So that I may remember why all things were created
Thursday, May 31, 2007
Backbreaking
I've been alone on the wards for the last two weeks, covering for other doctors who haven't been able to turn up for work due to sickness, study leave, last minute interviews, resignation etc.
So now, I have to attend my own ward rounds and look after my own patients, as well as carry the on-call bleep. However, due to the sudden lack of junior doctors in the Trust, senior doctors from other wards who are somehow unable to their own work have been dragging me to their wards to act as a Scutter. I'm not doing the extra work out of my own good heart - it's being forced on me because nobody else will take responsibility.
As a result, my own ward patients suffer.
I'm tired of all this.
Worst of all, I come home, and there's no fricking chocolate in the house. How am I supposed to cope?!
I have decided that I will start answering interesting reader questions on my blog. Of course, I will not answer questions on this blog about personal or confidential medical issues. However, quite a few of you have emailed me some interesting queries about being a doctor which I have often thought would make very good blog posts. I have also received questions about the weird and bizarre, from people who are perhaps trying to settle a bet or an argument.
So here's the deal. You can email me your weird questions to ickle_doc (at) yahoo (dot) com or leave them as comments on this post. Every Friday (or when I receive enough questions), I'll pick the one from the pool that I find most fascinating, and I will write a post about it on this blog. How does that sound?
Since it was Woof! that inspired me to start the "Ask TSCD" segments, I will start with his question first.
"When the umbilical cord of a delivered baby is snipped, does it hurt for the mother or the baby? If not, why?"
The cutting of the umbilical cord is painless for both the mother and the baby.
The umbilical cord is made out of blood vessels - two arteries and one vein - embedded in a jelly. The cord is not covered by skin, but a thin and slippery layer which is a continuation of the membrane that coats a newborn baby. This membrane, unlike human skin, does not have any nerve endings. Similarly, the jelly (called Wharton's Jelly) also does not contain any nerves. So, when the cord is severed, it does not cause pain.
Actually, the entire birthing process is pretty awful. Everyone knows that a woman in labour is in great pain. Women are in so much pain during childbirth, that some of them become delirious and start to hallucinate. During one of the births I observed, the poor mother was in so much pain that she started to see cartoon characters from The Beano running around her bed and across the ceiling.
What shocked me most of all was that when an episiotomy - a particularly brutal-looking procedure wherein the birth attendant takes a huge pair of scissors and snips a great big cut in the area where a woman is usually the most sensitive - is performed, most women barely notice anything. Granted, some local anaesthetic is introduced into the area first, but usually people feel some pain from the initial injection. The fact of the matter is that labour contractions are so horrific that being jabbed and sliced open with sharp implements is virtually imperceptible.
The other fact that people forget to consider, is that the infant is also undergoing great pain during birth.
First of all, the baby's head is getting moulded into a conical shape in order to fit into the birth canal. This means that the unfused skull plates of the baby's head will begin to overlap each other. I cannot see how this can possibly be a pleasant experience.
Additionally, with every contraction of the muscles of the womb, the blood supply to the placenta gets cut off so that the placenta later on detaches from the womb and is expelled from the womb. The placenta is that interface between mother and child which allows for delivery of nutrients and oxygen to the infant. This means that during contractions, the infant's supply of oxygen is cut off for up to 90 seconds. Try holding your breath for that length of time - you'll find it hard to last even one minute.
I think it is a blessing that babies are not able to form memories of the birthing process. It's too traumatic.
This week's Grand Rounds is hosted by ImpactEDnurse.
ImpactED nurse says: "For this week's Grand Rounds I threw down a challenge for writers to submit a post that they were particularly proud of. As you will soon see, there are some truly gifted writers amongst us; recording the narrative of their experiences as they bump up against the medical humanity. Do not rush these readings. They are in no particular order. But it is my careful consideration that each and every one has its own particular elegance well worthy of your time. Enjoy."
1. You. Yes you, will you just sit down and just be quiet for one second while I attend to another patient? Thank you very much. I am only one person and I can only talk to one patient at a time. You will just have to wait your turn, so go back to your bed and sit down.
