Struggling my way through the last few months of my medical degree, and wondering if you'll want me as your doctor at the end of it



This Blogger Has Moved

From now on, I'll be blogging from Just Up The Dose. Please change your bloglines subscriptions, 'favourites' folders, the links on your own blogs, and whatever else you use to track changes on this blog.

In the end, I was just getting too many hits from people searching for a hot milf to make their night a little less lonely. Milf's Anatomy was a porrly thought-out blog title, and I'm shedding it once and for all.

Please be so kind as to follow me to Just Up The Dose - my apologies for any inconvenience caused.

posted by Karen Little @ 7:19 PM, ,




Smooth

I'm sorry I haven't been posting as often as I should lately. Things have been a bit busy recently, and blogging always seems to be the first thing to suffer when I have too much on my plate. Thank you to everyone who still checks out this site every day, in spite of the fact that you're met with the same old post every day.

Yesterday was the Last Day of Family Medicine, and we did our exams. The first exam was an OSCE (after six years I can still never remember what that stands for - I think it's Objective Skills Clinical Exam, I think. All I can say is - 'Objective' my ass). The OSCE consisted of a few written stations, asking us to do things like write out a script and fill in the J88 (the legal document that needs to be completed after someone has been assaulted). The other stations were all practical, and required us to perform a consultation with a simulated patient (ie: an actor) whilst a doctor watched and marked us through one-way glass. Of course, we all felt entirely relaxed and unflustered in this super-natural and non-stressful environment, and so none of us babbled or fumbled or stuttered or forgot any of the things we would usually do, say or ask in a normal consultation.

Anyhoo, the first station was a 'chronic' patient, and had a woman following up for her hypertension. The second was an 'unselected' patient, and turned out to be a man with the main complaint of erectile dysfunction. In this completely natural environment where there was no pressure to behave perfectly and to not put a foot out of place, I just couldn't seem to stop glancing at the man's crotch. Well done, Karen.

The third station was a patient that needed counselling - she'd just been diagnosed with a sexually transmitted infection, and it was our task to convince her to modify her sexual behaviour. This station passed fairly uneventfully for me, but unfortunately for Iwan he was called on to demonstrate the use of both a normal condom and a female condom. Hardly a raging nymphomaniac himself, Iwan has never applied any sort of condom to anything. Also, the examiners weren't so kind as to supply a dummy-penis or even a banana for Iwan to demonstrate on, and so the 'patient' watched aghast as he first roled a condom onto his own hand, and then inserted the same hand into a femdom, at the same time consulting the instruction sheet that came in the package. There was also no paper towel in the room, so his next patient was the surprised recipient of a lube-enhanced handshake. Yummo.

On monday I start my final rotation, and it's the surgical sub-specialties: orthopedics, urology, neurosurgery and vascular surgery. If allgoes according to plan, I'll be a doctor is seven weeks. Wish me luck!

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posted by Karen Little @ 10:30 AM, ,




Cookies and Milk

On Friday night, my skin was the lucky recipient of two deposits of body fluids, both courtesy of Mental Health Care Users, as we say over here.

Cookies

The first was vomit, which came from a man who'd just overdosed on an antidepressant. Because the pills were so recently ingested, we filled his stomach with two litres of saline via an NG tube, to induce vomiting. Because he was comatose, we had to intubate him. The first attempt was unsuccesful, with the tube ending up in the patient's eosophagus. The casualty officer left that tube in place whilst she inserted the second one. Naturally, when this second tube touched the patient's epiglottis he gagged, and emptied half of his stomach via the tube in his eosophagus. I was standing a good two metres away from the bed, but that was still not far enough away to be out of range of the shower of vomit that this man produced. In fact, it's almost as if he aimed for me - from my nose to my belly-button, I (and only I - all the other doctors and nurses got off scott-free) was covered in the stuff.

