Ectopic in the Tropics, with Icky Photos

Hanging out with the curios sellers, buying jewellery. Only three working days left to this rotation, in Embangweni which is in the Northern Region.

******
An eventful month for me. Twins. Triplets. Breech deliveries. Cord prolapse. Uterine rupture. Ovarian cancer. Cervical cancer. Ectopic pregnancy. Tuberculous pleural effusion, tuberculous osteomyelitis, tuberculous cystic abscess, pulmonary tuberculosis. HIV positive, HIV negative. Kaposi sarcoma. Cerebral malaria, neonatal malaria, malaria with anemia, or just ordinary malungo. Kwashiorkor. Septic abortion.....

*******
Ectopic pregancy in Canada presents in a particular way: pain, positive pregnancy test, ultrasound showing no intrauterine pregnancy but not necessarily locating the ectopic, and not necessarily showing blood in the abdomen. But this is the fear: a ruptured tube and exsanguination (bleeding to death in the abdomen).

It is managed urgently or emergently depending on the level of pregnancy hormone and the presence of fluid in the abdomen. Either methotrexate to cause the pregnancy to abort and resolve, or if it is too late for that, surgery to remove the pregnancy and the source of bleeding.

In Malawi, women put up with incredible amounts of pain before coming to medical attention. And sometimes the results are surprising.

The doctor I have spent this month with tells a story of a lady who presented to Zomba Central Hospital because she was overdue. They confirmed her dates and tried to induce her labour, but nothing happened. They gave her repeated doses of drugs but her cervix stayed as tight as Fort Knox.

Eventually she left this hospital, because she felt she was not being helped, and presented to MMH. There, they performed an ultrasound and found that the baby was outside the uterus. The placenta had implanted on the outer wall of the uterus, and the amniotic sac was intact in the abdominal cavity. They performed a laparotomy to remove a live post-term female infant with apgars of 8 and 9.

Mother and baby did fine and went home after a week.

*****
Of course, this is unusual. I saw a lady who was sent to us by the prenatal clinic, known as sikelu or scale. She was sent for failing to gain weight normally. Her last menstrual period had been in April, but her uterus was 22 weeks, and felt, well, weird. There was a hard lump that felt subcutaneous in the epigastrium.

We did an ultrasound and what we saw led us to schedule a laparotomy for the next day.

The hard lump turned out to be a calcified fetus, which had died months previously, presumably when the placenta could no longer get enough blood from where it was attached to keep up with the fetal growth needs. It was largely resorbing and only some fetal parts were identifiable.

The placenta was attached to the woman's right fallopian tube, and had destroyed the tube. It had developed into a large vascular ball instead of the flat leafy shape we are used to. The lady had, on history, had a lot of pain in May and througout the pregnancy, really, but had thought it normal and never complained.

Her uterus and other tube were normal, and in all likelihood, she will be able to complete her family. She recovered without incident and went home a week later.

Missing Home

Well, sometimes.

I'm on the traveller's weight loss programme. More effective than Jenny Craig, faster than Weight Watchers. *sigh*

But my sister sent me this photo, and you know what? It makes me really grateful to be here.

Mangoes

How much does a mango cost? You know, the fat red creamy ones?

The ladies are selling them for under 5 Kwacha each. There are 275 kwacha to the British pound. It's highway robbery to take them away for that, but they are so plentiful, none of the locals are buying for more.

I love mangoes, and to help out the ladies I am buying tons of them. I expect to be orange and sweet by the time I go home.

*****

The hospital had a busy weekend. Two uterine ruptures: one baby survived, the other came in too late.

But both mothers survived. And you know what? That's a damn miracle.

******
This morning's entertainment: Young girl from Mozambique, from Villa Milanje. Hello. Oh, you're due this week. Having abdominal pain and that's why you came in. Okay.

Who came with you? (Every patient has a guardian to cook for them, wash their clothes, advocate for them.) Your mother and your sister? Alowetsani (bring them in).

And so in comes sis. Also pregnant, with a notebook which serves as a medical chart here in Malawi. Hm. A load of help YOU'RE going to be. Also due this week. No abdominal pain.

You're sisters? Yes.

Same mother and father? Ah, no.

Same mother? No.

Oh. Same HUSBAND. Not sisters, co-wives.

Both doing fine, both around 19 years old, both due this week. I hope he's faithful to both of you, because if not he's putting a lot of people at risk.

Tragedy

Woman presents in labour. Ominous past history: five pregnancies with two micarriages, one stillbirth and one live baby. But all seems well.

Baby's heart recorded at 9am as 150 beats a minute, normal for a fetus. Mother progressed slowly but steadily.

At 1340, the nursing notes say that the baby's heart rate was 122, still normal; and on vaginal exam they say the mother had reached 6cm, but they thought they felt placenta, so they sent for the clinical officer.

I showed up by chance. Nobody had called for the doc yet as the iCO was still examining the patient. He looked up with that nervous African smile that it takes people forever to understand does not mean happy, and said two of the most dreaded words in obstetrics: "Cord prolapse." I turned and ran for the doctor, who grabbed her dopplex and came.

Cord prolapse is when the baby's blood and oxygen supply, the umbilical cord, slips ahead of the baby's head into the mother's pelvis. When mum has a contraction, the force of the baby's head compresses the cord, cutting off baby's oxygen. You have very little time, minutes to get a baby out in that situation. It's hairy in the best of hospitals.

She handed me the dopplex, and ran to grab her ultrasound, ordering everyone to get ready for an emergency cesarean. I searched frantically for a heartbeat. I could hear placenta. I could hear mum's vessels.

But nothing. Nothing.

The doctor returned with the ultrasound and quickly visualised the heart. We were too late.

The intern clinical officer explained to the mother in Chichewa that her baby had died. She began to cry. The commotion around her stopped.

In Malawi, to respect the family's grief, only the immediate family are allowed to cry when someone dies. Imagine holding the hand of a woman who has just had her baby die, watching her cry and offering her words of sympathy while keeping dry eyes. Because to do otherwise would be to take something away from her.

And there was more pain to come. She still had to deliver the dead baby.

But there was no urgency now. We let her rest. The nurses didn't comfort her, and I had little to offer in her language.

A beautiful baby girl.

Happy Dance

CaRMS is finished!!!!

Nguludi

Another of Malawi's pretty little secrets, Nguludi is tucked away in the hills outside Limbe. It's a verdant valley with an unexpected mission hospital and church.

At the hospital, seeing patients: primary amenorrhea in a 22-year old. Would you believe Mayer-Rokitansky-Kuster-Hauser Syndrome? (oh, yes, of course) Blind vagina, likely no uterus, to be confirmed by laparoscopy because we are not convinced by the (very expensive but notoriously unreliable) radiologist's report that he "located" her uterus on ultrasound.

Update: A visiting gynecologist brought his old-school laparoscope. One generation removed from a magnifying glass in a tube, fabulous to see how it was done. So we got to see directly that there was in fact no uterus but only rudimentary fallopian tubes attached to normal-looking ovaries. So diagnosis confirmed.

Have we done the patient any good? Well, probably not. We could tell her that sadly, there is no chance of children here in Malawi. The technology for surrogates exists elsewhere, but not here.

******

Blantyre: The Celtel tower was the latest casualty of the lightning, so my planned couple of hours at the internet cafe to finish up CaRMS didn't happen. Hi-speed in Blantyre vs dial-up in MJ is the difference between 2 hours and 8 hours, and my blogging, it should be noted, has been done whilst waiting for my pages to load. Yup, still loading. Dial-up=no photos, sorry.

Anyhow, did you know the University of Toronto has an Office of International Surgery? Does this sound like it was made for me? And they are here! Believe it or not, providing access to the UofT Libraries to African surgeons! How amazing is that? Given how hard it is to get your hands on up to date print materials in this part of the world, and even if it wasn't, this is an incredible resource, which can only improve patient care.

