Friday, July 13, 2018

The Things That Medical School Won''t Teach You (9): The Ick Factor



I was just thinking about one recent night while I was on duty at the Casualty Department. As (bad) luck would have it, I ended up with the kind of patient that the nurses swore that I attracted to the department: someone with Per Vaginal (PV) Bleeding. Unfortunately, we didn't have ultrasound services operating at night, so we either had to send such cases out to a place where they could get urgent ultrasonography done, or tough it out with the little that we had at hand (good ol' back-to-basics medicine).

On this one occasion, I remember the patient being really embarrassed; it wasn't because of the invasive procedure that I was performing (which is the usual suspect); rather, she was embarrassed because she felt she was tasking me with dealing with this particular unsavoury medical malady. I just calmed the patient down, and let her know that this was basically what I had trained for, and she had no reason to feel ashamed. (I didn't mention that I'm also paid to do this kind of stuff, but money isn't exactly the thing I'd highlight as a saving grace).

This whole incident made me think about exactly what I've been through to get to where I currently am. As if on cue, the first memory that popped in my head was an incident from my internship - the surgical rotation to be exact. 

My rotation consisted of 4 sections (Male Ward, Female Ward, Theater, Casualty) which the 4 interns of the surgical department rotated among weekly. This just happened to be my first week on the Casualty rotation; so, it's Sunday morning - 8 AM-ish - and the Casualty Department is pretty nice and quiet...until it isn't anymore! They rush a patient in who's had a traumatic amputation of his right forearm. There's a tourniquet in place, but still, it's one of the more macabre things that you could witness in a day. Story goes that the gentleman set about using his chaff cutter early in the morning (before even 6 am), and while he was at it his right long sleeve got pulled into the machine, and his forearm followed thereafter. Thus, here he is before us, missing more than half of his forearm.
Dastardly as things might seem, you only get a few seconds of pause before instinct kicks in: get IV access, get vitals, draw blood for tests including blood grouping and cross-matching, shred clothing, run fluids to get his pressure up, get the patient warm and covered, call up theater to have it prepped for an emergency and then call up the Consultant Surgeon so that he can get down to the hospital pronto. Some of the steps actually overlap and are not so easily delineated in practice. So we finally get the man into theater to basically finish off what the chaff cutter started. (Unfortunately, the limb was too mangled and we were missing the other half which the chaff cutter must've  made literal mince meat of).  We deal with the veins and arteries, then we take care of any visible nerve endings, cut them as far back as we can; next we prune the bone fragments, remove the traumatized flesh and shape things up so that we can have a nice stump. All this is important because we want to improve his chances of being able to be fitted for a prosthesis later on, if the opportunity avails itself.
When surgery's over, he gets wheeled out into recovery, and we can all take a collective breath; and then, in one of those very weird medical occasions, we end up with a light moment. The anaesthetist had used Ketamine to anaesthetize the patient, (clinicians recognize Ketamine as "truth serum") so when he wakes up he's basically bawling about not being able to pay for the weddings of his unmarried son and daughter; he goes into detail about the whole thing (most of which goes over my head because he's speaking in Kisii), but the theater staff translate some of it for me in the midst of their chuckling. As always, my Consultant could be trusted to deliver a scathing remark, and even this time he didn't disappoint, "Why didn't he just leave that task for his workers to perform? This was just pure greed!"
By the time I met him in the ward, the Ketamine-induced reverie had ended, and he was stable. It might have seemed very heartless of us, but after the shock of the experience, I'd rather settle for a wailing patient than a dead one. On the plus side, we'd guaranteed that he'd live another day, such that he'd be able to thank his lucky stars, or alternatively be able to mourn for a lost limb.
I remember running into him at the hospital a couple of months later when he was coming to the hospital for physiotherapy, and he was in a jovial mood. I also ended up treating him for some nerve issues later on. It's always a strange experience when a patient who's had a limb amputated tells you they can feel their digits - in this case "Fingers" - itching or even hurting (the marvels of the human body). All in all, it was good to be able to glean a positive outcome out of such a bad situation.

Against the backdrop of such an experience, it should be clear that any medical professional before you (of sound training) is an amalgamation of many unique formative experiences, some of them quite terrible indeed. However, it is this very training which helps mould "book smarts" into actual experience, instinct and second nature. Many a time, I'm quick to remind interns that they haven't really had a true internship experience until they have intimately interacted with all manner of substances that a patient's body can produce. If your personal effects have not come into contact with Saliva, Blood, Faeces, Mucus, Urine, Pus, Meconium, Sweat, Vomit in any of their variations, then you've had a pretty sheltered internship. 

