If I Could Teach Them One Lesson

Registrars are meant to be clever people. Duh, they’ve graduated medicine and practised a few years and are brave enough to specialise. I’ve seen a lot of registrars do a lot of stupid things, but I won’t dwell on that because that’s not what today is about.

I recently heard a registrar complain, “If you think fourth years are bad, wait til you get the third years next week. I feel like a total babysitter! They don’t know how to do anything and I keep having to check up on them!”

I laughed along and told them to team each third year up with a fifth year to solve their problem. But that’s not what I really wanted to say.

I wanted to tell them how fortunate they are. What a big gift they’ve been given. They get to INFLUENCE the way those third years will view medicine forever. They get to influence the way they will do things for the rest of their professional lives. They get to give those third years confidence in what they are doing… or to deny them that confidence.

Registrars… you get to either make them hate ward rounds, or you can turn it into an experience where they will learn more in a few weeks than they have in their entire medical education thus far.

Do you realise what a huge opportunity that is? And a responsibility, yeah. But you’re doctors. C’mon, responsibility shouldn’t be new to you.

I had an amazing registrar for Internal Medicine in my third year, and a horrid one for Surgery. And as readers of this blog know, those impressions have remained.

I think medical professionals (and students) sometimes forget the benefits of community. You know that saying about how it takes a community to raise a child? It takes a community to raise a doctor too.

I’m so thankful that patient people taught me the simple things like histories and physicals, and helped me not to give up when I struggled to get IV-access on patients. I’ve had my fair share of impatient mentors, and they have had the potential to leave lasting horrid impressions.

Third years aren’t babies. In the medical world they are, perhaps, but they are also adults. So give them responsibilities. Teach them where you can.

Cherish your role in raising tomorrow’s doctors.

Latin, Law and Medicine

We are doing some forensics theory for two weeks. It’s a lot more work than the practical rotation I had at the beginning of the year, but also a lot less disturbing.

One of the specialists also has a law degree. They taught us something interesting: we can prevent justice from occurring. In a bad way.

Novis Intervenus Artis is a Latin term which directly translates to “by intervening with new art”. In medical law, it refers to the effects on a new intervention on a patient.

Here’s where it gets interesting:

You are on call in the ER. A patient is brought in with severe stab wounds and blood loss. He is unconscious. As part of resuscitation, you order two large-bore IVs. But because it is late on a Saturday evening, you forget in the rush to run the fluid through the line to eliminate air bubbles. 

A few seconds later the patient dies from a massive air embolism – which you inadvertently caused. 

It is likely that this patient would have died and that the person who assaulted him would have been found guilty of murder or manslaughter. But now he won’t, because your “new intervention” caused the death.

Do I sound like a fear monger? I don’t mean to be.

This scares me. Because I have lost loved ones to violence and because I believe in justice. And because I am a young medical student, soon-to-be a young professional: prone to mistakes.

Surgery Woes

The day you start Med School, everyone tells you that it is nothing like Grey’s Anatomy.

And when, two years later, you are finally unleashed upon the poor unsuspecting state patients, you realise: it’s exactly like Grey’s.

Except, funnily enough…  in surgery.

I finally made it to my third year abdominal surgery rotation. It is not really fun.

I suppose it may just be the luck of the draw, but I find it boring… pancreatic debridement, sigmoidectomy, rectopexy, appendectomy by the thousands.

Here’s some gut, here’s some more gut, oh look! There’s an organ! Oh, it’s rotten. Let’s cut it out!

And there is lots of… excrement. Let us not forget that. Somehow, to me, it is worse than placenta.

And the surgeons? They are quite temperamental.

Like I said, maybe the timing is just all wrong, but so far… I am not enjoying surgery.

I admit, it makes me a little sad. I have never been particularly set on it as a specialisation, but the field is so glorified. I cannot help but fear that not enjoying it, might mean I am sub-par.

Top Tips for Tygerberg Part I

Every year I get a substantial amount of queries from aspiring medical students regarding the school I attend. It is a prestigious university with some interesting factors at play, so it is wise for Matrics (high school seniors) to investigate their potential choices. They will be spending six years there, after all.

Seeing as the pool of high schoolers that know me personally is drying up I decided to post some of my usual answers here. A similar post will follow soon regarding studying medicine in general, but I don’t have that bit figured out myself just quite yet.