(no applause, just throw money)

*******

Sinterklaas. No, I don't speak Dutch either, but who cares. It was a fun Christmas party for the little kids and I won an elephant!

More Dispatches from Malawi

The postpartum ward is nearly empty. People are either not having complications, or they are not coming to the hospital. It is the planting season, the rains have begun, and everybody is needed in the fields. There is nobody to take a woman to hospital, nobody to stay with her once she arrives, and no money for transport besides.

So who is here?

An older lady, a Jehova's Witness. We removed a mass from her abdomen last Thursday. I will have to learn to bring a camera (but I know you would strangle me, Sari), because it was HUGE. Harder to deliver than a baby. She's currently doing well.

We don't have the path report yet, nor will we until the College of Medicine reopens after the holiday (remember THAT next time you are grumbling about how long they are taking with the frozen section), but the tumour looks very like ovarian cancer. We have de-bulked the tumour and omental cake, and done a TAH-BSO, but she had peritoneal seeding and studding over her liver. She had ascites, and this is already collecting again.

In Canada, she would get chemo, molecular analysis, maybe hormonal therapy.

Here, she will be sent home with painkillers.

This is my patient. This is killing me.

******
We had a lady come in, in labour.

Not unusual.

Ok, but she had already delivered on the way to the hospital; the baby, tragically, was born dead.

Twins, you say.

Well, that's what we were thinking. Push. Oh, there's the second baby, born alive. So small. Here comes the placenta. WTF?

Another head? Triplets!

Two babies born alive. 1.1 and 1.5 kg.

If you're religious, pray for them. If you're a scientist, courier us some BLES. Either way, they need help.


Update: The bigger of the two babies died the next day, of respiratory failure. There is no respirator, and the supplemental O2 only works when we have electricity, which we don't on Tuesdays.

Ulongwe TDC

To Malamulo Hospital (apparently, it translates to Commandments) today. Have photos of the OR (see the sidebar), including the lovely scrub sinks, and the buckets full of water because there is no running water today, pepani.

I didn't take photos of the hospital itself, because lovely as it is, photos can't do it justice. Colonial redbrick, 100 years old. Low buildings with covered walkways hemed in by arched 'windows,' vines and bougainvillea and all manner of well-kempt greenery.

The clinical officers were Jane from Kenya, a matter-0f-fact woman about my own age, and Blessings, a local young man, bright and attentive. They have minimal training but manage admirably at the front lines, undoubtedly better than I could running a ward without support at this point.

The cases were routine, two ladies with ovarian cysts; one had evidence of old PID in the form of extensive adhesions. Young as she is, her fallopian tubes appear to be so damaged that she is likely never to concieve, a disaster in a place that values a woman's fertility above most anything else.

We also visited Thyolo District Hospital which was under construction with the aid of Medecins Sans Frontieres while I lived here in the past (Hi Ibrahim, I wonder where you are and what you are doing, you jerk.). It's amazing, clean and modern yet very much fitting the environment. Fantastic. And they have a CD4 cell counter.

You see, people who test HIV positive in the absence of CD4 cell counts are not eligible for antiretroviral treatment until they get sick, WHO class III or IV. In limited resource settings this makes sense, saving the resources for the people who need them most. Unfortunately, some people in these categories are too sick to tolerate the ARVs; we have two patients at least who are in that situation. With CD4 cell counts, people in classes I and II may become eligible if they have a CD4 count under 200.

But a counter costs thousands of dollars in initial outlay and then in reagents and maintenance, so it is largely out of the reach of Mulanje Mission Hospital. They await with bated breath the introduction of the rumoured machine which can do the counts on a drop of blood and costs around $5000 instead of $20 000.

And maybe then the cracks through which our two ladies have slipped will narrow, and people after them will have a better chance at getting the drugs when they need them, before it is too late.

Teaching!

Great teaching this morning on the management of simple fractures and how to use plaster of paris.

More great teaching on cervical intraepithelial lesions and cancers by visual inspection of the cervix with acetic acid. I think my preceptor is more upset about this issue because we have already seen two ladies with likely invasive cervical cancer in her office this week (and it's only Tuesday).

It's preventable. Not generally curable, but preventable.

******
Things that Make Me Happy

• Kandodo warm bread


• Sunshine on the flame trees


• Not getting peed on when holding a baby


• Short power outages


• Mosquito nets


• Paying someone to iron my blouses (ever heard of tumbu flies? Yuk!)


• Frogs


• The massif turning pink in the sunset


• bug repellent with DEET


• headlight flashlights


• iPod


• pineapples

Things that Make Me Sad

• Children dying of malaria


• When the test comes back positive


• When she says her husband will beat her and throw her out of the house


• When you say, twins, and she says, oh, no!


• When you check the cervix and it's already too late

Mulanje District Hospital

One patient after another coming with a history of dead children and now infertility. Wanting to conceive. HIV positive. Some on ARV treatment, others newly diagnosed. And with no CD4 cell counter, until they get sick enough (WHO class III or IV), they will not be eligible.

I am sort of at a loss here. On one hand I want to say, you have had three children die of AIDS; your own lifespan is already limited, and the country is littered with AIDS orphans. Why do you want to make more?

On the other hand, I want to congratulate her for being alive and hopeful enough to want a baby.

And the third point of view, the one that counts, is that this life is hers, and this decision is none of my damn business.

Mulanje Mission Hospital

Lilongwe bus station and Old Town have largely been cleared of traders. No more thronging press of people!! Hopefully fewer pickpockets and outright theives, but someone still tried to nick my katundu.

You can still rely on curios sellers to lie about their names, and to speak passable English, and to help you out for a few kwacha. I paid one of the guys to escort me through the bus station which had been utter madness in the past. I was astonished at how it had changed, and the guy put me on the right minibus to get to Blantyre. And then I had to find my own way. And here I am.

It's gorgeous. In some ways, it has changed a lot, but not in others. There's a pizza place in Chitakale that does lovely thin-crust wood-fired (obviously) pizzas. You can have your choice of Coke or Fanta, or for a couple of Kwacha extra someone will run next-door and buy you a beer. There's a paved road from Mulanje Boma up the side of the mountain, leading to a posh hotel, Kara O Mula. The sunsets are spectacular, but the likely superb view down to the Boma is blocked by the enormous trees-not a complain, as trees are getting rarer. Apparently they are building a swimming pool as well.



Emmy works at tourism Mulanje, above the pizza place. Miriam has become such a lovely big girl, from being a babe in arms.


The Mulanje Golf Club has a small pool which, when I went, may as well have been my own private pool.


I am saying with my preceptor, a gynecologist who has been here for eight years, and a gracious host.


Here at the hospital. The operating theatre is incredible. Everything you need: Light, AC, a basic table that raises and tilts and splits, whatever. A small supply of suture material. Very basic anaesthesia: spinal (bupivacaine) or ketamine.



I assisted at a C-section, a couple of TAH's and some open evacuations of TOAs. I was present but not scrubbed for an emergency C-section on Saturday evening. I have to thank Joey in Montreal, the peds resident who helped me through NICU, because I was handed a blue baby from thick meconium and a nurse and I had to resuscitate him. I could hear Joey's voice saying "Suction, suction. Ok, good, now we have to stimulate the baby." Calmly, quietly.



Bradycardia.



I can't feel a heartbeat.



Bag, chest compressions.



Suction.



And suddenly, the baby pinks up. I have a heartbeat! He's breathing!



He didn't cry until later that evening but now he's perfect, crying and moving and sucking.



Scared the life out of me, little guy.



*******

Last night I was rounding with the doc in the labour ward. Two young ladies had come in but had not yet been assessed. One looked very familiar.



And she looked at me and frowned and said my name.



It was Alicia, a young lady who was a student of mine for three years while I was here in the past.



And she had a boy.

Lilongwe, Malawi

So, I'm here. At the Korea Garden Lodge and heading to Mulanje in the am.

