Medical Work Experience in Sri-Lanka

M
In S r i -La nk a n Ho s pita ls , 2012
JOEP JANNICK FERNANDO 9-20 July 2012
Joep Jannick Fernando joepfernando@aol.com:
w w w. J o e p F e r n a n d o . c o . n r 1
Adiamco
On Sunday evening, the day before my work experience would start, we went to a nearby Badminton Club, where we informally met Dr Reshan Godwin, whom would be organizing the whole 'hospital experience' for me.
A special thank-you to:

Dr Reshan Godwin Dr Niroshan Dr Prasad Medawatte Dr Quadir Jaleel Dr Ravi Basnayake (MO) Mrs Dr Kumarsingh Mr Ranaweera Dr Rohana Vidanage (FRCS) Dr Lalindra
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J o e p J a n n i c k F e r n a n d o!
Monday 9th July- Day 1 of Work Experience.
Today, at 10am I started my work placement at Park Hospital, where I met the doctor I would be shadowing, Dr Niroshan. Park hospital is a private hospital, which was quite small. After the introduction, we talked about what I expected, and wanted to do there. I expressed interest in A and E and Tropical diseases, as well as neurology and surgery. I was then told that in Sri-Lanka there is a specic department for A and E and OPD(outpatient department). Neurology and surgery was also not frequent in the small Private hospital; we were then offered a place by Dr Reshan Godwin (an orthopedic surgeon at a teaching Hospital in Colombo south) to a nearby hospital, which is private, but regulated by the government, called Oasis Hospital. After the talk, it was decided that Park Hospital was my base, and I could 'move out' upon appointments to other hospitals. The doctor that I was shadowing would be in from 7am to 1pm. We then decided that I would be staying at Park Hospital until 12 noon, where a director of another hospital would visit us, to secure other places at other hospitals. Between 10am and 12 noon, I visited a Psychiatric ward, within Park Hospital. The ward had individual rooms and a small number of patients (5-6). There was a lobby with several bystanders. There was also a locked gate, to prevent any patients from leaving the psychiatric ward (as this has happened in the past). The gate was locked with a padlock! I was then escorted around the area by the nurse, who had shown me all of the inpatients and told me their history. One of the patients was a teenage boy, whom was asleep. I was told that his parents had sent him here, due to violent behavior at home. The patient wanted a mobile phone, but after his parents said 'no' he lashed out and started to smash items in his house and sometimes harm his patents, out of anger. However, whats shocked me the most, was that a woman had both her arms and legs tied to the four corners of her bed with strips of linen. The woman did not look like she was in distress or pain, however I would not expect to see this sort of practice in the UK. My father, being a Mental Health Practitioner, told me that in the UK, they are tranquilized instead, sectioned under the MEntal HEalth Act, as this could seem as a breech of human rights(due to lack of freedom). However this practice was effective, as it prevented the patient from self-harming herself and/or others. I then spoke face to face, with an unusual case of an in-patient, who had been so for 22 years. The 78 year old woman was a diabetic, who had hypertension, and also suffered from depression, due to an unknown cause. When talking to her, she would talk about countries, and about the Sri-Lankan psychologists being the 'best in the world'. She would also talk about her travels, however she was hard to understand, due to her speech being slurred, possibly sideeffect from medication. When i asked her about how she felt about the ward in which she was staying, she said that she was happy, and that the ward staff were very accommodating. I asked her if anyone visits her, and she replied "my friends and family used to visit". She then went on to say that she has a daughter that visits her often. Dr Niroshan told me that in Sri-Lanka, families often 'hide away' their relatives who have mental health issues, as it is bad for the family reputation. He then continued to tell me that in government hospitals, the procedure in admission was very public and open, so relatives or friends of the family would easily know about it. Therefore, the family reputation would decrease. This is the same mentality in most asian countries. In private hospitals, the admission would be more private, and therefore people would not tend to know about it. During admission, the symptoms which are often quite common, include over-talking, being aggressive, and being suspicious of the people around them. They are then referred to the 'emergency department' where their history, and their family history is discussed and logged. After this has been done, the consultant is called, whereby medication is prescribed to calm the patient down. I talked to Dr Niroshan about the consultants, and he commented that they were never in the hospital, but had to be called instead. Some of the diagnosis in the psychiatric ward included: Schizophrenia, Bipolar Affective disorder, and major depression. Some of the medication used to treat the people in the psychiatric ward included: Olamzapine, Risperidone, and Midazolam. My father told me that in the UK the same is prescribed.
Before leaving the psychiatric ward, I realised that there was only one nurse in the whole ward. I then commented to Dr Niroshan and he said that it was a real problem, as dealing with more than one emergency at a time would be near to impossible. I then asked about ages of people, and I was told that people aged between 17-25 years were ok in their history and the main psychiatric problems in women starts at 30+. I was then informed that the people who were admitted into the ward are often very educated people who 'crack up' with stress issues, or simply lack the care, love and emotional support from the people around them. After leaving the ward, I met the doctor again, where we talked about universities, and any queries that I had. He then received a number of patients, with a range of conditions, from Gastritis to prolonged menstruation. Patient 1 Age: 20 The patient arrived, with tears, and a pain in her chest and stomach. The doctor then analyzed the situation, and looked at several variables and factors, such as where she was working. She was working at a small supermarket store, therefore receiving very small pay. He then diagnosed the patient with 'Gastritis' as she had it recently. The causes could be relating to stress and the skipping of meals. There are many things that the patient with gastritis should avoid such as oily/ fatty foods, and spicy foods. But, due to her low budget, she is probably unable to afford other foods. The patient was then injected twice with: Pantoprazole- to stop the acid secretion, and Domperidone- to stop the acid going up the esophagus, and to ensure that the acid leaves the stomach. The patient was then told to purchase tablets, which neutralise the excess amounts of acid in the stomach. Although the patient was diagnosed with a 'experienced guess', an endoscopy could be appropriate to conrm the diagnosis. However, this is costly to the patient, as it costs 50. (5 in Sri-Lanka is 1000rs so 50 is 10,000rs). Due to my low understanding of the digestive system, Dr Niroshan said out how it all worked, and told me that if she was left untreated, it could lead to death! He had shown me, using a diagram that Acid(stomach) + wound = pain. The Dr then also laid out many different scenarios and what could be done to stop it. If the acid would get close to the capillaries in the tissue of the stomach, they would burst/rupture, causing internal bleeding, which will be fatal to the patient, and inevitably need surgery to clamp the capillaries. If there is any sort of bleeding, i was told that the patients pulse rate would increase, and that if blood was being lost, the blood pressure would decrease.
Patient 2 Age: 21 The man arrived with a fever, which he said that he had for 2 days. His joints were aching and he was experiencing a lot of body pain. The patient couldn't sit comfortably, signifying that he was in a lot of pain and was very uncomfortable. In Sri-Lanka, at this time, there is an outbreak of Dingue-Fever (pronounced Dingee). The patient did not have any allergies to tablets. The doctor immediately said, "you need plenty of bed rest, and uids", to keep yourself hydrated. However, with this patient, there was a complication- the patient was on aspirin, as he had heart problems. The tablets usually prescribed to patients of dingue fever contradict with the aspirin tablets. If the man is positive for dingue fever, then he must see a physician straight away for medical advice. There is no 'cure' for Dingue fever, as of yet, but the medication which is prescribed helps to cure the u symptoms. Dingue fever attacks the platelets in the blood, which are responsible for clotting. Therefore, they are not there, and the blood 'leaks' into the body, therefore causing internal bleeding, which is fatal to the patient. The cost of the Dingue test was 2400rs, patient paid without hesitation.
Patient 3 Age: 48 The third patient was having a prolonged menstruation. This was her rst time. The patient is therefore bleeding, and a lot of blood has been lost. This can lead to Anemia- where not enough blood reaches the body, and therefore the patient is at risk of dying if there is no intervention. Hormonal medication (Primolut-N) was prescribed to stop the bleeding. The age of menopause is around 48, and the patient is 48, so no vaginal examination was necessary. If the bleeding persists, the patient was advised to see the gynecologist. Other causes could include a cancerous growth, whereby an operation is necessary to remove it, and clamp the bleeding vessels.
Ps: 18 mosquito bites on my right arm 13 on left arm!
Tuesday 10th July- Day 2 Of Work Experience.