Milk

The second deposit was in the form of breast milk, which came from a mental health care user with bipolar mood disorder. Her family were trying to have her involuntarily admitted after she 'got a little over-excited at church' that morning. I sat next to her and took a good, long history from her. We were having quite a nice conversation , and I really felt like I was having some good rapport going with her. Right at the end, I asked her if she had any other problems, and she stuck her hand down her blouse and hauled out a breast. This in itself didn't really surprise me - this is Africa, baby. People whip out their boobs all the time here. What did surprise me, however, was the soft 'tsssssst' that followed, and the sudden feeling of something warm and wet landing on my forehead and eye. Gross! Turns out she was lactating as a side-effect of her medication.

Now, whilst projectile vomiting is slightly more socially acceptable than projectile lactation, I would probably (given the choice) go for the breastmilk again. Less offensive in texture, smell and appearance, it doesn't induce a gag reflex in the recipient the same way that vomit does. The big question was, of course, to PEP or not to PEP? Breastmilk-in-the-eye is a rather obscure kind of injury on duty, and isn't really discussed with us when the matter of Post-Exposure Prophylaxis is brought up. The doctor on call with me said she wouldn't bother, but I know myself, and I know that if I didn't take all the necessary precautions at the time, that when I develop a cold in a few weeks' time, I'll be almost certain that I'm seroconverting. Fortunately, the lady was HIV-negative - and so am I - yay! If nothing else good came out of it, the experience entitled me to a free file and HIV test at the hospital I was working at. So now I know that the tonsillitis I'm currently struggling with really is just a regular infection, and not the result of a hideously suppressed immune system. As Pollyanna said, 'There's always something to be glad about!'

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posted by Karen Little @ 9:01 AM, ,




Grand Rounds is up!

Check out this week's edition of Grand Rounds over at Tundra Medicine Dreams. TheTundraPa has a great selection of posts, beautifully complimented by pictures of the Alaska and it wildlife.

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posted by Karen Little @ 7:57 PM, ,




When You've Earned a King Cone

On Sunday I did a twelve-hour call in Casualties as part of my Family Medicine rotation. It's a rotation I'm really enjoying for several reasons. The first is that it's really fun to work in Casualties: we see a very wide range of patients, with diverse problems. Most of them are actually sick, and so we see a lot of interesting pathology: from people with trauma and other surgical problems, to medical and gynaecological cases: they all start at Casualties and are first screened by a Casualty Officer which, for the last week, has been me. (Well, sort of.)

Secondly, the doctors of the department have been so incredibly nice to us. I know this sounds like a silly and wussy reason to like a rotation, but it's a big factor. Over the course of the last three years, I've discovered that the kind of person I dislike most is the Doctor-kind. From arrogant surgeons and abrasive orthopods to bitchy gynaecologists, sulky cardiologists and snooty neurologists, I've been shouted at, humiliated, abused and slave-driven by registrars from almost every conceivable specialty. Maybe it's because of the fact that most of the doctors currently in the family medicine department are young ones - community service doctors and medical officers who only finished a few years ago - and maybe it's the fact that the older doctors in the department got into family medicine because they're nice people who actually care about other people in the first place, but we haven't experienced the same kind of interpersonal stress that we usually do when faced with our seniors in a new rotation. The doctors listen to our patient presentations with respect, and don't sigh or crap on us when we suggest an inappropriate investigation or forget about another one completely. They give us time to to take tea and have meals, and even thank us for our hard work at the end of the day. They listen to our opinions and are happy to teach, and never seem to get impatient when we ask them to help us examine a difficult patient or perform a tricky procedure. It's really nice.

And then came Sunday evening. In all fairness, by 7pm, after a long, hard, busy call, I was rather grumpy. We'd had some difficult patients, like the Bronze Lady. She was a woman with emphysema who had been lying in the female medical ward all day, hurling abuse at whoever happened to walk past her. She was sort-of yellowish, and scrawny as anything. The history she gave was one of fifty years worth of heavy smoking and drinking. Every time she stood up, she fell over, and every hour or so her son would escort her out of the unit to have a cigarette. Upon return, she would scream hysterically at her son 'I'm going to fucking bite you! Help! Help! This man is molesting me! I'm going to fucking bite you!' The other patients giggled deliriously through their heart failure and stomach cramps and burning urine at the crazy white lady and her obliging son every time he brought her back into the ward.

