Musings of a junior doctor: Gastroenterology

Let me start with a short introduction. My name is Ally and I am a junior doctor working in the Australian medical system. My parents are both South East Asian migrants who did not actually need to force me into medicine because unfortunately for me, I was silly enough to make that mistake on my own.

No one in my family is medical and we had no idea that after studying a postgraduate degree and graduating with an MBBS in Medicine & Surgery, that I would still need to undergo the arduous path of internship and subsequent specialisation.

Although I hate the bureaucracy and heirarchy of the hospital system, I do enjoy my job and the insights that it brings in terms of human nature.

So without further ado, I'd like to share some of my musings on my gastroenterology term.

Malaena

Malaena is black tarry stool. And when I say black, I mean black. Like as black as Lord Voldemort's soul. It is essentially blood that has travelled from the upper intestinal system and has become oxidised throughout it's passage. It is usually indicative of a possible stomach or duodenal ulcer and warrants an endoscopy ('a camera test of the oesophagus and upper bowel'). I suppose what I wanted to share was that once you smell it, you will never forget it. For once, I was grateful for working during COVID-19 because having a mask let me hide the fact that I would go to work with cotton buds soaked in tea tree oil stuffed into my nostrils.

'DBE'

The Double Balloon Endoscopy is a new and improved camera test that allows for further investigation of bleeding in the bowel, surpassing the length of any colon visualised via a colonoscopy. This means that gastroenterologists can enter a patient's anus, travel through the large colon and travel into the small colon. It essentially works via a telescoping effect where one tube initially clears away the bowel whilst a second tube is then telescoped through. This process is repeated over and over. I was so excited when I was asked by the registrar to help assist in a DBE with one of the consultants' I had only heard of this new procedure and had no idea what it actually entailed. What ensued was 2 hours of me staring at a patient's backside whilst the consultant asked me to manoeuvre the plastic tube in and out of the bowel. All I can remember was the feeling of the warmth of the tube as it entered and exited the patient's body in my gloved fingers. 'DBE' should be renamed Don't Bother getting Excited.

How much blood?

Patients with liver cirrhosis bleed. There are a number of reasons for this but one of the main causes are their oesophageal and rectal varices. These are essentially blood vessels which have become dilated and easily leak secondary to back pressure that has been applied on them. I distinctly recall being asked by a nurse to stare into the toilet bowl of a patient who had alcholic liver cirrhosis and who was bleeding from his rectal varices. She wanted me to quantify how much blood was in the bowl. 5mL? 10mL? 20mL? According to my expertise, a drop of blood can actually turn a glass of water red. I stared into the toilet bowl and tried to think to myself, how much blood do I lose during my period? This sort of looks like that amount. I mumbled something like 10mL and scurried off. I still don't know how to quantify blood loss in a toilet bowl. Does anybody?

The human life

I saw the most patient deaths on my gastroenterology term as an intern than any of my other terms. Some of our patients were very sick and most of them were jaundiced and as yellow as The Simpsons. Pancreatic cancer can present this way. I remember seeing an elderly gentleman present with jaundice and have a scan of his abdomen showing a mass in his pancreas. The prognosis for pancreatic cancer is very poor, with a survival rate of <5% in 5 years. He was linked up with the palliative care team and died very shortly. I learnt that human life is very transient and can change after a single abdominal CT scan.

I had another patient who was a severe alcoholic and had presented with vomiting up blood. He was admitted to the ward on a pantoprazole infusion and was awaiting for an endoscopy, a camera test of his oesophagus for treatment of his oesophageal varices, the likely cause of his bleeding. He couldn't stand the fact that he was being kept nil by mouth for the surgery and unhooked himself of everything and left. I tried to reason with that man and urge him to stay. I tried to think about what was waiting for him out there. I doubted it was going to be a loving family and a warm home. I was fearful that he would not survive until the end of the year. I learnt that humans are not infallible but I am still yet to discern who was wrong. The patient for walking out or the doctor who admitted the patient for a procedure he was never going to undertake.

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