Fewer trees. Stiflingly hot. I feel very out of place but I suppose that's because I am. I don't feel as safe as I used to, which is a real shame. But maybe it's me.

Some changes for the better, though. Less outright begging. Less garbage heaped in the streets. The informal market is now a more formal one, though too small.

Lilongwe is haunted for me though, with the people I spent my time with. I can't close my eyes but I see them. I miss you, Marta and Jo and Jovie and everyone. It's hard to be in a place that was HOME, and know nobody.

Miss you, Jim, my lovely. Wish you could be here.

Grand Rounds 3.08

You can find it at the rumors were true. Enjoy.

Pharmaceutical fun

On the label of my antimalarial:

"...it may produce side effects in some patients."

"...if you develop a sudden onset of unexplained anxiety, depression, restlessness or irritability, or confusion (possible signs of more serious mental problems), or you develop other serious side effects, including a persistently abnormal heartbeat or palpitations...."

Okay, this is giving me palpitations just reading this stuff.

The dreams it gave me last time were wild... a friend of mine, a sweet little old Sikh gentleman in a Santa suit standing in his dining room which had somehow transmogrified into a ballroom featured heavily in one series of them.

A friend of mine had a dream that his grandmother had died. And then he realised that he was dreaming, and someone was waking him up to tell him that his grandmother had died. Then he realised that this too was a dream.... and it kept happening all night.

Most people didn't have any problems. Fingers crossed.

Flu shots

I got mine yesterday and my arm still hurts.

*whine* *pout*

And you're thinking, oh, shut up. Yeah, fair enough

The fat doctor says it best. Get it before it gets you or someone you love, like your asthmatic spouse or your Grandma, who might just get more than two weeks off work.

Ready for it

We fly on Thursday. Do family stuff in England. And then I get on that plane.

The first time I went, I really, honestly, did not know where Malawi was. I did not believe it actually existed until the plane landed.

And you know, that feeling was not so far off.

That there and here can exist in the same reality is not quite believeable. In some ways I felt like a time traveller. A Time traveller. Or National Geographic, actually. That people still live in thatched mud huts and wear rags and cook on three stones TODAY as in RIGHT AT THIS MOMENT is difficult to swallow while I consider whether I want to have raspberries or strawberries with my chocolate crepes and then worry about fitting into my jeans.

When I first arrived in Malawi, when I realised that alternate reality or not, this is where I was going to be living for the next couple of years, the culture shock threw me back hard. The staff at VSO were undoubtedly laying bets on whether I would ask for my ticket home this week or next.

I cried my way through the language lessons. I worried about my housing situation, because nobody I met could say to me they had actually seen my house. I couldn't face the pit toilet with scorpions and cockroaches and god knows what all. I was terrified of spiders. I had nightmares about giant mosquitoes and about being lost in the dark and about all the unfamiliar faces.

And I hate to say it, but everybody looked the same to me. I had never considered myself a racist, but I was from small town Newfoundland and I simply had no experience discerning black faces. I had no clue what to look for.

Terrified. Why ever did I leave Canada?

So eventually our training period was over and we all had to go to our various placements. My employer came to fetch me, and surprise, surprise, there wasn't a house for me (it would take six months to sort out a permanent one).

And where I wound up staying had a pit toilet.

And I had a tree frog living on my door.

And I learned the names of all three hundred of my students in the first six weeks.

And I got my neighbour's house-boy to teach me Chichewa.

And I made so many great friends.

And I stayed for three years.

And I still had nightmares about spiders, but I wasn't lost in the dark anymore.

Malawi

It's a small world sometimes.

Last night I was sitting in my favourite cafe, Croissant de Lune on St-Denis, having savoured strawberry+chocolate crepes with coffee. I was attempting to work on my final CaRMS stuff with their fab free internet...

And I saw someone wearing this on her T-shirt.

I couldn't help saying out loud "Oh my god, that's the Malawi flag."

Anyhow, this started a whole conversation about Malawi... turns out this couple had just returned a few months earlier from a two-year contract with WUSC.

Oh, it was fun. We had a great deal of comparisons to make. They warned me that the place has changed a lot: even fewer trees, more talk about bauxite open-casting on Mulanje Mountain.... which would make extinct the Mulanje cedar, ruin a beautiful environment, and provide huge amounts of money to a few very wealthy people while the rest of the money left the country and provided no benefit whatsoever to the local population, because of course the aluminum cannot be processed in a country without a good supply of electricity, so it would be exported (likely to SA) and most of the profit would go there.

What, me, rant?

Anyhow, we had a great conversation, and she put me in touch with some people in Malawi who might be able to help me out with transport, and it really helped to get me in the mindset to be going. Only a week now.

Thanks, Nicole. You'll hear from me.

PS: Check out this post on the American health system from the point of view of a med student.

All better... or not

Canon in D, on violin, by two volunteers, makes everything feel better just for a minute. Beautiful.

The residents are angry, at the staff and at the government for forcing the hand of the staff to this point. The senior residents have worked like dogs for five long years, and now they receive no teaching, no evaluations, are just ignored. Some are losing sight of the fact that any protest HAS to be against the government, but I think reason will prevail and work action will be taken against the government rather than against the staff.

Unfortunately, this will make the lives of the staff even harder, because any workaction by the residents will obviously make their workload heavier. I don't knowhowmuch pressure the government really wants to place on specialist docs, but their situation is currently untenable. I will update later with more info, but I need to get back to work.

UPDATE:A few excerpts from Bill 37, which is a law passed June 13, 2006 which binds the medical specialists to a 2% per year increase (while inflation is about 2.4% and medical specialists in Quebec already make on average only about 60% of what they do in the rest of Canada):

"The Master Agreement is renewed and binds the parties, with the necessary
modifications, until 31 March 2010.

"However, the provisions in the schedule relating to the remuneration of
medical specialists also bind the parties until 31 March 2010.

"No medical specialist may participate in concerted action to stop, reduce,
slow down or modify his or her professional activity or to become a professional
who has withdrawn.... Any notice of withdrawal or non-participation concerning a medical specialist sent to the Board after 12 June 2006 is null unless the medical specialist proves that the notice was not sent as part of concerted action. [emphasis mine]

"No person may, by omission or otherwise, prevent or impede the provision
of medical services provided by medical specialists.

"No person may help or, by encouragement, advice, consent, authorization or order, induce a medical specialist, the Federation, an association or any other person to contravene any provision of this division.

"A medical specialist who participates in concerted action to stop,
reduce, slow down or otherwise modify his or her professional activity commits
an act derogatory to the dignity of the profession covered by section 59.2 of
the Professional Code (R.S.Q., chapter C-26)."

Or you can read the whole thing here (if you click it, it downloads a PDF file from the Quebec Federation of Medical Specialists, 12 pages, no fancy graphics).

It's a bit like living in 1984, and I'm not talking about the year here. Particularly that bit I highlighted. Is this post then illegal? If you don't hear from me for a while, worry.

Shock

We have just been told that the only recourse the Quebec doctors have to the measures forced on them is to stop ALL teaching and administration duties.

As in: no formal teaching.

No reference letters.

No evaluation forms.

So, now what? I have a feeling I am about to be told that I am royally screwed, as will be anyone else who is depending on their elective supervisors to give them a letter.

Bye bye surgery.

Two weeks

I will be on a minibus, trying to breathe in the stifling heat of Malawi's tropical hot season.

1 Canadian Dollar = 125.941 Malawi Kwacha (when I was there it went from about 1:30 to 1:55).

The mangoes will ripen around the end of my stay, about the end of December. Bananas are year-round. As are passionfruit. And guavas.

I will be wearing sunscreen and a Tilley hat (oh so high fashion). I need to buy new sandals because I just realised I threw out the ones I was intending to take with me. Where in Canada sells SANDALS in NOVEMBER??? Ye Gods.

