Sunday, September 10, 2006
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,
- At 8:51 PM, mike said...
I suppose it makes sense that a general practitioner has to take all the miscellaneous cases.
So you're definitely not doing the GP thing then?
- At 11:59 PM, groverjones said...
Sorry, Mike, a GP doesn't take all the "miscelllaneous" cases; they take ALL the cases, then work out whether they can be managed with or without the help of a specialist.
Karen, it can be a bastard of a job at times, and coming to terms with the inherent uncertainty of the job is the hardest task of GP training, much harder than learning the medicine. Essentially it all comes down to those age old questions: "Why is this person presenting with this illness to me today?" and "Is the patient 'sick' (ie needs something done) or 'not sick' (ie watch and wait.)
Enjoy your term; for me GP is the only part of medicine I could ever see myself working in.
- At 10:51 PM, Miette said...
There is something very exciting about being a generalist that keeps it on the top of my "possibilities" list. I think that groverjones above summed it up best in his second paragraph.
It's really freaky how people with life-threatening illnesses can present so nonchalantly... wow. The DKA case and the abdominal trauma case... I wonder how many times small signs like that are missed?
- At 9:09 PM, said...
karen, once again, respect. i could never do it. good to know we have people like you around, though.
- At 1:36 AM, On the Same Page said...
I'm all for the sister's position! Then I'd be able to finally say what never gets to be said: "You came in here in the middle of the night for THIS? Go home, you dumbass, take some Tylenol, and call your primary physician in the morning." Ah, that was refreshing.
- At 1:43 AM, FooFoo5 said...
The "On the Same Page" post is me. Blogger re-connected me with a different name if I don't sign in with Gmail. It never ends...
- At 9:23 AM, said...
I am entering first year medicine and am trying to find out as much information as possible about what i am getting myself into :) I read your comments about GP's and as frightening as it seems, it also sounds incredibly challenging and rewarding. Is there any advice you can give me for things to take particular note of in 1st year? Or any extra work you would have done if you had known it would help you later?
If you have time - I can imagine your schedule would be impossible - I would really appreciate hearing from you. My email address is firstname.lastname@example.org.
Thanks so much!