Empowerment and Passion

So, it's the end of the first week of Internal Medicine. I'm looking forward to a weekend of relaxation. And by relaxation, I mean examining the inside of my eyelids. Eyelids being about the only part of the body I haven't examined this week.

I've been quizzed on a large variety of topics; from antiarrhythmics to Todd's paresis. Hot tip: if you mention that you're a pharmacist and your intern says "Me too." the drug questions will not stop. They will get harder.

The morning handovers and subsequent rounds are what I really enjoy; and, well, combined with the inordinately early nights I've been having, I'm more than happy to have these nice early starts for a long, long time. It's the first time I've had that "I could do this job forever" feeling in quite a while.

It has been intense, to say the least, and the next seven weeks are shaping to be pretty similar. Tutorials start next week, and they'll fit nicely into the part of the day I had been reserving for starting IV Lines. Of caffeine. On myself.

In truth, I did manage to cannulate my first living human. Yes, it took me two goes. No the patient didn't clobber me. No, I didn't stick myself.

Meantime, most of my colleagues will begin a chat with "So, what rotation are you on?", Medicine, "Oh, that sucks. You must be getting grilled."

I am, and I love it. It's pretty empowering to actually have the answer ready, and more so if you didn't look it up ten minutes ago. I think thus far I've been able to channel all my nervousness, enjoyment, excitement and, dare I say it, passion into study miles. I hope it sticks;

this empowerment and passion.

Aussie MedBlog Awards

DrCris, of AppleQuack and Scalpel's Edge fame, has initiated the Inaugural Australian Medical Blog Awards. A while ago she began nut out a list of all the Aussie medical blogs, and hey, if you're into Down Under MedBlogs, get stuck in. In fact, if you want to nominate a blog, just click on the first link in this post and follow the directions!

Here are The Rules:
  1. Nominations will be taken as comments on this post for two weeks, ending Friday 6th February at 6pm EDST. There is only one category this year - Best Australian Medical Blog. This includes doctors, nurses, ambos, pharmacists, medical researchers and patient blogs, along with many others. You could start with some of the blogs listed at the Australian Medical Blogroll.
  2. You may nominate one blog only (preferably not your own - you know it makes you look silly), so choose wisely.
  3. The nominations will be scoured by an international panel of bloggers, and a short list of 5 will be chosen.
  4. Polls (should) open on Monday 9th of February and voting will continue until 6pm EDST on Friday 20th Feb.
  5. I am the sole organiser of this contest, so this blog, AppleQuack, and my other blog, Scalpel’s Edge are immune to nominations (but chocolates will be accepted).
  6. Nominations and votes can come from international people, and non-medical people.
  7. It’s just a game, ok, so don’t take it too seriously. There will be another chance next year.

Anyhoo, I reckon it's a mantis idea. Even more humbling is that Sid over at Scriptie Makes You Fat has been kind enough to nominate me! Other nominations include the amazing Life In the Fast Lane, the honest and insightful OutBack Ambo, and the delightful Dragonfly Initiative. I'm honoured to be placed among such esteemed comrades.

So, yeah, check out the nominated blogs (they all rock!) and have a wee vote. Lovesit.

Action-ish

Today's the first day back at Med School. This morning felt like a holiday, not having to go into a pharmacy, and waking up a wee bit sleepy, but just feeling relaxed.
Once at the Hospital, the other students and I have been bombarded with timetables; seven in total, and told that everything's compulsory. The timetables are all coloour-coded and 'personalised' to each Take-Unit. Confusion runs riot.
The Head of the School has rolled in and massively simplified things; I don't feel quite as swamped by bureaucracy as a few hours ago. It may also help that we've been given the afternoon off to study.
Tomorrow I meet my consultant, reg and team and we're on Take in the arvo, which will be when it'll start proper. Then I'll begin the hard stuff. Huzzah!!
Study time.

