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.

Christmas: The other silly season

I hope you've all had a lovely Christmas/ Holiday period and I'd just thought I'd share a couple of corking papers in this month's British Journal of Medicine. Traditionally, the BMJ treats Christmas as a bit of a silly season when it comes to content and publishes papers which might be considered a bit frivolous at other times of the year. Anyway, these are my favourites from this year:

"Relevance of the expression “obs stable” in nursing observations: retrospective study"

"Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study"

Both papers are freely available as PDFs for your consideration.

See you all in the new year!

Long weekends and tiny epiphanies

I think I know how the panda feels sometimes

The last three weeks I've been running a project looking at communication between doctors and patients.

The last weekend I lost my brand new (less than 24 hours old) iPhone 4S.

These seem like relatively unconnected events, other than that they both happened to me. One, however is a causative agent. One is a symptom.

I know it is the most over-used cliched post for a blogger to talk about their experiences of depression. We get it, you feel blue sometimes, get over it etc. etc. But this past three weeks have had me becoming re-acquainted with something I thought I was entirely over. In what I now view as a former life, I was lab monkey who worked by themselves for 8 hours a day in a lab where I was the only person there, for months at a time. During that job, something broke inside me. I tasted despair and such crippling psychic pain that I had days of missed work where I would pad around my crummy flat and wonder what would happen if I just stepped out in front of the bus that went to my job, rather than getting on it.

It was, to say the least, not a time I remember fondly. The more I've learned about clinical depression, the more I am sure I was suffering from it. Not that I ever sought medical advice at the time or subsequently. I probably should have, with hindsight. But whatever. I think the loneliness of working a job that was going anywhere, by myself damaged me in a profound way.

I've written about this before in a brief post when it seemed like a more distant time.

Things changed when I moved to London, started nursing and making a positive difference in the world. Everyone I helped, healed me a little bit. I worked as part of a team who spent a lot of time together, worked hard, partied hard. I got married and learned to trust and share my space with someone. Learned that maybe I didn't have to bear the occasional weight of existential dread by myself.

But running this project for the past few weeks has involved me living as an observer, watching, not interacting or involving myself in some of the sadder aspects of human existence. 8 hours a day, by myself, in a crowd of people.

I think you can see where this is going.

I didn't pick up on it at first. Then slowly things happened. I passed up on going to the gym. On going to my Krav Maga classes.

Then I went drinking on the Saturday night. I was back with old nursing friends and we tied one on. We painted a small patch of Soho red. It was an explosive release of... Something for me. And I got drunk. blind drunk. In the process lost my 'phone and didn't care, because I was too busy drinking and trying to savour being a part of a group again.

Monday I was still a bit hungover. But, I pulled myself together enough to get stuff done and in recounting the weekend to med school friends, suddenly realised what was going on in my mind. This realisation has made all the difference. I'm now spending my spare time on the ward revising and learning and talking to the medics. Engaging with the world.

I guess my point in all of this is sometimes you're not as healed as you think and maybe it's a reminder to be on your guard against demons you thought you'd vanquished.

(Oh, and the sad panda shirt is from the A Softer World line at Topatoco)

How not to answer a question

Achievement unlocked: Completed first surgical placement
Status: Acceptable

Some consultants like you to stay quiet if you don't know the answer, some like you to take a guess because "I don't know is never right". But all of them like you to think systematically, to have a pre-programmed structure to your answer. There are some classic questions a surgical consultant will fire off and expect a quick, concise answer in reply - answer that can only be achieved by applying logical, systematic thought.

When we're taught this way of thinking it is generally with a smile on the face of the lecturer and a remark about how you can use the answer to avoid actually having any specialist knowledge in the topic or in actuality, having an answer to the question. If that sounds a little convoluted, allow me to demonstrate:

"What are the complications of this surgical procedure?"
"Complications of surgery can be divided into immediate, early and late, and further sub-divided into specific to a given operation or general to all surgeries. Immediate complications arise during the procedure or in recovery, early within 48-72 hours, late within weeks of the procedure..."