Here thus follows a short guide to studying medicine at Stellenbosch:

Stellenbosch Main Campus © universityfairs.com

The thing that is important to know about Stellenbosch Medical School is that the Health Sciences Faculty is located next to Tygerberg Hospital. When I was a wide-eyed and bushy tailed first year from 1000km away, I left home with big dreams of studying in the romantic historical town of Stellenbosch…

Only to find out that I would study 40 minutes away, not quite as beautiful. This has posed a problem to me on several occasions. My happiness is directly related to the aesthetics of a place. It has, however, taught me to enjoy the little gems of beauty: campus at sunset, campus after rain, campus during the springtime…

Another thing that causes concern in prospective students is the language policy. The medical course follows the “T-option”, which means that English and Afrikaans should be used in equal amounts during classes. Lecturers that cannot speak English must use Afrikaans slideshows and vice versa. Furthermore notes are to be available in both languages.

Needless to say this attracts many Afrikaans-speaking students, but causes some concern for students speaking other languages. I have, however, met many of those who chose Tygerberg for precisely that reason. There is nothing as difficult as attempting to extract a history from someone that does not understand your language. The ability to speak more than two local languages is even more valuable, but two is a good start.

The reason I consider our course to be superior? Stellenbosch FHS offers excellent practical training. We start early with clinical work and have access to a top-of-the-range simulated clinical skills laboratory. When on clinical rotations, students are treated as though they were qualified doctors apart from need their actions co-signed and quality-checked. I compare this to universities where practical work starts only in the fourth year, or where students have to get written consent for something as simple as drawing venous blood.

The final eighteen months of training at Tygerberg is called your student internship and is solely practical with no theoretical blocks. It is expected of SIs to conduct themselves as though they were already Interns – again very beneficial to practical training.

These are the tree most important things prospective students, in my mind, should know in order to make a good, informed choice. Be sure to ask if you have any other questions that need answering.

 

Things you need in hospital

During my internal rotation I learned something devastating: the wondrous white coat is simply not big enough. During the four weeks I did not button my coat up once – and I don’t think it has anything to do with the few extra pounds I have gained this year.

1. Stethoscope: The favourite tool of medical students; the day your first stethoscope arrives is one of excitement (anyone who is blasé about it, is just suppressing their joy). Don’t forget it; I have once or twice and felt naked the entire day. I like Littmann, mine is a lovely raspberry colour.

I wear mine around my neck, but med-school lore apparently states that students should keep their stethoscopes in their pockets.

Aside: You can use your stethoscope to test reflexes if you forgot your patella hammer; but if you tell anyone I will vehemently deny any mention thereof.

2. Gestation wheel: we use these in obstetrics, but since we got a few pregnant patients on our Internal calls, I like to keep mine handy. You can get a template to make your own or buy a nice plastic one. Mine was handed out at our campus’ society day – quite a nifty hand-out.

 

Aside: these are awesome to have on-hand when calls get quiet or boring. We discovered that one of our friends was most likely conceived on New Years’ Eve.

3. Illegal hospital supplies: We are discouraged from taking supplies in the morning to have them ready when we need them. In a private hospital where different wards are owned by different professionals this is completely sensible. However, in our public set-up, it is often necessary. Some staff nurses are lax in restocking their supplies from the storeroom, which is problematic if you are out of 22-gauge needles and your 92-year-old patient needs bloods drawn immediately.

You also often find that in a specific ward, only one glove-size is available at any one time. When I find small gloves, I stock up; as do my clinical partners when they find size 8½ gloves.

The “piggy” in the picture is my own. It’s like a specialised syringe, I don’t know it’s real name.. In our hospitals they are a rare find – even rarer than piggy-needles, which baffles my mind. They are awesome though, especially if you need 20mℓ blood (or more). They are much nicer than syringes. Similarly, butterfly needles are much nicer than normal needles of you need a radial arterial blood gas.

The name tag is what students often use to label their stethoscopes. You should not steal from the hospital though.

 

4. Tourniquet: In South African hospitals, people often use gloves instead. Avoid at all costs: it HURTS (go on, try it). Once our Intern was helping me with a difficult blood-draw. I said, “You can use my tourniquet, it’s brand-spanking-new.” He laughed and said, “And so it shall remain, because it will be stolen before it ages.”

They are really easy to misplace, but fortunately also quite cheap. Mine is an ugly orange, but I’m hoping to get a pretty one soon, like the one on the side. Patient’s do often call us vampires…

5. Pupil torch: Admittedly this was a bit premature, as it will probably be of more use in trauma. This one is dirt-cheap, but we also haven’t been able to discover how to change the battery or the bulb. I guess you just replace the whole cheapie.

