An Unexpected Test--Part 1

At 0800h I was standing in my room at the B & B, holding the silver emergency blanket in my hand.  I gauged its weight and worked at stuffing it into my already bursting camelback. The pack was full, mostly due to the 2L water bladder, but I had also managed to squeeze in 3 nutrigrain bars, a headscarf, my mobile, a few tissues, and a headlamp. My first adventure race was only 2 weeks away, so I had driven to Westport the night before to join the training group and suss out the upcoming racecourse. In a rush I’d ‘packed’ by basically throwing all my outdoor gear into the car, hoping I’d managed to toss in all the essential pieces of kit.

“I am only going on a road ride and a run, I am definitely not going to need my emergency blanket or my headlamp. The last thing I want is an overstuffed pack bouncing on my back while trying to run” I thought.

I pulled the blanket and headlamp out of the camelback and transferred them to the larger pack that I take on hikes. This pack always contains my mitts, 2 winter hats, spare socks, earmuffs, and rain pants. Just in case.

I couldn’t have predicted that 5h later I’d be pulling the camelback apart thinking,

“Wait!!! I had an emergency blanket in there this morning…did I leave it in or put it in my other pack?? Ohhh…”

So I finished getting dressed in my long biking pants, tank top, t-shirt, long-sleeved merino wool top, and windbreaker. I usually end up overheating and cursing every layer once my heart rate gets going, but it seemed windy enough to warrant the wool shirt. I kept it on and headed out the door for what I thought was going to be a morning consisting of a bike maintenance workshop, followed by a group road ride, and short run.

Due to a miscommunication with Paul, the trainer, regarding the schedule, I ended up cycling to the base of Croagh Patrick without my running shoes. He felt terrible and offered to head back to town and collect them for me.  I was embarrassed that I’d misunderstood the plan and contemplated going up in my clips, but he insisted, so I gave him my keys and waited.

By the time Paul returned most of the training group were trickling back into the parking lot after hiking to the shoulder. He handed the shoes over and suggested that I hike to the top (since that was how far I’d have to go on race day). He gave me his mobile number and said he’d go through the rest of the course with me on my own once I’d cycled back to town, later in the afternoon.  I was so mortified over being the most high maintenance participant of the day that I didn’t mention that I had no way of locking up my road bike while heading up the mountain.  I waited for everyone to leave and then negotiated with the elderly Irishman selling walking sticks from a stall in the parking lot. I told him I’d be 2 hours maximum and he agreed to keep an eye on my bike as long as I propped it within view of the stall.

It was noon, there were snatches of blue sky scattered amongst the clouds, but the top of Croagh Patrick was wrapped in a heavy grey fog. It was the best that one could hope for in terms of Irish weather so I struck off.  I started my GPS timer and (mostly cheesy) ipod running mix, trying to move as fast as I could up the mountain, partly to take advantage of the weather and partly because I didn’t want to keep Paul waiting once he was done with the training group.

An hour later I was nearing the top of the mountain, which is mostly a rocky scramble. Despite the cold wind and scattered rain, I had long ago shed all my top layers and was down to a sweaty t-shirt. I was hammering away with Daft Punk and Fat Boy Slim blaring, feeling good.

Then I saw a small cluster of people crouched down on the trail ahead.  I thought for a moment that it was just a group of melodramatic teenagers taking a breather from the sustained final push to the top. Then I noticed that one of them was lying on the trail with blood on her face.

I crouched down and she opened her eyes. I asked what had happened and if I could help. The person on the ground was a woman in her thirties with soft brown curls framing her bruised and swollen face. A cut across the bridge of her nose bled in a line down her cheek and along her neck. She was covered in a mix of raincoats and sweatshirts, visibly shaking. Her clear blue eyes opened when I asked her her name and she told me it was Maggie. A hover of teens surrounded her. They said she’d fallen and hit her head but she hadn’t been knocked out. A frantic looking middle aged man in a blue cableknit sweater and khaki pants spotted with blood approached me and said that mountain rescue had been called and that they were on their way.  I asked if there was anything I could do, he said “Uhhh…I don’t think so, mountain rescue will be here shortly…” 

In these situations I never know how to state my credentials, going into a ramble about being an ex-ER / arctic nurse, now 3^rd year medical student, with a smattering of trauma and backcountry courses, seems a little too long-winded and confusing. So I decided to distill it down to ‘student doctor’ even though it sounded vaguely ridiculous at the time. Especially since that part of my background was probably going to help me this least at this point.

