Thursday, 16 February 2012

The Moscow Rules

A helpful reminder

"Only the Sith deal in absolutes"

- Obi Wan Kenobi

Aside from the grammatical horror of that statement, I'm inclined to agree with the sentiment. It is very hard to abide by a strict, unbreakable set of rules. I suspect every rule has its exception and to deny that is to blinker your imagination to how complicated life can be sometimes.
That said, I try to live as moral and ethical life as possible and I keep next to my bed a postcard from the International Spy Museum in Washington, D.C. which outlines the "Moscow Rules". I'll leave you read to about them - suffice it to say they were simple, incisive rules to live (and survive) by for western agents during Cold War in the USSR. One of the things about them I like is that they can be adapted to many different situations, including the world of the medical student.

The Moscow Rules for Medical Students

1. Assume Nothing

Starting any answer to a senior's question with "I assume..." is almost guaranteed to get you a telling off. And rightly so. Equally, if the consultant says "Oh, we start around 9am", don't assume that you should turn up at 9am. Turn up at quarter to 9. Be seen to be eager - no one likes the guy who does the bare minimum.

2. Never go against your gut

In a similar vein, a firm, logical, wrong answer is better than the hesitant, mumbled right answer. You think you know the answer? Say it. Worst case scenario is you are wrong. When you are asked a question, think about the answer and say it. Don't "ummm" or "ahhh", it shows you doubt yourself. Would you trust the doctor who isn't sure of their own answer? Just don't leap in with an answer that you've not thought through. If you think that enlarged liver is Wilson's disease you better be ready to back it up.

3. Everyone is potentially under opposition control

You know how well you get on with that FY1? Just remember that they are there to do their job and you are there to learn. Same goes for the nurses. They're not there to be your friends - be friendly towards, certainly, just don't suppose that they should be used as a confident about their consultant or colleague who they know a whole lot better than they know you. I'm not saying that they'll tell on you, but it will colour their opinion of you, for sure.

4. Don't look back; you are never completely alone

You know how you said that funny thing to your coursemate at the nurses station about that patient with dementia? Chances are the nurses heard you, the patients in the nearby rooms heard you and, if you're very unlucking, your consultant who was just turning the corner heard you, too. Your behaviour should be professional and reflect the role people expect from you. 'Nuff said.

5. Go with the flow, blend in

Everybody has different ways of doing things, especially so in medicine. Every consultant likes a patient presented in a slightly different way, every FY1 has different tricks for cannulating that little old lady with the invisible, almost unpalpable veins. Learn from everyone, it will all come in useful one day. However, remember that your uni has a prescribed way of doing almost everything that they will want to see in the OSCE at the end of the term/ year.

6. Vary your pattern and stay within your cover

You are a medical student and people will generally have low expectations of you. Challenge this by getting involved with as much stuff as possible. Yes, you could do the ward round, lunch and then spend the afternoon doing bloods and cannulas, but didn't you hear the consultant mention a radiology meeting or MDT meeting after lunch? Being a med student is a license to go and see things and be involved in things that you just won't have the chance to do as FY1. Remember that.

7. Lull them into a sense of complacency

Maybe "lull" isn't quite the right word, but it's the first word that comes to mind, to misquote Chuck Palahnuik. If you want to be involved the more interesting aspects of ward life, be seen to be the one who rises to the challenge and succeeds. Hone your skills and show that you know how to work without direct supervision (and when to ask for help) if you want to be given the more challanging stuff.

8. Don't harass the opposition

The opposition could be anyone depending on how bad your social skills are! Don't harass anyone is probably a clearer way to intepret this rule. You know how they teach you that the nurses are pretty much the doctor's hand-maidens (even now, in the 21st century)? They're not. They don't live to serve you, they're not just waiting with baited breath to give you a job to do or to answer your questions. This extends to physios, OTs, SaLT, the whole nine yards. Respect them, learn from them and be friendly and helpful.

9. Pick the time and the place for action

Oh man, this question is burning a hole in me, I got to get an answer, how else will the consultant know how smart and insightful I am? If you have a question to ask, a skill you'd like to practice, be aware that the patient you are with is a human being. Do you think that the history they just gave of weight loss, night sweats and haemoptysis is indicative of lung cancer? Wait until the patient is out of the room and the doctor you are with has time to properly discuss your differential.

10. Keep your options open

Every new placement reminds me how interesting I find medicine. In the UK, at least, you won't have to follow single path in your career until your ST years (and even then people have been known to change). Try a bit of whatever sounds interesting in med school. Don't get fixated on how there is only one career for you in medicine, or you might miss out on something better.

Sunday, 29 January 2012

Describing fractures on imaging

I'm still uneasy around x-rays. If it's not a clear cut case of whatever, it can feel like a magic-eye picture and whilst the Consultant's eyes bore into my temples I am left saying "uhhhhhhh".

