Sunday, 12 May 2013

On Fistulae

A fistula (a Latin word originally referring to a set of pipes) is a communication between two surfaces that nature and anatomy have conspired to keep apart. If, as is so often the case, there is something to be found running over one surface it will inevitable spill across the gap and flow from one place to another. This is how we know that a fistula has developed; we watch something unexpected emerge.

I am no stranger to human suffering. I am hardly an expert, and my experience does not elevate me above any other person with a shred of empathy and a little information but I have seen people in pain, I have seen people despair and on the odd occasion I have seen people die. I understand that these are unfortunate truths of the universe and that they are magnified to an uncountable magnitude in certain parts of the world. I feel, in a vague way that offers no particular solution, that there is inequality in this world where life and death can often seem governed by forces out of control of the individual in question. I am aware that I have been incredibly fortunate in being born to a time, place and people that have equipped me with the ability to make some attempt to redress these inequalities. These are perhaps the best attempt I can make as a summary of my thoughts as they stood at just after half past ten today.

As I have mentioned before, I am currently in the middle of my medical elective. For inexplicable reasons, I have chosen to spent the two months I have in a leprosy hospital that sits somewhere on the the Terai plains in Nepal. I hope to write more about the day-to-day running of this hospital some other time, but for now I would like to focus on the singular encounter that happened earlier today.

The setting for this encounter is a clinical room in the outpatients department. They are small rooms, perhaps only 4-5 meters across furnished with two desks at which stand a chair and a stool. A curtain draped across one of the walls serves as a privacy screen for when an examination requires it, but this is rarely the case. The normal function of a clinic is people crowding into the room waiting for their turn to be seen by a doctor or paramedic. When I say crowd, I'm not being hyperbolic; there are often three or four other people in the room with you, peering over at the patient you are currently speaking to and there is always a rush to be the first to sit oneself down in the stool that officially confers patient status.

For the most part, the assessment is quick due to the sheer volume of people seen each day. Each doctor sees around 60 patients, and the paramedics may manage more than that. Altogether, roughly 400 patients are seen each day, though the numbers vary due to strikes and local festivals. Generally, a patient presents the part afflicted, a diagnosis is made quickly and treatment is offered. It is in this setting that the events of this morning unfolded.

The patient was a child, who looked so skinny that I placed her at perhaps 8 years old though her patient ticket read 13 years. She was dressed in a traditional red floral dress and wore a faded blue hoody on top. Most noticeably of all, she walked leaning on a stick, not being able to put the slightest bit of weight on her left leg which hung suspended in mid air.

"Aha, I thought. This is some injury to the leg. Perhaps a fracture. Or a painful knee or hip. Or..." And my mind began to run away with the usual list of possible causes of a limp in children.

Not being able to speak a lick of Nepali, I watched as the doctor I was with asked what the problem was, and was slightly surprised when the girl removed her hoody, turned around and began to lift the back of her dress up and this is what I saw there.

Around her sacrum, where the lower back stops curving inwards and swoops outwards there was a pus-discharging wound. This appeared to be a long tract that travelled under the skin and opened in another pus-filled wound on her left bottom. On her left hip, a tender and tensely hot swelling spoke of an abscess under the skin. Halfway between the two wounds, a little hole (perhaps the size of a biro's tip) spilled a regular trickle of liquid faeces. A fistula between her skin and her guts (entero-cutaneous, you see). Her parents explained that this had been going on for about a year.

This was the problem that faced us now; it was clear to both the doctor and I that something needed to be done. There was no real need of a diagnostic test; the issue lay leaking in front of us. It was a question of where the problem might be sorted, and who would pay the price. You see, each major hospital closest to this place is about five hours by bus, and they are all privately run. Some places have lower fees than others, and a subsidy from the government is possible, but when you consider that the family might struggle to scrape together the fare for the bus, it becomes impossible to imagine them paying to been seen at one of these hospitals, let alone receiving surgery.

Why couldn't they stay here? This is, I suppose, a leprosy hospital first and a general hospital second, but that might be enough. She could receive some IV antibiotics, perhaps have her abscess drained and given some decent pain relief. Then again, nothing comes from nothing and someone has to find a way to pay for these treatments. That is, of course, if we have a surgeon with the expertise to carry out a relatively complicated operation (made so by the longstanding nature of the problem). This child has a condition that would be challenging in  a fully developed country; can she actually be treated here?

