Helping hands

More than 60% of Sydney’s students participate in an international elective. The vast majority say the experience is beneficial, that they learn a great deal from being able to observe at close hand different ways of practising medicine. Over recent months, students have completed placements in a wide range of settings: in developing and
developed countries, and in community and specialist teaching hospitals.

Aimee Wisemann - The United States

By Becky Crew

At the hospital today everyone was like, ‘There’s going to be a blizzard, make sure you stock up on all your food!’” says Aimee Wiseman from her Weill Cornell Medical College dorm in a very wintery New York. She’s now halfway through her placement at the New York Presbyterian Hospital, her sights set on a career in global health work, which will combine her Law, International Studies and Medical degrees.

Image of Aimee Wiseman

Credit: Radius Magazine

“There were a couple of reasons why I chose New York,” says Wiseman, who has also spent time in Vietnam recently as part of the Sydney Medical School’s Ho ̇c Mãi scholarship. “‘Cornell has a well-established Office of Global Health exchange program and also offered a unique public health internship in addition to clinical medicine placements, which gave me the opportunity to combine my interest in public health advocacy and health policy with practical medical experience in one of the world’s leading hospital
facilities, New York Presbyterian.”

For the past four weeks, Wiseman has been training in an outpatient paediatric program that offers urgent and general care, plus a number of specialties to the city’s lower income individuals and families. “It was something we don’t really have an equivalent of back home, which was good to see,” she says.

“In the Medicaid Clinic, it was quite a different demographic to what I’d expected, so it was kind of a reality check that the eastside Manhattan experience was really different from what I’d preconceived,” says Wiseman. “The immigrant population is huge and they come from quite a broad-ranging area - Queens, the Bronx, Brooklyn - and 85 to 90% didn’t speak English as their first language. So often it would be the child talking and then the parent, and then the translator, and then you, and then the doctor! I knew that there would be Spanish-speaking people in New York, but I hadn’t expected that there would be such a huge proportion of non-English speaking communities, so that’s been interesting.”

Wiseman has also had the opportunity to visit a number of organisations responsible for instigating President Obama’s new Affordable Care Act, including the Centres for Medicare and Medicaid, the Greater New York Hospital Association and the New York City Human Resources Administration. “Places that you’d never get to go to as a student,” says Wiseman. “They were really honest in talking about the challenges in implementing the Act and how it’s affected the greater population of New York and America, and they talked to us about the advertising campaigns and how we should best approach our age group, so that was really good.”

Unofficially, the program has given Wiseman access to the knowledge of many other international students who spend time at Cornell on exchange. “I’ve met students from Singapore and England and there’s some from Peru and South Korea, so I’m having that international experience of talking to them about their medical programs and what they’re used to back at home,” she says. “And there’s a couple of students from the University of Sydney over at Columbia University too, so we’ve met up with them a couple of times, which has been good."

Simon Reid - Isreal

By Becky Crew

"Israel is just such an amazing country,” says Simon Reid, the current President of the Sydney University Medical Society, who has just finished a four-week elective placement in Jerusalem. “It has everything you want in a little, bite-size package. If you want rich history and culture, if you want great socialising and nightlife, if you want beaches or mountains... it just has everything.”

Around 60% of fourth-year students head overseas as part of the Sydney Medical School’s elective placement program. Having never been to a Middle Eastern country before, Reid chose to base the first half of his program in Israel. “I was quite worried,” he admits, discussing the conflict along the Gaza Strip nearby to where he would be. “In the weeks leading up, people were asking, ‘Are you still going? Aren’t you scared?’ But when I got there, I honestly have really never felt safer. I would feel a lot safer walking around Jerusalem at night than around Sydney at night! It was so different from what I expected. It turned out that it was completely fine.”

Image of Simon Reid

Credit: Radius Magazine

Based in the haematology department of Hadassah Ein Kerem, a medical centre in southwest Jerusalem, Reid counts himself lucky to have been trained in a Nobel Peace Prize-nominated hospital that treats its patients equally, regardless of religion or culture. “Jerusalem is a holy city for Christianity, Islam and Judaism, and every culture is treated equally at the hospital, there’s no discrimination on that part. I was also really happy to hear that patients who were Palestinian could still get proper, good quality health care in Israel,” he says.

Along with the food – “I ate hummus at least twice a day” – the religious aspect of Jerusalem was what Reid enjoyed the most. “Jerusalem is phenomenal. Even if you’re not religious, going to their holy places, you feel this spiritual energy just by being there. I went to the Western Wall on a Friday night, which was the holiest time, and there are thousands of people there to pray and sing and
worship. I must have looked so out of place, but it was just beautiful to be a part of all that culture and all that history.”

