Feather-weight Words

The Visual Analogue Scale (VAS) for pain is one of the first things they teach us when start clinical rotations in med school. You ask the patient to grade their pain on a scale of 1 to 10, 10 being the worst pain imaginable. More often than not, the responses varied between 6 & 8 with the oddball 9 or 10 dropping by like a diagnostic mystery for the fresh Dr.Houses to toy with. We were naive then, & took what was told to us at face value. When we started narrating the VAS scores to our residents, they asked if we really thought their pain was as severe. It seemed a stupid question - the patient is in pain, hence with us. Why would the patient lie? The resident explained - no patient lies, they merely embellish & it is your job to take into account their dramatic exuberance. They then showed us what they meant with a thirty something mother who lay in a bed nearby. I was first asked to obtain a VAS score like I normally do, by asking, "If 10 is the worst pain imaginable, how would you rate yours?". I got a 7. The resident then asked, "If 10 was the pain during your first childbirth, how is the pain now?". He got a 3. 

Being stubborn as I was, I argued that the logic couldn't hold true for all patients and the question posed was only applicable to women who had undergone childbirth. I continued to make my case stating that a patient's memory of past pain may fade. But, in hindsight, their dramatic skills also improve with time to compensate. A few years wiser, I find not all patients embellish, but that doesn't mean the physicians let down their guard. The ones that do exaggerate have various reasons for doing so - want more time with the doctor, think they'll get better treatment, if a little medicine is good then a lot must be better, & then we had the occasional  psych references. But, you'll find there is a deeply ingrained tendency to aggrandize in all of us. And it extends beyond the confines of the examination room. 

I'm not a grand old man, I'm still going through my one third life crisis. But, I still remember a time when the spoken word was taken at face value, when hyperbole was just a figure of speech, not a way of life. Since when did we collectively decide that grandiosity is a must to be heard? How often do you hear - You HAVE TO try this place, it's got the best [fill in some obscure dish here] in town!?, She looks like a million bucks, The dog that bit me was built like a wolf, I couldn't be more depressed, God hates me & my personal favorite - I love it.

To quote the ever-articulate Snow Patrol, "Those three words are said too much, but not enough". 'Love' it seems, is a word that's thrown around the most and meant the least, which puts me in a dire predicament. How does one actually profess love without being lost in a sea of hollow superlatives? Should I take the extra effort narrating the depths of my emotion, or should I in true romantic manner, hope she loves me back enough to comprehend it easily? Ok, that sounded corny. But, I'm still in a constant state of confusion - Did I make myself clear enough? When is it ok to stop? Bearded man in the sky forbid I offer an average review of [enter anything here], I'm met with bewildered looks. Since when did calling something average become an insult? And why do women take it personally when I don't agree with their choice of restaurants? Makes me wonder if there's some women-centric restaurant mafia I don't know about.

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There's an acute shortage of words in the English language. Well, that may not entirely be true, but there's definitely a paucity of words being used. "Whatever", "like" & "you know" may not be as dramatic as the ten biblical plagues, but they're definitely heralding the death of language. Add to that this incessant need to mess with the degrees of comparison, where superlative is the new comparative, comparative the new positive & positive is a long forgotten remnant of what the truth used to be. 

Speak your mind, but make sure you mean every word you say, even if it means you speak less.

We must never forget that the highest appreciation is not to utter words, but to live by them. 

- JFK 

Averagely yours,

SS

The Evolution Of Fat People

For students of medicine and biology, this is a lesson in evolution and anthropology. For anyone with a BMI over 25, this is a factual, motivational tool. 

It all started with Balpreet Kaur, a Sikh girl going about her business at the airport. She wore a turban and as per her religious beliefs, did not rid herself of any facial or body hair. As luck would have it, someone with a cameraphone found her appearance humorous and decided to share the joke with others on Reddit. He posted the picture under the 'funny' category with the tagline, "I'm not sure what to conclude from this". It wasn't long before she knew that she was the subject of discussion, often ridicule, on the social network. Her response to her detractors & critics is nothing short of a modern example of poise & dignity - "By not focusing on the physical beauty, I have time to cultivate those inner virtues, and hopefully focus my life on creating change & progress for this world". You can read more here. 

Just a few weeks later, I read about Stella Boonshoft. Stella is a girl of voluptuous proportions, who has been ridiculed by her fellow students, trainers and men of interest, because of being overweight. She shared a semi-nude picture on Facebook to show the world how proud and comfortable she was with her over-weight body. It was her emotional outburst that accompanied the picture which caught my eye. My first response, one I'm sure a lot of you would have, was - More power to you! But, then I thought of Balpreet. The similarities between the two women at first glance are great. Both are strong women with character, both have been ridiculed or questioned for their external appearance, both used social media to their strengths and were lauded for it. That is where the similarities end.