It was then, as I felt the tides of helplessness in the face of these questions swirl around me that something else happened; I felt something like understanding. Suddenly, two worlds that in my mind had been distantly separated, my hopefulness in the face of difficulty and her helplessness in the face of difficulty communicated with one another and something passed from her world to mine.

One can never tell exactly where a biological fistula will form, all that's really required is enough contact between the two surfaces and a change in the normal conditions. So to, those odd moments of connection with a particular patient's situation. As I have said, I have seen people in potentially worse situations but not felt quite that moment where the two separate worlds of their experience and my understanding join.

I do not know how the girl's story ends; a number of other factors made the father decide to take our offer of free oral antibiotics, painkillers and a dressing and to return when things with the rest of her family were more stable (which, incidentally could take up to another year), so there is a good chance I will never get the closure that helps to rationalize these connections between people. I can only hope I can somehow turn it to some positive end.

Monday, 29 April 2013

At the Mountains of Malarone Madness

The first part of this post will be information dense. I can only offer my deepest apologies for that, and promise that the second part will be a fluff piece of the fluffiest content I can generate- the literary equivalent of a pillow fashioned of marshmallows that have been savagely attacked with a bicycle pump.

So- inbetween now and the incredibly distant then of my last post, I have:

1) Found out that my first year working as a doctor will be in the Princess Royal University Hospital, Bromley.

2) I am to rotate my way through four month blocks of urology, gastroentrology and stroke medicine.

3) I sat and passed my final exams

4) I am due to graduate wearing this (can I pull those colours off? Will the gown be flattering on my generous-ness?)

5) I have travelled to Nepal, where for reasons best known to myself, I am to work in a leprosy hospital for the next seven weeks or so.

Phew. Glad that's out of the way. Now for the good bits!

Now, there are a few bits of context you need to know for this to make proper sense. The first fact to keep in mind is that a majority of my dreaming isn't something I'm aware of. I certainly do dream, as I've been reported as an occasional sleep talker, and there are the odd mornings when I'll wake with the nagging feeling that I've had some sort of nocturnal visitation; perhaps a dominant mood or feeling, or else a few words or sounds. Other than that, I can't say I have very much going there.

The second fact is that malaria is not uncommon in the part of Nepal where I'm currently living. Up in the mountains, it's much too cold for the poor anopheles mosquito to do her work but the plains and stagnant pools of water found in abundance here suit her just fine. So, I am obviously doing the standard (avoiding nude sunbathing at dusk and dawn, coating myself in insect repellent and sleeping underneath a gauzy net) but I am also taking a medication called malarone.

Malarone is a mixture of two antimalarials called atorvaquone and proguanil and is widely speculated to have the most tolerable side effect profile and commanding the highest price per pil. Not being especially keen on getting sun or heartburn, I opted for these.

It is around now, a week into taking them that I have stumbled upon the most curious side effect I have ever experienced; vivid dreams.

The nightly experiences are like nothing I've ever had before. They engage multiple senses and feel incredibly realistic, to the point that a few days later I'm still left with slight confusion as to what happened in waking or dream-states. They are populated (at the moment) by people I know closely who were (largely) behaving as I would expect them to in real life. They have (again, so far) been either neutral or extremely pleasant. The most curious one to date happened last night.

I was standing in the gardens of Keele Hall, and surrounded by medical students of my year all wearing incredibly smart clothing and talking pleasantly with one another. I had no idea of why I was back, because I was supposed to be in Nepal. I turned to ask a friend of mine why everyone was back from their electives early, and she explained that everyone had just come back to catch up with one another. She also explained to me that I'd have to pay for my own plane ticket back to Nepal, which disgruntled me a little. When asking her for more details, she turned a corner and suddenly all the familiar faces had been replaced with people I didn't recognize in the slightest. This confused me no end, and I remember elbowing my way through this crowd of well-dressed strangers. I asked myself "Why on earth did I come back early? How can I not remember the flight back?" and it was that moment that realization hit me and I spoke (or thought?) "Oh. It's a dream!"

And just like that, I woke up. There was no jolt to wakefulness, no sluggishness of thought that normally comes with being woken at random by some shock or start, just the same level of alertness that I had experienced in the dream.

I'm either going mad, or it's the Malarone.

Thursday, 7 March 2013


In idle moments, I sometimes imagine what it would be like to appear in a news headline. During more optimistic moments, I imagine a small personal interest piece in a local newspaper that reads "Medical Student Quite Nice, says Local Woman". When things are more gloomy, I picture an unflattering picture headed by "Killer Medical Student Misses Diagnosis". Until recently, this was just a daydream of sorts,  but has become incredibly real of late.