Today, I woke up very early - at quarter to six in the morning. The days plans are to visit Park hospital from 7am until 8.15am, therefore allowing me 15 minutes of transit time to the hospital mentioned in the meeting above, Oasis. Oasis is a hospital whereby more operations are carried out, and therefore, I can look at what I am interested in. However, most of the operations take place during the night time, so I will usually nish at 1pm, but today, I might re-visit Oasis Hospital to see an operation. During the one and a half hours, in which I have spent in Park Hospital, the Dr and I began to talk about the hospitals, and the levels of organization. We also talked about every hospital's management system being different, and some being better than others. After this, I asked about the number of beds and if there was a theatre in the hospital. He answered that there were 3 emergency beds, and that the theatre was not functioning very well, therefore not being used. He then went on to say that they often referred patients to other hospitals, as they have the specialist equipment that is required, and they are all very close to each other. We then started to talk about costs, as Park hospital is a private hospital. He said that patients were reluctant and angry to pay the charges for tablets and medication, which usually cost 1,300rs (6), whilst they would talk about going to expensive hotels (such as the Hilton) and drinking a cup of coffee and cakes which cost them around (60). While in the UK there is a set amount of patients, which a doctor can see, and a cap of 4 hours, in Sri-Lanka, no "cap" exists, therefore some doctors have to see 60-70 patients within 6 hours. This must be very difcult for the doctors, as it must be very tiring and hard to concentrate for such a long time span. Before we saw any patients, I was advised to call the consultants "sir" or "madam", as I would otherwise offend them. This was apparently adopted by the English in their practices, but in England, the custom has been abolished 50 years ago. After the talk with the doctor, a patient entered the ofce.. Patient 4 Age: 40 The patient arrived explaining that she had been coughing and sneezing during the night, (for 2 weeks) due to receiving a previous prescription of an antibiotic for her tonsillitis. The patient had no fever, and no difculty breathing. Dr Niroshan used the stethoscope, checked her tongue, and (strangely to me) tapped her face. I later asked why he tapped on her face, and he said that it was so he could check if any of her sinus' had been infected. If the sinus' were infected, she would feel pain. However, the result was negative, as she felt no pain. The doctor prescribed her with an antibiotic- Clarithomycin for her tonsillitis, and other drugs to decrease the amount of mucus in her nose, therefore, stopping her from sneezing and getting a sore throat. I then asked "what if the patient has a blocked nose, fever, and other symptoms?". He replied that more antibiotics would have to be prescribed. Patient 5 Age: 76 The patient arrived, with a growth on her throat. She was not on medication, and according to her history, had no previous history of illnesses. She suffered from a cough and a headache, which was prolonged for 2 days. The patient did not suffer of any asthma, or has no allergies to medicine. Her blood pressures were also checked, and her weight was
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checked. She weighed very little- only 33kg, which is a cause for concern. She had a lower respiratory infection, whereby an antibiotic was prescribed, along with some steroids. Although, the patient had a possible cancerous growth on her neck, i was told by the doctor that they should only discuss and solve what the patient wants solved, as people are often stubborn in listening to the doctors about issues which are underlying, but not bothering them. The doctor then commented the patients view was that the average lifespan of a patient was between 69-71 years of age, and that may be a reason not to take a closer look at the growth, which could possibly be cancerous. If the patient is then diagnosed, it could change their lives drastically, and treatment would be required, which would be costly to the family.
Oasis hospital visit

