Graffiti # 1

One of the first things I noticed about Paris, apart from the fact that it looks like a perfect model city from the air, was the graffiti. It's everywhere! And actually kind of cool.

Bonjour!

I hear the drums echoing tonight, but she hears only whispers of some French conversation ...

Um, Toto? I don't think we're in Africa anymore.

I landed in Paris 6.30am on Monday morning, spent 3 hours making my way to Gare de Lyon by bus, and then realised I had no idea how to find the hostel from there. By chance, my sister and her friends had gone to that very station looking for Internet access and as I dragged my luggage up the steps she bouced up to me, looking glamorous in a little black dress. What chance! Once I'd offloaded my bags we began exploring Paris together.

This new adventure is so completely different to Africa that I'm still not quite sure what to make of it.

At least the coffee's good!

Long-wa

Spending the night in Lilongwe, the capital of Malawi, I was woken up at 6am by a loud American talking to his friend on the phone: "Yeah, we're in Malaaaaari! We're in Long-wa, or Lang-wa, or somethin' ... "

Photo from Lake Malawi (not Long-wa)

Snore like a mosquito

Half asleep on the top bunk in a four-share dorm, I became convinced that I was being harrassed by a mosquito. Having slept every night for the last six weeks under a mosquito net, I was feeling a little exposed - and I'm sure Livingstone mosquitoes carry malaria just as well as those in Katete.

Flailing my arm sleepily about my head, I was unable to get rid of that whiny, buzzing sound - and in my dreamlike state decided that the mosquito must be in my ear.

And that's how I woke up at 3am with my finger in my ear, only to realise that the whiny, buzzing noise was my middle-aged American room-mate's snoring. And even when I was awake, it sounded like a mosquito. Special!

What's an Adelaide?

The store holders at the little souvenir shops around Livingstone are very good. They'll usher you in to their stall, "come in my sister, I show you what I've made. Looking is free, touching is free" and "ten different families rely on this one store, my brother made this, my grandfather paints these, nobody has bought anything this whole day, how about something small?" It's very effective.

They also try and connect with everyone personally - "Where are you from? Australia? Down Under! G'day mate! You are from Sydney? No? Melbourne? No? Perth! You are from Perth! No? Then from where?"

"Adelaide"

"Abba-what?"

Holidays

I've finished my six-week elective at St Francis Hospital Katete, and am now officially on holidays. I still have at least three more stories to share from St Francis - a little story of success, a story of hope and a story of heartbreak - so hopefully you'll see why my African elective has given me the best and worst of medicine so far. I'll post them all together in due course.

But for now, I'm at Livingstone enjoying Victoria Falls for a few days before heading to Malawi, where will end my little African adventure. I'm more tired now than I ever was during elective, but there are so many things to do and it seems like a waste to sleep!

Here's some advice for seeing Vic Falls:

1. Bring the best camera you know how to use

2. Bring a waterproof camera as well if you have one

3. Take a Microflight over the Falls, they look so different from above

4. Don't be afraid to get wet. The waterfall consists primarily of water (little known fact)

5. If you can't afford to stay at the Royal Livingstone, go there for High Tea and watch the zebras graze by the pool

6. If you can afford to stay at the Royal Livingstone ... wow. Donate some of your millions to starving children in Africa please

7. GO TO LIVINGSTONE ISLAND

Livingstone Island

This morning I stood on the edge of Victoria Falls and looked down.

If you ever go to the Victoria Falls, one thing that you must - MUST - do is go to Livingstone Island. We thought we'd seen the Falls yesterday when we walked around the park, but we hadn't. Not really. Here are some of the photos from today!

Some of my favourite safari photos ...

Ascites

So many patients on the female medical ward have ascites. Tiny, wasted women with giant, distended bellies lie in the beds awaiting treatment. Sometimes we can treat the cause – we have plenty of medications for heart failure and tuberculosis. Those with hepatic failure or malignancy can only be treated symptomatically, such as with an ascitic drain.

My friend did an ascitic tap on one woman with malignant ascites. The woman was keen to go home, but knew she needed her belly drained first. As my friend prepared the equipment, I brought in the screens – the woman immediately jumped up on the bed and drew her shirt up over her giant belly.

 

My friend inserted the cannula into the woman’s tense belly and attached a giving set, running the tube into a large metal bowl. Immediately, clear yellow fluid began draining into the bowl, flowing at quite a rapid rate. The woman stared, fascinated, as the bowl began to fill with fluid from her own belly. She began talking to us questioningly, but none of us know much of the local language yet. Was she in pain? Did she want us to stop? She didn’t look too upset.

Eventually we managed to call over a nurse to interpret for us. He smiled before relaying the message, “she wants to know if she’s allowed to touch the fluid. She wants to feel it”.

Well Done

The oldest doctor here is a 70-something English professor who is always dressed resplendantly with a new tie or bowtie for every day of the week. In his downtime he either paints scenes from the hospital, or sits on his porch reading the paper and smoking his pipe. He doesn't ever get flustered, he is a wealth of knowledge on Africal diseases, and he is very encouraging to the students.

