Despite my best intentions, I'd been avoiding the Razorback. I was beginning to push my luck a little; Christmas to New Year always provides plenty of work for unmarried locums far from family, and I was beginning to have visions of an attempts on Christmas morning at 5am or on the night of 29th December at 11pm between work and flying overseas. I'd gone so far as to dig out my lights and make sure the batteries worked.

I hadn't scheduled this morning as an attempt. I had planned to join the group up Palmwoods-Montville, as per a typical Tuesday. Last night, a change of plan required I be home and fully functioning before 8am, ruling out the somewhat longer group trip. Still keen to work the legs, and with the challenge looming, I decided that I'd have a go at The Razorback.

So, on three hours sleep and a handful of leftover chocolate, I found myself rolling steadily to the base of the climb. It was 5:45am, windless with the clean sun steaming away the morning dew.

I decided that, if I wasn't to outthink myself, that not looking at my bike computer would be important. I would ride on feel. I stood up on a few of the earlier sections, breathing deep. A few walkers were on their way down, more than the number of tradies in utes whistling up. I passed the NEVER TIRE sign. The road felt good.

At the start of the main climb, just prior to the shop, I got jittery and slowed. My heart was beating hard enough to take my pulse by listening. From about four feet away. I turned the pedals more slowly, sitting and looking around.

I started to overthink things, "I only have three more chances; work's chaotic from here on...", "How will I write about failing from here?", "What if I get a flat?" It was a little paranoid, for sure. I shook my head out and rolled on up, past the turnoff.

At the shop, I reverted to stake-based goals. There were twelve before Hell corner, I think. Things got heavy, and by things, I mean legs, bike, body and breathing. I stubbornly grunted and ground Rosie up the road, standing and pushing hard. I stopped looking up. I watched the white line roll under the front tyre and strained against gravity.


I looked across the road at the arrow signs. They seemed too short. I was past them. I was through Hell corner! The road met me, and I breathed deeply. I expected to pop with every pedal push. I hurt. I stayed positive. I just focused on turning the cranks.

The next few minutes were achingly slow. I briefly spun up to a comfortable cadence and sat, before The Razorback reared its head and stood me back up, sucking at the air. I rode along the ridgeline, the sun pouring across my left shoulder, casting an exhausted, wobbly shadow across Razorback Rd. I looked back down; my computer said 8km/h, and I wondered how I was still upright.

At this point, my vision went a little foggy. I felt awful, sure, but I didn't think I'd pushed too hard. I couldn't work out why I couldn't see. I mean, the white line was there, rolling under my tyres, the air was fresh and tasty. I wibbled and wobbled on the tarmac. I felt bloody feral. In retrospect, the setting was picturesque, but I was in far too much physiological distress to contemplate appreciating it.


Then, after a period of numbness, I clicked. I was riding so slowly that my glasses had fogged, and hence couldn't see a thing. I felt steady enough to take one hand off the bars, just briefly. I saw a corner, saw my chance and snatched them away into my pocket. Unfortunately, my vision remained little blurry and I was stupendously nauseous. I thought, "I'm too far through to quit now. Suck it up. Keep going!"

Then, around the corner, I saw a building. It heralded the chute up to the summit. Just five hundred metres more.

The road narrowed and the trees crossed overhead. I spied the bridge across the road. The nausea evaporated, and I felt stronger, accelerating both against the flattening gradient and the likelihood of success.


A couple beginning the descent, breaking hard, flew past and called encourangement. I knucled down and rolled over the final road mark, battered. I had finished the Razorback.

I struggled to a picinic table and lay down, drenched, dyspnoeic and delighted. After recovering with the help of a full bottle of water, I took a few snaps, twittered and hopped back on the bike.

I rode down the Palmwoods-Montville Rd, revelling in the cool fresh air, dry roads. I passed several riders, "Good Mornings!!" aplenty. I drove home with plenty of fresh goals whirling around my self-satisfied brain, and wolfed down breakfast. The Razorback was Conquered.

Some moments just seem to grab at the eyes and mind. The personality or passion on show, or the loud atmosphere aurrounding makes an imprint on both retina and hippocampus. Here are a few such moments;

It's July in Melbourne and a cold, damp night. The Italian restaurant blasts heat onto the street like a wood-fired oven. Inside, it's dark and relatively empty. The woman sits in the corner, alone, pushing her pasta around in small circles. One hand massages her temple. Her makeup is smudged and her bottom lip trembles as she quietly cries.

The beach is alive. Surfers, walkers, dogs. A couple, late 50's, lean back on the strings of a fabulous red and gold kite. Their faces beam broad toothy smiles at each other. My friend comments on the beautiful kite. They thank him and say they've been doing this once a month for many years. The kite was a wedding present.

She's young and a bit scared. It's Sunday afternoon and she wants the Morning After Pill. The bloke with her is in his forties, temples greying and fit looking. They're both in running gear and joggers. As she starts to answer questions, her voice trembles and she cries, overwhelmed. He quietly says, "I'll leave you to it" and wanders into the store. She's terrified, but okay and calms down; it was her first time. He pays for the medication and buys a dozen condoms too. "Make sure you use these next time, Daughter", he says caringly. "Thanks Dad," she blushes.

As promised, this week saw an attempt on the Razorback. Certainly not my best effort, however, and consequently not enough to break through the Corner of Doom.

I'd be lying if I said I felt fresh on Monday, thanks to a weekend of Cricket and work. Probably not the best state of body or mind to being trying the Razorback, but nonetheless, I had a crack.

I took the opportunity to refine some tactics and get my head in the right place. I nursed myself softly, softly to the shop at the Hunchy Rd turnoff. That's the point when the road climbs up and up at 12%, and the hurt really begins.

Meantime, I noticed two property names on the ascent. The first was an apt description of the scenario "Summer Hills", the second was an inspiration to look out for each time; "NEVERTIRE"

At the shop, I figured that taking it easy had slightly paid off; I felt better than expected, expecially considering I'd ridden a flat fifty earlier in the day. So, in a more positive state of mind,
I divided my goals into micro and macro and pushed the pedals from road-stake to road-stake, setting miniscule 30 metre goals to each corner. Not over-extending myself before the shop is a definite must for a successful attempt.

At the corner of doom, I again fizzled into an anaerobic mess. I'd clawed the last hundred metres to that point and the effort was more than enough to tip me into lactic-land. It felt like being slapped with a cold fish. One positive was the speed of recovery, which was substantially quicker than previous digs.

Last update, I was unsure if the deficit was psychological or physiological, and yesterday's attempt answered the question. Psychologically, I'm all over it. I can push myself until I pop. I can do tactics, and I'm pretty sure I ride smart. Physiologically, my endurance is improving, my hill climbing is much better than a few weeks ago. Today, I smashed my best time on the Palmwoods-Montville climb by two minutes. Unfortunately, when it comes to the sheer gradient of the Razorback I'm not quite strong enough, yet.

Part of me wants to run and hide from this bloody steep hill, to train on 'flatter' rides. I don't think that's going to work. So, I'll give it another crack. Again and again; I'll practice like I play, and hey, if that gets me up, then the challenge will be complete!


The Plan:
1. Keep trying!
2. Start easy, save energy.
3. Get stronger.
4. Be bloody minded.

Two weeks to go.

I know that medicine has hardened me, just a little. It struck me this week during a group ride. The bloke I was chatting with as we hummed through the suburban coast at 35km/h recalled a friend of a friend who'd recently died. She's had a heart attack in her early forties.

Three years ago, it would have really rocked me. I would have thought long and hard, empathy welling inside me, wanting to know the how and why. Thinking how awful, how unfair.

The first thought that jumped into my mind was, "I wonder what the likelihood of an MI is for a 40-something woman?" and visualized a distribution curve. Then, I considered possible risk factors. Then, I thought about the woman's family.

This all happened in a second. Three years ago, I would have thought "Gosh, how tragic!".

It's not that I don't care. It's not that I don't feel. It's just that sometimes, the things that rock a lay-person aren't as raw, as world-changing as they used to be. Evidently, I'm still thinking about this woman. I listened to my riding partner, he talked about the unfolding of events, the death itself, the funeral. Of course I didn't ask anything about risk factors or other medical things; he wasn't telling me the story because he was interested in all that.