Reid says while he only had a pool of about six Hebrew words to pull from, language wasn’t an issue, and the doctors were kind enough to have their classes and meetings in English for him. He’s now carrying out the remainder of his placement in the medical wards of the Karolinksa Institute in Stockholm, Sweden, where he’ll continue his interest in paediatrics. “I’ve been told I’d be perfect for paediatrics because I’m basically a big child. I’ve probably got the Swedish of a four-year-old, so while I can’t really talk to the parents, I can talk to the kids about cats and dogs and things,” he laughs.

Martin Seneviratne - Vietnam

This summer, I was privileged to do a one-month clinical placement in a military hospital in downtown Hanoi as part of the Ho ̇c Mãi program. The hospital itself was a picture of the eclectic history of Vietnam. There was a smattering of old French-style buildings – vine-covered relics of the Indochinese era – surrounded by a communist-style concrete megastructure with hammer-and-sickle symbols and gilded busts of Ho Chi Minh at every turn.

Although once a hospital for injured Viet Cong soldiers stretchered in from the frontline, today the hospital caters to civilian patients also. I spent most of my time in the department of plastic surgery – 10 elite plastic surgeons performing an amazingly diverse array of operations. I witnessed some wonders of reconstructive surgery. Sculpting two new ears out of rib cartilage for a young boy born with microtia. Reconstructing a breast using a DIEP flap taken from the abdomen. Reanimating the face of a patient with Bell’s palsy using a nerve graft from the lower leg. Surprisingly, there was also a lot of elective cosmetic surgery. The most common surgery was the blepharoplasty, where a small tract of epithelial tissue is excised from above or below the eye either to remove puffiness or, more often than not, to widen the eyes for a more ‘Western look’. The second most common was the nose augmentation, where a silicone nose is hand-carved by the surgeon and implanted above the flat nasal bone to give it a Western-looking bridge.

"I was struck by how hard these surgeons worked and how diverse their operating schedules were. Every surgeon would do both reconstructive and cosmetic across multiple sites – there were no super-specialists."

A few things impressed me about the hospital. I was struck by how hard these surgeons worked (often six and a half days per week) and how diverse their operating schedules were. Every surgeon would do both reconstructive and cosmetic across multiple sites – there were no super-specialists. I was also impressed by the level of technology available. The hospital had on-site a 3D CT machine, MRI, multiple cath labs, even a Cyberknife (a top-of-the-range surgical laser for inoperable tumours of which there are none in Australia). It was also fascinating to see a how a communist country operates with a user-pay healthcare system; the pros and cons of the less formalised surgical training pathway; and, the difficulties that arise from all major medical textbooks and journals being in English.

Overall, a magnificent experience! I owe a debt of gratitude to the Ho ̇c Mãi program, which every year brings almost 30 Australian medical and allied-health students to Vietnam, and reciprocates by offering fellowships for Vietnamese doctors in Australia. All of the local doctors held the program in the highest regard, which was a great help to us as students.

Patrick Kroek - Vietnam

On the drive in to Hue I was struck by the stark contrast between it and Ha Noi – the roads had actual lanes, for one thing! Hue is a much slower-paced, quieter and less congested city than Ha Noi; I can’t help but liken the comparison to that of the difference between Sydney and Wollongong, my hometown.

I have only been at the hospital for one week now, but my first week has already presented numerous excellent learning opportunities to me. I spent the past week accompanying Dr Minh on his daily tasks around the hospital, such as: performing neurosurgical procedures, visiting patients post-operatively, having consultations with various teams in ICU and emergency and working in Hue University Hospital’s ‘Gamma Knife Centre’.

Oh, and we got filmed for a news story, too. Dr Minh spends most of his time working in the Gamma Knife Centre; a centre for planning and delivering a special form of radiotherapy used mostly for brain pathologies such as brain tumours. The major difference between Gamma Knife and conventional radiotherapy is that it is a targeted, three-dimensional exposure generally given on a one-off basis in which a large dose of gamma radiation is delivered with careful precision over one long, intensive session. It is employed where surgical intervention is difficult due to either the nature or location of the pathology – for example, brain tumours of structures around the brainstem are generally too deep and troublesome for Dr Minh and his colleagues to treat surgically. Hue University Hospital does not have the facilities to perform the same level of neurosurgery as is seen in Australian hospitals, which makes the Gamma Knife Centre all the more pertinent.

