Medical Elective Report: Malaysia 2013

Transcription

1 Medical Elective Report: Malaysia 2013 Catriona Rother Placement 1 - Peninsular Malaysia Duration: 2 weeks (15/07/13-26/07/13) Location: Kuala Lumpur Hospital: Universiti Kebangsaan Malaysia Medical Centre Jalan Yaakob Latiff Cheras Kuala Lumpur Selangor Specialty: Accident and Emergency Supervisor: Dr. Ahmad Khaldun Ismail khaldun_ismail@yahoo.com For general elective enquiries within UKM: Dr. Muhammad Firdaus mdfirdaus@ppukm.ukm.edu.my Placement 2 - Borneo Malaysia Duration: 4 weeks (29/07/13-23/08/13) Location: Kota Kinabalu, Sabah Hospital: Queen Elizabeth II Hospital Lorong Bersatu Jalan Damai Luyang Kota Kinabalu Sabah Specialty: Respiratory Medicine Supervisor: Dr. Jayaram Menon drmjayaram@gmail.com For general elective enquiries within QEH: Flora Gabing flora_gabing@yahoo.com Elective Objectives 1

2 Objective 1 Speak to the doctors and medical staff within the unit and identify the three most common presenting complaints there. Take a history and perform a relevant examination for one patient with each of these PC s and present these patients back to one of the resident doctors. Gain knowledge in the investigation, differential diagnosis and potential management of each of these presenting complaints by the end of the elective period. Rationale: This will allow me to become familiar with the main health complaints that are seen within two different Malaysian cities, and the way in which these complaints are investigated, diagnosed and managed. If one presenting complaint is seen in both KL and KK, I will also be able to compare the approach taken in the two differing medical centres. Note: I have chosen to discuss my first placement only with regards to this objective as my second placement changed from being in General Medicine to Respiratory Medicine. As respiratory is a more specialised area, I feel my experience in the second placement is less relevant to this particular objective. Objective 2 Select a medical condition that is common in both the UK and Malaysia, and compare the patient journey for each of these in Dundee, Kuala Lumpur and Kota Kinabalu. Rationale: This will allow me to appreciate the way in which different healthcare systems approach, investigate and manage a disease and will ensure that I consider aspects such as healthcare provision and the distribution of resources in different countries/healthcare systems. Objective 3 Present either a written or verbal case study on a disease or condition that I have either never heard of before or never come across in a Scottish hospital. Rationale: This will develop my medical knowledge further and will allow me to think about tropical medicine in more depth than is expected from us in the Dundee curriculum. I will be able to research the signs and symptoms, diagnostic methods and treatment for something entirely new to me. Objective 4 Try to obtain as much hands on experience as possible throughout the elective period, by offering assistance with practical procedures in which I feel competent and observing local doctors/being taught (if possible) in techniques in which I am less familiar. Rationale: This will broaden my clinical experience hugely, and is one of the things I really hope to gain from the elective procedure. Completing practical procedures in an unfamiliar environment, with unfamiliar equipment and documentation, in a less-supervised way will be a challenge that will cause me to feel more accountable for my actions, and allow me to feel more confident in my practical abilities as a medical student. Objective 5 In comparison to Scotland, Malaysia is a particularly diverse and multi-cultural country. At some point during the elective period, sit down with the other students that I am travelling with and consider the role/importance of religion/culture/politics. Rationale: This will allow me to consider the non-clinical determinants of health, and whether there are any traditional medical practices that are not frequently encountered within western medicine that are commonly seen within Malaysia, and why this is the case. Objective 1 2

3 During my placement in A+E, I spent a lot of time in the primary and secondary triage zones. In primary triage I saw patients that had either self-presented to Accident and Emergency or had been transferred by ambulance, and was able to assist in their assessment as they came through the door. Although English is a recognised language within Malaysia, the country s official language is Bahasa Malaysia, and with such a multi-cultural population, many patients also spoke Mandarin, Cantonese or Tamil as their first language. Unfortunately, the majority of patients presenting to the unit either spoke very little English or preferred to converse with medical staff in their chosen language. This communication barrier obviously made history-taking slightly difficult. I was, however, able to assist with physical examination and would record the patient s vital observations and perform a brief examination, where relevant, before presenting my findings to the supervising medical officer (usually a non-trained