He was just telling me; I asked how her kids were coping. I hope they're okay.

I've been thinking about this post for a while; in fact, the idea was sparked one day in June as I strolled down a grey and wind-whipped beach.

On the surf's edge, a pale bronze light flicked the edge of my vision; it was some way up the shore. As I moved closer, I saw it was a tarnished dollar coin, and dusting it off, I pocketed it.

My memory travelled back a few decades to my second year at school. I was a new school, again. I liked this school very much; the teachers were cool. The Principal struck me as old - I'm not sure that he was - wise, genial, but to be feared by a cheeky six-year old.

One lunch hour, a pale bronze light flicked the edge of my vision. I trotted across to where the sparkle had appeared; the base of a tall tree, and saw that there were two coins. A one dollar coin and a two dollar coin, making three dollars. New Zealand had only that year swopped notes for these coins, making the treasure all the newer and more exciting.

I picked them up and looked around for their owner, who was not to be found. I went to the duty teacher and she suggested I give the coins to The Principal, which I dutifully did.

Around the time I finished secondary school, the Principal retired. He'd been in charge of the school for most of its existence, and it was a big send off. At the farwell, the Principal quietly passed an envelope to my Mum. It contained three dollars. And a faded post-it note;

"Capt. Atopic $3 handed in" and the date. I kept the coins at the bottom of my drawer. I was again reminded of the coins when I finished Pharm School and packed up to move out. They stayed with my other primary school treasures. The beach dollar sat on the window sill for months. The idea crawled to a dark corner of my memory, hibernating.

This week, I've moved house again. Everything boxed, schlepped and revealed. Meanwhile, The Principal's coins are stored across the Tasman. Unpacking my desk, I rediscovered the beach coin; and I remembered remembering.

Exams finished Friday, since which time my liver and sleep-cycle has copped an absolute pounding, thanks both to the end of year Cocktails and catching up with a good group of guys to watch the Windies v Australia at the Gabba.

Since exams I've been more than time-poor; I've played Club Cricket, moved house and driven some 600+ kilometres. I was planning on a jaunt up Palmwoods this morning, but even that failed to materialise.

So, a plan - roadmap, if you will - for the next fortnight; Palmwoods once, a long flat ride and a Triathlon on Sunday. Not exactly hill specific riding, thus far. Next week will be almost entirely off the bike, in Sydney. Running some hills each day will be on the cards and some good recovery time, too. Monday 14th will see a fresh attempt at the Razorback.

This is going to be a good, hard graft; 28 days remaining to ride!

I can't tell if Razorback's exposing a physiological or psychological deficit. Obviously, I'll need to ameliorate both to complete the challenge. There's certainly something about the 4km corner; it's the pincher and the popper. A few of the blokes in the Coast Cycle Club reckon the corner had a 35% gradient. Regardless, Razorback's last 1500m doesn't drop below 8%.

Current score (unchanged); Capt. Atopic 0, Razorback 2.

I've previously posted about my dislike of Ibuprofen & Codeine combination products. A few weeks ago met an example of my 'doom and gloom' ministrations, Corey.

Corey is thirty and has an addictive personality type. He's loved and kicked amphetamines, marijuana and benzos. He has been employed fulltime in a mid-level job throughout. He started taking Nurofen Plus(R) two years ago, and just over a year ago first nailed a 24-pack in a day. About January, he stepped up to 96 tablets a day, every day.

It was an eye-opening interview; I've only seen this kind of patient through Pharmacist's eyes. After a few minutes of talking with Corey, I asked a whole raft of questions about how many pharmacies he went to, what his usual 'symptoms' were, why he thought he needed so much and what happened when he was denied supply.

The money was never a factor, he said. It was about 'pain' and 'feeling normal'. He visited over forty pharmacies within a fifty kilometre area. If he got denied, he'd just go aroung the corner, returning to the first pharmacy a few weeks later. Corey said that he was rarely questioned about his use; he got denied or lectured a few times and copped more dirty looks than he'd care to remember. But, he said, without the pain killers he'd be in pain. He felt energised when taking them; during our interview, he expressed a desire to take more.

Corey doesn't have good insight, and I'd be pretty guarded about his prognosis. Why'd he even present to the GP? Five nights as an inpatient with Acute Analgesic Nephropathy and NSAID-induced gastritis.

---

The Australian Prescriber Magazine produced this well-written article article on Drug-induced Kidney Disease.

Most importantly, if you are concerned about your use of NSAIDs or NSAID/opioid combination products, or if you regularly take greater than the maximum recommended dosage, please see your doctor.

The challenge is to ride up The Razorback before 30th December. It's one of the steepest, most brutal hill-climbs on The Coast. Razorback is a 5300m ride at an average of 7.9%. This is the route;The Razorback was my climbing 'trial by fire' several months ago; it scared me off when I unceremoniously popped with a kilometre to go. Admittedly, my technique was awful, gearing atrocious and I was frankly unfit. This week I tried again and despite thousands more kilometres and over a dozen good climbs in the legs, I popped again. At the same corner.

The gauntlet has been laid; Razorback by Dec 30.

I thought I'd blog about the challenge not only to spice things up, but also to keep accountable. I also suspect self-induced suffering could make for interesting reading and some good photos, too. I'll post updates weekly on Wednesdays up until 30th Dec; 40 days left!

Today is exactly two years and one week since I first watched someone die. Actually, I watched two people die within and hour. It was in the cavernous and crowded Emergency Room at Viet Duc University Hospital, Hanoi.

The second man was less than twenty; he was jaundiced, cachexic and was becoming septic. He had metastatic cancer and was a waif. His breathing labored. His family kept vigil as he slowly, steadily slipped away. His eyes darted about the room, fearful, anxious. He looked at the three caucasians in the room and begged his mother and brother to ask us to help. The consultant watchfully guided us to the other side of the room. The man's breathing labored more, then began to slow and ease. His eyes flicked and rolled back and away; an hour later, he died.

Meantime, the first man had been hit by a moto. His trolley rolled into the room's fundus, pushed eerily, airily by a porter unseen. The whole world seemed to stand still. Then the consultant sprang to action, cleared out the myriad of Medical Students and ran the show. I stood next to the column in the centre of the room, out of the way. I couldn't understand any of the rapid, intense Vietnamese orders bouncing off the dirty, sterile walls. The student I'd been helping practice his English was now pressing on the man's chest, sweating in the Hanoi autumn heat. The girls hovered around in their white coats, eager to help. The senior resident again shooed everyone away. I stood there, gaping and dumbfounded as the man's mouth greyed, eyes glazed and froze forever.

The consultant turned to me and said firmly "Chết"; an unblinking stare, a quick shake of the head.

"He is dead."

My classmates and I had been let loose all day; mountain biking, hiking, swimming, the lot. As typical twelve yearolds, we'd ran amuck until well past our bed times. It was my second week at a new school and the entire yeargroup was at an Alpine camp for Orientation.

Being the second 'intermediate' year, there were only a dozen other new boys starting at the school. Mostly we were from other schools around town, except Freddie. Freddie was from Hong Kong and had cried nonstop since the day he'd been dropped off at the school's Boarding House.

The teacher, a man-mountain rugby player and coach known as The Fridge, had his patience slowly burning away with a teary, incommunicative and distressed tweenager. More than once, Freddie had been returned to the Boarding House in the middle of the day as he was so inconcolable.

At the Alpine camp, things hadn't improved much. Freddie had been on a few walks but he was still struggling to come to terms with his new life. Hardly surprising; we were twelve years old.

The first night, Freddie sat, awake and miserable, outside on the fort. The Fridge went and sat with him. They talked about moving and school and that sort of thing. Freddie asked what the white dots in the sky were. The Fridge was genuinely stunned. Freddie had never seen stars before; the light and air pollution meant that for a city-dwelling kid, the stars were a thing of mystery.

Freddie cried. Not from sadness or loss. For mystery and awe. The Fridge went to bed and Freddie sat up until the stars faded with dawn. He didn't cry in class after that night.

__

Earlier this year, my father had his lenses replaced. Not the ones in his glasses, the ones in his eyes. A few weeks later, I was home to visit. On the first night, after a late dinner, as we strolled across the garden he looked up. And kept looking and looking.

