Singapore Houseman Guide (HO Guide) - From an IMG's perspective

Disclaimer: The views expressed in this post are mine and do not reflect the views of the Hospital/MOH. 

Dear incoming HOs from overseas universities,

Before coming to Singapore, we were 'warned' multiple times regarding how hard life will be for a houseman/PGY1 (post-graduate year one) in Singapore, especially for those graduated from the overseas universities, a.k.a. the international medical graduates (IMG). During an orientation session, we were told that it will take 4-6 months for an IMG to be adapted to the local system, and an even longer period to be as good as the local graduates. Coming from the NHS, which is as multi-national as a healthcare system could be, I couldn't believe it - I mean, we managed to work with people from so many countries around the world, how would a more homogenous system (one that is much closer to my own culture) be an issue?

Well, for the first few months as an HO, I cried almost on a daily/weekly basis due to work-related matters. My fellow IMG HO and I almost started a counter on 'I-wanna-quit-my-job' to chart the frequency of us saying that phrase throughout the day as we were busy fighting fire on the wards, while the local graduates HO, who also demonstrated signs of struggle at times, had an incredulous look their face as they watched how we were struggling all the time. Eg. The panics we had while managing a simple hyperkalaemia, while the local grads went 'What? Just give the HyperK kit lah...!' but what is a hyperK kit?!

Honestly, the MOHH staffs and the hospitals' HR were really good and efficient in easing the IMGs into the system. There were barely any issues with the admin matters (the SMC registration, the Employment pass etc). They even organised orientation days (with really good food) and shadowing days for us. Our seniors were very understanding and caring towards us, though understandably frustrated at our incompetence at times. And of course, our fellow HOs (who were in their 2nd posting when the UK IMGs started), who are the most important unsung heroes of the year, who saved our lives and our patients' lives as we survived housemanship together. We also received a copy of the CTSP handbook (call-to-see-patient) and HO survival Guide from the local grads to help us during calls. However, there still seems to be a gap, esp for a non-Singaporean like me, that took me months to fill up, to function properly as a PGY1. Now that I completed PGY1 (with all the bittersweet memories and struggles still fresh in my mind), I hope that this post, alongside all the existing materials, would be in any way helpful to you, as you navigate this complex healthcare system.

NB: This is an attempt to fill in the gaps for IMGs, on top the existing guides, please read the guides before starting!

The Public Healthcare System 

There are 3 healthcare groups, aka 'clusters', that manage the 10 public hospitals in Singapore. They are Singhealth, National University Health System (NUHS) and National Health Group (NHG). The hospitals are:
- 7 general hospitals (Singhealth - SGH, CGH, SKH; NUHS - NUH, NTFGH; NHG - TTSH, KTPH)
- 1 integrated hospital (NUHS - Alexandra Hospital)
- 1 women's and children's hospital (Singhealth - KKH)
- 1 psychiatric hospital (IMH)

At PGY1 level, these clusters may not affect our daily life, but as one progresses up the ladder, each cluster has its own residency programme for different specialties, which may differ, but that is a topic for another day.

To learn more about the structure:
- https://www.moh.gov.sg/our-healthcare-system/healthcare-services-and-facilities
- Wikipedia - Healthcare in Singapore - has a good summary

Who is in your team? (aka 'Firm' in the UK) 

Depending on the hospital and the specialty you are posted to, the team structure may defer.

A usual medical team consists of:
- 1x senior consultant (SC)/Consultant (C)/ Associate consultant (AC)
- 1x registrar
- 1-2 Medical Officers (MO)
- 1-4 House Officers (HO)
- +/- Nurse clinician (if you're lucky to have one, will talk more about it below)

A usual surgical team consists of:
- 2-6 consultants
- 1 registrar
- 1 MO
- 1-2 HOs
- +/- Nurse clinician

While the hierarchy in the UK is generally quite flat, there is generally a steeper sense of hierarchy in the SG system, esp in the surgical teams. Before asking your boss out of coffee or commenting on his/her outfit, it would be good to gauge how your bosses are like and ask them what is expected of you.

Aside from your team, you will work with many other healthcare professionals, who will try their best to make your daily life better. Briefly, they are:

1. Nurses: Ward sister, staff nurse (SN), registered nurse (RN), nurse assistants 
2. Nurse clinicians - Usually a senior and specialised nurse. They are able to deal with nursing matters + are able to do most of the things you are able to do (except doing prescriptions, MCs etc...things that require your MCR number). 
3.  Physiotherapist (PT) - manages your patient's rehab, focusing mainly on the strengthening of the body. Commonly referred for therapeutic exercises and chest physio. Able to prescribe walking aids/incentive spirometry and recommend when CH is needed for further recovery. 
4. Occupational therapist (OT) - manages your patient's rehab, focusing mainly on improving patient's ability for independent living (transfer from chair-bed, carrying of oxygen cylinder), able to prescribe splints/mobility aids (eg scooters) and recommend when CH is needed for further recovery. 
5. Medical Social Workers (MSW) - for psychosocial support of the patient and family, financial support, discharge planning (application for a helper at home) (Click here to learn more)
6. Dietitians - for optimising your patient's diet (soft diet, normal diet) and also part of the parenteral nutrition team 
7. Speech Therapist (aka SALT) - for swallowing and speech assessment and therapy. Important for them to assess first if you think your patient is at risk of choking when eating/drinking! 
8. Pharmacists - Call them for any prescription related matters/doubts. They will usually look through your prescription and call you if any amendments/clarifications needed. During the night, there is usually a pharmacist on-call to save you through your calls too. 
9. Porters, podiatrists, radiographers, respiratory therapists etc

This list is not exhaustive!

What are the working hours like and what do you do on a daily basis? 

Firstly, please bid farewell to an-8am-start. (Sorry mate!)
Depending on the specialty you are in and the workload, the working hours differ but are generally longer than the ones in the UK. Also, surgical postings tend to have very long hours (the longest I had was 4am to 9.30pm).

Eg. A typical day in a medical team
6.30 am - Arrive at work. Discuss with HO/MOs in your team to allocate patients you need to take care of for the day. Start pre-rounding on the computer. For each patient, read through the overnight events, vitals, investigation results and put in a 'DRAFT ' morning entry. (Though a draft entry is not necessary, I like to put it before the ward round starts to allow more time for 'changes' (i.e. 'jobs') later on. To make a ward round more efficient, I would also see as many patients as I could and examine them before the round starts so my consultants may not need to go through all the steps again during the round.