His favourite praise is "well done" as in, "You did a lumbar puncture - well done" or "you got a chest X-ray on that patient - well done". It's nice to get praise, until you realise just how easily he dishes out the compliments, "you've been here for two days already - well done" or "you arrived on Wednesday? Well done".

Um ... thanks!

Burkitt's Lymphoma

I have been privileged to see many strange and wonderful diseases here at St Francis. Pathologies more advanced than the examples in textbooks, classic TB, advanced cancers, meningitis and a sample of the manifestations of HIV. There are a few things I wish I hadn't seen, although I'm probably better for the experience. One of the worst so far is an HIV positive 11-year-old girl with Burkitt's lymphoma.

We don't know how she contracted HIV - that's not relevant now. The large tumour in her abdomen, and the large tumour that is deforming her face and destroying her teeth are more of a concern at the moment. She lay there in pain on the morning ward round as we all crowded around, prescribed morphine, and decided how she would die.

Would we give her chemotherapy? It's just a short course, and we could do it here, but with her HIV, could her immune system cope? With such advanced disease, her chance of remission is incredibly high, so is it worth it? Save her from the lymphoma so she can die from some HIV-related illness? The alternative is to palliate an 11-year-old and wait for a few months for her airway to obstruct, her abdomen to completely fill with tumour and for her to die gasping for breath around a collection of rogue cells that we could have killed off for her.

In the end she got her chemo and we were all thrilled to see the tumour shrink over just a few days, so that she was able to eat, smile and giggle again. I hope it lasts.

Two Canoes

"He who paddles two canoes, sinks" is apparently a Zambian saying warning of the dangers of polygamy - it can be found all through the HIV magazines. Perhaps it should also be used at the marriage celebrant's office.

The male medical ward had an interesting admission last week - a 30-something man who'd come in with excruciating abdominal pain, pin-point pupils and bradycardia. He'd taken rat poison, which in Zambia contains organophosphates (not warfarin like at home). Memories may or may not have come flooding back from our very first PBL case. He was given atropine to good effect and has been discharged home.

Why would an apparently healthy young man take rat poison, you might wonder? Apparently his two wives had been fighting, and he'd gotten upset and had taken the rat poison. Too many canoes.

Translator

I sat in OPD with Gustav, a Norwegian medic. Our translator was an amiable woman with questionable work ethic. She yawned throughout, occasionally wandered off, and sometimes had to be asked twice to translate for us.

At one point she started picking her nose, completely unashamed, really digging her finger around and checking curiously to see what she'd dug out.

But she was nice, and friendly, and got on well with the patients. The second-last patient didn't even mind when she interrupted the doctor's questioning and exclaimed, "I need some medicine Gustav!" whilst filling out a prescription form for herself.

Ignoring the actual patient, she started describing her mouth ulcers in great detail. And nobody minded. Welcome to Zambia?

Public Health, Public Health

Public health messages are very important here. There are billboards everywhere, and magazines devoted specifically to the subject can be found on most nurses' station desks. As you would expect, most of these messages concentrate on HIV and AIDS. My favourite billboard is a picture denoting Abstinence, Condoms and Faithfulness as "life-saving boats in an AIDS flood". Most patients are sent for VCT (voluntary testing and counselling) so that they know their status (HIV negative or positive). There are centres for male circumcision, although the message still hasn't come across that circumcision won't PREVENT HIV infection; it merely decreases the risk.

Unfortunately, with most messages concentrating on HIV, a few things have fallen by the wayside. Rubbish is everywhere. At the bus station, people will buy plastic bottles of soft drink and then throw the bottle out the window, so there is a layer of plastic over the entire area.

Basic hygiene such as handwashing, and covering one's mouth when coughing, generally does not occur. I find this especially disturbing when half the adult population is infected with TB, and my friend and I are convinced we'll have TB when we get home.

Whilst women's rights are improving, women's health is not widely promoted and I have seen two cases of advanced breast cancer so far. Both women had noticed a lump in their breast growing over about a year, and both had cancers eroding through the skin. They had huge axillary lymph nodes and one even had arm pain from brachial plexus involvement. We sent them to the surgeons who would tell them that their prognosis was not good, as both cases were beyond surgery. You might wonder how they let themselves get that far, but these women genuinely had no idea what was wrong with them.

It's hard to say whether the public health message should be broadened, or perhaps if they should try and get the HIV message across and that epidemic under control before concentrating on other health care promotions. Either way, it's opened my eyes to public health.

Disappeared

"Oh, you're in Year 12! Fantastic! You speak English!" we were all unduly excited about the Zambian schoolgirl's ability to communicate. Unfortunately she had a sore throat and refused to talk much, however her school friends who came and visited helped us out with her history.

During the afternoon, my patient in the next bed went missing for a few hours. I really needed to do a blood test, so I asked one of the girl's friends if she knew where my patient was.

"Yes I do" she smiled

"Oh good!" I said, relieved, "Where is she?"

"She has disappeared"

Green Card

The "green card" is a patient's most prized possession in hospital or outpatients. It may be torn, worn and dirty, but a patient will almost never lose the card. On it is written their personal details, hospital number, and a short discharge summary from each time they've been in hospital.

