Category Archives: Medicine

Of Whipple’s and Acetabulum’s

28 Thursday Jun 2012

Posted by in Medicine

≈ 2 Comments


So, yesterday, we had the distinct privilege of watching one of India’s finest acetabular surgeons at work. We ended up walking into his OR and introducing ourselves to find one of the most humble, down to earth surgeons who ended up teaching us the entire time he was operating. It was fascinating. A complicated surgery that usually takes 6 hours to do ended up taking him just an hour- and at the same time he taught us about the anatomy of the pelvis, the way one repairs a break in the region and how to maintain the integrity of the joint.

After the surgery, we end up being able to step into a Whipple (catchily called a pancreaticoduodenectomy) – one of the most complicated general surgeries (made famous by Grey’s Anatomy.) It involves removal of a pancreatic tumor, typically from the head of the pancreas. Complicated beyond belief, it involves clipping the blood supply of the tumor, ligating each artery and finally separating and removing the tumor. Often the tumor takes the duodenum (the first part of your small intestine) with it. Then, you get to redo the plumbing. Namely, you get to reattach the stomach to the jejunum (the second part of the small intestine), as well as connect the bile duct and the pancreatic ducts to the jejunum. A bloody, messy and long surgery, it takes easily six hours.

It’s fascinating what all one can get to see as a medical student, the doors that open up and the view of medicine one begins to get. As second years, we’re seeing complicated surgeries and being taught by world class surgeons- simply because we’re part of the club. In the span of eight hours, we saw two rare and fascinating surgeries- which if you follow Grey’s you know most surgery residents fight to get to see.

30 seconds to Diagnose

21 Thursday Jun 2012

Posted by in Medicine

≈ 2 Comments

Tags

, , ,


Today we observed a day in the Outpatient Department of the Orthopaedic Clinic at the hospital I’ve been observing at. To give you an idea of the day, let’s start with this. 10 or 12 doctors saw over 250 patients in a little over an hour and a half.

Yes, that was 10 doctors and 250 patients. Yeah, that means they saw 25 patients each. In one and a half hours. Which means each doctor saw 16 patients an hour. Each patient got 3.75 minutes. Which seems higher than what we observed.

To paint the scene for you, we were sitting in the doctors office, in two chairs facing a eminent ortho surgeon. He was sitting in one chair, and the chair next to him was for the patient. Patient’s treatment cards were dropped off, and he called them in the order of the cards arrival. (Speaking of the cards, they cap patients at 250 per OutPatient Day- the first 250 get cards and subsequent treatment). So, the doctor would call out a name-  said patient would come in, and they’d sit down, by which time the doctor had asked them what the problem was. As the patient spoke, the doctor would be looking at their X-rays, CT scans, or MRI’s. Then, as they went along, the doctor would do a quick physical exam, without asking the patient to disrobe, scribbling in the card the whole time, tell the patient the treatment or tests required and send them off. Then, the next patient and so on. As time went along, the room got more crowded as patients started waiting within, other doctors would pop in for consults and more patients would be standing around while the patient being seen was being questioned about their ailments.

How different from the ideal patient encounters we’re taught in medical school. Forming a bond with your patient, open ended questions, exposing an area for a physical exam, vital signs, not to mention washing one’s hands all went out the window. The doctors worked like automatons, seeing patients one after another, sorting, treating, prescribing and diagnosing.

As it went along, we saw things we’d never heard of in the US. Skeletal Fluorosis, and Osteoarthritic Tuberculosis. Patients who had TB in their L3-L4 vertebrae, and patients who’s teeth and fallen out and bones were brittle due to excessive Fluoride. It was astounding, and though the doctor was swept off his feet, in minutes snatched between patients, or while the patient was sitting there we’d learn about these diseases and unique presentations of others.

I saw the benefits of the paternalistic model of physician-patient relationships once again. Patients who’d religiously follow the doctors lifestyle prescriptions. Anything they said, from exercise, to stop eating this, stop doing that, was met with a Ji, Doctor Sa’ab (Yes, doctor). The doctors would say, quite clearly, “This problem you’re having is due to your weight. Lose weight.” and the family would follow their orders to the letter.

Part of me considers that perhaps we should move back to a paternalist model of medicine, where the doctor knows best- you’ll solve the problem of non compliance. But, at the same time, doctors aren’t equipped to make a value judgement based on their patients lives. The only one who can do that is the patient. If I were enough of an idealist, I’d imagine that a perfect blend of the two exists to have neither’s drawbacks and both’s positives. I share no such hope- I just realize that some systems work in certain places and others work well in different places. It’s all about the culture and society you set it up in.

Thoughts?

Of Broken Spines and Missing Metacarpals: Observing at an Indian Hospital

20 Wednesday Jun 2012

Posted by in Medicine

≈ 1 Comment

Tags

, , ,


Over the last few days, I’ve started observing at one of India’s most advanced, most crowded and most over-utilized and understaffed hospitals. I’m starting in the Orthopaedics department, so in the last two days I’ve seen things clinics, outpatient departments and a couple of surgeries- including two spinal fusions (or spondylosyndesis- for the technically minded) as well as the beginning of a surgery involving a severely cut hand which was spurting blood from a severed radial artery branch.