6. Measuring tape: Another thing I acquired for Obstetrics, but quite useful when your patient has a lymphadenopathy (or anything else, really).

7. Reflex hammer: I bought the expensive metal one, although the cheaper plastic ones are much better for the swinging technique required for testing reflexes. The metal one is semi-collapsible, which is why it won. It also has a sharp end for Babinsky-reflexes and a pin on the inside. In the age of HIV and other blood-borne disease we don’t use the pinprick anymore, instead we use wooden toothpicks.

This book is probably my favourite of all medical textbooks – and it fits perfectly in your white coat’s pocket. Learn how to use it with speed and, like the stethoscope, don’t go anywhere without it.

A note on diagnostic sets: they are awesome, but very expensive and they are usually available in all wards. Due to their value you might need to ask the chief nurse for access to it.

I have seen senior medical students pull other gems from their bags: scissors, adhesive tape and breakfast bars. Don’t forget extra pens and paper for notes, either. Undoubtedly, one needs a bag – a satchel. I’m still looking for my perfect one: it should have a sturdy strap that can be worn across the shoulders and have an easy-to-organise interior. And because I’m a girl it needs to look good too.

The search is on!

 

 

Bleeding noses, Cocaine… All in a day’s work.

My Early Internal Rotation is coming to an end fast and despite torturous ward rounds, I must concur with John Abernathy when he says,

“The hospital is the only proper College in which to rear a true disciple of Aesculapius.”

Funny things happen on our calls – such as the 70-year-old granny who presented with signs of ventricular failure and seemed lucid as anything while telling me that she is as fit as a horse and has never experienced any health problems whatsoever. Until her (thick) file arrived and it appeared that she was quite well-known to our hospital. She then proceeded to tell me that it was certainly not her file; despite the coinciding personal details.

She was a darling.

A young man with Aplastic Anaemia presented with massive epistaxis. His nose had actually been packed by a regional hospital two days before and it had still not subsided. We called in the ENT and he told us we could watch if we donned the appropriate protective gear – the first time I had to cover myself for the patient’s protection and not my own (these patients can be extremely susceptible to any kind of antigen).

One of the first things the ENT said to the patient was that he brought some cocaine to stop the bleeding. You should have seen the size of his eyes! His mother looked a bit suspicious too.

The bleed turned out to come from Little’s Area, which is a highly vascular area of the nose that is quite easy to cauterise. It was chemically cauterised so the teenager didn’t get his (presumably first) run-in with Snow White. I couldn’t tell if he was disappointed or relieved; but he stabilised rapidly thereafter. I had never before seen someone needing transfusions due to a nosebleed.

Probably one of my rarest and most striking patients came in with severe polymyositis – basically an autoimmune disease against your own striated muscles. He started exhibiting symptoms 18 months ago and it could not be controlled by steroids. Currently he has some use of his toes and his hands only – the mnemonic goes “hairs, chairs and stairs”; illustrating how the proximal muscles are affected first.

The most striking thing was his mother and her entire support-network. Despite the fact that they clearly suffer, her strength and love for her son was evident.

Yesterday morning he unfortunately went into respiratory arrest and had to be intubated. The problem is that once these patients are intubated, it is extremely difficult to get their diaphragm to restart the work of respiration. Imagine being able to feel everything and experience everything, but not being able to move… and now not being able to talk as you have a tube down your throat.

From www.uvahealth.com

His mother was devastated. When you see someone you love like that, it seems they are on the brink on death. We explained to her that this is not the case. I guess it is open to personal opinion whether that is better or worse.

Internal Week 1: Many many sick people

I don’t really know how to start this post. The past week on Internal has been interesting, but I am not sure I have an opinion about it. I’m not sure if I like or dislike it. It is busy, it is very educational and there are many sick people.

I haven’t been able to get IV-access from a single patient on this block. Apparently that is to be expected because they are so sick, but it does not do much for confidence. I am certainly not going to put in an intercostal drain if I can’t manage an IV. And nurses can do it with their eyes closed.

We have seen quite a few people coming in with ODs. Tile cleaner, alcohol, antihypertensives, insulin, anti-epileptics. We don’t get to sit in on the psych consults so I don’t know how many of them were para-suicidal.

