Skills

We are discussing a PBL case with one of the GPs, when he begins a little speech: There are a lot of skills, peripheral to your examination skills and your history taking skills, that are really good to work on. And here at this clinic and this hospital, you will have more opportunities than your city colleagues to work on these skills.


Whatever it is, I’m sold. I must work on these skills.

One of these skills is changing colostomy bags.


I look up. As far as I can tell, he is serious. I recall that we have a patient in the hospital who is seeing the stoma nurse next week to learn all about his colostomy bag. How fortunate!

Sandwich

“You can only have one roll each, otherwise there won’t be enough”. We’re not used to these restrictions here, and I’m pretty hungry, but I acknowledge that it will probably be enough. I select my roll, and I make a good choice – chicken and lettuce, plenty of butter on the roll and generous with the pepper. I am impressed with the first bite and go back for another but there, millimetres from my previous toothmark ... is a fuzzy little caterpillar. The poor little thing must have feared for his life for a moment there. I show my coordinator, and she flicks the poor caterpillar into the bin and attempts to confiscate my sandwich. No thank you very much - with the very hungry caterpillar out of the way, that sandwich is all mine. Om nom nom.

Gastroenterologist

We had a session with a Gastroenterologist for one of our study days. He sure was a good teacher. What did I learn?

Gastroenterologists are not like most surgeons. In contrast to the “If in doubt, take it out” mantra, the gastroenterologist declared, “If it’s in a bucket you can’t put it back”.

Gastroenterologists are not haematologists: “This is a bone marrow. Who knows about bone marrow? I don’t”

Gastroenterologists can be generous: “Everyone deserves an ultrasound”

Gastroenterologists can also lose their train of thought: “Now where was I leading? Heh heh.”

And they can be a little strange. Student: “Do you just have naked large lady on there?” Gastroenterologist: “Yeah, I’m a bit like that”

Small Pleasures

• Suturing
• Early minutes
• Cups of tea
• Finishing assignments
• Long weekends
• Real mail
• Hugs
• Sunshine
• Sitting with my dog
• Playing on a playground
  
• Classmates getting excited about my shoes
• Correctly answering a specialist’s question
• Sleeping in
• Successfully cannulating a patient
• Patients who refuse to see students (= coffee break)
• Old ladies complimenting my hair
• Patients who make jokes
• Doctors who make funny jokes
• Discovering that people read this blog
• Hearing that some people actually like this blog
• Eating chocolate like it's actual food
  
• Getting dressed up
• Or putting on my pyjamas as soon as I get home
• Hearing from faraway classmates (they’re all far away)
• Going home to see the family
  
• Eating someone else’s cooking

Sometimes, I'm easily pleased.

My Old Lady

“I’ll let you see this lady. She’s pretty much a ... I’ll let you decide what she’s like” – and with that the doctor is gone, leaving me to see his 9am patient. It quickly becomes clear that she’s a lot of work. I’ve been in hospital, I’m better now, they’ve changed my medications, no I don’t need a script, I’m 87 you know, I’m meant to see a specialist what’s his name, no I already have a referral, and an appointment, look at these hands, no can’t you see that one’s weaker, I’m left-handed you know and I write with a special pen, oh, what am I here for? My leg’s red.

So I look at her leg. She’s had an ulcer for about a week but it’s going well, I’m just worried that the redness is cellulitis. She’s quite happy to scratch at it with her long yellow fingernails, but I ask if it’s painful all the same. Look at me! she exclaims, pointing to her (tear-free) eyes. But is it sore there, on the red bit? Oh, no, just the ulcer. The doctor agrees that it’s probably red from scratching and she should use a cream, but wants me to prescribe antibiotics just in case.

What is she allergic to? Oh, lots of things, I have a whole list but I left it at home, I can hardly take any medications, how could I remember what happens, it’s years ago, I’m 87 you know. I look up her recent prescriptions – they are many and varied, so we take a chance with Cephalexin.

