Nightmares

I get vivid nightmares often, but all through the last week on my internal medicine rotation I had the same recurring theme:

Needle-prick injuries

The dreams were always different, but they always involved some exposure to HIV, and the side-effects of the prophylaxis, and the fear of The Test six weeks later.

For the uninitiated, I should mention that the likelihood of contracting HIV from a single needle prick injury is minuscule, and even smaller when taking PEP.

 

But when your daily work revolves around AIDS, and you regularly see the effects of AIDS-related disease, the percentages aren’t soothing – no matter how small.

I have been extremely fortunate thus far. I don’t draw blood from a thrashing patient. I wear gloves even though they make palpating veins more difficult. I look around me and stay out of the way of people carrying sharps.

But the fear remains. I don’t need a dream analyst to tell me that these dreams are a mirror of my thoughts and fear, that much is obvious.

I just think this risk is underestimated, both by those in and out of the profession.

I don’t think the layperson realises the risk at which our lives are put.

Not a single casualty in this war is deserved.

 

Feeling Dull and Disillusioned

I’ve been told before, “You’d be a better doctor if you weren’t so emotional about life.” I don’t consider myself a superbly emotional person in public, but yes, I am touched by stories. If you scan through this blog you will see that stories of compassion or triumph are dear to me.

I’ve always believed that as long as it does not affect the way I treat a patient, it will be okay.

But maybe not.

If I am touched by the mother who brings her teenage rheumatological daughter pink milk and a favourite blanket to hospital, then I am also affected by the injectable drug-user who shouts at me for drawing blood “incorrectly and from the wrong vein”. Or the patient who tells me to “hamba” (leave) when she sees me entering the room with a drip-set.

And if I am happy because of a compliment given (probably without second thought), then I will easily be saddened when the same doctor is rude because of something I presumably did wrong. Or the nurse who is in a bad mood and tells me I will “just have to do without a blood culture bottle.”

I begin to understand why doctors are disillusioned about their jobs. I begin to see why they choose to change careers. I begin to see why they feel unfulfilled.

Sometimes, “helping people” just isn’t enough. When other healthcare workers are rude, and when patients are moody, and your employer (in this case the State) does not look out for you, and working conditions are terrible… it’s difficult to remain positive.

I’m not even qualified yet, and I feel like this already. I used to promise myself I wouldn’t become dulled to this work, that I wouldn’t become one of those sad, dissatisfied doctors.

But I don’t know if that’s possible anymore.

TTT: Best Procrastination Sites

So for about five months I’ve been meme-ing along with The Broke and the Bookish on a weekly basis – and I had no idea there were so many book blogs out there.

This week, TBTB asks about the Top Ten Blogs or Sites we visit regularly that aren’t about books. I think I’m going to like this, because I will finally get to know a little more about the bloggers behind the TTTs.

Here are some of my favourites, in no particular order:

1. Terribly Cute - I am very broody. And since I am nowhere near ready for kids, I want puppies and kitties (or anything smaller than a fully grown human, actually). But living in student dorms means that’s not really a possibility either. This site is the next best thing – and it really is terribly cute! They update several times a day. One of my favourites:

2. Street Anatomy combines anatomy and pop culture, and it is simply amazing. Anatomy is so not my strong suit AT ALL, but I’ve become more and more intrigued with it after Forensic Pathology. Be warned that some of the artsy stuff can sometimes be a little graphic – it is anatomy, after all. The picture alongside is Parisian Pole Ka‘s work. Click the image for the original post.

3. Semester at Sea does not really need introduction, but if you’re new to this blog you can check out my post about it here. It’s awesome and I keep checking it out because I’m just fascinated I guess. Also, I was in their blog the other day!

4. The Underwear Drawer is a blog by Michelle Au, about whom I have written before too. She writes about medschool, becoming a doctor (she’s an anaesthesiologist now) and motherhood. Her medschool cartoons are absolutely wonderful. You should visit them here.

5. Youth Journalism International is an organisation really close to my heart. I still write for them occasionally, and I now also focus on an “ambassadorial” role. YJI is a non-profit journalism organisation. I joined them in 2008. They offer students all over the world the opportunity to write, and students have covered things like natural disasters and the revolutions in Egypt and Syria last year. If you want to know what the future of Journalism and our world’s leadership looks like, you should visit here.