It took a moment before I started wondering - Stella isn't that great after all. She's been over-weight, & from her account, since quite some time. While she's had ample opportunity to change her lifestyle, she's chosen to  chide society for setting unreasonable ideas of beauty. She's lashing out because she's had a rough childhood. I felt for Stella, nobody deserves to be ridiculed or made to feel inferior while growing up. Adolescence is a tough age for most of us, and it's especially tough when you're made out to be an easy target because of your appearance. But, as a smart, informed adult, she missed the point by a mile. While Balpreet is a strong woman of conviction, whose religious beliefs are exactly that - HER beliefs; Stella is just another person struggling with her weight. She's adamant about her body being only her concern, but the medical mind in me refuses to accept that. Somewhere down the line, her weight will be someone else's concern too - her doctor's. 

Society's norms of beauty keep changing. They follow cyclical trends & are fairly predictable. There was once a time in Victorian England where a woman's ankles were considered far too private to be exposed, her bosom though, was let free to feel the wind. Caucasians are obsessed with tanning to get that perfect golden brown skin tone, and the already golden brown Asians are obsessed with fairness creams. Society is way tougher on women - waxing, bleaching, hair removal are all painful procedures without much merit, and a woman's life is a continual struggle to please that handsome man in the commercials. Are fashion houses and beauty product labels being unreasonable? Most times. Each time the billboards are plastered with a woman who is excessively thin to begin with and then photoshopped to look like Aphrodite, they're being idiotic. But, their idiocy is matched only by their financial success, because we lap up these perverse standard of beauty. This is the problem that Stella was addressing.

Some standards though, have withstood the test of time. A sculpted, muscular body, toned physique, smooth, supple skin, flowing hair have never been out of style. There is but one universal standard of beauty in the world that hasn't changed in thousands of years - Athleticism. The pinnacle of human endurance, agility, strength and skill, these athletes represent all that is good about the human design. They represent health in all its glory, & are universally desirable. Desirability - that's all it comes down to eventually, desirability as a sexual partner. 

One of my professors often said, "The fact that Isaac Newton's sperm never met an egg is one of the greatest crimes against humanity!". He wasn't wrong. To paraphrase Tom Cruise from Jerry Maguire - Show me the GENES! We choose our partners, on the basis of so many factors - their looks, success, wealth, potential for growth. But, that's now. Far back when we were just scavengers in the forest, we chose on basis of strength and speed. One's external appearance mattered a lot then, as it does now, because it is a sensitive indicator of someone's health & their genetic quality. Scour through medical textbooks, and there're hundreds of signs visible externally that signify internal disease. So flawless skin, hair, ripped muscles are all desirable. Its all about having the best possible mix of genes. The desire to find a suitable sexual partner, procreate and have offspring that represent everything that's good about us, is universal. So, the next time you're questioning ideas of beauty, ask yourself how much of it has been created by corporate propaganda, and just how much are we all born with.

In a lot of ways, the reason we're fat is the same reason we orgasm. A lot of people thought that the orgasm was a fortunate blip, a physiological event that didn't serve much purpose. They couldn't have been more wrong. Just imagine if we didn't orgasm at all. Would we all still be having sex if it wasn't pleasurable? Somewhere down the line, we would give up on sex & the entire human race would be wiped out, being replaced by a species that enjoys sex. So, sex is enjoyable for a purpose. It is nature's way of telling us that we must survive as a species. We may all struggle to philosophically describe the purpose of life, but a biologist knows it already - Survival. Life exists - in strictly biological terms - to continue and perpetuate.

Getting back to my original statement - we're fat for the same reason we orgasm. Fat is the most efficient form of energy storage in the human body. Carbohydrate stores last us only for a few days and protein is far too essential to our body, therefore utilized for energy as a last resort. Back when we were evolving and food was scarce, we developed a taste for fatty foods. Evolution was smart that way, it made us love fattier meals so we would seek out and completely consume them. Energy storage was of paramount importance; one never knew how far the next meal would be. Those individuals that developed this rich taste, survived more easily than those that didn't. Move into the 21st century, and we've inherited the same fondness for fatty meals from our ancestors. Except food isn't as scarce anymore, but our appetites are just as insatiable. A quality that was meant to ensure our survival, is exactly the reason for millions of untimely deaths. Maybe, just maybe, evolution screwed up.

Obesity has been rampant since the past 50 odd years, and has mirrored our growth as a species.  This progress has brought an abundance of food, technological progress, medical innovation; But, it is exactly this progress which is the cause of our collective "growth".