2. Stop stealing other patient's food.
3. Screaming "I WANT MORPHINE NOW" over and over again will not get you what you want, if it is not what you need. So stop asking. And get back to your bed, please.
4. No, you may not leave your decrepit mother or your energetic toddler here unattended. We are not responsible for visitors. You come back here this instant and take her with you to wherever you are going. The hairdressers, you say? Well, then she can go with you and read the magazines in the lobby. The nurses here are for looking after sick patients, not for babysitting visiting relatives!
5. Get back to your bed, please, I have 3 other patients to see first and they are all more sick than you are. So, please get back to your bed and I will see you when it is your turn.
6. Ms Pharmacist, do not interrupt me when I am talking to a patient and their family. Do not interrupt me when I am discussing a serious issue with them. Do not interrupt me when I am trying to break bad news. Especially do not interrupt me when I'm with a patient, in order to ask me to rewrite drug charts. Dammit, the drug charts can wait, can you not see that I'm busy? There are people crying here! Will you just get out of my sight! I will deal with the drug charts later, now just go away please!
7. GET BACK TO YOUR BED!!!!
8. No, medical staffing goon, I will not carry the gastrology team's on call bleep and the renal team's on call bleep and the cardiology on call bleep and the elderly care on call bleep as well as my own bleep. There is no space on my person to carry five bleeps and there is no anount of money that you can pay me that will make me physically able to be responsible for twenty two wards. So stop asking. Hire a locum doctor, I don't care, leave me alone!
9. AAAaaaargh!!!
10. Somebody help me this patient is trying to claw out my eye! Get her offa me! Get her offa me! That's IT! I'm fricking going home!
Whilst I have been hard at work this week, MDH has had a few days off for study leave.
Study leave? Yes, doctors are entitled to a few days off in order to attend training courses or post-graduate examinations. Sometimes, doctors are even allowed to take a few days here and there for independent study.
MDH has been using his time very constructively to do some revision and work on some presentations. He has also found time to run some errands down in the town centre – that is, do the grocery shopping and banking, get the car cleaned, drop off the winter clothes at the drycleaners…and visit the computer game store and trade-in some of his old Playstation 2 games for new ones.
I think MDH started out his computer game obsession with a second-hand ZX Spectrum that given to him by a friend. This is why 2-D platform games that involved lightning reflexes and accurate timing, like Manic Miner, are his favourite. He still maintains that the current games consoles are not sophisticated enough yet to manage a 3-D platform environment, although the graphics are impressive and beautiful.
The current Prince of Persia games are apparently the best in terms of the fluidity and flexibility of character movement (in his opinion). However, there is a great deal of inaccuracy when it comes to the representation of depth and perspective, which limits the speed and precision of character control. Thus, MDH finds that the action sequences in games like Tomb Raider are not as challenging as those in the 8-bit Sonic the Hedgehog or Super Mario Bros.
As I type this, MDH is busy running around a muddy wooden arena, defeating some sort of giant zombie cave troll. Using a shotgun that has a limited supply of bullets. In the pouring rain. With the aid of a wild wolf.
I am also engrossed. “AARGH!” I find myself hollering, as the giant zombie cave troll throws a boulder at MDH, “Dodge it dodge it dodgeit quickquickquick run away, run away!”
Meanwhile, the textbook lies, lonely and forgotten, in a corner of the room.
The toothless granny is a sweet old lady who lives in the hospital and has lost her dentures many years ago and smiles at you in an endearing gummy way. She is wrinkled and rosy and good natured and kind and hazardous. Be warned.
She will strangle you with your own stethescope when you are not looking. She will pull out your hair. There is much strength in those deceptively frail, delicate hands.
Do not eat anything presented to you by the toothless granny, especially the following:
1. Nuts. Especially nuts that appear suspiciously shiny. There are three questions you should ask yourself in this situation: (a)Why does the toothless granny have nuts in her possession? She has no teeth to eat them with. (b)Where did the toothless granny get the nuts from? The hospital does not supply nuts which are a choking hazard. (c)Why are the nuts coming from a packet labelled 'Chocolate Coated Almonds'?