One thing I picked up on the plastics rotation was describing fractures. Like so may things in medicine, and imaging in particular, there is a step-wise way to avoid missing out on any important details:

Always include the name of the patient, what kind of image it is, its orientation and when it was taken
Is it open or closed (does it fully penetrate the surrounding soft tissue)?
Is it transverse, oblique or spiral (exactly as the terms sound)?
Give the anatomical location of the bone involved and include the bone anatomy, too
Is there any joint (articular surface) involvement?
It is comminuted (more than two pieces)?

i.e. "This is a plain anterio-posterior radiograph of the right hand of John Smith, taken earlier today. There is a closed, oblique, mid-shaft fracture of the third metacarpal. There is no articular involvement and it is not comminuted"

Wednesday, 18 January 2012

ECG's and other deviant behaviour (part 1)

After an awesome and enlightening tutorial on ECG's from my new consultant, I thought I'd share some of the tips I wrote down. I appreciate a lot of people find ECG's old hat and this will not be high level stuff, but I've struggled with interpreting them for ages and found most lecturers to be lacking when it came to the slightly more complicated stuff (read: axis deviation). Anyway, this is the first part of my notes. Hope you find them useful.

As always comment on patient name, age, date that the ECG was taken (mention if chest pain was noted when ECG was taken).

  • Check the paper speed! (hopefully it will be 25mm/ sec)
  • Count the number of big squares between R waves and divide 300 by the number of squares
  • Regular? If not approximate rate by counting 30 big squares and count number of R waves then times by 10 to get the bpm
  • Sinus rhythm describes a QRS complex preceded by a normal P wave (Lead II is best for visualising P-waves, hence its use as rhythm strip

Cardiac deviation
  • To determine whether or not the heart is deviated to the left or the right look at leads I, II and III. Determine which leads are positive and which are negative; to do this compare the peak and trough around the isoelectric line and sum them. A positive lead has a higher peak than trough and a negative lead has a lower trough than peak.
    • If I and II are both positive, the heart is normally aligned
    • If I is positive and II is negative, the heart is left deviated
    • If III is positive and I and II are negative, the heart is right deviated
  • Further to this, when looking at I, II and III determine which is closest to isoelectric (the peak = the trough). The heart is at 90 degrees to that lead - though check that aVR is negative to confirm correct lead placement.
  • Are there P waves preceding every QRS complex? If not you may be looking at Atrial Fibrillation.
  • If there is a P wave, what kind of shape is it? If it M-shaped, it might well be P-mitrale. This is commonly seen in mitral valve disease, particularly mitral stenosis or a dilated/ hypertrophic left atrium. A tall, peaked P wave is indicative of P-pulmonale or right-atrium dilation/ hypertrophy caused by conditions such as COPD.
To be continued!

Friday, 13 January 2012

Why I may never eat crab

My wife is from Maryland and loves eating crabs. She promises me an almost transcendental experience next time we go back to visit her parents - we'll eat crabs fresh from the Chesapeake Bay, sprinkled liberally with Old Bay. I've never eaten crab before and thought it sounded wonderful. Notice the past tense there.

I was down with that until this week's NEJM showed me how eating crab can go wrong. The kind of wrong that comes with haemoptysis.


Friday, 6 January 2012

So this is the New Year

Aside from losing what little hair I have left over a project which developed a life of its own, broke out of the laboratory and terrified the local villagers, I've been listening to The Making of Modern Medicine, which was originally a series on BBC Radio 4 which follows the evolution of medicine from the time of Galen and the humours through to the mid-to-late twentieth century and high science.

Andrew Cunningham speaks eloquently and with good humour on a topic which I think too few medics have any notion about. In much the same way it behooves us to know how our own countries were born and a how they impacted the world, I think medics should know a bit about where medicine (as an art, as well as a science) comes from. The story has a very engaging narrative and includes, where appropriate, actual documents and notes made by doctors from the ages. Obviously it cannot cover absolutely everything, given that it covers several thousand years, but I think the editorial decisions made about which topics to focus on are well chosen.

For me, the biggest take home points for me were how we as modern medical students owe almost everything about the current teaching style to post-revolutionary France. "Little reading, much seeing and much doing" was the message from the teaching hospitals of Paris of the early 1800's - institutions which did not previously exist at a time when medicine was more about lectures and watching someone else dissect or perform examinations, rather than the student getting stuck in. The other resonant message was how medicine has moved from the times of Galen and Hippocrates when the patient would tell the doctor that they were unwell to the more modern, scientific world in which the doctor tells the patient when they are unwell - Indeed you cannot be unwell until a doctor says that you are unwell. I don't want to come off as reductionist about that point I can't help but feel that something has been lost there (as regards communication and relating to patients), something subtle but important.

Anyway, it's a great listen and very good value for money (6+ hours) - excellent gym fodder, when you want to take a break from the books and want something medical but light-hearted and engaging. And maybe someone else to read for you!

Amazon (UK) link: The Making of Modern Medicine
iTunes (UK) link: The Making of Modern Medicine

Clubbed to death

Causes of Clubbing

A friend of mine wrote this rather neat guide to the causes of clubbing, for those times when you want to wipe that supercilious smirk of the Reg's face following the question "Well, what does clubbing mean?".

Add him on your RSS reader of choice and follow him on Twitter - he does this kind of thing more often than is entirely healthy for a med student!

Sunday, 1 January 2012

A liver is not just for Christmas

A story on the BBC health website (generally a handy resource, I find) on how "detoxing" by staying off the booze for a month is pretty pointless:

"Detoxing in January is futile, says liver charity"

I'm not overly surprised at the stance, but it's nice that there is a statement from the British Liver Trust on the issue. Certainly, if people can be convinced that moderation rather than abstinence is a safer, healthier and perhaps more importantly, more achievable goal we would all be for the better - patient and doctor alike.

Seems a fitting start to the new year.