 

6. The Oatmeal – I’m not even sure how to describe this site. Part cartoon, part sarcasm, part satire. It’s good and entertaining, but be warned that there is sometimes some use of crude language and allusions to violence. Some “safe” cartoons for sensitive viewers include 15 Things About Coffee, What Your Email Address Says About You and How to Pet a Kitty.  I must admit, finding non-PG stuff on there was a little difficult. But the three above should be enjoyable if you are an oatmeal-ish person.

7. Creating Motherhood – I definitely try to stay away from those mothering blogs… It’s not that I am judging, it’s just that it’s not really me at all. There are some exceptions, like Dresden here. She writes about her long struggle with IVF, looking after her gran who had Alzheimer’s disease and now recently has a guest-blogging theme called In Times Like These, about difficult financial times (I wrote a guest post too).

 

8. PostSecret should really not be new to readers of this blog. It’s full of secrets and creativity and it’s awesome. A new set of secrets is published every Sunday. Just visit it, you will love it. You should also check out this TEDtalk byFrank Warren, who started it all.

9. New England Journal of Medicine 200th Anniversary Site – Okay, I suck at the whole medical journal, critical appraisal thing. I really don’t get why people can’t just write in normal English, so I can understand all their wonderful studies. So I don’t exactly have a favourite journal or something like that. But NEJM has this amazing site for their 200 year celebrations, and part of it has a great medical timeline as well as a library of classic clinical images that every physician should know. Yes, I guess I’m a nerd at heart.

Guess what happened here?
Click the image to be taken to the article.

10. Calcutta Kids is a NPO community health program in Kolkata, India – where I hope to do my elective soon. They’ve just launched their new website. They have done some amazing things, especially when it comes to reducing low birth weight and treating/preventing diarrhoeal disease. They also have a blog. This post about helping a little boy who was malnourished should give you an idea of the work they do.

The Day I Cried in Hospital

Yesterday was a bad day.

It’s been a bad couple of weeks, emotionally; me being weaker than I ever thought I could be. I’ve been able to retain my composure mostly.

However, during ward rounds our consultant looked up disinterestedly while I was presenting a rather interesting patient and said, “Today is your last day, isn’t it? So why is it that you can’t calculate the feeds of these children?”

© Jill Greenberg, “End Times”

At the beginning of our rotation my partner and I had asked the sixth years to teach us the formulae for feeds. They tried kind of half-heartedly and told us that it wasn’t part of our outcomes. The registrar  agreed.

So I responded, not in a sarcastic tone, “I’m sorry – I was under the impression it was only part of the sixth-year outcomes.”

And she responded, “I’m sorry, how old are you?”

She then went on a tirade of how even if it wasn’t in our outcomes we should have learned it. Her tirade consisted mostly of personal insults.

We committed to reading it up and moved on to my next patient. And then my eyes started tearing. And my voice got all husky.

“Sorryitsbeenareallybadday canipleasejustgocalmmyself”

And out I went. In tears. They were big violent sobs.

It was kind of embarrassing. I don’t let people who don’t know me get me down. I’ve never cried in a clinical setup, not even when a patient died. I wait for the privacy and security of my room.

I don’t know why this affected me so much. I guess it doesn’t help that for the past two weeks, we have been mainly ignored by the rest of the team. Our (valid) questions go unanswered. Our input into difficult diagnoses is ignored. We had three OSCEs today, and not once were we told what to expect. Not once were we tutored in anything except breastfeeding and X-rays.

So after really going the extra mile for a team that seemed to be inconvenienced by our presence, I guess I didn’t feel they reserved the right to scold us for not sniffing that we were expected to know something.

I managed to calm myself down, but every time somebody made eye-contact with me the hot tears welled up. I have cramps in my jaw today from clenching my teeth so much.

It didn’t get better after hospital. I was teary for the rest of the day.

It was weird for me. I don’t cry a lot. Ever.

Consultants are mean, and often. I don’t mind being grilled for answers. I find it thrilling, actually. But personal insults in a professional environment are just so… unprofessional. Here’s hoping I’m stronger next time.

Pouring My Heart Out About Birthing Plans

I’m not going to whine today. I’m not even going to be diplomatic.

Because I’m annoyed.

