Another Kind of Worm

During a tutorial this past week, the consulting doctor told us that the patient had a “drain worm”. Unfortunately the patient was present and awake, and his face turned an impressive shade of green. Our faces paled too, I’m sure.

The doctor rushed to assure the patient that it was not an actual squirmy-wormy, but a long strand of fibrin that often forms along the course of the ICD-pipe. It has the potential of clogging the pipe completely and leading to a tension pneumothorax, hence the relevance.

Regardless of it not being a “real” worm, this grossed me out more than the average medical phenomenon. Here’s hoping I never need an ICD of my own, because I would probably try to clean it compulsively.

 

In case you were wondering, you do get cases of REAL drain worms… in cases of severe Ascaris Lumbricoidis infection. Click the image for the full article.Hope I didn’t ruin your appetite or anything…

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.

 

Surgery in the Wild

So, here is a little secret about my horrible little third year surgery experience: I never got to assist. I never got to cut. I never got to stitch. I think it was a combination of me having a poor attitude, me being too scared to ask, and the registrar being an arse.

BUT my time in the rural Western Cape – with a superb supervising doctor – had me practising sutures and assisting in surgeries – it was awesome!

I think I could actually like surgery if it weren’t for the surgeons.

Yesterday I assisted in a female sterilisation. The fallopian tube really looks like a little flower…

But by far the coolese thing about that surgery was seeing subcutaneous sutures for the first time! The lady will have minimal scarring, and she didn’t even need a plastic surgeon. One day, I’ll do these like a pro!

Note: The downside to these sutures is that they are uninterupted. That means that if a patient should develop some wound-related complication, you have to undo all stitches to explore, rather than first exploring by only undoing one or two stitches. And they’re a little more difficult than interrupted sutures. Less tying though!

Male Medical Circumcision in Rural South Africa

Last year, I wrote about traditional circumcision and the dangers thereof.

The government has started an MMC-drive. MMC = Male Medical Circumcision. Non-traditional circumcision has its own benefits such as HIV-prevention, STI-prevention and apparently hygienic benefits too.

The goal is also to have traditional circumcisions performed in hospital, where health care workers are trained in the procedure and where infection control is better managed. It will take a while to achieve this in Africa, because having the procedure done in the hospital is often viewed as being “unmanly”.

Yesterday, the clinic in the rural town where I am now did an MMC-outreach. Initially we were only supposed to observe, but our supervisor decided we could assist. Which was totally super cool! I feel so much more confident with sutures and blades now.

I have to say, the patients were remarkably calm for the type of surgery they were going through… and it is done using only local anaesthesia. Brave, brave people.

You may recall that I hated surgery last year. Mayhaps it was just because we weren’t taught so eagerly.

Lost in Translation

It's apparently an iPhone game. I just like the font.

Little Brother (still) says the darndest things.

A while ago I posted the following as a status:

Practising Derms surgery on pig. Yummy!

But in my home language, “derms” means “guts”.

So, Little Brother tells The Family that Big Sister is removing pork gut for med school. Nomnomnom indeed!

The funniest thing is that a few hours later, one of my non-medical friends, ten years Little Brother’s senior, made the same mistake.

And people ask me why I love my country’s many languages…

Oink - look at the face!

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.

Treat Aggressive things Aggressively

I think we have established that I do not enjoy surgery very much. SolitaryDiner says that as a doctor you either lover surgery or you hate it – I can understand that.

But despite my dislike of the insinuation that the scalpel should become a replacement for the rod of Asclepius, I believe people must think rationally about surgery. There is a good place for surgery – and here I embark on the Steve Jobs train before it leaves:

I read recently that Jobs put off surgery for his cancer for at least nine months. It is now postulated that those nine months may well have cost him his life. Pancreatic cancer is an aggressive and deadly cancer and I have seen devastating cases thereof the past month. You are very lucky if it has been detected at a resectable stage.

My belief? Treat aggressive things aggressively.

