Milf's Anatomy

This Blogger Has Moved

2006-10-02T19:19:00.000+02:00

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.

Smooth

2006-09-30T10:30:00.000+02:00

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!

Cookies and Milk

2006-09-24T09:01:00.000+02:00

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!'

Grand Rounds is up!

2006-09-19T19:57:00.000+02:00

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.

When You've Earned a King Cone

2006-09-18T16:26:00.000+02:00

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.

Face Value

2006-09-15T19:59:00.000+02:00

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.

Respect, Man

2006-09-10T16:32:00.000+02:00

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.

'Real' Problems

2006-09-06T21:16:00.000+02:00

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.

Commenting Crisis

2006-09-04T09:56:00.001+02:00

OK, I'm aware of the commenting problem created by my changeover to Beta Blogger.

To comment on my blog now, you need to follow one of three options:

1. Sign in using your Google account
Don't use your old blogger login - use the login you do to get into Gmail, or your google account.

If you have no Google account:

2. Please select 'other' to comment
You will have space to type in your name and your own URL, so I will be able to visit you from your comment.

3. Comment as 'anonymous'
Obviously the least ideal, but you can still leave your name and URL in the comment body itself.

Please try these options out - I've tested them myself and they do seem to work. Let me know how it goes - and send lots of complaint letters to Blogger!

Also, I'll send out invites to people wanting to join Gmail (I think you can join by invite only) - send a request email to littlkaren[at]gmail[dot]com.

Karen the Eejit

2006-09-01T13:00:00.000+02:00

I was feeling all hurt and rejected over the course of the last few days because nobody was commenting on any of my posts. Although the statcounter was counting and counting away, the link at the bottom of each new article remained resolutely at '0 comments.' I was distressed.
'Gosh,' I thought. 'I must be boring people to death. They come, they yawn, they leave...'
I even resorted to begging people for comments in my sidebar - don't be shy! I exclaimed. And yet... comments there came none.

And then today I spoke to Wendy on the phone. We chatted about this and that, and then she asked, 'So why have you put comment moderation on your blog?'
Comment what?
I don't know how I did it, people, but somehow I put comment moderation on my blog without realising it. I quickly logged on to blogger, plunged into my posts window, and then the comment moderation window... And there they were. Stacks and stacks of comments, just waiting for blog-owner approval!

So, thank you all for writing to me, and telling me what you think. Comment moderation is off again, and you have free range.

Have a good weekend!

(The graphic is something I did on paintbrush to celebrate the end of anaesthetics - I just have to get the exam behind me now. Fitena always has these gorgeous graphics that I think she does on Paintbrush on her blog - thought I'd give it a try myself.)

Baby Catching

2006-08-31T15:13:00.000+02:00

Exactly one year ago, Iwan and I were both catching our final baby of our community obstetrics rotation. Over the course of the previous three weeks, we'd had to share a labour ward in a small primary care hospital with a copious number of student nurses, who were also there to learn all about parturition. These student nurses worked very set hours, and as you may well guess, these set hours coincided very heavily with daylight hours. Therefore, Iwan and I were forced to work nights, catching babies in the wee hours of the morning, prodding sleeping midwives to come and check that our episiotomies were sewn properly and to sign the deliveries off in our logbooks.

On average, we caught one or two babies a night each. We’d generally come in after dinner, at about 7pm, and then work until about three or four, depending on how many women came in and how imminent their delivery was. It was here, at this little district hospital, that I met my first Cuban doctor.

Now, a lot of negative hoo-ha has been made about the Cuban doctors in this country ever since their initial arrival a few years ago. I’m not exactly sure how the system works, but as I understand, the Cuban government allows their doctors to come and work here, as long as some of their earnings are sent back home. There have been doubts and questions about the role and competence of these doctors over the years, but let me tell you something: this country would be lost without them, because they are the ones who fill up the senior posts in out-of-the-way hospitals that no South African doctors want to work at.

One night, I finished catching my last baby at 2am. I decided to go to bed, leaving Iwan to finish off his last patient, which we thought would take another hour or two. At 7am, five hours later, I got an sms from him saying ‘Guess who’s still here…’ At 8am, I decided to go and offer him some moral support.

I strolled into the labour ward, and headed for the only cubicle that was curtained off. What I saw there is not what we call ‘safe practice’. Straddled atop the abdomen was a male nurse, pushing down hard on the uterus, his butt perched squarely over the mother-to-be’s face. Iwan was standing next to the woman shouting ‘Pusha, mamma, pusha!’ And at the foot of the bed, between the patient’s splayed legs, was The Cuban Doctor.

She was... well.. hirsute. Thick, glossy black locks streamed down her back and swayed into her eyes, which she kept pushing aside with meconium-stained gloves. Her arms were covered in thick, black down, and so were her legs. But she was also feminine. She wore and above-knee dress, and a giant religious pendant was nestled warmly between an immense set of breasts. And she was going to deliver this baby no matter what it took.

She grabbed the episiotomy scissors. She hacked away at the perineum for a while, and the screamed ‘These seesors are for cutting off the balls of the devil!’ before tossing them backwards over the cubicle curtain. The male nurse straddling the patient was looking moderately to severely uncomfortable, and she screamed at him, 'You didn't wash yourself today, and now you embarassed because the patient can smell you! Ahahahahaha!'

Turning her attention back to the patient, she joined Iwan in his encouragement. She grabbed a massive pair of delivery forceps, and clanged them together in the air above her head. ‘Vula, mamma, and pusha! Or else I am going to put this in your vagina!’ The baby’s head appeared, stat, quickly followed by the body. She clamped the cord and cut it. She smacked the baby hard on the bum, and it started screaming. The mother started crying. The Cuban Doctor exited the cubicle, washed her hands, and came back to loudly (and unintelligibly) tell me something about her own daughter. She then instructed us to sew the woman up, which I did.

As far as I know, that baby and mother experienced an uneventful post-partum period, and were discharged from the hospital later that day. Catching babies was a stressful time - I suffered one or two of my lowest moments in medicine ever during those few weeks - but it was also in many ways a wonderful time, and it was good to take a few minutes today to think about all that we've experienced over the last few years, now that our degree is drawing to a close.

Grand Rounds Is Up

2006-08-29T13:18:00.000+02:00

Garnd Rounds Vol 2 No 49 is up on Protect The Airway.

Grand Rounds is a weekly roundup of medically related posts, hosted on a different blog each week. Originally conceived by Nicholas Genes of Blogborygami, it's been running weekly for almost two years. You can check out the schedule and enquire about hosting or submitting here.

As I Lay Me Down To Sleep

2006-08-28T20:13:00.000+02:00

It's been just over two weeks since I last had any proper patient contact - although anaesthetists do actually talk to patients, it's definitely not to the same extent that other practitioners do. Because I'm only expected to be in theatre, and not to attend pre-op rounds, I get even less contact with patients - my interaction with them usually comes down to, 'Hi, I'm Karen. I'm the student for anaesthetics. Do you mind if I put a drip up on you?' A little later, I might say 'Have a good sleep!', and that's it. After the op, the patient is wheeled out to recovery, and I'm highly unlikely to see him or her again.

I guess this is why a lot of people choose anaesthetics - due to the lack of day-to-day care. There are no lingering patients, no little old ladies who just won't get better (or worse, for that matter). There are complications - sudden and sometimes disastrous ones - but they're dealt with quickly and with finality. As one anaesthetist said, bemoaning his rotation through ICU, 'I studied anaesthetics because I don't want to have to sit around and try to make them better. Now, I have to try to make people better all day, and all they do is get worse.' Anaesthetists are not in the business to cure - they're there to take your pain away and to help the surgeon do his job. (If there are any anaesthetists reading this: am I right? Or am I wrong? Let me know in the comments section.)

I don't think anaesthetics is really for me. For a start, it can be really boring. It's OK if you're working on something like a Urology scope list, where all the procedures are quick and you're up and about all the time, but getting stuck on a seven hour vascular surgery procedure is hell - you have to make sure you have reading material with you all the time. On the other hand, it can be extremely stressful: anaesthetic drugs are dangerous, and the complications they cause need very instant attention, and the slightest bit of hesitation could be disastrous. One anaesthetist the other day said, 'Anaesthetics can be really boring if you're good, but really exciting if you're bad.' It's sort-of a lose-lose situation, don't you think?

Another down side is that you have to deal with and work with doctors from other specialties all day long. Now, I don't know how it is in other hospitals, but over here, specialists from different fields live most of their lives in an uneasy truce, with surgeons believing they're better than gynaes, gynaes believing anaesthetists don't have the right priorities, anaesthetists thinking physicians know nothing about physiology, and so on. It's a constant battle to prove your superiority and assert your will over others, and anaesthetists need to deal with that all day long. Yuk.