I’m getting to read many ECGs. It is good practice. X-rays and CTs too. We have had lectures, but it seems that the real things is a much better teacher. We have seen some CTs with severe cerebellar atrophy, all but one due to alcohol misuse. That’s quite a common thing in the Western Cape, apparently.

A young patient taught me to trust my gut. She came in with decreased level of consciousness – GCS 8. When she was awake she was confused, resistant and agitated. She resisted tests for meningism so I didn’t know if she had neck stiffness or if she was just tensing her muscles voluntarily. A more senior student told me she didn’t think there was meningism. I was worried about meningitis, but because nobody else seemed worried and the patient didn’t actually have a bed yet, plus the doctor was busy with patients on ventilators, I assumed that I was being paranoid.

When I finally presented, the doctor concluded that there was meningism and he seemed extremely irritated with me. And with good reason – in the two hours between the patient’s admission and finding her an open bed, she could have died. If it was meningococcal we all could have been infected. I wanted to make excuses – and there are plenty good ones – but the only truth is that I should have trusted my gut.

Incidentally we think it probably is not meningitis, but renal encephalopathy. Again something I should have put together when I noted the little urine in the catheter bag and some proteinuria and haematuria. But I probably won’t know the diagnosis as we sent her back to the secondary hospital for a lumbar puncture – we need the beds for tertiary patients.

Brudzinski's Sign of Meningitis, courtesy www.health.allrefer.com

But so we learn. I suppose that is why they don’t just let us loose. I have learnt more in the past week than in the whole of my second year, I think. Just not how to get IV-access in a shocked patient – yet.

First day of Paeds

Today was my first day of my Paediatric Clinical Rotation – and it could not have come a day to soon. Psychiatry Theory was horrible and I think it may be best if I simply don’t check my marks.

If I thought a practical block was going to make me feel like less of an idiot I was mistaken though. The doctors are not rude (so far), but they sure don’t hold  back on the fact that we know nothing and are pretty much idiots. Which, I am sad to share, is the truth. I do not think that I answered a single question correctly today.

We have a patient with Shigella Dysentery turned septicaemia. He is in isolation. One thing is certain: I will know my microbiology, virology and pharmacology very well by the end of this block… and those are the sections I usually neglect. [I know, bad student. They're the smallest sections in the exams, okay!]

We have a lot of patients with HIV/AIDS and disseminated TB. It’s so sad.

I have a five-month-old patient with HIV (on HAART) and previous Pneumocystis-Jiroveci-Pneumonia. He is too good for a young child – he didn’t cry at all when I examined him. He seems to be doing better though (according to the doctors in the word). When I leaned over to listen to the percussion – he has a huge liver and spleen – he grabbed my hair, and smiled.

Paeds is a lot more chilled than Obstetrics. I don’t quite know if I will like it, but it seems set to be a very interesting experience.

Hands-on Learning… On a Weekeend!

This post should be about Psychiatry since that is what I am writing next week. But… it’s not.

There is a Maties Community Service Clinic this weekend. I put my name down as volunteer about 6 weeks ago, but cancelled because of that darn test. However, almost all the volunteers also cancelled (for various reasons), so I decided to go anyway. I would learn more there than in front of my books at any rate.

Where we are usually 12 students at the least (and often more), we were only seven volunteers today. One dietetics student, two students for screening and four for consultations. Which means that I got to do consultations on my own. I was extremely nervous as I have never really done a full consultation on my own. Fortunately the more senior students briefed me very well during the drive and so I felt a bit more at ease by the time we arrived.

Most of my patients were adults with musculoskeletal complaints, or children.

A lot of the patients we saw (the other consulting students as well) had mechanical complaints and it turns out that they were all either workers at fruit orchards or cleaners. And they were short and a bit on the weighty side. Which, if you think logistically, does explain how their occupations can contribute to their problems. Funny how even non-infectious, non-genetic complaints can cluster in specific areas.

A lot of mothers stated that they “want” antibiotics for their child’s cough – which is of course nonsense as one should try very hard to limit antibiotic exposure to little children and a cough without fever or yellow/green mucous does not warrant antibiotics. So I also got to practise explaining these matters in a good, sensitive manner to mothers.

One little girl was involved in an accident about a month ago, which got her sixteen stitches on her forehead. Since then she has secondary nocturnal enuresis, night terrors, a decreased appetite and behavioural changes. Here at least I managed to practise my psychiatry skills – and I am pretty sure she has post-traumatic stress disorder. At first it seems over the top, but if you really think about it, three year olds are not equipped to deal with the stress of accidents. So she got a referral to the psychiatrist.