Freddie hadn't seen the stars in twelve years of life. Dad wouldn't have seen them properly in the last forty years. He tells me they're sharper and brighter than they used to be.

A few weeks ago, I rode from the Coast to Brisbane with my friend Ice. Ice is a chilled-out guy and certainly can turn the pedals. Like all intrepid bicycle rides, we plotted out route and along the way found a nice place to stop. The 'town' Elimbah, which consists of a servo/fisho/bottle-o and a few caravan trailers. I went inside for chocolate and fluids.

There were two other customers; a kid of about ten and a bogan who passed for twenty. Evidently they knew each other, and when the younger bought a Diet Coke for his mum, the elder harrangued, cajoled and deprecated him for his choice. The faux-hawked bogan bullied him; "You're gonna get Cancer!" he sang, and stated that 'Normal' Coke was better for you. The teenage shop assistants smiled and flirted with the bogan, and the younger left, licking both his wounds and his ice-cream cone.

I paid for my chocolate and hit the road, saddened and more than a little perplexed by the happenings in Elimbah. Ice asked if there was something weird happening in the shop; I retorted that it was a weird area, let's keep movin'.

Cancer is a powerful word. It motivates people, it scares people. It changes how someone looks at the world. Cancer evokes a deep, primal fear of the unknown. Understandably, it's not a word doctors just waft around during a consult, and especially as a med student, you don't say the C-word to patients very often. Timely reassurance is important; there may be few things more comforting than the words; "You don't have cancer." But almost never, especially not as a threat, is the C-word used in a routine consultation.

I'm taken aback by the idea of threatening someone with Cancer because they didn't drink your brand of soft-drink. I know the bogan's was being malicious not dispensing medical advice, and that there's no limit to the kinds of insults people hang on eachother, but I remain surprised that such use of the C-word is a viable term of abuse.

Upon moving to Australia, I lived with a classmate whom I'd known through high-school and uni. In addition to Pharmacy, we both played Hockey, he at much higher levels than I. In fact, Rip was selected a few times in NZ underage squads.

One night after hockey practice, we were talking about a player in the club who, despite having capable basic skills, struck us both as uncoordinated. Rip astutely observed that the guy was 'frantic' on the ball. As sports-watchers will know, a good player seems to have 'time' every possession. This appearance of time, due to their superior skills and composure, may almost reveal their decision-making processes, but their opponents are powerless to act. Think Michael Jordan's clutch plays, Mark Waugh's magnetic slip catching or Dan Carter slicing through a defensive line.

The opposite, of course, occurs too. Not that it's shown on television or other international stages, but there are many, many sportists whom, in addition to poor decision-making, have rubbish skills. When they receive a pass or need to make a tackle, their eyes go big, their heart races and *bang* something happens. Either it's good or abysmal or lucky or sufficient; they've frantically played their part.

After a while, the conversation turned to pharmacy. Several parallels were evident between clinical practice and sport, and the metaphor certainly extends to doctors.

In pharmacy, the composed pharmacist copes well with a store full of people, a line-up of 'scripts, several requests for consults. They remain cool, calm and collected, they prioritise according to time, urgency and staffing factors.

Conversely, the same situation my fluster and frazzle an inexperienced manager. Patients wait too long and customers get shirty; no-one leaves entirely convinced that things are going well.

Confidence in one's skills is imperative; safe in the knowledge that you can handle whatever situation presents itself, from an irate customer, to a very sick patient or even an armed holdup.

Whilst I'm yet to see a completely flustered clinician, I'm sure they exist. Generally, though, docs seem to err on the side of composure, bordering on detachment. This is unsurprising, given the sheer volume of patients most clinicians see; their knowledge and skills are well honed. Moreover, a term or two in acute psychiatry certainly establishes a sort of Zen in most docs.

A good clinician has 'time', even in the most acute situation. They have strong skills, both physical and mental, and can action them systematically and repeatedly under stress. Their goals and approach adjust as the situation warrants, all with the 'big picture' in mind.

Rip, quite rightly, describes good sportspeople as 'clinical'; composed, accurate, consistent, aware. All evident to the keen onlooker, and sensed by teammates and patients alike.

Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground. This is the final in the series. You can read the rest of the series here, here and here.

At least one of the shop assistants at the Training Ground was terrible. I mean, dead set dangerous, unsafe. Now, I've got an optimistic attitude to shop assistants; they're the cornerstone of community pharmacy. This saga is not designed to "beat down" on Pharmacy Assistants, quite the opposite. Indeed, the tale serves as a lesson of How Not to be a Pharmacy Assistant. It is, thankfully, the exception to the many fantastic techs I've worked with, and relied on in Pharmacy.

Shelly was in her early thirties, and had been in pharmacy for three years. Shelly thought she knew it all. She was known say so in her piercing, sing-song baby voice. Instead, however, her practice of pharmacy was based on a few principles;

1. Always use the strongest thing you can think of, every time.
2. Skin means steroids.
3. If you give someone no choice, they will buy it.
4. All customers are infinitely more stupid than Shelly.
5. All pharmacists are a waste of space and glorified babysitters. They don't know anything about 'real' pharmacy.

Of course, these prinicples are all horribly flawed. Two incidents really sparked my concern that, in addition to atrocious customer service, complete with snide remarks about customer's clothing or ethnic background, really began to worry me.

In the first instance, a bloke in his sixties came in for some cold and 'flu medication. Pretty run of the mill, however, before Shelly even thought to ask, the man mentioned he'd had a heart attack and a 3 vessel CABG four weeks earlier.

He used the words "Open heart surgery", and mentioned his crackingly high blood pressure. No worries, says Shelly, reaching for some pseudoephedrine-loaded Codral. Alarm bells are ringing. Luckily, the patient saves his own skin by asking to talk to the pharmacist. Shelly mooches off in a huff after her suggestions a shot down in a ball of "Safe and Appropriate Medication" flames.

Not to be perturbed by a lack of knowledge or practical skills, Shelly goes about treating a young skater for a sore ankle. And by sore, I mean visibly broken. The kid hobbles in and perches on one of the shop's stools, whilst Shelly begins to 'help' him. I was actually surprised that Shelly was even serving this kid, considering her previous comments about skateboarders.

Nonetheless, she fetches him some ibuprofen, saying loudly "That is everything you'll need." At this point, I got 'ballsy' and sat next to the guy. Considering his version of the mechanism of injury, marked bony deformity and swelling of his ankle and inability to walk on it, it was likely broken. He needed to see a doctor. I pointed him in the direction of the nearest Bulk-billing doctor and he and his mate rolled off. Meantime, Shelly had got the message - she didn't want to help the little punk anyway - but she came over and tried to tell me off for 'cutting her lunch'.

"You're just the student," she hissed. I reiterated that the kid's ankle was broken. The boss appeared and told her to 'pull her head in', and for the time being, she did. Later that day he had some stern words and provided remedial education about WHAM, and saliently, when to refer to the Pharmacist. I found out that she was sacked a few months after I returned to Uni. I'm sure she's still working in a pharmacy somewhere.

This week, several of my colleagues and I had a flu-related sick days. Others decided that they'd bust through the snotty nose, sweats and fatigue and pull regular days on their Clinical Rotation.

Later a debate ensued regarding whether, as a med student, it was ethical NOT to take a sick day. My key point was that as students, we're there to learn, not to work. The learning experience is ostensibly a selfish one; we're not necessarily helping the people we see today, we're studying and experiencing in order to help future patients.

For sure, it's important that med students, and particularly doctors (in this time of shortage), not take frivolous sick days because of either self-induced illness or lack of motivation. It is generally seen as a strength in docs who "take one for the team", and work long shifts, irrespective of their physical health.

Whilst the "80-hour work week" debate rages on, with those who survived their 'trial by fire' with fond memories of comradeship and galvanized experience disagreeing with those whose common-sense and desire for work-life balance is branded as 'soft' and shying away from the vocation, I remain undecided on the issue.

One thing I'm more confident of, however, is that it's not appropriate to make sick people sicker for your own 'selfish' needs. Chances are that if you're sick, you're not going to be particularly focused or absorbing all those clinical pearls anyway. And you're putting your patients at risk.

