Really Really Bad Medical Joke

I've been studying embryology of the gonads for days and seriously, it has started to make me a little wonky.

So wonky that today, while drawing a schematic of how the undifferentiated gonad becomes either female or male, I came up with a really really bad joke about the process.

Why was the Mesonephric duct so hard to live with?

Because it was passive regressive. 

[Insert snare drum and cymbals crashing sound here.]

See what happens when you stare at these types of images for too long?

From Langman's Medical Embryology

Instead of a Post

I updated my "About" page.

Which means I put in the work of a post without being able to have the joy of anticipating comments from you, fine readers.

So I made a post about updating my "About" page.

Is that being a blogger-attention-seeking-whore? Yep.

Enjoy!

Computer Savvy

My shiny new external hard drive arrived today, it is a 1 terrabyte USB 2.0 WD and it only cost me 43 GBP! (Remember when external hard drives cost like $200 and only stored the memory equivalent to an ipod?) 

Anyway, I was excitedly unwrapping it when Tobie asked how much memory it had.

Me: It holds a terrabyte of memory.

Tobie: How much is a terrabyte?

Me: About 1000 gigabytes...so that is about...um (trying to think of a way to quantify memory size in a meaningful way to someone who only bought his first lap top in the past 2 years).

Tobie: About 1000 computers worth of space?

Me: Pretty much.

God he's adorable.

Really, I love his lack of techie skills because it also means he is not addicted to the computer, he is never texting when you want to actually talk about something, and he never has his cell phone on the table. Love. Love. Love.

Scratch That

After today's lecture on acute and chronic leukemia I can safely do this to my list of future career possibilities:

-emergency room physician
-orthopedic surgeon
-anesthetist
-OB/GYN
-palliative care specialist
-pediatrician
-hematologist

I actually retract my previous assertion that nerds go into internal medicine, and internal medicine nerds go into nephrology. I now think they go into hematology. I tip my pocket protector to that gang.

I know I am No Doctor But...

I probably shouldn't speak ill of profs at the school but today's clinical presentation on catheterization was beyond the pale.

Ok, I can forgive the demo going from sterile, to clean, to downright kidney failure dirty. After all, when you are explaining something it is hard to remember which gloves you had on when you were manhandling the penis, or whether or not you grabbed the cath with the same hand you opened the lube with.

But I have to draw the line at taking the giant tube of opened lubricant, inserting the end of it into the male urethra, squeezing, then milking in it's contents.

No. That is not on. Not only have you contaminated the lube, you've completely creeped out the patient with a medical hand job.

This demo was done for a group of students, most of whom have never seen a catheter, or a urethra, or a patient. I shudder to think of what will happen the first time they perform this on a real person.

And something I found out today in this alternate universe: in Ireland, nurses don't perform male catheterizations because it is "much more difficult" and "more likely to cause harm" than catheterizing females.  

What the...?

In 5 years of nursing I've only had to call a urologist once to cath a male but I can tell you that several female jobs have required 3 sets of hands, supporting structures, 2 flashlights, several foleys, rappelling rope, and a walkie-talkie system.

Still shaking my head on that one.

I'm going to retire with my previous google search now.

Trisomy X Facepalm

Last week's case was a baby with ambiguous genitalia (not that uncommon, turns out). So last night I was finishing up the homework for today's class and reading about different sex chromosome related syndromes.

I blame it on the jet lag because it wasn't until after I hit the 'search' button that I realized my folly in the google image search for "XXX".

Yeah, lets just say the first 10 billion hits were not trisomy X phenotypes.

Facepalm.

Alive

Hello again, Blogville. My apologies for the long silence, it was the result of limited computer access deep in the prairies of Alberta.

Just arrived back home in Ireland last night. Returned with more clothes and less hair. It was a hectic week of 'catch-up' with friends and family, fueled by cuddles from my nieces and nephews, and a lot of good espresso. 

Now I must tackle the ignored mountain of school work that is looming large.

Happy Easter all!

OB or not OB?

We have been up to our eyeballs in pelvic floor muscles lately as our last few cases have been covering pregnancy, babies, ambiguous genitalia, labor and delivery. 

Now normally I am not a fan about learning the differences between the somatic, autonomic, and visceral nerve supply to muscles, but I have to admit, knowing the practical applications for managing labor pain has made this memorization a bit more interesting. I am sure it is because I love procedural skills and can't wait to do my first nerve block, epidural, lumbar puncture, and perineal repair. I started thinking about all the hands on work that OB/GYN's do and then having thoughts that were alien to me until now ..."obstetrics? maybe?"