“I just want to make sure she’s ok, I am a student doctor...can I quickly check her out?”

“Wait…what?”, the man said, “oh thank God! You’re a student doctor? Once you’ve looked at Maggie can you come and see the girl? I think she is in worse shape.”

The girl?

It was then that I saw a second huddle of teens away from the trail, on a steeper aspect of the scree, about 5 meters away.

Oh dear.

I Heard It!! I REALLY heard it.

Small miracles, tiny accomplishments, baby steps forward.

Some days in medical school it feels like the 'teaching' just boils down to constantly being told how many differential diagnoses you forgot, how many signs you failed to elicit, and how many questions you didn't ask the patient. The constant deluge of information and things you ought to know by this point can begin to feel suffocating.

Until a miniscule but measurable gain occurs and suddenly, it seems worth it.

Like today...I actually clearly heard my first heart murmur which I confidently and correctly identified after performing a decent cardiac exam!!!

Pretty sure that at the exact same moment a unicorn was born and a leprechaun discovered a pot of gold.

I honestly thought that heart murmurs would always be a mystery to me and that there would never come a day when I'd be able to do anything other than pretend I heard it. 

But, nay! I heard it. I really heard it. And strangely, that made me smile. All day.     

Small miracles.

Mind Go Blanko

On Friday my new consultant (MNC) gathered together myself and the other doclings to do some bedside teaching. Normally I try to slink between the folds of curtain during these sessions as I really don't want to be pimped on differentials for pseudopseudohypoparathyroidism or some other disease dredged up from the Annals of Obscure Internal Medicine. But since MNC hasn't seen me examine / present yet he asked the handful of final meds to step away from the morbidly obese no-necked man who was sleeping with his feet at the head of the bed, and told me to conduct a complete cardiac exam and report my findings.

Yeah. It was sub-awesome.

First of all, I could hardly feel his radial pulse and my racing thoughts kept forgetting where I was in my count...was I at 14 or 24 when I had counted 15 seconds...wait...did I start counting when my seconds hand was at the 12 or the 1 position...where DID his radial pulse go--GAH!

Then I attempted to feel his carotid pulse which should have been located somewhere between his clavicle and angle of jaw (which were, in his case, resting comfortably on each other, heavily padded by folds of flesh). No luck, despite the patient kindly allowing me to dig around there for a while.

JVP? No. Bueno.

Ok, and on to the apex beat. Not so much. Heart sounds?? Is this stethoscope on?? Tap. Tap. Tap. I can't actually even hear his heart beating--hark?! Is that it?? No, that is the sound of my own blood rushing through my ears...

And now to my dazzling presentation. Sure, I'll just neglect to mention that he was hooked up to telemetry, and that he had cardiac meds at the bedside...even though MNC kept asking me, "is there anything else you'd like to comment on??"

"Er...he has a midline abdominal incision??"

"No, he's on telemetry."

"Oh, right." Yeah, the device you hooked cardiac patients up to everyday in the emergency department. The painfully obvious tangle of colorful wires stuck to his chest. Yes, those.

Surprisingly MNC did not shred me into tiny bite sized pieces. I suppose he just assumes that 3rd years are clueless. The major bummer was when he turned to the final meds and asked them how to manage the patient. I had to fight hard to not pull a "Summer" from School of Rock...

"Oooh! Ooooh!! ASK ME!! I know how to MANAGE a CCF patient!!! Really!!! YES!!"

But, no. My medical self had failed and my nursing self couldn't help me now.

Ah well, maybe my extremely low bar setting means I will appear to shine upon my next opportunity to examine and present.

Maybe.

:)

Alright. Medicine, I misjudged you.

I am sure this will induce some smugness out there to you medicine-y people, so I will say it just this once: you were right.

