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.

Le Document Pour MB.ChB.III

The inspiration for this document came during my second year while studying for an end-of-block test. At the same time, the then-first years were studying for Pathology, aided by “Le Document”. Somewhere in this time period I looked at a fellow second year, threw my hands in the air rather dramatically and exclaimed,

“I wish I had a Le Document for Second Year!”

Le Document pour MB.ChB.II can be found here. It focussed mostly on holistic wellness during a tough theoretical year. Third year is a whole new ballgame, with students finally set wild in the clinical environment. Theory modules are unfortunately still a reality and at my school, third years are haunted by Neurosciences and Musculoskeletal System.

I throughly enjoyed this year and fortunately I had some older friends who had some handy tips. Thus, some advise for new third years:

Do not freak out if you struggle to draw blood. Practice will make perfect. Accept any challenge, but look out for patients with good veins – they will boost your confidence.

Do not freak out if nurses know more than you do – chances are they have been practicing  longer than you have been alive. Respect them: they can either help you a lot, or make life extremely difficult for you.

ARVs are not a joke. Stressing for an HIV-test isn’t either  Never fool around with a contanimated needle or specimen.

OBSTETRICS: wear a mask when delivering a baby, amniotic fluid does not taste very nice. Always remember tbe infection risk. Wear goggles or a visor and an apron too. Note that if a lady comes in crowning it is not always possible. Remember that the mothers do all the work, it is your job to help them. Remember you are working with lives, always. If told to deliver a multipara, check twice with a doctor or matron.

Ask to take a picture of your first baby, you will not regret the memory.

PAEDS: little humans are resilient, but not made of steel. Be sure you know how to do procedures on them – do not attempt to draw blood from a little human with a syringe. Do not perform a procedure in their cot – it is the only safe place they have. For your own emotional well-being, try not to get too attached. And beware the paediatrician - just because they love kids does not mean they love you.

INTERNAL MEDICINE: this rotation is competitive and exhausting. Try to be on your supervisor’s good side. Take initiative. Look interested. Go the extra mile. Wear comfortable shoes. Read up about all cases on your firm, not only those of your own patients. These are good principles anywhere, but especially important in Internal.

Never underestimate the importance of a good history and a basic physical. If you don’t know what to do, start there. Have a method to your investigation, and a structured presentation.

FAMILY MEDICINE: Do not scowl at this rotation, there is a remarkable load you can learn here , especially if you learn to respect the multidisciplinary approach. Be well prepared for site visits, take sturdy shoes and hand- sanitisers. Take the time to understand you patients’ psyche and sociology, there are not many blocks that cater for this.

SURGERY: not my favourite rotation. Apparently doctors fall into one of two groups: those who love surgery and those who despise it. Surgeons can be scary and temperamental, but try to learn as much as possible. Attend tutorials even if it is easy to slip out. Assist in surgeries even if other students are willing to relieve you of your duties. Do not stress about assisting, you will be told what to do. Most importantly, know how to scrub in and practise your suturing.

With so much practical, theory becomes mundane. Do not lose sight of your goal. Attend classes. If you get bored, look for blogs, student sites or books to pique your interest. For example, The Brain that Changes Itself promises to be a great addition to neurosciences. A Life in Pieces is exceptional for psychiatry. Three Letter Plague as well as Disease are gripping. Musculoskeletal system requires great effort. Colour in, draw, use your friends’ anatomy and don’t let the skeleton stay in the closet.

Third year is wonderful and can ignite your passion for medicine once more. However, you must take good care of yourself. Sleep often, eat well.

And don’t forget your stethoscope.

Book Review: A Life in Pieces

This past year, one of my modules was Psychiatry. Matters of psychiatry have the potential to scare me, having heard of patients who tried to harm my fellow students.

My clinical psychiatry rotation will take place in my fifth year, and I am trying to build my knowledge and my confidence sufficiently so as to be the best I can for those future patients.

Recently I read a book by Dr Richard K. Baer, A Life in Pieces The Harrowing True Story of a Woman with Multiple Personality Disorder.

It follows a troubled young woman through seeking psychiatric help, to her doctor piecing together the puzzle of her mystery. The diagnosis comes in fits and starts and the treatment is novel and ground-breaking.

MPD is rare and the chance of a medical student ever encountering such a case is unlikely, but Dr Baer describes the therapeutic process with clarity and sensitivity such that it transforms the book into an invaluable source of insight and knowledge – and an excellent story.