The stoicism of the Vietnamese people became bluntly apparent when the patients undergoing Gamma Knife therapy did not balk or protest in the slightest during their treatment. The procedure involves having an incredibly uncomfortable frame being literally bolted to the patient’s head before they are locked completely motionless in the Gamma Knife machine for up to 20 minutes at a time.

Brook Sachs - Papua New Guinea

Image of Brook with the PNG locals

Credit: Radius Magazine

Our ward had 28 beds. A long corridor, with beds separated by a small table and the width of a sleeping parent on the floor. A half-size wall separating us from the ward just next door and a nurses’ station looking over them both from the front of the
room. Fans spinning on high. Parents wandering to visit each other, chatting, eating, bringing food back from the markets to share. Each family set up in their space. Camping out until their loved one gets better.

As we continued the rounds, we noticed that pathologies tended to be similar. Complications of HIV, failure to thrive due to congenital heart defects, TB, malaria and typhoid. The doctors took time to explain different pathologies and local treatment regimes. They spoke of the difficulties in obtaining first-line drugs, in the capacity to
often only deliver supportive care and the challenges of working in a limited setting. They’d accepted that many of the treatments they’d been trained to give weren’t available.

The doctor said we would begin with venepuncture and cannulation. I looked at the pile of resources laid out in front of me. No tourniquet, no tray for my sharps, or cotton buds or vials. And no butterflies. Only standard needles, one type of vacuum-sealed blood vial, sticky tape, gloves and alcohol swabs. When the doctor returned with his first charge of the day, I mentioned my difficulty in finding what we required. He looked at me in a way that said, you really are new here.

We don’t use tourniquets in this country. Just use a glove! On babies, tear off the beaded top part of the glove and tie that around their arm. And you don’t need a butterfly. Just pop the top off the vial. Don’t bother with a syringe for collecting the blood...you can drain it right into the vial. We watched as the doctor popped the plastic tip off a standard needle to drip blood from a tiny little baby’s arm and into the vial.

We watched the doctor do lumbar punctures on tiny children and babies. Because we have very few resources, lumbar punctures are performed either with standard needles or cannulas, depending on the size of the patient. And because there are never enough sterile drapes or kits, the doctors must improvise. Betadine all over the baby’s back and an alcohol wipe to remove excess from the injection site, lest the child have a reaction. Sterile gloves. Assess the position. Insert. Numerous times, patients required a lumbar puncture but the lack of an opthalmoscope to perform fundoscopy meant we wouldn’t take the risk. There’s no use getting a positive CSF culture if the lumbar puncture will cause a herniated brainstem.

"There is nothing like the joy of, first thing in the morning, seeing the mother of your tiny patient breastfeeding."

We walked past a man whose face had entirely been stitched back together after an episode of tribal violence. I wondered how the scars would heal. The first person we saw on our first trip to ED was a guy with a spear in his abdomen. A spear. In his abdomen. Yesterday, we saw a tiny little tot in the NICU. The little thing needed the heat lamp on and a pair of gauze protective sunnies. Today, that bed was empty. He died. Life is so fragile.

Today, I assisted on my first ever surgery. A C-section. I was so excited to see how they do surgery here. And to bring a little baby into the world. But the baby was stillborn. Apparently gone for a few days. I can’t imagine what that must have been like for the mum.

Emergency goes smoothly until it doesn’t. One morning, all the doctors disappeared by 10am. Night shift had gone home but day shift never came in. The afternoon came around and then the ambulances started arriving. Four patients rolled in our door at once. What had caused this sudden influx of patients? Later we learnt that ambulances from health clinics wait until they have a full car before heading down. Our motor vehicle accident patient with suspected basal skull fracture, had fallen out of the back of a ute around 7am. It was maybe 2pm when he arrived.

My first charge was the tiniest of little babies, not yet two weeks old. He had a fever. He hadn’t breastfed for almost 24 hours, had refused all fluids and he had neck stiffness. As I took the history and did an examination, each finding made me more and more worried. In Australia, suspected meningitis is a very serious thing and a child with suspected bacterial meningitis should be seen within two minutes. The panic was rising. What felt like hours, but was only 15 minutes, the tiny baby got his cannula and fluids. He would be resuscitated with fluids before anyone attempted a lumbar puncture. There is nothing like the joy of, first thing in the morning, seeing the mother of your tiny patient breastfeeding. He was feeling better. He wasn’t well yet but there was hope. And hope counts for a lot when you don’t have much else.