And so, at five minutes to seven, the night shift came on. I'd just finished presenting a patient with stomach cramps (oh, stomach cramps! The bread-and-butter of any emergency department) to one of the doctors on day shift, who gave me a plan of action. I then tried to hand over the patient to one of the night-shift doctors, telling her I was just going to go and draw the blood that the day-shift doctor had told me to. And then, at 7pm, home time, night-shift doctor said 'Let's go and examine this patient.' I had already examined the patient very thoroughly, leaving no system untouched, including her genito-urinary one. Night-shift doctor proceded to do another vaginal examination (which made me cross - nobody wants more than one vaginal examination in an evening), and re-described the adnexeal pain I had already told her about. She then turned to me and snapped 'Draw those bloods and put up a drip.' She tossed her gloves into the bin and marched off. By this time, all the rest of the day-staff had left.

I assembled my phlebotomy and infusion equipment, only to dicover that my patient was the Veinless Woman, who also shrieked and prayed in French every time I came near her with a needle. After examining every inch of her arms, I went and told night-shift doctor that I wouldn't be able to get a drip up, but would draw the blood. Night-shift doctor sneered. I then succeeded in pricking my patient three times without so much as harvesting a drop of blood. I went back to tell night-shift doctor that I just couldn't get blood on the patient. She glared at me and said, 'Draw femoral. I'm going to labour ward.' By this time, it was 19:45. I should have been eating my supper. I returned to the patient's bed, to discover that she (a midwife herself) was attempting to draw blood from her own foot. And it was just as she was pulling back on the plunger that the Bronze Lady stood up and, yes, fell over, right onto my patient.

AAAAAAAAAAAH!

I helped the Bronze Lady back onto her bed, and asked a sister to dress the abrasions that had started to ooze on her right arm. As I pointed them out to the sister, Bronze Lady spotted them too, and started screaming hysterically. Begging her to stop, I pointed out that it was just a tiny bit of blood oozing up through an old scab, and that we would dress it nicely for her and give her something for pain. Turning back to the Veinless Woman, I nearly cried with relief when I saw that she'd managed to fill a syringe with some of her own dark blood.


Why is it that it's always at home-time that we find ourselves in the most frustrating situations? Or is it the very fact that it's home-time that makes some situations so frustrating? From the rude doctor, to the two screaming patients, to a woman who only seemed to have 2.5ml of accessible blood in her entire body, it all just seemed like too much to bear. I bought myself a giant chocolate King Cone on the way home. And it was good.

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posted by Karen Little @ 4:26 PM, ,




Face Value

On Wednesday night a well-known criminal presented at Casualties. He arrived in his prison-orange, handcuffed and manacled, with an entourage of guards. They were escorted to a room we call Theatre Two, which is basically a high-care room where patients who need constant monitoring are looked after. Closed off by sliding doors made of one-way glass, nobody can see into the room from outside, which is why the patient was placed there. The patient is an easily recognisable figure and caused a considerable stir merely by walking into the unit. It was decided that it would best to keep him where other patients couldn't gawk.

I was given his file and told to see him. Now, I was still a teenager when this person's court case was underway, and although his name was familiar to me and i knew he'd done bad things, I wasn't really sure what those things were.

Walking into Theatre Two, I was met by a clean, fit-looking, middle-aged man. He greeted me, and thanked me for seeing him. I explained that I was a student doctor, and asked him what his complaints were. He explained them to me concisely, and gave me an excellent history including past and current illnesses, operations, chronic medication, and so forth. I drew some blood on him and explained what we were going to test for, which other special investigations we were going to do, and then told him to tell a nurse or call me if he experienced any symptoms or distress.

Although I only Googled him and discovered the full extent of his crimes the following day, his name was familiar enough to me that I knew in my heart that he was a mass murderer. I knew that he'd probably killed with impunity, and that by rights I should loathe him. And yet, I found that I wanted to give him good service. I drew his blood very carefully, and went to a lot of effort to make sure he wasn't uncomfortable - checking up on him perhaps a little more often than I usually do on my patients. I kept him updated as each new result came out, explaining each one to him, and asking him if he had any questions. When one of his guards tried to hurry me up and get his results out quicker, I actually called the lab and demanded that they speed up their testing. It's true that many of the Casualty staff were hurrying me too - the man's presence was causing some of them considerable stress - but I think I gave him slightly better service than what I usually give my patients. I always do my best, but here I think maybe I did just a little bit better than my best.