2. Malteasers or any other round chocolate sweet. Even Malteasers that appear to be individually wrapped in shiny red Malteasers wrappers. Do not eat them if the Malteasers feel heavier and squashier than they should be. Especially do not eat them if they feel, somehow, warm.
This evening, we had five new admissions onto the ward within one hour. The nurses were bustling about sorting each patient out, so I helped by taking an inventory of each patient's property. The healthcare assistants gave me some sterile plastic tubs to label - these tubs were for keeping dentures in.
Elderly patients are very prone to losing their dentures, especially in hospital where the unfamiliar surroundings can be very disorienting to them. It is not uncommon for patients to knock their dentures behind the bedside locker during the night or wrap them neatly in tissue only to have them thrown away by overenthusiastic cleaning staff in the morning. Sometimes, patients in adjacent beds will accidentally exchange mouthpieces with each other whilst they are getting ready for breakfast.
Missing or ill-fitting dentures can mean that a patient has even greater difficulty eating the already unpalatable hospital meals, and it can be days before anyone figures out why Mrs Senile Dementia appears to have lost her appetite. Just a couple of missed meals can wreak havoc on aging bodies and minds that have very little in the way of reserves. In order to maintain nutrition and hydration, the poor woman would have to be started on a drip - an unnecessary, uncomfortable procedure that could have been avoided.
At my hospital, the nurses help each patient to remove their dentures and place them into individually labelled containers. All the dentures are then brought to a room where some cleaning fluid is added to each container so that the appliances can soak overnight. The reason why the dentures aren't kept by the bedside is that some elderly folk confuse the containers for specimen pots (argh) or cups of water (double argh). Every morning, the nurses rinse and brush the dentures carefully and restore them to their owners. And all is well with the world.
The system failed today as one of the porters, whilst contriving to manoeuvre a trolley around a tricky doorway, accidentally bumped into a healthcare assistant who was walking around the corner carrying a tray of denture pots. Disaster and Chaos ensued thus:
In slow motion, about 30 denture pots flew into the air and 30 denture pot lids spun off in different directions like little white frisbees.
And 30 pairs of false teeth went clattering (chattering?) in across the vinyl floor, in a glistening pink-and-white pearly shower, accompanied by the horrified, musical screeching of 2 healthcare assistants, 2 porters, 4 nurses and 1 doctor (who was actually choking with suppressed laughter).
Unlike spectacles or books or clothing, one cannot use a marker pen or a sticker or an iron-on label to identify false teeth.
I grinned at the headnurse (who groaned in response) and gave her the thumbs up as my bleep went off and I was called off the ward.
This week, the medical bloggers' Grand Rounds will be located in the Vesalius viewing arena at Medical Humanities Blog. Gather round everyone, and pay close attention as we begin the dissection of theseinterestingcases...
Tips for medical students: How to Survive Lectures
Now, I don't remember very much about lectures in medical school, because to be perfectly honest, I was asleep during most of them.
With all the dim lighting, the comfortable high backed cushioned chairs, the soothing hum of the lecturer's voice, I just couldn't stay awake. Not for lack of trying, mind you. I did try sleeping early the night before, drinking caffiene-laden concoctions, avoiding starchy foods, sitting right in front of the lecturer, wearing uncomfortable underwear, getting a friend to jab me in the eye every few minutes...oh, everything I could think of besides sewing my eyelids to my eyebrows.
Unfortunately, the minute the lights dimmed and the powerpoint presentation began, my head would sink back against the headrest and I would be away with the fairies before the second slide. I would then shake myself out of my slumber about 45 minutes later, just in time for the concluding slide with the humourous cartoon, readjust my notes (now covered in doodles by my amused classmates) and prepare myself for another 45 minute snooze.
I became adept at avoiding getting picked on to answer questions during the lectures, like a sleeping ninja. And now, I will pass on to you my secret skills.
