It seems as though I’ve seen a lot of people dying recently. Dying as a verb – breath gasping, limbs seizing, guts retching; dying as a noun – interrupted, ventilated, brain dead. After all this time in hospitals – the medical student in the corner witnessing silentlyish the tragicomic human mess – I wonder what I’ll feel when it’s me or my loved ones. Will I feel it for real, or will it seem second-hand, as if I’m remembering something I saw once in a film?
Another blogger wrote a lovely post recently about some of the challenges of being a medical student, and about her motivations for doing what she does. It reminded me of all the times I’ve wondered the same question.
Medicine is hard. Really, you say? Didn’t we tell you that before you started? Well yes of course, and I knew that and yes, I heard all those doctors who told me not to do it. I’m not deaf. I’m not stupid.
Medicine has been hard in ways I didn’t expect. The work is pretty full on, yes, but not really harder than another degree. Worse has been learning to be a student again, summoning up motivation to study, and exchanging friends for textbooks. And while medical school is one thing, I suspect working life will bring additional…issues. I’ve recently applied for my first Foundation doctor job, a national process that gives final year medical students a vague illusion of choice and autonomy before corralling them into random hospital posts across the country. That’s how it feels anyway. I find myself resenting this process heavily, given that as a… mature… student I would quite like some say in where I settle down for the next few years.
And of course it will continue to be hard. More exams, more job applications, more relocations, less time with partners, friends, children…and of course the sheer hardness of being a doctor at all. Of remembering all the blood results of every patient on your ward in case the consultant asks. Of knowing what to do when you’re the doctor on call and someone stops breathing. Of working out the real reason Mrs Singh has come to your GP clinic and managing her 26 differing needs in a way that is sensitive and appropriate and evidence based.
And to think I used to have jobs where all I needed to do was turn up at 9:30 (9:30!) and switch the computer on.
So why do we do it then? Is it because we “want to help people”? It’s the obvious med school interview answer, but you can help people as a plumber, teacher, hairdresser, kid’s party entertainer, politician – and have more time for your family. Is it to get rich? Better to choose banker, oil company executive, footballer’s wife. Is it because we love science? The thing is, medicine isn’t science, not really – you’d be better off in a lab.
For me, well I’m still not sure and the answer will probably keep evolving. But it probably involves needing some kind of job due to not being an heiress, being nosy about other people’s lives, the rush of a busy shift on call, the amazement of seeing a brand-new baby or someone’s insides, the daily ethical dilemmas, the joy of getting a thank-you kiss from an old lady, the satisfaction of making a diagnosis, the sheer daily variety and, yes, knowing that – even if it was just for an instant, I definitely did make a difference to someone’s day. (It could have been a net negative difference mind, but hopefully not).
It’s interesting, isn’t it, that at the end of the day we often make emotional rather than rational decisions about the most important things in our lives. I didn’t make a rational checklist when choosing my boyfriend – most people would agree that to be weird.
I know that as a medical student I still have a somewhat unsullied view of the daily grind. If you quote this post to me one 6am when I’m about to start my hour-long commute to work having been up all night feeding the baby, you can expect to get a slap. But I will try to thank you afterwards for reminding me.
Yep, I’ll admit it. Part of the reason I’d been looking forward to my GP placement is that GPs sit down all day, right? And they start late and finish about 4 o’clock, right? And they drink loads and loads of tea.
I’m halfway through the placement now, and the day goes something like this.
