Clerkie Life


Clerkie Life: A Day in the Life of a Surgery Clerk

I asked my mom once, “Do you have any idea of what we actually do in the hospital as clerks?”

She guessed, “Went on rounds?”

Well, yes. We went on morning rounds with the residents. We also had teaching rounds with consultants. But really, has she never wondered why my white uniform turns brown every after duty, and how I still manage to sleep wearing them at the sight of my bed?

Gross, yes. But my mother had no idea.

Maybe you don’t, either. So using these pictures, let me share to you about my usual day as a clerk, specifically during my two-month Surgery rotation. Just read the captions. 🙂

Early Call Time

Clerks-On-Duty at the Emergency Room

After the conference and morning rounds, clerks on duty for the day first assume post at the emergency room. When there aren’t a lot of patients, we get to hang out and still have a lot of energy. Well, except for some…

Wards Clerk and SICU

Time to Scrub In!

Another clerk is assigned to scrub in on all emergency operations for the night. Ideally, the patient has to undergo anesthesia and internal medicine or pediatric clearance first, and the operation is scheduled during the day. These are called elective procedures, and the most common that I encountered was cholecystectomy, or removal of the gallbladder. The rest are emergency cases like appendicitis (with the risk of rupture), stab wounds, and gun shot wounds.

From Duty Is The Longest

In other departments, we get to rest or just do papers when we are from duty. It is only in Surgery where we are still in charge of all the carry outs in the wards during the day. Remember, the clerks on duty for that day are still in the emergency room and will only assume post at 5 pm.

That’s it! If you’re wondering, hmmm. I admit I don’t see myself as a surgeon in the future. I had a LOT of fun (probably the most fun my whole clerkship year) and I learned a lot of practical knowledge too. (Like, between two patients with appendicitis and ureter stones, which one would scream louder at the ER?) Still, I am not that excited about holding a scalpel or feeling lumps and bumps, unlike some of my other co-clerks. That’s how I know.

As much as I don’t want to limit myself with doubts or self-depreciating conclusions, I guess it’s nice to somehow limit my options. I just honestly don’t think I’m bad ass enough for Surgery! Hahaha.

My groupmates are probably thinking, “Finally, a specialization she’s not considering!” They say that before you even know which specialization you’ll take, you’ll know first which one you probably WON’T. I’m afraid I have an answer.

Goodbye, broken bones and joints protruding in all the wrong places.


Clerkie Life: Didn’t Expect This From Derma

Of all my rotations, I can say I learned the MOST in derma, probably because I started from knowing close to nothing.

Why? We didn’t have a separate derma subject back in med school. The most that we covered was describing skin lesions during physical examination.

I honestly feel like I missed out on a lot! I think I would have really enjoyed Derma as a subject. Anyway.

Derma Is NOT Easy

In the out-patient department, we encountered many cases of scabies, carbuncles, and impetigo, which we previously learned how to manage in Community Medicine.

What makes dermatology complicated though is the secondary lesions that develop because the patient took too long doing self-management with “katinko” and “BL cream”.

Diagnosis is very difficult, in my opinion. A dermatologist should be comfortable to ask detailed and probing questions, and have excellent descriptive abilities to properly document the skin lesions.

derma rotation

Half the time, we were struggling to describe patients’ skin lesions using proper words that can be communicated precisely with other doctors. Half the time, we were sorting through old charts. Haha, very clerkie.

One time, I referred a patient for having wheals all over her abdomen, for which I thought anti-histamine would suffice. Upon further probing of my senior, it turns out the patient also had the itch on her buttocks, groin, and underarms, but was too embarrassed to consult about that. I guess I was too embarrassed to ask myself. Wrong move. I missed the classic “circle of hebra”. The patient’s allergic reaction was due to her scabies!

Procedures, Procedures!

A lot of people think that dermas only do cosmetic procedures like facials, removal of comedones, injecting botox, etcetera. People seem to forget that there’s also a surgical aspect in dermatology!

I got to assist (or umm take pictures haha) on the day our residents did free surgical procedures on all sorts of bumps and lumps.

My favorite was this cute chubby skin tag. It was successfully removed in less than five minutes, using a neat technique that I intend to try myself one day.

derma skin tag

Other skin tags are kind of icky, but this one is very cute! Hahaha!