8 am - Start of ward round. Present your patients and note down the changes. Clarify with your boss for anything that you don't understand (or you may find it difficult to do the changes later on).
Eg.
- Referral: What exactly is the question/purpose for this referral?
- Radiology: What are we looking for in this scan? How soon should it be done? CT - with or without contrast?
- PT/OT - Weight-bearing status of the patient after the surgery (esp relevant for ortho)?

10 am - Coffee round. When your boss hands you money after the ward round to order drinks, please do not say 'Oh, I already had my drink this morning.' Take the money and as the most junior member of the team, this is your unofficial job - take the drink orders from all members of the team and order (Good chance to grab something to eat too!) Usually, we will sit down with the boss and go through our list of changes, clarify any further doubts and have a short teaching session.

10.30 am - Time to get cracking on the changes. Your ability to prioritise is the key here! This is how I like to prioritise:
- Anything the sickies urgently need: scans, referral, drugs, take blood
- Referrals a.k.a. Blue Letters. Please get the referrals out ideally before 11am. (More on how to refer below)
- Discharge patients - order the discharge medications ('TTOs') to allow the pharmacist sufficient time to look through your prescriptions and dispense them > complete discharge summary > MC > any memos for outpatient follow up
- Order any investigations needed
- Update patient and family
- Review any CTSPs or clerk new patients (sometimes this is done by the MO)

1 pm - Lunch/Teaching sessions. Depending on the posting you do, the department will usually arrange some teaching (often with food).

2 pm - Complete your changes and trace investigation results (aka 'chase results' in UK lingo). Put up a draft PM entry.

3.30 pm - Exit round. Usually the bosses will do a paper round for the stable patients. For the sickies/new admits, bring the boss to see physically if they want to.

4 pm - Do exit round changes.

5 pm - Hopefully....you're done with the changes. Handover properly and go home! If you're on call, this is when your phone will start ringing non-stop.

Surgical postings will differ slightly by having an earlier ward round as your bosses need to go to the OT (the earliest I started putting morning entry was 4am) and having a later exit round (wait the OT list of the day to end).

How to write a morning entry?

I personally find the entries in the UK and SG differ quite a bit. So this is just an example of the format of a morning entry:

<The team you're in > AM WR
s/b <insert the consultant/reg name after round>
Overnight events in brief
Subjective
Objective/On examination (O/E)
Investigation results
Issues list/Impression
Plan - Nursing, Allied health, Investigations (Ix), Management (Mx), Discharge plan

It may be difficult to make a plan when you first started off, but as time goes by, you will learn to make a comprehensive plan and you just need to confirm with your boss re the plan before executing them.

One thing I find very different as compared to a UK entry - the Nursing plans.
The nurses usually are very good at coming up with their own plan, however, for clarity sake, certains points are better written down in your entries, or the nurses may call you up to clarify with you:
1. Para - how often to take the vitals. eg Q4hrly para + SpO2 - to take vitals 4 hourly.
2. H/C - Hypocount. How often to measure the blood glucose. eg H/C TDS + 10 - to take hypocount 3 times a day and at 10pm.
3. Diet - Nil by mouth (NBM), clear feeds, full feeds, soft diet, full diet, diet of choice (DOC)
4. IO chart - intake-output chart
5. Regular turning, regular orientation
6. Weight bearing status (WB) - eg FWBAT (full weight bear as tolerated)
7. Anything else you would like the nursing staff to take note of 

The style of an AM entry differs from person to person. You will find your own format/style soon enough. I find writing a clear, well-formatted entry really helpful for everyone involved in the patient's care, and it will also reduce the need for the nursing staffs to call you up to clarify what was wrote in the entry. So, take some time to refine this art.

How to write an exit entry? 

No need to be as comprehensive as the morning entry.
Just key in any updates/results traced, and any changes in plan as compared to the morning ones.

What is a Blue Letter?

Please read the HO Survival Guide on Blue Letter.

This is basically a referral letter, from your team, to your senior colleagues, seeking their expertise. I find it helpful for your seniors to start your blue letter by explicitly stating the question you have. For example,

Dear Colleague,
Thank you for seeing this XXyo lady who has been admitted for XX.
Question: How do you ______________?
SBAR
Thank you once again.

Discharge planning

This is what takes up the most time in an HO's day - how to get the patient home. You should start thinking about this as soon as the patient is admitted under your team. As the community services available in the UK are very different from the ones in Singapore, I took quite some time to learn about this. The common avenues for discharge are
1. Home
2. Home with a caregiver. May require caregiver training from the nursing staffs/PT/OT before home. It is common for the elderly in SG to have a dedicated helper.
3. The Community Hospitals, aka 'Com Hos'/ CH, where patients can receive step-down care when acute care in the general hospital is no longer needed, i.e. when your patient is well and stable on the ward, but not exactly well enough to go home yet, then your boss (consultant/reg) will ask you to discharge plan. You may need to apply for the CH via the Agency for Integrated Care (AIC). Common indications for going to a CH are rehabilitation after surgery and wound care.
The CHs available are: Outram CH, Jurong CH, Yishun CH, Sengkang CH, Bright Vision CH, St Andrew CH, Renci CH, St Luke CH and AMK CH.
4. Nursing Home

Tip: If patient is ready for discharge but is unable to take care of him/herself at home and has no caregiver available, you will need to discuss with the family re the options. Get the MSW onboard earlier if you foresee any discharge issue. There is a service called Interim Care Service (ICS), where an interval helper takes care of the patient at home until a more permanent caregiver is available.
For more community-based services - https://www.aic.sg/

Common brand names 

'Please order Nexium.' 'Nex what?' 
Unlike UK which uses the generic name for most drugs, there are certain medications of a particular brand that are so widely used that everyone just uses their brand name instead.

Plavix - Clopidogrel
Lasix - Furosemide
Nexium - Esomeprazole
Losec - Omeprazole
Clexane - Enoxaparin
Dulcolax - Bisacodyl

Piriton - chlorpheramine

Telfast - fexofenadine 

Ketotop - ketoprofen plaster 

Maxolon - metoclopramide 

Fluimucil - acetylcysteine 

Anarex - Orphenadrine Citrate and Paracetamol 

Arcoxia - Etoricoxib 

Epilim - sodium valproate 

Keppra - levetiracetam 

Augmentin - Amoxicillin/Clavulanic acid
Rocephin - Ceftriaxone
Flagyl - Metronidazole
Tazocin - Piperacillin/Tazobactam
Fortum - Ceftazidime
Klacid - Clarithromycin
Bactrim - Co-trimoxazole

Please don't stress over this. You will remember them as they get repeated multiple times throughout the day. And if you really don't know, just ask!