Medicine has finally come of age. It wasn't until 1964 that we knew the link between smoking and lung cancer. Chemotherapy didn't give results until the 1970's. And AIDS was discovered only in 1981. The questions in medicine have shifted from 'What's causing this?', to a more reassuring, 'How can we treat it?'. We live in a spectacular time because important associations between diseases and causative factors have already been made. While we improve patient care with each passing day, there arises a greater drive and focus to reduce the number of patients altogether. Preventive medicine isn't a new buzzword, its the most important one. But, a culture of instant gratification means patients are more likely to demand a magic pill when ill, rather than take steps to prevent the illness in the first place.

Almost every obese patient I've counseled has said, "I just don't know what to do". As their doctor, one tries hard to make them see reason, to make them see the trouble that awaits. As their doctor, it's my job to tell them what to do. But, more often that not, the next time I see them - still just as obese - I listen to, "I just don't know what to do". Obesity is primarily a problem of the developed world, of the affluent classes. I do not say the problem lies with a lack of intelligence or information. That clearly isn't the case, most are extremely capable of assimilating the information we provide and acting on it. The problem is, they're careless and indifferent. Having foresight is what doctors are paid for,  but we cannot force it upon our patients; we can advocate, support, counsel and fight for our beliefs, but we cannot force them.

The age when patients religiously adhered to their physician's advice are long gone. The internet has disseminated information, both factual & fictional, in a way none of us anticipated. It is every patient's right to gather information about their health concerns and question their physicians about the same. It keeps us doctors on our toes. But, when your interpretation of the statistics does not match with ours, we urge you to trust our judgement. A figure of 1% risk seems trivial, until you become the statistic itself. I will not debate the prominence of environmental versus genetic factors in the surge of obesity, they both have an important role to play. Understanding the problem isn't enough, we need to acknowledge the magnitude of change required to overcome it and go about our business doing just that! Don't tell me that you don't know what to do. Such ignorance cannot be tolerated, your life depends on it.

Evolution doesn't ensure the survival of every being. 'Survival of the fittest' - As a high school student, I was perplexed with the choice of word - fittest. Darwin explained that survival isn't guaranteed to the largest, the strongest or fastest, but the one that is best suited to the present circumstances. He who adapts best, survives longest. The grandiose, seemingly indestructible dinosaurs were wiped out after the meteor hit because their large, inefficient, hungry bodies couldn't adapt to the scarcity of food that followed. Those that did survive, were the unlikeliest of creatures - mammals, which until then were a small, insignificant part of the ecosystem. And they rewrote the history of this little planet. Just as the dinosaurs, we're at the precipice of an enormous environmental change, that of relative abundance. Those that fail to change, fall prey to evolution ensuring only the fittest survive, in a literal sense. We need to stop dragging our feet because failing to adapt, means adding another chapter to the history textbooks. Except we don't need meteors anymore, when we've got McDonald's.

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Dear Med Student

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So there I was, minding my own business one day during rounds, when a pack of med students suddenly came up behind us. It's extremely funny to think you were one of them not so long ago, but one can't help but be critical of what they do. Circle of life I suppose. Big fish gets to criticize little fish, make it cry & then eat it.

There were all in their second year, in the first surgical rotation. It was so cute how they didn't know what to do. "Should we talk to the professor? Should we tell the resident to teach us? Should we have a look at the patients while the rounds start? When can we leave? Would they notice we're gone?"

Ah, nostalgia, why're you such a bitch?! Couldn't you make me reminisce without making me feel senile?

Anyhow, these guys walk upto me and ask which cases are worth discussing. I skillfully and effortlessly shot off patients that I knew would be too difficult for them, narrowing down on two cases. Seeing that I had to stay in the wards for the next one hour, I kept wondering if I should try my hand at teaching these noobs. Before I could utter another word, they had disappeared. One thing you have to appreciate about med students is, no matter how large a group they are, they can effortlessly appear and disappear!

So, my bungling batch of eager students, here're my tips on how to have fun, learn along the way & not make an ass out of yourself in the final year exams:

1. Study. I'm gonna sound like an ass, but yeah, you came to med school. You're not an arts student. So, stop asking when's the last day you can afford to start studying for exams!
   
   
2. Ask. It's wonderful what you can extract from your teachers with a simple, "Where? How? Why? What?" If you never ask, you'll never know.
    