She needs an ankle-brachial index done. I ask if she’s ever had her blood pressure taken on her leg? No. Ultrasound of her leg veins? No. Doppler, that sound familiar? No, none of that. I look up her notes. She’s had three colour dopplers on her left leg, but now we need to check her right. The nurse gives me a warning look when I request it, “she probably won’t let me!” But we have to try. As the nurse slips the sphygmo cuff around her ankle and begins to pump it up, my patient begins to howl. This old lady must hate me by now.

I have been despairing over this lady for almost an hour, and I must be getting a little terse. She doesn’t really like doctors and nobody likes medical students, so she must be eager to be rid of me.

But as I stand to usher her out the door she smiles and says, “when that nurse was pumping up that cuff on my leg I could feel my boobs getting bigger!” I suggest that maybe she should wear pressure stockings just for that reason, and she breaks into a hacking laugh and pats me on the arm before toddling out the door.

That 30 seconds was the best part of the consultation.

I'm glad she saved it for last.

The Hand

He’s doing a silly little job at work, nothing difficult, nothing laborious, just putting up an antenna for the break-room television. The drill bit slips and attacks his hand, drilling a hole in the webbing between his thumb and forefinger, angling down towards the wrist. His mates take him straight to the medical clinic - it's an emergency - but the nurses only glance briefly at his hand before sitting him down on a bed to await the doctor. Screaming children are given injections, old ladies’ leg ulcers are dressed, and he sits there bleeding. He probably wonders why he’s left to wait.

Finally some girl comes and introduces herself as the medical student. She quickly inspects his wound, asks him to wiggle his thumb around despite his pain, and starts drawing up injections. She looks him in the eye and tells him the local anaesthetic will hurt. He flirts a little, realises it isn’t helping, and sits back and grits his teeth. When his wound is properly numbed he watches, fascinated, as it is first rinsed and then scrubbed with antiseptic. He dabs at the blood running down his wrist.

Like many of the local patients, he asks whether she’s going to be a doctor or a nurse, and seems fairly impressed when he discovers that she will one day be a doctor. He is quite proud of himself when she puzzles over how best to suture his complicated-looking wound. And then the actual doctor arrives with instructions, “you’ll want to put one suture from the outside part here, to this part, and then ... actually I’ll do this one, you watch”.

He is much relieved.

Quoteblog #5

These are all courtesy of the pain management / musculoskeletal doctor who gave us a whole-day tutorial yesterday. Whole day tutorial, and it didn't even get boring!

“Students like food, pens, and testing reflexes”



“Every OSCE I mark, you get 10% for being a human being. That means you only have to get 40 out of 90 to pass”



“You don’t expose, you fail”



“All you get from stroking the insides of a patient’s thighs is trouble”



“And I don’t give a stuff about her breathing of course, unless she stops and then it just gets messy”



Neck exam on student:
“Ooh that feels nice” – student
“You’re not supposed to say that to your teacher!” – Lecturer, then, “Why don’t you come lie down”
“You’re not supposed to say that to your students!” – other student
“Face down please” – Lecturer



“A Trendelenburg gait looks like a constipated swan”



And one from dinner: “You’re asking orthopaedic surgeons to walk and chew gum at the same time?”

Red Herring

A patient comes in with chest pain.
"Have you had any paracetamol?" asks the nurse
"No, I took some Herring" patient

Bad Doctor

In my humble opinion, all of the doctors who I’ve worked with here are exceptional. Not every patient will like every doctor, but that’s to be expected, and most people can find a doctor that they really like. It kind of increases my confidence in the medical profession to hear how highly some patients regard their chosen doctor.

So it’s disappointing to hear about people’s bad experiences with doctors. Take my friend in the city, a gorgeous girl in her early 20s, who was sent home from work with a bad cold. She went to see a GP in her suburb, and the consult went something like this:

Young male doctor: “So when was your last PAP smear?” My friend sheepishly admitted that she’d never had one, and he offered to do one that day. (Note: most of the doctors here will offer to book a later appointment for this procedure, and the male doctors will give the patient the option of seeing a female doctor. And they never begin a consult like this). My friend was a little shocked, and firmly declined this procedure. After that he decided to finally ask, “so what brings you in here today?” My friend informed him that she felt unwell with a headache and a sore throat.

