Jonathan Tan Wei De, A189453, 8/8/24

2. What have you done?

Started my clinical attachment at University Hospital of Umeå in Oncology Department. I have been to the Oncology wards to meet different patients admitted due to different complications of their cancer such as sepsis, bone pain and altered mental status. Attended several ward rounds, as well as conducted history taking and physical examination (heart, lung and GIT)

3. Points to remember from week 1!

The goal in palliative care involving patients with advanced stage of cancers and metastasis to different organs is to improve quality of life. Relieving symptoms and emotional support is so vital by providing house visits and regular follow ups.

4. Your feelings & thoughts

I was nervous the first few days as I didn’t know what to expect. It’s very sad to see many palliative care patients in the ward with limited life span expectancy.

5. Any difficulties/concerns? How did you cope?

Language barrier to understand content when patients and doctors speak in Swedish, which is overcome by asking my doctor’s assistance for translation

6. 2 words to describe elective posting progress so far

Eye opening

7. Your plan for next week (Week 2)

Understand different cancer treatments, learning more Swedish

Low Zhi Yeow

A189483

Date of Writing: 10 - 18 August 2024

Date of Week 1: 29 July - 4 August 2024

2. What have you done?

I reached Stockholm, Sweden, with my friend, Jonathan Tan, at about 9 pm on 27 July 2024 (Saturday) by plane. Then, we took a train to Umeå, a city more than 600 km north of Stockholm. We arrived in Umeå at 8 am, but the sunrise at 3 am, visible from outside the train, was enough to wake us up.

We spent the whole day of 28 July (Sunday) moving into our apartment and buying groceries for our meals. The prices for daily groceries were not very different from those back home, but eating out or dining in restaurants/cafés can cost at least three times more than in Malaysia. One thing that I had to cope with was the cold climate, as the nights could be as cold as 12ºC although it was mid-summer.

My attachment at Norrlands Universitetssjukhus, or the University Hospital of Umeå, started on 29 July (Monday). Every day, I would change to the scrubs provided by the hospital and be present in the orthopaedics conference room at 7.45 am for the morning round. Unlike the ward rounds in Malaysia, the medical doctors and consultants first hold rounds in a private room. Then, the doctor in charge of a ward of patients conducts rounds with other members of the healthcare team (the nurse, the physiotherapist, the medical social worker and the occupational therapist) in a small room in the ward. After the morning round, I spent my first day in the orthopaedics outpatient clinic. A challenge I faced during the consultations was that almost all of the patients preferred to speak Swedish, although most of them could also speak English fluently. However, I had the opportunity to perform a lower limb musculoskeletal physical examination on some patients to check for neurological and musculoskeletal function affected by spinal trauma. My day usually ended around 3 to 4 pm.

The second day was exciting as I got to scrub in for a posterior lumbar fixation and decompression surgery. I was slow and clumsy at first, as it was my first time scrubbing in, but my supervisor, Josefin, was very friendly and patient when she explained and guided me through the procedures. We are required to wash our hands three times (firstly up to the elbows, secondly up to halfway between the hands and elbows, and thirdly just the hands to the wrists), followed by a hand-rub using Sterillium, a surgical rub-in disinfectant. During the operation, I had the opportunity to observe it right beside the chief surgeon and assist at the end by suturing the wounds. I was grateful for the opportunity, as I got to observe the operation clearly and closely, and it was my first time suturing a real patient. At the end of the day, Josefin has even given me a set of suturing kits! Thank you, Josefin!

On the third and fourth days, I followed Cecilia, a paediatric orthopaedist. In adult orthopaedics, I saw a lot of traumatic cases in the clinic, but in paediatric orthopaedics, the cases involving infants and children were more related to congenital/genetic diseases (with malignancies like osteosarcoma also being common). I also learned that in Sweden, all newborns with suspected hip dislocation or instability must undergo mandatory screening by clinical examination coupled with ultrasound scans to rule it out. I observed this being done on several newborns, including one with Marfan syndrome.

