The Cardiologist

There’s something magical about this brand of physician. They hear things that nobody else can hear. They seem privy to an occult lore of knowledge only accessible to those already embraced into the fold. Cardiologists are connoisseurs of a difficult art. They also have incredible intuition. Many of them do a wonderful trick where they simply glance at a patient, and then proceed to predict the underlying medical story before they’ve even listened to the patient’s heart. They’re usually right. Oh yes, and the final touch: cardiologists are always well-dressed. French cuffs with links, slim jackets, and perfect hair. All of this makes it very intimidating to be a student of cardiology! I find myself almost as intrigued by this elegant species of doctor than by the muscular organ they study.

Urology: The Wild & Wacky

It’s late on a Friday night. Friends are all at home, and the week’s work is done. The lights are dimmed, and soft music plays from the living-room speakers. A celebratory glass of wine on the couch before bed, and a chance to reflect back on the week.

Yes, that’s right, this was meant to be a cardiology week. The heart stuff was certainly interesting. I gained a lot of new knowledge, and began to develop a new skill: reading ECGs. The heart is undoubtedly cool.

But what returns in my memories from the week is not cardiology, but rather urology. On Thursday my clinical skills group spent some time with a nephrologist and made a visit to the dialysis unit. Technically dialysis is classified under nephrology, but it was here that I picked up an interesting story (told below) with urological significance. Today I was afforded the opportunity to observe in the OR with the urology service. What follows are three true, but wacky, stories gleaned from the week.

(Bare in mind that to a fresh medical student’s eyes, routine procedures can seem truly wild when seen for the first time.)

The Stone Hunter

(Disclaimer: this one uses the subject “we”. This is for dramatic effect only; in reality, I was doing nothing of value.)

Journeying to the ureter is like climbing a mountain – you have to be strategic about it, and will likely need to plan camping locations along the way. The first pass takes you up the urethra and into the bladder. Easy enough. We camp here. In fact, we establish a little supply chain back down to base-camp to secure our position. Next, with the help of some guide wires, we must find the orifices of the ureters. Burrowing our way into these, it’s straight on up in the direction of the kidneys. On our way, however, we pass the ureteropelvic junction –  a camp-site where kidney stones often get stranded on their descent. And sure enough, there we find some! Luckily we brought with us a laser gun. Like a first-person-shooter computer game, we zap those suckers with lasers, blistering them into tiny pieces that tumble down the mountain slope, and eventually fall out the urethral bottom.

The Birth

(Disclaimer: this one’s a tad graphic.)

The resident takes a sterile pen and marks two locations on the patient’s skin. Addressing the nurse: “Scalpel to Greg, please.” Now to Greg: “Go ahead and make your incision between those two points.” Slice. There’s now a sizeable hole into the scrotum. The layers are slowly separated until a large mass clearly crowns through the dilated wound. “Now apply pressure here, and slowly push.” And with slow drama, from the scrotum is born a lesioned testicle the size of a grapefruit. No, actually it was bigger (I’m not exaggerating). The mass-child looks like a jelly fish – swollen, with a clear outer membrane through which I can see the turgid fluid inside. A small puncture to the tumour, and suddenly fluid is jetting across the OR – onto the floor, and covering the resident’s gown. The neonate is sent to pathology. It’s a benign epididymal cyst.

Anatomical Excess

I recommend that you take care of your kidneys. If however, you end up needing a new one (and you are lucky enough to get one), the new kidney should last you about 10 years. They have a lifespan. For most people needing a renal transplant, 10 years is plenty long enough to allow them the pleasure of dying from something else. In the rare cases of congenital (= from birth) kidney damage, however, you might end up needing a replacement for the replacement. Now, what came as a surprise to me, is that this “replacement” would be more properly termed an addition – the old kidney is never removed. That’s because a transplanted kidney becomes so scarred into place, that the surgical removal is quite difficult. Plus there’s no benefit to removing it. So it is in this context, that our nephrologist tutor was able to tell us the story of her patient who now has five kidneys. Most of them are shrivelled up and non-functional, but still…. five kidneys!!

Drool

My lunch break (I got a lunch break today!) was spent watching for live updates from Steve Job’s announcement in California this morning: the iPad! Wow. I want one.

Construction Underway

Did I mention we’re getting a new medical school? Here’s how it happened:

Government: We’re short on doctors. You need to increase your class size.
Queen’s Medicine: But our classrooms are full already. We simply don’t have the space. And it’s not just lecture halls, but also clinical facilities, technical-skills labs, wet labs, and library space.
Government: Hmm… well maybe it’s time you had a new medical building. You can design it yourselves, and then we’ll help foot the bill if it means more doctors for the Canadian people.
Queen’s Medicine: Sure! Except that the “Queen’s advantage” has always included our intimate class size – we have the smallest medical class in Canada. We’ll commit to expanding, but never to a class size greater than 125 students.
Government: Alright. It’s a deal.