But, all that being said, I am enjoying the rotation. There is something rather beautiful about how all the mechanisms that keep a person alive can be manipulated by a few drugs, and the physiology of anaesthetics is extremely interesting. Also, I've had stacks and stacks of opportunity to place drips - I get most of them in on my first try now, even on little children. Hurrah! I'm still attempting to master the art of the intubation however, and the perfect spinal eludes me still. I've only got one week left in the rotation, and then I'm off to Family Medicine, back to the old 'Unselected Patient', which will be a whole new experience entirely.

The Children of Today

2006-08-24T20:38:00.000+02:00

Lindiwe* was quite fussy for someone who looked like she had a BMI of 2. One call, as was tradition, I asked her if there was something I could get her, and she told me she wanted a Milo (you know - the cold kind, that comes in a green box and you drink with a straw). The cafeteria didn't have that, so I got her chocolate milk instead. She looked at me with her huge eyes, staring up over her huge cheekbones and said in her high-pitched voice, 'Dis nie lekker nie.' A few hours later, when I came back to check on her, the milk was still untouched.

When we first arrived at paediatrics, we were horrified and indignant that in this era of plenty, a child could be as abandoned, neglected and abused as Lindiwe. Eight years old and measuring in at a mere eight kilograms, she was the poster-girl for marasmus. She had an enormous head perched on a body made of twigs. I'm sure if she'd had a little meat on her she would've been pretty, but her face looked like a skull, and when she smiled she revealed an eery set of big, white teeth. Lindiwe, however, was not the product of abuse by neglect. Her family had fed her plenty, and as we would see over the next few weeks we spent in the paeds wards, so did the hospital. In an institution known for doing things the cheapest way possible, no expense was spared when it came to Lindiwe: she got Cokes, Milos, starchy, high-calorie, tasty meals, heaps of fruit and vegetables, energy drinks and chocolates. Doctors and students brought her Steers chips (she licked the barbeque salt off) and KFC (she nibbled at the skin). But her tiny body was impossibly resistant to all the food we gave her, riddled as it was by a virus she'd contracted merely through the act of being born: HIV.

On good days, she would wonder about the ward, talking to other children, and playing with the doctors' stethoscopes. Some of the other mothers visiting their children would sometimes braid her hair, or play boardgames or build puzzles with her. On medium days, Lindiwe would sit at the table near the door, her bottom bones protected by a huge cushion shaped like a daisy, her head resting on her hospital pillow which had been placed on the table for her. Her scapulae stuck out from her back like a pair of big angel-wings. On bad days, Lindiwe would not get out of bed at all, and would reach her arms out to us as we passed by, asking us to pick her up. We usually did.

She was remarkably brave, and only ever cried when we did tests on her to try to discover which new organism was opportunistically making a home for itself in her body. I never saw her mother visiting her, and one night when she was looking particularly depressed, I asked her what was wrong. She said, 'I don't feel nice, and I miss my Gogo.' She cried and cried until she fell asleep.

Lindiwe is unfortunately not one of a kind. The paediatrics ward I worked in was full of children with HIV. There were a few kids with 'normal' childhood diseases - febrile convulsions, pneumonia and diarrhoea (with no underlying pathology), and the like - but most of the kids were there after being struck down by some hideous HIV-related illness. Tuberculosis, pneumocyctis carinii pneumonia, septic lymph nodes, and HIV encephalitis were the norm, and every day brought in a fresh wave of children with almost impossible problems, most of them stunted, wasted and marasmic.

Some of the children got better, some of them got transferred to a nearby hospice, and some of them died. The general goal was to get the child's current infection under control, start treating their TB, and then refer them to the Anti-Retroviral Clinic, which was a happy place packed with super-healthy children, ones you would never ever say had a lifelong, life-threatening disease. Lindiwe, unfortunately, proved resistant to all our efforts. In spite of all the snacks we gave her, she never picked up weight. TB treatment did nothing for her, and every time we thought we had her infections under control, she'd spike another temperature. Eventually, we conceded defeat, electing not to torture her anymore with lumbar punctures, blood tests, and supra-pubic urine specimens. We sent her home to her Gogo for palliation. Although it was heartbreaking, I think the doctors chose to do the right thing.

*Name has been changed

Gutless Wonder

2006-08-21T12:50:00.000+02:00

On Thursday night I was on call for anaesthetics again. I went up to the obstetrics theatre because there were a few caesarean sections lined up, and the anaesthetist said I could do one of the spinals. I was pleased. Spinals are an important thing to learn to do. I set up my sterile trolley, positioned the patient, and scrubbed up. I came back, donned my gloves, cleaned the patient's back, and picked up my spinal needle. It was at this point (about 1.5 minutes into the entire procedure - I wasn't dawdling), that the obstetrician said to me, 'No pressure or anything, but could you please make this chop-chop?' She waved her hand in the air to emphasise the last two words. Chop-chop.

What I wish I'd said to her is 'This is a teaching hospital, and I'm here to learn, and so I'm going to take my time and do this properly.' Forty minutes later, when she was still tooling about in the patient's pelvis and had bled her all the way into ICU, I wish I'd said 'Could you please hurry it up a bit?'

I didn't say any of these things. I just looked bug-eyed for a second, attempted the spinal twice, failed, and handed over to the anaesthetist.

Why didn't I say anything? Well first, and probably foremost, I didn't think of it at the time. And second, you never know when you're going to bump into someone again. Whilst my back-chat might have borne no weight in terms of the rest of my undergraduate degree, I might want to specialise in O&G in five years time, only to discover that the woman I'd sassed is to be one of my consultants. If I stay in this city, there's a huge chance I'll have to work with her again, no matter what I specialise in: pediatrics, anaesthetics, surgery, internal medicine, or even general practice - all the disciplines interact with gynaes at some point or the other. And she might remember me, and might make my life difficult. Which is why I'm glad I never said anything.

But at the same time, I'm annoyed with myself. Last year, one of my best friends was a final year girl called Anne, whom I often worked with. We were once on a ward round, when a registrar dropped something, and said to her, 'Pick that up.'

Anne looked at him, and said, 'Shame, is there something wrong with your hands?'

'No,' he said.

'Well then pick it up yourself.'

And he did. I wish I had the courage to stick up for myself like Anne does, and wasn't always terrfied that I'd have to kiss someone's butt in the future to make up for what I'd said in the past. I wish I wasn't such a gutless wonder.

Top Five Oh... My... Gosh...

2006-08-19T11:48:00.000+02:00

I'm loving the Top 5 orgy that Arcadia started so much that I thought I'd share a bit of it with you here on Milf's. Here are my Top Five Oh... My... Gosh... moments from the last six years as a medical student.

1. And then it fell off in my hand
Urology rotation, 4th year

We're sent to talk to and examine a fifty-something year old patient in the male ward. As soon as we ask him what's wrong, he pulls down his pants. We stare. We look at each other, to make sure each of us isn't the only one confused. We stare some more. His penis... well, it's not there. What happened? we ask. The man tells us that one day, a few months ago, he noticed a bump at the base of his penis. He didn't think too much of it, hoping it would go away. It didn't. It got larger and larger, until he couldn't pee anymore, and he went to his GP. The GP made a spot diagnosis of penile cancer, and forwarded the patient to the urology department at the local hospital, stat (as we say). The man elected not to go to the hospital. The tumour then started to outgrow its blood supply, and as we expect, became necrotic in the middle. This dead area began to erode through the man's penis until a few day before we saw him, at which point it, well, fell off in his hand.
'What did you do with it?' somebody asks. He looks at us like we're stupid.
'I flushed it down the toilet, of course.'

2. Suicide Saturday
Family Medicine Rotation, 5th year

Here's a link to a post I did a while back on Sort-Of Here, about I man I saw once in casualties who had shot himself in the face.

3. Palpation
Pregnancy and Neonatology block, 3rd year
Finally! We get to touch patients properly. And the first patients we touch are healthy, happy pregnant women. I'll always remember the first time I properly examined an abdomen (and a pregnant one, for that matter), under the guidance of a senior obstetrics consultant. He showed us how to measure the size of the uterus, how to work out which end was baby-head and which end was baby-bum. He showed us what he like to call his 'umbilical walk' - the horizontal movement of your fingers across the abdomen, in line with the belly button, to figure out which side the baby's back is on. He then took my hand and said, 'Feel here - that's a little leg.' And it was. That was probably the most exciting moment I'd had in medicine up until that point, and I instantly fell in love with O&G.

4. Sex Ed

Obstetrics and Gynaecology Elective, The Bahamas, 4th year

I was sitting in with a consultant in the gynaecology clinic at a hospital in Nassau. A woman came in, for what I remember as a general gynae check-up. She complained only of a small pimple on one of her labia. The doctor examined her, and told her there was nothing to worry about. As she was about fifty years old, the doctor also gave her some advice on menopause, and what she should expect from it. He told her about the mood swings, the hot flushes, the vaginal dryness. And he offered treatment advice. Now, here, when we're giving advice on the management of vaginal dryness, we tell women about things like Hormone Replacement Therapy, estrogen creams, and the use of lubricants such as KY Jelly. The consultant didn't mention these things. He said, 'It'll get dry down there, and then when you wanna have some fun, you have to get your man to lick it up a little to get it nice and wet.'