Internal medicine isn't terrible. I have seen some really interesting cases and signs...water-hammer pulse, palpable heaves...murmurs, palsies, and masses oh my! DiGeorge syndrome, death, dementia, failure to cope, hyponatremia, acoustic neuroma. And that was just one patient!  (I'm kidding. Sort of.)

The other good thing about this rotation is it has definitely removed any lingering doubts that I want to go into surgery or acute care. Internal medicine is just not my cup of tea, which is a good thing know when you are someone like me who finds something of interest in everything I am exposed to.

In other news, training for my race is going...well, it is going. When I see what I am supposed to be able to do at this point (as per the schedule they gave us with registration) I get a little nervous. It is only three weeks away and I haven't been doing multi-sport training yet, mostly because I just don't have time to do a 3h cycle followed by a 1h run in one day. I've just been trying to get out at least 5x per week with one sport at a time. This is not really good enough but it is all I can do right now.

I have already given a heads up to my medical team that I may end up becoming one of our patient's on Nov 12th. I know the registrar will take good care of me, she's very smart.

And now I must return to my daily meditation on the kidney, the neuro exam, and all things cardiac.

I Have "Hapless Female" Qualities

I took my little blue beauty into the bike shop today after my cycle for a 'tune up'. It was embarrassing.

Me: Hi. I bought the yearly maintenance package for my bike and I wanted to bring it in...

Bike dude [in hurried manner]: Ok, what does it need?

Me [suddenly realising how ridiculously hapless I am at very basic bike maintenance]: Yeah, it pretty much needs...um...air in the tires, a little oil on the chain, and...I dunno, the pedals tightened? Er...maybe the shifters...[stares at ground, toeing invisible mark on floor] shifted...[trails off, mumbling incoherently]

Bike dude [expression softens as realises he's dealing with moron of epic proportions and takes pity on me]: Ok, that shouldn't take very long [chuckles to self] we should have it ready by Wednesday [enunciating well and speaking very slowly].

Ok, so I am a ridiculous damsel in distress when it comes to my darling road bike (and killing spiders). 

Today's event cancels out the fact that I wielded very heavy machinery last week in a very non-girly way (with a steady hand and...ok...the odd high pitched squeal of delight).

I hate those moments when I feel like a hapless female, but dammit I don't have time right now to learn about gear shifters and spider aversion therapy...I am in the thick of it with trying to piece together a smooth cardiac exam without being reduced to a blubbering mess in front of the ward sister, the reg, the SHO, and several medical students.

And so, for now, I pay the bike shop 25 Euro a year for unlimited bike maintenance. And I am ok with that. Usually. 

Clinical Exam Follies and Triumphs

This week I had the opportunity to invigilate a licensing exam for doctors here in Ireland. Though no one actually said anything to us about confidentiality I am very certain that I am not able to blab about any sort of details. However, I will say that it was a fantastic learning experience to see how different people perform under pressure, how examiners basically set out to shred you to pieces, and how little things can really affect one's rapport with the examiners.

One thing I will take with me for when it come to be my turn on the sharp end of the short-case examination:  if you are told "examine body part [x]" then EXAMINE BODY PART X!!!!!

I was stunned to see people being told specifically to examine one organ or anatomical location to find them faffing around with other systems, only to the irritation of the examiners. The examiners would sometimes have to repeat themselves several times, "stop, examine x!"

There was one candidate who was my hero. She (somehow) remained calm, did very methodical and well organized physical exams, could rattle off differential diagnosis like a champ, answered all the examiners questions clearly and precisely, and was really personable to the patients. I was mentally cheering her on the whole time and wishing I was her. I also felt devastated for the people who started floundering, crashing and burning, knowing all too well the negative spiral of

stressed

mind blank

higher stress

flustered

adrenaline injection

mind completely barren of thought

fear of failure

despair

quavering voice

certainty of failure 

despair

despair

despair.

It was somewhat reassuring (or depressing, not actually sure which) to see that even people who have been doctors for years still get stressed and fumble during clinical exams, it is not just we doclings. 