At 9.10am, we departed from Park Hospital, and drove up the road, to a bigger hospital- Oasis. I then met Dr Prasad Medawatte, the chief medical ofcer, who got a nurse to show me around the hospital. In over an hour and a half, we managed to cover the whole hospital. Oasis hospital is compromised of two buildings- an old building, which is 12 years old, and a new building, which is 4-5 years old. We started off in the old building, at Ground oor: ETU - emergency treatment unit, where the doctor examines the patient, and then are sent to the channel consultation area, where patients are sent to various areas of the hospital to undergo further treatments. The laboratory sample collector is also situated on the rst oor, and is where patients samples are handed in, and then given to the main laboratory on oor 2. There is also a public cafeteria, drug stores, general stores (stationary, paper), an eye clinic, a cardiac unit and a dental clinic. Floor 2 This oor was dedicated to the pediatrics department. There are facilities such as a play room, and resident rooms. Floor 3 Oncology department- for cancer related issues and treatment. Unlike the usual departments, where doctors are usually on-call, there is a resident doctor who stays in the hospital at all times. There are also several medical ofcers in the area.
Floor 5 Maternity ward, where mothers usually stay 1-2 days after they have given birth. This is to keep them under observation. There is also a labour room. Floor 6 This is the 'luxury ward' area, where patients have a TV, a Microwave, a fridge, and it costs 7500rs per day, which is: 35.80GBP. This is a general ward, where patients from all over the hospital can stay. Floor 8 This is where the operating theaters are, and is where I will be going after lunch to see eye-surgery. There is also an endoscopy unit. (long cameras down the patients throats). There is also an intensive care unit, which has 4 beds.
The other building, is around 4-5 years old, and has two oors, possibly the oor numbers which i have missed outoor 4 and oor 7. Floor 7 Is a general ward, which has 25 rooms, and 5 extra rooms, for mild psychiatric cases.
Floor 4 There are more rooms in this oor, and a Dialysis ward (kidney failure). There was one patient present. There is also a senior citizens home, whereby the oor acts as a care home. Floor 3 In this oor, there is a Physiotherapy area, a spa, and various radioactive treatments, such as : X-rays, CT scans and a mammogram (to detect breast cancer). Floor 2 There is an auditorium and a HR department on this oor. Finances are also managed here. After the tour of the hospital, I was told that after 4 pm it becomes very busy. I asked where the busiest place at that time was, and the nurse replied that it was the Channel Counter. After, we arranged that I could see some surgeries take place, as tuesday was the day in which eye-surgery occurred. From 11.30 to 12.30, I will be in the ETU department - Emergency Transfer Unit. I was shadowing Dr Quadir Jaleel. As the ETU department was not very busy, he taught me how to do a few things, such as how to take a persons blood pressure: Firstly, you have to put the cuff above the elbow, and then pump the pressure up to 200. The equipment used to tighten the area around the patients arm is called: The Sphygmomanometer. A stethoscope is also used to listen to the pulse, and the systolic, and the diastolic pressure. The normal pressure is 120/80, and a cause for concern is 160-80. When with Dr Quadir Jaleel, i was shown how to take a patients blood sugar levels. In a normal patient, the levels are below 140. The doctors blood sugar levels were 105. More than 200 means that the person is diabetic.
I also spoke to Ranaweera, who was a male nurse in the Sri-Lankan army. When there was a blast injury, he had to nd a replacement for the loss of blood, the four Bs would immediately be checked. B - Breathing. Clear airway, if not breathing, articial respiration. B - Bleeding. Direct and indirect pressure is given. Hypovolemic shock, can occur, so plasma is given to the casualty. normal saline, or expanded
B - Break. If the humerous is broken, large volumes of blood can be lost, the joints have to be immobilized, and pain killers are often given. B - Burns. Pain killers are given, before the casualty goes into shock. If skin is burned, alot of uid is lost, therefore a lot of uid has to be replaced. To cover the burn wound, do not break the blisters, to prevent further uid loss, and cover in cling lm and non absorbent dressings. After the four Bs have been checked, the casualty should be transported to the nearest hospice, in the eld as soon as possible. After talking to Ranaweera, I waited outside the ofce of Dr Prasad Medawatte, where I started to type up the days events. At around 1.30 I followed Dr Prasad Medawatte upstairs, to oor 8, where all the surgeries happened. I was told that multiple surgeries occurred, one after the other. I decided that I would only need to see one for today. The nurses around the area gave me a wrapped packet containing blue, sterile trousers and a top. I was also givenh a cap, which i placed on my head, to prevent any hair loss, and a mouthpiece to cover my mouth and nose. The operation started at exactly 2:05pm, and was predicted to end in only 30-45 minutes. The operation was called a DCR -
Dacryo Cysto Rhinostomy. An infusion set with 5% glucose was used, and by the end of the operation, it was completely used up. More sterile, one use items, were carefully wrapped in paper, and given to the lead surgeon, Dr Palhakkara. The lead anesthetist, Mrs Dr Kumarsinghe asked me how many surgeries i had been in/ seen. I replied that this was my rst.
Mrs Dr Kumarsinghe told me that there were some complications, with the patient being fully anesthetized, as she was allergic to full anesthetic, or to some of the components. Therefore, only a local anesthetic was used. Mrs Dr Kumarsinghe continued talking to say that this operation may be "traumatic". She also said that many new doctors/ trainees would faint or feel/ be sick. The reason in which the patient needed an operation, is because of an infection which in effect, causes puss to come through the porous layer of the skin, and infect the eye. The reason for infection is as follows.. All excess tears, and water from the eyes comes down a tear-duct out the nose. However, with this patient, one of the tear ducts was blocked, and therefore no water would be able to come out the nose, and in effect was "trapped". So.. To simplify: Excess tears drain into the nose from the eye! At 2:05, the operation started. The operation also started to shock me, as blood was pouring out of the patients eyes. The patient was also in pain- making noises. The side which was being operated on was the left side. A cloth was then put on the patients face, however, at rst, she refused it. Local anesthetic was then injected twice, once under the eyebrow, and second, under the eye, close to the nose. The patient was in pain. The lead surgeon, then made a precise incision under the side of the eyebrow, next to the nose.
A suction pipe was being used to suck away all of the blood, which was in the incision area. Two surgical tools were used to keep the cut open, and therefore allow the surgeon some room to operate within the patients face. For me, the most shocking experience I had, was watching what the surgeon did next. To bypass the blocked tear duct, a hole had to be made in the side of the nose, where silicon tubing would be put in. The surgeon took a very sharp appliance, put it in in the cut, the suction pipe came in to suck up the blood, and then twisted it clockwise with quite a lot of pressure. The patient moaned/ shouted and moved her legs, to signify that she was in a lot of pain! However, the bone in the side of the nose did not break. Piece by piece, the bone layer started to ake off, and it was slowly, and painfully for the patient, removed. However, at the current rate, the operation would take very long, so to speed the process up, the surgeon asked for a surgical hammer. After he received the hammer, in yet another carefully wrapped packet, he took another new tool, which seemed like a surgical chisel, and started to chip away the bone in the patients nose. The surgeon was very precise, accurate and gentle, however the sheer brutality of the procedure shocked me. After a few hits, you could hear the "crumpling" sound, as the bone was crushed. To make it easier to visualize, it sounded as if, you took at dried leaf and then scrunched it up, in your hand, but quieter. Other surgical apparatus was then used to remove pieces of the bone which had been crushed, and were in the incision.
After there was a clear passage from the nose, into the incision, surgical scissors were inserted into the patients left nostril. Everything was ready and lined up. The operation had already taken 1:30 hours. However, due to the patient not being under full anesthetic, and only local anesthetic, she sneezed, and the scissors came loose and so did the opening of the cut. I believe that the surgeons, who were holding open the incision, removed the surgical apparatus as soon as they knew that she was about to sneeze, because she could cause injury to herself- the cut could rip open even further. As she sneezed, the surgical scissors became loose, and blood started to come out of the patients left nostril, at a frequent rate. The blood was then covered in cotton buds and pads, and the bleeding was contained. During the operation, every half an hour or so, eye drops were put into the patients eye, to ensure that the moisture in the eye is retained, and that there is no damage to the eye during the operation (becoming too dry). After around 30 minutes, more bone was removed, piece by piece, causing a lot of pain to the patient. Sharp wires were nally inserted through the patients thin skin around her eye.
The main surgeon, Dr Palhakkara told me to stand closer to the patient, so i could get a better view of the incision, and what he was doing. He then talked me through what he was doing - inserting a very sharp needle with a silicon tube through the thin skin around the eye, into the incision, and out through the left nostril. The surgeon and his assistants then ignored the silicon tube, as both sharp ends were "dangling" out of the left nostril. The surgeon was then given a vicril suturing kit (stitching), and he started to stitch the incision. After the incision was fully closed up, the surgeons assistant then tied the silicon tube, which was "dangling" out of the patients nose, 3 times, and then cut the two sharp ends off. More eye drops were then given to the patient, and immediately after, a cotton pad was placed on the patients incision, around the eye. The surgery cloths on the patient were then removed, and she was transferred to a portable bed, which was wheeled in by the assistants. She was then wheeled out of the surgery into the adjacent room, where she was under observation. After the operation was over, i asked the surgeon "how many operations do you usually do in a day?". He responded that he didn't do many of these complicated operations, but he would do 5-10 fairly straight forward operations per day, such as removing a Cataract. (Which I will hopefully see on thursday). The operation nished at 25 minutes past 4. And therefore took 2 hours, and 20 minutes, instead of 30-45 minutes!
Today has been a very long day for me - even as i return home, I am still typing up this report. Work hours - 7.15am to 4.25pm ( 9 hours and 10 minutes )
Wednesday 11th July- Day 3 of Work Experience

