Sunday, November 13, 2016

The Things That Medical School Won't Teach You (2) - Don't mess with the nurses!



This has basically been one very crazy week; a crazy year for that matter: first we had Brexit, and now...well I don't even know what to call that little stunner that our American compadres just pulled on us (Amexit hardly seems adequate). Oh well, if frustration voting is the current wave, I'm hoping it persists until next year so we can get some real change down here in Kenya.

But I digress; as an addition to my medical school series, on this occasion I'm highlighting a topic that's on a different end of the spectrum than my usual fare. So without further ado, another rule of thumb for the wise clinician: Don't mess with the nurses!

Whenever I've highlighted my experiences, they typically focus on the doctors; that's mostly due to convenience because trying to encompass everyone and the skill sets involved would make for much longer posts. If you happen to spend anytime near any sort of health facility, however, you would quickly come to the realization that most of your time is spent in the company of nurses, the true unsung heroes of the medical world.

From a lot of my posts, and a myriad of others floating freely online, you can understand that the life of a medical doctor is no mere cake walk. However, nursing is on an even grander scale of difficult. I would estimate that as much as 70 - 75% of all the strict medical work taking place at a hospital is carried out by the nurses. Nurses are so essential that - as I've experienced in Kenya - to get any sort of decent medical strike going, you need the nurses' muscle to weigh in on the matter. You can keep a hospital running with a few Consultant doctors and a full team of nurses, but you can barely even hope to run a mere Outpatient department with all the doctors in the world devoid of a single nurse on board.

As I've mentioned before,
"Contrary to common thinking, it is a team effort that helps save lives."
Therefore, the message herein is twofold: 1. Respect the nurses; 2. Fear what comes with crossing a nurse.

During my stint at the Memorial Hospital (circa 2006), I remember one of my colleagues highlighting the importance of nurses; surgical nurses, to be precise. Surgery is hands-on, and the consultant will only 'hold your hand' for so long. You are expected to gain competency in surgical procedures through the long respected traditional method: "See one, do one, teach one."
However, even in cases where neither your Consultant nor medical officer are around, you are never really alone! The surgical nurses are veterans and have participated in so many surgeries as assistants in the Consultants' presence that they could actually perform some of the procedures themselves. However, since they are not legally licensed to carry out the procedures, they can at least guide you.

Now, initially, interns may be unaware of this vast resource at their disposal. Particularly egotistical interns might even rub the nurses the wrong way and choose to treat them like second class citizens. Now, nurses are a patient lot, and will usually let things slide; however, should the aforementioned intern find himself stuck during a surgical procedure in which he is the primary surgeon, then the nurses will just be content to let him sweat things out on his own. Worse still, at the end of it all, the intern would have to call his superior in to assist him, which many times could end up with the intern being berated. To me the point was clear: Respect the nurses!

I would daresay that the greater part of the refinement of my surgical technique occurred under a nurse's watchful eye. Mr. Nyabaro taught me subcuticular suturing, Mr. Mutaroki schooled me on the surgical tools; Sr. Asiago, Sr. Lydia, Sr. Dinah, Sr. Judy and Sr. Alice augmented my effort in any procedure that I performed. When the tides had turned and I had become adept at performing a myriad of the tasks, then they all helped me teach these skills to the next bunch of interns and students.

Of note is one memory that is as clear in my mind as the first day it occurred. I remember on my very first night on call in Obstetrics/Gynaecology, there was a lady who had an obstructed labour so she required a caesarean section. However, I froze up on the table, and I couldn't extract the baby; the scrub nurse was the one who successfully pulled the baby out. In the same procedure, I had yet another stroke of bad luck: I was unable to find the edges of the uterus, so I was unable to suture it and progress any further. At that point, I had to call the Medical Officer to assist me.
He was livid! From the moment he made his way into the changing room I could hear him protesting and cursing me out! He made his way into the operating room and scrubbed in amidst all sorts of threats. At the end of it all, he told me to either shape up or he would have me dismissed from the Obs/Gyne rotation. It was at that point that I made up my mind to be as self-sufficient as possible; also, I decided that I'd rather rely on fellow experienced interns or nurses to get me through the rotation.

There is a silver lining to this particular story, though: the scrub nurse was so disgusted with the behaviour displayed by my medical officer, so she made a point of reporting him to my Consultant; personally, I'm more of a "let-things-slide" kind of person (Lord knows I didn't want any bad drama), but the nurse stood up for me, and in the end won me some respite; and for that, I am deeply indebted to her.