I have to get an appointment with someone who will prescribe me some lariam or something. But the dreams are super-wild. Not really nightmares, just way too real for comfort. Particularly for someone like me, who without benefit of psychoactive substances already regularly gets, as my mother calls it, "the Hag."

I will be attempting to convince myself that I am not REALLY afraid of spiders (of course not, that would be silly, they are usually harmless) even if they ARE the size of dinner plates. Yes, I have actually seen spiders that big. I have no idea what sort, I called them banana spiders because they lived in the banana trees. And they barely moved, and they spun the most amazing webs made out of tempered steel or something, you could practically hang your laundry on them.

Nor am I afraid of:
giant field mice
snakes of various colours and sizes
three-inch-long-flying cockroaches

Etcetera.

What me, getting a little nervous? What makes you say that?

"He's Peeing!!!"

Sometimes, medicine is truly surreal.

The above quoted from one of the ward nurses to our senior resident (affectionately known as Xena Warrior Princess). And everybody, myself included, smiled happily and said, "Oh, that's amazing!"

So, the transplant went well, and is taking. Fingers crossed.

The Downside

I was checking out a few of my fave blogs, and came across this post by an American ED doc.

Scary stuff, looking into the future. The thought that you could do your best for someone, using every professional resource available, and they, upset with what is probably an unchangeable outcome, decide to mount a lawsuit is one thing. The idea that as a doctor I could come to see each patient as "the enemy" is the most discouraging thing I have ever heard.

From another medical student we get this sort of attitude toward the patients he sees. And this.

The dinosaur points to a blog which has a great comment on the relationship between docs and patients.

For me, I guess I can see both sides. I once had a case where I was involved with the trauma team activation for two patients brought in one after the other. The first was a man shot by police. The second was the man he stabbed.

I did chest compressions on the stabbed man while the team looked desperately for reversible causes and signs of life, but unfortunately, it was too late.

I had to be involved with the care of the man who was shot for the next ten days while he recuperated from his injuries. It was a relief for me when he was well enough to be discharged (to his court appearances and police custody).

Zebras

I was given a short-notice project, which got postponed (possibly cancelled if I don't push to do it) on *zebras in abdominal pain.

I have come up with 10:
TB of the GI and GU tracts
porphyria
viscerotropic leishmaniasis
abdominal migraine
eosinophilic gastroenteritis
toxocariasis
familial mediterranean fever
lead poisoning
Henoch-Schonlein purpura
rectus sheath hematoma

Any other suggestions? I'd appreciate it.

Oh, there goes my pager (see below).

*zebras = the last thing you should think of when given any symptom complex. "When you hear hoofbeats, think horses [not zebras]

A Kidney

Kidney transplant meant to happen tonight. I have been up since 4am due to a presentation I was told to give today, yesterday, which, I might add, got postponed. Just as well, it would have been pretty cursory.

So what's my plan? Attempt to nap with pager in bra, set to vibrate, natch.

When called, dash in to hospital to (hopefully) scrub in. That way, even if I can't DO anything, (because, be real, there will be a staff, a fellow, a senior and a junior) I can at least squeeze in and occasionally have a good view of what's going on.

Right, nap time.

Transplant

This is a new thing for me. I'm not sure how I feel about the whole thing so far.

We "did a donor" tonight.

As in, a gentleman who had had a massive stroke a few days previously, and who had been declared brain dead shortly after that time, by very rigorous criteria, and whose family had requested in their grief that his organs, if possible, be used to help other people, had his liver and kidneys retrieved this evening.

As I write this, there is a man having that liver placed in his body to replace the one that has been failing him. Two people are being woken from a sound sleep and told that they may be able to stop having dialysis and go back to something like a normal life.

And though I know that the gentleman in question had died and the machines were breathing for him, it was still disturbing to see doctors do things to his body that would certainly kill him. I know that makes no sense.

An organ donation is a great gift. I signed my donor card years ago. This unsettled feeling doesn't make me re-think that. I just feel unsettled.

Saturday Night

This has been a great week:

Sorting out CaRMS documents. I have to PROVE that I am a Canadian, and that I did an undergraduate degree, and that I passed my ACLS. I didn't bother to prove that I can speak French, that's easy enough to prove in person. Du fonne, toujours.

For some reason they also wanted a photo of my smiling mug.

So that's done. The application and schools selection and letters are just about finished. Still panic-inducing every time I log in. Because what if I don't get accepted to a surgery programme? I can't picture myself doing anything else at this point, I have the "surgery bug" (as one of my mentors put it) so badly.

Working on a research project, just silly grunt-work, but someone has to do it. Chart reviews, not much judgement required. Nice to be involved with anything to do with trauma.

Got my airline tickets to England and Africa. My husband's uncle is getting married. And then I am off to Malawi. To deliver babies and do gyne clinics in a very badly underserved area with a doctor who has been there forever despite her annual threats to give it all up and move back to the States. She's a star.

Bought car parts on ebay. And earrings. And The World According to Garp on DVD.

Caught up on some sleep. Studied a little. Start in hepatobiliary on Monday, and am a smidge nervous.

Grand rounds

Wowee, this whole blogging thing.

If you want to see some excellent medical blogging, click the title line to visit Grand Rounds 3:5. It can get really late when you're enthralled. I especially recommend Tundra Medicine Dreams.

Money

I don't think I'm in it for the money.

It would, on the other hand, be nice to be able to afford to pay off my ginormous debt and buy a house, like a normal person.

So, I am working on my CaRMS, and it tells me what I will earn in various parts of the country as a first-year medical resident. This is salaried, for an 80-hour workweek, with moonlighting illegal here in QC, though not necessarily elsewhere.

And I was reading the papers, about the cols-bleus in TMR with a 36-hour week (paid hourly, with opportunity for overtime) demanding an 11% raise, and throwing a hairy fit when they were refused.

You know what? Even with no overtime, their gross salary is $5000-$12000 more than what I will earn, wherever I go. And, of course, if I was to stay here, once I finished my residency I would have to pay the government $300 000 to stay.

Remember that when you have to wait six months to get your gallbladder out.

Molly

Meet the newest of my nieces, Molly.

I don't think she has a middle name yet. Her daddy suggests "Ed's a nice name...."

And her uncle, my husband, continually insists that "Molly James" has a certain ring to it.

And of course, little Molly will need to be aware that if she had been born into a more traditional family she may well have gotten stuck with her grandmother and great-grandmother's names. No disaster, you might think. Oh yeah? How would you like to be called Verna Gertrude?

Personally, I think if you are going to name your child something out of a fifties rock tune, you may as well go whole hog and call her Molly-Sue. Which, if you ask me, is pretty darn cute. And also, it includes the name of another aunt, Ed's sister Susan.

(And she is, isn't she? Pretty darn cute, I mean.)

***** Congrats to Ed and Amy *****

Trauma draws to a close

Yesterday I was rounding on a group of patients. There was one young lady I went to see who is generally catatonic, but recently her meds have been changed, and she seems to be responding well.

So I tap on the door. I can see very well what she's doing, and when she notices me, she doesn't bother to stop.

"Hello, Mrs. B, how are you."

"I'm okay." She looks at me, then looks at her finger. "I'm just picking my nose."

"Mmmhmmm."

Well, what can you say?

*****

My trauma rotation has been incredibly interesting. I learned a lot about my city. I learned that a lot of trauma is predictable and preventable, and that carelessness can easily cost a life.

I liked not having to read the newspapers.

I liked being part of the team that took care of the hockey players: "Did you see that hit?! I guess we'll be meeting that guy at rounds in the morning... cool."

I loved taking care of patients in acute, unexpected situations. I loved that they got better fast and went home. I loved the decisiveness, the confidence in the training.

I'm on call tonight. Wish me luck.

Unsure

I don't know how you are supposed to feel when you are told a horror story by the police, and then you have to go in and provide top notch care for the person who they tell you is the creator of that horror story.