In Park Hospital today, things were a lot quieter, as we only saw one patient in the time span in which I was there - from 7.30-9.00am. I talked with Doctor Niroshan, and he looked at yesterdays report, and veried what I had written, and ensured that the events were as accurate as possible. Therefore, I was instructed to get some good background on common events and problems which people have. I was told to look at "Allergic Rhinitis' which is also more commonly know as hay fever. The problem with the name 'hay fever' is that it has nothing at all to do with hay. Trees are mostly responsible for causing hay fever, such as the pine tree. People are mostly allergic to grasses. Weeds such as plantain or ragweed also give people hay fever. To test for hay fever, skin tests are usually conducted. Skin tests include: intra dermal, scratch patch, and the RAST blood test. The symptoms of hay fever are: Conjunctival swelling, erythema, eyelid swelling, swollen nasal turbinates, middle ear effusion, and rings under eyes. The way to decrease symptoms, is to: use mite proof covers, air lters, and with holding certain foods. Steroids, such as strong nasal sprays are deemed as safe and effective. Antihistamines are also used. This morning, I also looked up "the correct use of asthma inhalers", as it was suggested to me by Dr Niroshan. Although, it is not the correct way, the patient can insert the asthma inhaler directly into their mouth, and take a deep breath in for 10 seconds, and then a short breath out. Certain inhalers, and other patients who do not nd the practice effective, tend to use a 'spaceship' inhaler, where the asthma inhaler is pumped directly into. The device then stops the gasses from escaping and therefore allows the patients to have more time to inhale. While researching, I also found out that puffs should be taken in between 1-5 minutes, and before exercise, 2 puffs can be inhaled one after the other. For small children, the same 'spaceship' device is used, and a mask is worn, whereby the children are instructed to take 4-10 breaths. After yesterdays operation, I was told that there would be several Cataract surgeries on thursday. Therefore, I decided that I should prepare by researching the operation (just as the surgeon does). The eye is made of proteins, and water. However when the proteins in the eye become older, the start to cloud the lens, and then the lens becomes infected. Therefore, the normal, quickest, and easiest procedure, is where 3 incisions a made on the edges of the lens. The infected lens is them removed, by the use of an ultrasound probe breaking the lens, and the lens then being sucked up. Eye drops are then given to dilate the pupil, and before this is going on, a local anesthetic is given. An intraocular lens, is then inserted, which is often made from plastic, silicone, and acrylic. If this procedure is adopted, stitches are not necessary. The patients vision should improve almost immediately. However a patch is put on
the patients eye, as sharp lights can damage the eye after. The intraocular lens should last the remainder of the patients lifetime, and should not need to be replaced. The patient is then under observation. Thats what I expect the procedure to be like, however, you can never be sure if it ill run very smoothly, or if any complications are to arise. Oasis Hospital Day 2 At 9:40am I was already in Oasis hospital, where I met the 'sister' (nurse), who gave me a tour of the hospital, a day prior. She asked me what I would like to do in the hospital. I suggested that I would like to go to the ETU - the emergency treatment department. Although it is not very busy, the medical ofcer, Dr Prasad Medawatte, told me that there would be a big operation going on today, whereby the stomach would be operated on. The operation is expected to start at 4:30, and last around 3 hours. Soon, I will be going to the theatre wards to nd out the name of the operation, so I can see what happens during it. Patient 1 Age: 19 Prior to Dr Prasad Medawatte telling me that there was an operation going on, we received a patient, whom had a fever, and was vomiting. She had stomach pain, however no body pain, so eliminating the possibility of her having the Dingue fever. The temperature was checked under her arm, and eyes were checked. The patient did not have a blocked nose. The doctor advised to the patient, that if the fever is still persisting tomorrow, have a Dingue test (a full blood count). The doctor prescribed the female patient: Domperone- to stop the vomiting. BuscopanPatient 2 Age: around 50 The patient was having an ECG- Electrocardiography. An ECG shows wether there are any problems with the patients heart, as the rhythm may alter and change. The procedure is harmless and painless, gel is applied on the patient, leads are stuck onto the gel. The patient had 6 leads on his chest, and one lead on each arm and leg. An ECG also shows the electrical activity of the heart.
After seeing the two patients, I made my way up to the 8th oor- the surgery. Here, I asked the name of the operation which would be carried out today at 4:30. The procedure is called a Laparotomy. The Laparotomy is a surgical procedure, where a large incision is made through the abdominal wall to gain access to the abdominal cavity. Another name for this operation is: Celiotomy. Access is given to any abdominal organ or space, however it depends where the cut has been made. Here is what is usually accessed: Digestive Tract- Stomach, colon Liver, Pancreas, Gall bladder, Spleen Bladder Female reproductive organs Appendix Due to there being a wide range of assessable organs, and one of the nurses is still unsure what is wrong with the patient, it is hard to predict what will be operated on after the laprotomy has been made. According to the photos that I have seen on the internet, things can get quite bloody! As the operation in which I attended the theatre to see began at 4:30, I was 30 minutes early. A minor operation had just started. The patient was a young woman who had spots on her face, and all over her body. The spots have to be removed, as if they are not, they could become cancerous, and grow even bigger. When they grow with age, a root develops. This makes the spots even harder to remove. The spots are called "ex lumps". Local anesthetic was administered underneath each spot. The black spots were then removed, and cut out. The skin was then sown back together, and covered in a patch. Before any incisions were made, the areas were covered in a brown dye, which i now know is an antiseptic. The operation was a minor surgery, whereby the duration should have been only 10 minutes, however, for the time I was there, the time had already exceeded its estimation. I then had to leave the operation, as the Laparotomy was about to begin
Before the operation began, I was told by the assistant surgeon, Dr Ravi Basnayake (MO), that the patient was 88 years old, and extremely unstable. The patient was wheeled in a portable bed. After around 15 minutes, all cables were connected. Compared to the other operation, the day prior, the conditions were more strict and I was told not to even go close to any of the sterile equipment or any sterile cloths. Due to my research during the day, I understood that the operation was going to be an: "exploratory Laparotomy". This meant that the stomach could be cut open, as explained on previous pages, and then the contents would be explored to try and nd a fault, or a problem. The problem which was found in this patient was that the bowel had become entangled and knotted. To me, the worst thing about the operation, wasn't the sight of the patients contents, but it was the smell of burned skin and fat. To cut open the patient, the main surgeon, Dr Rohana Vidanage (FRCS) put double gloves on, and used a knife to cut an incision through the fat. After this was done, an electrical skin/fat burner was used to open the stomach. The stench that came from the burning of the skin and fat was a sickening smell. Luckily, I did not throw up! As the patient was opened up, the leading surgeon pointed out that the patient had previous stitches. These stitches were cut, and the operation continued as planned. However, to my surprise, all the surgeons had a phone in the same room. The leading surgeon was even wearing a bluetooth headset while he was operating, and he even took a few calls! After an hour or so, all of the contents of the stomach were pulled out of the stomach and examined, to nd the problem. Once the bowel was examined, it appeared that it was entangled and knotted, therefore the patient was suffering. The tissue (white) between the bowels was cut, and eventually, the bowel was not in a knot any longer. There was something which shocked even the experienced doctors. There were multiple Diverticulae attached to the bowel. These Diverticulae do not affect the patient, as the patient is born with them. There is no apparent reason for these forming, and they should never be removed. If they are removed, the contents of the bowel will squirt out, and the patient will more than certainly, die. The repercussions of the entanglement of the bowel, are that the stomach has become bloated in a 'J' shape. After this, the secretion produced by the stomach was removed by a suction tool. After this happened, a glass bottle slipped out of one of the nurses hands, and smashed on the oor. I was slightly surprised to see some of the younger doctors picking the glass up by hand, and that there was no sweep to clear the mess up. Even after the operation, there were isolated pieces of glass, which could pose a safety hazard. Besides the broken glass, all safety and hygiene was excellent, and in the operation, a 'bait hugger' was used to keep the patient warm (43'C), and to prevent hypothermia from occurring. Hypothermia was a threat, as after 2 holes were made in the patients stomach, on each side, where drainage tubes were fed through, normal temperature saline solution was put in the patients stomach, to cleanse the organs, and to kill off any bacteria, before they could multiply and infect the patient. The solution was 'sucked up' by the suction tube each time. This was done twice. The third time, the saline solution was heated.
Finally, the patients organs were placed back into her stomach, and suturing began (stitching). This took quite a while, however, it had to be done very carefully, as the vital organs were extremely close to the skin. Making a puncture with the sharp end of the suture would be fatal, and the patient could die. So this shows that the end is even more important than anything else. If the surgeon is tired, (I certainly was), then the whole operation could end up as a disaster. An antiseptic was then placed on top of the sown incision, then cleaned, then stapled, and then the dressing was applied. P.s: If the wording makes no sense whatsoever, or todays report seems rushed, please bear in mind that todays working hours for me were excruciatingly long - 13 hours, and typing on-top. Now I look forward to sleeping!
Thursday 12th July- Day 4 of Work Experience