It is also worth mentioning that the evening of the third day was spent at the National Food & Drinks Party, an activity organised by the IFMSA SCOPE committee here. All the exchange students prepared food from their home countries to share, and we made Maggi Goreng and some Malaysian snacks (Tam Tam and Muruku Ikan Po Po). On the table, there were Swedish, Malaysian, Spanish, and French cuisine.

I spent my fifth day in the outpatient clinic with David, who specialises in foot orthopaedics. I observed a few consultations and discussed the cases with David, and the day ended early at 12 pm.

Over the weekend, I had a campfire with all the exchange students by a lake and visited Bildmuseet, a museum owned by Umeå University.

3. Points to remember from week 1!

• All hospital personnel have to change to the hospital scrubs every morning before starting the day.

• We refer to everyone, including the doctors and the nurses, with their first names. For instance, Josefin and Cecilia instead of Dr. Åkerstedt and Prof. Söderqvist.

• The door of the consultation room has to be closed when a consultation is going on. The privacy and confidentiality of the patients are very important in Sweden.

• Physical examinations are done by wearing gloves for hygienic purposes.

• After a consultation, the patient’s case will be recorded by dictation (the doctor dictates with a microphone, and the secretaries in the hospital will convert the audio to text later on in the Electrical Medical Record (EMR) system).

• Basic suturing skills and experience!

• The procedures of scrubbing into an operation.

• Read on the AO spinal injury classification for subaxial cervical & thoracolumbar spine.

4. Your feelings & thoughts

Initially, I was a little reserved as it was a new environment for me. I followed my supervisor by standing aside throughout the day and I did not have the courage to volunteer to assist as I was afraid that they would be annoyed by my lack of skills and experience. However, I slowly realised that they were very nice and friendly to me, and they respect medical students and our will to learn. Eventually, I started to be more courageous to volunteer for participation in performing physical examinations, discussing cases and interpreting images. Although I was still far away from being competent, they were willing to guide me as long as I was eager to learn.

5. Any difficulties/concerns? How did you cope?

I had difficulty with the patients speaking in Swedish. Therefore, I have to ask whether they could speak in English. I tried to catch some words from the Swedish conversation as well although it was a slow process. However, I could catch some medical jargon as they were similar to their counterparts in English.

I also had to overcome my fear towards the new environment as mentioned above. With the friendliness shown by my supervisors and the staff, I took the step to be more courageous and proactive.

6. 2 words to describe elective posting progress so far

• Foreign

• Friendly

7. Your plan for next week (Week 2)

• Learn more basic daily words and common medical jargons in Swedish.

• Involve more in hands-on procedures and be more courageous to discuss my ideas with my supervisor.

• Learn more about the differences in the Swedish healthcare system compared to the Malaysian’s.

• Visit more places in Umeå!

I was excited for my first day of attachment. The first day I went to the hospital, it was so huge and the hospital was separated into departments by building. I was assigned to be in general surgery. I was introduced to my doctors who are in the colorectal team. There is another student from Oman who is with me. We were being brought around the hospital to look around, where the surgeons always go. From the changing clothes basement to the surgery room and also the conference room. I found that something different from our university is that everyone has to change to a hospital wear everyday. Due to summer break, the hospital was rather chill. There were only a few doctors on duty and the elective surgery was not as intensive as usual. During my first week, I was able to watch up to 4 surgeries. The surgeons told us about the patient's condition before the surgery. I observed the right hemicolectomy with anastomosis. They used the stapler method to perform the hemicolectomy. I observed laparoscopic right hemicolectomy as well. It was a great experience watching all the surgeries. Some of the procedure Dr did some explanation. However, I hope that we can observe it nearer as some of the OT does not have a camera. One of the days, I observed the ERCP which they are trying to take out a stone from the bile duct. In the first week, the doctor assured me that we will be able to get a chance to assist during the surgery and I was very excited about it.

About my hosting local committee, they were so kind. On the second day of arrival, they hosted an upon arrival training for us, by telling us what to take note in the hospital, in Sweden and also some of the cultural differences. One interesting fact was about the "last pieces" of food. Swedish does not take the last piece of food, thus if you want to take it, claim yourself that "I am not being Swedish right now". The other day, me and the contact persons of the local committees had some fun doing beads together in the middle of the park. Then, we had the national food drink party where we brought the cuisine from our home country and we ate it together. It was fun trying out some of the Swedish meatballs and food from Peru.