What?

I nearly died right there and then, in my little student's chair. I thought she was going to slap him. But she didn't even bat an eye. She just asked, 'But what if he sees that little pimple then?'

5. Thank you

Community Obstetrics Rotation, 5th year

We 'catch our babies' in various rural hospitals spread out all over the country. We get assigned to one or other of these hospitals, go there for three weeks, work day and night, until we've filled our logbooks and are skilled enough to be considered competent midwives. I often feel like patients look at us as doctors and think we're the enemy. They just see all the pain we cause them, the way we disrupt their lives and routines with diagnoses and management plans, and then the often less-than-wonderful results we inflict on them. But for the first time, in my community obstetrics rotation, I didn't feel like that. Women whose babies I delivered said things like thank you, I appreciate your help, and I couldn't have done it without you. They asked me to name their babies. Obviously, I don't do this to be thanked or adored, but it was so good, for the first time, to actually feel like I was being useful, and had done some good for someone.

Whoops

2006-08-17T12:52:00.000+02:00

Ten pm last night, orthopaedic theatre, I'm on call for anaesthetics. I'm leaning over a patient, putting up a drip (which I get in!). I'm just busy wiping up the spilled blood and taping down the drip line, when I feel a pair of hands grab my pants from the back. The hands pull my trousers up - way up. I whip around, to come face to face with scrub-sister in charge. You know what she looks like: she's a big, black mama - the kind that clutches you to her bosom and suffocates you there, the kind that gives you just one look to make you back away from the sterile trolley at a rate of knots. And she is there, two centimetres away from my face, holding my waistband up so that it's in line with my ears.
'Uh... sister?'
'Your G-String is hanging out, and there's a nice looking, muslim boy standing behind you'
I glance over her shoulder to see that there is indeed a nice, possibly muslim, male fifth year behind her. He's staring fixedly at a point in the corner of the theatre.
'Oh, sorry... you know how big they make these pants...'
'Is it that the pants are too big, or are you too small?' She glares at me.
'I suppose... um... it's a bit of both?'

'Hmph.'
With that, she lets go of my waistband, which sinks down from my ears to my hips. She then turns around and stomps off.

Trust me, I'm (almost) a doctor

2006-08-16T15:02:00.000+02:00

)It would appear that I didn't do quite as badly on my surgical clinical exam as what I thought I had - today the list of people required to rewrite in November came out, and I wasn't on it! This means that I 'promoted' the rotation - I got more than 60% for the test immediately after the rotation, and as such don't have to do a final at the end of the year.

People always get freaked out when I say I need 60% to pass. They go 'You mean, you only need to know sixty percent of medicine to become a doctor? Forty percent of diseases... you won't know how to deal with?' This is not the case. In order to get sixty percent, I had to convince my examiners that I am a safe doctor. That is, I wouldn't miss a life-threatening disease in my patient, I wouldn't worsen my patient's condition, and I would manage the patient as well as a brand new GP should be able to, and then refer as necessary.

So, if you take the example of my clinical case: I had a patient with small intestinal cancer, or GIST, a rare disease. I didn't reach that diagnosis. What I did pick up, however, is that my patient most definitely did have an abdominal cancer of some sort and that he had lung metastases. I also knew which investigations to do for the patient, and I knew that he needed a specialised surgeon to manage him. Therefore, although I didn't know his exact pathology, I still did the best I could for him, or what a 'reasonable practitioner' with my level of experience should have done for him. My patient wasn't worse-off after I'd seen him, and I didn't kill him or neglect to do something that would have led to his death. Therefore, I passed. Granted, if I'd been able to spew up a pile of information about GIST, I might've gotten a distinction. But I didn't, and that's OK (I keep telling myself).

Now, who wants to be my patient?

Pants On Fire

2006-08-15T12:02:00.000+02:00

Rotating through anaesthetics always reminds me of the first operation I had that I can remember. Born with a cleft lip and palate, I've had many procedures, but the first one I can recall took place the year before I went to Primary School. It was a small bit of plastic surgery to my upper lip.

Little kids think operations are cool. I was pretty excited about the operation, imagining my stitches, thrilled at the thought of spending a night in a hospital. (Pah! I used to look forward to spending the night at a hospital!) I remember how bright and pretty the children's ward was, how I envied the kid with his leg all wrapped up in plaster and stretched out in some weird suspension bridge hanging over his bed, how cool the little hospital bands were that they strapped around my wrist. And I became almost delirious with excitement when the anaesthetist came around, and told me I was going to ride on the Magic Balloon.

'Oooh! Oooh!' I shrieked (I was a bit ape-like as a child), 'The Magic Balloon! Mommy, he said I can ride on the magic balloon!'

'Hmmm... That's nice, sweetie...' she said.

I bounced around the bed, cackling in delight. A Magic Balloon! I could hardly wait.

There's nothing like being wheeled into an operating room. I watch the flourescent lights flash by as I race down the passages, strangely dressed men and women flanking my stretcher. My mom and dad's faces, following me anxiously, saying goodbye and good luck as the big swinging doors close behind me. Before I know it, I'm on a thin little bed in a big, bright room full of beeping, sucking machines. And there, in front of me, is the man who is going to let me ride on the Magic Balloon. At last! He smiles at me, and asks me how I'm doing.

'Are you ready for the Magic Balloon?'

I nod eagerly. He holds up a big, ugly mask to my face, and says 'Breathe in deeply...'

I think, 'This isn't right...' and the last thing to cross my mind, as he pumps my little lungs full of nasty sevoflurane is 'Big.... Fat.... Liar....'

Waking up is awful. My throat hurts, and I feel nauseous. I try to say 'Mommy...' but discover my mouth is all stiff, and there's something nasty and bug-like attached to my upper lip. I doze off and wake up a few times. When I finally wake up properly, a big round nurse puts a nice meal of roast chicken and rice and veggies and gravy in front of me (I'm also a piglet of a child - I love food). I'm all ready to dig in, when my mom says 'Hang on a second.' She calls the nurse over. I'm getting a bad feeling.

'Is she allowed to eat that?' my mom asks the sister. The sister checks her chart. My nice, big, gravy dinner disappears. In its place is a bowl of jelly, a bowl of ice-cream, and some custard. Invalid food. Tears well. Operations are not cool.

On the plus side, when I went back to Nursery School, I was allowed to sit in the Special Chair, usually reserved for birthday boys and girls, for a day. Also, I had twelve - twelve! - big stitches in my upper lip. When other kids asked what had happened, I would nonchalantly murmur 'Oh, you know... I had an Operation.'

'Cool!' they would yell, and I would beam inside.

There was a bit of a sad moment when the swimming season started, and all the other kids (my little brother included) hit the pool for swimming lessons without me, because my mom was worried the pool water would infect my wound, which is a pretty valid fear. We don't like patients to wallow in water when they have open wounds - it encourages germ growth.

Operations are not cool, but they're also, unfortunately, a necessary evil. And although I was pretty ticked off with that anaesthetist at the time, I know he was just trying to make the whole experience a little less frightening for me. I'm still working on what I'm going to say to kids who are about to go under. In fact, if I hadn't experienced the crushing disappointment of the ride of my life turning out to be a long, heavy snooze, I would probably have tried to use the Magic Balloon trick as well. But little children, like dogs, can't be lied to. There's nothing worse than the mournful look of a child you've just let down.

Five things you should know before you start studying Medicine

2006-08-12T10:25:00.000+02:00

1. There's no such thing as a cure

Towards the end of House of God, the Leggo is talking to his disillusioned interns:

'But surely we can help them. Why, we even cure.' [says the Leggo]

'Most of us wouldn't know a cure if we found one in a Cracker Jack Box,' said Eddie. 'I haven't cured anybody yet and I don't know an intern who has. We're all still waiting for number one.'

It's true, you know. There's no such thing as cure. Sure, we can control diseases - we can try to take away the symptoms, or we can try to slow down disease progression. Surgeons believe they cure people by cutting disease out, but what they're really doing is disaster control. The great diseases of our time - hypertension, diabetes, epilepsy, asthma, HIV (to name but a few) - they have no cures, and probably never will. We can give medicines to make the diseases sub-clinical. HIV is an excellent example: antiretrovirals now kill circulating viruses and prevent viral replication, but you still have HIV, and we don't have anything that can change that.

There are infectious diseases we can rid people of such as pneumonia, meningitis and tuberculosis, but those diseases can just come back over and over again. You may cure someone's chest infection today, but in a few years' time, they'll come back with another, as well as a chronic disease you'll never rid them of.