And thus there is now a giant construction site opposite to where we currently have class. Things are moving quickly, because the government demanded a strict completion deadline to ensure their help in paying for it.

Check out the progress of our new medical building at this: Live Webcam!

As I said, the construction is directly opposite where I have my classes now. So if you’re really, really bored, and depressingly pathetic, you could watch that webcam long enough to see me walk by on the sidewalk (usually at least two or three times per day). Brown coat, blue backpack.

It’s exciting to think about all the new space for future Queen’s Meds classes. My class is unlikely to benefit since, although the building will be completed before we graduate, we’ll already be in clerkship working full-time in the hospitals. But future Queen’s Meds students can look forward to innovative lecture halls that permit small team discussions as well as large-group presentations, lots of new technical-skills and simulation labs, wet labs, and dedicated medical student study space.

Shallow Breathing

Crackle. Crackle. Air begrudgingly sucked into an unwilling chest.  “That’s it – over the left lower lobe. Do you hear them?” Crackle. Crackle. Yes; I can hear them. “Thank you Ms. B. for letting the students listen to your lungs. You’ve been a good sport.” We trail out – a procession of white coats.

Ms. B. was patient three, so there’s just one remaining. All four have trouble breathing. That’s why we’ve come to see them – to listen, to percuss, to witness lungs in decline. I’ve studied the signs: crackles, wheezes, stridor, dullness, bronchial breath sounds – mostly read from a textbook. Today, there’s a face and a name accompanying the crackles. What is, to me, a sign on physical exam is, to her, a struggle for air.

Patient four sits up in bed, arms bracing her chest up. There’s a mask on her face, and from it spills an eerie whitish gas. She’s breathing fast and shallow. Does the gas go where the air won’t? She has trouble keeping enough breath to speak to us in full sentences. There’s an anxious plea in her wide eyes. We listen. “Can you hear it?” Yes. Long after removing my stethoscope, I can still hear it. That’s a ghastly sound from a very troubled lung.

We return to the conference room – lots of pathology to discuss. Did we learn to recognize the signs? There’s now a face associated with each one in my mind. “Oh, and just so you get an idea of what you’ve seen today, recognize that while patient number two will likely improve, the other three won’t see the summer.” Crackle. Crackle. Pop. My own breath is caught.

As the hospital door swings closed behind me, I’m struck: this funk I’ve been in is shallow. How could I have not seen that? How petty to complain about not having a life because of school. The women I saw today are actually losing their lives. They fight for every breath. I’ve still got wonderfully healthy lungs. Time to stop my shallow breathing, and breathe deeply from the incredible opportunities I have. Enough feeling tired and out of breath, I’ve gotta use my lungs while I’ve got them. Inhale. Exhale. A breath of mortal air.

Babies are Cute!

Today in Clinical Skills: the neonatal exam . A neonatalogist taught us how to examine a newborn baby, mostly to ensure that they’ve made the transition alright from womb to outside world. A few new mums were willing to let us examine their babies. They were less than 12 hours old! Before today, I haven’t ever spent much time with a newborn. They’re so cute!! And you get this sense that there are many interesting things happening in their little brains. After the training session, we rounded on the neonatal ICU to visit with a few premature babies, and see how premies are cared for.

The Tyranny of Perfection

Term 4, Week 2. I’m doing well. I mean to say that I’ve found a makeshift balance between the ravaging machine of school and having a life, a person, an identity, away from it. This, an elusive treasure. The finding: clumsy and unanticipated, but ever so relieving.

Coming back here was hard. It took some effort. Objectively I can step from my mind and the mud-pool of emotions therein to see why: there is an oppression in this place. A tyrannical judge whose court punishes the slightest slip in adherence. The laws: number one, efficiency; number two, refinement; and number three, strength. One fall from perfection and you’re out. At least, that’s sometimes how the atmosphere here smells. There’s little solace in colleagues – all (myself worst of all) too consumed with making an impression. To show fatigue would be a frank admittance of weakness. Oh the whispers that would ripple should I fail. Exposed a fraud. That’s what they would say. It would be true.

No doubt perfection’s tyrannical rule increases output; we’ll be better doctors because of the painful gashes of its whip on our backs. But the weight of its dominion also cripples. It crunches, welds, and scorches. If allowed full creative authority, the end-product perfection chucks out is little more than a machine. A machine, where once there was a person.