A few weeks ago, the BBC ran the story "Medical students job offers withdrawn after exam marking error" and the Guardian went with "Medical students' job offers withdrawn after 'scoring errors'", both concerning a recent national mess up with the application process that final year medical students up and down the country went through. These stories have occupied my mind for the past two weeks or so, and are about to reach resolution tomorrow morning.

To those of you unfamiliar with the process of applying for a junior doctor's job, it goes something like this. First, one works through medical school. After four years, your academic performance is added up and gives you a number depending on how well you've done. Extra brainy points are awarded for doing intimidatingly smart things like having a previous degree, winning prestigious awards and publishing papers.

When you've accumulated all the points you can possibly grab (which is expressed as a score out of 50), it's time to sit an exam known as the Situational Judgement Test (SJT). Essentially, the test is a set of difficult ethical quandries, a set of solutions ranging from the painfully sensible to the dangerously stupid and your task is to rank them in order. For instance:

Q1: You are browsing the internet carrying out your ususal depraved harvest for pornography. On one website, you see one of your colleagues performing a rectal exam without proper personal protective equipment. Rank the following in order from most to least appropriate.

A1 Fall into a foul fit of ecstatic spasmodic convulsions
A2 Say nothing, but vicariously self-abuse yourself publicly
A3 Speak to your colleague privately about his examination technique
A4 Say nothing, but vicariously self-abuse yourself privately
A5 Speak to your colleague's educational supervisor. Bring pictures.

(answer: 3,5,1,4,2)

After a few questions like this, you end up with another score out of 50, which gives you a total score somewhere out of 100. With this score firmly in hand, you then rank the geographical areas available to you and are assigned to a place based on your score relative to all of the other 7000 or so medical students with the same idea.

On the 25th of February, that process returned it's judgement and told me that I was going to London (my first choice) after all. Months of stress melted away, and I began planning the first steps of my journey into junior doctor-hood. I wasn't quite measuring out curtains, but I certainly looked at a few colour tiles. This period of congratulatory self-satisfaction lasted all of 24 hours.

The next day, I received an email explaining that some national problem with the SJT. Over the next few days, the headlines appeared, and I received lengthy apologies that both clarified and confused the situation further. It eventually transpired that the whole thing would be remarked, then run again.

I await the results, which will arrive tomorrow morning. I wonder what my headlines will read then.

Thursday, 21 February 2013

Flowing Form

Hospitals, for all their bluster and motion, can be surprisingly silent places. I should perhaps clarify that I do not mean that hospitals are ever quiet- there is always an electric hum, an intermittent beep and the clatter of trolleys to keep one's developing headache company. Where hospitals make up for this is the surprisingly little amount of speaking one can get away with without very much effort at all. Whole hours can pass without a single word being spoken, and if one is a little selective with one's duties one can go a whole day with only one or two word answers to questions. Indeed, after a morning tackling a lengthy and complex discharge summary I was surprised to reflect that the words "I'm done now, what should I do next?" was the most sound I had made if we exclude the frantic tapping of keys on an ageing keyboard.

Only the opposite can be said for the world of primary care- the GP surgery is nothing more than talk with comparatively little in the way of other sounds to interrupt the flow of cadence. Oh, it is true that there are silences; some of which are just long enough to veer towards awkwardness, but these are just pauses that accentuate the main business that is chatter. Towards the end of some days, I find that my throat is a little sore and my ears ring with a confused whirlpool of multiple and almost inseparable narratives. The change is not unexpected, but the difference is more than I expected.

I think that the difference lies in the fact that in hospital, the stories are compressed, pre-prepared into some sort of pill form that is easy to swallow. Unless one is posted around the entry portals into the hospital, no patient is a complete unknown. Their histories are collected and summarised, their problems itemised and prioritised. Additionally, the patient has rehearsed their performance to a perfection that most actors could not match, they know the right phrases and especially expert ones can anticipate your line of questioning before one can ask it. One deals with the problems that arise within the narrow field of one's specialisation and refers appropriately for the rest. If one is sending someone along to a service that already has a pro-forma referral document in place, you are spared the difficulty of even picking up a phone.