The Shingles Paradox

A few weeks ago, I saw two cases of Shingles in about half an hour; neither of which were the typical abdomen or back distribution. Now, I've seen Herpes Zoster across quite a few dermatomes; mostly the abdo and back, a few CN:V(I), as well as my personal favourite, S1.

The first bloke knows the owner, Top Cat, quite well, and they for a few minutes. I get called over for a second opinion; as the presentation is somewhat atypical. The bloke's got a 'rash' on his elbow. Every once in a while he gets some 'pimples' and they 'itch' at night. I've actually seen this location for Shingles before, but to be more certain I take quite a long history. Well, long by pharmacy standards, anyway. We establish that yes, the first time was the most severe, and it keeps recurring. Exactly in the right C5 dermatome. Unfortunately, it's been happening for a few months, so there wasn't a hang of a lot that either we or a doc could do, but we referred him for ongoing management nontheless.

The second guy comes in a few minutes later. He tells the shop assistant that he's got a 'rash down there', and he needs some cream. It's a bit red and sore. He asks if it's fungal as he peels down the waistband on the left side of his underwear just enough to reveal the superior edge. He's given some anti-fungal and a steroid to 'take the heat out of it'. And, if it doesn't calm down in two days, come back and we'll see why it's being problematic.

Two days later, the guy returns. The rash is still there, and it's a bit weepy now. He again peels down his underwear, but this time, whether accidental or not, a bit more of his inguinal area is visible. The rash has a sharp point. Uh oh, I think, that's not fungal at all. I ask him if it's on the other side. Nah mate, it's just on the left, and all through my... hair... y'know. I'm now pretty certain that it's Shingles, and send him next door to the docs. It was likely at either T12 or L1, and was, to be fair, a pretty atypical presentation. I think it was within 72hrs of outbreak, which is at least a promising sign for any anti-viral therapy.

I was cranky at myself for not clicking onto this diagnosis the first time round. My history was inferior to the one I'd taken for the first bloke. Why did I ask fewer questions? Was it because he was a younger athletic bloke likely to have tinea? Or perhaps because it was a 'down there' rash? I appreciate that within a pharmacy context that an examination was out of the question, and that actually viewing the rash, in that location, is rare.

Anyway, whilst I was quietly contemplating this at home the next day, four phrases that I'd learned in the previous year and a bit echoed around my brain ;
  • Shingles is like chicken pox; it happens in outbreaks around the community. (PBL Tutor/GP)
  • Common things occur commonly.
  • You're more likely to see an uncommon presentation of a common illness than a common presentation of an uncommon illness.
and
  • Nothing but nothing will substitute for a good history and physical exam. Ever.
What is the Shingles Paradox?

Same illness, similar patients, contrasting histories, two 'atypical' presentations, still same illness.

Ties II

Ties are interesting things. A few years ago I visited an exhibition at the Otago Museum about their history. This is the second of two tongue-in-cheek posts about neck-ties and how I see them in health-care and professionalism, in Queensland.
The Queen St Mall is littered with businessmen wearing open neck shirts, jackets slung over their shoulders and sweat pouring down their brow. Meantime, as I've mentioned, the Qld Metro Hospitals are chocablock with tie-clad physicians, despite the tropical heat outside. There seems and odd irony about it; it seems that the the sweltering bankers and lawyers walk relaxedly between appointments, whilst the strangulated clinicians melt on sun-bleached wards.

The irony is all the more thicker when you consider that although office-based movers and shakers usually have more influence in the area of fashion and the 'professional' look, the health professions are supposed to excel in, well, health.


Ties bad for your health? Well, not so much the wearer as their patients. Quite a few of studies, of varying strengths, have shown that clothing worn on the wards accumulates all manner of bacteria, which can be then spread to patients. The tie, in particular, is of such a loose, flappy, dangly nature, it can't help but waft around the patient. Where shirts are washed between wears, ties are not generally subject to such stringent laundering. Basically, they're dirty, is all I'm saying. And if your patients get C. diff because you just had to wear a Piano-Key tie, well that's more tragic than the throat-garb itself.

