Elective

For my elective placement I spent 8 weeks in Malta working in the A+E department.  It was incredible.  I had really wanted to do an overseas placement to make up for all the summers spent working in an office, so I recklessly splurged my savings and loved every minute of it.  That said, Malta is actually a really cheap place to go, in terms of overseas electives.  Flights, admin fees, accommodation, bus passes, travel insurance and very generous spending money all came to just over £2,000.  I also didn't want to stay in the UK as Mr was deployed on tour while I was away.  I wanted to be completely immersed in whatever I was doing to take my mind off of worrying about him.  I didn't want to have to stop myself from picking up the phone to talk to him when I forgot that he wouldn't just be able to answer like he normally would.  I did kind of shoot myself in the foot with that plan though, as it turns out the free 30 minute phone call they get per week only works to numbers in the UK, and as they were closing down to come home they turned the internet off half way through so no skype calls or email either.

The Malta healthcare system works like the NHS and the case mix is exactly the same as the UK one too - lots of diabetes, chest pain and RTCs.  All of the medicine is written in English, most of the patients speak English as a second language, they follow NICE guidelines and use the BNF.  The major difference is that patients don't have a named GP, they can go to any one they like at any time, so no one keeps notes about the patient.  They would come in clutching their yellow cards to say what drugs they were on, but there would be no one to follow up on chronic conditions in the community, and lots of "inappropriate" ED attendances.  Because of this, there were 5 tiers of triage, and a nurse and a GP picked patients from the waiting room to say.  I stayed in the top three tiers.  The other big difference is that Malta is beautifully sunny and warm!  It was in the 30's for most of my trip, which is perfect for me.

I stayed in Sliema in the south in an apartment rented by the Malta Medical School.  The ground floor and second floor were occupied by the owners and their daughter and the top three floors were for medical students on elective.  Each flat had three bedrooms that slept 6 people.  They were lovely apartments - 3 mins walk to the beach, bus stop and shops and I could see the sea from the balcony.  It was great meeting medical students from all over the world and comparing training and hospital life.  There were students from Australia, New Zealand, Tunisia, Greece, Poland, Germany and the UK.

My days were 8-2 in the hospital with the afternoons and weekends to myself.  They also had lots of bank holiday Fridays they didn't expect me in for so I did some evenings and weekends to make up for it.  I could do what I wanted, so long as I felt comfortable.  They were very keen to have me involved.  I would wander around majors and look for interesting things going on, or pick from the list and clerk the patients first.  I would go to the resus calls and help site cannulas or manage airways.  Their medical school curriculum is like a UK one, except they don't get a chance to practise skills like blood taking and cannulas until F1, so they were very impressed I could.

In the afternoon I'd go to the flat rocks Sliema calls a beach and snorkel and at the weekend a group of us from the apartments would go site seeing.  Malta isn't very big and the bus pass for the week is very very cheap so it was easy to see the whole thing while I was there.  We went to all the beaches on Malta, which were beautiful but very crowded.  We went to Valletta - the capital, Mdina - the walled city, Gozo - the neighbouring island, we went hiking the cliff top path way and on my last day I went to a secret beach on Gozo on the advice of my supervisor that was completely deserted.
There were a couple of differences in terms of patients and the way cases are treated.  Being just off the coast of Sicily, Malta gets it's fair share of immigrants fleeing from Africa.  Boat loads turn up and live in refugee camps.  I never saw any out and about around the island, but I saw plenty that had gotten into fights in bars and come to ED.  We also had casualties evacuated from the war in Libya. These patients had no ID, didn't speak the language and were referred to by a number only.  They had life changing injuries from bullet and blast wounds and I spent a good while holding the hand of someone who had lost most of his bowels.  According to the translator, he just kept repeating "Don't leave me, don't leave me" over and over.  So I didn't.  He'd had a stoma bag fitted by Red Cross doctors in Libya, but the reality is he will never be able to eat well enough to overcome the malnutrition he will face by having poor absorption.  Another patient had blast wounds so severe, I could see the white of the bed sheet in a hole sized bigger than my fist that went through his abdomen.  When I got home that evening Mum told me of an attack in Afghanistan that had left several soldiers dead, including and American General.  The thought that my Mr could be lying on a bed in a similar situation to the patients I had treated that day was.... devastating.  I hoped that if he was injured, he would have someone there to hold his hand and smile at him, the way I had done for the gentlemen in my care that day.  I did hear from Mr that day eventually.  A single line to say he'd seen a lizard that day.  I could have cheerfully shot him myself, worrying me like that.

Malta is very religious.  It is one of the few places that still does not allow abortions, even if it costs the mother her life.  If you attempt suicide and are heard to say you no longer want to live, you are no longer deemed competent to make decisions about your medical care as you do not have your best wishes at heart.  On several occasions I watched people having ng tubes fitted to pour activated charcoal down because they'd taken an overdose.  On my last day, I saw the case of a holiday maker who'd taken an overdose but couldn't afford to pay the hospital fees.  The hospital had to treat them because of the overdose, unless their parents flew over to sign paperwork so they took control of her medical decisions as she was underage.  Unfortunately, it would take too long for them to arrive in terms of the window to treat the overdose and minimise liver damage and the patient was refusing to call them.  Furthermore, Malta does not have DNRs or TEPs, so CPR is always started, even in futile cases.  Unfortunately, the paramedics start CPR and bring them to hospital where they are either pronounced dead in resus or they get a rhythm back.  They are then taken to the corridor outside MAU to die because ITU won't accept them as they won't recover and MAU is full.  Equally, the general public do not like to start CPR because they are afraid of doing it wrong and they are not widely taught first aid like we are here.  So in younger people die because they do not get early CPR and older people have an undignified death because paramedics always do start CPR.

Malta was awesome, I had a great time, I met loads of new friends, I grew heaps in confidence and saw things I never expected.  If you like ED, go to Malta!  If you wanted to go there to do something else, others didn't enjoy it quite as much as clinics are held in Maltese and the other Doctors weren't so keen to translate.  So, if you want sun and a relaxed elective, it's perfect.

Heaven is a good book, a cup of tea and the most amazing cake with views over Malta at Fontanellas in Mdina 

Sunset at Cafe del Mar

Blue Lagoon on the island of Comino

The view from my balcony in Sliema

Partying with the locals at a village festa. That's the village church.  Each village has it's own day of celebration with all day fireworks that can be heard all over the island, church services and a procession through the streets behind the local brass band. 

The secluded bay at Wied Il Ghasri on Gozo