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... stupid exams :-(
28.7.10
23.7.10
selective memory
its been going on for a couple of years now. lots of my friends will attest to this: my memory is full of holes. some will argue that this is related to my gross alcohol intake (which is possible) or suggest that it's simply because my brain needs lots of down time (sleep, daydreaming, playing solitaire on auto-pilot). whatever the pathophysiology, the fact of the matter is, i simply dont remember a lot of things. is it because i dont make an effort to remember them? or is it because im not paying much attention in the first place? or do i really have an inability to form, store and/or retrieve memory? im really not sure.
it is certainly true that my mind wanders a lot. my concentration is often scattered between several tasks, little bits of neuron firing off near-simultaneously, all clamouring for my attention. certain things i recall relatively easily, eg the names of my patients' various relatives, entire monologues from plays and films; but sometimes entire conversations have apparently taken place - but i am convinced that ther other person is simply pulling my leg, much to their amusement and/or frustration!
so is my memory simply selective? do i only remember things that i want to remember? is it just a matter of paying more attention to everything i do? do i need to sleep more and drink less? perhaps...
it is certainly true that my mind wanders a lot. my concentration is often scattered between several tasks, little bits of neuron firing off near-simultaneously, all clamouring for my attention. certain things i recall relatively easily, eg the names of my patients' various relatives, entire monologues from plays and films; but sometimes entire conversations have apparently taken place - but i am convinced that ther other person is simply pulling my leg, much to their amusement and/or frustration!
so is my memory simply selective? do i only remember things that i want to remember? is it just a matter of paying more attention to everything i do? do i need to sleep more and drink less? perhaps...
13.7.10
tyranny of distance, part 3
in the bush, there is just not enough of some things.
what a horrible weekend: the hospital was so full that they had to open up day procedures to put patients in so that more people could come into emergency; our list pushed out to three pages for the first time this rotation; i was still doing my inpatient ward round at 5:30pm in the afternoon. the bed coordinator cajoled and threatened but there is nothing i can do! look at the bloody list:
- a third of the patients are oldies admitted from nursing homes because there are not enough general practitioners in town, such that the ones that are left are either overworked and dont have time to deal with anything more than a six minute consult; or they simply don't know and don't care;
- another third of the patients are oldies waiting for allied health input before they can go home or be placed: physios to improve their mobility, occupational therapists to set them up at home, speech therapists to work on their swallow, dieticians to buff up their nutrition, neuropsychologists to prove that they are incompetent, aged care assessment to tick that box - and even after that, they wait for a bed to be emptied from one of three facilities in town. waiting in hospital to go somewhere else to wait to die. what a lovely thought.
- the final third of the patients seem to comprise entirely of patients bouncing back with a medical problem that cant be fixed (eg end-stage copd), they wont let me fix (eg alcohol abuse) or i cant fix (eg fulminant hepatitis and malaena but no gastroenterologists in town).
so we did the best we could: patched up the oldies so they could go back to their nursing homes; kept the others in hospital so they received adequate nursing care; and provided band-aid solutions or palliative care to those who are simply broken, before they went back into the community or up to heaven.
why would anyone want to live in the bush? and... why do i want to live in the bush?
what a horrible weekend: the hospital was so full that they had to open up day procedures to put patients in so that more people could come into emergency; our list pushed out to three pages for the first time this rotation; i was still doing my inpatient ward round at 5:30pm in the afternoon. the bed coordinator cajoled and threatened but there is nothing i can do! look at the bloody list:
- a third of the patients are oldies admitted from nursing homes because there are not enough general practitioners in town, such that the ones that are left are either overworked and dont have time to deal with anything more than a six minute consult; or they simply don't know and don't care;
- another third of the patients are oldies waiting for allied health input before they can go home or be placed: physios to improve their mobility, occupational therapists to set them up at home, speech therapists to work on their swallow, dieticians to buff up their nutrition, neuropsychologists to prove that they are incompetent, aged care assessment to tick that box - and even after that, they wait for a bed to be emptied from one of three facilities in town. waiting in hospital to go somewhere else to wait to die. what a lovely thought.
- the final third of the patients seem to comprise entirely of patients bouncing back with a medical problem that cant be fixed (eg end-stage copd), they wont let me fix (eg alcohol abuse) or i cant fix (eg fulminant hepatitis and malaena but no gastroenterologists in town).
so we did the best we could: patched up the oldies so they could go back to their nursing homes; kept the others in hospital so they received adequate nursing care; and provided band-aid solutions or palliative care to those who are simply broken, before they went back into the community or up to heaven.
why would anyone want to live in the bush? and... why do i want to live in the bush?