I almost missed a worrying symptom in the same child. I did the history and examination correctly, but forgot to ask for her clinic card. When the sister on duty asked for it, we saw that the girl had been losing weight since November (that is, before the accident). We then tested her haemoglobin – shame, imagine pricking such a tiny finger – and it was only 8,5. So we gave her ferrous gluconate for a month, after which she needs to be reassessed.

New skill for the day: PR, otherwise known as the rectal exam. This was not one of my own patients, but a friend of mine asked if I would like to learn. The patient had symptoms of prostate pathology (urgency, hesitancy, overflow incontinence). The prostate was smooth but slightly enlarged (4cm according to the more senior student), although I couldn’t tell the size – my hands are small and these kinds of exams need practice and more practice, so at least I have started now.

I had my first run-in with Trichomonas Vaginalis infection. The patient mentioned a brownish discharge – sign #1 – and the moment she undressed the smell was distinct and obvious, sign #2. I did a PV (vaginal examination) just to be sure and referred her for a Pap smear, which is indicated based on her age and sexual activity.

I saw seven patients in five hours – which is not much as good doctor should see about 40 in a working day. Considering it was my first time seeing patients on my own I don’t think it was very bad, though. Especially since I was trying to be thorough.

My least favourite part? The musculoskeletal cases, but that is understandable: my class has not yet had our musculoskeletal block, so I know very little in the field. That, I trust, will change in the near future.

My favourite part about these clinics is that I am left without a doubt: this profession is where I belong.

Healing our Healthcare

South African public healthcare is in a state of crisis. We train some of the best healthcare workers in the world. Send a South African doctor to Haiti, to India, to a war-stricken zone, and they know what to do. They are used to working with restricted resources under harsh conditions. They save lives and are GOOD at it.

Yet I repeat: South African healthcare is in a state of crisis.

We may produce (generally) excellent doctors, but we don’t produce enough. The best ones tend to leave the country for greener pastures – read: higher salaries and better security. And labour laws combined with a general lack of managerial ownership prevents any form of consequence when doctors are slacking.

The minister of health, Dr Aaron Motsoaledi, seems to be hard at work to improve the status quo. There are reports that he wants current medical schools to increase their annual intake of medical students; while he also wants to initiate plans for one or two new medical schools.

The country currently has eight medical schools, which graduates a combined 1200 new doctors per annum.

A member of Parliament also recently claimed that, at this point, “We need quantity more than quality.”

With that, I couldn’t disagree more.

While I appreciate Dr Motsoaledi’s efforts – and I think he is one of the top members of the cabinet – there is a huge problem with his plan, and it hinges on general economics.

Medical schools simply do not have the capacity to increase their intake (and therefore also their output) of doctors-to-be. Doing so would require bigger classrooms, more staff, and bigger tertiary hospitals too, since these hospitals do only have space for a certain amount of fumbling students.

Medical education is already extremely expensive. In the majority of South African universities, it is the most expensive course on offer. And that is before adding the costs of textbooks, stethoscopes and diagnostic kits.

In order to remain in decent standing with the rest of the world, these schools also need to maintain a good level of research – which requires even more funding.

These universities therefore can simply not afford to accommodate more students as it is not financially viable to do so. If our fees continue to increase, many of us will simply not be able to continue their studies – and there one will already lose many potential doctors.

Looking at the state of our country’s finances (which, to be honest, is also not too great), it seems that the government will need to do one of the following – doing both will simply be too expensive.

1. EITHER build new medical schools (but ensure they are of good quality)
2. OR increase the financial support of existing medical schools.

Furthermore, methods of monitoring medical schools and doctors are essential. Clinical Skills Logbooks should become a national standard, and a good balance of practical and theoretical training should be policy. Furthermore, the government should at NO POINT jump in and qualify doctors who have not met the required levels of skill and theory (which apparently has happened). This only detriments the public and these individuals.

There must be clear-cut consequences for lazy doctors, or those who put their patients in harm’s way. This is not difficult or expensive, it merely takes some time and planning.

Improving South Africa’s health care situation is right up there with improving our education – two things which have the ingredients necessary to make our country great, but are simply not being monitored, supported and utilised effectively.

Never before has it been so clear that a holistic approach is the only approach.