As students, we have responsibilities to our patients of today; hence, when we come down with a cold, the 'flu or some other contagious URTI, we should steer clear of the hospital, the general practice and other clinical settings. We're far from essential employees; things work just fine without us. Summarily, the risks outweigh the benefits. So take that sick day, sit at home, wait it out; your patients will thank you.

Besides, we can't infect out books.

He comes because his wife told them to, or because his boss is sick of that hacking cough.

I sit quietly in the far corner, watching on. Mentally, I tick off the constitutional symptoms, and inspect the patient. I can tell this fella is sick, if not dying. The diagnosis is as obvious as a red light.

The GP's words suddenly dawn on him; "So, you think I've got... cancer?" He's terrified. The patient feels like he's jaywalked in front of Craig Lowndes' Falcon.

It unfolds as sinister, slow-motion poetry. It's fifteen minutes that will change his life.

Usually, the next question is "So, are you going to be just a GP or will you specialise."

Today, though, it was different.

The question was "Are you the nurse?"

Certainly a first for me. Unlike female peers who've doubtless endured the question hundreds of times to this point. Mostly, though, I was surprised that I got asked the question in General Practice. I even had a stethoscope on. Worse, I'd met the bloke before.

He looked confused when I said I was a Training to be a Doctor. As others have mentioned, Medical Student is a confusing term. Especially with all the Students of Natural Medicine and Students of Osteopathic Medicine out there. And, I'll be honest, I'm not the clearest speaker on the planet.

I sometimes hesitate to use the term 'Trainee Doctor'; it implies Intern/RMO too easily for my liking. My preceptor introduces me as the "Senior Medical Student"; I think that fits well in General Practice. It adequately conveys that whilst we're not actually leading the charge with clinical decisions and management planning, our input is educated relatively well respected. It is, after all, important to induce a good sense of knowledge and achievement in students

I pondered all this whilst doing the bloke's wound dressing. There weren't even any wrinkles in the Hypafix. He'll be back on Monday.

The first few times I work with a new shop assistant, I usually give them a bit of a workout. I'm not seeking to exact some 'trial by fire' but it is a kind of challenge.

As I explain to them, when a shop assistant gives advice, it's effectively the pharmacist talking. Also, when a shop assistant recommends a product, or does pretty much anything in a pharmacy, they're acting as a proxy for the pharmacist.

So, when I'm working with new people or training up someone fresh, I'm particularly fastidious when it comes to WWHAMM or WHAT-STOP-GO, or whichever algorithm is en vogue. That whole awkwardness that comes with asking about pregnancy, breastfeeding needs to evaporate pretty quickly.

This means that when you, as a patient, get asked those 'annoying' questions by my fifteen year-old assistant, they're coming from me. Because I want to help you, by making sure the medication is safe and appropriate for your condition and symptoms.

To a point, I expect shop assistants to be pretty cluey, and certainly to think about what they're doing. Some questions will often catch out inexperienced assistants, such as; "What's the strongest painkiller you've got?"

Other, seemingly soft requests, such as; "I need something to sleep." or, "I'd like some St. John's Wort.", will almost always need pharmacist interaction, ditto requests for Pharmacist-only medication.

Unsurprisingly then, an unquestioning assistant is a dangerous assistant. With time, pharmacy assistants pick up on the clues and subtleties of when to ask for help. If there's any doubt, the best thing an assistant can do is take a bit of your time, ask the pharmacist, ensure their advice is both safe and effective.

A much, much worse scenario is lay-person dishing out advice in my store. When I say "my store", it's because whilst I have few issues with a health problem being discussed by the public outside the store, in a pharmacy there's the potential for the advice to sound like it's coming from me. And hence, a there could be confusion over both veracity of advice, or even liability. Seriously, the kind of person who dishes out advice to someone they've never met in the pharmacy queue is likely to be completely wrong; the chances are they're here for advice too!

Next time you're in a busy pharmacy, I'd back the advice of a cluey fifteen year-old over some random. Especially when she's covered by my insurance. Remember, this is not amateur hour; shop assistants are trained to ask the right questions.

Within three seconds of my 3:55am alarm going off, I thought to myself; Is this really what I do for fun?

Coming off a challenging week in General Practice and sociable Friday and Saturday nights, I was heading to the start line of a 100km charity bike ride. In itself, that's not a huge distance, but a 5:00 kick-off and a 45minute ride to the start - in the dark - made for a bleary start to the day.

The ride was fantastic; I met up with Rocky and we headed into the wind. Then the rain came. I hadn't ridden in rain before, and luckily had only a single greasy-road-related unwanted adrenalin rush. Nonetheless, completed the ride including a very pacey last ten kilometers.

Then we headed our separate ways, and I rode across town to the railway station. I was thoroughly ready for a snooze. Upon returning to base I was famished. So, after a bite to eat and a cat-nap, I planned to head back to The Coast.

Ten minutes into the drive, two thoughts cross my mind;

1) I need some caffeine. This is odd, because I'm not big on coffee for anything other than a twice weekly social tilt. Nonetheless, I had the pangs.

2) I have hunger pangs. Tummy grumbling, dry mouth, gotta have chocolate and carbs and sweetness.

The Service Centre provided delicious doughnuts and energy drinks, and I wolfed them down. I dead-set smashed them back, and in pretty big amounts. I'm talking half a dozen doughnuts and two cans of energy drink badness. Yep, it was a total post-exercise binge. It was sweet. On the road again.

Quarter of an hour later, I'm heavy headed. My mouth is dry. Face flushed and thinking about sleep. There's an hour left to drive. I need a sleep.

I pull off the highway, heart racing in a mix of caffeine, adrenaline and pure pure glucose.

Parked by the sea, I edge the windows open and suck back some fresh air.

I feel nauseous and sleepy. The sickly sugar is pounding my temples. I set an alarm and float into sleep.

A binge-induced, post-prandial, parasympathetic overloaded state of zombiedom.

I wake up dry and flushed, chew down enough water to actually whet my lips unaided, eat some mints and fire the aircon up to full. I drive home, charging. Still nauseous, of course, but alert and focused.

As of tonight, I'm swearing off doughnuts.


.

Thank heavens for the deep end.

Earlier this week, I was sitting in a consulting room having a yarn to an old duck about her poorly controlled diabets and the phone rings with an internal page. It's the practice nurse with twenty-five years experience;

"Capt. A, I've got a difficult bleeder in the procedure room. Could you please come and do a venepuncture."

Gulp. "Sure, I'll be there in 3 minutes."

I wind it up with the duck, and through I trot. The patient looks pale and nauseated, not suprising considering they're massively immunosuppressed. He's also got about six visible spot bandaids in popular places for taking bloods.

Tourniquet, wipe, anchor, "sharp scratch". Two tubes, no worries. Not bad for the first time in five months.

GP's been a bit like that, thus far; much of the counselling and diagnostic paradigms echo that part of the Rural rotation. Rolling into the groove of the fifteen minute consult. Even the odd emergency or minor procedure. Someone experienced watching your back.

It feels good to be back; paddling hard, getting stronger, a bit of confidence, still bobbing about in the deep end with a lifeguard on duty.

The spring and summer have begun to unfold on The Coast, with planning for 2010 well under way.

In the annual (perhaps monthly) debacle of mal-administration, the cohort has been allocated to Clinical Schools for the final year. Substantially fewer people have been "shafted" as a whole but, as The Coast was vastly oversubscribed, quite a few of my friends have been spread across Queensland. Luckily, the SOM has assigned me to The Coast again for 2010.

The reduced time pressures of the last few months have allowed me actually get involved in the place where I live. Now, in addition to working several nights a week, I spend up to five hour periods outside, either sitting (on my road bike) or standing (on a cricket field).

It's about this time of the post that I prattle on about work/life/study balance, but honestly, the last week's been holiday, so there's been little study. There has, however, been ample opportunity to do all that goal planning and reassessment for the next six months.

There's one rota left this year, General Practice. The summer promises a good chance to travel, exercise and recharge before diving head-first into O&G and then Paeds as my first two rotations. My elective will likely include some more overseas travel, and then the specialties run to the end. Just like that!

The holiday has served as a chance to glance up from the books and assess the path ahead; It's very exciting. Being Saturday, my week's holiday is almost over; General Practice rotation begins on Monday. I can't wait!

Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground. You can read the rest of the series here, and here.