Truthfully, back in the days when I was an annoyingly-militant-vegan-self-righteous-naive-hippie I seriously considered midwifery (not to say that midwives are those things, I am just elaborating on a phase I went through in my early twenties). I even took my doula training and looked into various programs across the country in midwifery. The only thing that really held me back from pursing this career was the fact that Canada has some ridiculously archaic and paternalistic conservative attitudes regarding who ought to be bringing babies into the world. Depending on what province you live in it can be a seriously uphill battle to create a career for yourself as a midwife--that is, no hospital privileges, being shut out by the medical community, lacking public subsidies, and having to conduct only home births without OB back-up. I just wasn't up for the challenge, I guess. 

Fast forward to medical school where I continued to reject the Western approach to birth, until very recently.

We had an OB/GYN lecture us this week. She was Irish but had spent 10 years specializing in the US in high risk delivery and maternal/fetal medicine. Her lecture was delivered in a soft spoken but direct and powerful way. About half way through she stopped on the slide shown to the left, and said,

"I have always wanted to be a part of this event in people's lives. Even when it is cold, dark, and in the middle of the night I love to get up and head to the hospital knowing that this is what I get to be involved in. When the babies start looking the same and I am not thrilled to be there, I am going to quit. But right now, I feel nothing but privilege for being invited to take part in this pivotal moment in people's lives".

She apologized for how hokey it sounded but I felt that it was quite lovely, to hear someone speak so passionately and honestly about their career choice. I suppose it is what we are all striving for when we choose our future specialty, what are we passionate about? Am I going to love living in the O.R, or intubating patients in a helicopter, or prescribing chemotherapy regimes? It is so hard to know at this stage having only seen as sliver of the health care system. But when you hear someone speak from the heart, and they clearly do love their job, it makes you wonder...could I love constantly being sprayed with amniotic fluid and having only female patients for the rest of my life?

Maybe!

OB/GYN Pros:                                                                     OB/GYN Cons:
-lots of healthy patients                                                          -on call, forever and ever, amen
-plenty of hands-on procedures                                              -bodily fluid exposure extravaganza
-O.R from time to time                                                           -bad outcomes are very bad
-emergency situations*                                                           -only female pts
-many good outcomes                                                             -continuity of care
-continuity of care                                                                   -highly litigious
-many happy/excited patients                                                 -crazy women with 5 page birth plans
-immediate results                                                                  -having patient load
-the whole 'miracle of birth' thing                                          -the training

If nothing else, I am trying to keep my mind open to the possibility of areas that I hadn't considered. I know how most medical students start rocking in the fetal position (pun intended) when you mention their OB/GYN rotation but...who knows? Maybe I will be one of the lucky ones and will actually enjoy labor and delivery!

Or maybe I'll just end up with countless pages of blog fodder.

Either way, win!

*I know that sounds twisted...but I am wired to enjoy emergencies for some reason. I blame my mother for not breast feeding me long enough. (Hi Mom!) 


   

Good Thing He's So Darn Cute

On Friday I am flying back to Canada to see my family for Easter and CAN'T HARDLY WAIT!!!

Oh I am so looking forward to cuddling the baby twins, reading stories with my nieces, bike riding with my nephews, drinking wine with my sibs, and catching up with my mom. Just found out today that my BFF is also flying out for 2 days so I can see her avec baby-bump! Ah, 'tis grand so it is.

As I started mentally going through things to do before leaving Young Tobington here alone for 9 days, I remarked to him,

"Hey Tobes, I guess I am going to have to show you how to work the washing machine before I go so that you'll have some clean clothes when I am gone..." [snicker]

"I know how to work the washing machine!" [indignantly]

"Why don't you ever use it then??" [genuinely curious]

"Because you like doing laundry and I didn't want to ever take that away from you. It makes you feel like you've accomplished something!" [completely sincere]

Good thing he's so darn cute or the feminist in me might have strangled him with a bra hot from the dryer.

What We've Become

Tobie and I reached a new low in our relationship this weekend.

We've been feeling a little downtrodden lately, both of us dealing with the usual frustrations / stressors of school, lack of finances, and upcoming exams. I partly blame those reasons, and partly the fact that when you are in a relationship long enough you start to lose the need to 'look your best' for one another at all times. Mind you, I have always been just this side of completely hopeless when it comes to fashion sense, but Tobie usually looks rather dapper. As a result, I attempt to lift my game somewhat when he's around.