It's much easier looking at a green card than searching through a computer program for admission details or discharge summaries. It also has all of their outpatient encounters written on neatly torn pieces of paper stapled to the green card. As soon as somebody goes to outpatients, the nurses do a blood pressure, temperature and weight - more consistently than your average family GP.

Patients are also in charge of their own X-rays, which they collect as soon as they are done and carry to outpatient on metal drying frames. They keep them safe and neat and bring them along to every medical encounter from then on.

Perhaps it is because they don't have much other paperwork for things to get lost in, but patients are much better at looking after their medical records than we would be. It may be 'primitive' keeping everything on a single green card, but the system works. And I like it.

Tuberculosis

I thought I knew about tuberculosis. It was a lung disease which made you cough up blood and then die, like Nicole Kidmann's character in Moulin Rouge.

Then on Infectious Diseases rotation, I heard about an old man who'd gone for elective TURP and the next day started complaining of shortness of breath and shoulder pain. He'd had TB as a young man in Germany and it had lain dormant IN HIS PROSTATE until the TURP, when it had seeded through his bloodstream to his lungs and shoulder.

Here in Zambia there is TB everywhere, especially in HIV patients. It occurs in extrapulmonary sites (haven't seen a TB prostatitis yet) in 10% of non-HIV patients, and 70% of HIV-infected patients.

We had a lady with TB adenitis - massively swollen cervical lymph nodes due to TB infection. They'd started draining pus so she'd had someone open them up with a knife. Of course they'd become infected so she came in with open, purulent sores on her neck. More swellings appeared, so she was taken to theatre for debridement and drainage - pretty much the same thing she'd done at home, just with a CLEAN knife.

Another lady came in with a huge, swollen right leg and pus draining from a slmall ulcer near her knee. The joint was infected with TB, so instead of being hot it was cool, although it was very puffy and the joint was essentially destroyed by the infection. Her best outcome would be surgical fusion of the knee after the infection had cleared up.

There are patients with classic TB on their chest X-rays. They come in very sick, but their prognosis is usually very good if they complete their course of antibiotics (which goes for months). Good to know.

The Hill that was a Mountain

Well, I’ve climbed a mountain in Africa. Sort of. It’s actually called “Katete Hill”, but it was hard work walking up it, and on that basis I’m going to put it in “mountain” category.

My friend and I took the hike there today with 7 other students who are currently placed at St Francis Hospital. Usually with a biggish group you can usually guarantee that you won’t be the slow one, but I was pretty far back on our climb up. Now I’m not making excuses, but I had kind of planned to do exercise before coming overseas, and then I came down with pneumonia, so there is a reason for my lack of fitness. I think it’s called laziness.

It took us just over an hour to reach the top – it’s not a very long walk, but it’s quite steep for most of the way, and the ground in some places is just red dust with fine rocks which slip out from underfoot. There is no path to the top; you just have to find your own way. A good way is to start at the bottom and always walk upwards. It worked for us. We had to be quite careful though, because between most of the trees is a spider web, usually with a spectacular-looking spider in it. I took some photos, which I unfortunately can’t share with you due to lack of reliable Internet.

My favourite spider was a small flat one that looked a bit like a crab – it actually looked like it should have been a ground spider, but there it was in a web at face-height. My other favourite was an enormous black spider with bright yellow stripes and sharp-looking legs. As my friend put it, “I wouldn’t like that one walking on me”.

It was a hard walk, but the view from the top was a worthy reward. We could see the landscape of Zambia stretching out in each direction – flat land to the North and West with low hills in the distance, more hills (mountains) to the South and East. There was very little traffic on the road below – maybe one or two cars passed in the hour we sat there. The only sounds were the birds and various insects around us, and singing from the small village below. Beautiful.

Bedsiders

Every single patient admitted to St Francis has a “bedsider", usually a relative, who looks after them during their stay. If we are lucky the bedside will speak English and act as an interpreter, but this is rare in a poor rural area where very few residents have attended secondary school.

The bedsider performs basic tasks of caring for their patient, such as feeding and washing, leaving the nurses to take care of drugs and procedures. Almost all of the bedsiders are female – I didn’t really pay much attention to this in the female ward, but I really noticed it when I entered the male medical ward and discovered that most of its inhabitants were female bedsiders – about 3 for every male patient.

 There is a single male bedsider in the female medical ward at the moment. His wife is in with gross ascites due to liver cirrhosis, and has a hugely distended abdomen with about 25L of fluid. He helps her dress, helps her sit up, and washes her dishes. When one of the doctors drained some fluid from her abdomen, the hole from the drain kept leaking fluid, soaking through the gauze and running onto the floor. Her faithful bedsider took a mop and quietly mopped up the fluid which was running along the floor.

Thank God for bedsiders.

Taxis

As far as I can tell, taxis are local people who own a car and wish to make money from it. Perhaps they have special licences but it’s hard to tell. As you step out into a public place (like exiting an airport, crossing the border or getting off a mini-bus), you are immediately swamped with taxi drivers. The first one to grab your bag wins the fair, apparently, and so they all battle over the luggage.