Wake up, jump on bike, arrive at GP, weave through epic crowd of patients, walking sticks, pushchairs etc in waiting room, hoping that none of them are already on the lookout for me. Find consulting room, log onto computer, find GP supervisor, scan first patient’s records, call in first patient, listen to description of sore back/palpitations/cough/noisy neighbours/insomnia/incontinence/unemployment/divorce/pregnancy/itchy toe, ask semi-informed questions relating to symptoms, rack brains to check for obvious missed things, smile, examine back/chest/abdomen/toe, write in notes, ask about ideas concerns and expectations, check BNF, discuss options, ask questions, explain medications, call doctor, present history, write in notes. See next patient, do neurological exam, explain difference between tension headache and migraine, try to allay anxieties about medication side effects, calculate BMI, check appointment list, apologise to next patient for lateness, listen to chest, look at tonsils, take temperature, print diet advice, call the doctor, breathe. Feel a pulse, take patient for ECG, diagnose atrial fibrillation, discuss management with doctor, explain different anticoagulants to patient while doctor writes referral, pass tissues, make small talk about patient’s son who is training to be a doctor. Think about that cup of coffee. Join doctor on home visit, take blood pressure, write in notes, play with the dog. Drive back to surgery, grab lunch, mainline coffee just because I finally can. Return to consulting room, call in next patient, repeat.
The thing is, I was looking forward to this placement a lot; I always thought I’d like GP and I was interested to see how the days would be. I like people’s stories. I like that every patient has a social or psychological side to their presentation, and that that stuff matters to the GP. I like that I have responsibility here – my own list of patients each day who I see on my own. I like that when I say I’m the student doctor people actually nod and stay in the room, and even listen to what I say. I didn’t realise how crazy busy it would be though. I take my hat off to GPs. The job is phenomenally grinding and complex and they work their socks off. I don’t know if I could do it forever, I don’t know if I have it in me to care enough, in ten-minute slots, about every sore foot and infected finger and sleepless night that walks through the door, and then to be on-the-ball enough to pick out the cardiac arrhythmia, the sick baby, the case of cancer and do something in time. It remains to be seen if I can do that.
The thing is though… here’s the thing: when I get home each night, and stop to think about it, I have had an awesome day.
“Is that physio coming back today?”, asks Mrs Jones in bed three. “The dishy one? Oooh, he was so tall and dark. The most handsome young man you’ve ever seen.”
Mrs Jones is 91. “This is one of the many great things about geriatrics”, laughs the consultant. “You don’t hear this stuff anywhere else.”
I’m doing a three-week ‘career experience’ in geriatrics, and it’s great. It’s one of the fairly few specialities where you have to be a real generalist – old people come into hospital for lots of different, often interconnected, reasons. Perhaps they come to A&E because they’ve fallen over at home and broken their hip, but the geriatrician’s job is to work out why they fell and try to treat the cause. Did they have an arrhythmia, an abnormal heart rhythm? Does their blood pressure drop too much when they stand up? Are they unsteady on their feet because of cerebrovascular disease or Parkinson’s or arthritis? Do their medications need adjusting? Or is it just that they can’t see properly and their house is a bit cluttered? I love detective stories, so this kind of medical sleuthing really appeals.
It also takes more than just doctors to do the job. There’s no point in fixing Mrs Jones’s broken hip if there isn’t also a dishy physio to help her learn to walk again, an occupational therapist to make sure she can manage at home and a social services team to arrange carers to come and see her. And you have to care about people’s whole lives, not just their illness. What kind of house does Mrs Jones live in? Are there stairs? How many? Where? Who is at home with her? Does she have a husband who can help, or is she the one looking after him?
People say geriatrics must be depressing because your patients are old and so many of them will die. I don’t really see it like that though. We will all die, but these are people to whom small things make a huge and immediate difference. Like Mrs O, age 89, who cried with happiness the first time she walked again after her hip operation. Or Mr H who didn’t mind being in a residential home as long as it was close to his friends. We seem to fail so often in this country, in the way we treat our elderly. We need to get these things right – our parents and grandparents deserve this.
Of course there are sad things. My constant lament – that people come into hospital with some minor ailment and end up diagnosed with something worse – is ever present here. Like Mrs B, who complained of constipation and ended up with metastatic cancer.
And it is ethically fascinating. As my consultant says, “You can’t get as far as breakfast in our society without having to make dozens of ethical decisions.” And geriatrics is the same. Geriatricians decide on a daily basis whether patients can give informed consent for a treatment; when a procedure is in someone’s best interests; when it’s ethically right to withdraw active treatment and allow someone to die.