That's right...nurses protect the doctors too! I can give two example in this regard: when (as a fledgling doctor) you mess up and write up the wrong medication, dosage or route of administration, the wise nurses will bring it to your attention, correct you (in private without embarrassing you), and prevent you from causing major harm to the patients. Also, recalling the "perception of impending death" that experienced nurses develop, the nurses will be able to draw your attention to the most critical patients. Depending on the kind of hospital you work in, sometimes the workload is overwhelming; this means you have to be able to triage the patients so you can divert a limited resource (your time, energy) where it's needed most. To the inexperienced doctor, it might be easy to get overwhelmed by the work, and to come to grips with the challenge of managing patients in a resource poor setting; however, the nurses will keep you on track, thus protecting you, the patients and the hospital's reputation all at the same time.

Don't get me wrong, I have no delusions that all nurses are good people. Some particular painful experiences during my internship came courtesy of nursing staff. Like I've mentioned previously, (medical) school doesn't teach people how to be good doctors; the very same truth applies for nurses. What I am highlighting is the positive outcome that comes from working with good nurses, and in my experience most of them have been very good individuals. There is an unparalleled synergy that just makes the job a delight. I would compare it to a good marriage where you're so in-tune with your partner that eventually you become aware of their thought patterns and can complete their sentences. I remember trusting some midwife nurses so much that if they told me that they would be unable to deliver a child naturally, everything else became academic; I would schedule the mother for a caesarean section on the spot! (You know yourselves Sr. Zipporah, Sr. Lilian, Sr. Elizabeth, Sr. Rose, Felix and Nyambane). When people give you their best each and every day, then you in turn can give your best.

This post wouldn't be complete without me reminding you to steer clear of vexing the nurses. It is one thing for nurses to bear the heavy load associated with their work; it is yet another for them to feel underappreciated, especially given the nonchalant and boneheaded manner in which people of authority have usually dealt with them. Kindly, do not add to their stresses by treating them disrespectfully for they can act out with a vengeance; keep in mind that the camaraderie between nurses runs deep, and one slight against one of them could be technically be viewed as a slight against all of them. Imagine trying to get your work done without the aid of the nurses! Thus, act accordingly and pick your battles; you can't win if you pick a fight with the nurses.

Patients too should be mindful of the manner in which they treat the nurses. In the course of their practice, the nurses develop an acumen in simple things...like knowing the least painful way to administer a certain medication. Acting belligerent towards a person who might end up with the task of injecting you with a multiple cocktail of medications throughout the course of the day can end up causing quite painful ramifications. Therefore, please, be kind to your nurses (for your own sake).
Have a Blessed day.

Saturday, November 5, 2016

The things that medical school won't teach you (1)

It's been a bit overdue, but I guess I might as well jump into that whole list of things I stated about the "fine print" with regards to things medicine; let's start things off with a biggie: You will sacrifice a great deal in caring for your patients that will never be compensated.

I actually mentioned this as number 6 on my list, but it is as fine a point to start with as any other. Poignantly so with the latest spate of medical strikes that have occurred in different counties all over the country.

I don't know if there's any analogous experience outside of the medical field that can really prepare you for what practising medicine really entails. I should know: I've taken quite the long route to get to where I currently find myself - 10 years of post-secondary education (4 years of Pre-Med Biology and close to 6 years of Medical school). Interspersed somewhere in there is some volunteering and doctor-shadowing.

The medical profession is still one of those very revered fields (seems like the reverence currently far outweighs its economic incentives). I'm making a calculated guess that any parent would feel proud if they were to hear that their child had chosen to pursue a medical career; sadness may creep in, though, when they realize how much money they would have to invest in that decision. So we make the decision to follow this path, put in all those hours of work and commitment, choose the right schools, get adequate extracurricular activities that reflect well on our character; also, lest anyone forget, medicine today, just as it was in the past, is learned through apprenticeship; therefore, having a good mentor in the field helps keep you motivated, and can show you up-close the sacrifice entailed in your career choice.

So, when you eventually make it past medical school, you eventually settle down to one year of basic serfdom aka "the internship". I'm thankful here in Kenya we only spend one year doing our internship, because my Ghanaian colleagues have to spend two (dreadful) years as interns. As I mentioned earlier, learning medicine is done through apprenticeship; the nature of that apprenticeship can very often mirror boot camp at the mercy of an unkind Drill Sergeant. I would be lying if I claimed that any two internship experiences are alike; some people have relatively calm internships, while some people (myself included) go on to have troublesome internships (the universe can be so unkind). You may find yourself dealing with many a cantankerous consultant; if you're unlucky, the medical officers might also decide to make your life a living hell. In my case, I run across the foul trifecta while I was rotating in the Obstetrics/Gynaecology Department - the Consultants, Medical Officers and even some of the Nursing staff took turns dishing out grief.