Like the mini-buses, taxis usually only leave when they are full (hence all the guide books refer to “shared taxis” – there’s really no choice).

 Our mini-bus from Chipata to Katete, a 16-seat van, waited 2 hours before it left the bus station. For the last hour all the seats were full, but people kept coming along needing a ride, so the driver kept cramming passengers in. By the time we left there were 27 passengers on board, including 2 screaming babies. A colourful ride indeed.

EDIT: We hired a driver to take us to Chipata, a 90km trip to from Katete. On the way we were stopped by police and he was told of for “pirating”, or acting as a taxi illegally – they wanted him to paint his car blue to mark it as a real taxi. I’ve never seen a marked taxi, this is the first I’d heard of it. He had to pay a K54,000 fine (about $15) which I think was more of a bribe, before we were able to move on.

Medicine

I don’t know what I’d expected from rural Zambia, but the medicine here is really not too different from home. There is a lot of malaria and tuberculosis of course, and about 80% of the patients are HIV positive, but apart from that the common conditions are the same as home.

My friend and I are currently on the female medical ward “St Monica”. We have patients in with pneumonia, stroke patients, a woman with ascites from liver cirrhosis, a young woman with pericardial effusion, and a few with diarrhoea. I think the threshold for admission might be a little lower than home, because most patients live remotely and don’t have transport.

 

The ward setup is a lot different – you don’t get a private room unless you happen to be the only measles patient in the isolation ward. For most patients, the beds are lined up next to each other along the walls of the ward. There are screens for privacy during procedures such as lumbar puncture, catheterisation and pericardiocentesis (there have been two since we’ve arrived). Normal examinations are just done in front of everyone.

 

Apparently it is quite acceptable to discuss medical conditions in front of a large group, because traditional healers would have everybody in the same room in a circle, and they would go around discussing their ailments.

Similarly, the outpatients clinic is conducted in a small room with three or four doctors all working at once with different patients. There is a single examination bed behind a curtain, and two doctors will usually share a desk – one on each end. Privacy is not even optional, but nobody seems to mind.

Spare Tyres

Our taxi driver from Lilongwe airport manoeuvred between two cars which had been stopped by police on either side of the road. Curious, I asked him what was being checked.

“Licences. And these (tapping on his car’s registration sticker). And spare tyres.”

“Spare tyres?” I questioned

“Yes, if you do not have one, you get arrested. They say if you don’t like someone, you should steal his spare tyre”

Interesting, that people can ride on the back of trucks, our taxi didn’t have functional seatbelts, and many cars have massive cracks across their windscreens, and a spare tyre is the thing that could get you arrested.

That said, our driver from our accommodation in Lilongwe to the bus station carefully arranged my friend and I to keep all the weight off his completely flat tyre. Perhaps he was saving his spare for a police check.

Money

I always find foreign money something of a novelty. I took out some US dollars before the trip, which do not seem like “real money” at all. By the time I’d landed in Africa the notes had all crumpled and looked like they were about to fall apart.

I bought a coffee in Johannesburg airport – they happily accept US currency, but can only give change back in local money. I’m not sure how it worked out, but I paid $5US for my coffee and received 50c South African in change. I also discovered that the 50c was magnetic when I found it later stuck to my MP3 player.

Withdrawing some cash from an ATM in Lilongwe, Malawi, I was fascinated by the K500 notes (500 Malawi Kwacha), the largest denomination I’d ever seen ... until we crossed the border into Zambia and I withdrew K200,000 from my account (about $40AUD) and was rewarded with K50,000 notes. Amazing!

AFRICA!

I'm in Africa!!

My friend and I (well mostly my friend) have been organising a medical elective term in Zambia since early last year. She's been emailing, we've been researching and shopping, and on Saturday I even started packing - with the help of my boyfriend and his amazing tetris skills.

There wasn't much time to really prepare - we finished our Term 3 rotations on Friday and left the country on Monday, so it was a little bit hard to get excited as we frantically packed our bags.

Even on the plane, it was hard for reality to sink in. 6,000km trip to Kuala Lumpur followed by a 6-hour stopover (our plane was delayed by an extra hour). We slept on our backpacks in the airport and waited for our flight to Johannesburg, which was delayed by an hour, and then I slept for the 10-hour flight, only waking for meals and falling asleep by the time the tray was taken again. On the plus side, we arrived in the morning and I wasn't too jetlagged.

But now we're here in Katete, Zambia, staying at the St Francis Hospital and helping out as much as we can there. My friend and I are both on the female medical ward, "St Monica" for the time being because that's where the fewest medical students are. There are about 15 students at the hospital at the moment, mostly from England and the Netherlands, although most are leaving in a few weeks so we will probably move around the hospital to wherever we are needed most.

I'll try and share some of the stories here.

Infectious

Some might say that I'm taking my Infectious Diseases rotation a little too seriously. I turn up early for the morning ward rounds, I take many pages of notes, I gave a lunchtime presentation, and I know enough about the third cranial nerve anatomy to ask questions that stump the consultant (his fault, he made me look it up). I write in the progress notes, I examine patients, I participate in the team meetings, and I go and see consults.

