Enough, already

I am so exhausted right now. I feel like I just want to lie down and sleep for months.

I am happiest when I'm busy and have a list of things to do, but right now I just get to sit back and watch the anaesthetist do most things, and when the surgery is happening, I am pretty much watching somebody watch somebody else, which is the most exhausting kind of watching of all.

I would jump in and assist the surgeon, except there are third-year medical students on prac who should be doing it before me.

I would jump in and help intubate or put lines in, except there is a paramedic student there who takes precedence. I can sort-of see the point of this, except she is only in her second year out of four and is not very keen to touch a real patient, and I am in my last year and almost a doctor and will be expected to be able to be competent at managing airways in six months. Sorry, please forgive my frustration.

We are in the last week of an eight week rotation, in which we have been changing areas every week or two. This is thoroughly exhausting, as we have very little idea of what we are supposed to be doing apart from turning up every day. There are no lectures, the only teaching we get is from the staff we are working with on the day, and to be honest it feels like such a token exercise, which is a bit of a concern considering that this is the only critical care rotation that we get all year.

I would love to go to a lecture or three rather than take myself through a set of slides that may or may not have anything to do with what I am learning. I don't deal well with not having goals. I am very goal-centered.

Three more days, then I go on holidays, and then I have my Obs&Gynae rotation. I am looking forward to digging into this rotation, figuratively speaking. Bring on the babies!

The power of invisibility

Having been back at work for a few weeks now, I have worked out a new rule:

The more senior a staff member is, the less likely they are to look through or ignore a person in uniform.

This was particularly shocking for me to experience first-hand, as I went from "doctor" dress one Friday to "uniformed staff" dress on the very next Monday. Suddenly I went from a person who you would look in the eye and smile at on the way past, to being part of the wallpaper.

One thing that I have noticed is that the more senior staff members will still talk to me (without knowing I'm a medical student, although that shouldn't matter) but many of the interns and junior registrars will look straight through me, and one has even rolled her eyes when I show up to do a mobile x-ray. Seriously. She asked me to be there. I was pleasant and professional. She rolled her eyes. Somebody clearly has issues.

I know that this is a generalisation, and there are many junior staff who will talk to everybody they work with. It is just something that I really noticed between one "work" day and the next.

The screening x-ray on the dementia patient

Two weeks of work down, four to go. I'm still enjoying catching up with other people, although there are parts to the job that I find painful and mind-numbing.

Medical imaging is a lot harder physically than medicine. You have to move patients around all of the time - pulling them across the imaging tables, moving them into position, lifting them, pushing heavy equipment, pushing the imaging cassettes under 10+ intubated people in ICU rounds, as well as doing a lot of walking all day. It is quite hard work, and takes me about a week to get used to it again after I return.

I also find that I get a little angry when asked to do examinations on extremely demented elderly patients when the exam is pretty much for screening purposes. I understand that the doctors want to check for things, but I think that sometimes they send these patients to imaging because they can't talk to them and they just run as many "simple" tests as possible to get a profile of the patient's health.

My main issue with this is that a "simple" examination can turn into an ordeal when the patient is unable to comply or move. We have to force them into positions that are uncomfortable, push and pull them around and cause them quite a bit of pain and upset them, all for an exam that is effectively for screening.

A normal patient who can move onto the imaging table and stand up can have an abdominal and chest series finished in under five minutes - and most of this is paperwork time. (Yes, I know you are supposed to wait to take the erect abdomen - I do it first, after the patient has been sitting up in their chair for at least 10 minutes on the way to the department/waiting, and then do the supine. This saves time.) They walk over to the erect bucky (the upright thing that you use for chest x-rays and erect abdomens) for two/three shots, then lie down on the table for the last one. Easy. Fast. Painless. We have a little chat while I take the images (generally the highlight of the exam for me - I get to meet some truly interesting people), then they move on.

An elderly patient with severe dementia or severe illness who is unable to remove or respond, and who gets sent to the x-ray department on a trolley or bed is quite a different matter. We have to force them into the upright position by having a radiographer/wardsperson sit them forwards, jam a heavy block behind their back, force a cassette behind them on top of this, lean the back against it, and then run out of the room to take the image before their hands move across their chest fields or they slide off the cassette. Similar thing for the lateral chest, if we can do it - we turn the bed sideways and try to use the erect bucky. We often have to do it more than once, because they are quite difficult to take.

For a supine abdomen (you really aren't going to get an erect abdomen on a patient like this, unless you REALLY need it and can manage a decubitus), you have to force the patient to lie down flat, get them flat on their bed, then wedge a hard, thick block of plastic (the x-ray cassette) directly underneath their back, make sure it is in place, then run back out of the room again to take the image. If you are lucky and have trauma trolleys and your patient happens to be on one, this is much easier.

And this is if you ask for a simple abdomen/chest series. I have taken full spines on patients like this - for trauma, so it needed to be done, but it takes a lot of time and energy and is a challenge and a half.

I am gentle and patient. I always address the patient by name, regardless of whether they can respond or not. Other people aren't, but that isn't a topic for this post. The process is a lot more uncomfortable for the patient than I can get across in writing. They don't understand why somebody is hurting them, or telling them to do things that they don't want to do.