member of healthcare staff). As I gained confidence in primary triage, I was encouraged to make management decisions such as where best to manage a new patient, and was frequently involved in handing-over patients to the junior doctors in secondary triage. In secondary triage (also known as the red box ), the purpose was to obtain a more detailed assessment of the patient in order to further guide management. I would assist with performing a more thorough physical examination of the patient and was occasionally able to perform practical procedures such as venepuncture or peripheral venous cannulation. From here, patients would be transferred to either the red, yellow or green zone (ranging from most critical to least critical care) and I would usually follow them to observe their initial investigation and management. Three of the most common presenting complaints that I saw during my time in UKM were fever, chest pain and involvement in motor vehicle accidents. I feel that I learnt a great deal about the initial assessment, investigation and management of each of these presentations within the emergency setting. For example; I was able to practice my skills in the ABC assessment of emergency and trauma patients in a real-life situation. I learnt about the importance of the secondary survey and what this involves when assessing patients involved in a road traffic accident. I gained a little experience in the use of imaging in trauma patients eg. FAST ultrasound scanning. I received informal teaching on the differential diagnosis of acute febrile illness in Malaysia eg. dengue fever, chikungunya and Salmonella Typhi and learnt how each of these typically present. I also learnt important admission criteria for patients with suspected dengue fever eg. tachycardia, hypotension, prolonged capillary refill time, altered mental status and reduced urine output. I saw many cases of acute coronary syndrome and was able to practice performing and interpreting ECGs an identified weakness of mine. I also saw the use of reverse ECGs, where electrodes are placed on the patient s back to investigate posterior and inferior myocardial damage (something I had not seen before in the UK). I was able to revise the indications and contraindications for thrombolysis in ACS and witnessed the administration of thrombolysis on a couple of occasions. I was also able to develop some basic skills in triage and the prioritisation of unwell patients. Overall, the organisation and functioning of the A+E department in Kuala Lumpur was very similar to what I have experienced in Dundee and the initial approach to the emergency patient was based on the same concepts that I have been taught throughout medical school. As a result, I feel that the majority of what I learnt in Malaysia will be transferable to my medical practice within the UK. Despite spending only a short period of time in Accident and Emergency, I feel that the experience has been invaluable. At medical school, we are taught that 90% of the information we need to manage a patient is obtained from the history alone but having spent time in a situation where I was unable to verbally communicate with the majority of the patients I was assessing, I now also appreciate the importance of good quality physical examination. Additionally, I feel that I have developed skills in identifying truly sick patients through non-verbal communication and assessing physical appearance rather than relying on how unwell the patient tells me they are feeling! Objective 2 3

4 Asthma is a common condition in both Scotland and Malaysia and a condition that I witnessed management aspects of in both Kuala Lumpur and Kota Kinabalu. During my time in Accident and Emergency, many cases of acute asthma presented to primary triage, and I assisted in the initial assessment and management of these patients. Whilst in Kota Kinabalu, I was able to witness the outpatient care of asthmatic patients in Malaysia by attending a couple of asthma clinics. Despite UKM being a larger and generally more up-to-date hospital with regards to facilities and practice, the diagnosis and management of asthma seemed to be fairly similar in both hospitals to which I was attached. When comparing the asthmatic patient journey undertaken in Malaysia to that experienced by the average asthmatic patient in Scotland, however, there are several differences. The first difference that I identified in the way that asthma (and many other long-term conditions) is diagnosed and managed in Malaysia concerns the organisation and functioning of the Malaysian healthcare system itself. In Scotland, the majority of healthcare is provided by the national health service, with the first port of call for most patients with troublesome respiratory symptoms being their general practitioner. From this point, the GP can refer the patient for specialist investigation and management, as deemed appropriate. Although private healthcare is available within Scotland, it is a minority of patients that can afford to be managed under this system. Malaysia, on the other hand, operates a two-tier system of healthcare delivery, with a