It really is quite the sad turn of events. Despite all the knowledge we rack up in medical school, nothing quite compares to full hands-on experience with a living breathing patient. What we do in medicine is definitely far from the norm. Normal people aren't supposed to do the things we do. Normal people aren't supposed to see the things we see; poking/prodding/probing and incising/ligating/exploring the human body all while assuring you that we mean you more good than harm is a hard deal to pull off. And in case you haven't noticed, a lot of your friends in the medical field are a tad unhinged - possessing a wry sense of humour and unmatched fortitude. It's just the nature of the business, and unfortunately, you pretty much have to learn it on your own.

That's right, there is plenty that is learned on the job. One of the more fascinating facts about medicine is that despite the fact that we deal with death on quite a regular basis, no one actually teaches you how to deal with it (breaking news to the patients' relative, how to inform someone that they have a poor prognosis); no one lets you know how to deal with the fact that your actions (in)directly may lead to a patient's death; also, no one teaches you to develop the sense of detachment from the patient that keeps you objective come what may. Something else they may not emphasize is that you also become really adept at knowing your limits with regards to saving lives. Sometimes you walk into the ward and you have a pretty good feel about the patients most likely to perish on that day. At first, it unnerved me a bit that nurses would just mutter that
"the patient in bed so-and-so is a goner!" (rephrased). 
Dastardly as that might sound, it actually is a "good" thing because it lets you know where to focus your intervention the most. Also, it lets you know who needs to be referred out for special care that you may be unable to provide. However, if you're in a resource poor setup dealing with poor patients who obviously can't afford to go anywhere else, then you prepare yourself for the worst. We don't get to wash our hands of the impending death, but we can at least assuage our consciences of the guilt.

Sometimes people assume that this stuff is easier to deal with because (apparently) doctors make a ton of money. Personally, on many occasions, I've had people step up to me and state that "medicine is a calling!" When you have people from all walks of life constantly reminding you that your chosen profession is a calling, you better believe that the money will definitely not be commensurate to the amount of work you'll put in. If the money's the reason that you're choosing medicine as a career, I'd prefer that you chose one of a host of other jobs that require less schooling, afford you more free time, better salaries, and a life free from frivolous litigation and egotistical individuals. Apart from medical professionals, the only other professionals that gets reminded so much of being "called" are probably teaching staff. (that's not exactly what I'd consider good company!)

Despite all the challenges and pitfalls, there are many good doctors who are in this profession and conscientiously make the effort to care for their patients no matter what the circumstance; who aim to do good by their patients with whatever they have at their disposal. They take care of your precious defenseless children, they support you in your times of weakness, will care for your aged relatives when their feeble bodies fail them, and will add life to any person's days that they encounter.

It is a hard life, but it's a life that I enjoy; I've witnessed some crazy stuff, but it's interesting to share treasured war stories with my colleagues from time to time. Though, I do wish the government would do its part in helping us take care of our patients. I would definitely prefer the job satisfaction that comes with being able to adequately address my patients' needs over a pay rise. The government has absconded its commitment to the health sector and the majority poor; without giving us the tools to care for this society, they turn us into mere palliative specialists. Like I've already mentioned, I have already learned to be pretty detached in my line of work - for my own sake, and my patients' too; but having my hands tied any further would only make me bitter, cynical and ambivalent...qualities you do not want in any of your doctors.

Take home message: if you choose this life, prepare for a gamut of challenges, and for the reward to mostly be in the work itself. That being said, you should also remember that it is a noble profession, it is God-ordained. Not many jobs have as immediate of an impact on the people served; so embrace it, and make your mark in this world as only you can.

God Bless.

Dr. Strange Movie (Spoiler Free) Review


This has definitely been a superhero heavy year, and here comes another addition to the long list of superheroes to hit the big screen. As long as they're making great movies and telling good stories, I won't be succumbing to any comic book movie fatigue anytime soon.