They put a needle horizontally through the base of the skin tag, and made a quick incision under and against that needle to remove the whole mass. It left a nice, straight cut which was closed with one stitch. So neat.

Part Physician, Part Counselor

Skin conditions, being external manifestations of disease, can really affect the mental well-being of patients. I know this from experience.

Of all my siblings, I am the only one who didn’t outgrow my skin asthma condition. I’ve always had very problematic and sensitive skin. I regretfully triggered my skin asthma last September when I mindlessly snacked on lots of fried chicken skin. It hasn’t been fully controlled ever since. Notice why I almost never wear short shorts? 🙁

Now think of teenagers with severe acne vulgaris, or middle-aged women newly diagnosed with psoriasis.

derma psoriasis nails

Nails of my psor patient. “Describe the PE findings on the nails, doctora…” *croo croo*

A dermatologist should understand that skin disease may have more of an effect on a patient’s psyches than diabetes, hypertension, or other internal conditions with no obvious symptoms. I learned that dermas should take the time to understand how the patient feels about the disease, because this will also help in evaluating the effects of treatment.

If I were to choose derma one day, my motivation would be because I know what it’s like to have difficult skin, and it would be fulfilling to help others deal with their (usually and hopefully) benign condition. Not to mention the intellectual stimulation, patient interaction, and of course, the weekends off!

Dr. Pimple Popper Though

You’ve probably heard about Dr. Sandra Lee, the internet’s favorite pimple popper. I bet you didn’t expect this from derma either!


Clerkie Life: Ophthalmology Insights, Pun Intended

In Ophthalmology, we assess the patient’s visual acuity by first using the Snellen Chart, which most of you are likely familiar with. (If not, let me remind you of your P200 medical fee for a driver’s license.)

ophthalmology snellen chart

This is what we use to test for visual acuity.

If a patient couldn’t read even the biggest letter at a distance of 20 feet, he is brought nearer until he can do so. If not, we check if the patient can count fingers, detect hand movement, or identify a light source. Only if he fails these tests will he be declared to have a negative vision, an absolute eye, or basically – be blind.

When it comes to problems of the eye of any nature — whether serious or benign — most patients are very frightened of the possibility of going blind.

However, as I have observed, a lot of people attribute their declining vision to aging, and therefore do not do anything about it.

I was once the clerk-in-charge of a 66 year old cataract patient. Before her operation, she could only identify a light source, and everything else was blurred. After her 30-minute microsurgery, she was already able to detect hand movement.

This made her SMILE a big, goofy smile.

When was the last time I thought about my perfectly workable (though not 20/20) vision and gave a big, goofy smile?

This short encounter gave me an unforgettable glimpse of how regaining one’s vision has a profound impact on regaining one’s quality of life – and ophthalmologists get to play a big role in making that happen.

ophthalmology learning

Always glad to bring my lecture notes from third year to teaching sessions.

Who Wants To Be An Ophthalmologist?

Ophthalmology is one of the few specialties wherein the full spectrum of care is included in the practice.

There’s preventive medicine when a diabetic patient is asked to return annually to monitor for neovascularization. This requires co-management with the patient’s internist for the control of the systemic condition.

There’s medical management when a teenage boy presents with thick, purulent, and explosively profuse eye discharge. (Personal/social history will confirm that it was sexually transmitted.)

And of course there is time-in at the operating room, where surgical management is usually cleaner, quicker, and visibly life-changing. Examples of which are refractive surgery (LASIK) and phacoemulsification (cataract removal and lens replacement).

Add to that the fact that ophthalmologists are skilled to use special diagnostic equipment on a daily basis. Ophtalmoscopes and slit lamps are SO hard to figure out! I kind of give up on those. I need more practice.

Needless to say, I enjoyed every bit of my rotation and will not cross it off so easily in my future choices. 🙂

ophtha conference

Teachers and doctors can work together to make sure that kids have good eyesight, because a child’s vision is integral to his/her learning!

 

ophtha dinner

Fun duty nights with pizza!


Clerkie Life: Holidays On Duty and Compre Season

Very quick post to just once again pause.

Right now I’m about to end my 2 month rotation in Pediatrics. I honestly enjoyed every part of it – the precious newborns, the cute crying-then-laughing babies, and even the teenagers admitting to having sexual encounters and drug use.