Because I believe in the rights of the patient, and because I love obstetrics and neonatology I’ve been reading a lot of blogs where women share their birth stories.

And a lot of them write about how they felt cheated out of a normal vertex delivery. Because their labour didn’t progress. Because the CTG showed decelerations. And so the doctor rushed them to theatre, and delivered their baby in one piece, and saved Mommy and Baby’s life.

And that makes Doctor horrible. For saving two lives.

I believe in listening to a patient’s wishes. I believe in trying as much as possible to stick to a mother’s birthing plan. But I also believe in saving lives. And I will not stick to someone’s birthing plan if it will cost their life, or impede in any way upon their or their unborn child’s livelihood.

Dear mothers, if you do not like your doctor’s opinion, get a second opinion. If a doctor saves your life, or gives you a live healthy baby, try to see the bright side. It’s not that difficult.

Women and their babies DIE daily in developing countries because they don’t have access to theaters and C-sections or even the knowledge that a section is required.

If a doctor ignores your wishes without good reason, if he is a paternalistic arse, find another doctor.

Just know that had something gone wrong, you would have blamed the doctor, and would quite likely have good reason. So be grateful for your happy bouncy baby child. Please.

The Unhappy Doctor

My presence in the medical community has not been lengthy, but I’ve noticed one thing: A lot of doctors are terminally unhappy. I know they think we don’t notice their scowl, their rush to get out of the hospital, their snide comments when the patient is finally subdued by the anaesthetic.

I see it. I see the way their shoulders sag and the way they hate talking about news regarding medical science. I see how rude they are to each other, to their nurses, to their students and even to their patients. And it means one thing: They are miserable.

Medscape’s Mark Crane recently revealed a study where it was found that doctors are miserable. Only 54% would choose medicine as a career if they could go back in time. It’s an American study, but I’m willing to bet that South African doctors would have similar results. Perhaps even more so.

Anycase, much of the cited reasons for the disgruntlement relates to finances. Doctors don’t “feel rich”, they earn a substantial salary but also have substantial debts to repay.

I hope that this reason will disappear off the radar soon. There is a perception that doctors are rich. Firstly, I’m really not sure that one should enter a field to get rich. But secondly, those days are long gone. Patients are poor. The economy sucks. Managed healthcare and medical aids are sucking the life out of healthcare professionals.

To prospective medical students: If you want to get rich, this is not for you. Medical school is one of the most expensive fields of study imaginable. It’s long, it’s painful, it’s expensive. If you want to get rich, you need to go into the stock markets, into business, into innovation. Not that you should do that to get rich, either…

Another reason is time lost on administration.

This is a sad but true reason. Life requires paperwork. Lack of paper trails are the reason doctors have managed to give the wrong patient the wrong medication. Anywhere you go, there will be paperwork. I guess here we have to grow up and learn to deal. Or get an assistant (note, “intern” should not be synonymous with “paperwork scutmonkey”!).

But again, I’m going to be a little bitter about medical aid schemes here. The amount of paperwork they require and the amount of telephone-time they want is ridiculous. And they truly leach our patients of their money.

I had to make the decision to study medicine at the tender age of 18.

It’s a harsh fact that many of us decide to go into this field when we barely know ourselves. It scares me. I have so many other passions, and yes, sometimes I wake up and I dread going to the hospital. I don’t want to be a miserable doctor. But life sucks for some people, and we don’t always get to save the world like we dreamed to do.

Are you happy in your job (even if it’s not in healthcare)?

How do you maintain job satisfaction?

Can A Pill A Day Prevent HIV?

As medical students, the threat of needle-stick injuries and the subsequent use of Post-Exposure Prophylaxis (PEP) is a constant looming presence. Side-effects are sucky, viral resistance is sucky, HIV is sucky.

I don’t know how I missed it, but apparently there have been some significant trials for pre-exposure prophylaxis (PrEP). The article I found can be read here, and the original paper published in the NEJM is available on Google Scholar.

 

What it comes down to is that the trials were done with cohorts of men who have sex with men and/or transgender women who have sex with men. They were given Truvada, which is a combination ARV of Emtricitabine and Tenofovir. These are both Nucleoside Reverse Transcriptase Inhibitors and they basically inhibit replication of the HI-virus.