Common abbreviations 

'Please CRIB the patient.'
I think abbreviations are not just a product of the fast-paced Singapore healthcare system, rather the Singaporean culture as a whole. Some abbreviations make sense, some are just downright absurd.  It took me at least 4 months to learn most of the abbreviations I see on the daily entries from various parties. Again, if you don't know, just ask your colleague sitting next to you. It's completely acceptable to ask!

s/b - seen by
H/C - hypocount, blood glucose measurement
Para - parameters ie vitals
I/O - input-output
CRIB - complete rest in bed
FWBAT - full weight bear as tolerated
NWB - non weight bear
DOC - diet of choice
Nx- nursing
Ix - investigations
Mx - management
VS Afeb - vitals stable, afebrile
PEARL - pupils equal and reactive to light
FROM - full range of motion (joints, ocular movement)
L LL/UL - Left lower limb, upper limb
TOC - Take out the catheter
STO - Stitch take out
BO - Bowel open / BNO - Bowel not open
PU - pass urine / NPU - did not pass urine

cm - Latin: Cras Mane, meaning tomorrow morning; coming morning 

SOOB - sit out of bed 

SOBOE - shortness of breath on exertion 

CAP/HAP - Community-acquired pneumonia, hospital acquired pneumonia 

CGT - caregiver training 

WS - walking stick 

WF - walking frame 

QS - quad stick 

CAD - Coronary artery disease

PVD - peripheral vessel disease

HTN/HLD/DM - Hypertension, hyperlipidaemia, diabetes mellitus 

TTE - transthoracic echo 

TEE - transoesophageal echo 

MCHC Anaemia - microcytic, hypochromic anaemia 

NAGMA/HAGMA - normal anion gap metabolic acidosis, high anion gap metabolic acidosis 

Tw - total white 

RP - renal panel 

C/M/P - calcium, magnesium, phosphate 

c/s - culture and sensitivity 

PVRU - post-void residual urine volume 

ARU - acute retention of urine 

NOF# - neck of femur fracture 

AKA/BKA/TMA - above knee amputation/below knee amputation/transmetatarsal amputation 

POD - Post-op day 

PORV - Post-op review 

s/p - status post (eg s/p lap appendicectomy) 

DKD - diabetic kidney disease

RRT - renal replacement therapy 

SLED - Sustained low efficiency dialysis (SLED) 

VI - virgin 

NVD - Normal vaginal delivery 

DIL - dangerously ill 

CCOD - certificate of cause of death 

NEHR - National Electronic Health Record (where you can get information from other clusters) 

Careform/Maxward - DNACPR + not for escalation to .... (to specify) 

TCU - 'To see you' - follow up
TCU .... FBC OA - To see you with full blood count done on arrival
NFU - not for follow up

Abbreviations of a few specialties that are harder to guess (not all hospitals uses these..but just in case they pop up)

ANA- Anaesthesia
AIM - advanced internal medicine
CVM - Cardiovascular medicine
RES/RCCM - Respiratory Medicine
REN - Renal Medicine
GAS - Gastroenterology
DER - Dermatology
RHI - Rheumatology
END- Endocrine
INF - Infectious disease
GER/GRM - Geriatric medicine
PLM - Palliative Medicine
CTVS - Cardiothoracic and Vascular Surgery
NES - Neurosurgery
PRAS/PLS - Plastic surgery
CLR/CRS - Colorectal surgery
UGI - Upper Gastrointestinal surgery
OTO - Orthopaedic surgery
DVIR - Interventional radiology
DDI - Department of Diagnostic Imaging/Radiology

On-call 

Yes, you work 30 hours straight. 
I dread calls the most, but it is always also the time when I learn the most. When a HO is oncall, you usually work 30 hours straight. How is that possible? I could not imagine doing it too until I did it.
It starts with your usual day job, then at 5pm, your call duty starts and it continues until 8am the next day.  you At 8am the next day, you continue on with your usual morning ward round and hopefully, you get to go home by lunchtime when you are done with your morning changes. It's common to turn half-zombie by the next morning, but people understand. It is not a safe working environment for both you and your patients, but this is how it is for decades. There is some effort to move away from this, especially in the NUHS, but generally, it is still a 30-hour shift.

5pm is a busy time as this is the time when everything floods in.
- Handover. Different hospitals have different systems for handover. Some do it electronically and some call up the oncall team. Ask your predecessors how this is usually done.
- Admissions. For any admits that come in after 5pm, it is your responsibility to clerk them in, unless stated otherwise in your hospital
- CTSPs (call to see patient) start to come in. The nurses may call you (your mobile phone; we don't have pagers as in the UK), or in some hospitals there is a messaging system. There is usually a CTSP guidebook for HO, specific to each hospital. It will guide you on the common CTSPs and the management plan. Please ask your predecessor/seniors for it and read through before starting work! (You won't have time to read it when you are actually CTSP for it)

Pro tips:
Before call starts
- Have a meal and a drink. If you can, have a nap too.
- Make sure the on-call roster on the system shows your name
- Contact your MO before the call starts. Please let them know you are new and ask for help whenever you feel you are out of your depth.

During call
- Have a system of keeping tracking of your changes when you're on call so you don't miss out things!
- Have a shower/nap if you can, and a snack/drink as often as you can
- Remember - the sun will rise!

Practical procedures 

Setting IV Cannula aka 'IV Plug', taking bloods and doing an ECG are usually done by the FY1 in the UK. In SG, these are usually done by our very dedicated nurses, unless they have difficulty doing it. (some places may have an unspoken rule that the admission blood must be done by the HO). The nurses in SG do a LOT more to help us, so please be nice to them.

Common procedures that must be done by a doctor, i.e. you:
1. Group cross-match 'GXM'/Blood culture
2. ABG / Femoral stab
3. Male urinary catheter
4. Drain removal
5. IV medications - D50/HyperK kit/Lorazepam
6. Manual evacuation

You can technically do any procedures as long as you have sufficient supervision. (Eg IA line setting, VAC dressing change, Lumbar puncture, knee tap, PICC line culture, suturing, backslab) If you're not comfortable, don't do it or ask your MO to show you how to do it.