One of the pharmacists at the Training Ground wasn't interested in his job. Not at all. An ideal shift, for him, would be involve a technician to do all the dispensing. That way, all he had to do was check the 'script before it went out. And read the newspaper.

He read the Sydney Morning Herald, in its entirety, each and every shift. Quite an impressive feat. And potentially disastrous.

The Newspaper Pharmacist (NP) prioritised reading above everything except checking prescriptions, and in doing so, compromised his patients. He didn't counsel on new medications. He didn't give opinions regarding the most appropriated Pharmacist-prescribed medicines. He left the shop assistants to fend for themselves. He was thrilled that I could dispense, albiet at a lethargic pace.

The NP was a good bloke; he was intelligent and had wide ranging and interesting views on the world. Unsuprisingly, he was well informed on the state of the world, and we had discussions about everything from Casey Martin in the USPGA tour, to unfolding events in Israel, to the state of the Health system in Australia, New Zealand, the UK and the US. I became a better world citizen from my chats with NP.

It helped my pharmacy, too. Every time I worked with NP I would be thinking "He needs to talk to this patient." Or, "I don't think that's the right stuff." All this was sharpened by my idealistic student way of thinking. I was horrified at the lack of interest the NP gave to his work, more so given the poor quality of shop assistant (more on that next time).

From a tangible point of view, NP wasn't doing anything wrong. It was NP's failure to act, counsel and frankly, to care, that left me gobsmacked. By the end of the Summer, I'd firmly resolved never to be a newspaper pharmacist.

This was the consultant's opening gambit in a tutorial about dementia. We went on to discuss this idea and noted characteristic observations of an elderly dementing driver at an intersection,and the differences compared inexperienced drivers.

Younger drivers usually have superior reaction times, their mental processing can usually identify risks. However, inexperienced drivers may respond somewhat inappropriately to the perceived risk, resulting in "close calls" and situations that could well be described as a "lack of judgment".

A kid getting their license for the first time is excited; they feel great, and are often lauded by their peers and parents alike. They have achieved a new level of independence, and are becoming a fully functioning adult.

Conversely, dementing drivers have markedly slowed reaction times, and their mental processing is overwhelmed by the mass of information. Their inability to integrate large amounts of complex information in a very short space of time, and act accordingly, is the crux of the problem. The medical term is "executive function"; in dementia it is compromised.

Often though, the demented driver has some coping mechanisms in place. They may hesitate before selecting a gap, may stay close to home and avoid highways. Taking a license away from this person will leave them trapped and house-bound. They may feel demeaned and wronged, because they've never had a crash in their life. Their independence will be curtailed, and their outlook on their life may suffer.

Additionally, driving delirious or drunk is a bit like practicing medicine drunk; you put others at huge risk unnecessarily due to the short-term compromise in your executive functioning. Simply put, if you drink and drive, you're a bloody idiot.

These principles seem to echo into medicine;

We celebrate getting our license, we don't work or drive drunk and we're aware that as we get older, whilst our coping mechanisms and experience grow sharper, at the end of our careers our processing skills and executive function may diminish.

Then what? Do we continue to practice? Do we wait for the proverbial 'tap on the shoulder' from authorities? Or do we wait for an ambulance to pick up the pieces of our accident?

Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground. You can read the full series introduction here.

At the Training Ground, there were four full-time shop assistants, and I, as a student, slotted into the fifth spot. Four would work each day, with one opening at 6am and the rest trickling in before 8am. The four girls, between them, had established that the 'opener' would make the pharmacist breakfast each day.

This was a pretty sweet gig for the boss as the 'script trade was rarely overly intense, and the assistants, in addition to the usual order and stock managment, cleaned the shop from top to bottom each day, removing entire bags of breakdust.

On my first opening shift, I blearily arrived at the appointed 5:45 am and helped open the store. As rush hour began to subside, I asked Syd what he'd like for breakfast.

Syd laughs and says to me,

"Mate, you don't have to make me breakfast. And they don't either. Always remember that. Making meals or fetching food is something that's outside your assistant's job description, and you should never expect it."

Meantime Lillian, the older and more assertive of the team, has typically asserted herself, and whipped up the usual peppered tomatoes on rice-crackers.

Syd elbows me gently in the side and in a low whisper says,

"Remember, if they're even offering you food, that's a really good sign... Unless it's poisoned."

Some summers ago, I was lucky enough to work as a student at an interesting Pharmacy in Sydney. The pharmacy was particularly eye-opening for two reasons; the staff and the trains. It was before I graduated, and proved an important experience, with some vital lessons in staffing and a solid Training Ground.

The store was located in one of Australia's busiest station, a meagre 40 metres from the barriers. As a result, the shop was endlessly covered in a layer of brakedust. There was an open-style shopfront and no air-conditioning, so stale, rancid summer air wafted at the behest of the lazy ceiling fans. These too, were coated with an inch in black on all surfaces, and at their worst resembled startled bats, flying in circles.

The dispensary, too, was choked thick with black dust. A key job of the pharmacist or assistant was to wipe every item, not only so the label would stick better, but so the box could actually be read and checked!

The pharmacy was staffed by four assistants, myself and the pharmacist owner. In the afternoons, the pharmacist would be relieved a few afternoons a week by one of this two pharmacist mates.

The owner, Syd, (and consequently, his mates) was in his mid sixties. He was, at that time, my archetypal pharmacist; wise, banterous, compassionate and unflappable.

I also learned some really good skills from several of the Pharmacists who worked there, especially when it came to staff management. The lessons I learned were partly though necessity, partly through dumb luck but mostly from kind and honest teaching. This series looks at some of the lessons from the Training Ground.

I'm well and truly into the thick of Psyche Rotation, and true to my word, I'll not be bringing you any patient stories.

All in all, I've found psychiatry a potentially overwhelming area; it's not that the theory is gargantuan or the hours are terrifying or even that it's diagnostically mind-boggling.

The challenge, I feel, is that, for each and every patient under the Specialist Psychiatry teams, their issues pervade through every single aspect of their lives. There's no aspect that seems to escape the ravages of severe mental illness;

Physical Health
Interpersonal relationships
Education
Sociability
Sense of self
Money management
and more.

It all gets absolutely totaled. And it's all such a synergistic failure. Without most aspects of a person's life functioning, they're so vulnerable to falling, as my friend James would say, in a screaming heap.

I understand the management principles and theories for vulnerable patients, and I can see these being applied relatively consistently to a variety of situations. I, like the majority of staff, have great, realistic, hope for the patients, their management plans and their prospects. It's so frustrating when one of, say, fifteen aspects of a plan doesn't work the way it should and the patient's back to square one.

It's astonishingly precarious. And, I guess, when you apply that idea to patients in moderate and milder situations, that any one event or stressor can tip them into a severely dysfunctional state, it's pretty worrisome.

So, in a nutshell, that's my experience in psychiatry; overwhelmingly precarious. Oh, and one of the Fat Man's laws;

4. THE PATIENT IS THE ONE WITH THE DISEASE.

I'm not a violent man, but sometimes I really have the urge to yell at people. On this day, I kept it under control. Barely.

She was getting in my face. If that's possible to do behind an inch-thick glass screen.

Man, was I tired. The flight had been at least ten hours, and Singapore Airlines aren't really built for 6 foot four Barbudans who are used to lounging about. Well, not in economy class, at least. Still, the food had been exceptional; a welcome relief from the three solid weeks of curries I'd endured through Goa and Tamil Nadu.

But now I'm standing at customs, trying to get home for a sleep, and this woman asks me what my business is.

"I been on holiday."

She looks me up and down, looks at my well-worn passport. I'm proud of it, y'know. For a start, it's a Barbudan passport, even though I'm an Aussie. Plus, there's about twenty five, maybe thirty countries in there. Some weird ones too, like when I went to visit my mate Nas in Botswana.

Anyway, the uniform behind the glass starts leafing through my stuff pretty intently. And she says, matter-of-factly,

"And how did you get the money to pay for your trip?"

Who asks that? Since when do customs care how punters bankroll their holiday. That really pissed me off. She's asking me because I look different. I got smart;

"I stole it of course."

And the cow calls her boss. He waddles over in his grey knit jumper and starts giving me a dressing down. He asked what I'd said to the customs woman to get him over there. It told him that it wasn't cool to ask where someone got their money. So he asked me.