I've said it before: in medicine, we don't save lives - we just prolong them. That's not necessarily a bad thing - nobody wants to live forever - but it's something you've got to come to terms with, and it's one of those slow, creeping realisations that could really get you down.

2. Doctors are no longer respected

In the past, doctors were highly revered members of society. Seen as great and learned, the rest of the populace looked up to them with awe and respect. Unfortunately, the general public has now realised what we knew about ourselves all along: we're just mechanics. And nobody loves their mechanic.

As a doctor, you're going to take abuse. Many people now see doctors as opportunistic thieves who thrive on the misery of others. You may think I'm exaggerating, but it happens often at parties and other social gatherings. Some idiot will first try to squeeze some advice out of you ('I've got this lump here...') and then start slagging off the medical profession in general, complaining about doctors fees, the price of medicines, the low cure rate, and so forth. I don't have statistics to back myself up, but doctors are probably the most highly sued group of people in the world at the moment. Investigative journalism shows (South Africans: think Carte Blanche), newspapers and other public information services provide daily accounts of the failures, mistakes and atrocities of the medical profession. We're under constant attack.

The public now (rightly) expects a service from their health care practitioners, and they are easily left dissatisfied. Remember this, you hopeful future medical students. Patients are not going to hold your hand and say 'Oh, thank you doctor!' They're going to look at their scars and say'And this...?'

3. Doctors do not get rich quick

There are doctors who rake it in. There are doctors with houses in Johannesburg, Cape Town, and Provence. Their are doctors who own fleets of Ferraris. These doctors are old, somewhat lucky, and very often they are talented in ways that you or I will never be.

I know - private banks try to recruit young medical students because of their 'future earning potential'. Pretty girls marry ugly interns because of the possibility of a nice mansion in the future. But, friends, let me tell you: your chartered accountant and actuary friends will have bought their first Beemers long before you've even managed to trade your student skedonk in.

Think about it. Firstly, you have to study for a minimum of six years. That means, by the time you've finished the basic degree, all your other friends have been qualified for two years already. Then, in this country, you're bound to the state for another three years: two for internship, and one for community service. After this, you can try to go into private practice as a GP, but you're unlikely to have the capital to fund a venture such as this. If you choose to specialise, (and you're lucky enough to get a registrar post immediately after com serv), you're going to be slogging away in a government hospital for at least another four years. Now you do the maths: if you started medicine immediately after high school, when you were eighteen, you'll be thirty-one by the time you're done specialising (if all goes smoothly). Now, at an age when many have bought their first house already, have almost completed their families, and are very nice and settled down, you may start to amass your fortune. Good luck.

4. Doctors are not all that good-looking

Girls, I know that you think all male doctors look like Carter from ER, JD or Turk from Scrubs, David Shepherd from Gray's Anatomy, or House from, er, House. Boys, you're picturing Elliott or Carla from Scrubs, Abby from ER, or Meredith or Izzy from Gray's.

In real life, doctors look like real people. And often, a little worse. The men... well, on my first day at medical campus, I'll admit I was overwhelmed by all the male specimens lounging about in their white coats. But the novelty wears off. Many male doctors are wonderful people, but many are temperamental, arrogant, peevish and nerdy. Some of the women are gorgeous in spirit and body, but many carry a chip so large that they actually have no shoulder left, and tend to be overly hostile and aggressive towards anybody they suspect may try to undermine them. Guys, if you think you're going to net yourself a hot little nurse, think again. The only nurse-doctor couple to get together after Chris Barnard married Louwtjie (and we know how that turned out) was Turk and Carla. And that was on TV. Most of the nurses you'll encounter are harassed women who'd rather be at home with their children than helping you to find a pair of sterile gloves.

I know it looks so romantic when that pretty nurse with the curly hair from ER goes home with the hot russian doctor after work, but in reality, post-shift doctors have hair on their teeth and something that smells like a dead hamster in their armpits. Many doctors say they just couldn't be bothered to put on makeup in the morning, never have time to go to gym, and constantly walk around with something that could be paint or blood or their coat-cuffs.

Don't go into medicine to marry up. It's probably not going to happen.

5. All that being said

Medicine is still a wonderful profession, and I wouldn't choose to do anything else.

The gist of things

2006-08-10T11:32:00.000+02:00

Did you know that GIST stands for Gastro-Intestinal Stromal Tumours? I didn't, until last week Friday, which is a shame, because the patient I was given for my practical surgery exam had just that.

I don't know how it is in other fields, but in medicine, oral and practical exams can only be likened to pooing in public. It's awkward, hideously embarassing, there's nothing you can do about it, and you can only hope that the class bully doesn't point at you and say 'Ha-ha! She crapped her pants!'

On Friday, we were subjected to a series of three humiliations, known here as the Big Surgery Orals. The first humiliation consists of a patient exam, and the subsequent presentation of that patient to a pair of consultants (who you hope are mature enough not to point and say 'Ha-ha! She crapped her pants!'). The second humiliation is the X-Ray exam, where a pair of consultants put up, say, a CT scan, and sigh heavily when you can't identify basic structures such as the liver. (Once again, you hope they're mature enough not to wrinkle their noses and say 'What's that smell...?'). The third humiliation is a pure oral, where a pair of consultants hurl questions at you and generally intimidate you so much that you can't remember basic things, such as where the appendix is (and again, you hope they don't point to your soiled undies and giggle).

I think orals are unfair, because in those forty-five minutes of sheer torture, you can't possibly hope to demonstrate what you've learned over the course of a seven-week rotation or, indeed, a six-year course in medicine.

My patient had a cancer of his small intestine. This is a disease so rare, that it falls into that category we in medicine refer to as 'the pink canaries'. I didn't want to talk about the small intestine cancers, so I actively tried to steer my examiners in the direction of the pancreas, saying 'But... even though he has none of the other signs... he could still have pancreatic head carcinoma?' (I said something along these lines several times). They didn't fall for the trick. They wanted to talk about the small intestine. I was granted a brief reprieve when they stuck the CT scan up and asked me to tell them what I saw. I pointed at something and said 'There's a big tumour here.' The thing I was pointing at turned out to be the stomach. *sigh*

For the X-Ray exam, I got a CT Scan taken of a person with... you guessed it... pancreatic head carcinoma. I missed this cancer. (Although, in my defence, it was really small, and I didn't miss the other signs of the cancer).

'How do you expect the patient to look?' asked consultant number one.

'Bright, bright yellow,' said I.

'We have a nice medical term for that.'

'Oh... very jaundiced?'

'We call that deeply jaundiced, my dear. Deeply.'

Consultant number two put up an abdominal X-ray, and I correctly pointed out all the dilated colon. The consultant then made a big loop sign on the X-ray. 'What's this?' he asked.

'Uh... more dilated colon?'

He made the loop sign again, but bigger.

'What's this?'

'Uh.... dilated descending colon?'

'What's this?' He made the loop sign again.

'Oh! Oh! Sigmoid volvulus!'

'Well, why didn't you just say so?'

(Because, you grumpy old tumour, you're making me nervous and I can't think)

For my oral, one of the consultants who had been present for my patient presentation asked me what I'd like to talk about. At the time I was relieved, and had a passable discussion with him about colon cancer, but in retrospect, maybe he just gave me the open option to give me an opportunity to make up for my dismal performance in the patient exam. While we chatted about tumours of the large bowel, the uber-consultant sat staring at the desk, lower lip protruding miserably. His big specialty is trauma and the head and neck (earlier in the day he'd done what can only be described as rape to my friend Anria - he asked her to classify salivary gland tumours, as well as varicose veins. Eek!). When I was done with the colon, this old man asked me about the differential diagnosis for right-sided groin pain in a young female. Now, this is not a difficult question. I know the answer very well. First I said 'It could be a salpingo-oophoritis' (an infection of the ovary and tube). This was the wrong thing to say. He launched into a tirade about how this problem was associated with vaginal discharge, that it was a bilateral pain, blah blah blah blah blah. (The only thing he didn't say was 'Ha-ha! She crapped her pants!') When he was done, I said 'Uh, ovarian torsion?' (all self-confidence now gone, of course).

'Yes man! Why didn't you say so in the first place?' I couldn't answer him.

Five minutes later, I was expelled from the room, leaving an unpleasant stench behind.

In the passage, I bumped into a nervous anaesthetist, waiting to talk to uber-consultant about some or other patient. He asked me how it went. 'Oh, you know...' I said. He nodded in understanding. I'm glad there are other people out there who get it.

