slightlymoving

i spent this morning with the local ACAT (aged care assessment team). and i really enjoyed it. i think geriatrics and palliative care are two interesting areas of medicine that (in some ways) get overlooked.

as part of the morning we saw two potential clients for assessment. they had markedly different reasons for the assessment being requested. one was a 75 year old man with progressing dementia who is being looked after by his son - and the focus was primarily on respite care. the man had become more verbally abusive and difficult and the son needed a break. the second was an 80 year old woman who had had shoulder surgery and needed some assistance with ADLs when she returns home (which she was keen to do asap) from hospital.

there was a moment during the assessment with the woman where she talked about sometimes feeling lonely (her husband had died a few years ago), particularly in the early evening. she is able to occupy herself during the day by going to various groups, but now that she’s living on her own it’s the time between eating dinner and going to bed that make her saddest.

and, while residential care would offer her more social contact, she is not nearly ready for it and wants to maintain her independence as long as possible. it made me feel that we get so locked into the idea of couples and nuclear families that when it gets to this stage, we become limited in the possibilities. i’ve always been interested in co-housing, and it seems to me that having a situation where you live and share with more people than your immediate family would be beneficial at all stages of life. something to consider for the future…

in medicine, there’s an incredibly embedded hierarchy and tradition that often means teaching methods are slow to change and knowledge acquisition is, in some ways, made a goal in and of itself. part of this system involves memorising long lists… of conditions, side effects, drugs, outcomes, risks, limitations, benefits, statistics, anatomical features… to name a few. some of these lists are useful and are worth having at immediate recall - but many of them are almost pointless to remember because of the detail, the lack of use, and the utility of them.

recently, at a grand rounds presentation, a young fresh-out-of-medical-school intern condescended half the audience by stating he was dropping the topic down to medical student level and briefly discussed the mechanism of action of steroids. he then proceeded to ask each student present to name one side effect of steroid. i think i was about 6th in line and when it came to me i couldn’t think of anything, so i said so. it caused a little uproar in the room, which was fascinating in a number of different ways.

firstly, there were a few encouragers, suggesting that i did know more side effects and could think of one. there was a call for nudging my neighbour to get a whispered answer - accompanied by some whispered answers. there was a scornful call of that’s just not good enough. and finally a plaintive voice saying it was important to know as it will be on the exams and you’ll get asked a lot as an intern.

amazing really, to get such a varied and active response.

for me though, it highlighted some of the things that concern me about medical education and the lack of thought behind such methods for consolidating knowledge. the assumption here is that the intern was attempting to help us learn and not simply assert a knowledge hierarchy - and i’d like to give him the benefit of doubt.

the main concern for me is about equating immediate recall with knowledge. if you can answer a question with a list then you show you know something - when of course, that’s not necessarily the case at all. i often see some students reeling off a list in answer to a question but most of the list having absolutely nothing to do with the situation at hand. i suppose it comes down to ways of thinking and working. a computer might be good at processing through lists to determine appropriate choices according to set criteria - but most humans are not. the best clinicians i see are attentive to their patients so that when they give them steroids, for example, they don’t reel off a long list of possible side effects (mind the buffalo hump won’t you) but engage with the patient about observing changes and symptoms.

a list will always be written down in a book. or on your iphone. or on wiki.

there’s more to this post but i’m a bit tired after that effort…

Jacob and I performed tonight. First time together since the start of the year.

We had a fairly short warmup time, which served to show us just how little stamina we have. And during the day we’d been discussing our practice and teaching and thoughts about improv process. Entanglement.

The performance went reasonably well and in reviewing I think that while we have a strong performance ‘muscle’ our dance and compositions ‘muscles’ have atrophied somewhat. I’m keen to see what happens over the next few nights…

Earlier in the day I’d listened to the Hon Nicola Roxon talk at GP’09 conference about national health reform. The Q+A that followed was interesting and was recorded as part if their ‘consultation’ process. I like to think that the reforms are being approach in an open and strategic manner, but it’s hard to tell right now.

Oh oh… Starting to mix my posts…

subtle title, i know.

but right now i can still smell faeces. this morning was my second major involvement in a MET call. i’ve been to a number this year but mostly just as an observer (or contributing in very minor ways). this time though, i participated and gave closed cardiac compressions to a man in his 60s who had gone in to arrest following thombolysis for an AMI. in the process of trying to help this man by breaking down the thrombus causing the MI (using retaplase for those who want to know), he’d gone into a reperfusion injury arrhythmia and was in VF. (as a side note, isn’t wiki great)

we’ve been going over ACLS and i knew this was a witnessed and monitored arrest so according to protocol he should have been given 3 defibrillation shocks as initial management followed by CPR. he did get two, but then there seemed to be a delay while waiting for a senior clinician. in the meantime cardiac compressions were commenced. he had no output (no pulse) and was being bagged and the monitor continued to show VF. once the senior was there another shock was given and CPR continued on… but then, despite staying in VF for the next 15 minutes it took that long for another shock to be ordered.