Sensitive readers should beware: the reasons for the subject’s disorder are graphic and painful. The book remains gripping, though heavy. Once started it is difficult to consider putting it down.

I am now half a doctor

I suppose it is appropriate to share the good news on Thanksgiving, even though we do not really celebrate the holiday in South Africa: I passed my third year final examinations.

If you have been following this blog, you will know that I started the year with the will to be a “better student” and it did not always work out too well. Third year ended up being a little tougher than expected. Regardless, I am thankful that I get to enjoy my short summer holiday without studying for a rewrite, and I am thankful for the myriad of people who have supported me throughout this year.

When on holiday (or procrastinating), I like to pretend that med school hasn’t swallowed up all of my creativity. This was the product of my recent dip:

I am thankful for all those who stood by me and told me that no, I wasn’t an idiot.
And I am thankful that the first three years of med school are over.
Now, on to the next three.

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.

Inspired by the Elderly

After you’re older, two things are possibly more important than any others: health and money. 

Helen Gurley Brown

I am currently on my Family Medicine Rotation. We visited a nearby old-age home yesterday. I was not really looking forward to it, but it blew my mind.

I love old people. I love hearing their life stories and when I was little, my granny and I often visited a nearby old-age home. I like to think I brought some joy to some old people who could no longer talk and who had no other visitors than Grandmother and the tiny blond-haired girl.

Anyway, the old-age home my group visited yesterday is a sub-economical home. One-hundred-and-forty of their 153 residents are state patients. It has three levels, but no elevator. It has one registered nurse on duty at any one time.

I did not like the smell as we walked through the corridors. And I did not like the way the hope dimmed in some of their old eyes when they realised that we weren’t visiting grandchildren.

The geriatrician had some patients talk to us.

We met someone with Parkinson’s Disease – the first time I have ever encountered this. We met a lady who looks and sounds like she is in her 60s, but is actually 86 and has raised eight children. And we met a gentleman who grew up in the Congo and has the biggest smile and the most adorable raspy voice.

He was quite funny. The doctor told him, “These are young doctors, tell them what is your problem.”

To which he gave us a quizzical look and demanded, “What is your problem?”

He told us that he was born in 1914 and when he saw our amazement he laughed, “Mandela is a little behind, yes!”

"Vetmaak Hoekie" or "fattening corner": the sign above the tuck shop in the home.

South Africa is very behind with geriatric care. Do you know that there are only ten geriatric specialists in the entire country? Surgeons here will not touch an “old person”, even though it has been shown that the elderly simply need to be prepared better for surgery.

South African politicians do not care much for the elderly – they do not hold many votes or much money either.

I find this so sad. Every elderly citizen contributed somehow to our country. They deserve some more respect.

I enjoy Family Medicine – it is so much more than science. This is ART.

A Reason I Love My Clinical Group*

Me: Y’all have to be nice to me. I have the Apley’s**.

Guy 2: We have a better textbook.

Me: Which one?

Guy 1: Apples

Me: That’s not a textbook. And I prefer naartjies.

Guy 1: It is. An apple a day keeps the doctor in.

* I sincerely hope you find this as hilarious as I did. Some of my other friends responded with blank stares.

** Textbook: Apley’s System of Orthopaedics and Fractures

Humanity means nothing if it doesn’t involve the weak

I hate memorising things – even something as straightforward as the Glascow Coma Scale. Fortunately there are plenty opportunities for me to practise the important things in the clinical environment.

The first time I had a patient with an obviously lower than 15/15 grading the patient was in her early fifties and referred from an old-age-home. Note the discrepancy here. Her grading was M5, V2, E2 with a total of 9/15. In other words, she localised pain but could not obey commands, made noises but no words and opened her eyes only to painful stimuli.

She was known with epilepsy and hypertension, but when she was found unconscious by her caregivers her rapid glucose displayed only “Hi” – in other words, higher than 30mmol/ℓ. They administered Actrapid and sent her our way. When she arrived at hospital her glucose still displayed “Hi” and we administered more Insulin while rehydrating her.

The bloods drawn for a formal HGT read 74mmollℓ. She had high ketones in her urine – not high enough for the sickly-sweet ketotic smell.

This patient had no previous history of diabetes, yet she had DKA or HONK (hyperosmolar non-ketotic coma). The truth of the matter is that these complications of diabetes do not simply arise overnight.