Good And Bad

This Saturday my interview on CBC's national radio show White Coat Black Art will be airing. I am a little nervous (ok, a lot nervous) about how it is going to turn out. The interview with Dr. Goldman was the day after my USMLE exam so there were a couple of reasons that I may not have been overly articulate. However, I still really enjoyed the whole experience and was flattered to be asked on the show (considering I've been a dedicated fan and listener since it's inception years ago).

My prediction is that my contribution will only be a tiny piece of the show, but I am still excited and pleased about the exposure that the blog will receive. Of course now any thinly veiled anonymity will be removed and I'll be having to keep Asystole on an even straighter and narrower course. 

The interesting outcome of increased traffic is usually increased trolls. I was really surprised (oh, how naive I am sometimes) at some of the troll-y comments when my "Advice to Interns" pieces were published on KevinMD during the summer. I suppose I just have to remember that some people really take themselves too seriously and do not understand 'tongue in cheek' nuances.

So we'll see, maybe trolls, maybe increased traffic, maybe nothing.

For now I am being kept quite busy putting together my research project (in surgery, of course!), training 6 days a week for the big race next month, compiling a report on the elective /residency woes of Canadians Studying Abroad (CSA's), and trying to keep a smile on my face.

That last part is sometimes proving to be the hardest of all tasks! But as Shakespeare rightly pointed out in Macbeth, 

"Come what come may

Time and the hour runs through the roughest day". 

Jaws of Life Teaser Photo

I am writing a post about the brilliant trauma course...but in the meantime...allow me to present ABB wielding an actual jaws of life. This photo taken shorty after I cut a car door off (hence my demented appearance).

Does this jaws of life make my thighs look big??

The really hilarious part was that the firefighter handed it to me, showed me where the 'on' button was and then told me to 'work away'. 

Yeah, in Canada I would have had to take a 2 day safety course, sign release forms in triplicate, show proof of tetanus immunization, and demonstrate to a workplace hazard team my ability to handle the machine before being allowed to turn it on.

What could possibly be more enjoyable than handling a machine that crushes metal at 600lbs per square inch???

Oh 'twas a good day, so it was.

Good Trauma

For the past 2 days I've been at an Advanced Trauma in the Community (ATC) course, and yes, I did get to smash a car window and use the jaws of life! There will be photos and yarns soon to follow. Oh, and a breakdown of how I cycled through wanting to be a firefighter, police officer, and paramedic throughout the day.

If I had been wearing Star Wars pajamas then I probably would have completely morphed into the 7 year old boy living inside of me.

Trauma, woot!!

Sunday Riders

So today Pádraig (the surgical SHO) and I decided to do a reckie of the road biking portion of a race he's competing in next week. We started at the Gap of Dunloe (a.k.a Kate Kearney's Cottage) and ended at the Torc Mountain waterfalls. A fabulous ride in part due to the spectacular scenery the entire way, and a delicious visit to my favorite purveyor of fine Irish food: The Avoca Café.

I also learned a couple of things today. For instance, my tiny little sewing-machine of a car can fit two road bikes in the back and two people who love blood and guts in the front. GO TOYOTA YARIS!

Another lesson learned was that not only are directions from Irish people usually nonsensical and obscure, the road signs are equally unhelpful. Unless, of course, you are looking specifically for tea and scones or a farmhouse with ensuites. Have you reached a fork in the road on random back country lane? Are you searching for a particular town or road number? Sorry. Can't help you there. Tea and scones? Take a left.

I've been to the Moll's Gap Avoca a couple of times but have always approached it from a different direction. So after a particularly sustained uphill we decided to pull off and have snacks, figuring the Avoca was at least another 20kms or so away. After some Clif bars and trail mix we started up again on the bikes, only to come across the "AVOCA, 500 METERS" sign within about 3 mins of departing.

I did hear Pádraig scream "NOOOOooooooooooooo!" through the fog.

I think he made up for the disappointment in having already eaten lunch by putting himself into a pre-diabetic-coma with the most delicious banoffee dessert evah.

And it was all downhill from there, friends. An outstanding day, topped by my new routine of sauna / ice-cold shower / sauna / ice-cold shower at the gym.

Ain't life grand?

New purple Icebreaker, for the win.