26.6.10
managing people
there is a lot more to being a medical registrar than looking after patients. actually, when i think about it, thats usually the easiest part of my job. most patients have relatively straightforward problems: exacerbation of a chronic illness; some sort of infection; social issues; or simply being old and having less physiological reserve. it's really a matter of triaging, writing up the drug chart or making a referral to allied health, and seeing what happens.
what i find to be most challenging is actually having to manage people. striking a balance between leading and learning from my consultants; supervising my residents to make sure they are safe, yet giving them a degree of independence to learn how to think for themselves; teaching the students while trying to study myself.
lots of my friends and colleagues are thrilled to be registrars, and hate the idea of doing resident jobs, the mundane tasks of rewriting drug charts and putting in iv cannulas, and the lack of freedom to make treatment decisions. well, i dont mind the mindless tasks - i find them quite satisfying, actually - and i find that i have a great deal of influence on my patients' inpatient experience even if i dont get the final say on how their medical problems are treated. on top of all that, being a resident is far less stressful than being a registrar! so, yeah, i am looking forward to being a resident again when i return to melbourne...
what i find to be most challenging is actually having to manage people. striking a balance between leading and learning from my consultants; supervising my residents to make sure they are safe, yet giving them a degree of independence to learn how to think for themselves; teaching the students while trying to study myself.
lots of my friends and colleagues are thrilled to be registrars, and hate the idea of doing resident jobs, the mundane tasks of rewriting drug charts and putting in iv cannulas, and the lack of freedom to make treatment decisions. well, i dont mind the mindless tasks - i find them quite satisfying, actually - and i find that i have a great deal of influence on my patients' inpatient experience even if i dont get the final say on how their medical problems are treated. on top of all that, being a resident is far less stressful than being a registrar! so, yeah, i am looking forward to being a resident again when i return to melbourne...
13.6.10
tyranny of distance, part 2
the diabetes educator had left her the previous day after a 2 hour "catch-up", apparently well except for ongoing unstable bsl (which had been going on for years). she found her in the same position 24 hours later, unconscious, gcs 11 and febrile. with no obvious explanation for her temperature of 39.5 (impressive for a 82 year old), mild neutrophilia and a surprisingly normal crp, i asked the ed resident to do a lumbar puncture. id just done a question on herpes encephalitis and aciclovir was on my mind. sure enough, the csf came back with high proteins, relatively normal glucose and (drum roll please...) 100% mononuclear cells. and so the aciclovir went in. the next day we noticed she was having seizures and added phenytoin. her gcs fluctuated between 6 and 8. things looked bad.
her closest family was her dead husbands nephew 110kms away. he was the only one that seemed to care (i will try to come up doc but it wont be until the weekend cause im working) but didnt feel comfortable making medical decisions for her. there was a son in wa, he said, and gave me a number that didnt exist. apparently there were three more sons in holland, and i left a message on an answering machine after a (what i presumed to be) dutch "please leave your name and number..." routine.
later, the son from wa rang me. i guess the nephew had better luck getting on to him. he was angry that switchboard had made him wait (on long-distance) while i was in a family meeting (rapid deterioration in a woman with extensive stage small cell lung cancer). but he quickly got the picture. no he couldn't come, he said, because he didn't have the money. and he didn't want to be stuck here if she died. did he wanted mum to go down to adelaide or melbourne for further investigations? no doc what's the point? shes in her eighties and shes had a good life. i promised him id let him know how things went. later on i overheard some nurses talking: apparently my patient is loaded. ahh...
i shut my ears and quickly moved on to the next patient.
her closest family was her dead husbands nephew 110kms away. he was the only one that seemed to care (i will try to come up doc but it wont be until the weekend cause im working) but didnt feel comfortable making medical decisions for her. there was a son in wa, he said, and gave me a number that didnt exist. apparently there were three more sons in holland, and i left a message on an answering machine after a (what i presumed to be) dutch "please leave your name and number..." routine.
later, the son from wa rang me. i guess the nephew had better luck getting on to him. he was angry that switchboard had made him wait (on long-distance) while i was in a family meeting (rapid deterioration in a woman with extensive stage small cell lung cancer). but he quickly got the picture. no he couldn't come, he said, because he didn't have the money. and he didn't want to be stuck here if she died. did he wanted mum to go down to adelaide or melbourne for further investigations? no doc what's the point? shes in her eighties and shes had a good life. i promised him id let him know how things went. later on i overheard some nurses talking: apparently my patient is loaded. ahh...
i shut my ears and quickly moved on to the next patient.
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