Oh, and I have pneumonia.

I've been coming in every day with a hacking cough, making my presence felt throughout the hospital. I really should have stayed home, but nobody said that was okay, so I kept on coming in. Pretty dedicated, you might say.

But then I made a fatal error last week and went to a compulsory workshop without informing my supervisor.

The very next day, I was called in for a meeting with absolutely no warning and berated for my "disappointing lack of attendance". Had my supervisor told me off for spreading germs throughout the hospital, I would have understood. Had he focused on my appalling lack of knowledge of antibiotic use, that would have made sense. 

But he was disappointed in my attendance. 

So disappointed that he might just fail me.

Maybe I should cough louder so he knows I'm here.

Signs of Pain

How will you know when your older patients are in pain?

Will it be the classic head-in-hands posture?

The downcast expression?

The phrase, "I'm in pain?"

Will you recognise the signs?

Technique

Many of the patients seen by the Infectious Diseases team are IV drug users. As it turns out, injecting random substances into your veins is actually dangerous. Any bugs that you inject go via the venous system to the right side of the heart, where they can lodge and form vegetations on the heart valves. Once the vegetations become larger, they can affect blood flow, and also flick off to the lungs. From the lungs, apart from causing infections, they can wash to the left side of the heart, and from there … the rest of the body, even the brain.

We have patients with infective endocarditis (infections around the heart), infections in the brain, infections in the blood.

You’d think that Infectious Diseases doctors would be strongly against IV drug use, when patient after patient appears with serious infection, in need of IV antibiotics, with no veins available because they are all scarred and collapsed. What bothers the consultants the most?

“There’s no attempt at sterility at all”

Yes, the consultant is most annoyed about technique.

Last week we were called to see a lady with pus pouring out of her eye due to a bug commonly found in dirt. At first it looked like she’d injected with a dirty needle and the bacteria had entered the bloodstream. Later it emerged that, having ruined all of the veins she could find, including her jugular veins, this lady had injected into her eyeball. Straight in. Turns out the bacteria was just a contaminant on the swab, and most of the damage was done from the chemicals in the drug. I think the eye is being removed this week.

How’s that for technique?

Tests

"With a hammer in your hand, everything's a nail isn't it?" - Infectious Diseases consultant after the Endocrine registrar ordered a variety of (endocrine) tests on a patient with septic shock.

The Library Museum

Perhaps indicative of a shift towards electronic references, the bookshelves in the Infectious Diseases office are stacked full of dusty, outdated textbooks. Titles such as "The Quinolones" from 1986, "The New Generation of Quinolones" from 1990, a cassette tape about Hepatitis B, and "Current Chemotherapy" from 1977 line the shelves. Until a 2010 White Pages appeared, the 1996 street directory was the newest book in the room. It's like a tiny little museum.

Like Pulling Teeth

People cringe and shudder when I tell them I had all four of my wisdom teeth out on Friday. In the chair, as opposed to under general anaesthetic in the operating theatre. I was a bit trepidatious at first too, having sat with my sister while she had hers removed a few years ago. I still remember the crunching sounds.

Now that I am officially in the aftermath of the whole operation, I believe I can safely say that the most painful part was getting the dexamethasone injection to the arm. Of course I'm very glad I got it - it stopped me from getting a giant swollen "chipmunk face" after the operation. And it only hurt as it was being injected ... and for a few minutes afterwards - but as my Dad always says, "it'll stop hurting once the pain goes". Surprisingly, it was even more painful than the local anaesthetic which had to be pushed in through the bone of the lower jaw.

If you're already a little squeamish, I suggest you stop reading now. The following passage contains graphic details of an operation that I technically didn't see or feel.

- insert transition music here -

Like any surgeon, the dentist wants to get the operation over and done with as soon as possible. He lets the anaesthetic work its magic, and then says, "Ok I'm just going to push" as he slices the gum with his scalpel. Grabbing the tooth with his pliers, he gives it a knock, and with a quick crunch the tooth is separated from the jaw.

My tongue is almost completely numb with anaesthetic, but I have mild shooting pins and needles and I am convinced I can feel arterial blood spurting onto my tongue. The assistant passes some gauze and it is packed against my bleeding gum. "That came out easily" she says, and indeed it did.

The dentist pulls out the top two first and then moves on to the bottom teeth, which he says are usually more difficult. He has approximately ten million years of experience (he's been my dentist my whole life), and as it turns out, he is right. 

The first of the lower teeth comes out easily enough, but the final tooth clings to the lower jaw and does not want to leave. Blood begins to pool in the back of my mouth - so much that the assistant has to switch the suction device to a larger one - as he cuts, pulls, wiggles, drills and taps at the tooth and gum. I request to spit, but he tells me that I can't spit straight and that I should just breathe through my nose and let the assistant suction out the blood. I tell him that I can feel him moving the tooth around, and start freaking out that I'll feel the excruciating pain of the nerve being torn when the tooth finally lets go. He tells me to "hang in there" because it's nearly over.