What we have to do is remember that maybe, just maybe the story is missing some details, and maybe things aren't as they seem. We have to remember that the person in front of us, monster or not, is still a person. We have to remember that even if the story is true, this person should be allowed a trial, and that we are not the judge or jury.

You know what? Never mind all of that. When you are in the middle of a trauma, your training takes over and you think about the circumstances later.

But it is still difficult.

Early morning fun

So, I try to arrive a little early most days to make sure the patient list is accurate and everything is ready for us to round.

A couple of days ago I did just that, and ten minutes before everyone else was due to arrive, I was riding alone in the elevator watching the floors pass by.

*ping* and the elevator stops on the ninth floor. My colleague peers into the elevator, and says "Oh, good, it's you." He's been on call all night and looks harassed.

"Have a good night?"

He grins and hands me two phones and two pagers. "Here, take all of this; Ali and I are heading into surgery. There's a guy who got stabbed in the heart and he's bleeding again... give them to the team taking over."

"Cool! Have fun!" The doors glide shut and I keep going up. And as I arrive where we round and note that our team has not yet arrived, you can guess what happens:

"beep, beep, ring, beep ring!!!!"

GAH! Trauma!!

All I could think was oh-no-I-have-everyone's-pager-how-on-earth-will-they-know-there's-a-trauma-I-am-just-the-medical-student-I-think-we-may-be-needing-a-tad-more-backup-than-that!!!

Life is fun. Sometimes it really does like to bite you in the ass at 6:56 am.

Friday Call

So, as weekend calls go, a Friday call is generally considered to be pretty sweet. Spend the day with the team, take pages (and in the case of the surgery team, traumas) overnight, round at 8am, help the incoming student with notes and cleaning up scut, which is minimal on the weekend, and out of there usually by 1030 or 1100.

Which all falls apart when there is no incoming student.

It was actually a great call. Sort out minor stuff till 2300, then grab a few Z's. Until the trauma pagers (all 7 of them!!) start to go crazy at 0315: "trauma team to trauma room." Rub the sleep out of the eyes, grab for glasses, what did I do with my shoes?

Shoes located, down 18 floors to the trauma bay.

Pedestrian vs car high speed. Head injuries. ABCDE, X-ray, CT everything, get a reading from an unhappy radiology resident, ICU, neurosurgery consult, ortho consult. Whew!

When it is clear that our patient is well taken care of, back to 18 to sleep a little more.

Wake up to a change in the light. The rising sun is red red red. Clear sky to the north and south, but the view from our window looks east over the city, and a low black cloud like smoke is obliterating the sunrise and the city and sending chills down my spine.

The door bursts open and a nurse says, "Your patient is in trouble, come now!"

A lady with a bowel obstruction having conservative management has had sudden onset of excruciating abdominal pain. She has been doing well until now.

Vitals, morphine, stat abdo series, draw bloods and ABG. Is that hernia reducible? Is the NG working? Could she have a clot? What are the vitals now? Will a CT help?

0800 finds the senior resident and the medical student rounding. The trauma junior who has just finished his parachute call in ICU takes pity on us and helps us with the notes and orders (cool, thanks). When there's really very little left, he leaves, to get a well-deserved sleep.

And as I am running through the labs, *beep, beep, beep* "trauma team to trauma room." Technically I don't have to go, but I came to do trauma.

18 floors down. Elderly lady, apparently run over and dragged by a car. Driven by her elderly husband. He is devastated; he didn't see her. ABCDE, X rays. Pelvic fracture, needs wrapping. Hypotensive. Angio or CT?

Back to the floor, finishing up. Call the junior to let him know about a couple of minor issues which can only be cleared up by someone who can order medication, and he says "Pre-Code Orange (Disaster): a bridge in Laval has collapsed; there are definately injuries and some people might be heading our way." Oh no! Okay, I'm sticking around then.

Back in ED, take the down time to suture up a big laceration on someone's leg.

Eventually, we find out that all the injured people have been sent to the other trauma centre. And by now it's 1600. Back to the floor to tie up loose ends, then call the senior with an update. He asks me to check on one more thing, and then sends me home to sleep. Or eat, actually.

And then I went for crepes with my husband.

A Crappy Day

So, yesterday's post were about the problems of the world, which I can't do much about.

Today's is much less ambitious, but futile as well. My own little problems.

I woke up this morning, having had a very disturbed sleep due to the sound of dripping water. Not a new occurrence, this has been going on for over a month (last month it was "fixed," the ceiling rebuilt, and the very next day I heard water dripping on the not yet plastered ceiling... but they plastered it anyhow).


For more days than not I have been waking up to a flood in my bathroom. Dirty water from a spillover pipe in my upstairs neighbour's apartment. Unhygeinic to say the least. They finally tore down the ceiling again, and now when I shower this filthy water drips on me. Disgusting!!

The "repair job" in the photos is my solution to that, at least.

My landlord says she is getting a plumber in on Monday. Four more days of gross, unhealthy, icy cold and filthy water everywhere. Why Monday? Because that's October the first, the day she has to turn the heating on, and she already has the guy booked for that day. God forbid she get him to do both a few days early, it's certainly been cold enough to warrant it. All I can say is, thanks a bunch, Rachel (the landlord).

************

So then I go to work and have a lousy but boring day (trauma is no fun when there is no trauma, and don't get me wrong, it's not that I want anyone to get hurt.... but if they're going to get hurt anyhow, I'd like it if they did it on my shift). I accomplish nothing and manage to piss off my senior resident due to not being entirely with him (combination of bathroom and other personal stuff).

And when I get home I get paged by one of the other medical students who has taken issue with the call schedule (which she and the other students arranged in my absence) and wants me to switch a call. Which I was willing to do, but to arrange it tomorrow. Except, when I asked if we could sort this out tomorrow, she whined. And now I am very much inclined to tell her to suck it up. I detest whiners.

We shall see which me wins.

Grrr.

Keep it a land of peace.

I spent nearly three years in Malawi as a volunteer with VSO, from 2000 to the end of 2002. It was a life-altering experience, which made me absolutely certain that medicine was what I wanted to do with my life. I had exposure to development work and crisis relief, having been there during the 2002 floods and the subsequent famine and cholera outbreaks.

All of that said, I loved the country and I want to go back.

A little background info...

Population 13 million, Malawi is a small country in Sub-Saharan Africa. Malawi never had a civil war but lives next-door to Moçambique and suffered with that country through the 1970’s and again in 2002 during the floods. It had the dubious distinction of being named seventh poorest country in the world in 2001. And that was before the most recent famine.


The national industries (tea, tobacco, sugar) are privately owned, by foreign interests. Most Malawians are subsistence farmers, even those who have a nominal job on one of the plantations ($40 a month doesn’t feed a family of six in any economy). Balanced diets are rare. Running water is a luxury, and even a proper bore-hole isn’t guaranteed in a given village.

The Health-care System

Based upon the British system, Malawi has a two-tier system of free government-run public health care, with expensive private hospitals for those who can afford to pay for them. The differences between the two systems are staggering, but also obvious. They are everything that Canadians fear will happen here: whereas the private system has everything anyone can expect from a hospital, with prices commensurate, the public system cannot afford doctors or equipment. Waiting lists are enormous, and people often die simply trying to get to see a health professional.

“Medical Officers” are pseudo-professionals with one to two years of post-secondary training who often wind up running their own clinics. The country in is the process of developing its own medical school, if for no other reason than the fact that its medical school candidates have been until now trained in Britain, and tend to be poached by first-world nations rather than returning to work in Malawi.

The Challenges

As elsewhere in Sub-Saharan Africa, the main roadblocks are poverty, malnutrition and HIV. And like elsewhere, the three are interlinked. The official figure in Malawi is 14-17% of the population are HIV positive. HIV is killing off the productive generation. There aren’t enough teachers, labourers, farmers.... breadwinners.... parents. Education suffers. Food production suffers. Famine ensues, more die. Infant mortality is one in ten, average life expectancy is 41 years. National industries suffer, poverty increases.