3. Stop acting like an ass at rounds. You may not realize this, but the hospital does not revolve around students. You contribute zilch. So, if you're attending rounds, you will be respectful to those who are working and pay attention, or at least not grab our attention
   
   
4. Don't EVER reveal you're a student. A lot of patients in government hospitals already have a mortal fear that they're entrusting their lives at a substandard medical center. And then we have students who keep talking in Hindi & Marathi, asking each other questions, discussing crap, displaying their ineptitude, acting casually with the patient. There is nothing casual about fifteen people discussing your illness while you're lying alone on a bed in a strange place. Act like you know what you're doing even if you have no idea! Be confident, read beforehand, think about questions you'd like to ask and what physical exam you'd like to perform. Don't just show up, read the diagnosis on the chart, and then happily poke and palpate away.
   
   
5. Do not be a critic. You will come across a lot of teachers over time that could do little more to grab your attention; worse, you could meet people who are hell-bent on teaching treatments that you could lift off any TV show depicting a witch-doctor. When you're being taught, you must be grateful. The next time that person is arranging a clinic, ask yourself if you learned anything the last time & decide whether its worth attending. Run around, follow, stalk, bully & pass on death threats to good teachers! Get them to teach you anyhow! Learn from them, emulate them.
   
   
6. Teach. I can't give enough credit to my senior friends who taught me so well over the years. It was their clinical acumen, patience & support that pulled me through the exams. Medicine is all about passing on one's knowledge, whether it's to a colleague or a subordinate. Teach because you want to be taught. Circle of life. 

Indecision Conundrum

"He's the best of the lot. He sees things others don't or at least things that others ignore & takes the final call." I heard a resident speak of a junior surgeon in my hospital the other day. He also commented on how others are scared of committing themselves to a line of treatment. Fellow interns, how many times have you gone through a file and read, "Dr.ABC has assessed the patient and suggested continuing conservative line of management with review if any change in condition"? It's definitely easier on the surgeon, it's easier on the relatives, but most importantly, quite often it's easier for the disease. 

Every few weeks, each hospital holds a Mortality & Morbidity meeting, to reassess what went wrong with the selected cases for review & offers advice on how to best manage similar situations in the future. I am yet to attend such a meeting, but have been told that every care is taken to be sympathetic to the state of the presenting doctor & avoid such terms as "accuse" and "blame". People die, that's the harsh reality of our profession, it's worse when they die due to human error; and mistakes do occur regularly. The worst errors are those of omission. But, sadly these are seldom discussed at these meetings. Not operating is often the easiest choice that a surgeon makes. This is most true when a problem is often complex and survival considered bleak. His morality rates are kept in check, he goes on perform surgeries where the prognosis is optimistic and everybody goes home happy, including the patient, albeit not for long. 

From what I can see, some of these surgeons ought to grow a pair. If they were so interested in watching from the sidelines, they should've become physicians instead. There's no sense of discovery, no enthusiasm of finding the unknown. What's so great about opening a patient for an appendectomy & finding an inflamed appendix? Nothing! Ever been in a massive surgery where they operated for something else instead? It's magical. You hope for a fruit and find a fruit tree instead; every surgeon's dream, or at least I used to think so. And while I'm at it, people need to stop treating the pancreas like it's the fucking plague. I agree it's insanely difficult, the protocols aren't well-defined & predicting a prognosis is often more difficult than the surgery itself; But, still! I'm sick of hearing people go on about what "should have" been done two, three weeks ago and how how the patient is now inoperable. This rant is dedicated this awesome surgeon who joined us at rounds today. I wish he'd come 10 days earlier, I would've witnessed one awesome surgery!

The Boy Who Cried, "Doctor!"

n a land far far away, but not so different than ours, there lived a young boy. Moving through the streets around his home, he gathered tiresome looks from those who knew him; this boy was not the most popular chap around. Wearing the most smug look, prancing around with his friends he created trouble wherever he went. 

While other boys his age would be considered naughty or hyperactive or be diagnosed his ADHD, "Royal pain in the ass" wouldn't not be on the differential list! He would beat down other kids & act like he was the victim. The minutest of scrapes while playing would be advertised as a life-threatening disorder to the others around him. He craved this attention, loved having his family pamper him, loved the idea of missing school, loved blaming others for his mistakes & loved the idea of getting away with it all!