His next question? Try and guess from the choices below:

a) How long have you felt unwell?
b) Is it getting any better or worse?
c) Have you tried anything for it?
d) Are you sexually active?
e) What's your favourite colour?

You probably think I threw in the last couple for a laugh, but no, this doctor chose option D. My friend says that during the consultation, the doctor asked her a total of seven questions relating to sexual activity, when all she had was a sore throat and a cold.

He ended up prescribing her antibiotics, but as he handed over the script he told her, “I wouldn’t be in a hurry to start taking this – you’ll probably just get thrush”.

She called me a few days later to tell me about it, and then asked if I thought it was weird, from a medical student's point of view. I think it would be weird from anybody's point of view.

It's All Relative

I'm chatting with a friend online on a Sunday afternoon.

He's had the week off. I had last weekend off, but I had a big assignment due so I used it to study.

He spent his Saturday at a football match with a friend. I spent 10 hours at the hospital.

He slept in this morning and is wondering what to do for the rest of the day. I snoozed my alarm once and then went in for ward round, and I'm hoping not to be called back in this afternoon.

When I tell him that I only spent three hours at the hospital this morning, he replies, "oh. Easy morning then".

Yeah, sure.

Concussion

A family brings their teenage son in with “delayed concussion” from football on a Saturday afternoon. The younger brothers and sisters, Mum and Dad are all crowded around, anxious to help out in any way. I struggle with his history in so many ways. For starters, I’m a bit of a novice with head injuries at this stage. And then there’s the casualty nurse occasionally popping in to interject my question with a similar but wordier one before the patient can answer me. Not to mention the boy’s mother, who is worried about her son and tries to answer all the questions for him. And then there’s the boy himself, who obviously has amnesia and can’t remember anything of the game or afterwards. As we wait for the doctor to arrive, I ask him a few questions.

“Who did you play today?” I ask

“I can’t remember his name” announces the boy after lengthy deliberation

“Do you know where you played?” I ask, wanting to know which town the game was in

“It would have been the wing” – the boy hazards a guess at his usual position

Hard to say whether we would have this much trouble communicating without his head injury, or if he is trying to compensate for his amnesia, but it's pretty serious and the doctor doesn't waste much time before calling an ambulance to ship this boy off to a bigger hospital.

As we're waiting for the ambulance to arrive, the doctor sends me back into the room to assess the boy's lower limb reflexes. He has a lot of trouble with the instruction "just let your leg go loose", and we struggle for a while as he first lifts his leg straight up and then forces it down on the bed, but eventually I manage to bend his knee for a patellar tendon reflex. Everything is normal until we get to the Babinski. I turn the tendon hammer around and use the scratchy end on the sole of his foot. As his left big toe curls upwards his girlfriend, who has just arrived, mumbles, "that's so weird". She has no idea.

Viral Infection

We had to give a PowerPoint presentation a couple of weeks ago on a selected cardio topic. I chose 'cardiomyopathies', and although I was nervous about presenting in front of the big-shot cardiologist, I think I went OK. But I was shocked and dismayed when I took my flash drive back to my computer afterwards and was rewarded with the following message:

The shock came mostly from the fact that SOMEBODY ELSE had given me a virus/worm. I am normally quite capable of destroying my own electronics without any outside assistance. In fact, once I managed to shut down the entire university intranet while I was living on campus. Don’t believe me? No, you know me too well. It was twice. Twice, I single-handedly shut down the university intranet by inadvertently picking up a virus in my travels. I was banned from connecting for quite some time, and I had to study using books, just like the olden days.

I have since learned all about anti-virus programs, so don’t worry – I’m pretty sure this one’s no longer contagious.