Whatever the reason for her being admitted to the care-facility (we later saw that she had some cognitive developmental issues), her family clearly wanted her to have a good standard of care. The fact that she had to slip into a coma before they even checked her glucose means that the care she was given was decidedly sub-standard.

I won’t go into the details here, but upon placing her urinary catheter this was confirmed to be so.

In trying to get a collateral history from her sister – I was trying to ascertain just how conscious the patient usually was, considering her epilepsy-medication was Phenobarbitone – it dawned that the sister hadn’t seen her in months.

We are said to have humanity because unlike a great many animals, who don’t merely get rid of the weak: we find ways to help them flourish, or to help them live their last days in dignity. It did not really seem to be the case here. I must remind myself to remain non-judgmental.

Many disease processes are not preventable. A healthy young man dies suddenly of a heart-attack, while an obese one lives well into his eighties. A young baby suffers epilepsy and in one attack the oxygen deficit causes permanent brain damage.

But this episode was preventable.

Our patient recovered well and her sister decided to take her out of the nursing home. A week later, when they came to collect the glucose-monitor, our patient was dressed in new clothes and her hair was clean and cut. She waved at us, smiling her half-toothless smile. Childlike, you could say.

I do hope she does better this time.

Why we panic before exams

Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond imagination.

Maryanne Williams was wrong.

Imagine having ploughed your life and soul into a degree for three years and having nothing to show for it… unless you continue for a further three years.

Third year medical school is like no-man’s land. It’s too late to leave graciously, but too early to envisage your degree.

It is this cusp that presents the very real threat of losing all that time and effort: not making it.

Leave now and you have to start over. Our credits are nearly worthless in most other degrees. It is no longer a matter of being “the only thing” you want to do. In fact, it may well be one of the many things you do or don’t want to do.

But that turn in the road has been passed.

It is now the only thing you can do. You must do.

Eventually you get to choose a specialty or become the Minister of Health or save the world; but finish the degree you must.

And so imagine the situation where and exam has the very real possibility of labelling you: BAD.

As with eggs, there is no such thing as a poor doctor, doctors are either good or bad.

Fuller Albright

Save face and leave? Or stay and become a substandard doctor?

I wrote this the night before my Internal OSCE, stricken with panic. I survived (and passed), but it does not change the truth of uncertainty expressed here.

Some bragging rights

The past two days have given rise to some interesting patients in my firm. To protect patient confidentiality I won’t be giving all the detail, but here goes:

A female with some cushingoid features, presenting with acute severe bilateral frontal headache and diplopia. She had papillodoema. Our differential diagnosis was subarachnoid haemorrhage, benign intracranial hypertension and glaucoma (in that order). The brain CT showed a pituitary mass lesion, which explains the pressure-effects. We are now waiting for confirmation from neurology and radiology of the type and so on. A macro-adenoma would explain the cushingoid picture too. We are also waiting on endocrine blood results.

An immune-suppressed patient presented with upper limb weakness and meningism. When I entered the ward yesterday he was having a generalised tonic-clonic seizure. His scans don’t show any indication of Tuberculosis. The doctors are planning to do a lumbar puncture for the JC-virus, which causes Progressive Multifocal Leukoencephalopathy (PML). It causes inflammation of the white matter of the brain at multiple foci. It is a demyelinating disease like multiple sclerosis, but progresses much faster. It is one of those viruses that is presumed to be dormant in a great many of the population, but kept under control by our immune systems.

We also had a middle-aged patient present with extremely decreased level of consciousness and a rapid HGT of “Hi”. That’s what the monitor does when the glucose is higher than 30mmol/ℓ. She is known with hypertension and epilepsy only and was severely dehydrated. Blood gas displayed respiratory acidosis and she had Kussmaul Breathing. We gave her a normal saline IV and treated the hyperglycaemia. The labs came back with a 72 for blood glucose. (!!)

My last patient has suspected Guillian-Barré syndrome, with a two-day history of lower limb paralysis and one day of upper limb paralysis. No cranial nerve fallout, no sensory fallout and no respiratory involvement. The history is slightly suggestive and she is areflexic, but we are still waiting for lab results – the doctor is not entirely comfortable with a diagnosis yet. The full name, by the way, is “Acute Autoimmune Inflammatory Demyelinating Polyneuropathy”.

At any rate, Internal certainly is not boring.