"And where did you get the money?" What an arsehole.

I told him.

I'm a cabbie. Y'know. I work hard for my money. I don't mean this nine to five white collar crap. I'm talking hundred hour weeks, sometimes a hundred and ten. I drive for four different blokes, at all hours of the night. I work my ring off. And now this cow with a sprayed-on uniform asks where I get the money to travel. Maybe I'm just one of those guy who attracts attention for the wrong reasons.

He keeps asking me questions, and making me repeat myself. He says he can't understand my accent. How dumb is that. I mean, I can only speak english.

Eventually, they let me go.

We all knew that she wouldn't have asked if I was white.

It wasn't mine. Of course.

It was a cold Melbourne day. I'd been waiting for the St Kilda tram for half an hour. Or thereabouts. My memory seems to whirr and grind more than it used to.

Eventually, whirring and grinding up the tracks came the tram. Ding! It breezed to a halt, and I climbed on.

I think the young man behind me was being impatient, but I took my time. Stick. Steady. Left foot. Right foot. I tried to get to my seat before the tram took off. Sometimes I fall over if the tram moves suddenly.

This time, it didn't and I went to a seat near the front with a "Reserved for the elderly" logo. I sat down. The tram still hadn't lurched forward, and I looked around.

There were few people on board. Not surprising for a Tuesday lunchtime, I supposed. There was a young mother with her swaddled progeny sitting two seats down. A couple of Asian students were sitting close to each other, talking quietly and using their mobile phones.

Near the back, three youths with heavy Lebanese accents were energetically reliving their football game from the previous night, their grainy, jubilant voices echoing around the cabin like the corridors at the G. Nearer the front, one of the local homeless men sat with his collars pulled up around his ears. He was shivering, and the newspaper insulating his torso poked out around his neck as he moved. He talked to someone unseen.

The tram still hadn't moved, and I looked around to see the driver gesturing at me animatedly. He shook his head and rolled his eyes. I didn't hear very well anymore. It seemed like he'd been trying to get my attention for a while. He said something loudly about there being a "Good kid trying to help."

The young man was standing just next to me. His clothing was too small; a white t-shirt clinging to his sinewy shoulders like a drowned rat. He had white headphones jammed into his ears, cord twisting and trailing into his black jeans pocket. A black, red and white chequered belt saved his sparse pants plummeting to the depths of his ankles. The arm, his left, replete with angel tattoos reached out with a bag.

"You left this on the street."

I looked at him, confused.

I did? Oh. How embarrassing. I do that sometimes. I get forgetful. His tattooed knuckles and leather-bound wrist awkwardly, delicately, put the bag on my right knee.

The bag was brown, hessian. It was squared and had two handles. Like those new fangled green things that Coles and Woolies try to sell us. The hessian was moulting a bit.


The tram trundled off forward. I looked up to the mirror, the Arabic driver still shaking his head in frustration.

The bag was quite heavy; I couldn't remember what I'd put into it. I couldn't remember if it was my bag, actually. The heaviness felt like some cans of food. I like to make spaghetti, so I thought maybe I'd picked up some tomatoes at the supermarket.

I tried to put my hand inside the bag, but the opening is zipped closed. I fumbled with the zip. I was unsure; I didn't think the bag was mine. Why would they give it to me if it wasn't mine? My old hands don't open zips very well. Maybe someone kindly closed it for me. I must have forgotten about it. My memory had been going with age. I felt perplexed.

The creaking of the breaks whispered through my hearing aid like a ghostly shriek as the tram made a stop. We were still for a few seconds, and a young girl alighted. She had long black hair, porcelain skin and a forlorn look about her. Her midnight lips were pierced by a silver ring, her eyes surrounded by inky colours. She, too, had white headphones and angel tattoos. She moped to the back of the tram as it moved, and took out her mobile phone.

The bag was still on my knee. It felt cold through the hessian. I shoved my smallest finger into the small gap near the zipper's end and wriggled it. It moved open a few inches, but I still couldn't glimpse the contents.

I squeezed my hand into the bag. Maybe there was a small can of baked beans in there too. I liked baked beans. If it was a small one I could give it to the homeless man. It didn't feel like there was anything more than maybe three cans inside. Perhaps two big ones and a small one.

I'd been shopping earlier, but I couldn't remember what I had bought. I went to the newsagent for the paper, still under my arm. I wracked my mind for which cans I'd paid for. Still, it was nice for the driver to wait for the young man to get my bag for me. The young man was sitting a few seats down from me on the other side of the tram, nodding his head and white headphones.

I grasped the smaller can, it felt odd. It was small for a can of food. Still, it was cold and metallic and has a ridge at one end. Perhaps it was a can of beer. I couldn't think why I'd by a beer, except to give to someone. I turned the can on its side in my hand, so my thumb could hold it, just so. Then, I pulled it out of the bag.

Something beeped. Everything hot. Everything white. Someone, a scream. Everything red. Everything cold. Silence.

It wasn't my bag.

.

There's an old joke about the mechanic and the surgeon, in which the mechanic mentions that he does the same job and the surgeon says "Try doing that with the engine running."

Patients often compare their bodies to motor vehicles, an idea I've recently developed it to point out how stubborn people are when it comes to seeing their GP or generally seeking Medical advice.

It's that point of a consult when the Pharmacist asks if the patient has seen their doctor... or even thought about it. I'm going to put a mechanic's spin on each of the four usual responses;

1. It's too expensive.

A visit to the doctor, during the week is going to cost you a maximum of thirty bucks as a gap payment. Many people use bulk-billing Medical Centres. You remember, the free ones.

A service for your car? That's $220, without blinking. Money well spent?

2. I have to wait for too long, it's inconvenient

Sure, medical centres and emergency departments can make you wait. Sometimes, you might be an hour behind your scheduled appointment, other times you'll sit in the ED waiting room for six hours, or more.

Last time you got your car serviced, chances are, you changed your entire day around. You had someone meet you at the mechanic's to give you a ride to work, or you shelled out for a cab. All that will add up to at least an hour out of your day. Worse, though, think about the last time you broke down. When your engine started smoking or the radiator blew; did roadside assistance get there in half an hour? How about two hours? And the whole mess, took what, about five hours...?

3. I can't get an appointment.

It's true, doctors are busy; the good ones seem to have appointments booked for at least the next three weeks.

I'd also warrant that you're willing to wait that period of time to book your car in. Why is that?

4. By the time I see a doc, I'll feel better. I don't want to go when I'm healthy.

I recently met a bloke who hadn't seen a doctor in forty years. He was fifty five. He'd had some very worrying symptoms for the last three months, and was just happy to push on.

Pretty sure that he would have his car looked if the engine rattled or the brakes creaked for that length of time, even if they sounded fine before he got it into the shop.

What's more, the motorists just love getting their cars serviced at 10,000km, 20,000km and so on until, at 90,000km, when the car can still be sold, the ad reads "Full service history."

-

In short, people will devote time, money and energy into getting their pride and joy seen by a good mechanic. But for some reason, they don't devote the same amount of energy into looking after themselves. Please, don't wait for the engine to blow. Go and see your doctor.

Despite a slow start, I'm enjoying Psyche Rota more than I thought I would. I haven't posted much about it, because although I've a penchant for good tales, humourous anecdotes and fresh perspectives, I'm not going to be posting any Psychiatric patient related stories.

I just don't think it's cool; Psyche patients are a particularly vulnerable population, and mashing together individual delusions for the purpose of a story would, I feel, over-emphasise 'wackiness' without either giving due creedence to their serious disability, or helping to reduce the seemingly insurmountable social stigma that comes with chronic mental illness.

I will admit I've heard patients describe delusions and hallucinations that are, on the surface, funny. I'm ashamed to say that the first time I listened to a patient report some of their delusions I couldn't maintain my poker face. At least, not for the first thirty seconds. As the patient continued, a feeling of deep sadness washed over me.

The thoughts were this person's reality.

A student arrives at the scene of a car crash. It looks as though the crash ahs happened a few minutes ago, as there are small crowds around the occupants of each of the cars. There's no smoke, but one person is lying on the ground, looking unwell-ish.

The student pulls out of the line of traffic, screeches to a halt and gallops over to take charge...