She Was Mine

There aren’t many patients in the hospital, but they are all demanding our attention this morning. Ward round is disjointed, and the doctor sends me to assess patients and report back just so we can get them all seen. There are patients coming in and patients being shipped out – the one pair of ambulance officers seems to be constantly marching our halls.

An obese woman presents to casualty with 9/10 retrosternal chest pain. She came last night and was given antacid and sent home, but the pain has returned and now nothing is helping. The doctor is busy, very busy, so the patient is mine. I take her history and discover that, but for the fact that she’s never had heart problems before, she has EVERY SINGLE RISK FACTOR ON THE PLANET for a heart attack. Diabetes, hypertension, hypercholesterolaemia, obesity, family history, and of course she’s a smoker. Still I’m not sure – she has a long history of gastro-oesophageal reflux, and she says her pain is alleviated by sitting up and (eeew) burping, so maybe it’s the same old thing?

I ask the doctor what to do but he is still very busy, and he tells me to do the full workup and then come back. So I examine her and find nothing remarkable, place the most beautiful cannula (I'm so proud) and take some bloods, and do an ECG. Her troponins come back borderline, but the ECG shows ST elevation in the posterior leads. The doctor sees this and suddenly she’s not my patient anymore, she’s Priority 1, she gets morphine and maxalon and clexane and she’s sent away with the Flying Doctors to the city.

But for that brief moment, she was mine.

More or less anaesthetics

I have a “Pain and Anaesthetics” tutorial scheduled, which sounds pretty serious, but my classmate assures me that it’s just a regular theatre session with the anaesthetist. So I turn up a little before 8.30am, change into scrubs and wander out to theatre to find the nurses frantically drying condensation off the walls, windows, equipment ... everything. The air-conditioner has mysteriously broken overnight and the operating theatre has turned into a warm humid cave.

The doctors haven’t arrived yet, and eventually the girls make an executive decision to move theatre into our trauma room, and we wheel trolleys of sterile equipment, linen etc down the hall. Our hospital is not exactly state-of-the-art, but trauma room, as one nurse put it, is “like operating in the third world”. There is barely room to fit all of the equipment, and we are claustrophobic before the list even starts.

The GP surgeon eventually turns up a little after 9am, and speaks to me briefly before walking off in an unknown direction. One nurse tells me not to worry, “you’ll never work him out”, but I tell her it’s ok - I’m with the anaesthetist today. And that’s when she informs me that there will be no anaesthetist for today’s list, and suggests that I run away now.

But it’s too late. I’ve already been seen.

Quoteblog #4

“Cataract operations last 15 minutes. You can duck out 4 times an hour to go to the toilet if you want to” - Opthalmologist

“And just remember when you’re answering these questions and you can’t think of any more, just say idiopathic” - O&G Specialist

“And if you forget one, you’ll have so many others, the examiner won’t even notice” – O&G Specialist

“I had an operation on my appendocyte” patient

“Oh God ... footballers” – Orthopaedic surgeon

“Oh my GOD! That’s very very small” – clinical tutor inspecting a student’s skin ‘lesion’

“Enjoy your oddity” – Pathologist’s advice to medical students

“Their urine will be radioactive for a few days after ... it’s a β-emitter so it won’t even clean the toilet properly for you” – Pathologist re: diagnostic test

“The second tray is for the religious – vegetarian, whatever you call it” – Lunch lady segregating the sandwiches

“I like dots. Dot, dot, dot, dot” – Student showing off her PowerPoint presentation

“Whether she’s got a shed of a pelvis, doesn’t matter” – O&G Specialist on the value of pelvimetry

“You can decide whether you’re an intelligent doctor or just a poor donkey eating grass” – O&G Specialist gives us some options

“There’s no person – male or female – without any problems, and they’re not all PMS” – O&G Specialist

How do they know?

How do they know I'm ridiculously intelligent and HOT?

That's it, I'm covering up my webcam.