Mrs Brown is 95. She came in several weeks ago after a fall in her nursing home, and then developed pneumonia. She is frail and sick, and has dementia, and her family want her to be allowed to die peacefully without any more aggressive treatment. My consultant agrees, but for some reason she has been started on antibiotics anyway.
Mrs Brown has fallen to one side in her hospital bed, tiny against the pillows. A bag of antibiotics hangs from a drip stand by her bed, snaking into a cannula in her hand. My consultant tries to rouse her but she doesn’t speak, just grips his hand in both of hers and doesn’t let go. “It’s frustrating”, he says. “What benefit are we giving her with these antibiotics? Take them down. Take the cannula out.” He turns back to Mrs Brown and squeezes her hands. “Are you alright? Is there anything I can get you?” She opens her eyes for the first time and smiles. “Can I have a nice cup of tea?”
Travelling alone can be exciting, freeing, lonely and boring in equal measure. On one hand you can do whatever you like. No-one will know if you spend whole evenings watching The Apprentice on YouTube rather than doing something cultural or sociable. On the other hand, you’re at risk of spending whole evenings watching The Apprentice rather than doing something cultural or sociable. This is probably ok.
Travelling alone requires that you deal with certain potentially uncomfortable situations, such as going out to dinner alone. Many people have strategies for this, such as arming themselves with a book or a phone so they feel less awkward and block out the horror of the situation. Some write blog posts about being alone, thus convincing themselves that they’ve sidestepped the issue. Other people revel in the moment, gazing around confident and prop free as if to say, “Yes, I’m dining alone. I’m a free and competent human being”. I’ve never met any of this latter group.
Travelling alone also means you have fewer cool photos to impress people with on Facebook. Endless photos of scenery or temples with no-one in them quickly become boring, and so you start taking photos of food, which are worse. However, being alone provides the opportunity to use the timer function on your camera to set up arty selfies, so you can look cool and pretend to have friends.
A less fun part of travelling alone is when you get ill, which invariably happens. This lone traveller heartily recommends stockpiling plenty of bottled water to avert death due to dehydration, then resigning oneself to 36 hours of gazing at the ceiling fan.
Finally, an important part of travelling alone is meeting other people, which can make things more fun. Some people are good at this and manage to strike up easy conversations in bars or on buses. However, there is the risk of looking desperate or – worse still – ending up with a new companion who you find even more boring than your own company. For this reason it’s sometimes better to stick to travelling alone.
Today being a day off, I decided to cycle up the road to the wonderful Angkor temples. They’re beautiful, as is the tropical forest around them. More about that in the guidebooks.
Road travel in Cambodia is great fun.* There are surprisingly few cars; most people travel by the cheaper motorbike – or motodop - and there are also a lot of bicycles. The way it works is like this: starting from a side street, join the main road with speed and aplomb. Looking back is for wimps. Follow everyone else’s lead in riding along on the right hand side as fast as you can. If that’s the wrong direction just turn round and ride against the flow instead. When overtaking, beep your horn or bell as loudly as possible, then race up the middle and hope for the best.
Transport is a sociable affair. A moto with less than three people on board is a moto wasted. Standing, sitting on your dad’s shoulders and riding side saddle are all ok. Acceptable activities whilst riding your moto include drinking iced tea, chatting on your mobile phone and breastfeeding. Sometimes, if there are police around, you should consider wearing a helmet.
A moto is an all-round family vehicle, perfect for driving your mates to school, taking your girlfriend on a romantic sunset drive, and it’s still good three kids later. More than three kids and you need a cart. Happy riding!
I had hoped to spend my elective in some busy general hospital, seeing terrifying things and learning a lot. It hasn’t really turned out that way, but my time at the river clinic is showing me something else instead.
This is ‘GP land’, as they say at home, but with little capacity to do anything beyond the basics. No friendly ambulance a phone call away; few diagnostic tests. GP land in extremis. Sitting at the doctor’s table in our one-roomed floating clinic, I watch the local villagers as they come in – often barefoot, mums breastfeeding, stooped old ladies, kids staring wide eyed at the strange white doctor. Some are really sick; others are here for their weekly health check, taking advantage of the free clinic and its medicines.