The more I think about it, medical practice sounds a lot like Motherhood. I doubt any mother would deny that they've had to weather all the aforementioned substances in taking care of their families; in our case, the only difference is that many a time we are doing this stuff while taking care of complete strangers, which might make it harder.  

The medical practice involves getting accustomed to a cornucopia of sights and sounds (even smells!). I'm reminded of my stint at Messiah College when I took an elective Anatomy class, which had somewhat of a tricky time slot; my only choice at getting a meal was either to eat right before the class, or grab a meal after it ended at about 5pm; the first time I had that class, I might have skipped the instructor's reminder to change gloves often because the smell of cadaver-infused formaldehyde seemed to leach into the gloves and become one with my skin. I vividly remember that I grabbed a burger as my late lunch that day, and it took sheer willpower to finish it as I battled my sense of smell to get through with the deed. Wouldn't have taken much imagination to have me reckon that I was sinking my teeth into some good ol' cadaver-du-jour. Fast forward a week or so later, and we'd all gotten so used to dissecting the cadaver, I'm pretty sure we could've had a meal in the classroom (if the situation had called for it).

My instructor - Sheri Boyce - told us that it wasn't unusual for some people to end up forgoing some specific meals after spending some time in the class. There was just something about the consistency of  roast beef or spaghetti that strikingly resembled some of what they were dissecting in the cadaver, so they could never bring themselves to sample those foods again. (Glad to say, I had no such problems, even in light of the "hamburger experience").

However, nothing reminds you about how much you've changed, until you interact with "normal" people. I don't quite remember how it happened, but one day a group of art students popped in to sketch the cadavers. Apparently they had the sentiment that sketching the human body in its most raw form was the pinnacle of an artist's experience. I guess they weren't prepared for what that raw form would look like once you'd peeled off some of the layers. All I can remember is that they came in with their sketch pads raised and started to watch us work, but for such an animated crew (some of whom I had interacted with) they were unusually quiet. Next time I peeked over, their sketch pads were down by their sides, and they were just staring, their faces a few shades paler. Suffice it to say, my attention was more fixed on the cadaver, with all the sharp instruments and sharp shards of bone posing quite the imminent risk, so I never really quite noticed when the artists disappeared, but when my attention shifted to them later, they were all gone. Takes a really strong constitution and some getting used to to handle some of this stuff!

I don't think it's a mere coincidence that one of the words I've used most often today is experience; that really is what makes all the difference. First time experiences need not be so pleasant with regards to half of this stuff because it really is a steep learning curve. I'm reminded of

  1. a few medical school colleagues who would go faint at the thought of having their blood drawn or at the sight of blood; (always astounded me how afraid some medical staff are of needles!)
  2. that one time I had a nursing student hold a child as I was attempting to perform a lumbar puncture (spinal tap). Must've been something about the novelty of the experience and him bending down to hold the child (maybe dehydration), because a minute or so afterwards, he felt light headed and I had him go sit down on a nearby bench where he promptly passed out.
  3. drawing blood from a patient in the casualty department, and having his relative (who was standing by for moral support) suddenly collapse in a heap onto the casualty floor. Oh the joy of having one emergency suddenly turn into two!
  4. the smell of singed flesh when first encountering the diathermy. Nothing quite prepares you for the sensation of burnt/roasted human flesh when someone uses the diathermy to cauterize tissues or to cause clotting.
  5. dealing with any sort of perforated gut contents. You'd think the patient was sick enough when you reviewed them in the wards, but when you get them on the operating table and open them up, the most nefarious of smells will assault your senses. It's like literally being immersed in a septic tank. We always joked that the operating room was done for the day after such a procedure. Would need thorough cleaning and the grace of God before another procedure could happen in there again.
  6. standing in during a delivery, and guiding the mother on when to push during her contractions; this one time though, the mother, being uncooperative, grabs my arm instead of her knee, promptly painting my coat sleeve with meconium. (Sadly, civilians seldom believe me when I tell them that child delivery is not the "sanitized process" they believe it to be, especially with regards to the mother's psyche)  


Fortunately, medical training is a marathon, and not a sprint. Ideally, a good superior will not hold initial uncertainty and inexperience against you, but will use it as a teaching point to enable you to gain the confidence you need to become a skilled clinician. (Perhaps it might even allow them to reminisce on how they were when they started out); and it is always an opportunity to derive a much needed laugh at the comedy that arises.
"We learn to do something by doing it. There is no other way." – John Holt
As usual, people should revel in the fact that "their medical friends" are all a little insane; but then again, someone would have to be slightly unhinged to do what we do on a daily basis. May your little bit of insanity bring stability and healing to this precious world.

God Bless

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