There are hundreds of programmes in existence in Malawi trying to break the cycle at all points, and I was part of several of them during my time there. As a teacher, bringing a little piece of a better education to try and give a few students a chance to do something other than labour on a tea plantation. As an AIDS activist, with my students, encouraging them to challenge stereotypes and to protect themselves.

The fact that the antiretroviral drugs which have converted HIV from a death sentence into a chronic disease in the first world are still not available to all but a very lucky few in Malawi should not be overlooked. A few thousand out of the estimated 2 million people who need them are actually getting these drugs according to UNAIDS.

Nobody asked me but...

Our responsibility is not to throw money at the problems of this country. It is not to send little packages and consider ourselves as having done “our part.”


We need to be activists, to push the World Bank to treat this country fairly so that it doesn’t spend its GDP paying off interest on its debts ($3 billion!!) rather than on its people. We need to be aware of the corruption that has been crippling this tiny country, which built this massive debt (Banda died a very wealthy man, and Muluzi bought a house in Knightsbridge at £11 million around the same time the country’s grain reserve mysteriously vanished in 2002), and to make it known that this is unacceptable. We need to denounce tied aid. We need to force our government to advocate for Malawians to get better prices on prescription drugs, just as it forces the drug companies to give us reasonable prices.

We need to be aware and wary of the Live-Aid Legacy which paints these strong and intelligent people as people who need our help. They don’t need our help, but they do need our co-operation.

Panic!!!

I have just logged onto CaRMS and spent an hour or so filling out forms. I am now officially in FREAK OUT mode (and if I knew how to get those letters to jitter and blink in red and green, well that would express things much better). I cannot imagine that in five weeks I will be altogether sorted and ready to take that next giant leap which is residency. Although, I suppose I am as ready as anyone. At least I'm sure about my choice of programme.

Still, it is A BIG DEAL.

*******

On the heading to Malawi front, I have deposited my grant, and my adorable husband and I have been baking apple pies like it's going out of style (or like the apples are threatening to become a mouldy muddy mess in the corner of the kitchen). And we have managed to raise over $150! Not bad for something that started out as a pleasant afternoon apple-picking at Rougemont.

********

Just started my Trauma surgery elective. Wooohoo!!

We start at 645am. Booo.

I have a fun team and the staff are great and also young!! Wooohoo!!

I am on call three of the next four weekends. Booo. Including the Thanksgiving Monday holiday. Double booo.

Confused? You betcha.

Ndipita ku Malawi

(I'm off to Malawi)

Not now, but eventually.

I'm just realising that it's coming sooner than I think, mid-November. Two months only. I had better get cracking.

I'm doing an elective in Obstetrics and Gynecology at Mulanje Mission Hospital in Mulanje District, with Dr. Sue Makin. I am beyond excited, and a little apprehensive.

I have also just recieved my token for CARMS. I had better get cracking on that as well.

Yoicks!

And so it goes...

Things are slowly returning to normal here. Life is going on, the city is picking up and continuing, a little sadder but certainly no less vibrant for all that.

Getting a little distance, taking a deep breath.

A classmate of mine, Sara, an alumnus of Dawson, was on the trauma team last Wednesday when the gunman struck. She writes:

"My first patient was a pretty young girl who told us what happened, in disbelief that something like this could happen to her. She was very stable and stretchers were being wheeled in faster than we could count, so I left that patient with a physician and moved on to the next one.

"Two more stretchers came in, and I found myself the only physician/resident/student with a young man with severe injuries. I began to assess him, ABC’s; he told me his name, the place and date, and what happened. Dr. N. asked if I was the only treating physician, and when I answered yes and gave him the info so far, he came to join me. I began to listen to the patient’s breathing and feel his chest, when all of a sudden he stopped answering my questions. I looked at him and noticed his eyes weren’t focusing on anything or anyone, and all of a sudden he became unstable... The head Trauma staff .... told us to send him to the ambulance room for assessment and management because other patients were coming in (routine in a major multiple trauma, basic triage protocol – save who you can and then save who you maybe can). (ADDENDUM - he's doing very well now)

"Right now I find myself feeling so guilty for loving to work in Trauma; I really do love this work because I am good at it and can help people. Yet to love Trauma seems as if I love to see people hurt – but this is so far from the case. I just feel, if people are going to get hurt I want to be able to be there to help them. But I feel horrible inside, like I asked for something like this to happen when I know that’s not fair to myself. I can’t help it though.

"And I keep thinking – wow, I went to Dawson. I loved it there, I still remember the place inside out. I can picture the scene without watching the news."

For me, it was walking home from the hospital in the rain, coming to roadblock after roadblock, flashing police lights in the murk. I felt like I was in a war zone, but it was my neighbourhood. It was walking into the hospital the next morning and being challenged by a police officer as to what my business was there. It was the security stationed at the doors of the ICU, and the news crews swarming around the entrances to the hospital.

But you know, the streets have reopened. The city is coming back to itself. The students will return to Dawson hall tomorrow.

Our own little lives are taking over again.

I'm going to make a conscious effort to forget the name of the coward who was so desperate to be remembered for something and so detached from reality that randomly shooting a group of innocent young people seemed to him the right way to do it. Have you noticed that the Montreal Gazette has had the class to refuse to put the sick bastard on their front page, but has reserved the front page for Dawson and its students? Good job guys.

Back to reality, and I'm thanking my lucky stars I live in a place where an act like this is not political, and not an everyday occurence.

Angry and Horrified

No.

Montreal should be a safe place. Kids should be able to go to school. This is not allowed to happen.

So how does Stephen Harper respond? Scrap the gun registry. Story here. Too early for debate my ass.

Sick sick sick.

You know they have reported that those guns, including an automatic weapon and a handgun, were legal and registered. Automatic weapons are legal in Canada? Really? This has got to change.

Nothing like this can be allowed to happen again.

Wednesday in Montreal

Everybody I know is in varying degrees of shock. I know my friends are okay.

Our hospital responded well to what was happening, and had most of the ORs cleared in minutes for emergency patients. Surgeons of all stripes came out of the woodwork to make sure everyone got the care they needed. Five people eventually needed emergent surgery. I don't know how they're doing and even if I did I suppose I wouldn't really be at liberty to say anyhow.

I'm not going to put a link to that coward's blog, I'm sure if you want to see it you could find it yourself. I haven't looked for it.

My heart goes out to the family that lost their daughter.

To the other families, hang in there, we are thinking of you.

This is not my Montreal. This is still unreal.

Random Tuesday in September

It was a pretty good one. Local weather nice.

Rounds 7am not quite sharp, but thereabouts (small team, all human). Not much on. Patients that were on death's door a few days ago are going home, and are impatient for their chest X-rays to be confirmed and their discharge prescriptions to be filled. So it goes on a thoracic surgery floor, as elsewhere.

One patient has gone back into atrial fibrillation after esophagectomy, so cardiology will have to reasses him, though his blood pressure is stable and his rate is between 80 and 120. He feels fine and doesn't know what we're so fussed about. We're worried about an anastomotic leak, and his swallow test is today. And we want to be able to anticoagulate him so he doesn't get a stroke.

We contact oncology and ENT for other patients, prepare discharge papers, chase path reports, check today's bloods and chest X-rays. Clinic in the morning to follow up post-surgical patients. I meet a lady who survived when her esophageal cancer and subsequent radiotherapy caused a diverticulum into her left atrium which led to near exsanguination. She was saved by a gastroenterologist who had his wits (and a Blakemore tube) about him, and by a lot of luck. I meet a gentleman with renal call cancer who has had all sorts of things resected and is still going for cure.

Result of our patient's swallow test? No leak. Cardiology says rate control, and we can anticoagulate now.

And then OR. Paraesophageal hernia repair. Did you know your colon could migrate into your chest? I bet this guy didn't either.

Music chosen by the surgeon: Scar Tissue, by the Red Hot Chili Peppers.

