About Them Asses...

I know I haven’t write about my Clinical Life as Medical Student that much anymore. I know maybe some of you wondered (or not) whatever happened to us in HTAR. Are we sinking and fade onto a background and be just as ordinary? Well the reason is, I am not too keen to write about it or maybe I just don’t remember much of the details at the end of the day. I am that wrecked of brain from all those sleeplessness and overcompensation that I might dangerously confabulated about it, believing that was actually happen. Life was just like a routine now and somehow along the way you lost all the excitement you once had and given-up to temptation of slacking and be plain Joe or Jane. At least to me it is true.

In regards to this topic that most likely to draw you into clicking this link and expecting to see butt cheeks, lemme tell you this, I am sorry because you ain’t got one and I am not sorry because you are pervert. Hahaha…

Assessment…that is what it stands for.

Well, this second round of assessment actually involving Theory Part and Clinical Part. The theory part is a common travelled part where you do nothing much but to scratch them OMR papers then go home and pray. Because whether you know it or you don’t, them OMRs still handed out lead-scratched all 30 freaking rows of it. Whether the answers right or wrong, let just leave it at that. Worry for another day.

The clinical part is what I called purgatorial. It made me go ghetto and pedestrian. This is the part where you HAVE to know or you are risking yourself getting embarrassed in front of examiners. To mention about examiners in a plain sentence is an understatement. What I meant by examiners were Head of Department of Ophthalmology and ENT and them Super Specialist.

This is our first Clinical Assessment ever so expectation should never be held high. I can sense adrenaline all over Ambulatory Care Centre (ACC) and Fight or Flight response were homogenous. This is where an interest for survival reached 0, nobody care about eating when they are busy making love to their previously abandoned reference books, notes, ink-fresh flashcards and short notes. This is unanimous conformity to self-massacre and we are on undivided agreement of trading Clinical Exam with our own live (or was I the only one?).

This is a summary of how examination in Ophthalmology Department went on. You were given 10 minutes to examine a patient while being evaluated by Ophthalmology HOD and Super Specialist. The trick is, you know nothing much even a slightest of patient history. You need to rely solely on your power of observation and Clinical Examination skills or you can choose to slit your carotid and fake injury by intentionally dislocating your hips. Either way, you are dead.

Before the examination started, everyone from the same group will be quarantined. We were called upon one by one. Those who have been called and tested, we’ll never see them again. No or contact connection whatsoever. Not until the whole process is over.

In that room, your examiners are waiting while row of patients with multiple ocular ailments anticipating their turn to be examined. The time-keeper lady seemed so dangerous or at times a life-saver. It was a dimmed lit room and all eyes were onto you and your every move, all ears were listening, it was as deafening silence as a pure tone audiogram room. All you can hear is your own heartbeat or at times your cold sweat erupting out of your sudiferous gland and sliding down your cheek. All the silence will be broken by a question…

“Please examine this patient eye and continue…”

That question by itself was deadly mandatory. It wasn’t like you were given options. Like…

“Examine this patient...or don’t, we love you anyway. XOXO your examiners”

Cases possibility are ranging form as simple as Corneal Ulcer or Squint to as complicated as Glaucoma, Relative Afferent Pupillary Defect (RAPD), Uveitis, Cataract, Post-Op Cataract with Pseudophakia, Papilloedema, Diabetic Retinopathy etc etc.

What I am trying to say is, you just don’t know what are you going to get. Patient aren’t going to manifest according to textbook. They will come with lots of clinical manifestations. You have less than 10 minutes to diagnosed them or your ass will be roasted to charbroiled. Sounds superlative am I? Well wait till you get your ass on a grill rack, then we’ll talk business.

My personal experience as a second person of a first group from an entire batch to undergone this first ever clinical exam in my entire life since last Clinical Methods subject, it was nervewrecking. The group that came after us were considered as lucky. They already knew what to expect, how the room going to be, what type of question will they get, to what extend the reading is necessary. They got tips here and there, they get more time to practice, they know what to do and whatnots. Basically we learned from theory, we haven’t yet practiced it on real person and be judge on the correctness. Whatever crap we did in the ward with patient, fooling around a slit lamps and taking less than adequate history will help you...not much.

So there I was standing before them, trying to silenced my heartbeat, faking a smile to greet both examiners. It was crooked like CNVII palsy.

Row of patients behind them looking at your with their pathologic staring eyes expecting to see you making fool of yourself and there he was, my patient sitting under a dim light. Not for dramatic espionage drama interrogation scene, but to be examine by you with a unilateral dilated pupil. *if only I saw it sooner*

“Please examine this patient’s left eye with a flashlight and proceed.”

There was a period punctuation mark in my head by the end of resonance emitted by that questions. All my examination proper was magically deleted from my brain and I was there standing, swallowing my own saliva nervously, looking at that patient, formulating what to do next. Shall I put a gun to his head and threat him to tell me what the freak is wrong with his eye or I’ll blow his brain out. But wait, I am not in that espionage movie. This fella is a foreigner, I couldn’t decide whether he is Indonesian or Bangladeshi, they all look the same to me.