Today, I woke up at the usual time, 6am. However, it was not like other mornings-I felt weak and very tired. That was probably due to the extremely long day yesterday! I was told by Dr Niroshan, that the reason for me being so tired yesterday evening was not only because of the long hours, but because of the anesthetic which was inhaled by the patent via a mask, during the operation. That is something new, which i didn't know, Although I have eaten a sugary cereal breakfast, I am still very tired. I should refrain from doing very long days again, as it has an effect on the day after. Today, there is a change of plan - instead of going to Oasis hospital early in the morning, I will be staying here at park hospital for a longer duration - until 1 o clock, as I hope to get some more exposure, compared to Oasis hospital, which has been receiving very few patients over the past few days. I was then instructed to research and look at a few things, for my own benet, so I could get a background of what frequently occurs in this area. Firstly. I researched the development of the Stethoscope, and i found out that there were 3 or 4 stages: Monaural --> Binaural --> 20th Century --> 21st Century I looked closely at the monaural, which started off by a doctor called Laennec. The usual procedure for listening to the heart and internal sounds was by putting an ear to the patients chest. However, Laennec had a female patient, and was embarrassed to put his ear to the woman's chest, and therefore, he remembered an experience from his childhood, and rolled up precisely 24 sheets of paper, and then placed one end on the patients chest, and one end in his ear. He was amazed at what he heard! He heard all of the usual sounds, but the sound was amplied, and therefore he had made a breakthrough. He made wooden versions of his invention in a workshop, in which he set up inside his house. He called his invention 'Le Cylindre' as he did not want any complex names. After a while, he endured a lot of scrutiny from his medical friends and professors, as they suggested that it should be called a 'Stethoscope. This was because if the word is split, it means: 'To hear' and 'The chest'. Over time, the shape and the materials developed . An earpiece was added on and a smooth surface, to ensure that no pain is given to the patient. After the binaural stage, came the 20th century style stethoscopes- the same shapes in which we see today.
The 21st century stethoscopes are more concept designs, as not every surgeon has them. They are electronic stethoscopes, which wirelessly send the sounds to a computer or mobile device, such as a smartphone, or tablet. The electronic stethoscopes record the audio samples, whereby they can be stored in a database, or analyzed for the surgeons future reference. After researching and reading the history of the stethoscope, I was called out of the ofce to spectate a nurse giving a patient an injection. The injection was done very slowly, as the patient was in pain. The injection was an antibiotic, as the patient was suffering from an infection. I was told to look at 3 different types if injection- intramuscular, Intravenous, and sub-cutaneous. I looked at youtube videos for Intramuscular, and sub-cutaneous, however i could not nd an intravenous one. Instead, i looked at an Intra-dermal injection.. A subcutaneous injection, would be like injecting insulin, but at a 90* or 45* angle. Before injecting, the skin would be pushed closer to each other, then the needle would be inserted. The injection should take 3-5 seconds, to be fully injected into the patient. An Intra-Muscular injection would be injected in areas such as the deltoid. Before the needle is injected, the reverse of the Subcutaneous is carried out - the skin is pulled away from each other. This injection is usually carried out at a 90* angle, and should take around 5 seconds to be fully injected. In an Intradermal injection, the layer beneath the skin is injected.
As, all the side effects and problems of an injection depend on the drug, and the volume given to the patient, also varies with the drug and the patient, i have chosen Contraceptive Injections, to outline the problems. The problems are that: weight is ofter gained, the bone density is slightly lost, and that hair often falls out. After this, i briey looked at the correct use and disposal of syringes and needles. (see picture)
There was a violent case, whereby a patient was admitted to the psychiatric area. According to the patient, men were necessary to remove the patient from his residence, and place him in a jail like cell, where the room was secure and the subject was isolated. The patient had depressive thoughts and spoke of suiciding. Upon the doctor talking to the patient, a male 16 year old, abusive language was thrown at the doctor. The student was an A level psychology student, who was said to get straight As in all of his test bar one, a science. The patient then started to point out aws, and made a request to the doctor, so he could see and speak to the patients. However, this was not advisable, as his parents were responsible for sending him to the psychiatric ward. The patient had been severely depressed, for 3 months, and said that he liked to watch 'comedy' lms. The patient had no family history of psychological issues, and no friends, due to him being a brutally honest person, as taught to do so at school. For example, if someone was cheating in class, he would point them out straight away to the teacher. The boy, was said to be extremely bright, and did not want any medicine, as he clearly laid out that it does not actually solve the problem, but it only 'dopes' the patient up. He probably learned about all of these things from his psychology course, and then made a reference to the safety of the room- not having padded walls. The doctor then assured me that the patient could only harm himself to a minimalistic proportion, and not kill himself. The patient was then out under suicide watch. Due to the patient only being 16 years of age - a minor, the patient could have been 'sectioned' as they would in the UK, however, as his father was there, he gave consent for medication to be given. In a bag, there were many linen straps, where the patient would be tied up. Dr Niroshan called the patients doctor to ask wether it was ok to tie him up. The other doctor replied over the phone "if necessary'. Five men walked into the room accompanied by a nurse who had the injection. The patient started to swear at the men, and suddenly, they restrained the patient on the bed. The patient, was shouting, and became aggressive, and resisted the men for over 2 minutes. Soon the struggle was over, a man had him in a headlock, an other man had the legs contained, whilst the other had the legs contained. There was a man turning him, if i can recall, and then simply the nurse injected him with Dormicum ( Midazolam ), which is used to produce sleepiness or drowsiness. In 10 minutes, the patient should be drowsy, and sleepy, where by the second drug can be injected- haloperidol which is used for the treatment of schizophrenia, acute psychotic states, and delirium. Before the rst drug was injected, and after the patient was restrained, he kept begging "ill go freely".. "ill go freely", however the men restraining him did not let go, instead, they kept a tight grip. I am guessing that this had happened, as the men who were restraining had seen it all before. Besides, would you take an aggressive psychotic patient's word? I thought so. If we return to the time where the doctor was seeing the patient, the doctor asked to see if he was conscious and aware of the month. The patient responded positively, even telling him the day and the date. However, the patient was unsure of the day, as he said thursday at rst (which was correct), and then quickly added "or wednesday". After the patient pushed the doctor away, Dr Niroshan told me that the patient seemed like a perfectionist, and was agitated, as things were not going correctly, or his way. I also saw a security camera in the lobby for security purposes. The father was also slightly distressed his son being held down and injected. He wanted to see his son, but he was told not to, as it would only aggravate his son, and make him even more aggressive. The father was assured that his son was not being injured or harmed. After, i was told that the patient was given a second dose, of the same medication, and 10-15 minutes after, he was nally asleep. I asked how long the patient would be staying in the psychiatric hospital, however, Dr Niroshan said that it all depends on the patient and that it is extremely difcult to estimate. However, at the rate in which the patient is being treated, the guess is under a week. Correct tablets and injections will then be given, and the patient should be diagnosed After this, i was left alone to do some more background research, which has already been typed up above, and afterwards, i sat down with the doctor, and we started to engage in a conversation about politics, which lead on to the progression of the country and also the mentality in which people have - not allowing the country to move forward and become developed. P.s Today was not such a busy day for me, however, the nal psychiatric case was quite shocking in ways..
Friday 13th July- Day 5 of Work Experience