It’s a different world in this hospital- there are patients in all directions, waiting in hallways, on floors, in every situation imaginable. The patients are waiting patiently, waiting for a doctor to come through quietly enduring whatever they’re suffering. As the doctors come through with a bevy of senior and junior residents on rounds they spend barely a minute talking about a patient. They don’t talk to the patient, nor do they attempt to explain anything. They discuss it amongst themselves, reaching a decision on how to treat the patient, with a look at the diagnostic imaging, a glance at the wound, and a few words from the resident who looks after the patient. The first few patient interactions, I was shocked- how could one responsibly be doing this, I wondered? Then, I saw the number of patients. Day one, we rounded on over a hundred patients in a little over an hour. After that, each resident had to run to get to doing all they had to do- be it treating, testing, surgery or whatever. As they do so, they speak to their patients, telling them what decision has been reached, how they will be treated and an estimation of when.

These residents and attendings are treated by patients and patients families with a reverence that is amazing to see. The paternalistic philosophy of medicine is very much alive and well here- the patients are not consulted about their decisions, they are simply told. Decisions are made and communicated to the patients, and for a vast majority of them, they seem to like it. The physicians act and are treated like rockstars, with admiring glances and awe in their wake. It’s a heady combination this, and I can admit to getting swept up in it as I go along. But, for one, I feel like a bit of a fraud in that white coat- I’m a second year med student, not a practicing orthopaedist and I still have a little trouble reading CT scans. So each time a patient comes up to me, with a look on their face that grants me that same level of awe, I feel not yet worthy.

Day two, as we rounded, I saw a woman badly injured, lying on a gurney unconscious. We didn’t speak about her or discuss her, nor did we even acknowledge her presence. But as I walked by and looked her mother and sister in the eye, I felt this sudden urge to speak to them- not for the minimal medical advice I could have given, but to perhaps offer comfort in a difficult time. I understand why it can’t be done in the restrictions one works under in this type of system. Yet it makes me wonder if doing so for years will make one detached and cold to the people one came into medicine to treat.

Each day more patients requiring an OR come in than can be treated by the staff and resources available. So, the backlog grows day by day. The numbers of patients who need closed reduction grows in such leaps and bounds, that they require a day in the hospital but stay a week.

That being said, I’ve seen some of the faculty do amazing work- surgeries with a cleanness and economy of time, energy and resources that speaks of their comfort and competence. At the same time, as you walk the floors of the wards, you see what they’re up against- the sheer numbers that could overwhelm their prodigious skill, and the constant fear in such overwhelmed hospitals- infection. I can only imagine how they must feel, their pride in a perfect spine repair or reduction being reduced to bitterness when their patient dies from an infection acquired due to too many people in too small a space.

I will try to post regularly as I go along, but that’s assuming time permits.

A Year in Medical School: Reflections

12 Tuesday Jun 2012

Posted by in Medicine

≈ 3 Comments

Tags

, , ,


It’s almost been a full (calendar) year since medical school began. I’m officially a second year medical student- and this year’s been a momentous one. As I look back on it, here’s some of the things that I learnt along the way.

Fire Hose: Med School really is like a firehose you’re supposed to drink from. It’s high pressure, it’s intense, it’s humanly impossible to get it all down your throat. The idea is that you gulp, swallowing big but manageable amounts and manage to just keep drinking. That’s the challenge.

Intelligence may not help you: If you’re one of those people who managed to get through PChem class napping, or didn’t have to freak out about Biochemistry, or Immunology in college- you’re probably going to have a tough time in med school. ‘Cause no matter howsmart you are, there’s no way of intuitively getting a lot of the material that you’re supposed to learn. A lot of it’s just good old fashioned memorization. And you might as well resign yourself to having to learn to actually work- because the material may be made easier by your intelligence, but you’ll have to learn to work really hard in a disciplined manner- which for me has been terribly challenging.

Big Fish, Big Pond: Everyone in medical school will be a copy of you. Some will be better copies of you. One of my classmates, went for a 10 mile (I think) run, before taking his MCAT. A group of them get up every morning to practise crossfit before coming to class. Others still, run half marathons, or teach part-time, or design prostheses, or are involved in every single thing at the school. Prepare to deal with a lot of people who may do things you do- and to your mind better than you can do them. That’s the idea of moving from where you were the best (or the only one) to being a group that has an MCAT average of 34, and a GPA of 3.8

Find Your Bliss: Med School’s not nice to you (scratch that- life’s not going to be nice to you). It’s important to find what you love to do, your anchor to sanity and stress release and make it a part of your routine. For me, that’s exercise. If I don’t go to work out for a couple of days, I start feeling a little down. For other classmates (who are musically gifted, unlike my tone-deaf self)- it’s music. For others, it’s running, or cooking, or playing with their dogs or significant others… It doesn’t matter what it is- just find what you need and do it regularly.

