Servicing the giant revolving door

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.

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In which the author overcomes hurdles and ends up somewhere unfeasibly hot

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.

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A busy elective

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.

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Siem Reap. Heat not shown.

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”.

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Start of the mission

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.

Reception

Reception

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?

Is there a doctor on the plane?

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.

Pteromerhanophobia to Phnom Penh

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.

Medical origami

My first GP tutor at med school was an inspiration. He would often whisk us away from other tasks because he had a patient with an interesting clinical sign he wanted us to see – some poor man with hyperreflexia perhaps, who would then be subjected to a line of six bright-eyed medical students inexpertly bashing his knees. He once drove us for half an hour across town for the sole purpose of listening to a pleural rub. And he’d come out with gems like “If you don’t know what’s going on, send the patient to do a urine sample. It makes them feel better and gives you time to think.”

Anyway, one day he taught us some quick origami for keeping children entertained in clinic. I promptly forgot his instructions, and a couple of years on I’ve lost count of the times I’ve wished I could remember them. I mean, as someone who spends most of her time hanging out in the corner of clinic rooms*, there are a lot of occasions when it’d be nice to have something to cheer up the restless little sister of the boy who’s been brought in with chickenpox or something. Luckily I found the original in a drawer the other day, so here goes:

Take a square of paper (the page from the back of your notebook is fine). Fold it diagonally, then turn over and fold horizontally, as so:

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Bring the corners in and fold down to make a smaller square. (I suspect this bit has a fancy origami name.)

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Fold the top and back layers down so you have this:

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Now fold the top sides down to the centre – both layers – to get this:

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Extract the flap that’s in the middle, and fold it up and over the outside, like this:

IMG_2697Turn over. The next part is the fiddliest, but worth it. Fold out the top layer of each triangle from the middle, like this…

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… and add personality!

IMG_2701Et voila! He fits on the end of your finger.

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Our tutor claimed that he wasn’t doing too well in his paediatrics clinical exam years ago, but then made this, made the kid smile, and passed. I reckon that’s a skill worth having!

*I mean obviously I’m working really really hard at the same time, but sometimes you can get away with this stuff while the doctor’s back is turned.

Medical mnemania

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There are hundreds of medical mnemonics out there to help poor hapless students remember their facts. I just found this photo illustrating one to help you remember the types of thyroid cancer: Please Feed My Alligator (papillary, follicular, medullary, anaplastic). Anaplastic tumours are the worst (and also closest to the alligator’s mouth). The picture also happens to illustrate brilliantly how I feel about my exam tomorrow.

While we’re at it, I found another excellent mnemonic the other day about catching cats as a way of remembering the Glasgow Coma Scale (‘decorticate’ sounds like ‘caught a cat’, which you’d do with flexed arms… oh never mind). It made my day anyway.

o-BRIDES-THROWING-CATS-570This could be a fun topic to go on with, but I suppose I should revise. Do you like mnemonics as a way of learning? Have any favourites of your own?

 

Some basic taxonomy

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Exams are back. Or, we’re back at exams. There are a few distinct species of medical student who emerge at this time of year. Here’s your handy guide to recognising them:

The super-competitive one.

Says: “I was in the library ’til 1am last night, then my housemates and I went through all the Parkinson’s plus syndromes before practicing the hip, knee and elbow examinations. Do you know the chemotherapy regimens for myeloma? They’re easy, I did them this morning.”

Found: on the ward or in the common room, discussing rare syndromes with other members of same species. Usually wears shirt, ID badge, stethoscope and smug smile.

The self-depreciating panicker.

Says: “Oh my god, I’m definitely going to fail. I spent all of yesterday looking at cardiology and I can’t remember ANYTHING!”

Found: in the library, semi-visible behind huge pile of books, notes, highlighters and can of energy drink. Wears stressed expression.

The overly nonchalant one.

Says: “Oh yah, whatever, I never do that much revision. I was playing rugby/trampolining/running a half marathon yesterday. I got 82% last year though.”

Found: having a coffee and chatting loudly at table next to self-depreciating panicker.

Note: no matter which species you identify with, or even if – god forbid – you think you’re normal, it is never ok to adopt either an a) non-competitive or b) contented demeanour. Think revision sucks but you’ll probably be ok? Nope, no way. It’s just not said.