Yes, yes, its friday the 13th.. Nothing bad has happened..yet! Today, i will be doing the same day as yesterday, where I will only be staying at Park Hospital. Due to the lack of emergency patients, I had a talk with the doctor, and he said "although you are not here to study, in this hospital, there is not much else you can do". I was then given a sheet of paper, of things to research. I was also told that, although the men were harsh in restraining yesterdays patient, they were professionals in their job- one was a retired policeman. I then started to look at ECT- Electro Convulsive Therapy. I read some mixed reviews of the treatment on the Internet. Many professionals believe that it is a safe treatment used to split ullage the brain for psychiatric patients, while other reviews suggest that it is 'marginally more effective than a placebo (sham ECT)'. ECT has also been viewed as harmful by the public, psychiatric professional, and mental health professionals. It has also been portrayed negatively in several lms, as an act of violence. My father who is a specialist in mental health, stated that he is.....for/against ECT because of........... M The ECT procedure is as follows: http://www.theuniversityhospital.com/ect/procedure.htm After watching multiple YouTube videos about the procedure, I then looked at the pages full of comments of people arguing why that ECT is bad, and many people saying that it is good. Although, most of the comments are written by psychologists, and higher level students, I managed to understand the general jist of things. I also read a lot of people who had undergone ECT in the comments section of the video. I then saw that some ECT patients said that it "saved their life" and various other comments, while others say that it "did nothing" for them. 2 days back or so, I saw a patient who was undergoing an ECG - an ElectroCardioGram. However, in America it is called an EKG. I was asked to nd out why by Dr Niroshan. I found that in German- it is called the ElectroKardiGram, and as the EKG/ECG was a German invention, that's why it is called an EKG in America.. Willem Einthoven was the German who invented it (however his name being a very Dutch name). I was then told to look at the process of Venepuncture, the method in which blood is withdrawn from the patient, so a full blood count can take place (FBC). Puncturing a vein with a needle to draw blood is the denition of Venepuncture. A patient had then arrived with concerns about the color of her urine - dark yellow. The patient had no other symptoms present. She was not allergic to any medicines or drugs. The patient was sent to have a urine test, and the report would be ready in under 30 minutes. The doctor couldn't guess what the patient had, as she suffered from no other symptoms. We are just awaiting the report now. In the meantime I was told to look at UTI's - urinary tract infection. This is caused by a bacteria. In the UK, half of all women suffer from this at least once in their lifetime. The main symptoms. Which the doctor asked the patient were: "do
you experience a burning sensation when you pass urine?" and "do you need to urinate more often?" and "is there a pain in your lower stomach?". The patient answered negatively to all the questions. I believe that the patient has simply, not been drinking enough, and therefore her urine is a dark yellow. We will soon see what the Doctor says, once the report is seen. I also looked at Cystitis, the most common type of UTI in women. Other symptoms of an UTI include passing blood while urinating. Advice on the NHS website says that cranberry juice should be taken if possible, and that the patient must keep themselves hydrated. While visiting the lavatory, I realized that the tap was broken, and that urine was spilt on the oor. These unhygienic conditions are not good in any hospital, and I believe that if Park Hosptial is to maintain its standards, as a private hospital, it should denitely clean the toilets up. I resorted to the Hand Sanitizer, which I carry around with me at all times! Due to today's report being extremely short, at the rate in which it is going, I have decided to show the contents of the bag I carry. The bag, is more of a satchel, but here goes: Notebook+pen Glasses case(if wearing contacts) Hand sanitizer Mobile Phones (2) Wallet Pair of latex-free gloves Contact Cards Price conversion table Spare pen During the placement, I also carried another bag, with lunch and water, and I would carry my iPad with me. I was then advised to look at a patient report, although all reports differ to the hospital, in which they originate from. Heres a sample one which I found on the Internet:
Monday 16th July- Day 6 of Work

After a relaxing weekend, where I studied History- Medicine, and my IT course books, I was awake at 6am. I then prepared for my day, as usual, I would, have a shower, put my work clothes on- white shirt, black trousers, and a colored tie, and then double check my bag to ensure that everything is in it. We then travelled to park hospital, where I met Dr Niroshan. I then asked wether there were any new psychiatric patients. He called the ward upstairs, and the nurse responded that there were no new patients. But I was free got talk to any. I then walked up two ights of stairs, and was greeted by the nurses, who opened the locked gate for me to enter the ward. I then was shown the woman, who was an inpatient for 22 years, however, due to the language barrier, I was unable to tell the person escorting me, and after a struggle of 2 minutes, I stepped out of the room and pointed to the corridor. It worked- as we then saw a patient who was suffering from mental depression. However, I was actually unable to talk to the patient. Instead, the father was talking to me about his son. I therefore realised, that not all of what he is saying would be accurate. It is possible that the father does not know how his son is really feeling. The father also seemed slightly confused, and when I asked how long they had been in the hospital, he rstly said "3-4 days", while after a few minutes, he would say "2-3 days at the most", when re-questioned. When I asked about why and how he was brought to the ward, the father said that he started to become aggressive and violent, and started to blame things, such as the food being to hot, to his mother. He also started to use 'obscene' language around the house, and had uctuating moods. The father then said that he saw an advert in the newspaper, in which he called the doctor, and had 3-4 secret meetings, without the sons knowledge. The doctor then gave the father a pill, and without the son's consent, the father somehow gave the pill to him. Once the pill was in effect, the father then called the hospital 'guards' to his house, where his son was taken. Although there were 4 men, the patient, 21 years of age was resisting and ghting the men. The father then said "he is unable to control himself". When I asked the father about how the patient was feeling, he said on his sons behalf, that he was not happy and he wanted to go home. However, the father only wanted his son to be on adequate medication to ensure that his son gets back to 'normal'. The patient also was frequently going to the bathroom and coughing and washing his hands. I asked why this was, and the father commented that he had been coughing a lot recently, and the had been a lot of phlegm in his throat. He was then often washing his hands, and the father said that it was relating to his mental health issues. When the patient was rst admitted, he was tied to the bed, as he was aggressive and a possible threat to himself. When I asked the father of his sons future plans, he looked at me and said, "nothing", "he doesn't know". The patient was 21 years of age, and had been living alone, and only saw his family at scheduled times, where a meal would be provided for him. I was also told that the patient did not sleep well during the night time, but slept during the day. I then enquired about the amount of medication the patient took. The father told me that he takes some every day. I was then told that the patient has some good days and some bad days. We were then talking about the prices, and I was told that 1 day, costed 10,000rs. That is equivalent to around 50. However, after talking to the father, he then changed the price to 8,000rs. The nal question which I asked was: how long do you think your son will have to stay in the hospital. He then responded with "5-6 days at the most". However, this is only opinion, and not fact, as he does not have a professional medical insight. After and during the questions I asked him about his son, he asked me about the UK, and what I was doing in Sri-Lanka. However, he asked me multiple questions which overlapped, and asked me the same thing more than once. This could be because he was unsure of my response, or possibly because the father has some short temporary loss and/or mental health condition! A patient then entered Dr Niroshan's ofce, and he was complaining of fever and body pain. Immediately what sprung to my mind, as well as the doctors, which was: Dengue fever! The doctor then asked some more questions to conrm the suspicion and the patient responded that he had a sore throat, a cough, a sensation of burning in his eyes. However, the patient did not have a headache, or a difculty breathing. Nor did he have any allergies to any medicines and nally a normal Oral temperature was taken. The doctor then said that a Blood Test needs to be done, however, if a Dingue test is done, it is far more costly than a normal blood test. A normal test was done, and a urine sample was also taken. The doctor then prescribed some medicine, advised that bed rest was important, as well as plenty of uids. As I was going to Oasis Hospital at 9.00pm, I asked wether the report would still be available for viewing tomorrow. The doctor replied "of course!". The doctor then told me to look at Dengue, so I found out that Dengue is infectious and is caused by a virus. It is transmitted by vectors (mosquitoes), which only bites during daylight hours. I also read that anyone can catch dengue, however the most vulnerable people were: older children, adolescents, and adults. Dengue is also an example of a selflimiting disease, as it clears up by itself, and medication is only given to numb the symptoms. After infection it take around 6 days for symptoms to become present, such as: High temperature-40*C or 104F A severe headache Muscle and joint pain Facial ushing Skin rash
After the visit to Park Hospital, I travelled to Oasis Hospital, where I met the ENT doctor again. I sat with him, 2 patients and not much else happened. 20 minutes after seeing the second patient, he asked to see the iPad. I then handed the iPad over, and funnily enough, we played scrabble!! We couldn't nish the game, as there were simply no more combinations left, and the tiles had nished!
Tuesday 17th July- Day 7 of Work