From all the vibe surrounding this movie, and the praise for its visuals, I was definitely poised to watch this in 3D, and definitely at the IMax Theatre. My twin brother organized this one on the fly, thus, despite not necessarily being a fan of being in downtown Nairobi that late, we settled on the 9.50 pm showing yesterday night. (I can attest that this time the IMax didn't do us dirty by starting the movie while we were still lined up outside the screening area. I gotta say, though, the IMax has one of the worst concession stands I have ever come across; drab and inefficient, it really spoils what should be a good total experience).

I'm pretty sure that this movie has already gotten a myriad of comparisons to other movies of yore. Of course there's the alternate reality type of thing entailed in this movie's plot, so The Matrix and Inception (especially due to the trippy visuals) will get tossed around a lot. This is an origin story, and Dr. Stephen Strange is an egotistical individual, so Iron Man will also get mentioned a lot. At the end of the day, it is clear that Dr. Strange is its own unique movie, and it one-ups all those other movies it gets compared to.

The movie is a linear narrative, detailing everything from the evil turn of the antagonist, to Dr. Strange's fall from grace and his desperation, and finally to his humbling and metamorphosis into a hero. Benedict Cumberbatch shines as the fledgling hero, interesting to watch in all his emotional turns, and lending gravitas to this comic book movie. His arrogance is more akin to Dr. House MD than to Tony Stark. He's not a bad person, per se: his demeanour is just atrocious (like some great doctors). By the time this movie even comes to an end, he's not yet even become the great Sorcerer Supreme that people usually know him to be; but, he's a humbled man rising to the challenge that has been unceremoniously tossed his way.

We have some good turns from everyone involved, especially Chiwetel Ejiofor, Tilda Swinton and Mads Mikkelsen. Seems like they threw an extremely gifted bunch of thespians into a mere comic book movie, but I'm not complaining. However, in setting up Kaecilius in a role that the comics usually reserve for a certain unnamed villain (no spoiler here!), I feel like some of Mads Mikkelsen's role might have been sacrificed. Therefore, as usual, people will complain that we've been given yet another weak Marvel villain. In the grand scheme of things, he's a secondary antagonist - similar to Loki playing second fiddle to Thanos in The Avengers, but being the biggest sinister presence within that movie. Fortunately for Loki, he'd had a pretty well established history by that time.

It would be very remiss of me to fail to mention the visuals of this movie, which are very much an unsung character in this movie. If you've ever picked up a Dr. Strange comic, you'd know that trippy visuals are par for the course with this character. This comic truly was Inception (and then some) before Inception was an inkling in Christopher Nolan's mind. However, bringing those visuals to life as beautifully as it was done here is in itself a superhuman feat. Once the Ancient One lays her hand on Stephen Strange's head, you are in for the ride of your life. I'm pretty sure Astral Projection has been done before, but this movie sets a new standard for what astral projection SHOULD look like. I'm not sure whether Dr. Strange has a faithful animal companion in the comic book, but this movie filled that role by imbuing the Cloak of Levitation with that manner of sensibility. From the moment the Cloak make its onscreen presence, it will be delightfully seared into your mind. As for the locations, London, New York and Kathmandu are stunningly shot and a beauty to behold.

This is a Marvel movie, so the colour palette is warm, and though the mood get heavy at times, it is lighthearted most of the time, and the jokes do hit the mark. I also love the characterization portrayed in the movie. Typically, Stephen Strange is the resident egotist who needs to be humbled. However, everyone in this movie, even the well-meaning sages, are shown to be flawed. Even the well meaning good deeds performed with the best of intentions can sometimes backfire terribly, and those ramifications are what will be explored further in what is to come in this franchise. It really highlights the Yin and the Yang really well; that there's a bit of good in the most evil of people, and likewise a bit of evil in the most good of individuals.

I had only one gripe in this movie, and it comes during that otherworldly visual street chase scene pitting Dr. Strange and Mordo against Kaecilius and his minions. In most of this movie, Dr. Strange and Mordo, whether they're winning or overwhelemed, are typically stoic and keep fighting. However, towards the end of that scene, they appear unnecessarily powerless and feeble, which serves as an exaggerated prelude to the tragedy that follows. It could have been played out differently, but like I said, minor gripe.

This movie is a beautiful addition to the MCU, and is probably their best Origin movie story to date. I'm looking forward to seeing how the Sorcerer Supreme will fit into the MCU from this point onwards. I can only rate this movie as an A+; I suggest you give it a watch in IMax 3D if you get the chance (wouldn't want you ruing missed chances of you wait till it comes out on Blu-Ray).

God Bless.