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.

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/

 

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.

Moved to Tears

In Addis you have to take internet time as it comes. Today’s Daily Prompt was to “describe the last time you were moved to tears”. I initially missed the end of that sentence [by something beautiful] in my haste to get everything done before the next power cut. So here there are rather more tears, less beauty.

Yesterday, following my Ethiopian surgeon friends on their ward round, I realised that – until that moment – I had never seen someone really, truly in pain.

After surgery on a joint, perhaps a knee or an elbow, it’s important that the patient starts to move it again so that the joint doesn’t stiffen into one position.

Picture yourself standing in an operating theatre watching a boy’s leg being sawn in two. And then imagine, the next day, seeing him literally screaming in pain as he’s told he has to move it, swing his knee over the bed and kick it back and forth. You know exactly what’s under that bandage. You can only imagine what he’s feeling.

I realised I’d never witnessed that amount of pain before. It was worse than blood or needles or seeing someone cry or be sick or fall.  I didn’t know it would be that visceral, immediate, personally excruciating. I didn’t know it would make me want to faint, vomit, and be moved to tears.

http://dailypost.wordpress.com/2013/08/10/daily-prompt-beauty/

On learning to love surgery

“The way these things usually go wrong”, says the surgeon, muffled through his green mask, “is when you don’t take out enough bone”.

Several months ago in the deepest darkest English winter, I decided that I wanted to have an interesting summer holiday. To do something useful, something exciting, maybe have a bit of an adventure. Some emails, a grant application and some disorganised packing later, here I am. In the CURE paediatric orthopaedic hospital in Addis Ababa, Ethiopia.

CURE is a private hospital. Operations are performed mainly by local Ethiopian doctors trained at Addis medical school, but funding comes from external donors – national and international. The hospital is relatively small and quiet, the equipment is good and there’s plenty of time. The waiting list, though, is long.

Children come from all over the country for specialist operations they can’t get elsewhere. One very common presentation is clubfoot, a congenital condition that means the foot (or feet) turn down and inwards. At home this would be treated early using combinations of foot supports, braces and special shoes, but here the kids have no choice but to walk, and years of walking means that the bones deform. If they’re lucky enough to get to CURE they can have corrective surgery. Much of the problem with clubfoot is in the tendons and ligaments, so they have ingenious surgeries such as Achilles tendon lengthening, posterior medialis release or anterior tibial tendon transfer. If the bones are deformed they might have a triple arthrodesis, which involves cutting out a wedge of bone in the foot, tearing out the cartilage with pliers and letting the bones fuse in a new position.

I’ve been known to be squeamish about surgery. Hey, this is the blog of a medical student with needle phobia, right? I was fully prepared to come here, the strange medical student from the UK, and faint in the OR while watching something hilariously minor. But I’ve been fine. Actually I’ve watched some of the most gruesome things I could have imagined: a little girl with osteogenesis imperfecta having her femur sawn in two and rejoined with a metal rod; a total hip replacement; a 13 year-old boy having his entire back opened up to remove 11lb of lipomas. I even helped sew a skin graft onto a little boy’s hand, metal rods drilled into each tiny finger to keep them straight – and for some reason I’m just fascinated, and awed.

Surgery here seems simple, and necessary, and utterly life changing. I can see exactly why some people like it so much.

Decisions

The consultant looks up from his notes as Mr Mitchell walks in.

“How are you?”

“I’m fine! Just back from holiday.”

“Right. Well, I’ve been looking at your CT scan, and we’ve found a little… blob… on your kidney.”

“Oh, right”.

“Yes. Look, here’s your scan. This is you!”

“Oh. Yes, right”.

“See here? This is your right kidney. See the shape of it? And there’s the left one. Now. Can you see that extra bit at the bottom? They look different.”

Mr Mitchell seems nonplussed. “Ah.”

“That’s the blob I was talking about. I’m afraid it looks malignant”.

“Ah. What does that mean?”

“It looks like cancer.”

“Ah. Oh. Can you fix it?”

“Well, almost certainly yes. The tumour hasn’t spread anywhere else so we have a couple of options. We can go in and take it out, and leave half the kidney behind. But you can see the lump’s quite big so there’s a chance we might miss a bit and there’s also a risk of bleeding. Alternatively, we can remove the whole kidney. You can survive with one, you know.”

A lot of people think you get wheeled into a hospital ill and walk out better. But every day I see the opposite – people who walk in feeling fine and come out with more than they bargained for. I sit in the corner of the room and watch Mr Mitchell’s face, amazed as always at the trust people have in their surgeons. And at the momentous decisions they can make when put on the spot.

“Ah. Yes. I think removal is the thing.”

One step back

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If you’re reading this, chances are you came here via a Google search related to ‘medical students’, ‘fainting’, and ‘operating theatre’. Welcome.

So this morning I went to theatre for the first time and saw a laparoscopic appendectomy. I mean I saw ten minutes of one, before backing hurriedly out of a door I really shouldn’t have used and lurching into the corridor. (Yes, I realise this is an embarrassingly low-key surgery to faint in). Did you know it requires two scrub nurses to escort a dazed medical student into a coffee room? This is apparently for health and safety reasons. You’d think they’d have other priorities, such as the girl on the operating table with three holes in her abdomen.

Waking up again is the weirdest part of fainting. I lay there as my brain clicked its way through various possibilities like a surreal fruit machine. Am I in bed dreaming? At a Halloween party, surrounded by revellers dressed up in scrubs? Lying across three chairs in the surgical coffee room, a load of off-duty staff looking at me? I blink and focus. It’s the latter. Oh… crap.

I realise this isn’t an ideal story if you came here looking for reassurance. But don’t panic. I’m here as your somewhat foolhardy guide, proving that it’s not the end of the world and – as the nurse kindly reminded me – it happens to everyone. I got up to go back to theatre, and as I Ieft the room a surgeon walked in… and fainted.