Also, note that: Death certification and Consent taking can only be done by the MO. The only consent you are allowed to counsel as an HO is the Blood Transfusion consent.

Symptomatic medications 

This is another topic which I found myself dealing with very often, during the day and while on-call, which was not taught in the UK, mainly due to the NHS and its funding system. Patients here love love love the symptomatic medications. Yes, it doesn't cure their diseases, but if it makes our dear patients feel much better (and thus can sleep at night) and it doesn't harm them/interact with other medications, why not make them feel more at home?

Some common medications which are generally safe for HOs to prescribe while on-call:
Acetylcysteine - mucolytic 'thick phlegm'
Bromhexidine/Dextromeorphan - antitussives (avoid in elderly population)
Guaifenesin - expectorant
MMT/Buscopan - stomach cramp
Lactulose/Senna/Dulcolax - constipation
ORS/Kaolin/Probiotics/Lacteoforte - Diarrhoea
Melatonin/Chlorpheramine - insomnia
QV cream - dry skin
Ketoprofen plaster/gel - joint pain

Caution: Please be careful when using these medications. Please assess/review the patient before prescribing them!

For a list of common medications: http://www.geraldtan.com/doctors/druglist-130505.pdf

What to learn during your shadowing period: 

- Structure of the hospital (toilet, food, water, lab, ED, OT, ICU/HD)
- How to put in entries, look for investigation results
- How to make referrals
- How to write a proper discharge summary
- How to order medications (inpatient and discharge)
- How to refer a patient to a community hospital

What to obtain from your predecessors before you start 

- List of useful phone numbers of the hospital
- Add you into the existing communication group of the team (eg WhatsApp)
- Handover of the patients
- Tips for surviving the posting
- Ask them nicely to update the discharge summary before they end their last day

What to do before you leave a team 

Usually, we change teams on a monthly basis. Before you leave the team, please:
- Update the discharge summary (a basic courtesy for the incoming HO)
- Make memos for your successor (if you're nice) just in case the patient gets discharged on day 1 of handover

Further reading before starting your Day 1:

- HO Survival Guide - http://www.geraldtan.com/doctors/HO-Survival_Guide_ver31.pdf
- CTSP handbook (to obtain from your predecessor of the hospital you are going to)
- Download MIMS on your phone - BNF equivalent


Life will be tough as an HO, but remember
- there's an end to this
- try to learn as much as possible from your seniors because when you are the senior, your HO seek guidance from you
- take care of yourself before anything else - eat, sleep, drink, pee, poo and play - just like a normal human being
- everyone else struggles too. Talk to each other, help each other as much as you can
- seek help if you are unwell

Don't kick up a fuss

In a month's time, I would have completed my apprenticeship block - the last placement of my entire medical school life. It's surreal. From struggling as a foolish, ignorant first year, to a 4th year who flustered at every single stressful situation, to now, an almost-qualified doctor who still don't know much but at least when sh*t hits the fan, it doesn't show on my face as much. It has been a long arduous journey but by God's grace and strength, I persevered through it all.

'Where will you be working?' That's almost guaranteed the first question from anyone we meet in the hospital. 'Unfortunately, I will be leaving the country...' I answered every time, unsure if I should be showing sadness for leaving or to show my excitement for going to an environment which I've experienced and loved; But, just to be safe, I'll say, unfortunately. It's strange seeing everyone doing admin work for their upcoming job and rota, for we were just struggling with our exams like any students do just 2 weeks ago. It's strange to leave this massive institution of NHS as well. The spirit of putting others above oneself is definitely something I've seen many times in this institution regardless of my location of placement. It's beautiful, this selflessness. The NHS was not in the current state it was in when I first started medical school 6 years ago. It's just a bit odd and sad to see it in the state it is in today. Apart from the news in the media and the shortage of staffs, the most obvious change I've observed over the past 3 years is the decline in morale of the junior doctors. It started with the junior doctors' strike more than 2 years ago, which I helped to cover some of their jobs on the ward. The spirit of unity and solidarity was at an all-time high then, but things started to go downhill after that. I've always been very pessimistic about where the NHS will head from here, but with the recent political revolution in Malaysia (something that I was pessimistic about and couldn't quite believe has happened as well), I am more hopeful that the healthcare in England will be better...one day...just you see.

I'm not sure how quickly I will adapt to the new environment, but I am holding onto the hope that it will be the environment I will flourish in. With a recent racist incident that happened during one of my final OSCE stations, I hold onto that hope even tighter. It was a neurology station. The moment I walked in, even before I introduced myself, the old white male patient went 'Ni hao...' Of course, I was utterly gobsmacked for a while. I have had COUNTLESS of such encounters during my short clinical career life in the NHS thus far, so one can say I'm well accustomed to dealing with racist behaviours, but I have never expected to have to deal with THIS during my final exam. I mean, if this is part of passing the exam as a foreign medical student, then fair enough. But I was not told about this and I was marked on the same criteria as other students! Under a huge time-pressure and the desire to pass the examination, I just pretended nothing happened and continued my examination as usual. I wasn't sure how the examiner reacted to that as I didn't even have time to look at him. I have to finish my examination.

Just a few days ago, I learned that I passed all my exams. 'That's all that matters,' I told myself, 'Don't kick up too much fuss, don't prolong your stay, just graduate and out of the country you go!' I'm not sure if this is the right thing to do. I've talked to several colleagues about it, and of course, they were all shocked. However, as of my current state, I'm very content with where I am and I think I will keep the situation to just at that. The only thing I am worried is, I am not sure who is the next 'foreign' medical student who will face the same situation as I did and how will he/she react. But whatever happens, just know that it's not your fault, be strong and pass your exams. That's all that matters, for that moment.

'Don't be late for tea!'

'Is that all you've got?' the old man with multi-pack tissue rolls in front of me asked as we were queuing at Farmfoods.

'Yes, but don't worry bout me.' I said hurriedly as I gestured him to go ahead, with a 2L bottle milk in my hand.

'Don't let me hold you back. You go first. Really, go ahead!'

So I went ahead and paid £1 for the 2L milk. What a bargain, I thought. 

As we both left Farmfoods, he shouted 'Don't be late for tea!' I don't quite know how to respond to that as I was really going to make tea when I reach home, so I just laughed at his comment. Then we both went on our way.