Often the doctor and I have three sets of notes at once as a young mum presents her runny-nosed toddler, her feverish baby and her own painful abdomen all at the same time. We see lots of common things – a boy with bacterial conjunctivitis, an elderly woman with a painful hip, a small child with a chest infection. Our tools are a stethoscope, auroscope, pen torch and The Oxford Handbook of Tropical Medicine. The contents of the drugs box have been selected carefully for the setting – metronidazole, ciprofloxacin, albendazole, paracetamol, oral rehydration salts.
I can see how useful the clinic is, in this location so far from any other formal health care, but from a medical perspective I find it quite frustrating. Perhaps I’m too inexperienced in primary care. I wonder how many people here have HIV and other STIs, and realise that probably nobody knows.
A young woman presents with vaginal discharge, and the doctor asks me what I think we should give her. “Well…what colour is the discharge? Is it itchy?” I can’t speak Khmer, so the doctor is translating the histories for my benefit. “She says it’s clear, and a bit itchy. What do you think?” I’m not feeling great about this. Even if I wasn’t just a medical student, I’m pretty sure I’d still be reluctant to make a diagnosis based on three words: ‘clear’, ‘itchy’ and ‘discharge’. “Can we have a look at it?” I ask. “She doesn’t want to show us”. I’m not really surprised. Anyway, the team dentist is seeing another patient behind the curtain. “Can we ask about sexual partners?” “Well she’s married”. “Is her husband likely to have other sexual partners?” “Sure. But we can’t ask her that.”
In the end the girl goes away with metronidazole and clotrimazole to cover all bases, and I’m left with a sense of futility. Without knowledge about STIs, and without her husband’s co-operation, she’ll be back again and again and again. I realise that, without good public health and education, doctors are simply footmen servicing a giant revolving door. In a way it’s why I like general practice so much – through patient education, primary care doctors get to prevent illness, or at least treat it before it gets bad. It’s frustrating to see a situation where there are so many obstacles to health.
I travelled more than 6000 miles to do an elective in Phnom Penh. And, y’know, defied probable death and stuff. So when I arrive to find the hospital empty except for maybe one post-op patient and one receptionist (asleep), I can’t help feeling a bit let down. Ok, so perhaps medical electives are basically a glorified jolly for privileged white kids, but I’m here now, I flew a long way and I want to see something.
Ok, fine. Smile. Operation audacity.
A few emails and a long bus ride later, the elective fates have deposited me in Siem Reap, possibly the hottest place on earth. Google says it’s 37 degrees. My headache says 57. It’s a welcoming town though, all golden pagodas and motorised tuk-tuks, and women selling fruit I’ve never seen before by the roadside.
My destination: The Lake Clinic. Run by an ex-American nurse and staffed by local doctors, nurses, dentists and midwives, it’s a small organisation that provides basic health care to remote communities. They don’t officially take medical students, so I’m feeling pretty fortunate and happy to be here.
TLC consists of two teams who travel to remote locations each week – one on a lake, one on a river – and set up pop-up floating clinics for three days at a time. People living here are some of the poorest in Cambodia, and getting to the nearest health centre or hospital is usually too far and too expensive. So TLC brings basic free health care to the communities, as well as providing health education and making referrals.
I’m joining the river team. We meet at 6am and load the minibus – waterproof boxes of drugs and medical equipment, mosquito nets, food and loads of bottled water. It’s a three-hour drive to the river, then a boat. The last hour is mostly dirt track – bumpy and narrow, winding between rice paddies, and mango trees, with chickens strutting beneath houses on stilts. I can see why we’re here – I wouldn’t want to get sick here – it’s an hour at least to the nearest health centre, and it’s… how can I say this… SO. HOT.
Eventually we stop on the river bank and transfer to the TLC boat for the next leg. Presumably this river was once shaded by lush rainforest, with birds and monkeys in the trees. Sadly we’re a hundred years too late. Most trees have gone to make way for farming, and the riverbanks are lined with noisy diesel motors pumping water up onto nearby fields. I’m reminded of a line from my Oxford Handbook (page 389 this time). “The world moves on, tarnished, tawdry and trashed”.