now, i know i’m not that experienced, but all evidence points towards early defibrillation being the only intervention that makes a difference to outcome in arresting patients. some reading on the efficacy of a MET if you’re interested. and he did get early defib, but not according to protocol. it’s possible a 3rd early shock would have depolarised the heart enough to get it back into rhythm… but then, i don’t know if the protocols are based on level 1 evidence - it would be difficult to perform a RCT or get ethics clearance.

so, this guy did eventually get back into sinus rhythm but was intubated, put on a ventilator and then transferred by helicopter to a major sydney hospital. he wasn’t looking good, and if you read that article above only about 17% of arresting patients survive to discharge. in the midst of the ACLS (oh, he wasn’t sedated initially and was reflexively/voluntarily responding to the pain of the cardiac compressions) he defecated.

the smell has stayed with me all day.

if you don’t want CPR, make sure you have an advanced care directive. have a read of this article for one doctor’s thoughts on CPR and why he doesn’t want it.

seeing i teased earlier i thought i’d chip away at those thoughts.

i’ve assisted in (and watched quite a bit of) abdominal surgery in the last 4 months or so. a lot of these have been hernia repairs, but also laparotomies, appendectomies, nephrectomies, hysterectomies, and even an open cholecystectomy (and a bunch of laparoscopic cholecystectomies).

it’s been fascinating to see the layers of the abdominal wall exposed time and time again with different body sizes and shapes. after making an incision in the skin most surgeons will then use diathermy to burn through the subcutaneous fat. this will expose the superficial fascia (fibrous tissue, at this location named Scarpa’s fascia, bloody eponyms) which is often divided with a scalpel. in the more lateral areas this exposes the external oblique muscle which is superficial to the internal oblique.

a common procedure is (after incision) to place a clip on the external oblique and retract to expose the deeper layers. this clip often stays in place for the duration - as it makes accessing the external oblique easier when closing (i assume - all of this is observation, btw).

below the internal oblique is the tranversus abdominus, then the transversalis fascia followed by some peritoneal fat and finally the peritoneum itself.

when forceps are attached and you’re asked to retract or hold, the surgeon will smoetimes let you know how hard to pull (or not as the case may be). this also applies to retractors, but when you’re holding onto a tool that is biting into the tissue it’s good to be paying attention. what has been interesting for me is that each layer has very different properties - and having seen more than one assistant yank too hard and pull a clip off or tear some tissue, there’s a learning about the tensile strength of these tissues that is only really developed by practice. because, of course, as people age the properties change - and each patient is different.

while it’s not the most important thing to consider, any extra trauma places an additional load on the patient’s metabolism and repairing function. and there’s a need for sensitivity and alertness in assisting that means being aware of the physical properties of the body in front of you. which, if you’ve read any of my posts on dance, ties in with presence and sensation.

that is all for that one :)

there are a bunch of things i want to write about.

but i’m just too stuffed. hope i remember them and get back here. quick list: tensile strength of different body tissues. faecal disimpaction. standing during surgery. poise and presence in the OT. intubation and teeth. sensation. material for the spine.

in April last year the Australian Indigenous Medical Electives Database website (www.aimed.org.au) was launched at the National University Rural Health Conference. it’s a great initiative that you can read about at the NRHSN website - essentially it’s a user contributed website that aims to encourage students to undertake Indigenous health electives by displaying reports and advice from previously undertaken placements.

if you’ve clicked on the link above though, you’ll be disappointed. the domain appears to still be registered, but no longer redirects to a server.

i was extremely interested in this project when i was at the launch and not long after registered for the site (it was built using Joomla!). unfortunately though, even at the launch there were many bugs in the site that made it both unusable and presented a very unprofessional front to a worthy idea. some of the faults were simple permissions issues and others (i think) were to do with the installation of unsupported modules that had security vulnerabilities. the site contained malware and was severely compromised.

i wrote to the developers of the site with my feedback and also with offers to help fix the problems. unfortunately the key developer was about to become a father to triplets (so i was told) and i don’t think the instigator of the project was IT literate enough to deal with the problems. so the site remained live (and infected with malware) for the next 6 months at least and then the instigator of the project handed it over to the NRHSN.

so now it stands defunct. i do hope that someone picks up the ball and gets it up and running again. it’s a good idea.

i’m not sure why i’m writing about this other than to express my frustration with such a good idea falling over. i suppose there’s also an issue of the funding used to develop the project and the accountability involved - i’m not sure of the amount of funding, but i do recall that it was funded. at the same conference i presented a paper on rural health clubs using open source software and free hosting - using arms.asn.au as a case study (a site i put together using Jomla!). it cost a total of $45.51 to get up and running (not including the hours i spent working on it) with free hosting provided by an australian hosting provider for not-for-profit companies. i suppose that’s one of the pitfalls of open source - that if you’re not aware of the possible issues (like security) then it can lead to all sorts of problems…

anyway, that’s enough of a ramble for now.

what a day.

i’ve fallen off the blog wagon. or am i back on the blog wagon. i still don’t remember what fallen off the wagon means - must google it. too much twittering or twatting or whatever it is.