government-run system co-existing alongside private healthcare. Many patients receive care from both private and government facilities throughout their life, depending on their health priorities or what they can afford at any given time. General practice does not seem to exist in Malaysia in the way that it does in the UK with the majority of doctors specialising in one particular field. As a result, so-called primary care in Malaysia is a fairly complicated system of government-run and private specialist clinics, which generally rely on the patient referring themselves to the appropriate clinic type in the first instance. Another obvious difference in the management of asthmatic patients between the two countries could be seen in the provision of medication. Although the Malaysian Thoracic Society recommends the same step-wise approach to asthma management as that followed in Scotland, the government-run clinics and hospitals do not provide medication free of charge unless the presentation is acute whereas our prescriptions in Scotland are paid for by the national health service. Prescriptions would be written within the government clinic that (as far as I am aware) the patient would then have to take to a private clinic or pharmacy to pay for. Additionally, I noticed that once a patient had received a diagnosis of asthma in Malaysia and had received a prescription for appropriate therapy, there seemed to be no regular review or follow-up of these patients within the government healthcare system, as is often the case in the UK. I also observed a differing approach to the management of acute asthma during my time in A+E. The UKM emergency department had a small room solely for the use of patients experiencing acute asthmatic exacerbations. These patients would present to primary triage, where we would conduct an extremely brief examination documenting their vital observations. They would then be permitted entry to the asthma bay where they would effectively self-administer nebulised bronchodilators until they felt well again. This was a system that I found very interesting, as to my knowledge we have nothing similar within our own emergency departments in the UK. Having discussed this issue with the unit s medical staff, it seems that it may be the case that some Malaysian patients, unable to afford to pay for regular inhalers, choose not to - instead presenting to Accident and Emergency acutely when they become symptomatic where the therapy is then free of charge. Considering this objective has highlighted several learning points to me, which I hope to carry with me into my future medical practice. I was able to understand the importance of developing a good knowledge of the organisation and funding of the healthcare system in which I am working. This is particularly important to me as I hope to spend some time working overseas in the future I was able to appreciate the way in which healthcare delivery must attempt to fit demand as was illustrated by UKM s acute asthma bay. I was also able to witness the limits that are put on government-run healthcare in Malaysia and the impact that having to pay for a prescription that one cannot afford may have on a patient. Objective 3 4

5 During my placement in Emergency Medicine in Kuala Lumpur, I saw many cases of Dengue Fever. The presentation was so common, in fact, that the department had a separate 8-bedded bay dedicated to the management of these patients. As mentioned previously, I was often involved in the initial assessment of these patients and grew to recognise some of the criteria that would warrant admission to the assessment bay. Rather than presenting one single case study during my time, I was frequently asked to present patient s histories and examination findings to medical staff within the dengue assessment unit, as a way of practicing handover communication skills. In addition, I spent several mornings observing the work within the dengue assessment bay, learning about how these patients are managed. Towards the end of the placement, as my confidence grew, myself and the other student I was working with would develop a provisional management plan in triage and hand this over to the assessment bay staff also. Dengue fever is a condition that I had very little knowledge of prior to my time in Malaysia. As I saw so many cases of dengue fever, I was encouraged to do some self-directed learning around the topic and feel that this taught me a great deal. Dengue fever is a viral infection spread by mosquitoes, and is commonly seen in tropical countries such as Malaysia. In recent years, the incidence of dengue fever has increased dramatically, particularly in urban and sub-urban areas - and is a major health issue within UKM hospital in Kuala Lumpur. There are four documented serotypes of the dengue virus. Infection and recovery from dengue fever provides life-long immunity against that particular infecting strain, however, repeated infection may occur with the other serotypes. Patients suffering from dengue fever typically present with a high fever and flu-like symptoms. When working in primary triage I was taught to suspect