A · Limited · Narrative

Sorry for the recent lack of posts. I've been *thinking about things*.

Before all the boring heavy stuff:

Surgeon comes into theatre, scrubbed, and dons his gloves - latex free, because apparently we're out of "normal" gloves. Scrub nurse comments on his particularly 'green' appearance (what with the gown being green, and the latex-free gloves being green...) 
Conversation ensues about the lack of latex-ful gloves, and the reason for being green (apparently it's not as hard as it sounds ;-)
Surgeon: So, are latex-free condoms green, too?
Scrub nurse: Only the apple flavoured ones...

Things you should know - 
1. Find out whether your patient who presents for a pap smear has had a hysterectomy before you try to identify the cervix. Most hysterectomies are complete, and remove the cervix too. *That's* why you can't visualise it with a speculum.
2. Post-Herpetic Neuralgia lasts weeks to months to years. It's generally not a good idea to tell the patient this straight out.
3. You won't hear your patient's heartbeat if you haven't clicked your stethoscope on. You might hear a wide variety of ambient noise from the ward, though...


Okay, so now for the gloomy bit.
I've decided to stop blogging. 
Although I don't necessarily agree with it, there is a traditional 'cone of silence' mentality that surrounds the medical profession. It's written in the Hippocratic Oath as:
"To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else."

So, when Hippocrates wrote that, he was concerned about 'quacks'. Now, the mentality has shifted a bit, I think, but its the same principle - and this is the bit that concerns me - that people (particularly non-medical people) might lose something in finding that doctors are merely human. My sense of humour here in no way implies that I rejoice in my mistakes, merely that I accept them and will learn from them. And hopefully others will, too. 

Whether or not 'patients' (for the purposes of this post, a uniform group comprising all who are not doctors, nurses, etc.) can accept and understand the learning process (and most are incredibly generous with their time and stories), there is benefit to believing their doctors (and medical students) are superhuman.

Sure, these days we talk about 'informed consent', and patients *should* know what's going on, all the time. But to what extent? Do they need to know it's your first time suturing? Do they need to know your success:failure ratio of cannulas, compared to that of nurse A and doctor B? 

I guess what frightens me, in this era of pathetic 'current affairs' shows and defensive medicine, is the idea that someone will have had a medical student miss a cannula on them, and sue for pain and suffering, using this blog as evidence. An extreme (and hopefully surreal!) example, but just that *little bit possible* in the current climate.

There are two other 'relative contraindications' to blogging. The first, and most obvious, is patient confidentiality. As you all know, I rarely mention patients at all, and when I do the names, dates and complaints are changed. And none of you know where I study (with a few exceptions).
The second is the first part of the Oath quoted above. My stories of Dr SYS, Dr LaBS, Dr WAFS and Dr NeRA, taken out of context, may seem insulting. Obviously, those who read carefully know of my lasting respect for all of them, and all the wonderful talents they bring to medicine. 
So while I've tried to keep this blog all about me (and not about patients or teachers), I think it's too fine a line to judge, especially in such a public domain.

I want to write a book one day, detailing all of my experiences (many of which haven't made it here). In the meantime, I'm emailing friends and family, who know me, and know that I'm well-intentioned and competent. I still never mention identifying details, but I trust those people to know about the requirements of confidentiality.

To those of you who know me in real life - send me an email if you'd like to receive those family and friends emails. To those who don't, I'm really sad to lose touch. If *you* feel safe to 'reveal your true identity' (This is way too much like spiderman...) you can email me at ausmedstudent@hotmail.com, and I'll add you too (this applies mainly to LJ friends and my links list, above - I know from experience that I can trust you! :)

Until then, may all med school bloggers have more intestinal fortitude than me... 
AMS

I sutured today!! Three stitches in a finger. Blood everywhere. But it was *great* (I also missed 4 cannulas...!!!! In nursing staff. Only one in a patient.)

I spent the day with Dr NeRA today. Because of the nature of his work, he has lots of regular (ie weekly) patients, who he's known since childhood. He's great with people of all ages, and the patients are very comfortable with him.

[An aside: as in this blog, in real life I call all my supervisors by their title and surname. I think it's respectful, and I think it reinforces the dynamics of the teacher-student relationship. I also call patients by their title and surname, unless they're under 25ish, or they invite me.]

One of his regulars came in with her new boyfriend, for a scheduled checkup. Dr NeRA (who, remember, is Nearing Retirement Age), was greeted with "Nezzzzzaaaaa!", Which I thought was *fantastic*. Cracked  me up.

One of my previous supervisors approved of my title-surname approach to patients. Had I not been doing it already, he probably would have advised me to. An elderly inpatient of relatively long standing - we'll call her Betty Howard - was a beautiful old lady, who greeted me every morning with "Good Morning, Ausmedstudent." Every morning, I'd reply with "Good morning, Mrs Howard" - and she'd say "Call me Betty."

After the third day she'd said that, I began to greet her with "Good morning, Betty." Now, during this period, Betty's doctor (my supervisor) had been on leave. On his return, here was an insolent medical student calling a lovely elderly lady by her first name! Luckily, it became apparent to him that we were on first name terms. 

I must have seen 250 patients since then, and fewer than 10 have invited me to address them by their first name. I like it that way :)

I've had a good few days. One of my long-term inpatients from my last rotation told me he'd noticed my confidence growing of late, which makes me happy :-) (He's the same one who wolf-whistled a while ago).