Friday night we both wanted to just go out for dinner so we could bypass all the razmatazz of cooking/cleaning, but then after the realization that there still is nowhere decent in town to eat on a student budget we decided to just splash out and buy some steaks and make ourselves something good.

One delicious steak, mushrooms, homemade ceasar salad, and baked potato later we were about busting our jogging suit waistbands, so we headed out for an evening stroll. Tobie had the decency to put on some pants. I stayed in my pit-stained t-shirt and unfortunate lycra capris.

Though, for the record, he chose are the pants we call "the frontal butts" because they make him look like he has a butt, in the front.

The 'triumph' of a frontal butt.

Almost home, walking back on campus, we were discussing what movie to watch. Tobie suddenly stopped and said, "Look at us! Look what all the stress and lack of sleep has done to our fashion sense and ability to live it up on a Friday night. We've basically given up. We've become those people who go out in jogging suits with mustard stains their shirts, then sit in front of a television set after a hard week."

We both started howling as we took a look at ourselves. Yep. We then started playing out 'worst case scenario people' that we could run into. We both thought of our friend Kris who (IMHO) is by far one of the most beautiful, well dressed (and sweet) women in my class. Her Manfriend is also a snazzy dresser. We imagined going around the corner and running into the two of them, both dressed immaculately and stylishly...then...pan to us.

Shorts cut to make legs as unattractive as possible.

Us [spoken with awkward lisp]: "Hey guys! Fancy meeting you out here on a Friday night! Hey, you guys want to come over for some seven-up, beans on toast, and chicken wings dipped in ranch sauce?? We're probably going to watch a documentary later!"

K & G [smelling good, looking great]: "Um, that sounds great but we are going out for martinis at a new bar that just opened downtown".

Us [mindlessly kicking the dirt with our orthopedic shoes]: "Suit yourselves!"

Maybe it is a good thing that Tobie and I are going to be apart for a little while, and that we're both heading into professional-ish roles again soon. Lord knows, we've fallen so far already we may never return to baseline. In the meantime, you might be able to catch us on an Irish version of What Not to Wear.

Wouldn't That Make You A Sadist?

So, in my anatomy book, in the discussion about estimating pelvic measurements in a pregnant woman, I came across this gem of a phrase:

Another useful clinical guide is the subrapubic arch: the examiner's four knuckles (i.e. his clenched fist) should rest comfortably between the ischial tuberosities below the pubic symphysis. 

In other words, you should be able to comfortably rest your fist between the patient's sit bones, under their pubic bone.

Ehhh...author? You might want to come up with a better way of describing that. Especially for some of the borderline Asperger's very literal-minded males in my class. Thanks.

Currently Reading: Ice Bound

 

My mother bought me Ice Bound ages ago and somehow the book has traveled from my life in Kelowna, Revelstoke, Whistler, Mission, Prince Rupert (twice!), Ireland, back to Canada, and then back to Ireland without ever being lost or read--which to me seems like an 'untouched possession' record of some kind. I know that it has made all those journeys because I found, tucked inside the front cover, a handbill for the blood donor clinic in Kelowna from 2007. Maybe I just needed a break from reading about cold exotic places, or maybe I was irked by the thought of reading about a female doctor while I was still desperately trying to get into medical school. Either way it traveled with me for a long time before being cracked open. 

I started reading it a few nights ago and wow, am I ever glad it didn't end up sold at the "great auction of all my personal belongings" in the spring of 2009. 

As the cover states it is about a emergency physician from the US who travels to Antarctica to 'winter-over' as the medical staff at the American base. While she is there, she (somehow, haven't gotten that far yet) finds out she has breast cancer but has no way of leaving until winter is over, 8 months later, and planes can land at the base again. As a result she ends up having to diagnose and treat herself with the limited resources there on the base. The photos inside are intense, including one of her biopsying her own breast.

So far it is very well written and paced nicely. Of course a part of me can identify with the tingles of excitement that she gets with the prospect and then departure to such an extreme location. The packing and preparation scenes certainly rang true with my previous life of Northern adventures, and it made me smile at the reminiscence of having no bloody clue whatsoever of what I was getting myself into.

And like most books I've been reading lately, this one has me hooked which means my hours of sleep are infringed upon as the only place I can find a way to make the day longer. 