In the morning, I went to Park Hospital, where I met Dr Niroshan again. We then began to talk about the days arrangements. I told him that I would be visiting Oasis Hospital at 11am, whereby I could watch an operation at 1 pm. However, as I type at this moment in time in Park Hospital, stupidly enough, all my apps have decided to go and update themselves. With a poor Internet connection compared to the UK, this is like torture, as the iPad has become slow, and I can not type from the app in which I usually type from. I also worry that the whole document which I have typed up might erase itself, however I have condence in apple to back my work up. I will transfer the notes below soon.. The doctor and I then began to talk about why not so many people actually came to Park Hospital. I was told that there were insufcient facilities, as most of the time, they simply transfer the patient elsewhere. For example, in Park Hospital, there is no ICU facility, or any labs or X-rays. The doctor then continued to say that the biggest factor was management, as without proper management, the hospital will not attract many people. Patients have also complained that there is no special feel to the hospital, as when the patients arrive they are not welcomed and do not receive a greeting. The doctor also said that it was not all about the quality of the patients stay, or the quality of treatment, but it was all about prot margins for the big bosses. However, he added that this was where ever you went, and that all places were the same. I then asked the doctor about salaries and information, which was kept more private to the people themselves, therefore I was told the pat the following are simply approximations:
Junior Nurse Nurse
Doctor
Consultant
Surgeon
5,000rs 23.85
25,000rs 119.25
42,000 200.34
2,000,000 9,540
4,000,000 19,080
(Based on weekly exchange rates..current rate Tuesday 17th July 2012)
I was shocked at the wages of the people working in the medical eld. To make things worse, I was told that the minimum salary for a basic laborer was 14,000rs. So I questioned why the junior nurses only got 5,000. The doctor then responded that it's who the big-bosses know, and the junior nurses don't know their rights. I was told that if the government questioned the hospitals, they would say that food and accommodation would be provided. This is true, however the accommodation is terrible- medical people are treated as 'animals'. I was then also told that the private sector pays a lot less than the state, which really shocked me, as if anything, I would have thought that it would have been the other way around. The doctor then said that this was as, if the private sector paid more, then everyone would choose to work at the private hospitals, and nobody would work for the local hospitals. I was then told that the private sector was controlled by the rich. I then added "corruption of the rich, at the workers expense". To the person reading this in the UK, or any other countries, the basic cost of living- not including accommodation, as that varies too much is 9000rs per month- 3 meals per day, one cup of tea. However, this varies greatly where in Sri Lanka the person is. These statistics were taken from Colombo, where the hospital is. The food given out is no way near luxury food, and is almost always bought outside, and not prepared at the residence of the employee. If we look back at the table, I was told that the high paid medical professionals, somehow manage to evade paying taxes, so the gures above are 'in hand' wages! I was also surprised about the jump from doctors to consultants- as it is a huge difference. I was then told that doctors nd it very hard to actually get to consultant level, as all the consultants manage to push them away from progressing to their level. If we look at the difference between nurses and doctors, yet again the jump is not that far, although the doctor has to do so much more work, and be in medical school for 5-7 years. I then
asked if the medial system in Sri Lanka, cost anything, and he said that it was free. I asked wether the medical schooling was good, he replied "excellent for a developing country". I then asked the doctor about the ideal salary. He said that the ration 1:12 should be followed. so 14,000:XXXXX
Half way through the chat, 2 parents entered, with concerns about their 10 year old child, who had 3 blood tests done, and the reports had been given to Dr Niroshan. The child had 4 days of fever, however, did not have any fever today, and yesterday evening. The patient is not active. Usually, Dengue is assumed, and due to the child not having done a Dengue test, and only full blood counts, the 2 reports were compared and analysed. The number of red blood cells had gone down. The number of white blood cells had fallen drastically, to suggest that infection is present within the patient. The number of platelets had also decreased, therefore this also relates to infection. The cause for concern in this patient was the number of liver enzymes, as this is usually looked at to asses the status if the child. The consultant was called, and parts of the report were told to him. The next course of action, was to bring the patient to a hospital, which could admit them, and then further investigations would be done, along with monitoring the patient closely. The doctor told the parents, that the child's condition was not serious, but that what had to be done was to prevent the condition from becoming serious. After the patient had gone, we continued the chat, as mentioned above. The doctor also mentioned that a while back, they had set up a pediatric ward, however it was a complete failure. There was a kids corner set up, but I haven't seen one child there, so I assumed that. Yesterday, when I talked to the psychiatric patient's father, he said that it was too costly for him. I then talked to the doctor about it, and he said that other hospitals would include more- as they would charge individually for all things. As this was all inclusive, it included food, doctors, and some medication. And I was told that the same thing happened yet again- as they could go to a mental health hospital, however, they want to maintain the family's image, and 'hide away' their patients. At 11, I will be visiting Oasis, whereby I will be seeing an operation at 1pm. I was lucky enough to see an operation about a cataract after all, as I was supposed to go sometime, during last week. Everything that I researched came up, as I expected, however took far longer than I expected, taking around an hour per operation. I watched 2 Cataract surgeries, whereby the same procedure was followed. A plastic sheet with pockets (to allow draining) was used and put over the patients face. An incision was then made on the plastic to allow the surgeon- Dr Palihakkara to operate. Special clamps were used to move the eyelids apart. Due to this type of surgery being extremely precise, the surgeon had a seat, and a magnifying machine, which was set to 10X. An incision was made at the top of the cornea and local anesthetic was placed in the cornea and in the white of the eye. The pupil was then dilated. The surgeon then told me that this was the latest technology. The lens was then cut from the sides, with an ultrasound probe and then was sucked up. The intraocular lens was then inserted via an injection. I was surprised that this happened, as in my research, I had read and seen nothing like it! Eye drops were then inserted, and the operation was over! This was repeated twice, and while the second patient was being operated on, the doctor said that he found it quite hard, as the patients eye had kept moving. The operation took slightly longer and as too much ultrasound is no good for the patients eye, the surgeon used a procedure called "the chopper", where the pupil is "chopped" up into small pieces with very ne, precise instruments and then sucked out. This requires a lot of skill and a steady hand!
Wednesday 18th July- Day 8 of Work

Today, I met Dr Niroshan at Park Hospital at around 7:30am, as usual. I let him read the report, that I had written yesterday. He then started to tell me something really shocking. One of the nurses who had been working at the hospital, for over 1 and a half years, had become seriously ill. Blood tests were done, however, everything seemed ne. Yesterday, the nurse had fever, diarrhoea and was vomiting. Her condition was bad. You would think that the employers would look after their staff, but no, since it is not a legal obligation to look after the staff, the hospital will not cover anything. Sine the hospital is in the private sector, things have to be paid for, which a nurse can simply not afford, she has to go to the government sector to seek treatment. She was in such a bad condition, that she had to be put on a drip, and the doctor said, that if the hospital could provide basic things, it would be ne with the employers. He then gave me an example of this for me to relate to in the UK. Funnily enough, he choose KFC (Kentucky Fried Chicken). The staff do not have to work during their lunch and break times, and meals are provided for free, or heavily discounted to the staff. I then told the doctor that today might be my last day, and that I would be visiting a government hospital afterwards, which I am looking forward to, as there will be greater exposure to patients. Dr Niroshan then told me about the hierarchy and what to look for to identify certain structures and stafng. There would be 3 types of laborers, sanitary, ordinary, and attendants, who would usually wear light yellow trousers. I was then told that they don't often do their jobs well, and take bribes from poor people to arrange things for them. Nurses would wear black, blue and white clothes, and would often be intimidated/ indoctrinated by the laborers to do things for them. The doctor suggested 2 Tamil lms which I should watch- 'Angadi Theru' (meaning the high-way) and 'Vazhakku En 18.9' (court case 18.9). We watched the beginning of the rst lm, where a bus ran over multiple workers. Once the wi gets sorted out, I will try to watch the rest, as he said that the lm is signicant to aiding my knowledge. I was then told to research and look at various types of traditional medicine. I then looked at traditional Chinese medicine briey and found out that it was more legend than actual history. Shen Nong was also mentioned a lot as a divine cultivator, and the founder of herbal medicine. He also taught people how to farm. I also had read that the Hung-Di-NeiJing was the oldest medical textbook in the world, and that it included topics on: Physiology Theories of medicine Pathology Prevention Diagnosis Treatment Acupuncture
Moxibustion Tulsa http://www.purifymind.com/HistoryMed.htm Today, will be my last day at Park Hospital :( I enjoyed the experience here, the doctors were nice, kind and friendly, and I would like to mention a special thanks to Dr Niroshan, who I was shadowing! Although at times, the hospital wasn't busy, tomorrow at a government hospital, he said that I should be shocked. I will at 11am visit Oasis Hospital until 1pm for the last time also. Afterwards I visited Oasis, not many patients arrived, so I talked to Dr Jaleel, and said my goodbyes. He then said that I would see him on British TV soon- as his ambitions were 'coming true, and he was going to make it big in playing for srilanka's cricket team. I also asked him to write a little note for me.. As follows:
Thursday 19th July- Day 9 of Work