That was a short exchange between an old Bedfordshire man and I while we were shopping at one of the cheapest frozen food stores in town. Not that I am a fan of frozen meat, but the things on sale there are cheap, and since it's the direct opposite of where I stay, it's the place I frequent almost daily when I am on my hospital placement here. The short exchange we had in this store was heartwarming to me. It may mean nothing to a regular member of the extremely polite British society, but it meant a lot to me. It made me doubt, should I even leave this country? 

Just a few days ago, it dawned on me that this is actually the final year I will be in this country. 5 years ago, I arrived in this country for the first time. I knew almost no one apart from the freshers who were travelling with me, and I could not understand what the immigration office was asking me to do. I thought I spoke reasonably well English (at least for the Malaysian standard) but this British accent was something else - it was like a completely new language to me! 

During my undergraduate years, I interacted mostly with Malaysians or Singaporeans only, and I shy away from all the local students. Partly because the MAS/SGeans were the cure when I felt homesick, but partly because I could not understand why do the English students love to 'go out' so much! ('go out' meaning go partying, go to the club, dance etc.). I was not a fan of alcohol, and I have been brought up with the idea that 'one who drinks alcohol' is probably 'one who is morally wrong in every other aspect of life', what more on going to the club and dance!? It was hard to mix in with the local students when you always miss out their social events. So during my first three years, the English people I actually interacted most with are my supervisors. 

Most people graduated after 3 years, including the group of friends whom I regularly hung out with. The only people left are medics and a few engineers, who hid in their labs most of the time. 

Year 4 is the first clinical year in Cambridge. As a clinical student, you're like a nomad - you move from one hospital to another, almost every month. I was barely in Cambridge at all. And in placements, the only 'friends' you have, are other medical students, and probably a few FY1s. It was also daunting for me initially as this is the first time I have to go into the hospitals and talk to patients from various backgrounds in the English cities/towns/villages, young and old, white and non-whites, and most of them, not in the perfect mood 'to have a little nice chat' with you because they are sick, that's why they are there in the first place. However, thank God for my very helpful supervisors, doctors and colleagues, I actually had not much problem doing things a medical student is supposed to do in the hospital/GP surgery. 

Fast forward to now, I am actually quite comfortable talking to patients, to my seniors and to my peers in clinical school. Although I do get the occasional well-intentioned, curious 'Where are you from, dear?' 'Are you from China/Vietnam/Japan/Korea?', and the occasional purely racist comments (esp when I don't have my stethoscope or my student doctor badge on me), I have been getting along well with most people. I don't blame the regular white guy/girl who hurled racist comments at me on the street because, in some of these villages, I am literally the only 'Asian' face they see. The last time some of these old men saw an Asian face was probably during the Vietnam war they were in during the World War! 

However, I do get quite anxious when I am having group discussions in non-clinical settings, eg during student conferences and in the church. It is particularly difficult whenever I am the only true, Asia-born Asian in the group, carrying a thick Malaysian accent. Perhaps I am just being overly-sensitive, but there were times when my opinions were ignored conveniently and what I wrote glanced over during a discussion. There were times when I spotted a room for improvement in the discussions, but I just put a foot in my mouth because who cares about my opinion anyway, just let it be, even though the work will not produce the best result it could. And sometimes during breaks/lunch during conferences, I was left with no seats in any group so I had to plant myself in any seat I could find.  Sometimes, I approached other people and try my best to strike up a conversation; sometimes, people who took pity on the girl who sat by herself and came to talk to me. However, often, the same person whom I had an interesting conversation with just an hour before, somehow can't recognise me at all when we met again because I am just another Asian face and they couldn't tell the difference between our Oriental faces. 

I am not saying this sort of situation happens on a daily basis, however, it does not happen too infrequently as well. It makes my heart aches whenever it happens. At first, I thought it's probably my lack of communication and persuasion skills to charm strangers that resulted in people not taking my opinions seriously. However, I've experienced these things when my aSEAn friends were with me as well, and they agreed, it was clearly...racism, subtle or not. 

Racism is a common thing around the world, regardless of which country you visit. I grew up in Malaysia, where there are many races, ethnicity and religions. Racism is just part and parcel of our daily life there. We either take it as a joke, or it's just institutionalised racism forced upon us, what can we do?Live your hard, work hard and be the person who changes this fact, top-to-bottom (if you're one of the leaders of the country) or bottom-to-top (if you're like me, a normal person on the street). We all make racist jokes against each other and have a good laugh about it. There was not much ill-intentioned racism going on on a daily basis, or at least I know that I can confidently fight back if anyone tries to do that to me because Malaysian Chinese is a 'minor race' in Malaysia but it's actually not quite 'minor'. And I can fight back because I was born in Malaysia, how dare you ask me to go back to China?! Besides, we live with people of different races and interact with them on a daily basis, there really isn't an excuse for someone to be outright racist to everyone every single day. 

However, in the UK, I am truly a migrant, a minor race, a historically-viewed-upon-as-inferior group of people. I have enough insecurity within myself as a medical student and my language skills which I need to deal with, I just not guts to fight back when people present with subtle racism against me, especially in a professional setting or in a church setting. And if I decide to fight back against that random racist dude on the street, it is completely possible that I may get beaten up. Therefore, most of the time, I just ignored and get on with life. It was during those moments, I felt like I want to go home, I don't want to tolerate this for the rest of my life because what have I done to deserve this? I came here, studied hard and contributed to the economy (shopping!). What have I done that made me less than a random dude on the street to deserve those racist acts? 