dengue fever if a patient presented with a sudden high fever (~40 C) alongside symptoms such as headache, pain behind the eyes, myalgia, nausea and vomiting or skin rash. A small minority of dengue fever patients develop the potentially fatal complication of severe dengue (also known as dengue haemorrhagic fever), and I was also taught to recognise symptoms of this complication, such as severe abdominal pain, persistent vomiting or abnormal bleeding eg. nosebleeds, bleeding gums or haematemesis. I learnt that repeated infection with different dengue virus strains increases the likelihood of a patient developing severe dengue. Within UKM, the diagnosis of dengue fever was clinical, and as the condition is self-limiting, with symptoms usually ceasing after around 10 days, the majority of patients were sent home. There were instances where admission was necessary, however, and I developed some knowledge in recognising these patients. Admission was preferred in any patients demonstrating signs of dehydration eg. hypotension, prolonged capillary refill time or reduced urine output and was also necessary for patients with suspected severe dengue fever. The treatment of dengue fever is supportive therapy - and patients that required admission were monitored on the assessment bay, and usually prescribed paracetamol and regular intravenous fluids. Besides learning specific details about the infection itself, assessing and managing patients with suspected dengue fever taught me several more generic skills. I acquired experience in knowing when best to admit a patient and when a patient is OK to be managed at home. I was able to appreciate some of the difficulties in prioritizing patient care within a limited space. There were only 8 beds available on the dengue ward and these were almost always full. I saw the UKM doctors making decisions as to which patients were most unwell and taking into account factors such as family support and the ability for the patient to be cared for adequately at home. I also developed my ability to assess a patient s fluid balance through the mornings I spent within the dengue assessment bay. I feel that my elective experience highlighted the importance of self-directed and continued learning within the medical profession to me. I was frequently examining patients who were suspected to have illnesses of which I knew very little about and was therefore prompted to read up on that particular condition. I hope that this learning point will stay with me and encourage me to constantly update my knowledge and practice throughout my career. Objective 4 5

6 Unfortunately, this is one objective that I feel I was not able to achieve as fully as I had anticipated during my time in Malaysia. I had hoped to gain lots of experience in practical procedures throughout both placements, however, this did not seem to be feasible when I was actually there. In Kuala Lumpur, I was surprised at both the level of staffing and the number of Malaysian university medical students working within the department. There were dedicated medical officers whose main job roles were in venepuncture and peripheral venous cannulation - so often these practical procedures were performed almost instantaneously as the patient came through the door, and we didn t get the chance to practice. There were also large numbers of newly qualified junior doctors who seemed to have less experience in performing practical procedures than we obtain at the University of Dundee. Because of this, the priority was usually (and understandably) to allow the junior staff to practice their skills. From speaking to the Malaysian medical students that were working in the department, it sounds as though their training with regards to real clinical exposure and practical procedures at that particular hospital was less important within their curriculum, and occurred much later on in their university career than in Dundee. The student groups in UKM were also much larger than I am used to in Scotland, meaning that any practical procedure that is offered to the students can usually only be performed by one student at a time, meaning that lots of the more introverted students never really have a go - and are less confident as a result. Perhaps because of this, some of the doctors within the department seemed less comfortable in allowing us to perform even very basic practical procedures as it may be that they are used to medical students with less confidence and less experience. In Kota Kinabalu, there were no medical students and much fewer staff members, meaning that the situation was slightly better with regards to obtaining practical procedure experience. Working solely in one ward meant that I was more able to integrate myself within the Respiratory Medicine Team and would be given jobs to assist the junior doctors with whilst on the morning ward round. Usually this involved clinical examination but I was able to perform venepuncture and peripheral venous cannulation on a couple of occasions. I had expected the equipment to be very different from that which I am used to using in Dundee and anticipated that this might