will allow ourselves to relish in pride and maybe a little bit of arrogance that day and perhaps even the day after before getting back to reality (and humility of course). Because who are we? WE ARE CHAMPIONS!!!! There were so many smiles and laughter abounded that evening. Even our Burger King dinner at the train station tasted like it was manna from the heavens. This time, I wasn’t taking the train of shame back home- I was on the train for champions!

What a day to remember, and I probably will not forget this for a very long time to come.

Hallelujah, praise the Lord.

Ketamine is a strange strange drug…

I saw my first ever Ketamine induction yesterday.

It was for a 6 year old boy undergoing bilateral medial rectus botox injections. Apparently, other general anaesthetic agents attenuate the electromyograph signals needed to locate the extraocular muscles too much, and thus render them unsuitable for this procedure.

The boy was shown a little toy snake as a form of distraction whilst I cannulated him.

Then, the ketamine went in.

His eyes remained open. He continued to blink despite looking a little blank. He continued to breathe. He also continued to move his arms about.

Somehow, I don’t know how, my consultant was able to tell that the child was “ready.” She was able to tell that he had been anaesthetised despite him still looking completely awake.

The procedure took all of 5 minutes. We gave him a small dose of midazolam at the end to “dumb down” any emergence phenomena that may subsequently manifest. Then, we transferred him to the recovery area. We shut the doors, turned down the lights, and kept the area as quiet as possible.

The little boy continued to look around whilst in recovery, occasionally picking at his cannula. Then, he started calling out “snake! snake!” He was very obviously having visual hallucinations of the little snake we (erroneously) showed him before his anaesthetic. He started lifting up his covers, and picking up the snake which seemed to have slithered onto his body. The boy did that repeatedly for a good half an hour. Occasionally he would try and get rid of the snake from his body. Other times, he would lean over the bed rails saying “where has the snake gone?” Throughout this entire time, we just watched him deal with his hallucinations. After all, the teaching is not to disturb the child or engage with them as it worsens their nightmares. But what an awful experience it must have been for him!

I wondered how we would know that the child has recovered from his emergence delirium. My boss said that you would just know, because they will start speaking to you properly. True enough, as though someone had flicked a switch, the little boy suddenly came to and asked “When is the botox going to be done? Where is my daddy?” It was then that our recovery nurse finally said her first words to him “it has already been done,” and he cheered.

Seeing as he had finally recovered from the ketamine, the recovery nurse wanted to give him a sticker for his “bravery.” The boy claimed that he did not really like spiderman. “What do you like then?” she asked.

“Snakes” he answered.

It’s disconcerting when unexpected emotions creep up on you…

I was chatting to one of my juniors whilst at work the other day. We were talking about the horrific situations within which we often find ourselves stuck in in our line of work, and how we have all learnt to cope with the physical and emotional toll these take on us. Yet, no matter how hard we try to forget and move on, there are always certain patients who seem to stick in our minds for a very long time…

I was telling her about the story of a 21 year old boy called Michael whom I looked after as a junior doctor 4 years ago.

Michael was a patient on the haematology ward that I worked on as a F2 doctor. He suffered from acute myeloid leukaemia and had been in the hospital for a number of months receiving chemotherapy. As he was one of our long-stay patients, I had gotten to know him fairly well and had taken it upon myself to take ownership of his care and well-being in the hospital.

I remember seeing him on a Friday ward round (my own, as the consultant did not round on a Friday and the registrar wasn’t about in the morning). Michael was semi-asleep, hiding under the covers when I checked on him. However, he claimed that he felt good and had no physical complaints at all. His vital signs and bloods were all stable too.  Michael then let on that he was desperate to be “released” on home leave that weekend. Seeing as there was nothing really to stop me for letting him go home for a couple of days, and on agreement with my registrar later in the day, we said goodbye to Michael that afternoon and “see you back on Monday!”

Monday came around soon enough, and Michael came back onto the ward that morning looking dreadful. He had become really unwell over the weekend. The diagnosis? Pseudomembranous colitis. In fact, Michael had become so poorly that he was promptly admitted to the intensive care unit. Whilst he was in ITU, he was aggressively resuscitated, started on inotropes, and provided with a course of strong antibiotics. He did not respond to the treatment at all. In fact, he responded so poorly that it was felt that there was not much more we could do to “cure” him. “Flogging” his body with further aggressive and invasive treatment was not going to do him any favours… it was only delaying the inevitable, and denying him the option of a good, dignified death. The only choice hereon was withdrawal and palliation.

Now, despite being so terribly ill, Michael remained compos mentis throughout. He decided that he did not want to remain in the ITU, but instead chose to be transferred back to the haematology ward to die. He wanted to be in familiar surroundings, with people whom he knew loved him and had cared for him these past few months. During the time when the ward was arranging a side room for him to return to, Michael even wrote a goodbye and thank you note to the staff on the ward. It was heart-breaking to read.

The atmosphere on our ward was sombre on the day Michael came back to us. There was a dark cloud looming over all of us all day, and a heaviness in our hearts that weighed us all down. He had come back to the ward with a syringe of noradrenaline to keep him alive, and we all spent the day agonising over the count-down to a time when the noradrenaline would run out– the time when death would be pronounced over our dear patient and friend. Throughout the day, the staff on the ward took it in turns to go and say goodbye to Michael (who was still fully awake and aware). No one came out of his side room with dry eyes. Even the counsellor was found sobbing uncontrollably after going in to see Michael.

As for me? I did not go and say goodbye to Michael that day. I was awash with emotions that I knew I would never be able to take control of if I even began to lose it. I had 2 patients in 2 side rooms next to each other dying on the ward. The nurses were disraught. Yet there are still so many other patients who needed looking after. I was sad but had to remain in control. I pressed on with a brave face and a constant need to dab my eyes with my shirt or a tissue all day.

I wondered what it must have been like for Michael to be inside that side room waiting for the Grim Reaper. What could possibly be going on inside his head as he looked at the syringe’s plunger slowly inching its way towards the nozzle, knowing that when the 2 parts kissed, the candle of his life will be snubbed out? I wonder how difficult it must have been to say goodbye forever to his girlfriend and his family? How can anyone be ready to leave at age 21? What about marriage, children, career, dreams, retirement? How can one die in peace when there are still so many regrets in life? How did Michael feel witnessing everyone crying over his soon-to-be passing? How did he control his feelings in the midst of the chaos of emotions that was poured out onto him?

Michael died at approximately 7pm that awful day.

As I was recounting this story to my colleague that day, I found my eyes welling up in tears yet again. The little pearl drops of fluid rolling down my cheeks completely took me by surprise. It has been 4 years since Michael died after all. After such a long period of time, I had expected the rawness of witnessing such suffering to have somewhat healed already.

Nevertheless, like I said, some patients just seem to stick in our memories for a long long time. Their story becomes a part of ours, and I guess their memory lives on.

Michael, you are not forgotten by this stranger.