I also spent Christmas Day and New Year’s Eve on duty at the Pedia wards. Although I was away from my family and other loved ones, that was still a different kind of fun. I realized that this year I spent most of my waking hours in the hospital, since when I’m at home all I do is hibernate. That explains why I’ve grown to love my duty-mates, residents, and patients. 🙂
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I admit I’m also starting to feel sad that my clerkship year is also about to end. Can you believe it? One more week in Pedia and I’ll be off to my last rotation – OBGyne!

But before that, there is one last hurdle my batchmates and I have to go through before graduation – compre! Ever since first year med, I’ve dreaded the fact that by clerkship year, there’s going to be a comprehensive exam of ALL our subjects from day one. That’s why all throughout med school, I religiously took down lecture notes and organized my review materials safely in my hard drive.

However, I didn’t know it would be this hard to actually start studying. Over the Christmas break when we had skeletal duties, I started opening my Biochemistry notes and actually found myself LAUGHING because hahaha how the hell did I memorize all that for the sake of an exam? It just goes to show the great lengths we are all capable of if we just set our minds to it.

That said, time to overcome our one last hurdle. This month of January, we’ll have all our weekends off to study for our Monday exams. Here’s my study buddy!

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Clerkie Life: Psychiatry Rotation

Psych in Med School

Diagnostic and Statistic Manual of Mental Disorders

DSM 5 – the bible for diagnosing Psychiatric conditions. Click image for source.

Psychiatry was one of our minor rotations, and we got to spend one week seeing unbelievably real patients that  I used to only read about in Kaplan. This made Psych so much more interesting to me!

The psychiatric conditions we studied in med school were based on the DSM 5 criteria. DSM stands for Diagnostic and Statistical Manual of Mental Disorders. I actually really enjoyed the subject. The lectures were well-organized and so were my notes. Also, our exams were in essay format! It was a welcome challenge, and though I didn’t always get high grades, studying Psych was something I easily enjoyed.

 

 

 

 

Coming Into The Clinics

I will never forget the first patient I ever interviewed. She was 24 and married, and has been complaining of palpitations for months. She blamed it on her constant fights with her mother-in-law. She’s been to the ER twice, with a multitude of diagnostics ordered that all turned out to be normal. Finally, the internist referred her to us for a Psych consult.

psychiatry rotation

I did her anamnesis or her life story. Interestingly, I found that she grew up with physical and sexual abuse, and had two previous attempts of suicide. Believe it or not, it was the first time I have been entrusted with something that personal. I almost didn’t get that information because I was hesitant to ask at first. My diagnosis then became more likely. I finally showed her a list of symptoms, and she fulfilled 8 out of 13. Panic disorder it is.

Panic disorder, according to DSM V, refers to recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of a list of 13 physical and cognitive symptoms occur. The term recurrent literally means more than one unexpected panic attack. The term unexpected refers to a panic attack for which there is no obvious cue or trigger at the time of occurrence—that is the attack appears to occur from out of the blue, such as when theindividual is relaxing or emerging from sleep (nocturnal panic attack).

Imagine the relief on her face when our in-house Psychiatrist confirmed her condition. No, her palpitations were certainly not due to a life-threatening heart condition. Yes, other people have panic attacks just like her. And yes, she can take medications to control her symptoms. All it took was a brave visit, and she and her husband went out the door seemingly cured already.

That’s the kind of relief only a sincere and patient doctor can bring. I admire our Psychiatrist, and I learned a lot from her example.

There were also other success stories, such as one patient who used to hear voices while working on a cruise ship, urging him to jump. Creepy? Those are called auditory hallucinations, which are usually seen in psychotic disorders. After months of good compliance and close follow-up, he’s ready to go back to work now.

There was also a guy about my age who recently went through a break-up and started showing risky behaviors such as mindlessly jumping from the second floor balcony. He said he wasn’t attempting suicide, but was simply giving in to an uncontrollable urge. At the same time, he had feelings of worthlessness and difficulty sleeping. It appears he was having a mix of manic and depressive symptoms, such as those seen in bipolar disorders. His mother was so relieved that finally, some medicine can help bring her son back.