Loser

2006-08-07T11:29:00.000+02:00

Groverjones left a comment on my last post regarding the trick to not 'getting shouted at' - he said that if we always clean up behind ourselves, not leaving all our rubbish and medical waste for the ward nurses to deal with, our halos will only be slightly tarnished when we accidentally soak their linen with patient blood. This put me in mind of a conversation Iwan* overheard in the cafeteria the other day:

He was standing in the queue to buy himself a reward (for, you know... getting up in the morning) when he happened to overhear a particularly sanctimonious house doctor telling her friends about a nurse who'd told her to clean up after herself.
'..and I said,' (she was telling her friends), 'sister, am I here to tidy up, or am I here to save lives?'

What
a
loser!

There's no excuse for this kind of inflated opinion of your own importance.

*Speaking of Iwan: on Thursday night he was getting all prepared for his ~~execution~~ surgery oral on Friday. He hauled out an old, long white coat he hadn't used in a while, to discover that two of the buttons were missing. He then diligently removed the remaining buttons, and then sewed for matching buttons onto the coat. After that, he washed it, and ironed it, and then hung it up on his wardrobe door. It was at this point he saw, written in tiny letters on the left shoulder, the words

'Iwan is a lurv machine! Hairy like animal!'

We think this little testimonial to Iwan's virility was left there by our friend Anria. It's a good thing he noticed it in time... It would've been highly unfortunate if it had first been spotted by the seventy year old consultant leaning over Iwan's shoulder as he squinted at a CT scan on Friday!

PS: Whoops! Originally posted the wrong link to groverjones - I've changed it to the link he sent me. It now links to his home page.

IVI

2006-08-03T13:31:00.000+02:00

A friend of mine has little cards that say 'If you fuck like you park, you're never going to get it in.' I have a morbid fear that one day a patient is going to look at me and say 'If you fuck like you put up drips....'

The Intravenous Infusion is my nemesis. After six years of medicine (three and a half of those in clinical rotations) and thousands of attempts at infusion placements, I am still disproportionately relieved every time the cannula goes into a vein and fluid actually starts dripping through the chamber. Along with the sound of my back bumper crunching into a tree and the sound of my cellphone plopping into the swimming pool, I dread the sound of a nurse's voice saying 'Student! Student! Please can you help us with a drip...'

Dripping is not like drawing blood. For a start, you can't put the drip in the elbow (cubital fossa) where the veins are nice and big and close to the surface, because as soon as the patient nods off (which patients are very apt to do) s/he is going to bend his/her elbow and scrunch your nice, soft cannula into a tight little 'V' that allows no saline, antibiotics or analgesia to pass. Secondly, drawing blood simply requires you to get the tip of the needle (which has, like, a 1mm diameter) into a vessel and suck. Dripping requires you to insert an entire cannula (which is, like, 6cm long) into a vein, and to then infuse fluids through this cannula for a number of hours or days. This is hard because:

Veins contain valves. The cannula can often absolutely not pass through these valves.
Veins bend. You can then drive your needle through the vein wall further upstream, giving the nice old lady you're busy working on a huge haematoma and an uncheerful disposition. (This particular trick is known as 'popping' the vein)

You can stuff drips up in other ways too. You can mistakenly infuse an entire litre of saline into a person's forearm fat instead of their cephalic vein (this trick is known as 'tissuing' the drip). The patient's arm will then swell up like a balloon, become exquisitely tender, and be lost to all near-future drip attempts. If you actually get the cannula into a vein, you can spill a few hundred millilitres of the patient's blood on the nurse's nice clean sheets while you fumble for the drip line to attach to the cannula (this trick is known as 'getting shouted at'). Another very special trick I once performed involved putting up a drip perfectly, and then watching in morbid fascination as first the drip line, then the drip chamber, and then the drip bag filled up with bright red blood. The patient and I were both staring blankly at the now-cherry coloured bag of Ringer's when the surgery consultant happened upon us.

'My dear,' he hissed facetiously,'we stopped bleeding patients in the eighteenth century.' With that, he ripped my tourniquet off the patient's arm and stomped off. The blood started running back into the patient's arm. I smiled sheepishly.

There are many things I can do well - place catheters and nasogastric tubes and draw blood and suture wounds - but the IV line is still something I just can't seem to master. We have a game we play amongst ourselves: if there is a particularly difficult patient to drip (one that has had a stroke/is in hypovolaemic shock/is morbidly obese), we say that whoever gets the drip up can call themselves Drip God for a day. I am never Drip God. I'm just the person who ruins all the nice veins so that we have to call the Drip God in. I don't know how many times I've sat with a patient's arm in my lap, abandoned cannulas sticking out all over their pin-cushionoid limb, saying, 'You know I'm not hurting you on purpose, right?'

I guess the trick is plain perserverence. The other day I was in theatre when an anaesthetist stuck a cannula as thick as a pencil into the tiniest little vein possible on the patient's hand.

'Why do you do that?' someone asked him.

'Because I can,' he said.

Maybe, one day, I'll be able to, too.

12 sleeps

2006-07-30T18:44:00.000+02:00

Things are a bit busy on the University side at the moment, which is why I haven't posted in the last few days. I have two weeks left of my surgery rotation. That's:

2 weekday calls
2 weekend calls
2 clinics
2 elective theatre days
2 academic ward rounds
1 surgery oral exam
1 surgery X-Ray exam
1 surgery patient exam
1 paediatrics/plastic surgery OSCE
1 general surgery written exam
12 sleeps till a big-ass piss-up

Wish me luck for it all, folks! I'll give you a decent post again as soon as possible. In the meantime, check out Sort-Of Here for my July post of the month, and some thoughts on the state of Johannesburg.

About Turn

2006-07-26T22:25:00.000+02:00

Today we got to see the softer side of The Prophet.

It was in connection with a female patient he'd operated on a few days ago: he'd done an axillary lumpectomy for her. That is, he'd removed a node in her armpit. I'll be honest: I don't know the patient's full history. She's about forty years old, and has breast implants. I don't know whether or not he knew she had breast cancer at the time of the procedure, or if he only had a high index of suspicion.

Anyway, she was discharged the day after the lumpectomy, to come back for her histology results at a later date. Then, yesterday, she was admitted by the physicians when she presented to the hospital in severe respiratory distress. The physicians did a CT scan, which showed tumour in both of her breasts, with infiltration of both of her lungs. They consulted the surgeons.

When hearing of the consultation, The Prophet first declared that all physicians were 'brrrrainless idiots' in general, and a particular foreign one that he'd dealt with personally a nincompoop. He then screamed (in true Prophet style) that '...we'll do a biopsy for them, nothing more!'

On arrival in the Medical ward, his harrassed team (my friends and I) quickly gathered all the tools necessary to do a breast lump biopsy. We delivered them to The Prophet, who was standing next to the extremely distressed patient. She was in a lot of pain, breathing very rapidly and very shallowly. She made a gasping request for the oxygen mask, which she pushed against her face as The Prophet palpated her breast, looking for the best site to biopsy the mass.

As he prepared for the procedure, The Change came over him. The foaming, shrieking prima dona we are all so used to was suddenly replaced by a man with the most gorgeous bedside manner.

'Now, my dear,' said The Prophet, in a voice we'd never heard before, 'I'm going to give you a small injection to numb the area. I'm just going to clean a bit first, so it might feel a little cold.'

The patient nodded as he swabbed the breast with alcohol. He injected the lignocaine, and two small dots of blood appeared.

'Ooooh, sorry...' he crooned. 'Now, I'm just going to put a small needle in, it shouldn't hurt too much. Are you ready?'

The patient nodded again, and he took the first biopsy. After dropping the core he'd obtained into the formalin, he said 'You know, I think I've got a good specimen, but just to make sure, I'd like to take another one. Is that OK with you?'

The patient nodded for the third time, and The Prophet quickly took another biopsy. After cleaning up and dressing the wound, he glared at all of us.

'Who of you are going home first?' he demanded. (Admitting to your consultant that you were planning on going home shortly is never a good idea. We all looked at the floor.)

'Because,' he went on, 'this specimen must be seen urrrrgently by the pathologist.' (The nearest pathologists are 20km away from the hospital we're currently in.)

'I will phone the professor over there, if one of you would be so kind as to drop the sample off.' (A few of us put out our hands to take it).

The Prophet then proceeded to lambast the radiographers per telephone for not not coming immediately to take an X-Ray of the patient. He called the brainless physicians to tell them he'd take over the patient. He took her hand and patted it and said 'Don't worry, my dear, we'll take care of you now.'

On leaving the ward, he said 'You know, this is a verrrry serrrious problem. It is a verrrry sad case.' He shook his head mournfully. And then he glared at us again. 'Did any of you keep that troca?' he demanded. We stuttered and generally said 'no...'

'Well,' he said, 'go and find it. I want you to practise using that thing on apples.'

And with that, he scuttled away, white coat flapping quietly behind him.

Why trauma ticks me off

2006-07-24T18:36:00.000+02:00

If a local South African soccer team is scheduled to play against Manchester United on any given day, one of two things will most certainly happen:
(a) The team will lose, and a pile of people will then drown their sorrows, and then stab each other.
(b) The team will win, and then a pile of people will celebrate by getting drunk, and then stab each other.