knock my confidence somewhat. Although the equipment did look slightly different, for example the hospital used a simple needle and syringe to take blood rather than the vacutainer devices that I have grown used to in Dundee, I realised that this did not really matter and was still able to perform this procedure competently. Although I achieved fairly little with regards to performing practical procedures myself, I was able to observe a great deal of procedures in both placements - some of which I had never seen before in Scotland. For example, in Kuala Lumpur, I witnessed arterial line insertion, long and short central line insertion, male and female urinary catheterisation and intracranial pressure monitoring. In Kota Kinabalu, I observed procedures such as arterial blood gas sampling and chest drain insertion. I learnt a lot from watching these procedures as, because there were usually several doctors present, there was always someone free to quiz me about the indications for a particular investigation or intervention, or the anatomy behind the procedure! In a strange way, not being able to perform as many practical procedures as I would have liked has been beneficial. Through comparing myself and my other Dundee colleagues to some of the Malaysian medical students we met, I realised that we are generally more confident and more competent in performing basic practical procedures as we have a higher level of experience. This has made me really value the training that we receive at Dundee, and has highlighted the importance of being patient with students and encouraging them to get involved and develop their skills and confidence. This is something that I hope to remember and implement when I am teaching students in the future. Objective 5 6

7 Malaysia is a multi-ethnic, multi-cultural and multi-lingual country with Chinese, Malay and Indian influences apparent almost everywhere you go. I was traveling as part of a group of five medical students, and as our surroundings were so different from what we are accustomed to in Dundee, we actually found ourselves continually discussing the subject of this objective throughout the elective period. An interesting comparison could be seen between Kuala Lumpur and Kota Kinabalu, with regards to how the patients in these cities approached their own healthcare. Kuala Lumpur is very technologically advanced and Westernised. Whilst working in UKM Medical Centre I was struck by how well informed many of the presenting patients were. Of course there were patients of lower socioeconomic status who were generally less educated with regards to healthcare - but the attitude of many Kuala Lumpur patients that I came across seemed to be that they were in-charge. This could perhaps be related to the fact that private healthcare and government healthcare are operated fairly simultaneously in Kuala Lumpur. I mentioned earlier that it is common for patients to receive care under both systems and from what I can understand, investigations for example are undertaken far more commonly within the private sector in Malaysia, as the patient is willing to pay for what they want. I observed numerous consultations within UKM (a government-run facility) where the patient was requesting an investigation that the doctor argued was unnecessary. In Kota Kinabalu, however, a less developed area, the patient s attitudes were markedly different. The majority of the consultations and interactions that I witnessed essentially involved the doctor stating the management plan that was to be undertaken, and the patient agreeing - with very little discussion or patient involvement in any decision-making. Another finding that I was struck by was the widespread use of traditional Chinese medicines, both in Kuala Lumpur and Kota Kinabalu. I knew very little about this form of alternative medicine prior to my time in Malaysia, and as such, was required to do some learning on the topic. Chinese medicine can refer to several different forms of therapy, however, the type that I came across most frequently was the use of herbal brews that are chosen to combat a particular illness or anatomical site. I noticed a higher level of traditional medicine use during my placement in Kota Kinabalu as compared to KL, with many respiratory patients presenting to the hospital only after they had tried several forms of traditional therapy. Unfortunately, my impression of this was that many of these patients were presenting to hospital late, and their prognoses seemed generally worse as a result. I feel that experiencing these differing attitudes and practices has been very beneficial for me, however. I feel that I have learnt to be more open-minded and accepting of alternative medicines in general - as even if they offer only psychological benefit, disagreeing with a patients chosen method of treatment is something that I will need to learn to accept and keep to myself, as long as the patient has been allowed to make an informed decision. I was also able to consider the impact that a patients community and lifestyle can have on their attitude towards healthcare and what they feel entitled to. 7