And finally, it is over. I'm allowed to sit up, and start drooling blood into an emesis bag that my boyfriend thoughtfully brought along. The dentist was right - with my tongue and lower lip completely numb, spitting is a challenge that for the moment is beyond me.

I am convinced that I am going to bite my giant, swollen lower lip. I am convinced that my face is distorted beyond recognition. I try to convey these thoughts to the dentist and my boyfriend, but they just laugh. They are mostly laughing at my speech - with my tongue and lip anaesthetised I am not particularly articulate. The dentist shows me a mirror so that I can see my completely normal-looking face.

Well ... normal apart from the blood around my mouth. And the blood in my teeth. And the blood that is coating my tongue. I mop it all up as best I can with tissues, and am sent on my way with scripts and recovery instructions.

My sister leaves work early to pick us up. She wants me to talk so that she can laugh at my numb blabbering, but at the same time keeps freaking out at the blood that keeps appearing on my teeth. In the end she overcomes her squeamishness, and her and my boyfriend make fun of me for several hours until the anaesthetic wears off and I can speak normally again.

Recovery has been surprisingly uneventful. I can eat normal food, I can talk normally and I'm not in any significant pain. Much, much better than I'd expected.

One Track Mind

Me, catching a bus to the city: "One student ticket please"

Bus driver: "I'm not going up to the university!"

Me, "No - you're going to the city"

Bus driver, "Oh. Well, yes"

.

How to: not get sued

One interesting tidbit that came out of last week's Patient Safety Workshop was a handy guide to "which doctors are likely to get sued".

Apart from the fact that male doctors get sued much, much more often and for much, much more money than female doctors, here are a few of the factors that influence whether or not your patients will sue you:

Doctors who are "late, rude, inattentive, poor/non-communicators, and apathetic" are more likely to get sued.

Doctors who ask questions, laugh with their patients, explain everything, and allow sufficient time for a consult are less likely to get sued. It also helps to be honest and apologise if you do make a mistake, and not just hand the patient to a different doctor.

As one GP told me last year, "if your patients like you, you have to do lots of things wrong before they will sue you".

So now the question is, should we spend more time learning how to be nice, or how to be competent? Or should the less likeable amongst us be trying even harder at med school?

I'm on the wards!

Clinical Pharmacology term is over, Infectious Diseases term has started, which means ... I'm back on the wards! And back amongst all the craziness that will appear if you just see enough humans in one day.

Standing at the nurses' station writing in patient notes yesterday, I observed a patient in a wheelchair zooming along at an alarming rate using just his one arm and one leg to propel himself.

After a few laps, as his anxious face started to become red and shiny with exertion, the nurses began to question him. As he flew past he explained breathlessly, "I've put on a kilo in one day! I have to get it off!"

And therein lies the danger of the Daily Weigh.

Save the ... car?

I almost sold my car this week. Pulling out of a multi-story carpark, I was stopped by a middle-aged man in his tradie ute. 

"How much?" he asked.

I gave him a funny look as I tried to come up with an answer - I couldn't recite the carpark's hourly fee.

"How much FOR YOUR CAR?" he rephrased

I explained that it wasn't for sale.

"Change your mind?" he asked, pointing at the signs in my back window.

I tried explaining, but after several minutes I had to physically pull down the signs so he could read them ...

How to: put your audience offside

Assume they're going to be rude and inattentive, and immediately get defensive and try to counteract it. 

Try saying something like, "I respect your experience and knowledge, and all I ask is for you all to do the same for me please. Thank you."

It should take a good ten minutes before they look at you with anything but resentment.

Mission accomplished!

Patient Safety Workshop

One third of the Year 4 class wasted their entire Thursday at a 'Patient Safety Workshop' - the other 2/3 will do the session later in the year. I also wasted my Wednesday doing the pre-readings and answering thought-provoking questions such as "What are the potential holes in the Swiss cheese?"

Today we sat through lectures, watched videos, split into groups and brainstormed, and wrote on whiteboards. On the plus side, some parts were quite entertaining, it was good to see classmates, and we got morning tea and lunch. But overall it was quite long and tedious and could have been summed up with, "Do your best, but we're only human and we need systems and protocols for the protection of ... well, everybody".

However, I wouldn't have liked to miss the first video. Picture this: a stressed ED doctor had just hung up the phone - "it's not good enough, really. It's -really- not good enough" because the lab had lost some blood samples. In sauntered the ED nurse who got in nice and close to him, flirted briefly and then asked suggestively, "is there anything I can do to help?"

At this point, about 30% of the group was convinced we were about to watch porn.

Highlight of the day.

Journal Club

It was my turn to present an article at the Clinical Pharmacology Journal Club yesterday. This was something I took very seriously and I spent hours analysing my chosen article and working on my Powerpoint presentation. I also prepared a batch of delicious biscuits to bribe my audience into listening attentively.

In hindsight, I probably shouldn't have chosen a review article about a drug  that was written by someone on the payroll of the drug company. And I could have found a more reputable journal than "Swiss Medical Weekly" which, I think, is only published online. But it gave me plenty to talk about, I learned a little about dronedarone (an amiodarone derivative that is less effective but less toxic - unless you count the liver damage), and now everybody has heard of a journal called Swiss Medical Weekly. 