Worth it though. I highly recommend checking it out.  

A Good Workout

Is when you bend over to stretch your hamstrings and sweat pours from your neck into your mouth.

Disgusting? Yes.

Proof you are having a good workout?

Definitely.

Comment in Response to 'Glimpse into the Arctic'

I posted the Globe and Mail article on my FB page and received some insightful and interesting comments as a result.

One comment was from a phenomenal Nurse Practitioner, Dana, whom I worked with years ago in Victoria--one of the nurses who inspired me to adventure North in the first place. I should really do a series of posts just on her because lordy the woman was not only one of the smartest people I've had the pleasure to work with, but also one of the most hilarious. Pretty sure if she and my friend Janet worked in the same ED the universe would spin off its axis and all disease would finally be stamped out for good. In all seriousness though, she has truly seen the spectrum of health services in this country and I am more than happy to provide a platform for her to shout from.

I asked for permission to post her comments here and she granted it. See below. 

Then the clincher to this whole thing in my career is I started going to Northern Manitoba....it makes Nunavut look good.

I recently went to a place called Wasagamac (look at the youtube video that says "Housing Crisis in Wasagamac") Anyway a population of about 2000. 2 working nurses and an NIC that is strictly admin. 85% of the population IDDM out of control, approx 40-50 born per year. Usually 15-20 residents per shanty, most have no source of heat, incredibly sick babies (with 2 nurses), tons of pathology in these kids, several with mickey tubes for feed, tons of rickets, no access except by boat so no medivacs at night, of course addiction and violence out of control, no RCMP detachment, the closest is in Garden Hill and only water accessible in day light hours. 

The price of a cucumber in January was 7.12. 

I had PTSD when I got out. I had treated a baby daily for RSV, grunting resps, RR of 80 blah blah. Unable to get her out. NIC states she is not the sickest, has been like that since birth and we will continue to treat her in community. I call Wpg, the ER doc screams at me that Health Sciences in not on contract anymore due to non payment from Northern Medical (a government agency that doesn't pay bills promptly) so they will not accept anymore medivacs until the bills are paid....Yells and rants at me on the phone and tells me it sucks to be me cause he isn't accepting. medivacs will not come without an accepting physician....

The GP that I am suppose to call says "ya thats the way it is just do your best." It is so unbelievable and I am so throughly disgusted I cancelled my next contract and am NEVER returning north, especially to Manitoba. 

Anyway watch the video if you have a moment and spread the word. Health Canada made me sign an agreement that I would not discuss conditions...huh? I came out of there after 15 years of northern nursing with PTSD and total exhaustion....on call constantly and worked 24/7 pretty much. Pay check for 2 weeks was over 10,000 net, so not worth it and just all wrong...And politicians want to talk about 2 tier health??????


We work with the sickest population both mentally and physically with no resources or diagnositcs and make a responsible diagnosis then arrange for appropriate treatment? An impossible job. These folks are at great risk. Hell no one even expects any advanced practice or experience anymore.

How can this be Canada? I have been from Beaver Creek (Yukon and most westerly community in Canada), to Cape Spear NFLD (most easterly) to Grise Fjiord all in one year as well as everywhere in between. I have been doing outpost in all 3 territories and Man. since 1995. It is appalling and gets worse every year. I have seen things that keep me awake at night. The problem is the situation gets worse and worse and worse...

--

I recommend watching the short documentary she mentions. I would say 'unbelievable' but I have seen similar situations in the North and sadly it is much too believable. I wish I could say what some solutions might be to all of this, but I have no idea where to even start, except to bring some attention and awareness to what is happening in these communities. The realities these people are living should not be acceptable to Canadians. 

Glimpse into the Arctic

Many of you who read this blog know that I spent 2 years doing contracts as an outpost nurse in the Canadian Arctic. I often find it hard to put into words many of the experiences that I had there, or what it was that kept pulling me back. The work was very challenging, mostly well outside my knowledge base and comfort zone (as a nurse who had only been working for a year and a half). But clinical learning curves are steep and dizzying, and soon I found myself missing the autonomy and excitement that the North held for me, especially when I returned to urban ED's where I was not at all involved in determining how a patient would be managed.

Recently a very good article was written in the Globe and Mail about Nunavut. If any of you have ever wondered about the realities of the Canadian Arctic and the Inuit people, I highly recommend reading this piece. It will certainly give some insight into the world that I spent some time in, and the struggles we, in turn, faced as health care providers*.