The patient that arrives in a GP's clinic is a different breed altogether. Even the most practised of patients is a novice in this particular situation and their presentations are legion. Sometimes, it is not a question of sifting as a prospector might, but to ride a rapid to an uncertain destination. Occasionally, this necessitates wild changes of direction. For one patient, the story started by sounding like a persistent fatigue that would not lift, to the mysterious fluid swelling of a failing heart to the choking chest pain that is angina's calling card. By the end of it, I was merrily writing up a prescription for the standard statin and aspirin and sending on his way. It was then I recalled the fantastic journey that had meandered from system and symptom to this undiscovered pathology and it was thrilling; the verbal equivalent of a pioneer spirit.

The problem with these wildcard histories is that they sneak up on you when least expected and a trickle becomes an overpowering torrent in no time at all. For instance, I was going through a patient's medication with two priorities in mind:

1) her heartburn, which seemed poorly controlled

2) the fact that she was on an inadvisable dose of a sleeping tablet

The second priority ended up turning into a lengthy round of negotiation and side-tracked me completely. I was forced to dive deep into a chasm to search for the origins of this sleeping tablets and to assess it's current fitness as part of her regime. She argued that her sleep was important to her, and while I conceded that I didn't wish a sleepless night on her, I didn't feel it prudent to continue things as they were. It was a swirl of priorities that chased itself for a bit, but we eventually separated with an agreement that I hoped she could stick to. I confess, I was swept away in this and when she left my room with a plan to cut down on the sleeping pills I reflected that I had missed an opportunity to work with the heartburn problems she was having.

General practice; it's like white-water rafting, but you wear much less protective equipment.

Thursday, 14 February 2013

An F5-ing Experience

I am not opposed to online dating. In fact, the internet is a very fine place to get to know interesting people as well as some of the more interesting parts of their anatomy. It is, however, when it comes to my future career that I find myself firmly opposed to the idea of any form of online process.

The way that a aspirant junior doctor applies for a job is an unusual process in and of itself. Essentially, one slaves away at medical school learning and passing exams; the relative success with which one performs determines a score, which can be supplimented by various scholarly achievements and awards. This score forms half of the eventual number that decides how well one does when it comes to securing a job. The other half arrives from a test called the Situational Judgement Test (SJT), where one is required to answer a number of potentially difficult ethical dilemmas and is marked on how appropriately one responds. The oddest part of this system is that you never get to know how well you've done in the SJT before you apply for a job; you literally start with half a score.

When the application begins, one doesn't have to do the usual prostitution associated with jobseeking. There are no trick questions about greatest weaknesses or the kind of egg one would be. There is just a list of available geographical area, and you need to put it in order of preference. A great list is then collated from the top scoring candidate to the very lowest, and your position in that terrifying list gives you the rough location which you will then spend the next two years.

I suppose that none of this is too outlandish- there are a number of jobs, a number of applicants and the spaces are filled in the most efficient and fair manner possible. The problem, the chief bane of my existence at present is the fact that all this happens on a website.

You see, I know intellectually that the results of my application will never be released any sooner than the deadline (25th of February, if you want to send condolences on the day), but some part of me wonders if somewhere buried within the code of the website is some sort of secret trigger that is opened by constantly refreshing the page that will hasten the day I find out where I'm ending up. Checking for updates has not quite yet become a daily ritual, but it's certainly heading towards that way, and I am resisting the urge to set the login page as my homepage.

I haven't long to wait, and I'm sure that when I know the result I'd rather that I didn't; reality will settle in a little too quickly. I don't feel ready to be a junior doctor, and I certainly don't want to be matched up to some location somewhere in England that obliges me to transform into one.

That said, I'm just going to go check the website one more time.

Monday, 11 February 2013

On Nights

There is a curious moment in every night shift when tiredness and enthusiasm balance on a single point. It is a sublimely perfect state to be in, and too much of one thing can tumble you from your zenith to either the jittery state of caffeinated tension or the slothful slump of exhaustion. During this period, one has lost the naive feeling that one can accomplish anything, but one isn't completely crushed by the impossibility of fatigue. It was at this point that I was first called to review a patient. It was around 2AM. 

Reviewing a patient comes in several flavours; in this case, I was asked to review a cannula and potentially site a new one. This particular task is one that I have become extremely familiar with and equally anxious about. I flushed the original cannula, and found the thing to be spreading the fluids uselessly out into the surrounding tissues. The thing had to come out. 

The search for a vein is one that happens in steps. First is a quick scan, looking for any likely looking bulging ones. Following that, one begins to look in the places they tend to congregate; the crook of the elbow; the back of the hands; the place where the thumb and wrist join. In utter desperation, you can begin to cast your eyes downwards to the legs and feet as you mutter to yourself "nothing ventured, nothing gained."