Me? Well, I’ve clearly developed a fetish for post-it notes and have pink and green spots swimming in front of my eyes. Now, what’s that syndrome called again?

 

Crossing the line from a normal person to a doctor

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There are some things in medicine you’d think it’d be quite important to get right. To have good technique and know what you’re doing. For, you know, everyone’s sake.

Yeah, right.

Doctor: “So, what do you want to get out of this clinic today?”

Me [uncharacteristically prepared]: “Well I’d like to understand the basic management of some of the common urological presentations, like haematuria and prostate cancer. And I’ve never done a PR, so I’d like to learn how to do that if possible.”

Doctor: “Great! We’ll see what we can do.”

Half an hour later, in walks Mr Unsuspecting Prostate.

Doctor: “I’d like to examine your prostate if that’s alright”.

Mr P: “That’s fine, doctor”.

Doctor: “And we have a medical student here today. Do you mind if she examines your prostate as well?”

He sits back down at his desk, leaving me standing there with a glove, a sachet of lube and a patient in front of me in the foetal position. I think this is most awkward I’ve felt since coming to med school. I guess I thought there might be some…instruction. I’m aware that if I ask what to do it might make Mr P feel more uncomfortable. And yet if I don’t, I might as well be any old person off the street who just happened to find a glove, some KY jelly and an interesting opportunity.

Oh well, perhaps that line was crossed a while ago. Anyway, I should know. How hard can it be?

I sigh, choose a finger, and go for it.

—-

Fitting: https://dailypost.wordpress.com/2014/03/27/prompt-the-great-pretender/

 

Standout

Anyone white person who’s ever been to Africa will know that you can’t come here and expect not to stand out.

Each country seems to have a different word to describe its white visitors. In South Africa they say ‘mulungu’, in Rwanda ‘muzungu’. Here in Ethiopia it’s ‘farange’, or ‘farangi’.

Sometimes it feels like a taunt; more often just an exclamation. I’ve walked through South African villages and had small kids literally run down hillsides towards me, shouting “Mulungu mulungu mulungu I’m fine how are you! I’m fine how are you! I’m fine how are you!”

My Ethiopian hosts, however, are a little more restrained. Who are they to be seen running from hillsides? Anyway this is Addis; anyone who tried that would probably be hit by a taxi.

Oh, I stand out alright. And there’s no discrimination: I can count on being equally ‘farange’d by young girls, teenage boys and old women. But it’s the delivery that never fails to crack me up. It’s so completely deadpan. I can only imagine that the conversation goes something like this:

“Yeah, I know, what a bastard right? So I told him if he ever treats me like that again – white person – I’ll be going out with Worku instead.”

Or: “Can you believe the price of nappies these days? I might have to start getting those reusable ones, but they’re disgusting and anyway – white person – what can I do when there’s no water half the time?”

Clearly the only explanation is that there’s a nationwide Ethiopian game of farange bingo going on that I don’t know about. I love it.

http://dailypost.wordpress.com/2013/08/15/daily-prompt-standout/

Bedrest

The patient limps through the door and eases himself into the chair by the surgeon’s desk. I’m sitting in on a private orthopaedic clinic. I’ve only been here ten days, so my Amharinya is limited to things like ‘thank you’, ‘coffee please’, ‘no’, ‘yes’, and that strange sharp intake of breath that means yes.

This man is obviously in pain though, and the pelvic x-ray tells me why. He has avascular necrosis of the hip – his hip bone is wearing out.

I listen to the surgeon taking a history, pointing at the x-ray. The patient nods, shakes his head, looks tired. Eventually the surgeon produces a pad and writes out a sick note. I peer over his shoulder.

“He needs bedrest.”

The patient nods, takes the note, limps out.

“Bedrest?” I say. This is nothing I’ve learned before.

“Sure”, says the surgeon.

“Of course what he really needs is a total hip replacement, but he can’t afford it. He works as a security guard, so all I can do is tell them he needs bedrest, and at least then he can take the stress off his hip and he’ll be in less pain.”

Bestrest, not surgery. Just a single moment, a tiny glimpse for me. Here, a daily reality.