today at the hospital i had a little meltdown. mostly internally, but i couldn’t hide it either.

i’m not sure exactly what the trigger was, but i had an overwhelming sense of being hopeless, of not knowing enough, of wondering what the hell i’m doing in becoming a doctor. and it’s not that i haven’t had these doubts or thoughts before. i think going into a completely new field it’s almost expected that there will be times when it all seems too difficult. but it wasn’t even that things felt too difficult. more that i didn’t know enough.

i understand this to be a common experience for medical students as well. i think i may have mentioned it, but we had a lecturer once mention the ‘insurmountable knowledge mountain’ that you face when you begin studying medicine. there is so much to know and only a limited amount of time to learn it all.

i had thought that moving into the clinical years would alleviate some of these concerns for me. i know i learn well by doing. and to some extent it has - or at least it has confirmed the things i do know i can do. like communicate well. have empathy. actually be involved with the examinations - listen, feel, observe - without simply going through the motions (of course i’m still accumulating my knowledge bank there though - the subtler signs aren’t always that clear!). but the other thing that has happened is that i’m painfully aware of where my knowledge ends. and also, sadly where things i once knew well have slipped away.

so… i can accept that i can’t know it all. and i can accept that i’m still learning - and will continue learning. i suppose i’d just like to be able to not get as dejected as i did today - to remain equanimous when confronted with my own shortcomings.

eh, will try and get back to something interesting!

i’ve been confronted again by the way knowledge is acquired and represented in medicine. and with the differences and similarities between how i *know* things in the arts compared to how i know them in medicine and on a third view, how i know everyday things.

man, that sounds convoluted.

in medicine you have to show how you know things. you have to present to other people - colleagues, peers, superiors, teachers, examiners. and the presentation is sometimes as important as the content (just like art, eh ;).

my struggle with this is partly to do with my sense of how i know things. reciting a response to a question from something my memory has managed to retain while reading doesn’t make me feel like i know that fact at all. yet i constantly see people at my level stating such facts with absolute conviction and certainty - as if they *know*.

i’m not quite explaining myself, but there’s a gap between knowing something that is based on simple recall and knowing something that comes from a deeper theoretical understanding and even knowing something from a developed and practised expertise in something. all of these things can work in acquiring knowledge and understanding, but i often cringe at the arrogance of some people who are using a recall knowledge with the conviction of someone who has known the same fact in a deeper way.

that’s still not quite it. will have to consider this a bit more i think.

today was a day for a couple of firsts.

at the hospital we all carry pagers. as students, most of the messages we get are test messages that ask us to call the switchboard to let them know the pager is working. the other messages we get are MET calls, which tell us which ward and which bed to go to. a MET call can be for any acutely unwell person and is considered an emergency.

last week there were a couple of calls that turned out to be ok - no resuscitation or major interventions needed - and the response is quite phenomenal. within a minute or two there are generally 15 to 20 people at the bedside. so we all felt pretty comfortable about being involved in a MET call.

today though, there was a call that was much more serious. we (the students) had been sitting in our common room about to have lunch when all our pagers went off. dutifully, and if i’m honest, with a sense of excitement we all rushed to the bed indicated. when we got there the patient was being hoisted out of a bedside chair onto the bed and a team was already assessing his status. the ward nurse then chose two students to stay and ushered the rest of us further away. for the next 45 minutes the team gave continuous CPR before the senior doctor requested they stop as further treatment was deemed futile. 45 minutes is a long time to have people compressing your sternum at 100 beats per minute with enough force to pump blood through your heart and around the body.

this happens all the time - it’s not uncommon. and we all have some idea of it from television or the movies. but the reality is so different. for one, the duration makes it much more intense. it’s not over quickly - and it takes a lot of physical effort. but the things you don’t hear about are to do with how the patient can be involved in it all. most depictions have them as passive recipients or CPR or other interventions. but this man was still breathing on his own - slower than necessary, but regularly. and he was making these terrible sounds - which were mostly to do with his respiratory effort making air push past the tracheal tube and causing a rubbing, moaning noise.

but the most striking thing was when the call was made to stop - and the staff cleared the tubes and cannulas and ECG leads and general detritus away from the patient’s body. when they were done he was still breathing - just. still putting some effort into living, despite there being no possibility of surviving. very little sound now, just a weakened struggle to continue that diminished over the space of a few minutes. and then nothing.

about a hour after that, i attended my first autopsy - and no, not the same person. this was another alien experience. of course we’ve been exposed to cadavers already in the course, but not in this fashion. all the cadavers are preserved. this body was not. and compared to the dissection work i’ve done, this was about as blunt as it gets. while it was a little odd to be there at the start, by the end i didn’t feel so uncomfortable. there were a few moments that i found difficult. the use of a pair of long handled secateurs to cut through the ribs to then remove the chest plate and expose the organs was intense. the noise mostly. and the peeling of skin from the skull to allow access to the brain was also a little creepy. but by the end, it felt like the anatomy lab again. rough cuts through single organs to expose any pathology.

a big day.