Open Up: Med School seems to foster this intense belief that you need to hide your feelings as weakness that your classmates will use against you. Firstly, if that’s true- you go to a terrible med school. Secondly, nine times out of ten, what you’re feeling is common to a majority of your classmates. Try to share and see- you may be surprised.

Social Life: They say you can’t have a social life in medical school. They say a lot of things. They’re wrong. It’s important to have one- it’s essential to your state of mind, and it’s easy to do. Just don’t make your social life the center of your existence, and you’re good. For example, I go out for meals with friends fairly regularly. I go visit people when I can, and I go do fun things when I can.

Time is Short: I started med school a somewhat different person than I am today.  Who didn’t. I specifically mean in terms of a willingness to do stupid things. Let me explain. I started, not averse to, but not searching for adventure. Now, I’m setting up sky diving plans for the end of the summer. I’m hosting a Thanksgiving dinner at my house (it’s adventurous because I’ve never made a roast Turkey…), I’m trying to make international trips when I can, to see the world when I can.

Live with Someone: I’m someone who needs a degree of human contact from time to time. That’s called being a human being. Some people are capable of managing without any for a week at a time. Hats off to them- I can’t do that. So, I suggest living with someone. You can choose someone in med school or not. Pro’s are that they’re not going to throw a party the night before the anatomy final- unless they’re really fun. They’re going to get your stress, and you can help each other out. Cons are- they’re in med school. You need friends from outside of med school. I live with a classmate, and it’s great- but in that situation, find people not in medicine you can connect with.

Be better: Every day of your life, you should be better than the day before. It sounds exhausting. But it’s important. So, this summer, I’m learning to cook a few more dishes than I have in the past, as well as continuing to try to get into shape. Find what you’re weak at, or want to be better at, and go.

Don’t get doughy: I say this with the conviction of being a recovering Pillsbury Dough Boy. I started college, and over the course of college, put on 60 pounds. The first year of med school I lost 20 of those. A lot of my classmates gained instead. Med school’s stressful, and we all like to stress eat. So, try to exercise, stock up on healthy food, don’t eat at every pizza thing the school does…

Prepare to be Poor: I’m going to graduate medical school $250,000+ in debt. Accept that, and chant it to yourself. It’s not meant to scare you, and you’re meant to push it to the back of your mind. It makes failing out of med school an expensive proposition but they actively work to prevent that. Still, that leads me to…

…But don’t live like a pauper: Since you’re going to be $250,000 in debt, at least live a little bit. Don’t subsist on Ramen noodles and water, and don’t live in a cardboard box. But, at the same time, no need to mistake yourself for a Rockefeller. Moderation in all things, as Petronius said. Still, sometimes a nice dinner at a nice restaurant, with a good bottle of wine can make a week. Just saying.

If you’re a medical student, or were one, drop your words of wisdom in the comment section. Do you agree/disagree? What would you suggest?

If you’re going to med school, ask away.

And if you’re a layperson, thinking, wow, doctors (and doctors in pretension) are crazy- you’re right.

 

 

Thanksgiving over a cadaver

01 Friday Jun 2012

Posted by in Medicine

≈ 2 Comments

Tags

, ,


Written in a narrative medicine group at Temple- this is one of my first pieces about medical school.

An interesting conversation occurred this Thanksgiving, when I went to visit a family friend. I found that automatically, as I spoke, my thoughts and words drifted back to my experiences these last few months. And so, over a dinner of turkey and mashed potatoes, I was talking about my cadaver. Some looked at me in horror, some in disgust, and some in a sort of awe. Most in some combination thereof. They asked me how it felt to have your hands deep in someone’s remains, if I felt queasy, if my hands shook. All the while there were murmurs, “inappropriate Thanksgiving conversation” and “Yeah, talk about cutting dead people like meat while I eat turkey.”

So in deference to some of those opinions, I spoke of cheerier subjects- health care reform, politics, football, cricket. Yet later, as we sat sipping Shiraz at the fireplace, our talk again turned to the morbid nature of my calling. I found myself giving accounts of the ED- of patients with AAA’s and sub-arachnoids; my experience in he psych ward where someone was brought in for having sex with a cat; and the psychiatrist’s gallows humor- asking what breed the cat was to see if the act constituted bestiality. I spoke of how comfortable my lab group became with our cadaver; leaning over and resting an arm on her as we scoured her abdomen for the superior mesenteric artery.

And as I spoke of all these things, I wondered where my past self had disappeared. The person who before med school would talk at length about Dostoevsky and Nietzsche; not aortic dissections and canker sores. I wondered at the ease and even the glee with which I had recounted stories of gun shot wounds and PCP addicts- of lives torn apart and limbs rent by the violence I was becoming accustomed to. I wondered, was I in the name of learning to “fix” humans, giving up my humanity?

This means of cloistering one’s mind, one’s emotions from one’s work is a survival mechanism in medicine. Or so I’ve been told. One must wonder- is the cost perhaps too high?