That being said, there are many moments and people that made my time in the UK extremely lovely. Just so I don't forget this country, with her 'many curves and edges', once made me feel that this is my second home, I'm going to list them here before I leave:

• The countless waves of laughter my placement buddies and I had in the pubs and in our kitchens, in Bedford, in Bury's and in Ipswich. We often laughed about insignificant things, but that's how we kept each other sane after a full day in the hospital. (People thought we were drunk when in fact, we only drank soft drinks and the free tap water!) 
• The carpool with Calum, Sreela etc to and fro placement. Why did they want to go out of their way to drive me home, without expecting anything in return? I don't know, but they are probably the nicest English (and very importantly, Scottish) I've ever met and the ones who made me feel I am not alone in this country. 
• The F1 on my respiratory ward in Bedford, Ahmed, and the SHO, Laura, who I only met a few weeks before, who taught me so many things on how to be a 'doctor', who were more anxious and excited than me for my first ever job interview and couldn't stop asking me how the interview went and when will I know the outcome. And Ahmed, who walked to Tesco to buy Prosecco and a chocolate cake just to celebrate when I got my first a job offer. 
• My GP practice in Year 5, that went above and beyond what was required for them to teach us and inspire us to become GPs. And for providing us with an unlimited supply of coffee and tea to last us through the GP weeks. They were the ones who cultivated the love for English tea in me. 'Nothing a nice cup of tea can't solve.' 
• The generosity of my college, Caius, and Trinity College, for providing me with luxurious student accommodations at unbeatable prices for the entire duration of my time here. 
• The patients who let me poke and prod them about, when they were at their sickest, just so I can be a better doctor, one day, hopefully, treating someone, somewhere on this planet. 
• The pretty changing seasons - the many colours on the trees during autumn, the snow-covered Cambridge in Winter, the flowers and bees filled spring when there is the 'just-right' temperature, and the hot-but-not-so-hot summer which you can just lie on the grass the whole day. I hated the cold at first, but I've grown to love these beautiful seasons and perhaps, I have become more used to living in the cold than the hot and humid weather now. 
• The formals, the college gowns, the Latin grace before meals and the cheap and great wine from neighbouring European countries. (haha! Looks like I've learned to love something else apart from tea.) And you know, the countless things which are weird to do anywhere else in the world, apart from Cambridge. 

There are many more instances which made me feel like I don't want to leave this country, ever. I will continue to add to this list until the day I depart, the wonderful moments I want to remember forever. And hopefully, I will return to this tea-filled land one day. Regardless, home will always be home - where there's 24/7 good food, where there's barely any grey sky and where I can speak in the languages I'm truly comfortable in and be fully myself, again. 

An Elective in Peru and Cuba: Peru

This was written as part of my elective report 'What is a Hibiscrub?', so excuse the cringy formal/reflective language used. 

The Inverse Care Law

The healthcare system of Peru is made up of a public sector and a private sector. The public sector is funded by two main types of health insurance – the Social Health Insurance (EsSalud) and the Comprehensive Health Insurance (SIS). While EsSalud is a mandatory insurance paid by the employers of all formal sector workers, SIS is an insurance funded by the government and international aid, which aimed to provide free or low-cost healthcare to those living in poverty and extreme poverty. Each of these insurances has their own healthcare facilities. While the EsSalud facilities provide more comprehensive and modern medical treatment, the SIS facilities only provide essential medical treatments with an emphasis on maternal and child health.

Before I arrived, I did not know how important the hospital I was placed in, Hospital Antonio Lorena, was to the people of Cusco. Cusco is one of the major cities in Peru, situated at 3500m above sea level, in the valley of the Andean mountain ranges. The city is the main commercial centre for the Quechua-speaking indigenous people of Peru; many whom still reside in the surrounding villages. In contrast to the Peruvians who live in the urban areas, who were literate in both Spanish and English and who were the beneficiaries of the EsSalud insurance, there was a high level of illiteracy, poor living conditions and transgenerational poverty amongst the indigenous people. Their rights were often neglected. There was no health insurance for this group and thus, no modern health care until the SIS was introduced in 2002. While there are many EsSalud hospitals in Cusco, Hospital Antonio Lorena is one of the two hospitals dedicated solely to the SIS beneficiaries in Peru.

When I arrived at Hospital Antonio Lorena, I was shocked to see the hospital buildings were made up of blocks of shipping containers. This was different from the photo of the hospital I saw online. The gate of the hospital was shut tight, with a big banner saying ‘National Doctors’ Indefinite Strike’. There were many doctors congregated outside the buildings, shouting, raising their placards and drumming. They seemed to be protesting about their low pay. There were another group of people outside the hospital’s gate, shouting, raising their placards and drumming as well, but they seemed to be protesting about an entirely different issue – ‘Save our Hospital!’ was written on one of their placards.

Fortunately, I could register myself for my elective. Initially, I planned to do three weeks of Emergency Medicine. Due to the doctors’ strike, I did not have much choice but was placed in Paediatrics for two weeks and Infectious Diseases for one week.

Later, I learned that the doctors had not been paid for months and this indefinite strike had happened a few times since last year. I also heard that the original Hospital Antonio Lorena was undergoing a major refurbishment. Therefore, this was just a contingency hospital until the work completes. However, doctors told me, even though it has been three years since the work started, the new hospital was nowhere near done and will probably take at least another three years to complete. I visited the construction site of the hospital, but there were no workers there at all on a Wednesday afternoon. What about the group of people protesting outside the hospital? I learned that they were probably the representatives of the poor. Instead of funding the refurbishment of Hospital Antonio Lorena, the local authority decided to channel the funding to building a new international airport in a nearby village to boost the tourism industry to Machu Picchu. The work on Hospital Antonio Lorena was therefore halted.

Unlike EsSalud or other social insurance schemes, SIS’s budget is fixed and does not adjust to the increasing number of beneficiaries. It also does not help that the General Government Expenditure for Health in Peru has remained stagnant at 4-5% GDP for decades. In the past decade, the government worked hard on the issues of inequality in access to health services. However, due to political corruption (a pervasive ‘culture’ from the ministers to the farmers, as the Peruvians put it), the opportunities to boost the personal economic situation took precedence over the welfare of the people. In this adversity, the poorest group suffered the most as they were left with almost no accessible health services. 

Fuelled by the poor access to health services, poor public health education and high illiteracy rate, the vulnerable rural population bears the brunt of nutritional deficiencies, maternal and perinatal death and communicable disease in Peru. These patients often present to health services, if at all, when the conditions are dire. In Paediatrics, I saw a 5-month-old boy with Kwashiorkor disease and globally-delayed development due to parental neglect; In Infectious Diseases, I saw cases of severe mucocutaneous leishmaniasis and advanced AIDS. In a short period, I saw many extreme pathologies which I thought only exist in textbooks. More appallingly, these diseases hardly exist in the metropolitan of Lima, just few hundred kilometres away. Based the Dahlgren-Whitehead rainbow we learned in our Public Health lectures, I knew that to resolve these heart-wrenching problems we will need to tackle the wider social determinants of health. However, in reality, how much influence do health professionals have over these factors? 