"Nobody move him! I'm a MEDICAL STUDENT!"

There's one person knelt by the injured person's head. Let's call him Frank. Frank is holding the patients head straight. The Med Student addresses him with a tommy-gun barrarge of questions;

Did you see what happened?
Have you called the ambos?
Did you move him?
Is he breathing?
Does he have a history of seizures?
Has he been talking?
What is he allergic to?
Is he bleeding from anywhere that we can't see?
Is there family around?
Where are the other passengers?
What's the formula for the area of a circle?
Does he have a fever?
Is anyone carrying a defibrillator?
What's his pulse?

The student frantically begins to examine as much of the patient as possible, without moving him or touching him, making Hmms and Ahs at each graze or scrape.

To which Frank responds, calmly. He was in the care three behind the accident, and saw everything happen. The patient is breathing by themself. As the ambulance's sirens come into earshot over the hill, he quickly answers all the relevant questions, and mentions that he suspects the patient is on drugs.

The Medical Student is somewhat surprised by this last statement. He looks up sharply at Frank and says, "That seems a bit harsh. Just because he pranged into the car in front doesn't mean he's on drugs."

Frank shrugs as the ambos roll up and start triage. The patient on the ground is being loaded up, and Frank explains to the Ambos what happened, how the scene has been treated and managed

The Ambos listen intently, and thank Frank for his help, before heading off "Seeya later, Frank

Meantime, the Medical Student is confused, and standing around with his hands in his pockets. Talking to the crowd, trying to give them advice about their problems and what to do next. Evidently, not used to being utterly useless.

As Frank goes walks to his car, the student jogs over and says, "So, are you a nurse or something? 'coz you did really well to assess that guy and call the ambos."

Frank mentions he's an intensivist at the local Tertiary Metropolitan Hospital.

Medical Students don't often talk about failure.

They talk about the idea of failing, the fear of failure or, in hushed, disdainful tones at the front of lecture theatres, about someone who didn't pass. Some medical students have never flunked anything in their lives. They are wholly unfamiliar with the bitter taste, the anguished self-reflection or the smell of raw failure.

Earlier this year, I failed a rotation.

Shock.
I eagerly looked up my marks and was hit by a bus. I hadn't just failed one component, I'd failed a bunch. I felt sick to the stomach. I wanted to call someone; to talk to someone, but I was on rural and thoroughly isolated. Not all bad, I thought, I can wallow in shame and self doubt for a few days. Which I did.

I sat in the house at SQuIRT in shock. I went over each exam in my head. I clearly remembered each patient, what they looked like, their names, their differentials.

Analysis.
I recalled the facts of the long case; I'd presented it pretty weakly, and the examiners hammered me for questions. Of this I was least confident, I mean, I knew the patient had Congestive Heart failure, but, well, I'd made a hash of the presentation.

I knew I'd made a Zebra diagnosis for one patient which was wrong; I'd had the actual diagnosis in my list of differentials. The presentation was a deforming polyarthropathy of the hands.

The last chap had a pleural effusion. I skipped vocal resonance, but asked for a CXR when I got heard decreased breath sounds, and noted the opacity's menisceal appearance in the appropriate hemithorax.

Fear.
I hadn't felt particularly confident at the time; they were clinical exams with Professors and I was intimidated and nervous. Really nervous. Frankly, I thought that I'd done poorly, but not this poorly. And not in all of the exams. I could recall several exams I'd sat in the past where I'd had that 'just enough to scrape through' feeling, and I'd had that same feeling afterwards.

I'd never failed anything before. I felt empty. And dumb. And scared. My underlying sense of academic invincibility had been smashed over my head like sugar-glass bottle in a kung-fu movie. Dazed. Scared.

Frustration.
I called my parents and vented frustration; I was still too proud to admit that I'd made a hash of things. I didn't want to do eight more weeks! I wanted to graduate on time, with my mates. I sure as hell didn't want to go through the 'special application process' for intern jobs, and start the year late. I am not the person who fails! I don't fail.

Self doubt.
But I had. And not in a small way. Self-doubt nibbled at my toes, then ankles and wrapped around my knees. I felt like medicine could be tackle me to the ground at any second. I was, of course, still seeing patients out at SQuIRT. I started asking basic questions that I knew the answer to. I wanted to know that I had some clinical acumen. Late at night I'd stare at the roof, thinking about becoming a doctor. Was I smart enough? Did I have the skills?

Determination.
About 2am, something clicked. I am smart enough. I do have the skills. Of course they're not perfect. This is a learning curve. I need to know more. I will learn more. I thought long and hard about what I'd done wrong, and what I'd do differently. I had a bloody long list. I will be a doctor, and I will be a bloody good one. I will learn from this setback and retake my medicine.

Frustration, again.
The next morning, I rang my clinical school, and arranged to meet with the Prof. I wanted feedback so I could see exactly where I'd gone wrong. I had some ideas, but I needed confirmation and some direction. He was honest, brutally honest. We discussed both my clinical and professional shortcomings. He reassured me that I'd be able to stay at the Coast when I resat the rotation. We talked through some styles of clinical thinking, and he reassured me that my rationale was sound, that I was safe. There was still a nagging, frustrating feeling in the back of my brain. It wouldn't go away. I wanted to have passed, and couldn't change it. Grrrr!

Relief.
Back out Rural, I bided my time, I had a list of deficiencies in my knowledge that I felt were too glaring to be ignored. I corrected and ameliorated the obvious holes I'd established, and focused on the exam block. At the start of the subsequent rotation, I got an email from the SOM. They'd done an audit, and they'd goofed. Turned out I'd passed everything but the long case, barely. I didn't have to repeat the rotation, provided I passed a Supplementary exam. It was in six weeks' time. I felt back in the game, barely. I wasn't drowning, but I felt a swimmable ten kilometres from shore.

Determination, again.
I wrote down my long list and began to study; I wanted a structured approach. I put together a plan. I had a timetable. I planned to see patients. I would join in remedial classes. I asked for help from previous clinical mentors. I read and read. I consolidated. I did a practice exam with the Prof. He gave me a solid pass, with some pointers and tips. I was studying for two rotations at once, and by jove, I was going to bust my chops to past that supp'. I'd been given a chance, and with knowledge, practice and determination, I'd take it.

Self doubt, again.
I sat the exam. It went better than the first time. I was less intimidated. I was methodical. Two aspects in particular I was unhappy with; one of which was time management. I fluffed away my post-interview planning time, and my structure suffered. After the exam was finished, the markers casually requested I attend for feedback a few days later. I blanched. I wasn't sure what to think. Had I completely blown it? I'd constructed a solid list of differentials, and was able to discuss the key pathologies at play. I felt like I knew my stuff, that I had a well-rounded plan for the patient and a good grasp of their situation. Oh no. This was starting to feel bad. I had a sleepless night. Or two. Self-doubt was back. I considered that I might have failed. Seriously considered.

Relief, of a sort.
I showed up for the feedback session prepared to discuss, and learn. I'd rationalised that if I had to re-sit the entire rotation, I'd lost only pride, and gained the chance to learn again. I passed.

The relief wasn't that total, complete weight-off-shoulders feeling that usually comes with passing "final" exams. It was partial; I had achieved the mark, I'd learned much about myself in the process. This rotation wasn't a final anything; it was a checkpoint. Amongst else, I learned to be more systematic and logical. The lessons are still raw.

I still get whiffs of the smell of failure. I'm not intimate with the scent, and nor do I want to be. Until a few weeks ago, I couldn't have told you what it was.

I've heard flagrantly ridiculous stories about Medical Students doing and saying silly things. Sure, everyone does silly things, but these ones are all a result of a student's inflated self-perception and their lack of humility. Or perhaps plain arrogance. This is the second in a series of three. (You can find the first one here.)

A girl in the year ahead of me, Sonya, related the following incident;

Sonya was out on the town in Brisbane, having a big Saturday night along with her good friend and classmate. They wandered to the bar for a drink and got talking to a good looking young chap. Tall, clean cut, big smile and nice eyes. Sonya is most clear about these features.

He was a Medical Student. A charming one, initially, and he regaled them with stories of just how hard medical school really is, and the dedication required to become a doctor. He was in first year, and the second semester had just begun. Nonetheless, the lad was charming.