The study basically found that PrEP lead to a significant reduction in HIV-contraction. Which is awesome.

But what I want to know, is how does that work, physiologically? If NRTIs prevent viral replication, how can it be considered to be true PrEP? Truvada is often given as PEP. So, perhaps, it’s still just PEP, given before the risky event occurs. But doesn’t this kind of continuous ARV administration bring about a risk for resistance if the person does acquire HIV?

There are some costs attached to PrEP, as with any drug. Which makes it quite likely that the rich will be able to afford it and the poor… will have to stick with condoms.

I want to know about side effects: Truvada has them. Lots of them. But different people react differently to them, as with any drug. Would this be a viable option for medical professionals? Would it be worth it, for medical professionals?

And why on Earth did I only hear about this now?

As always, I’d love to know your thoughts on this – whether you are gobsmacked with me, or you actually have answers to my confusion.

Conjoined Twins: When Surgery Inspires

After not watching series all year, I picked up on Grey’s Anatomy again. Yes, I watch Grey’s. In fact, I enjoy it. So sue me.

ANYWAY, season 8 episode 11, “This Magic Moment” was about a once-in-a-lifetime surgery performed to separate conjoined twins (Andy and Brandy).

It reminded me of a time when I had just started reading (I was about five or six) and I read an article about conjoined twins in one of our local magazines. These girls were not in the position to be separated, as they shared a body and some organs. As a little girl, I was a little horrified. Their story also inspired me. Their attitude was remarkable. It is a pity I cannot remember who these twins were.

They were a lot like Abby and Brittany in this video:

A lot can be done for conjoined twins these days. I would guess that some of them are also aborted. Conjoined twins separated in Madagascar passed away about a week ago. Madagascar hospitals do not quite have the resources of more advanced countries. And anything can go wrong.

I saw this video of the Garrison twins who were successfully separated (DiscoveryTV wouldn’t let me embed it, boo). They were intriguing also because they have one healthy triplet. They were not as lucky as the twins in Grey’s, as they each ended up with only one leg. But they are flourishing today, as you will see if you Google them.

One can wonder what they would have chosen had they grown up conjoined. Perhaps they would not want their lives any different, perhaps they would. I am not in the position to guess.

But I was reminded why surgery can inspire me. I may hate cutting open an abdomen and poking around in guts, but this – this is life-changing, wonderful work.

 

Thyroid Thursday and Crazy Trainees

Ah, the life of a training pharmacist: I have now been taking Eltroxin for one month and three weeks. The last time I had to fetch my repeat, I had the bad luck of walking into a pharmacy where the pharmacist had gone to lunch and left the place in control of his trainees.

At first I thought they were just spinning a little – a little overwhelmed.

But then I heard someone exclaim:

Trainee 1: “But we don’t have Eltroxin 50mg!”

Trainee 2: “So just make her take more than one tab a day!”

I got a bit of a fright and waved them over – and resisted the urge to ask if they were trying to kill me. (Because I know that mistakes are easy to make.)

The script says 50 MICROgrams, not miligrams.

Doctors: Guardians of Human Rights

Today is Human Rights Day in South Africa, in memory of the Sharpeville Massacre and the many other human rights violations in this country’s history.

The Truth and Reconciliation Committee reported that “[h]ealth practitioners [...] have a unique responsibility in society, as healers, to understand and alleviate causes of human suffering, and to promote health.” This being the larger, holistic sense of health.

It is true that doctors made themselves guilty of human rights violations during Apartheid, although not always implicitly so. It seems that bureaucracy did it for them: doctors would see only white patients (in great facilities) or only black patients (in shoddy facilities) not by their own doing, but because those were the facilities patients were admitted to.

There were, of course, those doctors who had more concrete roles, such as those who certified that the deaths of many political prisoners (such as Steve Biko) were of “natural” causes.

It is easy to say that ethics should have prevented them from such action. It is easy to say that doctors should have stood up against such atrocities. I would love to make that claim.

But when I think logically I know that the matter is not so simple. The kind of duress placed upon free speech was widespread and affected white South Africans too. There were those who didn’t know what was going on, and those who were also became painfully aware it was to silence them.

Here is hoping that doctors today can and will make their voices heard, not only in South Africa but the world over. We have long had the image as leaders of the community – let’s embrace it rather than shun it.