The effort to reverse the Inverse Care Law

While I was overwhelmed by the inequality I saw, a few doctors in Hospital Antonio Lorena showed me how they maintained professionalism and improved the lives of those who needed them most. For example, several paediatricians chose to stay in the ward and care for their patients instead of joining the indefinite strike with their colleagues, because they knew that no one would be saving those children if they choose to walk out indefinitely. Besides, even with the constraints of funding, they tried to deliver an evidence-based practice. When first-line investigations and treatments were not available in Hospital Antonio Lorena, the doctors were resourceful in seeking evidence-based alternatives for the patients to achieve comparable outcomes. Even with the little they had, they were relentlessly helping those neglected by their society. Therefore, at times when I am fixated with the disputes we have in the NHS, these Peruvian doctors’ attitude towards their patients reminded me to look beyond these dissatisfactions and to be a doctor who truly cares for the people. 

Unfortunately for the Peruvians, there were times when the second-line treatments and investigations were not available in Hospital Antonio Lorena. During these times, the patients could buy those services and items from third-party laboratories and pharmacies in town. This creates a strange picture which there were many pharmacies and laboratories situated right outside the hospital’s gate, and patients would bring along their cannulas, saline intravenous solution and drugs to the clinics and wards. However, this also means that these services, which are available only on out-of-pocket payments, are not available to those who just cannot afford to pay anything at all.

Conclusion

In conclusion, this elective gave me an experience which I did not expect at all. When I departed from Heathrow, I expected this elective to be an extension of the Infectious Disease placement we had in clinical school. However, it has taught me much more than clinical knowledge alone. This elective showed me what ‘lack of resources’ truly means; it is a harsh reality for millions in the Latin America.  It had taught me to appreciate every little thing I have been taking for granted in the NHS: the ubiquitous Hibiscrubs in Addenbrooke’s, the freedom to do audits and to access the latest scientific articles, the capacity to order fancy investigations, the support each of us has to groom us into a safe and competent doctor and so much more. It has also taught me that if an opportunity arises in the future, I could and I should contribute more to the developing nations either directly, by being a doctor for the people there, or indirectly, through doing researches which the results are easily accessible to the doctors in these developing nations.   

An Elective in Cuba and Peru: Cuba

This was written as part of my elective report 'What is a Hibiscrub?', so excuse the cringy formal/reflective language used. 

I did two weeks of General Surgery rotation in Hospital Manuel Fajardo and two weeks Obstetrics in Hospital Gineco-Obstetrico Ramon Gonzalez Coro. As expected, the biggest problem I had during my time in Cuba was the language barrier. Even though I could understand basic Spanish, the Cubans spoke at a breakneck pace and with a strong accent, which made it almost impossible for me to take a history from the patients. However, there were more surprises for me apart from the language barrier. 

The Lack of Resources

When my General Surgery supervisor brought me to the theatre changing room on my first day, I was surprised to be offered reusable surgical masks and head covers made of cotton fabrics. When I was changing into my surgical shoes which I brought from home, the other doctors were surprised to see the odd looking ‘flip-flops’ and offered me a pair of cotton shoe covers. I was at loss of how to use those covers until a nurse showed me how to tie them over my shoes. When I arrived outside a theatre room, a registrar told me to scrub in. ‘What is a Hibiscrub?’ she asked when I asked her where can I could get Hibiscrub from, a soap ubiquitous in Addenbrooke’s Hospital. She proceeded to show me how to scrub: first, by using a bar of regular soap for 5 minutes; after rinsing, apply an alcohol mix, which left strange white residues on my hands and caused the skin on my palm to peel.

The equipment in the theatre was all reusable: from cotton surgical gowns to the enormous pieces of green cotton fabric used as drapes, to the metal yankeur suction tube. The only things which were disposable were the swabs and sutures. The waste they had after any surgery was a little 2L plastic bag, as compared to the 2-3 large garbage bags we had in the UK. While in the General Surgical Ward, instead of the usual surgical site drainage bags we have in the UK, a white surgical glove connected to a plastic drainage tube with duct tapes was used in place of a drainage system.

Apart from disposable items, the hospitals lacked laboratory-based investigations, imaging equipment and medications. This used to be the reason why Cuban doctors were so good at diagnosing based on the clinical picture alone, instead of relying on imaging. However, I also witnessed the harsh reality of not having X-ray machines, CT and MRI scans readily available in clinical practice. An 80-year-old lady with painless jaundice was admitted during my placement. Although the doctors suspected that she had pancreatic cancer, they were unable to offer her CT scans to check for metastases. The only thing they could offer her was a staging laparotomy. I secretly hoped a palliative care doctor was referred for her, but judging from the lack of a CT machine, I wondered about the availability of palliative care here. During the laparotomy, they found multiple metastases and a blocked duodenum. She deteriorated rapidly after the surgery and died the next day.

Due to the economic sanctions, the Cuban surgeons had few disposable items and imaging equipment at their disposal. Although I was at awe with the creativity of the surgeons, there is a limit to their improvisation skill. After the death of patient with jaundice, I became more aware of our reliance on technologies in our daily practice in the NHS. These experiences made me realised the luxury we have always enjoyed in the NHS, both as a doctor and as a patient. For example, as a junior doctor, I would be able to order any investigations just with a few clicks on the computer without actually considering the costs behind them, and I can be sure that the results will return me soon. These experiences revealed to me the real costs of these investigations and treatment. Thus, I should be more mindful when using the resources available, using them only when there is a valid clinical reasoning behind each investigation, instead of doing it ‘just as a baseline’.  

The evidence-based practice?

Since the beginning of medical school, I learned about the importance of evidence-based medicine and how a simple study like Ignaz Semmelweis’ comparison of the mortality rates in obstetric wards cared by doctors and those cared by midwives had spared countless women and newborns from agonising deaths. As medical students, we were all told to wash our hands numerous times since day one of our clinical years to prevent spreading pathogens to our patients and ourselves. Despite so, I often washed my hands in the wards with the sole intention of avoiding reprimands from the infectious control nurses. In Cuba, I witnessed the consequences of not adopting this simple yet effective evidence-based practice. Due to the lack of proper hand-washing facilities nor gloves in the clinics and wards, I often witnessed doctors examining patients, one after another, without washing their hands in-between. As a result, surgical wound infections, wound dehiscence and large surgical hernias were familiar sights. It was strange to see these iatrogenic pathologies every day, yet no measures were adopted to improve the situation.  It was even more strange to see patients keep coming back to the same doctor to seek help and even thanking the doctor for his willingness to treat their complications! This would have earned the doctors lawsuits in the UK! 