This Saturday, the latter occurred.

I was fortunate enough to be on call when the victims started coming in. To say that they were all stabees is in fact a generalization: some of them had been shot, and some had been beaten with bricks. When asked what happened, the patients generally gave an answer that went along the lines of 'I was walking down the road, and then I looked at this guy, and then he stabbed me/shot me/pounded me with a brick.' Some are fairly candid, choosing just to sigh 'Ai, iDronka...'

They started to pour in at around midnight. Iwan and I were summoned from our nice university beds to come and suture. The corridors of casualties were lined with stretchers piled with individuals in various stages of intoxication. Most of these people were scheduled to be stitched up by casualty nurses, who do so much of this type of thing that they have suturing skills to rival that of the average plastic surgeon. Being on call for surgery, Iwan and I were called to see a (drunk) patient who was found to have developed a compartment syndrome in his left leg.

By the time we got there, he'd already been booked for his fasciotomy, and was scheduled to be in theatre within half an hour. We quickly sewed up some minor cuts on his back, face and right leg, and then followed him into the operating room.

At 2am we scrubbed up. At 9am, seven hours later, we took our gowns off.

See, this guy had been stabbed in the back of his left knee. After opening the posterior, anterior and lateral compartments of the leg to relieve the pressure, the surgeon (who had fortunately just completed his vascular surgery rotation) went to look for the bleeder, only to discover that the patient's popliteal artery and popliteal vein had been lacerated. Now, what you basically need to know here is that these are each the biggest artery and vein of the lower leg respectively. Without your popliteal artery, you'll lose your leg; without the vein, you'll develop venous hypertension.

What ensued was an extraordinarily delicate and complicated procedure that involved harvesting some vein from the patient's contralateral groin area, opening it up to create a flap about the size of your pinkie nail, and suturing it over the holes in the damaged vessels. I was the little girl that stuck her finger in the dyke: my job was chiefly to apply pressure to the spurting areas and to pull on the vascular loops that controlled the bleeding from further away.

The entire matter was exceptionally costly (to the health system, not the patient - who just pays a nominal fee). There's seven hours of theatre time, seven hours of anaesthetist time, seven hours of vascular surgeon time, seven hours of scrub-sister time. Then there's the cost of a few days in ICU, the cost of the procedures still to come (this morning, there was still no foot pulse and the operation had to be re-attempted). There's the cost of the materials: the sutures, the antibiotics, the autoclave time for the five different sterile sets that were opened. And then, of course, there's the value of the limb that's future still hangs in the balance, which (in the words of Mastercard) is priceless.

And all of this was completely unnecessary. Call me conservative, but sometimes I wish alcohol and all hand-held weapons were banned entirely. The majority of the trauma I see (and I see trauma very much on a daily basis) is due to a combination of the two of these, and it's completely preventable. That’s why trauma ticks me off.

Saying it Straight

2006-07-21T20:53:00.000+02:00

Spotted this on jiggscasey's blog - isn't it brilliant? Buy merchandise with this picture on it at CafePress.com.

An estimated 24.5 million sub-saharan Africans are currently infected with HIV. One of the biggest challenges we're faced with is trying to get people to practice safe sex. I wish it was as easy as just saying it straight.

Read all about what our ex-deputy president, Jacob Zuma, thinks safe sexual practise is.

The Prophet

2006-07-20T14:23:00.000+02:00

If you study medicine at my university, you will rotate chiefly through two government hospitals. The first is the tertiary academic hospital, located squarely in the centre of the city. The second is a secondary hospital, which is located far, far west, just before you enter the city's adjoining township. This hospital is dead ugly. It doesn't even look like a hospital. It consists of a series of open-air concrete walkways, sheltered by sheets of corrogated iron. When it rains, these walkways flood where they've caved in, and every morning caretakers sweep the medical waste and trash down the gutters which run alongside the walkways. There are fliers all over the notice boards detailing strategies for the re-eradication of the hospital's roaches. I correct the spelling and grammar in these fliers with a ballpoint pen. Some of the wards have no curtains between the beds, and some of them have no beds at all. These are boarded up and silent, waiting for the day our health department will finally have the money to provide them with enough nurses and clerks and doctors.

And in the middle of this hospital, in the heart of the surgery department, lurks The Prophet. Students have a knee-jerk reaction to doctors older than forty: they immediately call them Prof, regardless of the doctor's actual qualification. The Prophet is not a Professor, and every time a student says "Uh, excuse me Prof..." he shrieks: "I am only Prof if by that you mean Prophet! And I am a prophet! I preach and preach all day, words pourrrrrr from my mouth, but nobody hears them except the walls!" He shrieks this several times a day.

The Prophet likes to shriek a lot. He tells us that tomorrow is theatre day, but that two patients haven't pitched. "It's a disgrace!" he screams. "Non-complacency is rrrrife!" A wave of white saliva laps over his lower teeth. As the wave is about to break in the corners of his mouth he sucks it back. He stares at us. "I mean compliance," he says. "Non-compliance is rife."

He sidles over to the next bed. He looks like a colourless beef-olive: his white jacket forms a long, tight tube around the tubular body beneath, his head and neck squeeze out from above the collar, topped by a greasy grey comb-over. The next patient has a deep vein thrombosis. The Prophet hates DVT, because you never cut these patients open. He bellows that it's a medical problem, and that the physicians should be handling these patients.

"Where do these patients follow up?" he yells at the houseman.
"At our clinic..." she mutters.
"What?" he screams. (The Prophet has been working at this hospital for nigh on ten years. I can't believe he's only discovering the DVT disaster now) "And the INR, who draws the INR?"
"We do..."
"What? This is a logistical nightmarrrrre! It is an a-bom-in-a-tion!"

He sucks the wave back, and the house doctor nods sheepishly. There's nothing she can do about it. The Prophet prods the offending leg in disgust. "In the old days," he declares, hand tucked severely into one pocket, "this would not have happened."

He grabs his satchel and stomps out of the ward. We're relieved that the round is over.

Oh, My!

2006-07-19T17:14:00.000+02:00

Dr John Crippen, writer of the NHS Blog Doctor, has published the most wondeful post on me. Thank you so much! I'm not sure I deserve all the nice things he said, but I did print out his post and showed it to my mom. She said, 'What a nice man!' and I agree.

I read lots of blogs. Really, I do. I click on every link in every blogroll that I find. I read piles of crappy posts in the hope that there's something mind-blowing just around the corner, and I'm always sure that there's something that's going to make it all worth it just one click away. And in all my blog trawling, I've reached the sad conclusion that only about 10% of blogs are actually readable. And only 3% of that 10% is actually good reading. Dr Crippen is in that top-top 3%. I'm not just saying that because he was nice to me. I've been reading his blog for a few hours now, and hopefully (one day) I'll have been through all the posts, because it really is worth the while. Go check it out, folks. Go there now.

On another note, I would just like to say (because the matter is coming up more and more frequently) that I know exactly what a MILF is. 'Little' is just a nickname - my surname is in fact 'Milford'. When American Pie came out, Milf became another nickname, and I'm sticking with it.

Now, I hope you all have a smashing afternoon, and that you like my new template (I'm still working on the graphic).

It's Not Always That Great

2006-07-17T19:42:00.000+02:00

I was so sure my patient was going to die this weekend. In the wee hours of Friday morning she received an open laparotomy for the intra-abdominal abscess that had formed after her last operation, which had been for bowel obstruction. When I saw her on Saturday morning, she was gasping into an oxygen mask, confused and delirious. She asked me several times when her stomach was going to work. The previous night her blood pressure had been unreadable, and the doctors on call had put up a central line to resuscitate her. Today, Monday, she's miraculously still with us. She's less confused , her stomach has worked, and she has a blood pressure. But her wound is leaking bagsful of bowel content. The doctor says this hole will close by itself, but I'm not so sure.

On call on Thursday, I was interviewing another confused man when he vomited and his heart stopped beating. We intubated him and took turns to do chest compressions. We set up a line and pumped him with adrenalin. We shocked him what felt like a hundred times. Every now and then we'd feel a pulse and the ECG would show sinus rythm, but then it would disappear, and we'd carry on with the resus. After fifty minutes he was declared dead. We think he might've had pancreatitis.

This morning I admitted a man with colon cancer. On Wednesday he's going for a hemicolectomy - the removal of half of his colon and hopefully all the cancer with it. But when I examined him, I could feel hard lumps in his liver, and matted lymph nodes in his groin, so he's pretty much guaranteed to have metastases. I think he'll be dead in a few months. He's only 37.

Sometimes it feels like we don't cure anyone. We just prolong things, drag them out until we've exhausted every last resource the body has, and it just shuts down. For some people, this happens sooner than others. I don't know who is better off.