In short, ties suck. They are barely fashionable in tropical climes, unnecessary when it comes to conveying a 'professional' appearance, impractical for physical examinations and they're a haven for infectious organisms in transit. As two UK surgeons nicely surmise;
"We would, in addition, suggest the abandonment of the outdated and impractical neck-tie as part of the expected male hospital doctor’s uniform."
Lintott P. Parry D. Let's lose the tie. [Letter] Journal of Hospital Infection. 48(1):81-2, 2001 May.

Ties I

Ties are interesting things. A few years ago I visited an exhibition at the Otago Museum about their history. This is the first of two tongue-in-cheek posts about neck-ties and how I see them in health-care and professionalism, in Queensland.
A previous housemate of mine, Ironman, loved his ties. He had no fewer than three Wallabies Rugby ties, in his myriad of choking-scarves. Evidently, I'm not super fussed about them, these days.

I used to love ties. About five years ago. See, the culture of my well-heeled private school was such that the ability to tie a Double Windsor was, for a brief period of time, an awe-inspiring skill to one's fifteen-year-old peers.

Through Uni (in NZ), ties made the odd appearance for formal dinners, placements, 'Professional Practice' sessions and job interviews.

On my first day of work as a pharmacist, I wore a tie. Maxwell laughed at me. Rightly so, in hind-sight; it was 38 Celsius. I melted. Welcome to Brisbane. Don't bother until May. I didn't.

I will, however, that my dislike for ties maybe due to my sizing; I prefer not to look like I have a drag-chute behind me, however, since my neck and waist are quite disproportionate, my choices are either sans tie or Paratrooper.

I have worn a 'Ben Casey' once, quite recently, but I've never been a big fan. I feel that the dispensing jacket puts up a bit too much of a barrier; in the same way that Docs in Australasia don't wear lab coats, they're on the outer. Unsurprisingly, the high cut collar makes me feel like a cross between the Incredible Hulk and a Priest.

These days I wear an open-necked shirt to work. I'd rather go tie-less in a nice shirt and feel relaxed than look like a stressed out used-car salesman who's just trying that wee bit too much; tacky shirts are one of my pet dislikes.

Hospitals seems to have quite a strong tie culture although, I've usually been able to avoid wearing one thus far during Clinical Coaching. Chances are, though, a trip to the tailor might accompany the start of rotations. Yurg.

What about you; do you wear a tie to work? A Lab Coat or Ben Casey?

A helluva shift

I know I've already posted once about storms, but it's been a big summer for them;

It was my last day of work and the Pharmacy. I was couch-surfing for another ten hours after the shift finished, and then I was heading to Europe. Yup, it was that post-exam, pre-holiday shift.

The day was a stinker; about forty degrees, and every one in the area was going a bit mad. About three o'clock a lady and her teenage daughter come in about a rash, and mention the sky is looking pretty black. Batten down the hatches, team. I moved my car under cover as the rain began to spit. We broke out the torches, more 'just to be safe' than anything.

Fifteen minutes later, night falls. A bit odd for the height of summer. Then the sky turns orange and yellow and opens. A good thunderstorm has drops that feel like blobs of oil. This stuff was most unrefined and heavy, both viscous and vicious. The tom-tom players on the roof sounded like they'd taken some sort of amphetamine overdose.

Rain lashed in through the front of the store and the gutters swiftly filled. I checked the rain radar; it was dark red and black over the surrounding six suburbs. The lights flickered in the lightening.

We closed the doors, and the water began to seep underneath. One of the shop assistants peered out the back door, to discover the carpark under a foot of water, which was now lapping over the back steps. The lights went out. The computer's backup whirred into action an began beeping like an ICU monitor. On went the torches.

We closed the Pharmacy; and put a label on the door "Emergency needs only; please knock". One bloke insisted on a box of Nurofen Plus. He opted to stay for a few minutes, but his impatience got the better of him and he dashed into the fallen sky.