The way things should be.

Shamelessly purloined from The Brown Stuff:

"You should start out dead and get it out of the way.

That way, you wake up in a retirement home feeling gradually better every day.

You get kicked out eventually for being too healthy. You go and collect your pension, then when you start work after a decade or two you get given a gold watch on your first day.

You work for 40 years until you're young enough to enjoy your retirement.

You drink alcohol, smoke, party and are generally promiscuous and you get ready for school.

You eventually become a kid, you play, you have no responsibilities, you become a baby and then...

You spend the last 9 months of your life floating peacefully in luxurious, spa-like conditions: central heating, room service, larger living space every day.

And then, you finish off as an orgasm."

Willow: June 1988 - September 2006

She was just a cotton-puff with pink ears and a short pointy tail when we got her, somebody else's unwanted pet (the baby brother decided he would much prefer a puppy). My mother said no way did she want another cat, no, we were not allowed. But then she saw her.

She used to climb curtains.

She used to walk across the top of the birdcage and the budgies would bite her feet.

She used to come running when she heard our car approach.

She used to bounce over 7-foot fences and tightrope-walk them.

She used to burrow under the bedclothes and sleep in the crook of my knees. And bite me if I moved.

She used to knock the decorations off the Christmas tree.

She used to sleep with her tail in the electric heater so we would come home to the stench of scorched cat hair.

She taught my sister's kids how to be gentle with animals.

She used to shed like you wouldn't believe.

She used to purr like it was going out of style.

She used to come and wake me up when it was breakfast time.

She used to sleep under a mangled pine tree in the garden.

For 18 years, she was our good friend. She had a great cat-onality, and she remained our Willow right to the end. Needless to say, my family and I loved her.

Willow, I'm going to miss you.

Back in action

So the camping trip was partly lousy and partly fab. Sites were a little packed in, but otherwise no complaints, and the setting is fantastique.

Nothing worse than waking up and realising that you have somehow managed to pitch your tent in an area that resembles high ground but is in reality a small lake bed.

*sigh*

But the sociable bit was fun... and the mini-putt was fun.... and when the rain eased off (the next day) we went kayaking. The lake is a knockout, just gorgeous.

******

I'm also back in the OR on electives now. With a great staff who lets me *do stuff*. I got to do an incision today. A big one, for a thoracotomy. Right down through the muscle, but not into the chest wall (one step at a time). I got to use the scalpel and the cautery. AND I helped to close.

(jumping up and down in an excited-four-year-old-on-birthday sort of way)

*******


In other nonsense: So, the little car in the top right of this blog is my red rabbit from 1984, believed to have a 1.8L GTi engine. White vinyl seats. Manual transmission. I have been driving giant automatics most of my life, so this baby has been a real adventure, but you know what, I am finally getting pretty comfortable with it. Yay!

My Camping Grocery List:

beer
POM bread
cup-a-soup/ramen
marshmallows
KD
tangerines/peaches/apples
weenies+buns+ketchup
peanut butter
marshmallows
raspberry jam
beer
cheese
sliced ham
miss vickies
milk, salt, oil, teabags, whisky
marshmallows
oh, and beer

Cleaning up the neighbourhood

Currently at Brulerie St-Denis with a fantabulous "Chocolaccino."

Mmmm, foamed milk and chocolate sprinkles....

There was a great article in the Montreal Gazette today about a town called Grand Maman in New Brunswick. It's a small town with an out-of-proportion drug problem. The entire community is aware of the people who have been encouraging this, and have identified a few "crack houses."

On July 22, things reached a boiling point and mob justice prevailed. Someone apparently set alight this "crack house," and the community members prevented the fire trucks from reaching the house to extinguish the flames. Nobody was hurt, but the house was completely destroyed.

What have our fine lawmakers done? They have made a point of a "show of force," sending 70 RCMP to protect the home of a second drug dealer when rumours were spread that the same thing might happen again.

They have charged the citizenry with various offences, including arson, and obstructing a public highway.

To their credit, they ordered the drug dealer to not return to the island and to stay away from all residents. But he's not in jail.

*sigh*

The Harper government is considering closing down the country's only safe-injection house, Insite, by simply allowing its permit to expire. Here in Montreal, the police routinely plant themselves in a cruiser immediately outside a needle-exchange. Not exactly a welcoming sight for peoople making an effort to protect themselves in the worst of circumstances.

What are they trying to prove?

Virtual Bubble Wrap

Yes, it's silly. SO?

Watch out for falling cows

Need I say more?

Sometimes I feel like....

Sometimes I feel like I've been had.

To do medicine in Canada, you have to be the top of your class. You have to be motivated. You have to be involved with the community. You have to really want to do it.

Sometimes I feel like medical school is our teachers' way of saying: "You think you're so smart?"

Okay, put on this glove and put your finger up that guy's butt.

How smart do you feel now?

Studying

It's hard to get motivated to study for the psychiatry exam now that:
a. It's summer.
b. There are kayaks.
c. I have absolutely decided I want to do surgery. Or obstetrics. Or something else that isn't psychiatry.

*sigh*

Here I come, DSM-IV!

You know you are meant to be a surgeon if....

1. The word biopsychosocial gives you a rash.

2. You consider faking sick every Tuesday for the next six weeks, because that's your Clinic Day.

3. ...and you're pretty sure you wouldn't be missed anyhow.

4. You spontaneously come up with evil nicknames for your Internal Med rotation (my personal favourite, predictably: Infernal Medicine).

5. You don't get psychiatry. At all. Not even a little bit.

6. Your reaction when your delirious patient turns out to have an abscess, and leaks pus everywhere: Fantastic! Now she'll get better!!

7. Even after six months, you still love your scrubs.

8. Crocs!

9. You now know that coffee is an ART.

10. You actually say the words "Why don't they just take it out?" ....in a nephrology lecture (yes, Mitch, that's you).

11. Two words: "Hot surgeons"

12. Left alone, you invariably switch the TV to the open heart surgery on TLC.

13. Your role model: Dr. Nick.

14. You can say the words: "Splenectomy, cool!" and mean it. Even at three am.

15. As a kid, you were the one peeling off the bandaids and saying, "Can I see it?"

16. More to come...

The Newbies

Ah, they're so cute. So fresh and enthusiastic.

So YOUNG. No, I'm serious, they're all about 19 or 20, or the group I met was.

Today I had my first meeting with the new group of first-year medical students. My university has this unique in Canada programme of "Med-P" which is where kids make the choice before entering university, and apply directly to medicine. Usually the kids of doctors, they often have a more complete view of what they are in for than do most nineteen-year olds. They do a one-year access course to give them the foundation in science and then they work like hell to catch up with people who have undergraduate- or graduate-level degrees.

They generally are more enthusiastic and energetic than the jaded graduates. They study harder, obsess about details and exams and how to pass. They all pass, of course: they're brilliant!

And they have no idea what else is out there.

Good luck, kids. Try and have some fun. Don't get old before your time.

The Language Police

For those of you who don't live in Quebec, you may think I am making this up. Those of you who do live here know I'm not.

Recent reports that the Office de la Langue Francaise has been out making sure that you can get your crappy coffee in French: spotted at a local Second Cup harassing the baristas. They passed, if you're interested.

Don't we have anything else to do with our tax money?

What's moccachino in French, anyhow?

Toronto AIDS Conference

I did an elective in the ER of one of the local hospitals.

One patient who presented was a beautiful young lady of 19 who had some or another minor health problem that she wanted checked out, maybe a sore throat, I don't recall.

What I do recall was asking about her medical history, she had two interesting things to say: she was four months pregnant (and things were going just fine, thanks).

And she was HIV positive from birth.

According to the WHO, transmission rates in the absence of any intervention are 15-30% through pregnancy and delivery. These rates are reduced by half with basic intervention, giving this lady a greater than 90% chance of having a child who will not carry the HIV virus.