1. Pick your position carefully. Lecturers tend to look up and out towards the middle and back of the theatre in order to achieve better voice projection, so you will be just out of range of their gaze if you sit in the front third of the room. The first two rows in my lecture theatre were usually empty, and I used to sit around the fourth row, right in front of the lecturer and then fall fast asleep.
2. Avoid sitting near or underneath the lights. The human eye, being lazy, tends to be drawn towards the light, especially in a dimly lit room. You want to avoid sitting where attention will be drawn to you by pool of brightness, making you glow like a beacon in the dark. Even in a brightly lit room, there are still dim areas, especially (surprisingly) towards the middle.
3. Stick to clean, understated fashions. You want to avoid drawing attention to yourself, so stay away from bright, warm colours, fancy headdresses and merchandise with big readable slogans. Otherwise, the lecturer will immediately mentally label you as 'Red shirt guy', 'Shaggy goatee guy', 'Yellow hairband girl' and pick on you. Additionally, do not sit near anyone who is foolhardy enough to be so conspicuous, or you will risk being subconsciously mapped as 'Person sitting behind the Washington Redskins cap', 'Person next to Power Rangers, Go!.
4. Have a ready answer. There are a few generic answers for most medical related questions that are non-specific enough to be considered correct in almost any context. It is useful to have a few carefully selected responses ready for when the lecturer interrupts your snooze with a question. You only need to ramble on in a clear but slow and monotonous drone just long enough for the lecturer to get bored with you and move on to the next person. Examples:
Question 1: What are the common side effects of this medication? Answer: GI disturbances like nausea, vomiting, diarrhoea, Allergic reactions presenting as a rash, angiooedema or anaphylaxis...
Question 2: How would you manage this patient? Answer: Take a detailed history from the patient and collateral history, perform a full physical examination including blood pressure and finger-prick blood glucose measurement, get IV access and bloods including a venous gas, consider radiological investigations...
Question 3: What could this patient be suffering from? Answer: Infections such as tuberculosis or HIV, Autoimmune conditions such as Lupus, Sarcoidosis, Endocrine disorders such as Addison's disease...
5. Create an aura of silent invisilibility around yourself by waving your Wand of the Imperceptible three times anticlockwise whilst maintaining the Stance of the Disappearing Echidna. You can also invest in a RomulanCloakingDevice which removes traces of your presence from the lecturer's radar. In other words, don't snore.
4. White coat (optional, doubles as pillow or blanket.)
To be considered an exceptional medical student, this is what the survival kit contains: 1. Sweeties/Chocolates - to be used as bribery and emergency rations
2. Spare change amounting to at least £2 - for the out-of-hours coffee, crisps and sandwiches machines. Saves you crying in despair when you realise the canteen is shut and the machines don't accept notes.
3. Disposable Gloves - For those moments when the consultant suddenly asks you to feel for a femoral pulse in the unwashed groin of a recently incontinent patient, and you are ten metres away from the nearest glove box. Also useful for making balloons to entertain the paeds patients and as an impromptu tourniquet for all your phlebotomy needs.
4. Hand Cream - if you've been following the strict infection control policy, then you will need this. You can also use it to ingratiate yourself with the nurses.
5. Small Rare Items (7): Neuro-pins, safety pins, cotton wool balls, tongue depressor, pen torch, indelible marker, tube of Aquagel
Consultants will occasionally get the notion to hold an impromptu teaching session and will want these random things. However, these items are not always readily available on the wards (because doctors hardly use them) and are so small that they are hard to find on a moment's notice.
Instead of spending half an hour searching for these objects during a ward round, just put a few in your pocket when you come across them on your meanderings through the hospital (of course, ask the nurse-in-charge first, don't just go around nicking stuff!). Then, when the consultant has another one of his brilliant ideas for Student Education, you can whip them out of your pocket Doraemon-style and then bask in the awe of your classmates.
However, these items should all fit comfortably into one pocket of your white coat. If you need to carry a utility belt in order to store all of your rare items, then you are trying too hard. This is not the Legend of Zelda. Leave the Master Sword, the Pegasus shoes and Pendant of Courage at home.
postscript: Here's an example of trying too hard, courtesy of the University of Maryland School of Medicine, Class of 2006.