Orthopaedic Consulting

The patient is waiting in a separate room, his X-rays already up on the viewer. The other student and I hover behind the orthopaedic surgeon as he inspects the images. I know that I should be looking carefully for the pathology – after all, the surgeon might ask for a student’s opinion, and I wouldn’t want to look silly. But something keeps catching my eye. Just below the pelvis, where one would expect to see only ... well, soft tissue, there is a cluster of bright white rings and bolts. This man is pierced. And not just once, no – there must be at least 10 of the things, creating a rather distracting focal point of the image.

Fortunately, the surgeon doesn’t ask for our assessment right then and there, he just goes through the consultation and sends the patient on his way.

Later, in the privacy of the surgeon's office, we have a look at those X-rays. The surgeon points out some discrete lighter patches around the hip joint, and asks what we think they are. I’d honestly not noticed them before, and the other student can’t answer either. The surgeon informs us that they are clips to stop bleeding arteries, indicating that the man has had surgery in the area before – probably a hernia repair. Oh, right. How boring.

The surgeon then waves his hand vaguely at the image of the man’s crotch area, “and what’s ... all this?” “Piercings”, I announce confidently. The surgeon briefly ponders what possessed the man to get this done. I point out that the man had a wedding band, and suggest that maybe his wife made him do it. The surgeon gives me a blank stare, and I know I’ve gone too far – I probably shouldn’t be speculating on a patient’s intimate life with a prominent surgeon who I’ve only just met. He then says, “there are a lot of things I don’t understand about ... life”, ruminates some more on the issue and then blurts out, “could a wife REALLY make you do that?!”

Later in the session we have a short break between patients and the surgeon reflects on the morning. “We’ve done a fair bit today” he says, “we’ve done acute knee injury, supracondylar fracture, axillary nerve, rotator cuff injuries ... and piercings”. Clearly it’s had an impact.

Computer Genius

She’s making a newsletter for work, and she’s run into some computer trouble.

“It won’t type in this box, look!” as she bashes random keys.

The cursor tracks along the screen, and a red squiggly line slowly grows, but there is no text. I lean over, change the font colour from white to black, and save the day.

For almost a minute, I am a genius, and the failures of the week fade to the back of my mind.

Small victories are still OK.

The War

There was a war on, and all of us were required to fight. I didn’t know many of the other 'soldiers', but I know a few of my classmates were there, so that was comforting. We had a few drills, where we had to run to the store room, take up a mask and a rifle, and line up on the hill ready to shoot. On command we would lie down on our bellies and army-crawl forwards towards the “enemy”.

The masks were all standard, but there were three types of rifle – some with a golden butt, some with a wooden butt, and there were a large number of completely plastic rifles. On the day we were finally required to fight, I was one of the first to reach the store-room and had first choice of the rifles. I immediately picked up a golden rifle and realised it was terrible, so I selected one of the wooden ones, but took the time to pick one without a wonky sight. Clearly the plastic ones were not first choice.

And as we were in the midst of the battle, I turned to one of my classmates who just happened to be there and said, “this would be a great excuse for an extension on Wednesday’s assignment”. And she laughed.

Crazy dream. Point of the story: if anyone wants to start a war with our cohort, let me know by Wednesday.

Image from http://trombonestuff.blogspot.com/2007_06_01_archive.html
Not sure about original source

Big Scary Student

I’m in theatre with my GP supervisor today, and he’s got a full list of skin excisions to do (our day ends up running from 9am-8pm). Somebody switched the on-call roster, and he’s been on call all night, so he’s sleep-deprived, grumpy, and late. Adding to the general awkwardness, he’s injured his foot and has to limp around in a giant moon-boot. I do my best to be helpful, drawing up local anaesthetic, cutting sutures and generally staying out of the way. And I’m doing well – we all are; eventually he starts to smile.

During a break between patients, he ducks across the hall to radiology to have his foot X-rayed. I’m in theatre preparing to draw up some more local anaesthetic, and I realise we’re out of 1% xylocaine. What to do? I ask the nurses, and their advice is to go ask the doctor.

