May Day

Not exactly sure where April went. Well it involved a holiday to the UK, then buying a house and writing my QE1 exam. Oh, OK, that is where April (and the beginning of May) went.

Since residency started I feel that I am standing on the platform of a subway station. The days go whizzing by, past my face, at a speed that leaves everything a trailing blur. Then for a moment, the subway stops and people pour out, and pour in, bumping past me. Some linking eyes, some carrying on, some talking, some silent. I remain still and the chaos moves briefly around me, then the doors close and everything speeds up again. There are these blips of human interaction that stand out, but much of it remains a blur.

I kick myself for not writing, even just for myself, every night. I really ought to try and start doing that. Maybe that will be my mid-years resolution.

Things have been in a state of flux. I recently went through yet another soul searching time in my post-graduate training. I am gearing up to apply for my +1 year (in Canada GP's can undertake extra training in things like emergency medicine, anesthetics, surgery, obstetrics, palliative care, sports medicine, etc). I always knew I wanted to do this +1 option but I've gone around and around with what area to specialize in. I thought for a long time that it would be emergency medicine, but if I am honest I am getting to be COMPLETELY over EM. I am just tired of all the abuse that goes on in the ED, in every realm: patients abusing the system by going to emerg for non-emergent presentations, patients abusing the physicians and nurses, and then the specialists abusing us when we call to consult them. I still love a sick patient, a surgical patient, a procedure-needing patient, but that is about it. I just don't want to do it full time. A shift a week - sure! Everyday? Shoot me now.

So I thought about anesthetics. 9 months in the Big City and then 3 months in my current city. I like the procedural side of anesthetics, and I love airway management, but I am not a detail oriented, thinking person. I am a cook, not a baker, if you can appreciate the vast difference between the two personalities. I can force myself to be detail attentive but it requires a lot of mental energy. I realised that I was choosing this option more because it has greater portability and demand currently in Canada. It wasn't what I truly wanted to do in my heart of hearts.

Thus, I decided to apply for the Enhanced Surgical Skills program (ESS). It is one year of surgical training that is divided between 6 months of obstetrics and 6 months of general surgery. In the obs component you learn c-sections, essures, tubal ligations, instrumental deliveries, and other office procedures. In the general surgery component one is expected to become proficient in performing hernia repairs, appendectomies, lumps and bumps, scoping, and any other procedure you feel you ought to provide to your community (some do tonsillectomies, carpal tunnels, etc).

So now I am pumped. I have found an accepting community that will give me privileges in this scope of GP-surgeon practice. The applications are in the fall (for a July 2015 start) but I'm already trying to get as much experience as I can with these enhanced skills. It's been great, having loads of obstetrical procedures here as well as being scaffolded up on basic surgeries...all by kick-ass GP-surgeons!

It's weird feeling like things are possibly falling into place. I've had so much internal conflict and so many questions about what I ought to do with my career. I have always felt that family medicine was an uneasy fit for me since I started residency, mostly because there are many things about FM that I do not love. THIS feels like a fit, it feels like something I can hold on to and mold into what I want it to be in the future. I hope.

FIRST CUT!!

Dear Diary,

Today I had the chance to make my first scalpel to skin incision. M.C was very nonchalant about the whole thing. I had set up the tray as per usual (thanks to years of nursing and having to set up many a tray for minor ops) and then he just casually said to me, "okay, so work away there...get a blade for yourself..."

Yeah, I tried to play it cool but I am fairly sure that the eyes-popping-out-of-my-head-with-questioning-stare gave it all away.

He smirked and pretended to have something to do away from the patient while I went about (excitedly) excising my first skin tag.

This was followed by a sebaceous cyst excision and another skin tag removal (of a patient I had seen 1 month ago and booked for the procedure). She said she hadn't felt a thing, and that I was worth every penny that he was paying me. HA! I shall never let M.C live that one down.

I was pleased to learn that I have a steady hand and do indeed get a rather large kick out of cutting people (in the socially acceptable cutting to cure sort of way). I am sure that such a milestone is something you never forget. Course I am happy that this happened in one of my favorite little hospitals, on Valentine's day nonetheless.

Today was a good day.

Sincerely,

ABB

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.

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!) 


   

Two Cool

2 days ago we had a confirmed (by CT) case of mastoiditis!! This may not seem overly exciting to some folks, but really, it is quite a cool and rare thing to see in North America. Mostly because it is a complication that can arise from an untreated inner ear infection (which almost never happens because ear infections--often viral and self-limiting--are usually overtreated with antibiotics). It was in a patient who had had ear pain for several days following a dive, but had left it until he became unable to sleep due to the discomfort. He presented to the ED with abd pain and dizziness but as he was checking in also mentioned his ear ache.

Vital signs were unremarkable, pt was a fit, middle aged man.

We had a brand new doc on, doing her first locum in an ER so we were all just getting acquainted. When she came out of the room and asked the radiology tech to be called in to conduct a CT of the head we all looked at her like she had two of them. The charge nurse was clarifying,

'For an abd pain?'

'I think he's got a mastoiditis.'

Ohh kaaayyy.

Naturally I went in to take a look, because I am nosey. And I wanted to see why she was suspicious. It is a bit of a zebra diagnosis for an ear ache.

He was exquisitely tender even as I gently pulled his ear up to look in with the scope. I saw a very boggy, swollen, angry looking tympanic membrane with some bloody drainage in the canal. Ohhhh. It looked ugly. And I have seen MANY nasty ears in my time on Baffin Island (hence the colloquial term 'Baffin Ear'). He had only mild post auricular edema and no remarkable adenitis. So we had been a bit skeptical to call in the tech as well as waking up the radiologist who is on call EVERY night and never gets a day off. But sure enough, the CT showed (not the actual CT below but one stellar comparison) the fluid filled area where air ought to be---note the right sided mastoiditis on example below. His looked exactly the same.


So he was admitted, ENT consulted for the morning, started on IV antibiotics and analgesics. We all complimented the doc on her good catch. Many would have sent him packing with an amoxil script. She said the main thing that caused her to suspect the diagnosis was the level of pain that this guy who 'didn't seem like the type to complain' was expressing.

Cool part one.

The second cool thing that happened was I got to give my first cortisone injection! It was a combo of cortisone and marcaine (the marcaine is a longer acting anesthetic--what your dentist uses to 'freeze' your mouth). It was on this guy who was complaining of severe, chronic shoulder pain. He was a very tall bodybuilder and had massive shoulders, covered in tatoos. This made the bony landmarking somewhat of a challenge but apparently I did a bang up job because he said he never even felt the injection. About 15 minutes later he walked out of his cubicle, came up to me and said 'my shoulder has NEVER felt this good, I cannot remember a time when I didn't have pain!'

Ahh, that was just the marcaine talking. But I took the compliment nonetheless. He then asked if I'd do his other shoulder while he was in the department! It was great. I was happy to have the doc talk me through it and glad that the outcome was a positive one (and that I didn't rupture his tendon or something!!!)

All in all, it's been a good week.