So I started by introducing myself to that patient, (in English ladies and gentlemen). What the cookies? He is obviously seemed pedastrian then why the heck am I conversing in English. But we never know, this fella might have been university graduates from a foreign country for all I know.

I ask him, “Do you prefer me to speak in English atau Bahasa Melayu,”

“Melayu,” he replied. Damn, I am so screwed.

I explain my general inspection to the examiners. Then I stuck again. Now what?

Next I asked him for any painful site around his face. He pointed to his left eye. Of course. I was offered a big torch light by one of the examiners but I prefer my own torch pen. His lid is sticky, his conjunctiva and sclera is injected, and there you go my little culprit, I saw some white deposit on his cornea. I am freaking happy, I am so excited that I forgot to do all of other examination proper. I didn’t check his right eye, I didn’t do pupillary light reflex test, I didn’t mentioned to the examiners what I should do first before I proceed with examination of anterior chambers. Instead I am searching into my whitecoat pocket for my cotton buds.

“I would like to do corneal reflex test,” what in mercy of God.

“No need, tell us what you see.”

“This patient eyelids and eyelashes look normal, there’s an injection and redness in his conjunctiva and there is a white patchy deposition on his cornea at an inferior part.”

“Okey, do you know if there is anywhere to explain about location of the lesion other than what you told us?”

I pondered for a while. Try to recall if there is such memory in my brain.

“I think maybe we can divide the eye into quadrant. Superior nasal, inferior nasal, superior temporal, inferior temporal. The lesion is on inferior temporal of course.” both examiners nodded.

“What do you think this patient has?”

“I think he probably has corneal ulcer or keratitis. It can be caused by infections by bacteria…like commonly pneumococci…or viral, fungal infection like in vegetative eye injury, protozoa…or maybe by trauma, exposure keratitis and if he is wearing contact lens, it could probably be caused by that too.” I told them like I was told before. To talk and talk and talk until the examiners stop you.

“Which one do think this patient has?”

“Infection, bacterial keratitis?” damn, I should look at that patient as whole and surely he works at palm oil plantation and of course it is vegetative injury and yes it is fungal you prick. Plus he has that funny smell. What am I thinking?

Both examiners nodded while writing something on the marking paper. Hope it is not 0.

"What would you do to this patient?"

"First I will give him cycloplegic to rest his pupil. So he won't strain his eyes. Then I will give him broad antibiotic." I should add 'spectrum'

"Okey, don't you think we already gave him cycloplegic?" I seriously hope that they won't ask me what type of it.

Damn! Fark! I re-examined that patient's eyes. His left pupil dilated like 6 to 8mm. The one finding I failed to mention. "Yes, this patient is on cycloplegic."

"Why didn't you mentioned it in your initial finding then?"

Okey, if I puke or shat my pants, will I be excused?

"I'm sorry, this patient have injected conjunctiva or sclera, white deposition on his cornea and dilated left pupil,"

"That's fine. Do you know why we give cycloplegic to him?"

"Other than for examination purpose, I think it is to relax the iris so patient won't strain."

"Why?"

"So that he will not make it worst. To prevent acute glaucoma?"

They look at each other with a funny stare. I remember at exact point I am bullshiting myself. Cycloplegic is the one thing should be avoided to prevent angle-closed glaucoma. It was contraindicated for cookies sake. Damn! Fark! Damn! Fark! Damn!

"Glaucoma? Are you sure?" that disturbed look on his face, like a punch on my stomach.

"I don't know sir," it should easy if I just admitted it at first place. Again my ego won't let me until this point.

“Okey, let say if he wore contact lenses, what investigation would you do?”

Hell no, he is not that vain to wear contact lens. But I answered them anyway.

“I’ll take corneal scraping and that contact lens and send them for culture to identify the bacteria and to decide on which antibiotic to start for treatment.”

“What will be your advice for this patient?”

“I’ll ask him to stop wearing contact lens until his cornea heals completely.”

“And after that? If he decide on wearing contact lenses again, what will be your advice?”

“My advice is that he should keep his hands clean before inserting and removing contact lens and to keep his nail short because he can accidently nicked his cornea if he didn’t.”

They both nodded again. Writing again.

“What about contact lens solution. What would you do to it.”

“Well if I am not mistaken, the solution can only be used up to a month upon opening and passed that, it needs to be disposed. Because it is nutrient rich solution and bacteria can probably grow in them.”

“Any other thing you want to do to that solution?”

I scratch my head imaginatively. “I’ll send it for culture?”

They nodded silmutaneously.

“Would you advised this patient to wear a contact lens again?”

“Yes, after his cornea is fully healed. If he want to.”

“The same contact lens?”

“No. A new pair.”

They both look to each other. Nodded. “Okey you can go,”

I thanked the patient and both examiners and leave faster. Fuhh! I scurried away. That place repelled me. I felt sick in my stomach, my heartbeat won't go down. I needed fresh air. There, at the balcony, I actually gasping for proper ventilation...of warm air.

Humor me for one last time.

THE END