The clinic is a large floating hut moored to the opposite bank. We’ve been travelling since 6.30am but there’s a morning clinic scheduled, so everyone sets to work hanging curtains, setting up folding tables and arranging the ‘pharmacy’. The whole thing is amazingly well designed, and within minutes I’m standing in a fully functioning, one-roomed, floating health centre.
I’ll be assisting the team doctor. Our ‘doctor’s box’ contains a BNF, stethoscope, auroscope/pen torch, thermometer, electronic BP machine, tongue depressors, a pulse oximeter, the Oxford Handbook of Tropical Medicine, and some documents outlining local prescribing guidelines. Most of the things you’d expect for a doctor in a primary health clinic… except with no hospital nearby, no easy referral.
We take a seat, the doctor and I, and await our first patient. And luckily we have a fan. Did I mention that it’s hot?
Doha to Phnom Penh. We take off in the witching hour, planes waiting on the dark desert tarmac like strange sea creatures. Does anyone ever actually stop in Doha? Second flights always feel like no-man’s land to me: between two unknowns, a stranger to everyone. And night flights, as everyone knows, are the ones that vanish. From an unknown to a mystery.
Anyway, by the second flight I’m often too tired to care. And this one’s half empty, so I manage to lie down and sleep for a while.
I’m woken by a loud thump. To my mind, thumps on planes always = imminent death. Looking round however, I realise that a man has collapsed in the aisle behind me. There are a host of, well, hostesses around him and he’s just starting to move again – looks like he fainted. He’s ok, I think, lying back down to sleep. Also, plane still in air – phew.
That’s when I hear the announcement. You know, the announcement. “Is there a doctor or a nurse on the plane? Can any doctor or nurse please come quickly.”
Me? Naaaah, I think, looking round. There has to be a doctor or nurse on this huge plane somewhere. They’re pretty common professions. Several doctorless and nurseless seconds go by though, and I find myself standing up. I thought this moment would terrify me, but it doesn’t. (I’d be more terrified if I wasn’t pretty sure the guy has only fainted).
“I’m not a doctor” I say, going over to the huddle of hostesses. “But I’m a student doctor”.
They turn. “Oh, thank you doctor”. (Did they hear me?) A case appears containing a handheld sphygmomanometer and a shrink-wrapped stethoscope. Can you check his pulse and blood pressure for us, and write a doctor’s report?
Can I? Well, this is what I’m training for. I put the cuff round his arm, so grateful for those lessons, way back in first year, on how to measure blood pressure by hand with a stethoscope. It’s a surreal moment, listening for the Korotkoff sounds over the roar of jet engines. I take a quick history too, checking there’s nothing else going on.
I’m lucky, the guy is ok and I’m confident to write that down (stating clearly my student status). Returning to my seat, I realise it’s the first time I’ve had to use my skills – however basic – in a real situation, far away from guidance. It feels good.
Something about me: I’m afraid of flying. Really afraid. Nights before a flight I’ll lie in bed made breathless by the certainty of an imminent, terrifying death. Plane crashes are statistically highly unlikely, you say? They happen, I say. Who’d you think is on that plane that vanishes or tumbles out of the sky in the dead of night? It has to be someone – why not any one of us – why not me?
At the same time though, flying fascinates me. Ascending, taking off, watching as your home your country becomes the whole world. Flying changes your perspective on everything. The way back gardens become snow-ridged mountains. The lives and loves and wars played out across hundreds of cultures below as you eat your pseudo middle-eastern sandwich from the Doha section of the airplane meals dept and watch reruns of Friends. It’s another dimension. Marco Polo took 24 years over this journey.
Anyway, there’s a huge world out there; sometimes you have to balance risk of death against the probable gains. And I’m off on medical elective – two months in which we’re let loose to do anything we like (related to medicine), anywhere we like in the world. How on earth do you make a choice like that? I chose a small surgical hospital in Phnom Penh, Cambodia, specialising in cleft lip and palate repairs, burns reconstruction, trauma surgery and cataract surgery. Phnom Penh! It’s almost worth it for the name alone.