The difficulties that I faced was about the food. The prices are so high in Sweden especially freshly cooked food. The only cheap option that I have.

That ends the first week of my exchange. It was full of excitement, surprise and culture shock. I am looking forward to next week.

Disclaimer: we are actually not allowed to take any photos in the hospital or during the surgery, thus it is difficult for me to take any photos in the hospital unless we are allowed to do so :(

1. What have you done?
   During the first week, I was oriented to the hospital environment and introduced to the local healthcare system. I shadowed doctors in the General Surgery department, observed ward rounds, outpatient consultations, and participated in small discussions with other students on clinical cases. I also familiarized myself with the workflow of patient management in Oman, which is quite different from what I’ve seen before. Every morning, we will have a morning discussion including all medical officer and consultant. They will discuss the case together and shared their opinion. After that, we had class with our supervisor, Dr. Hani. If he was busy, we will had class with one of the registra from trauma team. After the class, we had our lunch at the hospital cafeteria. In the afternoon, we attached to the operation thetre to observe the surgery. Unfortunately, we had no chance to scrub in due to too many exchange students. I observed a right cubital fossa lipoma excision.

   At night, we had dinner with all the exchange students at a nearby restaurant. We had a great time there and I have enjoyed so much.

   
   

2. Points to remember from Week 1!

   • The importance of understanding patient history thoroughly to navigate complex diagnoses.

   • The value of being adaptable, especially in cross-cultural settings, to effectively communicate with patients and colleagues.

   • Recognizing how healthcare policies and available resources affect medical decision-making.

     
     

3. Your feelings & thoughts
   I felt a mix of excitement and nervousness in the first week. The learning environment was quite different from Malaysia, and I initially struggled to keep up with the local language and cultural nuances. However, I enjoyed how welcoming and supportive the medical team was.

   
   

4. Any difficulties/concerns? How did you cope?
   I found the language barrier to be the most significant challenge since many patients spoke Arabic. To cope, I asked colleagues for translations and started learning basic phrases in Arabic. I also leaned on my peers for help in understanding certain medical terminologies used here that differed from what I was familiar with.

   
   

5. 2 words to describe elective posting progress so far
   Eye-opening, Challenging.

   
   

6. Your plan for next week (Week 2)
   My plan for Week 2 is to actively engage more in patient discussions, ask more questions during ward rounds, and try to pick up more Arabic phrases to improve communication.

Name: Lee Xin Yi

Matric number: A188524

Date: 4/8-10/8

2.        What have you done?

On the 3^rd of August, my friends and I landed on the land of Oman early in the morning, around 7.30 AM.  We were first welcomed by the heat and a huge sun hanging high up in the sky. I still clearly remember the temperature reached up to 40 degrees. After waiting for minutes at the pick-up point, our contact person (Abdul Malik) picked us up from Oman International Airport and drove us to our dorm. On the journey, we introduced each other and had a wonderful chat about the cultures in Oman. He was very welcoming and helpful in showing us the nearest hypermarket, restaurants, and ATM from our dorm.

Before our arrival date, we were already informed about our room number, so we just claimed our room key and settled down. The dorm provided us with free breakfast, lunch, and dinner every day on the 8^th floor so we had our first breakfast as we were starving after long hours of traveling. In the dining room, we met our first friends in this exchange! They were Anda and Denisa from Romania. Then we walked to the nearest hypermarket and bought groceries from our 1-month stay in Oman.

The next day (4^th of August) marked our first day of clinical exchange! We were having our attachment at General Surgery department in the teaching hospital of Sultan Qaboos hospital, located in the heart of Oman which is Muscat. On our arrival day, we already had a short and sweet hospital tour in the evening. Jihad who is one of the medical students there brought us around and showed us the location of different department and their wards, as well as hospital cafeteria. We also met our supervisor who is Prof Dr. Hani, the senior consultant of general and trauma surgeon.