Mental Illnesses and Psychiatry

After my quick rotation in Psychiatry, I realized that all the diagnostic criteria I had to painfully memorize in med school were realities for a lot of people. However, most cases remain undiagnosed because of the stigma brought about by having a mental illness. Discrimination and prejudice persist, mostly because of what we see in the movies or because it’s easy to assume that these patients should just “snap out of it”.

No, you can’t just snap out of your depressed mood if your norepinephrine and serotonin levels are depressed as well. We must remember that mental illnesses are real diseases that affect a person’s brain, which then influence the way the person thinks and behaves. Just like diabetes or high blood pressure, psychiatric disorders are also biochemically based and require long-term treatment.

mental illness stigma

Mental illness ranked as the top stigmatized illness. Click image for source.

I remember taking an online medical specialty aptitude test before, and it revealed that my personality was best suited for psychiatry. Surprising, but then again – why not? Since no two patients are alike, there will always be intellectual satisfaction in this field. More than just listening to childhood stories and prescribing drugs every month, I believe psychiatrists can really change a patient’s life and form very fulfilling long-term relationships with them.

Who knows? 🙂


Clerkie Life: Five Firsts, Thanks to my ENT Rotation

When I look back at my rotation at ENT or the Department of Otorhinolaryngology – Head and Neck Surgery, I will always remember the many firsts I experienced here..

1) First time ever to go inside an operating room!

Well, it’s not as dark as it is  usually portrayed in the movies. And it’s also not as spotless clean as I thought it would be. Only those scrubbing in are supposed to maintain a sterile working field.

Observing an operation with my co-clerks Elle and Mia

Observing an operation with my co-clerks Elle and Mia

2) First time to scrub-in!

The case was thyroidectomy, and I was the clerk in charge of the patient – everything from the history and physical examination, her clinical abstract and patient discharge summary, chart notes, and assisting during her operation.

Usually, there’s a scrub nurse in charge of handing the instruments needed by the surgeon and returning it back after use. For cases with small incision sites and working areas (such as thyroidectomy and appendectomy), the clerk assumes the role of the scrub nurse.

ent OR 3

Me being all clueless

Eventually, I learned not just what the instruments are, but when they are needed and the order at which they should be (quickly) handed. Like if there’s a bleeder,  “clamp” “another clamp” “tie” “mayo” “suction” – until the surgeon doesn’t have to verbally instruct anymore. Little clerkie just knows. :)) Thanks to Doc Maisie and Doc Karen for teaching me!

ent OR 2

Me being all useless (lol)

ent OR 1

Me being all useful! Haha!

3) First time to suture in the Emergency Room.

More about that in this post – “Learning How To Suture By Seeing, Doing, and Teaching” 🙂

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My work area AFTER I was done stitching up the boy’s face

4) First time to successfully insert a gauge 18 IV cannula.

YES, I went through the whole Internal Medicine rotation without having to insert the “green” aka the longest and largest bore needle into a poor patient’s vein. However, for all patients about to enter the operating room, this is a must because anesthetic drugs and possible blood transfusions require a good flow.

Happy that I got this right in one shot on my first try. First timer's luck, I admit, because I failed in the next few ones LOL.

Happy that I got this right in one shot on my first try. First timer’s luck, I admit, because I failed in the next few ones LOL.

5) First time to kind of confirm that I am NOT for Surgery.

Our chief resident joked about it once, when I scrubbed in on a mastoidectomy case and I (regretfully) made a face when he asked me to trace the tunnel that we just created.

“Au, anong gusto mong specialization? Siguro hindi surgery no?”
(“Aura, what specialization are you considering? Probably not Surgery, no?”) 

In hindsight, it was pretty cool that we drilled a pathway for the ear discharge to exit but still – I hate bones uhuhu. That time, the thought of just touching it already made me cringe.

Blurred and resized on purpose, but you get the ideaWell, not just bones. In the emergency room, we saw for ourselves cool and crazy (and wtf) cases such as self-induced neck lacerations done 5 days prior to consult.

“Is that the TRACHEA??” (Barf.)

“This has been an open wound for 5 days??” (Barf.)

Nope. Nope. I’m glad this was too complicated for a clerk to suture.

 

Nonetheless, this is why it is so fun to be a clerk. We get to experience many memorable firsts in the hospital, and right now we are still allowed to oohhh and aaahh in excitement. Some of use are even allowed to blog! Lelz 😛