Cape Dorset (the town heavily featured in the article) was my first Northern contract and I can tell you, it was a profound culture shock. Unsettling too, living in a place which produced such beautiful and unique art...as well as brutal and horrific violence. Many of those mentioned in the article are people I remember, and it deeply saddens me to read about the dangerous unraveling in that town. It is not hard to imagine, when you read the statistics on Nunavut, why MSF equated my Northern work to "3rd world experience".

A flood of memories came back to me as I read the article. I saw first-hand the results of the violence and poverty during those days as a homecare nurse.  I saw the threadbare existence of one of my elder and infirm patients whose son would leave only bruises and cuts on the old man's balding head as evidence of his visits. Not only on my patients, I would see the reality of the violent community even on the faces of our staff, like the interpreter I worked with, who showed up one Monday morning with two black eyes.

There was the young girl, who stole her grandfather's pain medication so she could sell it on the street, a girl I naively thought was so sweet for picking up his prescription. Paulassie had severe rheumatoid arthritis, and despite his condition remained a renowned soapstone carver. During homecare visits I would often find him in his back porch (when temperatures were well below -30) painstakingly working on a sculpture, many of them destined for high-end galleries in Montreal, Ottawa, or Vancouver. Through the interpreter he'd tell me stories about his early years living in igloos and animal hide tents, hunting and fishing with his father. As a young man he was a guide, often taking the early doctors and nurses by dogsled to the scattered settlements when Inuks needed emergency treatment. Wild stories about blood transfusions in tents, from staff to patients when births resulted in hemorrhages, or tales about those that survived hunting injuries only because the air was so cold it froze the blood before they could bleed to death.

He promised to carve me a little stone nurse on my next visit. Sadly, he died before my next contract there, and I often wish I had asked to buy one of his smaller carvings as a reminder of this man and all that he represented.

So many more moments came to me from those days in Cape Dorset, staring from my office window across the glare of the searing white tundra, seeing the reasons for the hopelessness which permeated the health center sometimes; the ongoing TB outbreak, the domestic violence, the malnourished children, the alcoholism, the young pregnancies, the deplorable housing situations, the lack of meaningful employment for local residents.

Yet that isn't the full picture, and I suppose I'd have to sit typing for a long time to accurately try and convey the beauty in those tiny hamlets, scattered across the North, connected only by airplanes. The mirth that has remained despite the hardships, the strength of the women and men trying to better their communities, the natural talents of many print-makers, carvers, and story tellers. The ability that some still have to survive on a landscape that would kill most us in a few days.

Drum dancer during Nunavut Day celebrations.

I am going to go back there someday, when all these USMLE questions and elective requirements are a part of my history. For now though, I have to pretend to see the importance of learning about G-coupled proteins and which enzymes convert pyruvate to oxaloacetate.
---
*Of course, I would be remiss to write a post about the North and not mention my favorite book written about the place, Consumption, by Kevin Patterson.

Summer Placements--Yipeeee!

Vista from the road near Dingle.

The school has just released our placements for 1st semester of third year. I am very excited as I found out that I will be rotating first through surgery in Tralee, County Kerry.

So, surgery is the thing I am most looking forward to next year as it will allow the greatest leap from my experiences as a nurse...and not to mention the fact that I adored every minute in the O.R this summer!!

I had originally asked to be placed in the Big Regional Hospital but then the placements coordinator emailed me and asked if I'd consider going to Kerry for the entire year. I had put Killarney (near Tralee) as my preference for GP placement in 2nd semester so moving for the entire year made sense.

I hummed and hawed for the evening, drank two glasses of wine, called a few of my Irish pals for advice, then responded "yes" before wondering what I was getting myself into.

The hospitals in Tralee are much smaller than Big Regional but the location is one giant beautiful wide open space of mountains and ocean. And I will be close to Killarney and Dingle. For those of you who've been to the area you'll be able to appreciate why I am so excited to be a 30 minute drive from the Ring of Kerry.

Dingle Harbor

The other interesting thing is that there is only going to be one person from my class at the same hospital as me, and we'll be on opposite rotations (he'll be in med while I am in surg). He's actually one of the most down to earth and sincere lads in the class--plus he's a fellow West Coast Canadian! So having a bit of company (of the quality variety) will be good. My heart is always in smaller centers, I adore rural health care and I think for electives it will be nice to be as far away as possible from some of the competitive knobs in my class.

Fingers crossed I land some decent preceptors...