There was a brief interlude in the rain; we walked outside to the streetside, where a Honda-CRV had been bogged and abandoned in the deluge. Bogans strolled through the knee deep water in bare feet, board shorts and Eureka Flag tattoos, inspecting one of three pile-ups at the intersection. The traffic lights began to flash orange as the towies latched up the first car.

The blackness returned, and the rain continued, heavier than before. The lightening and thunder was past us now; ravaging the suburbs to the north.

The ceiling had started to drip a few minutes into the storm. Then it leaked proper, like a tap being turned on over the vitamins section. All the umbrellas, usually open on display were turned upside down to collect water. Every contained capable of holding water was utilised. Bailing ensued at regular intervals. The dispensary lights began to leak; luckily they were between shelves and the medicines were spared. Except the Controlled Drugs Safe, which was sodden. I phoned the boss with a damage report.

There was about two inches of water on the western side of the store, the ceiling was a mix between buckled and water-logged. It all felt a bit unsafe, so the two assistants and I hovered in the doorways. The back storage area was the worst hit; it was five inches deep and refusing to drain. The stock was destroyed. It was about seven o'clock. The store was sinking.

I tried to make some use of the time, and checked some websters in a seat under a doorway.

The boss phoned back, saying he's come down to suss out the damage an hour or so later. He brought a halogen lamp and the place looked like a crime-scene. We closed up the place, phoned the security company and triple checked the locks. I handed in my key. The lamp guides us to my car, where the boss thanks me for my last two years and diligence and farewell pleasantries are exchanged in the wet, warm night;

That's one helluva last shift you've had, mate.

Why can't we just all be people?


Yesterday, for the second time in as many public holidays, the owners of my pharmacy were the victim of racism. Rather than express my deep shame and boiling frustration in many long paragraphs of rant, I'll just describe each of the situations;

Preface: For the public holidays, Maxwell (the boss) elected to run with the three-pharmacist, no shop assistant team; highly expensive, but also extremely effective and knowledgeable. No patient would be left waiting to 'speak with the pharmacist', because we all were. Our badges said as much. The team was me, Maxwell and 99 (his wife).

One: So, on Boxing day, an elderly lady rolls up and asks about buying a nebuliser. 99 takes the lady to show her the nebulisers, and explains our range of exactly one nebuliser and the cost of $200. The customer asks how it works, and 99 explains. 99 also tries to establish if the lady has the medicine required for the nebuliser and that she's used one before. (I don't know about you, but for most people about to shell out $200 on a nebuliser, you'd want to have all this stuff so it's not just pumping, well, nothing...). The lady becomes cranky and asks to speak with the pharmacist. 99 asserts that, yep she is the pharmacist, but Maxwell comes to her help and continues the explanation anyway. At the pause in the conversation, the lady says...

"I want to speak with an Australian. I want that man there to tell me about it." and points at me. I sold her the nebuliser.

Two: Last night, one of the more regular sufferers of 'cold and 'flu' in the area comes in for some pseudoephedrine-laced tablets. Thanks to the Guild, the Police and a few other organisations, there's a thing called Project Stop which tracks who's buying it and (probably) on-selling it, or just turning it into amphetamines by their lonesome. That's why a driver's license is required to buy the stuff. This particular bloke, we suspect, has been using a few different licenses, and he presented one that was out of date. Maxwell, quite rightly, denied supply, and was met with the response...

"Just f*#k off back to your own country, you f&*king maggot." as the guy storms out.

Racism is something that really winds me up. It encapsulates so many things that are messed up about humans; fear of the unknown, arrogance of the dominant culture, an inability to understand people that are apparently in a different situation from oneself, isolation of someone who is 'different' and basic bullying. All this stuff occurs within any society, it just seems that when there's more than one culture involved, it's multiplied in intensity.

After the first incident above, 99 said cynically, "Sure, some people still think that way. But who the hell is rude enough to say it?"

For me, Batman's oft-used line says it all;

"Why can't we just all be people?"