And this bothered me a lot post-call. Had I really given a convicted mass-murderer preferential treatment? Had I really apologised when I put a needle in the arm that held a gun that killed so many? And if I had, why had I done it? Was it because the man was, in a way, famous, and I wanted to impress? Was it because I felt a rapport with the man because he came from a social class more similar to mine than many of the patients I see?

These questions hassled me all day, and left me heavily doubting my integrity. But now, I think, maybe I was being a bit hard on myself. You see, I took the patient the same way I take all my patients: at face value. If I took extra time to explain his results to him, it was because he asked me to, and questioned me in detail about them. Later that evening I took the same amount of time to explain what exactly angina is to a rehabilitated alcoholic, one I didn't know from a bar of soap, because he also asked me to. The prisoner was polite, and he didn't swear or spit at me, like so many of the patients we see in Casualties do. He was undemanding, and thanked me for my help and professionalism, and never once complained that he never saw a real doctor, and never told me that I look more like I belong in a high school uniform than in pair of scrubs. I appreciated his conduct, and reciprocated with good conduct. I wouldn't say that my conduct is ever bad, but there are times when I've been sharp with patients who were drunk and hurling abuse at me, or impatient with individuals who were uncooperative and stubborn.

There are a few things to learn from the whole situation, I think. The first is that you truly cannot judge a book by its cover: the physical appearance and conversation of an individual can easily hide the true person underneath. The second is that having a good patient makes it easy to be a good doctor. And the third is that there are times when we are bad doctors, even if we don't realise it. It is perhaps when we are with patients that we subconsciously believe deserve the least care, that we need to work the hardest to remain fair, consistent, and unjudgemental.

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posted by Karen Little @ 7:59 PM, ,




Respect, Man

As part of my family medicine rotation (which I started on Thursday - so long, anaesthetics!) I am required to do calls in Casualties at the district hospital in the city centre. My first call was on Friday night. I arrived at varsity on Friday morning, semi-fresh as usual and with lots of food. I left on Saturday morning with a pair of sore feet, a body-fluid-spattered white coat, and a newfound respect for the general practitioner.

Basically, anybody can pitch up at Casualties. In a well-functioning Casualties department there's supposed to be some sort of triage system, where those who urgently need medical care are sifted from those who can wait. The district hospital I'm currently at is massivley understaffed, so the triage system is a rather rudimentary one that basically consists of the sister sitting at the reception desk. The general rule is that anyone who has been brought by an ambulance, anyone who has a referral letter, and anyone who is bleeding or unconscious can come in. Otherwise, it's up to the patient to convince the sister of their disease severity, and up to the sister's gut to decide who needs to come in. A kind of uber-bouncer, I wouldn't want that sister's job for all the money in the world: several times I walked past the desk and saw patients screaming at her, threatening her with legal action, physical violence and lifelong misery.

Anyway, the result is that the casualty officer's next patient can be suffering from absolutely anything. On Friday night, I saw women with threatening abortions, appendicitis, dysfunctional uterine bleeding, urinary tract infections, soft-tissue shoulder injuries, asthma attacks, broken wrists, hyperglycaemia and possible deep vein thrombosis. I saw an eighteen year old boy with diabetic ketoacidosis (DKA), several stabbees (and trauma still ticks me off), a man with a ruptured-something in his abdomen after being hit by a car, and one man who (rather oddly, I thought) said he was a sexual predator and wanted to be admitted to the local psychiatric hospital. (After I'd finished interviewing him, I presented his case to one of the casualty officers I was working with, a superwoman of a doctor from Burma. 'This is a very danger-wous man, Ka-wen,' she said. For the rest of the evening I couldn't help but feel a little bit nervous every time I walked past him, and caught him staring at me.)

