Snow White’s X-Ray Phenomena

Radiology tutorials make me sleepy. I don’t find them boring, strangely… they just send me straight into narcoleptic episodes. But this one was fun:

Basically, neonatal X-rays (yes, they do periodically expose those little things to X-rays) can be divided into different presentations.

Grainy, Streaky, Blacky, Fluffy, Hazy, Bubbly and Dotty. And of course, Snow White.

 
Grainy and Hazy chest X-rays are characteristic of Hyaline Membrane Disease, which is caused by surfactant deficiency in the newborn. This leads to low lung volume and is quite common in premature infants. It’s often described as a ground-glass picture.

The consultant didn’t really elaborate on Fluffy and Dotty, so if you know them be sure to introduce me.

 

Streaky chest X-rays are associated with Transient Tachypnoea of the Newborn. Unlike HMD, TTN is more common in term infants without labour complications. The disease is said to be mostly self-limiting. These X-rays are said to resemble “streaks”, usually with a very prominent illustration of the transverse fissure of the right lung. TTN is also sometimes referred to as a “wet lung”.

 

Blacky is just that: a very black lung, indicative of a pneumothorax.

Bubbly is my favourite because he displays exactly like you would expect: bubbly. Unlike Grainy and Streaky and Hazy which really might as well be the same damn thing. Bubbly is caused by a diaphragmatic hernia – not fun, but easy to recognize.

And Snow White? Generally an under-exposed X-ray, that looks snowed-under and all white.

Obviously I can’t walk into an exam and say, oh this is Bubbly and blah-blah. One must actually be able to know the clinical relevance. But that’s not asking too much for a doctor and this remains a fun way of making the learning process easier.

Med Students Do Crazy Student Things Too

Earlier this week I saw this fun experience occurring right before my eyes. And for once I had a camera on hand and snapped away shamelessly:

There were three kids from my campus who were collecting some boxes and things (for what I don’t know). Problem one was that for everything to fit, only two of them could sit in the car. The other problem was that everything couldn’t fit- they needed the roof. But they didn’t have rope to tie it.

So they made a plan. Without a helmet. I hope they didn’t get a fine, because considering I haven’t heard of an accident I assume they arrived at their destination safely. Perhaps their destination was somewhere on campus.

Anyway, I laughed.

Cool Medical Students of History: Paul Langerhans

This is a Langerhans cell. Langerhans cells are dendritic cells found in the epidermis (that is, the uppermost layer of the skin) and should not be confused with the Islets of Langerhans found in the Pancreas – and incidentally named after the same person. Langerhans cells are antigen-presenting cells – in other words, they form part of the body’s protection against antigens, and present these to the immune system.

 

This is Paul Langerhans. He discovered Langerhans cells at the tender age of 21 (that’s younger than I am now). He did mistakenly believe they were part of the nervous system due to their dendritic appearance – but whatever. It was not long thereafter that he wrote a paper on the anatomy of the pancreas and referred especially to the Islets of Langerhans, which we all know and love.

Upon further reading up, I found rather disappointingly that Langerhans did not really have any ideas what either of these structures did, just that they existed. That’s less remarkable… and somehow I doubt that these days anyone will be so acclaimed for similar discoveries.

But again… he did make a fairly cool discovery at a young age. I suppose maybe those days you weren’t considered a dimwit or a baby at 21. Also, life expectancy was considerably lower those years, and Langerhans went on to develop Tuberculosis and eventually die at age 41.

Ode to a Great GP

Med School is tough. It makes you feel like an idiot. The consultants don’t help much. They seem to forget that we are here to learn first, and only later to be examined.

So for Family Medicine, I expected to be supervised by a specialist family physician. Instead, we were one of the few groups working with a general practitioner. And from now on, you can give me a GP like him any day.

This doctor was so eager to teach. When I told him I had never done a lumbar puncture, he said, “That’s okay, I’ll walk you through it.” He definitely chucked me into the deep end very often, but he made sure that I managed to swim.

We made stupid mistakes often, and answered his questions incorrectly, and he smiled and corrected us.

When we did something without being asked, he praised us.