There have been a few problems in the university's organisation of my rotation - hence I spent yesterday in theatre (not due til next rotation) and today in the dementia clinic. I saw a couple of Caesars, then started to feel a bit queasy. I had to leave, and I'm ashamed to say the doctors present probably thought I wasn't up to the 'gore' of theatres. I was just sick - went home and slept for four hours. For all those wondering, I'm also not pregnant (unless anyone's seen a new star in the East)

Today was great, too. The geriatrician spent a great deal of time with each patient, which is refreshing after ED! It's also very necessary, to get the full story on each patient. On the way out, late tonight, I saw the first star, and stopped in my tracks...

"Starlight, Starbright, first star I see tonight. Wish I may, wish I might, have the wish I wish tonight." I may or may not have subsequently mentioned cannulas.

Results are out for another year - hope everything went as planned for everyone, and that tonight is one of celebration!

To all/most of my link list - I can't comment on your blogs atm, because blogger doesn't like my passwords. But I still care :)

On Monday, we had a lunchtime tutorial on continence. Three volunteers were asked to present a case for our tutor - Dr SYS. Unfortunately, two people were absent, so there was a total of four of us in the tute. I, of course, hadn't volunteered. I also spoke *not a single word* during the tutorial. This behaviour may have precipitated the following event...

Dr SYS said to one of the nurses today - 

"Ausmedstudent's still scared of me. I've been trying! I'm not scary, am I?"

RN: "You're not scary, you're just not very approachable...."

(This conversation was, of course, relayed to me via said RN...)


This is after a conversation with ANE (of nearly-needlestick fame) last night. She asked me who was the best teacher of my previous rotation. My answer was, of course, Dr SYS. ANE had thought Dr LaBS would have been the best teacher. I have to say, Dr NeRA's doing a great job, too.

When I look back, it's probably not that Dr. SYS is overly scary - more that he was my first supervisor on a clinical rotation, and I was his first student. It's a awkward path to forge together. I almost wish I'd had a different rotation first, because now I'm much more capable of dazzling people with my brilliance... and could probably derive more benefit.

So, today was supposed to be my day in ED with Dr. SYS. Unfortunately, he remains unwell, so he wasn't put on as 'first', and seconds (and thirds, etc.) can't have students. Fortunately, Dr. Bean was rostered on first and had temporarily misplaced his student (I didn't ask) so I spent the day with him.

Dr. SYS did ask me to examine a lady with a large pleural effusion, which I did while he'd stepped out of the department for a moment. I tried to elicit the common signs - namely, dullness to percussion and absent breath sounds. I also listened for changes in vocal resonance and vocal fremitus.

Subsequently, I went back to seeing outpatients in a consult room. Dr. SYS came in to get something - and asked me whether I'd elicited the signs I'd mentioned above. Apparently, he can still grill me when not only am I not his student, but I'm not even his student-in-ED-for-the-day! On the upside, for once I had done all I'd been expected to. 

I left at about 6.30 to have dinner with a friend, about 7km away from the hospital. JD is also a medical student, so we were 'debriefing' on our respective days. She mentioned something about an AAA - an abdominal aortic aneurysm - and the thought struck me that I'd felt a very pulsatile abdominal aorta in an elderly man presenting with epigastric pain, and failed to check with Dr. Bean or to document it. 

So, straight after dinner, I drove back to the hospital (the opposite direction to my house) to mention it. Dr. Bean re-examined the patient, and it turns out it was all in my head. I think this obsession with AAAs is largely attributable to Dr SYS - one of his favourite 'surgical sieves' is "What Must I Not Miss?", a phrase he repeats during every patient discussion. And his favourite example is the AAA in epigastric pain.

I have a(nother) headache  :( Tomorrow, I'll be in ED again, this time with Dr NeRA. If I'm to feign intelligence for another whole day, I shall have to be off to bed.

So, Dr. NeRA is my new supervisor. He's *so* laid back, he puts Dr. LaBS to shame. He asks third-year-appropriate questions, and gets me to see third-year-appropriate patients. I'm so well adjusted in his presence it amazes me! 

I saw a patient today who wanted to start the oral contraception pill. It was so fantastic to be able to discuss something I knew something about! And, when I presented the case, it was a relatively short and succinct one - and my patient (and her mother) applauded! 

So, in case we needed further proof that my Dr.-SYS-phobia was all in my head, I've been calm and relaxed all day, even when I stuffed up. Or perhaps I'm more familiar with stuff ups. And Dr. NeRA has had students for many more years than Dr. SYS, for whom I was his first victim student.

Tomorrow is another ED day with Dr. SYS, so we shall see how I go! I think I've grown up over the weekend... :-)

Well, as some of you have noticed, I've changed my blog layout and stuff. I think it looks all grown up :) 

I also decided my blog needed a more abstract title, and I got this one from a book of essays I'm reading at the moment. It's by Peter Goldsworthy, who's an author and a GP, and who wrote Maestro, one of my favourite books of all time. In his essay, he talks about the central character of Maestro being a 'limited narrator'. I've provided the link in the previous entry. Obviously the term is one from literature generally, and not peculiar to him.

Speaking of ''in with the new", it's my first day of a new rotation. The next six weeks consist of drugs and alcohol and psych, and more ED. My new primary supervisor is Dr. NeRA - Nearing Retirement Age. (Aside: his naming as such is not a value judgement; it's merely that his impending retirement is his favourite topic of conversation...) 

Also featuring:
Dr. YAM, who's Young and practises Alternative Medicine 
and the perennial favourite, Dr. SYS.

I'm still in the same clinical school, so Drs. LABS, WAFS, and Bean may still make the odd appearance! :) I have a splitting headache, so I'm off to bribe the nurses for a panadol or two. 

Who is Eduard Keller? And what does he have in common with Dr. SYS?

A "Limited Narrator".