From the ninth floor of the hospital, you can see the whole of Pretoria North, and the Magaliesberg behind it. There's one road going over the mountain: it is silvery white, and merges with the white sky above, so that it looks like someone has cleaved the mountain range in two. Francois once caught me looking out there and said 'You know, when you go over that mountain, there's not another opera house for 10 000km'. I don't know how true that is, but the principle is correct. Still, sometimes I want to take my little Golf and drive over that mountain, and keep driving till there is nothing and nobody, and I can leave all the bad things that happen to us behind.

A Pain in the Anus

2006-07-13T23:36:00.000+02:00

You know it's going to be a big night when you walk into casualties and there are three twenty-something year old men lying in a row, on their stomachs, clutching their backsides.

I'm rotating through surgery at the moment. Surgeons consider themselves only slightly superior to God. You see, whilst God created everything from the mouth to the anus, the surgeons fix everything from the mouth to the anus. Hence: superior.

Anyhow, the three men clutching their bums. After taking a quick history ('Eish, it started hurting. I can't wipe.' X3), spreading the cheeks and then sticking a KY'd finger up each of their rectums (I changed gloves in between), I realised I had an emergency room filled with a perianal haematoma (like external haemarrhoids), a perianal abscess (like a huge zit), and a perianal sebaceous cyst (like... um, nothing. I'd never seen anything like this before.) The chance that all three of these men should have presented at the same time, to the same hospital, with the exact same symptoms, is minute, but it happened. Doctor-in-chief (my registrar) declared that there were no beds, and that all three of them would be dealt with in casualties. I fetched three suture packs.

Now, all three men had different pathology, but the management was essentially the same. Anaesthetise, cut, squeeze. Yee-ha.

The first problem is patient positioning. Whilst all three patients assumed the fetal position without difficulty, they struggled to remain that way. The anus under seige tries to hide. They clenched their buttocks against our hands that furiously tried to spread them, they thrust their pelvises forward whilst we tried to get as close to the back door as possible, they straightened their knees while we begged them to bend.

The second problem is that that area is really sensitive. Like, really. Also, the guy who went first seemed intent on terrifying the guy who went second (and so forth) and screamed like a girl as soon as I stuck the needle in his ass. As the surgeon sliced open his haematoma and squeezed out the clots, he howled 'Maweeeeeeeeh!' (The 'weeeeeeeh' part must be pronounced with vibrato. 'Mawe-e-e-e-e-e-eh'. I'd previously only heard this word muttered forlornly by women passing live children through their vaginal canals. It apparently means 'mother'). He muttered 'Eish, eish, eish, my bra' through the cubicle curtain to the man with the giant perianal zit on the other side.

Abscess man was second, and I had the honour of cutting. Now, people, admit it. You love the feeling of a zit well squeezed. And this was zit-squeezer's heaven. After numbing the area, I made the tiniest incision over the abscess ('Eina, fok!') and whoosh, was rewarded by a little river of pus. That kind of thing makes surgery worthwhile.

We did the man with the cyst last, and I have to give him credit. His procedure really was the worst (he was the only patient to require stitches) and he made the least fuss. The cyst looked a bit like an extra scrotum attached perianally (as I was about to start cutting the surgeon even said 'Crap, where are his balls?' Luckily they were safely tucked away). I hacked away at the skin, gouged out the cyst, and was left with something that resembled a tunnel. So I cut the extra skin away, and then started stitching. This was not so easy, because the wound was on the upper buttock, and hence turned away from me (as a second year anatomy lecturer of mine would have said: 'Orienteer nou jouself'). Thus, in order to stitch, I virtually had to turn myself upside down (picture: hair hanging in squeezed-out cyst contents. Euwee.) The wound looked really good at the end though, even if I say so myself.

In spite of the fact that I caused three men considerable pain, they all hobbled out of the emergency room looking relieved and more comfortable. They even said thank you, and told me they were looking forward to sitting down again.

See, I know it sounds incomparably gross, barbaric and filthy, but there really is nothing in the world as satisfying as medicine. I love it a lot.

And really don't marry these people

2006-04-20T20:47:00.000+02:00

Karen's Rough Guide to the Personality Disorders - Part III

The Avoidant

The Catch Phrase: 'Oh, don't mind me, just being my usual retarded stupid moronic embarassing fucked-up self'

The Giveaway Traits: Particularly sensitive to criticism and rejection, avoidants insult themselves before you can insult them.

The Pathology: These people basically suffer from an inferiority complex... they think others look down on them and are constantly criticising and ridiculing them.

You'll be miserable if you marry an avoidant because: avoidants need a massive amount of uncritical acceptance. If you call the dinner they made anything less than scrumptious, they'll assume you hated it, that it tasted like dog poo, and that by extension you hate them too.

On the plus side: it could be worse - they could be narcissists.

The Borderline

The Catch Phrase: 'You've broken me down so much I'm gonna kill myself! No! Don't go! I love you!'
The Giveaway Traits: Self-mutilation is the biggest, loudest, reddest siren you could have when it comes to borderline personality disorder. These people thrive on having 'issues', and have intense, complicated and ultimately unhappy relationships.
The Pathology: as in most of the personality disorders, borderlines are essentially extremely insecure, hate being by themselves, but can;t form normal relationships with other people. Borderlines were very often sexually abused as children.
You'll be miserable if you marry an borderline because: these people turn on the drop of a pin. One minute you're the bee's knees, next you're the spawn of satan. There's no in-between.
On the plus side: All you broody types out there will at some point in your life fall in love with somebody who needs 'saving'. This person will probably be a borderline. Be warned though: saving these people is a virtually impossible, soul-destroying task.

The Antisocial (aka The Psycopath)
The Catch Phrase: 'Hello Clarice...'
The Giveaway Traits: Animal torture, theft, drunken driving, drug abuse and murder may all be part of a psycopath's repertoire. Very scary, however, is that the psycopath may display no symptoms of his pathology at all, and may come across as charming, sensitive, and dashingly handsome.
The Pathology: Psycopaths have no regard for such petty concepts as consequences. They feel no remorse and don't care about other people. Discipline and punishment has no effect on them.
You'll be miserable if you marry a psycopath because: he may or may not slit you from sternum to pubis while you're sleeping. But he probably will abuse you verbally, emotionally and physically, and spend all your hard-earned money in casinos.
On the plus side: These people make for good crime writing (think Hannibal Lecter)

Don't marry these people either

2006-04-17T12:20:00.000+02:00

Karen's Rough Guide to Personality Disorders - Part II

The Schizoid
The Catch Phrase: 'I'm just gonna hang out at home by myself tonight...'
The Giveaway Traits: These people don't like other folks - they choose lonely jobs, don't get involved in relationships, and don't have sex. They dig things like astronomy and maths, and have a curious fondness for animals.
The Pathology: Schizoids have little to no interest in normal attachments and human relationships.
You'll be miserable if you marry a schizoid because: s/he doesn't want to marry you. And you'll never have sex. And you'll have lots and lots and lots of 'freedom weekends'.
On the plus side: You'll have lots and lots and lots of freedom weekends...? And these people do often give to the world genuinely original and creative ideas.

The Schizotypal
The Catch Phrase: 'Well, when I went to Og with the aliens...'
The Giveaway Traits: Read horoscopes aplenty, believe in palm-reading and have an immense interest in all things weird and wonderful. They're 'strikingly strange'.
The Pathology: Apperently, schizotypals lack insight into their own feelings, but are hugely sensitive to those of others, particularly negative feelings. They prefer their fantasy life to their real life.
You'll be miserable if you marry a schizotypal because: schizotypals occaisionally decompensate to become floridly psychotic - not the kind of added burden you want at family gatherings.
On the plus side: schizotypals can always tell you exactly how Jupiter is affecting your life at this point in time.
Not to be confused with: Schizophrenics - a whole new kettle of fish

The Obsessive-Compulsive
The Catch Phrase: 'Who the fuck put my pink shirt in the middle of all my blue shirts? Fuck!'
The Giveaway Traits: Obsessed with order and routine, these people have to have things just so. They don't really have a sense of humour.
The Pathology: These people are emotionally constricted and need to control their lives in a way that they can't control other people.
You'll be miserable if you marry an obsessive compulsive because: you'll never be able to do anything spontaneous - movies, dinners out and weekend getaways will all have to part of a strict routine.
On the plus side: these people make excellent bureaucrats. A few obsessive-compulsive personality traits can be good for you - your life will be orderly, and everything you do, you'll do properly.
Not to be confused with: obsessive-compulsive disorder, where sufferers are unable to suppress recurring thoughts, and feel forced to act on certain compulsions. (Read this book)

The Histrionic
The Catch Phrase: 'Oh my god it's so good to see you! Uh... what's your name again?'
The Giveaway Traits: These people are loud and attention seeking. They dress in big, bright colours, throw temper tantrums and laugh hysterically.
The Pathology: Essentially deeply insecure, histrionics need constant reassurance.
You'll be miserable if you marry a histrionic because: they're no good at maintaining deep, long-term attachments. Vain, fickle and self-absorbed, histrionics are all about themselves.
On the plus side: actors and people who force themselves into the limelight (think Mariah Carey) often have histrionic personality traits. It's the ideal environment for them.