So we all learned something.

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Let's get medical ...

You might be wondering about the lack of medicine-related posts on here. Just to scan through, it would appear that I have switched my priorities to politics, and that's not good for anyone. 

Yes, I am still studying medicine, and my faithful pink stethoscope tags along with me every day. It's just that ... well, I'm doing a Clinical Pharmacology term, and whilst nobody can truly claim to know what Clinical Pharmacologists do, one thing they don't do is see patients. And seeing patients is where all the best stories come from.

No wait, I remember, we did see a patient today. We ventured down to Intensive Care because we'd heard that a patient there had a high Vancomycin level. The levels should be between 15-20 - below 15 the antibiotic is ineffective, and above 20 it starts to become toxic to the body. This man had a level of above 60. After standing at the foot of his bed and staring at his chart, we established that he'd been given a dose last night when it should have been withheld. 

My supervisor chatted briefly with his treating doctor, and then we went for coffee.

Good story.

Save South Australia

South Australia is in a dire financial situation. That is why the Minister for Health is not-so-reluctantly diverting money from several perfectly viable and much-needed country hospitals to help fund a controversial new tertiary hospital in the city. It's justified, apparently, because overall the Government is spending more on Health than ever before. 

It's also spending more on Plasma TVs for prison inmates than ever before, and more on appearance fees for Lance Armstrong. It's spending up big on private parties at Clipsal 500 and office re-fits for MPs. 

Spending money does not equal doing the right thing by South Australians.

Spending money properly would be a terrific start.

The Haircut

If anyone's curious about the outcome of my dreaded haircut at last week's Shave for a Cure, I'll tell you now. I had planned to cut off 15cm of my ponytail, and thought that was pretty drastic. However, my sister and a few classmates made the executive decision that 15cm was not dramatic enough, and promptly chopped off 25cm.

I stayed (relatively) calm, for I'd had the forsight to make a hairdresser's appointment for immediately after the event. I casually sauntered up to the campus hairdresser only to find that he wasn't there! Apparently the med society had given him the wrong time for the event, cancelled at the last minute, and he'd gone home for the day.

Panic!!

On my little sister's advice I went into the city and got an appointment with a hairdresser who was incredibly supportive of the Kitten Hospital as well as the Guide Dog society. After agreeing that curly hair should NEVER be layered because it turns into an afro, she trimmed, straightened, and before I could stop her, LAYERED by hair.

And now, unless I straighten my hair, I look like a pom-pom.

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Country Rally

South Australians may have heard about this morning's Country Rally on TV or radio - especially the traffic report. Some might have seen it first-hand as a large group of vehicles entered the city limits during peak hour, all bearing signs displaying obvious disappointment in the Rann Government's handling of ... well, basically everything to do with South Australia. 

The "Save the Keith Hospital" group was especially prominent, clearly upset that Rann can justify spending  (amongst other things) $500,000 on a VIP Clipsal 500 party for MPs, $2million to convince Lance Armstrong to compete in the Tour Down Under, but refuses to back down on cutting $300,000 from Keith Hospital's funding.

Most passers-by were sympathetic to the cause, some even jumping up on the steps of Parliament House to join the group as they paused for photos and interviews. My boyfriend and I were accidentally interviewed - accidentally because we had no intention of being interviewed, and because the newsman thought we were innocent road-users who got stuck between the protest vehicles. Next time I'll put signs on both sides of the car!

The purpose of the rally was to raise awareness of the issues facing country people right now - and there are many. To those whose mornings were spoiled by the delays, think about your friends in the country whose way of life is being genuinely threatened by the current Government. And if you see a group supporting a cause that strikes a chord with you, I'm sure they'd  love you to join their fight - make it yours too!

Not all those who wander are lost

I saw someone today with a "not all those who wander are lost" T-shirt and felt compelled to go and look up this poem from J.R.R. Tolkien's The Lord of the Rings. A bit nerdy of me, yes, but it's a good poem.

 

All that is gold does not glitter,

Not all those who wander are lost;

The old that is strong does not wither,

Deep roots are not reached by the frost.

From the ashes a fire shall be woken,

A light from the shadows shall spring;

Renewed shall be blade that was broken,

The crownless again shall be king.

 

 

Good drugs, bad drugs

She presented with weight gain, amenorrhoea, and a noticibly "round" face. 

She looked like she had Cushings ... but all the tests came back normal.

What could it be? Was she on any medication? No ... oh, except for the cream she'd been using for her psoriasis - a potent steroid cream, which she'd been slathering on her skin many times a day.

Sure, it had stopped her itch - it had also made her bloated and unrecognisable, stopped her periods and made her panic about early menopause.

In the same consultation that all this was eplained (and a dermatologist referral organised), she mentioned a sore throat and asked if the doctor could "give her something for it". 

Because medications can't do harm, right?

Save the ...