To top it all off, most of these x-rays are normal. It was a screening exam for a patient, and may have been much more acceptable if the patient would have a better outcome and prognosis with treatment. Extraordinary measures for patients who are not going to understand what is happening and have bad prognosis - well, that is just cruel. I have heard it referred to as "atrocities" in medical circles, moreso when talking about extreme medical intervention for patients who won't recover and should be make comfortable, but it is a similar principle.

I often wonder whether the doctors who order these would think more carefully about whether or not they needed them if they knew what we have to put the patient through in order to get the images. One of my favourite physician teachers told us that you should know (or at least suspect)the results of the test before you order it, and you should always be able to give strong reasons for every test you order.

Obviously the doctor is the person responsible, which is why I do the best images I can for them, so that they can decide where to go from there. I just can't wait for the day when all I do it the physical exam - it is a breeze compared to the imaging, particularly for the patient. It would also be nice if the doctors had any idea about what they were asking us to do to their patient. Not all chest x-rays are equal.

At the start, I found it really hard to get back into imaging because you have to make people uncomfortable to get diagnostic images. I shied away from making patients experience pain. It isn't pleasant, and I won't be upset when I don't have to do it any more.

Yet more medical school bitterness

Assignments - I never do well on the ones that I expect to, and I somehow ace the ones that I wonder are going to be good enough.

I can never tell which ones will be which.

I got two results back this week. One was for an assignment that I did a lot of work for on the main project itself, but did the write-up very quickly and wondered afterwards if it should have been more "academic".

The other was for a group assignment that I did, where we all put in a fair bit of work together. As group assignments go, you all put in work into the one thing and hope your side of the work doesn't let everybody else down.

I aced the first one and got a mediocre mark for the second. Funnily enough, I would prefer it to be the other way around, because I'm dissapointed for the group. I know how we all worked on this one.

I guess passing is the main thing.

Why?

Why is it that it is easier to accept the decision of a parent to not vaccinate their child if you aren't close to them, but when they are very close to you and they tell you about the alternative literature they are reading and believe, and have decided against vaccination, it is something that is very hard to accept?

Yes, I respect the right of the parent to not give their children "pointy kisses." (See The Underwear Drawer's comic on Paediatricians.) It is just difficult when they accept the word of complete strangers over the opinion of those closest to them.

Things that bug me Part 1*

Warning: rant alert!

People who think that they know more than their specialist because they can use Google bug me.*** Particularly when they don't realize that they are coming across as being at least as arrogant as the doctor they are criticizing for the exact same flaw. (Arrogance, not using Google. Although if my doctor used Google in front of me during a consultation, my eyebrows would raise slightly.)

Yes, everybody has a right to educate themselves. Everybody SHOULD educate themselves as much as they can. We would all be a lot healthier if we all took responsibility for our own health.

However:

I have friends who do this, and it bugs the hell out of me, particularly when they insist that something they have read on the web contradicts what the doctor says, so the doctor must automatically be wrong.

It also really bugs me when they contradict something I am explaining to them because of said "alternative" information sources, when the topic something that I know very well because of years of experience in my previous job. (Particularly when the opinion they are asserting is, quite frankly, physically impossible for anybody with normal human physiology.) I realise that by saying this, I might come across as being arrogant, but trust me in that it isn't.

We are all entitled to our own opinion. They can take my opinion or leave it. I'm just a medical student, and don't give out medical advice, and this was not about me playing doctor. If they want to ignore my basic explanations of how the body works, that is up to them.

But if they ignore what I have to say completely and brush me off, in spite of the fact that they have known me for years, surely it should be obvious that this could be somewhat injurious to the relationship. I'm their friend, and they know that I have a lot of experience in certain things. Ignoring what I say is hurtful and disrespects my feelings.

Said people have also complained about the advice they received from their medical specialist, because they thought he was covering his back rather than helping them. When I explained that he was just following accepted health policy and evidence-based practice in that area, they still insisted that he was covering himself.

I wasn't there with them at the doctor's office. Perhaps he didn't explain himself very well, and wasn't seen to take their concerns into account and work with them to develop and implement a model of treatment that they were all happy with. But he was certainly the one in the room with the experience and knowledge to deal with the situation as safely and as best as possible.

I guess this is why it is a very poor idea to treat friends and family. Because a patient has every right to their own opinion about things, and should not feel obliged to follow what the doctor says because of any prior relationship. Also, the doctor should be able to remain neutral and impartial to the patient (while being empathetic and welcoming, of course) so that they can accept when the patient does not want to listen to what they have to say.

I think it is also fair to say that people, friendships and priorities change over the years, and so what was once a firm friendship can become difficult to sustain because people who once seemed very similar have become very different in small but important ways.

*I don't have a follow-up planned, but I'm human, and I know that many publishable things will bug me in the future. I now have more than one hundred posts. Wouldn't a series be cool?

*** Please note: I am not talking about patients with chronic illness who can become specialists in their condition and share things with their doctors that they did not know. I know a number of these people personally, and they rock. I'm talking about people who look up the basics on the internet and get sorely misled.