Today, as usual, I woke up at 6pm, however due to the fact that I would be visiting a new government hospital, the meeting was scheduled for 11am. Therefore, as I have said goodbye to the people at both hospitals, I'm at home, waiting for 3 and a half hours! At 9.00 we left the house, to visit the National hospital of Sri-Lanka, the biggest in south east Asia, having 2,600 beds, over 32 acres.We waited for an appointment for 2 hours, where, we could talk to a plastic surgeon, as I would be working in that eld for the next 2 days. I then met Ed Stanley, an Australian, who was on clinical placement in Sri Lanka (for his nal year in medicine) for a week, and had 5 weeks remaining. He told me that 10 minutes before I came in, a patient had been holding his own nger in his hand, which had been detached. The rst patient that I saw had a keloid scar, which doesn't heal properly, as It keeps getting infected by hair growth. Numbing cream had been out on the areas, however, the patient has a phobia of needles. The patient got the scar by having a heart bypass done. I also saw that there was a makeshift sharps bin, which was used as a compromise. Local anesthetic was then injected, and funnily enough, while this was going on, the song: 'highway to hell' was being played, to 'relax' the surgeons. We waited for the local anesthetic to be injected, and then the area within the scar was cut out, as If a fresh cut was made, another keloid scar would form. Therefore this was a way of 'tricking the body'. After it was cut out, it was sutured, and then a dressing was applied on the cut. The second patient that I saw had Botox injected, for a reason unknown to me, in a grid pattern, where it had been drawn on the arm. I can already see the huge differences in lifestyle between employees of the government and private sector. I the government sector, the pay is better, therefore they talk a lot about technology, and apps for example, which they can easily afford, while a private sector employee wouldn't be able to afford these 'luxuries'.
Although today's report is quite short, I have only spent around 2 and a half hours in the hospital, and I feel that there is far more exposure in this hospital compared to Park and Oasis Hospital.
Friday 20th July- Day 10 of Work

Today, is my nal day of work experience. I will be traveling to the National General hospital again, where I was yesterday. I plan to arrive there before 8, as the surgeon told me that we would be meeting early, as we would be moving onto a different area. Apparently it was a clinical day on Fridays, but I have no clue what that means, so I will have to wait and see. I arrived at 10 to 8, as I would be seeing an administrator for a certicate, to prove that I was actually in the hospital. I will also be making multiple photographs. I arrived at the staff room by taking the ground oor elevator, to the second oor, where I had to walk down a long corridor to reach the ofce. The area was full of patients, it was so crowded! I then met Dr Lalindra for the second time, in the ofce. He introduced me to his colleagues, who were eating, talking and making jokes. It did not feel as if it was the work atmosphere, as I saw it more like a family.. The atmosphere was nice, and welcoming. The clinical day meant that we would not be seeing any surgeries today, but instead, we would be looking at patients and planning surgeries. This was the equivalent to an OPD (out patients department). Compared to Oasis- and Park hospital, at 8:15, there are over 25 patients waiting to be seen! The difference is huge between the government and private sector, purely because of money. However, while National Hospital has no shortage of patients, it's beds, and operating theatre lights (eg), are not as good as in the private sector, therefore, I can see the differences in funding. In Oasis Hospital, each theatre is sectioned off during an operation, while 2 operations take place in the same room in a government sector. The government sector hospitals are also under supplied, as they do not have essential equipment - such as a dedicated sharps bin. Ing During the clinical day, we saw a lot of patients, with a wide variety of issues. One of the patients had their ngers fused (arthrodesis). We are unsure of the cause, which is probably secondary trauma. A different patient wanted a tattoo removed, so he could join the police force. As lazering the tattoo off, is far too expensive, it was decided that a local excision with skin grafts must be performed. We were then told that this patient had the least priority over others. While we were called out off the ofce to look at a patient, we saw a different patient who had their skull and right side of her face open. There were also signs of infection on the wound, as Candida Thrush was forming. This was not extremely bad, as it shows that the persons immune system is working adequately. The medical term for this is: right sided temporal zygomatic and buccal regions. These sorts of injuries are usually caused by electrical burns in adults, however, this was a child, so trauma is expected to be the cause. Whilst looking around the area, there are several RTA's - Road Trafc Accidents. I was also quite shocked, as there are over 35 people including doctors in one room, the size of 8x5m. The corridor is also packed with people to see the consultants- today will never end!!
We have also seen some very rare cases- such as mobious, where the patient can not show emotion. In the face, there are 16 muscles for facial expression on each side, and the patient normally wont have any, as they were not born with them. For these cases, the treatment is called with gracious reanimation. The time is 10.05. As there are no online records in Sri-Lanka, everyone has to have a note-book with their entire medical history, as this is the only way that doctors can see accurate notes written by other medical professionals, without constantly phoning them. While being here, I have also seen many broken bones and x-rays. More and more patients are accumulating outside the room, at 10:23, there are 26 people inside, and around 30-40 people outside. There has also been some trauma cases caused by RTA's. I have also seen a patient who had a skin graft, 2 years ago, and it was becoming dry and itchy, this leads to infection and is called infected eczema. I was told that due to the woman living far away, home remedies will be used, such as boiling herbs ect.. I was told that the patient's documents were usually recorded on devices, and sent to India, where they would be typed up, and faxed over. I was also told that plastic surgeons deal with everything apart from burns. My general observations, are that there's are plenty of patients who have hand related problems.
Nature of the experience: One to one sessions with doctors Sitting in ENT walk in clinics Observatory capacity in surgery, witnessed x6 operations in theatres in one general and in one private hospital I will conclude that the experience was great, and truly interesting. I also know what I want to do in my later life, and I will start the preparation for medical school in whenever time I have free. I was advised by the Australian student that I should get a part time job, as it will stick out on my CV. Therefore, I will try to nd work in a pharmacy, in the UK, which I can sustain, and gain more medical experience from. I will also do some volunteer work to ensure that I also am committed to whatever I do. In the three hospitals, oasis and Pam were very similar- small amounts of patients, while the National hospital was teeming with patients. My experience prior to working in a hospital was tiny- I only used to watch a few surgeries/ hospital setups on the television. My knowledge was acquired by talking to the doctors and surgeons, and doing independent research. I also plan to try to work in a hospital in the UK- maybe next year! I believe that, from this experience, it has been highly benecial to my learning, and understanding of medical practices in a developing country, and my fathers country- Sri-Lanka. I have also seen many cultural aspects embedded into the society, which is also an experience. While I stay in Sri-Lanka, for 2 more weeks, my main concern is the Dengue outbreak... Wish me luck!
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Medical Work Experience in Sri-Lanka

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Medical Work Experience in Sri-Lanka

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In S r i -La nk a n Ho s pita ls , 2012

JOEP JANNICK FERNANDO 9-20 July 2012

Joep Jannick Fernando joepfernando@aol.com:

A special thank-you to:

Monday 9th July- Day 1 of Work Experience.

Ps: 18 mosquito bites on my right arm 13 on left arm!

Tuesday 10th July- Day 2 Of Work Experience.

Oasis hospital visit

Wednesday 11th July- Day 3 of Work Experience

Thursday 12th July- Day 4 of Work Experience

Friday 13th July- Day 5 of Work Experience

Monday 16th July- Day 6 of Work

Tuesday 17th July- Day 7 of Work

Junior Nurse Nurse

(Based on weekly exchange rates..current rate Tuesday 17th July 2012)

Wednesday 18th July- Day 8 of Work

Thursday 19th July- Day 9 of Work

Friday 20th July- Day 10 of Work

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