This post: my public refusal. I simply object. No more, I say. Perfection be damned, I like my blemishes just fine. And though they may include inefficiency and weakness, I plan to keep them.

And yet … I lie. I’ll go back to the work-driven master. Tomorrow, and the next day too. And I’ll forget about the crippling, and about the machine too. This post then: a reminder. To be read on days when the reign of perfection’s rule seems too heavy to bear. To remember Term 4, Week 2, when for five short sentences I launched a mental coup.

Images of Lawyers and Doctors in Literature

I’m taking an elective. Because my already-full course-load isn’t nearly enough class. Because my social life could be insulted even more than it already is by lack of time. Because I’m an idiot.

It’s called ‘Law 570: Images of Lawyers and Doctors in Literature’.

The class will be comprised of 12 law students, and 12 medical students. We meet once per week to discuss readings from novels, plays, and short stories that somehow relate to how doctors and lawyers are perceived in literature. The reading list looks great!

Our first meeting on Wednesday whet my appetite for the course. We started the session by listing adjectives that describe (or, that are perceived to describe) lawyers first, and doctors second. It was informative to hear which adjectives the law students generated for us, and oppositely how we described them. In both cases, I think the list was different than we would have generated for ourselves.

In general, the lawyerly adjectives tended towards head-strong, whereas the doctorly adjectives were more heart-strong. This difference in how the professions are perceived may not be true “in the wild”, nor may it be what a client/patient would want in their lawyer or their doctor.

I’m excited for the course! I’ll keep you posted.

GU

We’re back . We start with the genitourinary system (GU). In characteristic fashion, we’ll spend two weeks looking at GU from a medical perspective (nephrology), and one week from a surgical perspective (urology). In my biased opinion med school can spend too much time teaching medicine . I’d like to see more surgery.

Kidneys are intriguing! Surprisingly so. I wasn’t sure I’d enjoy it. But there’s some mathematics involved (good), a decent amount of anatomy (very good), and some pretty cool physiology. Kidney physiology is some of the most conceptually difficult stuff in medicine, so it’s fun trying to puzzle it out. At times it has been quite engrossing, as evidenced today when I found myself glancing at the clock to realize that it was four o’clock, and I had yet to stop for lunch. Oops.

Tonight caught me awkwardly trying to palpate (feel) kidneys – my own, since then I could push harder. I don’t think I would subject anyone else’s abdomen to that much pressure. But no results; I couldn’t feel them. I’m told that’s a good thing.

Book Review: ‘Mrs. Dalloway’

In spirit of the holidays and relaxation, something completely un-medical…

Mostly from a dutiful impulse, I picked up ‘Mrs. Dalloway’. Every committed reader should venture at least once to Virginia Woolf, I thought, her name being so highly renowned and yet, in my mind, shackled by mystery and vague notions of a troubled, suicidal, lesbian romantic. Upon investigating Woolf’s historical life, I’m glad to have set my misconceptions in fact. And the novel itself was truly unique.

First in form: ‘Mrs. Dalloway’ is a streaming fabric of thought – sewn together by wisps of sentence fragments, and without the benefit (or distraction) of chapter breaks. It took some getting used to. The prose drifts through real-life action, flashbacks to previous events in memory, and even the hallucinations of a particular character. As an amateur reader, I had to be carefully aware which action actually took place in the lives of the characters, and which occurred only in someone’s mind.

Also unique: the voice. Soft. Self-aware. Sensitive. Woolf’s voice – which is distinctly feminine, contemplative, and perceptive – narrates the story. She highlights meaning where appropriate and points the reader towards subtle details that otherwise might have gone unnoticed. No other could have told the story in quite the same way.

The content of the novel follows an unremarkable day in London. The tolls of Big Ben give structure to the day; Woolf had originally titled the book ‘The Hours’. Mrs. Dalloway makes preparations for her party, which will ultimately unite the many characters introduced during the course of the book. The reader receives a commentary on London life both through the eyes of Mrs. Dalloway, and through the seemingly unrelated character of Septimus Smith, who suffers from shell-shock (Post Traumatic Stress Disorder).

A dominant theme is Woolf’s insistence on people as islands. She explores the inner secret places that we hide from everybody else. Can you ever truly know a person? Woolf suggests that each one of us stores a part of ourselves beyond the reach of any other – even our most intimate friends and lovers. To be human is to be isolated. Understand that although troubling at first, this idea is not inherently cold, or defeatist. What makes Mrs. Dalloway so endearing and memorable a character are the cherished secrets she hides from all others – her preserved individuality.

So what began as a duty, ended with much enjoyment! I’m very grateful for this holiday time to take a mental break, and explore other diversions!