I’m not a doctor (yet). And I by no means have the right to judge Jobs’ decision without knowing his reasoning behind it.

Nevertheless.

Several years ago, an aunt of mine was diagnosed with an intraocular cancer. Her ophthalmologist and oncologist felt that they could save the eye’s vision and opted for radiation. Suffice to say the ophthalmologist who treats my father did not agree. He warned that the eye should have been removed immediately. At the end of the radiation all she could see with that eye was dark and light.

In 2007 she woke up sick one morning. A single trip to the doctor revealed that her cancer was back. This time it was everywhere – stomach, bone, liver. She died less than two weeks later.

My uncle never recovered losing his wife. He committed suicide last year.

Incidentally a family friend was recently diagnosed with the same cancer. Her doctors removed her eye immediately. She is still doing well.

A friend of mine has an older brother who was born with malignant melanoma. At the time, he was one of the few such babies who would survive – due to an aggressive approach. More than two decades later, he is still alive and kicking.

Sometimes there are too many contraindications for surgery. That I understand.

But doctors must learn to look after all their patient’s needs. And patients must make educated decisions.

Great Frustrations: Patients who do not take Responsibility

The thing that bothers me the most is when patients allow a disease to progress so far that almost nothing can be done – especially when something could perhaps have been done.

My surgery rotation has had numerous such cases.

Once, during a night-time call, the most horrible, moist stench filled the entire corridor of the casualty ward. The cause was a patient with anal carcinoma… so advanced that he had a 10x6cm lesion where his anus should have been. It had completely destroyed much of the muscle and all of the sphincter.

This image is the closest I could get on Google, but it is not nearly close enough:

http://www.gastrohep.com/images_pdfs/images/medium/mallison35.jpg

The link is safe, but the picture is a bit graphic for sensitive readers.

Two days later a lady entered the ward with the worst venous ulcers I have ever seen (not that I have seen terribly many). I could see one of the metatarsals of her right foot. She was in so much pain, but that she had waited til now to seek help goes beyond my understanding.

The thing about the Western Cape is that the Department of Health here has gone through a lot of effort to ensure that there is a community health clinic walking distance from any settlement in the province.

So as much sympathy as I have for these patients, I simply do not think they have a valid excuse.

Another Day in the Frontal Lobe

Did I ever tell you that a single book gave me the push I needed to accept my spot at Med School? The book in question was called 28 Stories of AIDS in Africa, but this is not about that book.

In previous years, books were like my daily bread and water. With the workload and activities of university I seem to have been starving for almost three years. I read the odd book, but struggle to find a book that will touch me without instantly sending me into a downward spiral of depression.

During a rare gem of a three week holiday, Ouma and I went on a little excursion to the library. Here’s what I found:

Another Day in the Frontal Lobe by Katrina S. Firlik, non-fiction

Firlik is a Neurosurgeon in the USA. She writes with wit and insight about the road that brought her there: from the decision to be Pre-Med, to Med School, through seven years of residency.

She avoids the various pitfalls of medical biographies:

She does not jump up and down cheering her team on as the one and only.

She does not impress upon the reader that her job is the worst or most difficult.

She does not focus overtly on research or her work in the field.

The writing is unapologetic and honest. As a medical student (albeit in a different country) the autobiography cleared up many doubts in my mind helped me to alter my way of thinking about medicine a little. It was enlightening.

It is also perfectly suitable to the layperson though. I found myself reading entire excerpts to my parents and they thoroughly enjoyed it. When Firlik touches upon medical subject matter, she is sure to make it clear enough for those without a medical background.

I would also strongly suggest Another Day in the Frontal Lobe to anyone who enjoys reading about women making it in the professional world.

A mention must be made that the author impresses her view regarding religion once or twice. She is by no means degrading, but religious readers should be able to read past it and still hold on to the story.

If you have an expanding blood clot in your head, you want a skilled brain mechanic, and preferably a swift one. You don’t care if your surgeon published a paper in Science or Nature.

Firlik, Another Day in the Frontal Lobe

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.