A new day of a surgeon or doctor in this hospital kicks off with a morning meeting that discussed patient cases in the ward and their radiological findings. The meeting usually lasted for around 1 hour. It was similar to the clinicopathological conference (CPC) that we had in HUKM. We joined their morning meetings and followed the ward rounds right after. I managed to palpate a huge lipoma on a patient’s right thigh. The doctor was also kind to teach us how to interpret a normal CT TAP and compare it with another with positive findings. In the first week, we also managed to watch a few cases of hernia surgeries, including open and laparoscopic. It was my first time watching a laparoscopic surgery and I was really fascinated by the skills of the surgeons.  

During the times when we finished our hospital routine, we had small tours around the town of Muscat and sightseeing. The local committee of the organization organized some tours for us so we did not have to struggle with transportation. We visited Al Alam Palace, or “Flag Palace” in Old Muscat which is one of six palaces belonging to the ruling monarch Sultan Qaboos. The original structure was built by the Sultan’s great-great-great-great-great-great grandfather over 200 years ago. The place is used for official functions like welcoming foreign dignitaries and heads of state. Al Alam Palace is surrounded by the Portuguese-built Mirani and Jalali forts which were constructed during the Portuguese invasion. We entered Muttrah Fort and went up to the top to enjoy the golden hour (sunset) of the day. We were able to view the small towns, country roads, and jetty with boats along the coastline. The scenery was too breathtaking and I think this is the moment when I fell in love with this country, Oman.

On a Thursday evening, my friends and I were invited by one of the exchange students from Thailand named Nice to visit her Omani friend. We had a traditional Omani dinner with real Omani food and eating culture.  We talked about cultures and religions of our own and had a great time enjoying ourselves in the pool. As only girls were allowed to the party, we were having really fun to have a girls-only chit-chatting session in the pool. The night was filled with the laughter and hospitality of Omani girls, I love them.

3.        Points to remember from week 1!

• All the discussions and communication between doctors, nurses, and other healthcare workers are conducted in English. They also use full English in the Medical course.

• I learned to interpret radiological images of CT before every surgery that I observed: the CT TAP is best observed starting from the anus and tracking along the colon and small intestine.

• Hernioplasty: I learned about different types of mesh and the mesh they used for hernioplasty is Ventralight. Ventralight™ ST Mesh is indicated for use in the reconstruction of soft tissue deficiencies, such as for the repair of hernias. In indirect inguinal hernia repair, the mesh is also used to wrap around the spermatic cord to prevent damaging it. For umbilical hernia, the umbilicus is detached from the linea alba, and the omentum is cut to expose the small intestine so that it can be pushed back into the abdomen before sealing with a circular mesh.

• There are very less patients in the ward compared to Malaysia – only 5-6 patients.

• The privacy of the patients was at the top of their list, so we were not allowed to take pictures freely in the hospital. In the ward, they have all the curtains closed for each bed to create a private space without any disturbance. You have to lift the curtain a bit and ask for permission so that you can go to the bedside.

• DO NOT MISS THE BUS!!! The bus only picked students up at the dorm at 7.30 AM every day and back from the hospital on 2.30 PM. Once you missed the bus, the only choice you had was to grab a taxi because it was quite impossible to walk such distance in the extreme heat.

  
  

4.        Your feelings & thoughts

I had a mixture of feelings – excited but anxious and worried in my first week in Oman. As this was the very first time I travelled to a country outside of Asia, I was excited to see the other side of the world. At the same time, I felt the distance of me away from home and I am the minority in Oman as there are very less number of Asian people in Oman. I was worried that they would not be so welcoming to us. But at the end of the first week, I found that my anxiety was solved as they showed their biggest smile and welcomed us when we introduced ourselves to everyone we met in the hospital. I was also fascinated by the hospital environment- clean, spacious and built-in Omani style.

The only feeling I left at the end of the week was just excitement as I couldn’t wait to meet all the exchange students from all over the world.