Eventually, I located a vein in one of her feet. The skin around the area was dry and tough looking, but it yielded to the needle and I held my breath. There. A little red flash in the plastic tubing. I was in the vein. The nerves and exertion had tipped me out of my serene balance, but a flare of satisfaction kept me going as I secured the thing in place.

It was around 4AM that I was asked to see this lady again for the same problem, my new cannula had gone the same way as the old. At this point, I felt that I was flagging and I pleaded my inexperience and inability and one of the nurses exercised their expert craft and secured access again. The lady, who had previously been talking to me had fallen into a silent, fitful slumber. 

It was 7AM that I was called to see the patient for the final time, and things did not bode well. She had become drowsy to the point of unresponsiveness and her breath had taken on this terrible quality, like it was trying to escape out of the bottom of well. I looked at the junior doctor who was with me as we examined this lady and nodded as he suggested we call for senior help. 

At 7.30, alarm bells rang and I knew before seeing the chaos unfold which room everyone was going to be running to. Being close, I ran too. 

I will spare you the details of the final moments, but the whole affair highlights the human tendency to focus on specific details rather than the terrible whole. Even as everyone in the team unfolded into their roles, even as I helped move and hold things in place, I couldn't help but notice my lone cannula half-dangling uselessly from her foot. She was pronounced dead shortly afterwards.

It was on leaving the hospital that moment that I rediscovered that curious balanced tipping point. I can only surmise that the sleeplessness of the night and the residual adrenaline had clashed to produce this tranquil, becalmed state. It seemed an odd thing, that a whole day's events could have just happened compressed into a few short hours and that the sun just kept on shining.

Thursday, 7 February 2013

On Hiatus

Thursdays are not normally my best days.

The enthusiasm and work ethic I generate over the weekend tends to wilt and droop a little as the week goes on, and by afternoon time I am the spiritual equivalent of a bunch of dried roses long forgotten in some dusty vase.  It is in tribute to the common theme of lacklustreness that I demonstrate the re-launching of this blog after a rather long time away.

Where have I been? The simple answer to that is that I have been away. I took a holiday from writing somewhere around the end of my third year of medical school and the holiday extended itself throughout my fourth year and a good section of my fifth. It is a holiday that I have recently returned from burdened with several souvenirs and the possibility of a tropical disease of sorts.

The more complex answer is that for a time, I felt like writing had stopped being a useful or productive thing for me. Inspiration to write was everywhere and flowed freely, and I genuinely felt better for having whatever was going through my mind down in text. Something changed at some point and it felt harder and harder to come up with material that didn't feel contrived or written for the sake of it. If inspiration was a spring, it had dried up and I was left sipping cupfuls of sand wondering why my mouth was so perishingly dry. So, for a time I stopped and found it nearly impossible to think about starting again.

The pause, I told myself, was to be a pregnant one. It would be one of growth, maturation and development. It would give way to a miracle of new prose and people would remark that I had a wonderfully healthy glow.  Despite these best intentions, a pregnancy normally lasts around 294 days while the time between this post and my last will be closer to 543 days. This pause cannot be called pregnant in the conventional sense, not without upsetting a number of obstetricians.

What this has been, I can confidently state, is a hiatus. It is a good word, meaning a natural gap or fissure, derived from the Latin verb hio meaning "to yawn". It encompasses passages of time and space, and also the mysterious way that the stomach may roll or slide up into the diaphragm. It is as good as any to describe the interval between then and now.

So, from this hiatus you can expect some changes. The first will be a little polish and change to the site design; I think that after a few years of being tormented by green it's time for a slight palette swap. The second will be a slight alteration to the content of this little collection. Where before I wrote when and what the fancy took me, I think I could benefit from a little structure to my writing. Therefore, I plan to post twice-weekly with the two themes of "Memory Mondays" and "This-Time-Thursdays" where I focus on the past and the present or future, respectively. I naturally reserve the right to additionally deviate from the schedule to write about typically off-topic subjects or perhaps the all-too-familiar moans about other aspects of my life. As it should be.

So, if there's something you want me to write about, stop writing about or just to say hallo; pop a comment somewhere and I'll do something about it.

A number of interesting things have happened between my last post and this. I have helped someone be born into this world, and watched a few people take their leave of it. I've been covered in at least three different bodily fluids, sometimes unexpectedly. There are also another of exciting developments to come shortly, largely involving the terra incognita that is to come. Interesting times on the other side of the yawning crevice, then.