So I venture across the hall to Radiology and see my doctor leaning on a chair strapping on his big moon boot – obviously he’s just had his X-ray. He seems to catch my eye, so I stick my head around the corner and ask quietly, “we’re out of 1%, is 2% ok?”

He looks up in surprise, loses his balance and topples over backwards. As in, completely over backwards, and the next minute he’s lying on his back with arms and legs sticking up in the air. I can only look on in dismay – he’s going to be furious, the rest of the day is going to be hell, and it’s all my fault. So I am much relieved when he dusts himself off and laughs, and then proceeds to tell all of the theatre nurses about his accident. Very much relieved.

Although, I must have look quite terrifying when I approached him, because he asked me later, “were you wearing a mask?” For the record, no, I was not.

Relaxed

He's a regular to minor surgeries. Today he's here to have three of his skin lesions excised - one possible basal cell carcinoma in the crease of his nose, another behind an ear, and a possible squamous cell carcinoma on an eyelid. He doesn't seem too concerned, but then he's taken his hearing aid out so I can't really ask him. He doesn't even grimace as the local anaesthetic is injected, although I'm sure it must sting his nose at least.

Before long, there's an area sheet over his face and the doctor is working on him with a scalpel. As the doctor excises the second lesion, the nurse hears a strange noise. "Is that ... is he ... ?"

Yes he is. He is asleep, and snoring.

Medical Specialty Aptitude

I took a "Medical Specialty Aptitute Test" a little while ago, just because I thought it would be interesting. It's quite slow to load and has hundreds of questions on many pages, so it took quite some time to complete. And after all that, the results weren't what I was hoping for and so I have decided that it's a load of rubbish anyway. Since my hopes and dreams (currently) involve me becoming a GP and maybe also doing anaesthetics, I was rather disappointed with the following results:

1. Radiology

2. General Surgery

3. Thoracic Surgery

4. Pulmonology

5. Haematology

6. Radiation Oncology

7. Infectious Disease

8. Nephrology

9. Nuclear Medicine

10. Obstetrics / Gynaecology

Where was GP? Number 33. Anaesthetics? 28. I'm probably mostly puzzled by Pathology appearing at number 17.

I suppose the quiz has some sophisticated method of determining your aptitude based solely on your personality type. And if you're the type of person who gets fed up with slow-loading million-question quizzes, maybe you should be a surgeon or a pathologist, and stay away from too much patient contact.

Not happening. Look out, patients!

Tracker

It’s amazing what I've discovered by installing a tracker to this web page. I may not know your name, home address or favourite colour, but I do know that you use IE 8.0 / Firefox / Chrome, and your computer is running Mac OS / WinXP / WinVista / Win7 and that you visited my site for 0 seconds/ 4min 13seconds / multiple visits spread over more than one day. It’s nice to see that some people, not limited to but including my Mum, make return visits. And I seem to have been visited by somebody on every continent already, which is nice, although I’m pretty sure most of them arrived here quite by accident. Here are some of the Google searches that have led to my occasionally peer-reviewed (PTR, Puddle, Vonbon) and vaguely semi-informative page:

“schoolgirl had chest examined with stethoscope for sore throat” – UK

“pinkstethoscope Champ” – UK

“champ pink stethoscope” – New Jersey, US (is there a champion pink stethoscope out there somewhere? Is it mine??)

“cystic fibrosis stethoscopes” – California, US

“dirty stethoscopes” – Utah, US

“urologist nurse gown” – Florida, US

“which way do you insert the stethoscope” - Massachusetts, US (more than once, and then they tried “insert the stethoscope”. I hope they found what they were looking for)

“which way do stethoscopes go in your ears” – California, US (at least they know it goes in the ears – good start)

“pink urine scrub solution” – Israel

“stethoscopes ashamed” – Iran

“Thomas Jefferson stethoscope” – Philippines

“anaesthetist rocks” – Cape Town, South Africa

Thanks for visiting! I'm sure that you don't find all / any of the right answers here, but I hope you have some fun along the way.


“We’re supposed to do that, when we find what we're been trackin!”
Copper, The Fox and the Hound