Tips for medical students: How to Survive Ward Rounds
1. Turn up early for the ward rounds and introduce (that is, ingratiate) yourself to the house officer. The house officer will probably know who the new patients are and will give you a brief summary of their problems (if you ask nicely), so that you can do a bit of quick reading before the round. Chances are, the questions directed at you during the round will be related to the new patients. It is also good to bear in mind that each consultant has a set of pet questions that he or she likes to use to torture unsuspecting medical students with - the junior doctors will know all about them and will be able to help you out before the round starts.
2. Introduce yourselfto the nurse-in-charge - he or she is the boss of the ward, so it's very important for him/her to know who you are and why you are loitering around. The nurse-in-charge will also know your consultant's idiosyncracies!
3. Bring your ownstethescope and pen torch. It looks sloppy if you have to keep borrowing the house officer's precious stethescope.
4. Carry a notebook - useful for doodling and for writing random things down that you want to look up on Google later on. Additonally, some consultants really like to see their students looking busy and interested.
5. Invest in good quality footwear. Comfortable, sensible shoes are key to your survival on the ward round. If you have not yet mastered the Doctor-walk, you will probably find yourself limping pathetically behind everyone else as they sprint up and down the stairs on the 3 hour ward round. You need to try to keep up with the pace of the ward round, even if you're bored to pieces. If you slow down the ward round, you will incur the eternal wrath of the junior doctors.
6. Get organised. Medical students tend to hang at the back of ward rounds because they don't want to get in the way. This is one of the reasons why students will get ignored during their clinical attachment. You can be useful by anticipating what the doctors want to know and having that information in front of you, ready and waiting. During each ward round, doctors always do the same things with every patient - check the observations charts, drug charts, get notes and Xrays. By dividing up simple tasks amongst yourselves (one student to get the notes of the next patient, one to get the Xrays/Blood results, one to hold the obs charts etc.), you can each get a chance to be involved as part of the medical team.
7. Be observant. For heaven's sake, if you see the junior doctors struggling to carry files and X-rays, HELP THEM!!!
8. Don't sneak off. If you need to leave the ward round early, let the doctors know. Contrary to what you might think, your sudden absence from the round is noticeable. Sometimes, a well-meaning consultant may slow down the ward round (eternal wrath!) to wait for you to catch up, only to become annoyed when it is clear that you have disappeared.
9. Be prepared. Carry a small bottle of drinking water and some sweeties. You never know how long these ward rounds take! Sweeties are also useful for bribing nurses and junior doctors.
10. Afterwards, stick around. If the consultant doesn't whisk you away after the round for a quick teaching session, it is best to ask the house officer if there are any post-round jobs you can help with or observe. The junior doctors are well aware of your (poorly-hidden) desire to go for lunch, so they will be impressed that you've offered to help out. You never know, they might even treat you to coffee afterwards!
footnote: Don't forget that if you slow down the ward round or otherwise anger the junior doctors (eternal wrath!), you can redeem yourself via a Dance Of Humilation, as demonstrated by the Australian Medical Student in the following clip:
This week, Grand Rounds is hosted at The Blog That Ate Manhattan - in the form of a tribute to medical blogosphere's beloved surgical registrar, Barbados Butterfly, who was suspended for writing one of the most thoughtful, educational and beautiful medical blogs that I have had the priviledge to read.
I remember looking through your music collection, the first time you invited me round to your flat. Being the good host that you are, you had gone to the kitchen to get drinks for everyone, and left us sitting in your room. The others were chatting away about the upcoming examinations and I was listening in on the conversation, and rummaging through your CDs.
I have always believed that one can judge a person's character by carefully examining his or her taste in music.
Interestingly, you had arranged your CDs in order of mood, instead of by genre. Lighthearted Mozart's piano concertoes rubbed shoulders with the Best of the Beach Boys. Billie Holiday, sad and soulful, stood next to Tracy Chapman and Tchaikovsky's Swan Lake. Music obviously affects you emotionally and you listen to it with more than just your ears.