Hurrah for her. Such hope for the future for all of us.

And really, my best wishes,
wherever you are, lady.


______________________________

If you are wondering how I have time to write all of this, it's because I am currently doing a *yawn* psychiatry rotation. And half the staff are on vacation.

Go summer!

Who is your doctor?

One of my classmates, to me, commenting on another classmate:

"I don't know if someone who has a tattoo on her breast that can be seen when she wears her regular clothes should really be a doctor."

Do you agree?

What about body piercing? Tattoos that aren't visible when wearing professional attire?

Or something simpler: would you trust a doctor who wears jeans and a T-shirt to the office?

You know, he probably wished he had said that to someone else when he spotted my (more discreetly placed, but visible in scrubs) tattoo a week or so later. *Heh heh*


Update: I knew I couldn't be the only one doing this... and she's waaaaay funnier, check this out.

Last Call

Everyone's heard about being on call. Come on, you watch Gray's Anatomy, I know you do.

Have you heard of call karma? This is the mystic force which determines what happens every time you are on call. Everybody has it; some have it good and some have it bad. And you learn very quickly which you have.

I did a trauma rotation with a guy called Dan. Dan is in training as a physician assistant with the Canadian Armed Forces. Dan had the ultimate in good call karma:

"Just call me Buddha: rub my belly and nobody in the whole city gets hurt."

Great stuff if you need an uninterrupted night's sleep, but not so much if you have *finally* gotten a placement in a world-class trauma centre and are intending to get some practical training in how to deal with trauma.

Never mind. My theory is: when Dan gets licensed and sent to a war zone, we will have sudden and inexplicable world peace.

This post is dedicated to Dan, for sharing some of his call karma with me so I can write this while ostensibly on call, but in reality I am twiddling my thumbs and avoiding studying.

Which I intend to do, starting:

Now.

The Big Decision

Okay, it may not seem like a big decision to most people who have just got on and done it. You know, finish school and find a job that you will be doing for the rest of your life, as in forever. Unless you decide to quit and get another job. But basically, most people pick something and stick with something in that general direction until they retire, no?


What do I know? All I seem to talk to most of the time are med students. Or teachers, but those come in two flavours: some knew from birth they wanted to teach; others never did figure out what they wanted to do so they figured they'd be teachers.

And so.

Surgery. Emergency. Family. Or even obstetrics. Radiology has its advantages. Internal medicine... no, I'm kidding, although infectious disease really appeals to me.

I very much envy the people who came into med school saying 'I want to be a neurosurgeon/anaesthesiologist/pathologist," who have come all this way, happily arranged electives, and are currently researching schools which have the best programmes for whichever was their calling.

My choices haven't changed much since the beginning, but my reasons have.

Obstetrics is so much fun. Exhausting because you just can't predict when the next patient will go into labour and so your days are looooooong and your nights disturbed. And there are babies! And they go home with mommy when they start to poop! But seriously, it's amazing to be involved with births, be it mum's first or fourteenth.

Family medicine is the most versatile of the degrees, with the added bonus of being a two-year plus fellowship residency as opposed to the others which are all five years plus fellowship. But you can do anything. If you can handle the clinics.

Emergency. Oooh. Set aside the romance factor that you see on ER (although there are quite a few hot emerg docs....), it's got the energy, the unpredictabiity. You need everything you ever learned in medical school, down to the smallest differential. You need the guts to act on your own, as well as the ability to work with a team. And the best part is, with rare exception, ER docs don't do call. They do their shift, they go home. Wow.

And well, surgery. I liked the idea of surgery because it was the thing that worked when everything else failed. It's the only cure for most cancers. But I kept getting warned away by people who were in surgery residencies who are unhappy and exhausted.

But then I did my surgery rotation. I was exhausted. I was overwhelmed by the arrogance of some surgeons, disgusted by the stunted personalities and by the rigid hierarchies the residents felt the need to enforce. I was stunned by the treatment of the senior residents by the staff under the guise of teaching them to practise clean and careful medicine.

And you know what? I loved it anyway. I had a great team that worked beautifully together under a young and vibrant staff surgeon. I learned that my immediate-gratification type personality was ideally suited to surgery, as was my hands-on attitude, and my memory based on doing. Most importantly I found that surgery would take me where I wanted to go: war zones, hurricane aftermath, crisis relief.

(And hot surgeons? Oh, baby!)

I have three electives planned and a fourth in-process, all surgical. I have so much to learn. So wish me luck.

Happy Mom or Control Freak?

I was, I admit, looking for seomething else when I ran across this.

Okay, I sympathise with her. Everyone wants a happy, healthy birth experience. Can I tell you how it feels from the other side?

I spent two months assisting at deliveries at a fab hospital. Great delivery rooms, great nurses, variable but largely fantastic docs. The role of the student changed as we got more experience. We started by doing initial assessments, cervical exams, fetal heart monitoring; we spent a great deal of time with mums and really developed trust. During the second month, we were often the ones who did the actual delivery, with the doc standing by to ensure that we did not make mistakes and there for us and for the mum in case of emergency.

The mums with the eight-page birthing plans were generally considered to be the bane of the labour ward's existence. The nurses often took such plans as an affront to their professionalism, and a sign that the patient had unrealistic expectations of the birth. Such plans set up an adversarial relationship right from the start, and when your nurse is going to be your main caregiver and coach for this most important of events (and don't kid yourselves, in my experience male partners are great but rarely are they a load of help in the delivery room, mostly they just piss off the woman having the baby at some point; nurses REALLY get it), it's kind of a good idea to have the nurse on your side.

Obviously nobody wants the birth of their child to be medicalised, treated like a sickness. But most people want the security of a hospital just in case. Surely, anyone who cares enough to make a birthing plan like this also cares enough to discuss the reasons behind an episiotomy, a forceps delivery, or a caesarean with their doctor so they understand when and why each decision is made and can come to an agreement, rather than writing it down in a manner that suggests without such a plan the trusted obstetrician would just be out of control.

In a modern labour ward, most of this birthing plan is standard practise anyhow.

The point of all this is that a mum who comes to the labour ward with a list of demands has come in with the wrong attitude. She has set herself up to get upset about the little things rather than to appreciate the experience and to appreciate the people she needs there with her.

_________________________________________________________


On a related note:

While I was delivering those babies, nearing the end of my two months, a lady came in expecting twins. In active labour, yada yada...

I was soooo excited. I could relate to this lady; I come from a family with huge numbers of multiple births, twins and triplets. I'm kind of convinced that if I ever get pregnant, it's likely to be twins (I know that's ridiculous, but...).

I was thrilled, and I asked to participate in the birth. And out came the birthing plan. I was "excess personnel" it seemed. No medical students allowed. Oh cheerio. I suppose it didn't matter in the end, I certainly would never have been able to develop a therapeutic relationship with this woman who spent all of her time in labour shouting at her nurses, swearing at her husband, and being rude to the doctor. She even tried to throw out the resuscitation teams who were present for her babies' sake! She got upset about everything.

I was sad for her way more than for me in the end; her experience was miserable.

A Confession and a Question

I have a confession to make.

I am not a doctor yet. One more year to go. Lots and lots to learn. Lots of sleep to be deprived of, lots of friends to not talk to, lots of life to miss out on and then to rediscover at some as yet undetermined future time when things will settle down (or so I am assured).

This blog is my way to think outside the books.

I hope it will contain discussions about Canadian healthcare, international health, residency in different specialties, whatever. Maybe people who are a little farther along can offer some advice.

What's been on my mind recently is predictable enough: CaRMS, the match, interviews. We had a meeting at our med school recently, and the topic of illegal questions was broached. Apparently many female first-year residents said that at some point during their numerous interviews, they were asked the following: "Do you intend to have children during residency?"

Do you have any recourse if you get asked something like that?

Who will believe you if you say no? Should you say no? Should you say yes?

The only thing I have figured out for sure is that getting up and storming out is not the best option.