It's just that he didn't ask anything about the women he was 'chatting up'. Well, not for a while. He was, however, very emphatic about discussing the joys and rigors of Medical School.

The conversation continued for a good ten minutes, and the chap eventually asked what the girls did for a living. They informed him, good naturedly, that they were several years ahead, in the same programme.

He recoiled in disbelief. "No you're not." he said, "That's bullsh1t!".

The girls gently assured him that they were, indeed, at the same university, in the same course. He didn't take it well at all. His body-language changed, the look in his eye went from 'dreamy and flirtatious' to panicked and floundering. He'd said some quite arrogant things, and was now feeling a pinch of humility. He had to prove himself. He said;

"If you're in medical school then, then, then... tell me about the bilirubin pathway."

The girls looked at each other with surprise. They smiled politely, and began to leave. Sonya swears she heard the young man expounding his knowledge of stercobilin, conjugation and the like as they hurried past.

In her own words, she was just "Having a moment"; an insignificant yet highly embarassing lapse of concentration, one of those Rabbit in the Headlight moments;

Deep in sonorous conversation with her peers, Alacoque was unwittingly just a minute or two late for the morning's meeting. She wandered into the auditorium and, finding it to be quite dark inside, unhesitatingly flicked the lights on;

The radiologist presenting the case halted, mid-sentence, as the image behind him disappeared.

Fifteen consultants and their respective teams turn and stare at Alacoque. Some are squinting, but most can clearly see her outline at the back of the theatre.

She stands alone. Guiltily, her hand lingers by the switch, her notepad over her open mouth, agog with surprise, eyes filled with terror.

An eternity passes. Someone clears their throat.

She blanches, exclaims "Sh1t! Sorry!" several decibles louder than her previous chat, and hastily exits.

Without turning off the lights.

An awkward pause ensues as the consultants and junior medics giggle amongst themselves. After a few seconds, the radiologist runs to the switch at the top of the auditorium, turns the lights off and resumes his presentation

Alacoque, having regained some colour in her cheeks, was, of course, gently ribbed by her team for the duration of the morning rounds; She is recovering, gracefully.

I've heard flagrantly ridiculous stories about Medical Students doing and saying silly things. Sure, everyone does silly things, but these ones are all a result of a student's inflated self-perception and their lack of humility. Or perhaps plain arrogance. This is the first in a series of three.

A good friend recently relayed to me the following story;

We were at this ball, it was a ball for all Victorian Medical students, and a bunch of us Deakin-folk had gone along to enjoy ourselves. The blokes among who had suits wore them, the girls dressed up nicely, and we caught the buses there expecting a good time. We did indeed have a pleasant evening, soured by only one nefarious incident.

Bob's in his early thirties, and was being his usual friendly self, engaging new and different people in conversation. He found himself having a chat with four immaculately groomed seventeen year-olds, in what were visibly expensive tuxedos. They mentioned that they were in their first year of medical school, how fantastic it was, how smart they are and several other arrogant missives.

The clincher was the point of the conversation where they took the time to stop focusing on themselves, and asked which Med School Bob was at.

He replied "Deakin" and they laughed.

Bob, quick as anything, says, "I wouldn't laugh if I was you; Deakin's a four year programme, and yours is six. I hope, for your sake, you're not the intern on my service in six years time. Think about it, chumps."

And he walked off. The tuxedos stood there looking dumb. Until they remembered how awesome they were and went off to find some chicks.

The Yellow Jersey, prize for the 'General Classification' is undoubtedly the most coveted in cycling. This is the best of the best; team leader, hill climber, accelerator, tactician. The pre-race contenders this year included the resurgent Lance Armstrong, Aussie Cadel Evans, youngster Andy Schlek and the eventual winner, Alberto Contador. These posts are groupe du maillot jaune;

Mudphudder is an intern and, like reaching the Yellow Jersey, it's all about pushing limits, where "each day things are made a little tougher than the previous day just to see if that’s what pushes me over the edge." Raw stuff.

At the forefront of current healthcare discussion is President Obama's public health plan. Mother Jones, RN weighs in from a nurse's perspective.

Leslie at Getting Closer to Myself considers a new anti-Lupus drug from the patient perspective, with some healthy skepticism in a very well written and rational post.

Doc Gurley interviews the British-born award-winning novelist and historian, Jacqueline Winspear, in a vid-post honouring the death of two men - the last WWI British vets, Henry Allingham and Harry Patch.

The mountains, for all but a few, spell pain. It is where the winners and losers of the Tour are decided, and the Polka Dot jersey is awarded to he who dances up the Cols fastest and most consistently. 2009 has seen Italian Franco Pellizotti take control of the Mountains, first winning the polka dot jersey in the 13th stage, and he hasn't let it out of his grip since;

How to Cope with Pain blog examines some of the evidence for accupuncture as analgesia. It may be useful for some types of pain, but probably not for the wrecked cyclists.

Canadian Medicine News' Sam Solomon reports on a recent medico-legal decision that could have interesting implications regarding non-emergency mid-air care.

Louise at Colorado Health Insurance Insider posts about the importance of joint responsibility in healthcare. You can't be pushed up a mountain, nor can patients summit unassisted.

Sprinters' Jersey
Big strong blokes, well adept at picking a point and driving it home, at speeds of up to 65km/h on the flat! Aussie Brad McEwan is a three time Green Jersey winner, claiming the sprinter's title in 2002, 2004 and 2006. This year has been a battle royale between Brit Mark Cavendish and Thor Hushovd of Norway;

Paul S. Auerbach at Wilderness Medicine shares the result of repeated toenail trauma.

Over at Health Business Blog, David ponders; Less is More. He thinks.

Barbara Kivowitz' post at In Sickness and In Health sights a recent study on Caretaker Stress.

This year's tour has not revealed any new drug dopers, but 'Gear'-related controversy is never too far away from the Tour. Last year, Riccardo Ricco freakishly broke away from the lead group several times, winning two stages before being disqualified for using CERA, a synthetic form of erythropoetin. French Customs even searched some of this year's team support cars at border crossings!

Dr Shock considers the Unintentional Consequences of FDA Black Box warnings on SSRIs.

Unintentional consequences certainly go hand in hand with blood doping... hypercoagulability, anyone?

Medical marijuana has been a hot topi recently at EverythingHealth; Toni Brayer posts about the services offered in California.

At Florencedotcom, Barb discusses recent politics in California, and notes wisely that "equating occasional long reaches down a dark foxhole with 'patient safety' is a huge disservice". Oh, and that California is full of bad actors.

Crash!
Sometimes things just go badly; on the 16th Stage of this year's Tour, Jens Voigt crashed whilst descending at around 75km/h. He was unconscious for several minutes, and was treated at Grenoble Hospital.

At Listed as Probable, this compilation of incidents fits this category perfectly, on a light note.

Bongi posts about foreign gratitude when an ill-informed international phone call querying his care.

Sometimes it's actually safer to apologise for your part in the crash, as Apologizing for errors halves malpractice suits, according to ACPHospitalist.

Team directeurs

The Directors Sportif are the master tacticians of the tour. They plot and plan and map the future of their team's race, emphasising individual rider's strengths whilst achieving the best overall result for the team. Much like the authors and commentators of health policy;

Medicine and Technology's Dr Joseph Kim considers that Healthcare Reform may push doctors away from clinical medicine.

Kim over at Emergiblog recently attended the BlogHer 2009 conference, and she relays a session she attended with Valerie Jarrett, a Senior White House Advisor.

HealthBlawg covers a recent Conference he attended in NYC; Social Communications & Healthcare. Dave Harlow describes it as "a lively event with an energized crowd."

Le Peleton
No summary of le Tour would be complete without a mention of the peleton. French for 'platoon', these riders are the guts of the Tour. It's amongst the peleton the domestiques ply their trade, climbers hide in the sprints, sprinters attempt the climbs and the Grand show that is the Tour unfolds!

Grupetto
The grupetto or autobus is a group of sprinters who are poor climbers. They work together as a bunch to survive the treacherous passes in the Alps and Pyrenees. Traditionally, the last man in the tour is known as the lantern rouge, and until 1989, the rider wore an actual red light! More often than not, the grupetto make it all the way to Paris...