The thing is, the generalist has to know how to handle everything really well. Yesterday, explaining this newfound wisdom to Rowan, he said 'No duh!'. I suppose he doesn't really understand because he's a Lay Person. You see, if you're a urologist, you only have to do urology really well. Everything else is somebody else's problem. The generalist, on the other hand, has to know what to do for anyone in any kind of acute situation, and has to be able to do it well. For me, the most terrifying part of this is that I could miss something really important. The teenager happily typing an sms on his phone and telling his mom he wanted to go home was not someone I suspected of suffering from the life-threatening emergency that DKA is. The only sign of a ruptured hollow viscous in my pedestrian-vehicle accident patient was an abdomen that was a bit more resonant on percussion than usual. When he discovered he couldn't pass urine and we placed a catheter for him, the bag filled up almost instantly with bright red blood, and when his X-Rays came back there was a sliver of air under his right diaphragm - the man needed an urgent operation, and the only hint that he needed it on clinical examination was a bulgy tummy.

For my family medicine I have to complete a portfolio, and one of the components of this portfolio is a list of all the problems I manage during the rotation. Next to each case, I have to write one thing the case taught me. On Friday night I learnt a lot - from the art of reassurance to the use of a glucose sliding scale, it was probably the most practically challenging night of my degree so far. And although it was long, and tiring, and I barely had time to eat, I really enjoyed it.

posted by Karen Little @ 4:32 PM, ,




'Real' Problems

For the last year or so, my mom has been struggling with a condition called plantar fasciitis. Essentially, it's an inflammatory condition of the foot - her plantar fascia (the connective tissue on the sole of her foot) is sore and inflamed, making it difficult for her to walk or exercise.
Plantar fasciitis is one of those diseases that doctors don't really like, because of how limited they are when it comes to treating it. It's not like a middle ear infection, which will probably get better after a course of antibiotics. People with plantar fasciitis might experience some symptomatic relief by taking painkillers or anti-inflammatories, but there's no pill that will magically make the disease disappear, no quick injection that will solve their problem once and for all.

My mom is an active person - she used to walk her dogs for kilometres and kilometres every day. She did weekend hikes once a month, and went mountain biking every weekend. When her right foot became sore, it was a Big Deal. And there didn't seem to be anyone who could help her. She went to our GP, who recommended inner soles from an orthotist, which just seemed to make the pain worse. She went to an orthopedic surgeon a friend was bookkeeper to - after half-heartedly excluding a variety of diseases, he basically prescribed some rest. Even I tried to find help: I once attended a lecture by a rheumatologist, where plantar fasciitis was mentioned in passing. After the lecture I went to the doctor and asked if he thought my mother would benefit from seeing a rheumatologist. He snippily replied that he was sure that some overworked rheumatologist in this town wouldn't mind taking a break from treating people with 'real' problems to see my mother. I didn't tell him that I considered my mom's problem very 'real' - by that time her foot was so bad that she could barely clean her own house. Instead, I bit my lip and vowed never to refer any patients to him.

Eventually, after much frustration, disappointment and anger, my mother arrived at a sports' physician, who tried to treat her with physiotherapy and steroid injections in her foot. These didn't work, and my mom finally ended up at an orthopod specialising in feet, who did a small operation for her (on Monday - we're still waiting to find out if it worked).

The whole thing has been a very important lesson to me. Pain is a problem that general practitioners are faced with on a daily basis. People come with all sorts of pain: back pain, shoulder pain, stomach pain, ankle pain, head pain, heart pain. And often, no 'proper', medical cause can be found, and no 'proper' cure can be offered. We know plantar fasciitis is caused by overuse of a foot, but we don't know exactly what the mechanism is, and we are certainly at a bit of a loss when it comes to treating it. And because we struggle to find anything to do for the disease, and the others so much like it, we don't want to deal with it, or with the patients presenting with it. We often feel such patients are being unnecessarily difficult, whingy and annoying, and that they don't have 'real' problems. The truth is, these patients' problems are very real to them, and if we deal with them with impunity or disinterest, our patients will remember that and hold it against us forever.

posted by Karen Little @ 9:16 PM, ,


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