5. Any difficulties/concerns? How did you cope?

• On the fourth day in Oman, I got my Oman SIM card which I bought from Vodafone (one of the telecommunication companies in Oman). It was suggested by the local committee of SMAMMS because they provided us with a student offer package. After I put in the SIM card, my mobile data could be used for only 2 days, and it did not work anymore. So I contacted Jihad to help me and communicate with them but the person who sold us the SIM card was not responsible for solving my issue. In the end, I took a taxi to the nearest telecom shop, hoping that they could check what was wrong with my SIM card. Luckily, the serviceman was so kind to make me a new SIM card for free after I explained my situation to him. And thank god that he can speak simple English.

• Most Omanis can speak simple English, especially young people. However, their accent sometimes is too strong so it is difficult for me to understand them sometimes. I think it eventually takes time for me to get used to their accent. I will also try to learn simple Arabic words that can be used for simple communication.

• Oman has a tropical desert climate and we visited them in their scorching summers. The temperature can rise to 40 degrees Celsius in noon! I think I have to keep myself hydrated and avoid outdoor activities in the noon if possible.

6. 2 words to describe elective posting progress so far

 Adventure begins!

7. Your plan for next week (Week 2)

• I plan to involve myself more in the surgery and ward rounds to learn as much things as I can.

• I plan to visit other departments if possible as I hope to experience different departments besides General Surgery.

• I hope I can visit more beautiful places in Oman.

• I will try my best to make new friends!

My first week in Naples has been enjoyable. There are six incoming students from around the world, and coincidentally, we are all girls! On my first day at the hospital, the Danish student and I were introduced to the professor and residents in the colorectal surgery department. Despite not being very fluent in English, they were warm and welcoming. They even conducted an ultrasound on me after noticing my hemithyroidectomy scar!

Every morning, we followed the doctors during ward rounds, where we review pre and post op patients. Surprisingly, due to being understaffed, there aren’t many nurses, and the doctors take on many aspects of patient care like changing urinary catheters and doing wound dressings. We also observed several laparotomy surgeries. One of the more interesting discussions this week involved a patient with ovarian cancer and colorectal metastasis, where her laparotomy wound was left open and treated with Abtera therapy (a type of wound dressing I hadn't encountered in Malaysia)

3. Points to remember from week 1!

On reflection, this week showed the importance of being adaptable and expanding our skill set as doctors. In some settings, we may be required to perform tasks outside our conventional role to ensure patient care. The experience also made me reflect on the realistic challenges doctors face, especially in resource limited environments where every skill can contribute to patient outcomes and it’s essential for us to be prepared to step in wherever needed.

4. Your feelings & thoughts 

I felt super excited and fulfilled during my first week. It was eye-opening to immerse myself in a different healthcare system and experience a new cultural backdrop. It broadened my perspective on patient care and management, especially when comparing how things are done in Malaysia versus Italy. I felt more open-minded and curious about how other countries approach medicine and healthcare delivery.

5. Any difficulties/concerns? How did you cope?

One of my primary concerns was the language barrier. Many of the patients do not speak English, and I realized how important it is to at least grasp basic phrases in Italian to communicate effectively. Besides, taking photos in the hospital was generally discouraged unless permission was granted, which was another challenge to navigate.

6. 2 words to describe elective posting progress so far

Exciting, Fun

7. Your plan for next week (Week 2)

Plan to observe more operating theater (OT) sessions across different departments.

2. What have you done?

On my first day of the elective, I was introduced to my supervisor by the SCOPE Italy contact person and given a tour of the thoracic and vascular surgical department. Alongside with me, there was one student from Indonesia and another student from Brazil on the same team. I also managed to observe a few procedures such as bronchoscopy and central venous line insertion. I also participated in pre-operative and post-operative patient evaluations, learning how to conduct patient assessments and discussions on treatment plans with the attending surgeons. After we completed our hours in the hospital, my friends and I would head to the hospital cafeteria to grab a bite. The routine would repeat throughout the week and I learned a lot and had a very fulfilling experience. Mondays and Tuesdays are the only days reserved for operations so on the other days we would observe minor procedures and have discussions with our supervisor. I learnt that August is considered vacation month in Italy due to it being one of the hottest months in summer and the high temperatures that could go up to 40 degrees celsius, hence there are not many operations scheduled in the month of August and a lot of hospital staff take time off during the period. Therefore, the hospital was much less busy than HUKM in this month. On Wednesday, the local committee organized a National Food and Drink Party, all of us brought our traditional foods, I cooked rendang using a pre-mix I brought from home and it was a fan favourite! I served it along with bread. It was so fun and interesting to try all the national foods from different countries and hear about the history of the foods as well. My favourite food to try was the potato pancakes from Hungarian that was to be eaten with Lecso, a type of vegetable stew in a jar.