It was amazing. And did we walk all over him, like doctors appear to think will happen if they show a modicum of humanity?

Nope.

The best part ever?

The doctor called us a bunch of over-achievers. This was by far the funniest, and most heart-warming thing for two average medical students.

First Psych Consult

At a recent community volunteer clinic, I had my first proper psych patient. I have dealt before with suicide attempts, but those were unconscious patients in casualty and thus did not present the opportunity for a consultation.

This patient came for help herself – something I though was a good sign. Her affect was blunted and she was clearly depressed. There was a positive history too.

Nevertheless, I initially assessed her as low-risk. She wanted a referral to a psychiatrist and I was happy to give it to her.

Realising that I have not yet done a practical psychiatry rotation, I asked a senior student for a consult. Good thing too. He assessed her as high-risk. I had forgotten to ask about death ideation and suicidal ideation.

Things I learnt?

1. Know when you don’t know;

2. Brush up on psych;

3. There is a reason they make us study for centuries.

Matryoshka (disambiguation)

Medical Students quickly become desensitised. It is a coping mechanism and it works well – not the least because it makes us laugh. Nevertheless, it’s no wonder people think we are weird.

Case in point:

Clinical Partner and I discuss our feelings on autopsies.

He says,

“Wow… doing that autopsy on the pregnant woman was like having one of those Russian dolls”.

To do or not to do

On our campus there is a fair amount of animosity between those who are involved in non-academic activities (such as community interaction and student government) and those who are not.

Those who are involved feel that the others miss out on personal growth and, quite frankly, are doing humanity a disservice.

“The others” feel that they are at university to study, and that that is what they will do.

If you know me, you know that I am annoyed by individuals who refuse to get involved.

But every once in a while, I imagine something horrible. What if you start enjoying your extra-curriculars more than your course? In a course such as this, where it is so extremely important that you enjoy your work, if you wish to survive the long hours and the difficult patients?

What if your hobby, instead, becomes your passion?

Med School: The Reaping

They supposedly do this thing at the beginning of medical school:

Look to your left, look to your right. Only one of you will graduate in the allotted time.

I don’t remember them doing it for our class, three years ago. I used to think it was because they were committed to getting us all to the end of med school in one piece.

Nowadays, I think I may just have bunked that lecture. Or fallen asleep during it.

Of my original clinical group, only two of us remain. One person may not even be in my year anymore, soon.

I have seen brilliant medical students not only fail, but get excluded from their course. These are students whose notes I have used to study for exams. These are people who taught me to draw blood or put up an IV or resuscitate a patient.

I understand that medicine is a tough field. I understand that doctors hold the lives (and livelihoods) of their patients in their hands. But I have to wonder if we are assessing whether one is a “good doctor” correctly – if people like me get to stay, and people like them have to leave.

This is South Africa. We cannot afford rotten doctors. But nor can we afford to produce so terribly few doctors.

I am seeing some of the best doctors being removed from this profession before they are even part of it. And there is nothing I can do about it.

“Interviewing” our Forensic Pathologist

The Forensic Pathologist in charge of our clinical group these past two weeks was one of the best doctors that has worked with us.

She gave us confidence and got us to such a point that we were willing to ask questions.

We asked her why she decided to go into this field, and she said that it is always intellectually stimulating and that the hours are, for the most part, conducive to a good family and social life.

She says that she also loves paediatrics, but the periods on call are inhumane, and easily squashes the most passionate paediatrician.

We asked her if she misses patient contact, and she admitted that she does – but that there are also many things she doesn’t miss.

We also asked her if she eats meat: she does.

I have rarely met a doctor who manages to cause such enthusiasm in a group of tired medical students.

She realised soon enough that our knowledge of anatomy was poor, but instead of making us out as lazy, she went out of her way to give us a crash-course.

On Friday, our last day of the rotation, she ensured us that we would always be welcome to approach her with questions, even one day if we are family physicians in rural areas (where GPs perform autopsies).

I may actually be interested in this specialisation now. There are still many years to decide, and many matters to consider, but I am so thankful for her enthusiasm.

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.