I remember thinking, as I looking through the classical music you owned, that you had picked the usual Mozart, Beethoven and Tchaikovsky...but also some more obscure pieces by Mussorgsky, Rimsky-Korsakov and Grieg. Similarly, the jazz CDs included the usual staples of Billie Holiday and Ella Fitzgerald but also the lesser known Sidney Bechet. I also noticed (no my great satisfaction) that there was no R&B, Drum&Bass or House (music in vogue at the time). This made me think that you actually spent time searching for music that you enjoyed, forming your own opinions, instead sticking to the well-known and popular.
Being the open and unashamed person you are (thick-skinned?), you weren't afraid to admit to listening to the 'cheese' that is Dusty Springfield, ABBA, the BeeGees, Jackson Five. There was no trace of snobbery or pretention.
You had some interest in contemporary music as well - Crowded House, Manic Street Preachers, Red Hot Chilli Peppers. There was diversity present, and you were not limited to what is considered 'easy listening' - you seemed to be adventurous and broad-minded.
Over the next few months, we exchanged music with each other. I introduced you to John Rutter, the Bangles, Dick Lee (to your utmost horror). You shared with me R.E.M, Shaun Mullins, James Blunt. We learned more about each other as we shared more and more.
Eventually, we got married, so that we could have complete access to each other's CD collections. Now we choose music together and share our findings with each other.
I still remember the first CD I bought you for your birthday - Gershwin's Rhapsody in Blue. It was a guaranteed winner (who doesn't love Gershwin?), but still I was nervous when you unwrapped the package. Your eyes lit up with delight. "Excellent!" you said, under your breath, almost reverentially. And I was so, so happy.
glam·our also glam·or (glăm'ər) n. An air of compelling charm, romance, and excitement, especially when delusively alluring.
1. Charm: Having a pleasing or attractive quality Certainly, patients do seem to find doctors pleasing and attractive. Why, only this week, I sat and had a most delightful conversation with one of my liver-failure patients who became over-excited after being advised to cut down on his alcohol intake. In fact, he took great pleasure in comparing my intelligence to various species of blue-green algae, as well as my appearance to that of the flamboyantly coloured rear of the baboon. Afterwards, he spat appreciatively in my general direction.
2. Romance: Having a mysterious appeal, as of something heroic, adventurous or beautiful Well, I suppose you could say that being able to directly impact somebody's life in a positive manner is quite heroic and beautiful. Although, disimpact is probably slightly more accurate. I often disimpact many a suffering individual - manually, of course - and this always results in instant relief from unbearable discomfort.
3. Excitement: The state of being emotionally aroused or worked up Oh, definitely, definitely. It's a wild, intense sort of life. Just yesterday, I rescued an escaping patient from running headlong into traffic. First, I executed a full body tackle, bringing the frail demented lady to the ground on the muddy grass verge. Then, I jabbed her in the buttocks with a sedating injection, whilst she screamed and elbowed me repeatedly in the face. Afterwards, I triumphantly dragged her back to the ward, to the cheers of onlooking burly workmen from the neighbouring building site, all waving their hardhats in the airs and shouting loudly about abuse. What a rush! glam·our also glam·or (glăm'ər) n. An air of compelling charm, romance, and excitement,especially when delusively alluring. I think it's very important to read the small print when it comes to choosing a career. I still love my job. Mostly.
This week, Grand Rounds is at Shrink Rap - your source for all things Quacking, Quackers and Quacked. The topic this week is 'Bring Your Own Brain' (the ethics section is particularly interesting) and there is even a podcast put together by the Three Shrinks!
Down the street where I live, the cherry trees spread out their slim brown arms, laden with pink and white blooms. The grass lies quiet under a carpet of silky petals, bright in the sunlight. Playfully, the sweet spring wind reaches out with her cool hands, pulling blossoms off the branches, gathering up the petals from the ground. The flowers swirl around me, landing on my face, on my clothes, in my tousled hair. It is a pink and white cloud and I am in the midst of it, laughing.