I've been wearing a "Save the Keith Hospital" powerband for weeks now. Unfortunately, millions of people wear powerbands for a miriad of different causes, so people tend not to read them anymore.

Last Friday, however, I had a winner. My hairdresser spotted my powerband and read it aloud, "Save the ... kitten ... hospital"

"Save the KEITH Hospital" I corrected her hastily.

"Cute!" She replied, oblivious, "I donate to the Guide Dogs"

<facepalm>

World's Greatest Shave

I've done it. I've joined the Leukaemia Foundation's "World's Greatest Shave".

No, I'm not quite "brave" enough to shave my head, but I will be chopping off 15cm of my precious, precious hair for the cause. Or, correction, the highest bidder will do the honours. And it's happening this Friday. And I'm regretting it already.

Some might say that it's a bit of a cop-out, "just getting a haircut". Maybe it's not a big deal for some, but it's a big deal for me. You see, I haven't been to a hairdresser for 12 years, when I went in for a trim and the hairdresser cut off more than I'd anticipated. For the last 12 years, the only person I've trusted to cut my hair has been my little sister - because I know where she lives and she knows how upset I'd be if she cut it too short.

My mum, who's been urging me to get a proper haircut for ... well, probably 11 years, freaked out a little when I told her what I was doing. Maybe she mean that I'd hypothetically look better with short hair. She's warming to the idea now, I think.

If you'd like to support the cause, head to the World's Greatest Shave website,   http://worldsgreatestshave.com/. You can click "Donate" on the bottom of the page, or click on "Sponsor" to find individuals to sponsor. Me, perhaps?

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Politics

I really have to apologise for the political posts that have been occasionally cropping up here. I'm sure you don't come here to read about the failings of the South Australian Government or Minister for Health. You probably get enough of that from television, radio, newspapers, your friends ... actually, you probably see enough of their failures for yourself on any given day.

I don't like reading about politics. I don't like to get angry when thinking/hearing/talking about politics. I don't like caring about politics. But at the moment I do care, and this bothers me greatly. I want to say, "Premier Who? Health Minister Who? Never heard of them. Now let's stop talking politics, it bores me".

When people like me start thinking, caring, complaining or talking about politics, there is something very wrong.

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Mundulla Show 2011

The Moot Yang Gunya Festival (Mundulla Show) continues to grow and develop as one of South Australia's most unique festivals, adding new attractions each year whilst somehow maintaining the feel of an old-fashioned country show. I regrettably missed seeing the Gravel-Shovelling Championship, which by all accounts was a real crowd-pleaser. I did however manage to squeeze into the packed marquee to watch chef Simon Bryant give one of his live cooking demonstrations with local ingredients including lamb and free-range turkey.

Utes from the ute muster filled up the cricket oval, the ambulance was called several times to the motorbike area, a live band blasted out covers of classic songs from the back of a semi-trailer, and I ... wandered around taking photos. Here are some of my favourites:

Above: Simon Bryant during one of Saturday's cooking demonstrations

Below: Greg Willoughby, showjumping convenor and newly-inducted Life Member of the Mundulla Show Society

Above: Sydney Olympian Jeff Bloomfield and the beautiful stallion Anton

Below: Sprite, the cutest dog in the world

Above: spectators for the Junior Championships

Below: The traditional "Blessing of the Horses" on Sunday morning

Above: the cutest pony in Sunday's harness competition

Below: Clydesdales resting between classes

Above: Jasmine Dawe and "Rip It Up" competing in the Junior Championships

Below: Junior showjumper having a bit of a "miss" on Sunday

Above: Paige and "Hendrix", winners of the Junior Championship

Below: Matt Afford, winner of the C Grade Championship

Above: Kristy Bruhn and "Belcam Cosmic" competing in the A&B Grade Championship

Below: Anthony Thomas, winner of the A&B Grade Championship

It was great to see the amazing showjumping horses that we have in South Australia jumping at their very best over the weekend. Mundulla Show is renowned for its quality jumping surface (thanks to the Mundulla Football Club for maintaining such a beautiful oval) and coursebuilder John Wilsher made sure the fences were at maximum height to properly showcase the ability of the horses and riders. I never thought I'd enjoy a show where I didn't bring a horse of my own, but the competitions at Mundulla were inspiring to watch. Congratulations to all involved.

Mystery Spider

Does anyone out there fancy themselves to be a bit of a spider expert? Because I found this fine specimen last week and can't for the life of me figure out what type of spider it is. If you need a bit of size context, that thing he's eating is a bee. Click for a (slightly) larger picture.

Save the Hospital, Save the World

On Pens

I am a good medical student because I always carry a pen. True fact.

If my supervisor needs to sign a form (as so often happens), and finds himself searching frantically for a pen (as so often happens), I will hand him mine. And he will say, "that's a good medical student" even if I have botched everything else all week.

But despite that glowing feedback and the lingering sense of accomplishment, I do not like lending my pen to doctors for two reasons:

1. A doctor will never voluntarily return a pen
2. Doctors will occasionally often chew on a pen, regardless of whether it belongs to them

Two reasons for not lending, and two reasons that make it very hard to ask for my pen back.