Don't marry these people

2006-04-16T16:40:00.000+02:00

Karen's Rough Guide to Personality Disorders - Part I

The Narcissist
The Catch-phrase:'People pick on me because they're jealous of me. They know I can do all of their work by myself'
The Giveaway Traits:Narcissists either take criticism very personally, or seem to be completely immune to it. They tend to be painful in most social settings, due to their ability to talk about themselves ad nauseum
The Pathology: The narcissist's view of himself is in eternal conflict with the rest of the world's view of him. Essentially, the narcissist thinks he's best thing since sliced bread, whereas everyone else feels he's a bit of annoying prat. Narcissists can never be happy, because the only thing that makes them happy is absolute blind adoration, and that's never going to happen.
You'll be miserable if you marry a narcissist because: he thinks, no, knows that he is better than you, and you're gonna get talked down to, a lot. The narcissist requires nothing less than pure obedience and adoration. They tend to marry trophy wives (someone who makes them look good) and often go well with people with dependant personalities.
On the plus side: Narcissists are often well groomed. And they make good surgeons.

The Dependant
The Catch-phrase: 'Is everything ok? Did I do something wrong? Do you still love me?'
The Giveaway Traits: Dependants hate to be alone even for brief periods of time. They have a pervasive pattern of submissive and dependant behaviour - they'll do anything to keep the peace, for the sake of a relationship. Dependants prefer to be unhappy than alone, and so will go to the extent of putting up with an abusive partner. Excessively indecisive, they need stacks of advice and reassurance before making any decision.
The Pathology: Essentially, dependants need someone else to make themselves feel validated. They hate being alone.
You'll be miserable if you marry a dependant because: their goal in life is to be in a relationship, and so you won't really get that 'real' feeling.
On the plus side: A dependant will do anything to keep you happy. They're loving and unjudgemental , and don't talk back.

The Paranoid
The Catch-phrase: 'Just what exactly do you mean by that?'
The Giveaway Traits: Chronically and absurdly suspicious of everything and everyone, paranoids perceive other people's actions as demeaning and threatening to themselves. Bigots, jealous spouses and litigious cranks often have a paranoid personality disorder.
The Pathology: The theory is that paranoids attribute to others the thoughts or impulses that they can't accept in themselves. In other words, a married paranoid will look at another woman and think she's hot, and then assume that his wife is cheating on him.
You'll be miserable if you marry a paranoid because: if she (or he) doesn't think you're banging the neighbour, she'll assume you're slipping arsenic into her yoghurt. Her hypervigilance will drive you up the wall and into the madhouse.
On the plus side: There's no slipping one past these guys...

2006-04-15T16:41:00.000+02:00

I'm delighted to announce that I've only got four days left in my psychiatry rotation (two, if you exclude the actual day of the exam and the day before the exam when we'll get time off to study) - hurrah! I haven't really enjoyed the rotation, for a few reasons. The first is that i'm not really keen on the discipline as a whole - just as many people don't enjoy examining vaginas all day and will therefore never be gynaecologists, I really don't fancy examining heads all day. The other thing is that psychiatry is just a little too chilled. I know that going home at 11am every day and getting fridays basically off sounds great, but I'm feeling very housewifey and uninspired... not what I studied six years to feel.

Last week a patient attacked Anria - her and Iwan went to the chronic closed female ward to do a round. The chronic closed wards are where you see the same things you see in movies - shrieking patients walking around in their undies, swatting at their hallucinations and muttering to themselves in corners. It's unclear what Anria did to offend then 100kg schizophrenic woman in front of her, but before she new it the woman had grabbed her hair and was screaming 'Is dit fokken lekker? Is dit vir jou fokken lekker?' The whole incident wasn't too serious - the patient quickly got a shot of something in the ass and four hours of isolation, stat. As she and Iwan left the ward the patient was hanging out the window screaming 'Tell that little bitch never to come back here!'

I think it's that last sentence that really upset Anria, especially as a week before a patient in another ward had told Anria that she didn't want to talk to her and would only talk to me. These kinds of incidents are the type that really get us down... I guess we pride ourselves in being able to talk to people, and in getting people to trust us, and when patients openly display their dislike of us it makes us feel like terrible failures. I don't think Anria's doing anything wrong specifically - it's true that she can be a bit on the blunt side - I think it was all just a bit of bad luck.

Anyway, next up are the Internal Medicine sub-specialties: cardiology, neurology and dermatology. I've heard it's an even more relaxed rotation than psychiatry. Can't hardly wait...

the blues

2006-04-13T19:18:00.000+02:00

So, I decided to start this blog of my life as a final year medical student because it's a topic I just really can't shut up about. I was just reading Kirstin's blog, where she talks about her depression, and I started to post a comment but I had so much to say that I thought I'd just dedicate a whole post to the subject on this blog. I'm rotating through psychiatry at the moment, so it's pretty appropriate. Anyway, here we go.

So, when we talk about depression in medical terms, we talk about a major depressive episode, or a major depressive disorder. There are other mood disorders, but I'm just gonna stick to major depression.

Mental illness is like all other illnesses: when we diagnose it, we use certain criteria. Just as when you have hypertension, you have to have a blood pressure reading above a certain level, when you have depression, you have certain symptoms. The symptoms are pretty vague, and I'd guess that almost every single person that has ever lived has at some point in their lives met the criteria for a major depressive episode. Symptoms include feeling depressed for most of the day almost every day, totally losing pleasure in all activities, significant weight loss or weight gain (without dieting), insomnia or excessive sleepiness almost every day, agitation or excessive lethargy almost every day, feelings of worthlessness or guilt, difficulty with concentration, and recurrent thoughts about death. To have had a major depressive episode, you must have felt five or more of these symptoms in the same two week period.

Does that sound like you at some point in your life? Yup... sounds like me too. Now, the big question is, whether or not to take pills. First, you've gotta exclude another cause for your depression. Are you a drug addict, an alcoholic? Ditch the crap and you'll start to feel better. Do you eat piles of burgers and fries and veg out in front of the TV all day? Goddamn, I'd feel depressed too - get off your lazy ass, run to the green grocer (using your legs, I mean) and buy yourself an apple. It'll be the best thing you've done for yourself all week. Has something major happened in your life, that set off your depression? For example, did someone close to you die, or did you recently move to a new city, country, or school? In that case, you're not depressed. You're suffering from bereavement, or you're experiencing an adjustment disorder. Give yourself time - your mind isn't a trampoline that just springs back into place no matter what gets thrown at it. Then, some other medical things - is your thyroid gland OK? Do you have epilepsy? Do you have syphilis, or HIV? How about schizophrenia, an anxiety disorder, or obsessive compulsive disorder? All of these can cause depression. And then lastly, and this will be the hardest for you to admit: do you have a personality disorder? In other words, is your personality such that you just can't cope with life, relationships and yourself? People with personality disorders are often depressed, and it's hard for them to get healed, because the process involves them changing who they are.

So, after you've fixed all your possible causes of depression, and you're still glum, you have to go for meds. I must confess: I'm very anti-pills. See, pills come with so many catches. The first, and most important catch to me, is that if you take anti-depressants for your blues now, you have a 66% chance of relapsing once you've finished your course. And when you relapse, you're gonna have to stay on pills for the rest of your life. I think that sucks.

Secondly, are all the side-effects. The most commonly used anti-depressant these days is still the SSRI fluoxetine, or Prozac. If you're taking Prozac the original, you probably won't get all the shitty side-effects, but most of you are gonna be on a generic form of fluoxetine, which is gonna give you headaches, insomnia, a runny tummy and nausea, it's gonna make you anxious as the most stoned stoner, and it's gonna kill your sex life. EW.

Then, you have to take the damn things properly. 'Two months worth of pills' is NOT enough. It takes at least six to eight weeks for the pills to really start working properly, and then you have to stay on them for at least six months. If you ditch them as soon as you feel better, you're gonna fuck out again. And you'll have learned nothing from the experience: you'll still have the shitty habits and crappy life that led to your depression in the first place.

So, I guess the message that I wanted to get across with this post is that depression is like lots of diseases, and you need to try and manage it intelligently. Just as someone with high blood pressure should first lose weight, kick the fags and take up swimming, someone with depression should treat the things they're doing wrong and that their body is doing wrong first. And then, if you'e still sick, take your medicine properly. Don't fuck around with your mind. It's pretty much all you have.