The lack of resources might have curtailed any effort to do audits or research to improve the situation. However, I believe there is another factor dampening the research culture – the constant use of socialist-based propaganda to reassure themselves and the public of the current state of the healthcare system. After Fidel Castro’s successful use of propaganda to unite the Cubans in the Cuban Revolution, the government maintained an intricate propaganda machine, including all broadcasting facilities and publishing houses. The culture of using propaganda to unite the Cubans seemed to infiltrate the medical field. When asked about their health system, the Cuban doctors have only the highest praises and nothing less. Their unacceptance towards criticism was evident when a Colombian trainee doctor lamented about the state of the system to one of the elective students. The doctor later received very disapproving comments from his colleagues. Besides, as elective students, we were not allowed to conduct audits too. This surprised me as I learned from another elective student who was at the same time as I did that each primary care centre has a statistician and they were obsessed with collecting data! Several African medical students studying in Cuba told me that they were not taught to conduct any audits, partly due to the lack of resources, and partly since all statistics were heavily monitored by the government. The doctors were pressured to produce favourable statistics to protect the international ranking of Cuba healthcare system and Cuba hardly ever allow independent verification of its statistics. I have also witnessed how clerking sheets and observation sheets were completed in the hospital. The doctors filled in clerking sheets, which in theory would aid in taking an extremely comprehensive history and examination, without having interacted with their patients for more than 2 minutes; the 4-hour-post-partum observation sheets were filled in within the first hour postpartum. Although I would not generalise these actions to the culture of the whole system, they provoked my scepticism towards the stellar statistics reported to international organisations from Cuba.

Furthermore, Cuba is also a country with an inadequate and heavily-censored internet connection. Although I was unsure if this was due to the US embargo or it was part of the government’s effort to prevent Cubans from assessing outside culture and information, I witnessed how their healthcare system suffered from their isolation from the international medical community. During my four weeks in both hospitals, I have attended several teaching sessions and teaching ward rounds with the local medical students. However, during those sessions, I did not see any professors quoting any evidence from any scientific journal during their teaching. When questioned about their clinical reasoning, anecdotal pieces of evidence were often used to justify their actions. However, how are the Cuban doctors supposed to assess the latest NEJM when the internet costs USD 1.50 per hour, but an average Cuban doctor earns merely USD 60 per month? Besides, most Cubans who have never been outside of the country were unable to understand simple conversational English.

Throughout my time there, I worried about the quality care received by the patients and at times, secretly blamed the doctors who did not wash their hands for the infected surgical wounds. On hindsight, perhaps the cause of those infected surgical wounds was more than the bacteria on the doctors’ hands, rather a cumulative consequence of the environment they were in. 

We had to wear white coats! (and I really wore the sunglasses on the way to hospital)

An actual Caribbean beach, where we spent hours doing nothing but chill

They said the friends you made during the hardest time in your life will last. I think so too. 

My new friends in La Habana (and the ones without which I couldn't have survived the hospital)

Salsa - the Cuban way

A must.

Learned about the dual currency, and learned how to use them to our benefit. 

Those stains are not blood.

An Elective in Cuba and Peru: The Ultimate Packing List

When we first booked the trip to Cuba and Peru, we didn’t realised the huge contrast in climate between the 2 countries. Cuba, a hot and humid country, just like Malaysia, but probably at the peak of the hot season; Peru, a dry and cold country, at the peak of the Southern Hemisphere winter in June-July. We did not realised these differences until 1 day before our departure when I was busy moving out of my rented house + packing for the trip when Kevin checked a Salkantay trekking website which said, ‘The temperature may drop before zero degrees.’ It was then when I removed a Cuban hat (it was a souvenir from my friend, Han Rong, a few years back) from my luggage, frantically dug my winter coats from the boxes I have packed and squeezed it into my exploding luggage. So unless your trip involves travel to an extremely hot country, then an extremely cold country, which requires you to have equipment for 5-days long trekking and equipment to work in the hospital as a medical student, the following list shouldn’t bother you too much:

General

• Winter coat
• Thermals
• Sweaters/jumpers
• Beanie
• Gloves
• Swim suits
• 2-3 casual shirts
• 2 jeans/casual pants
• 2 trekking trousers or exercise pants
• 3-4 set of working clothes
• A nice dress – for nice dinners or to go to nice places
• Enough underwear to last you for ages…
• Sport shoes
• Flip-flops
• Work shoes
• Souvenirs for our hosts
• Plastic bags and zip-loc bags   

For working in the hospital:

• Stethoscope
• A thin, short white coat ‘batas’ – not the type we used in the UK for dissection or biochemistry lab
• Surgical scrubs
• Surgical slippers
• A small Oxford handbook/medical pocket book

For Salkantay trek (5D4N):

• Sleeping bag – one which can protect you from -10 degrees + wind during the night in the snowy mountains
• Extremely durable, water-proof trekking shoes – one which fits perfectly, else you’d get blisters
• Small bag pack
• Water bottle
• Snacks – can be bought right before the trip
• Walk stick (optional) – I didn’t had one
• Hat – to protect against the strong UV in Cusco-Machu Picchu 

Toiletry bag

• Shampoo – toiletries were not provided in any of our accommodation throughout the trip
• Body Soap
• Facial cleanser
• Insect repellent
• Lip moisturiser
• Face and Skin moisturiser
• Waterproof sun screen SPF 45 and above
• Alcohol hand gel – you’ll need it for hospitals and for eating out
• Tooth brush
• Tooth paste

First aid bag

• Lots of plasters
• Antiseptic cream
•   Paracetamol
•  Antihistamine
• Activated charcoal
• Loperamide (antidiarrhoea) – not advised to take this but for just in case
• Mountain sickness drug – we had acetosalicylic acid + caffeine, instead of acetazolamide as we don’t want to take diuretics during hiking for obvious reasons!
• Courtesy of our Occupational Health Department, we actually had sutures, SteriStrips, swab and cannulas with us in our first aid bag too. (LOL. I have yet to suture outside the theatre!) 

Tip: I also brought my ever-handy Longchamp handbag and a cloth recycle bag so I could use them when walking around in town. 

This seems like crazy amount of stuff, but these was just enough to get us through the journey, without having to buy a lot more on the way. We forgot to bring gloves, so I bought a pair for about £1 in Cusco.

We managed to packed all these into 1 big luggage (25kg) and 1 rug sack. And we're all ready to go!