3. Points to remember from Week 1!

• I go so much exposure to different surgical procedures, including thoracic and vascular surgeries.

• I was able to familiarize myself with the surgical instruments and techniques used in both open and minimally invasive surgeries.

• I managed to learn the importance of communication and teamwork in the operating room.

• I got analyze the differences between the practices in Italian and Malaysian healthcare

  
  

4. Your feelings & thoughts

I felt a mix of excitement and nervousness during the first week. Being in a high-stakes surgical environment was both inspiring and overwhelming. I was amazed by the precision and skill of the surgeons, and I appreciated the chance to observe complex procedures up close. At the same time, I felt a bit out of my depth initially, but each day brought new learning opportunities that boosted my confidence. I was also a bit concerned with how well I was able to adapt, but having my friends and such supportive supervisors really helped to me get familiarized in this new environment.

5. Any difficulties/concerns? How did you cope?

One of the challenges I faced was understanding the fast-paced conversations between the surgical team, especially since some were in Italian. To cope, I made a point to review surgical terminology in both English and Italian, and I asked the attending surgeons for clarification whenever needed. One of most important things to know was operation theatre in Italian which is "sala operatoria". This was so that every morning I would be able to ask the scrub nurse in charge what procedures and operations were scheduled in the operation theatre for the day. I also spent extra time reading up on the surgeries I observed to better understand the procedures.

6. Two words to describe elective posting progress so far

Exhilarating and challenging

7. Your plan for next week (Week 2)

In Week 2, I plan to become more hands-on with assisting during surgeries and to deepen my understanding of thoracic and vascular pathologies. I also aim to improve my Italian medical vocabulary to better communicate with the team and patients. Additionally, I hope to follow a case from initial consultation to post-operative care, observing the continuity of patient care.

3. Points to remember from Week 1!

• I was able to gain exposure to different surgical procedures, including thoracic and vascular surgeries.

• I was able to familiarize myself with the surgical instruments and techniques used in both open and minimally invasive surgeries.

• I learned the importance of communication and teamwork in the operating room.

• I was able to analyze the differences between Italian and Malaysian healthcare

  
  

4. Your feelings & thoughts

I felt a mix of excitement and nervousness during the first week. Being in a high-stakes surgical environment was both inspiring and overwhelming. I was amazed by the precision and skill of the surgeons, and I appreciated the chance to observe complex procedures up close. At the same time, I felt a bit out of my depth initially, but each day brought new learning opportunities that boosted my confidence. I was also a bit nervous about adapting to this new environment, but my friends and my welcoming supervisor made it much easier.

5. Any difficulties/concerns? How did you cope?

One of the challenges I faced was understanding the fast-paced conversations between the surgical team, especially since some were in Italian. To cope, I made a point to review surgical terminology in both English and Italian, and I asked the attending surgeons for clarification whenever needed. One of the most important Italian words I learnt in this week was "sala operatoria" which means operation theatre, this was so that every morning I could ask the head scrub nurse what were the operations scheduled in the operation theatre for the day. I also spent extra time reading up on the surgeries I observed to better understand the procedures.

6. Two words to describe elective posting progress so far

Exciting and interesting

7. Your plan for next week (Week 2)

In Week 2, I plan to become more hands-on with assisting during surgeries and to deepen my understanding of thoracic and vascular pathologies. I also aim to improve my Italian medical vocabulary to better communicate with the team and patients. Additionally, I hope to follow a case from initial consultation to post-operative care, observing the continuity of patient care.