Do you see how that answer isn't an answer at all? And how it is completely right at the same time?

At first I thought it was a technique to bore the consultant and get them wave you into silence, firing off the next (and generally harder question) at the student next to you. But then when I thought about it a bit more, I realised this is such a useful way to manage your knowledge. Rather than having a randomly assorted list of things, you can partition them off, divide them up to help guide your care and treatment modalities with a clear understanding of the most likely cause and the relative seriousness of the complaint.

Whilst there having been important take-aways from this placement, such as the fact I don't think I'm going to be a surgeon, or how busy and yet elegant the anatomy of the hand is, the notion of systematic thinking and how to apply these kind of techniques to make me a better doctor is my top learning point form the past six weeks.

Fighting Trousers - Professor Elemental

Well it made me laugh and not just because he raps about "chap hop".

(via Life in the Fast Lane)

Poppin' my cherry

I couldn't see his mouth move, but his eyes were firm but kind:

"Is this your first time?"
"I want to hold this, and pull firmly up and back. Easy, not that firm"

His guidance was even-handed, congratulating my successes and admonishing my failings:

"When I want you to hold it, I'll pass it to you"
"No, you're holding it wrong, wrap your thumb and ring finger around it, and use your other hand for support..."

Oh dear.

Sorry, I thought of this post on the tube home and I couldn't resist. Today was my first day scrubbing in on surgery and it was brilliant. A lot of my coursemates have had negative experiences in theatre which has really impeded how much they get out of their surgical rotation. In medicine the classical educational concept is "teaching through humiliation"which is not without it's merits (I will never forget the complications of gallstones after a registrar took my umm and ahhh laden answer to pieces), but when you're in theatre, being told to GTFO because you didn't know the innervation of a particular muscle is just mean. Yes, you should bone up on stuff before your placement and doubly so if you know the operation you're likely to be scrubbing in for, but if you don't know the answer to a particularly esoteric question you shouldn't lose the rest of your potential learning.

I was felt so nervous scrubbing in but I think I really lucked out with friendly and helpful nursing staff and a my registrar being a great teacher. I was ended up in a procedure I wasn't expecting and hence couldn't answer a fair number of his questions (none of which were unreasonable), but my answers of "sorry, I don't know" didn't earn me a sound bollicking, but rather an answer and an explanation. I will not forget that the things I learnt, feeling like a plum and quietly turning red.

And I'm looking forward to the next time I get to scrub in.

Oh, come on!

So, here I am half-way through my plastic surgery placement and loving it.

It took a bit of time to get started, but mainly because I didn't play to my strengths enough and was a bit of a wallflower.

No longer.

I'm getting on well with the team and it's nice to be getting stuck in with history taking, wound washout and dressing, bleeding and cannulating like a mo' fo' and seeing some fascinating cases.

I've really been boning up on my theory, too. I can talk on the difference between an FDP versus and FDS injury, the need for aggressive management of necrotising fasciitis (or "nec fash" as we say in plastics :P), the implications of loss of sensation of different digits or why surgery is so much better than medicine (I'm still not entirely sold on that argument...)

Sitting with the consultant in his clinic still generates existential dread, though. I'm not sure that ever changes, to be fair, as I have seen SHOs and SpRs with an expression I recognise - the "oh god, I have no idea" face. I thought I was doing okay on my last clinic... Only to have One Of Those Questions come up:

Mr Hand: "What test am I asking the patient to perform?"

(the patient is making the familiar "inverted prayer" I know is Phalen's test)

Me: "Phalen's test"

Mr Hand: "And what is the positive Phalen's sign?"

Me: (silently sighing with relief) "Pain or tingling in the hands"

Mr Hand: "And when did Phalen write his paper on this test?"

Me: (OMFGWTFBBQ) "No idea, sorry"

I almost laughed because I thought he was being hyperbolic. Turns out, not so much.

*sigh*