Bismillah..
It was a quiet day, Coronary Care Unit seemed quite settle, not really busy I supposed due to all beds being occupied impeding transfers from other district hospitals. We finished ward rounds early, getting a pat from behind from Prof of cardiology as I reiterated guideline regarding perioperative diabetic management for one of our patients going for CABG surgery. Hmm, what to do, digging myself back into books and notes, learning and learning the superficial, academician style of medicine. Well, not that it is wrong, but it is probably not the art of practising medicine.
Knowledge is extremely important, and internship year is the year to really put yourself in and out of adrenaline test of thinking, how am I gonna manage this patient bio-psycho-socio-spirituo and behaviourally if I were the doctor. Being a junior in the team, but aiming for the best possible care for patients, it means questioning about what senior doctors do and why they do what they do. I mean that’s probably the best way to learn about patient care being a junior member of the team. It is complex, but made easy by good teachers and good examples. I remember reading an article for junior doctor talking about the real way to learn is to be in the ward, seeing, involving, assisting and questioning what happens, why it happens. Knowledge is the basis and transforming knowledge into practice and into context would be a constant moral, intellectual and spiritual challenge for us in all walks of life. I suppose, managing patient is all about looking it holistically. My professor taught me the mechanism- establishing diagnosis, assessing severity, assessing precipitating factors, recognising underlying cause and reconsidering diagnosis. I feel like adding one more, ensuring patient comfort and support.
Last night, I came across this advice about how to be a good doctor. As a medical student, it seems obvious, go and clerk your patients. Transition into internship year, that will still probably be the case plus added responsibility of needing to know ins and outs of your patients and their care. In doing so, the dimension can be narrowed to keeping to what is essential about each patient, having hooks so that you can remember each different patient.( Amazing how consultants and registrars were able to remember all their patients without having to look at a piece of paper). I found the following advice as I read further being quite important, “go and visit your patients.” In Islam, we get rewards when we go and visit sick people. It is part of our obligations and what we owe to our brothers/sisters when they are sick. Now, why is that? There are many reasons when we logically think, from seclusion and fall from familiar support structure which leads to hospital/institution delirium to sadness, anxiety and fear dealing with diseases, and daily feared, invasive procedures. Being reasonably free, I went to visit one of my patients awaiting CABG and aortic valve replacement (AVR) surgery which will be this Thursday.
Mrs B, 80ish lady, presented to ED about 2/52 ago with gradual increase in SOB, NYHA class 2. She initially presented with fatigue, night diaphoresis and murmur. (Night sweats + murmur = bacterial endocarditis unless proven otherwise). She has been having moderate-severe aortic stenosis for quite a while, with still reasonable ejection fraction and only mild dilatation of left atrium. Pulmonary capillary wedge pressure was 24, Right ventricular pressure was 96 mm Hg which suggested pulmonary artery hypertension thought to be caused by LV failure after ruling out PE and OSA,also portal hypertension 2ndary to schistosomiasis – caused by schistosoma mansoni and other schistosoma species causing pipe-stem fibrosis of liver, rare in NZ but common elsewhere in the world). Trans-oesophageal echo showed no vegetation of aorta or bicuspid valves, hence SBE was ruled out. Coronary angiogram showed triple vessel disease which indicates the need for CABG surgery to improve symptom. The trick in this lady was that we were not sure which could predominantly cause the SOB, because it is a symptom that can be caused by both aortic stenosis and coronary artery disease. Hence, treat both since it can be contributed by both factors. ( if it is chronic stable angina on the background of IHD, how much stenosis does not matter, current evidence shows that treating by optimal medical therapy is as good as CABG or PCI in terms of mortality rate. CABG and PCI in this situation improve symptom but not long-term mortality.
Surgery was planned for her and her name was on the surgical list already. “The Angel experiment”, that was the book she held and read attentively as I near the bed and watched her for a while. Mrs B has not got any family members near the city she lives except her only son who had gone blind. She has two adorable cats that she shared the story with me, named PC and Midnight. She exercises her mind by doing puzzles nearly every day, filling her days in this temporary “hotel” while awaiting her big surgery around the corner. She is a lovely old lady who seems to enjoy her life, being gratitude and missing her grand-daughter and great grand-daughters. One of her great grand-daughters developed multiple sclerosis at the age of 4 years old, a very young age, suggesting diseases and challenges afflict people irrespective of common statistical age. She is now waiting for her grand-daughter who will be reaching Dunedin soon. I spent some time with this nanny, joking and chatting, maintaining professionalism but sharing common human values with her. Alhamdulillah, it is really a privilege to be in this field, because you are able to talk and reflect, checking defects and correcting with good deeds. I felt her like my own nanny in humanity, a sense which can be quite different if I were to only come and pull up curtains during ward rounds, checking obs. , writing consultant/ registrar ward round notes and saying “enjoy your breakfast” at the very best.
I suppose being a good doctor really means having therapeutic but also human relationship. Being humble as a doctor, sharp as a clinician will be the key to excellent patient care and well-being. It is recognising your medical obligation in the context of broad human values but also recognising humanity in your narrow medical context. It is caring for a pluralistic society, projecting “litakunu as-syuhada’ alannas” ( so that you can be the witness to human being) as commanded by Allah SWT and being self-critical to yourself. It is a struggle, to combat passivity form of laziness. I believe life is a dimension for constant learning, an opportunity to better one-self, with hope and pro-activity, not down and passivity.
۞ وَقَضَىٰ رَبُّكَ أَلَّا تَعۡبُدُوٓاْ إِلَّآ إِيَّاهُ وَبِٱلۡوَٲلِدَيۡنِ إِحۡسَـٰنًاۚ إِمَّا يَبۡلُغَنَّ عِندَكَ ٱلۡڪِبَرَ أَحَدُهُمَآ أَوۡ كِلَاهُمَا فَلَا تَقُل لَّهُمَآ أُفٍّ۬ وَلَا تَنۡہَرۡهُمَا وَقُل لَّهُمَا قَوۡلاً۬ ڪَرِيمً۬ا (٢٣)
Thy Lord hath decreed that ye worship none but Him, and that ye be kind to parents. Whether one or both of them attain old age in thy life, say not to them a word of contempt, nor repel them, but address them in terms of honour. (23)
Abu Asr- 13/12/11
Question for medical students?
1) What are symptoms and signs of severe aortic stenosis?
2) What is the commonest cause of aortic stenosis in young, 20ish Caucasian people?
3) How can sub-acute bacterial endocarditis complicate aortic valves?
4) How do you treat a patient with SBE affecting prosthetic valve?
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