He would run off to the Doctor for every cough, sneeze or burp. It started with body aches, moved on to migraines, escalated to visual disturbances & toned down to tasting problems. The doctor lent him a patient ear, and tried hard to arrive at a diagnosis. Finally, as the boy walked out of the casualty, he asked his parents if anything was bothering him at home. Met with a curt "No", he made a mental note of all that went on. The next day this boy came with another bout of abdominal pain. The doctor examined the boy thoroughly & after he was sure the boy didn't have any signs of pathology, he wrote down a long list of tests. "There has to be a reason that these pains keep coming back", he said, "We badly need to investigate because it could be systemic seeing his history. This is a necessary evil, but, wouldn't you want to be sure your child is healthy?". His parents could do nothing but nod in unison. That night they questioned the boy, "Are you sure you're ill? These tests are very expensive". The boy could not have his lie exposed so late in the game & rather demanded the tests, foolhardily saying something will surely be revealed. And so the cycle of lengthy, expensive tests began. A few days, pockets full of cash, many tubes in many orifices later, each paper read, "All findings within normal limits".

These papers were shown back to their Doctor who could do little to justify his happiness at being vindicated other than saying, "This is great news, your son is perfectly healthy!" And so the parents finally understood what  was actually wrong with the boy. Over the next year, not another day of school was missed; scrapes were not treated & dressed like battle wounds; & a fever would be deemed a fever only if the thermometer said so! But, this wasn't because of a lack of effort on the boy's part. There were still that many headaches, stomach cramps & flatulence, except that it usually disappeared after an hour at school or if the family so decided to eat out or take a trip.

One fine day, the boy noticed a pain in the right abdomen, radiating to his navel. He promptly brought this to his mother's attention, who brushed it aside like the million other times. The child's abdomen kept swelling, it kept aching, until finally he fell unconscious.  Expect the child wasn't faking anymore.

HTMKK

Nobody likes a faker! Not one bit! Not in bed, not at the workplace, unless those two happen to coincide. What's the most irritating part of a faker? That they continue to "act out" even when they've been "found out". They will just refuse to give up; talking about a good-for-nothing idiot persevering (wrong place, wrong time)! But, what angers me most is that I can't label my patients - Fakers. It seems someone came up with a cool term - Malingering. So, I'll have to run with that since using outdated terminology is frowned upon in medical circles. Look at what happened to the Ayurvedic doctor who said he was practicing Voodoo! 

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There're a lot of malingering patients I see regularly, we call them "chronic cases", we know their entire past medical history, family history, bowel time-table & even what they had for dinner last night, simply because we see them "chronically", at times more often than I see my family. Their papers read like the what's what in medical symptoms. Not a single organ system is missed, there're always gonna be multiple complaints & usually they come back within a day, "because the meds don't work".

Modern medicine has thrown in everything to try to describe this "condition". They deem it to be a serious disorder that "handicaps" a large section of the population. I, being the young medical marvel that I am, see it for what it is. I don't go around labeling patients, "Systemic Candidiasis Syndrome", "Fibromyalgia", "Chronic Fatigue Syndrome" or some other Voodoo, sorry, ayurvedic crap like that! Sometimes, a pussy is just a pussy! Surprised?

You can't show up in my clinic every other day with tingling & aches & a general feeling of unwell and have the balls to demand a diagnosis. I've run my tests, I've given you a head-to-toe examination, & yet, you have the nerve to question my medical knowledge? I've filled out your entire case history, written out the prescription for body pain & THEN, you remember you've got chest pain? Guess what? Fakers often tend to forget which symptom is to be given top priority, they're not too bright. They heave when they see me, but when they're with the nurses, their breathing normalizes. They come with a BP of 140/90 & say they have "Chronic Low BP". You know what? I should probably just immortalize my name in medical textbooks by creating criteria for a new condition "Pseudo-hypotensive hypertension syndrome". First 100 doctors to make that diagnosis will get a 1000 referrals & a pen from me!

To all these people who have the tolerance level of a fish outta water, watch the next video & Harden The Fuck Up (courtesy of MDOD): 

I have an old friend, extremely laid back & couldn't care less about any damning news you may have to give him. He came up with HTMKK, short for "Haan, to main kya karu?" for whenever someone shares some shitty info he doesn't give a crap about. For those not fluent in Hindi, its literal translation is, "So, what I am supposed to do"; But, when used correctly, it means, "I don't really give a fuck!"

So, don't be surprised to see FSD, HTFU, & HTMKK on your prescription the next time you see your doc

From elbow-deep in a uterus to neck-deep in crap!

My family wants me to become an obstetrician. Bringing life into this world, they say, is the most noble thing a doctor can do. Some of my friends want me to do the same, they're shit scared of going to unknown doctors; the remaining ones say they won't let me ever come within a 100 yards of them! Me? I'd love to take up the science, it's an exciting line. There's a deep appreciation one can gain for the process of childbirth when you're elbow deep in someone's uterus, as I found myself to be on several occasions over the past month.

Yesterday was my last day in my OBGY rotation. I think my eyes should be tearing up right now (cue soft dramatic music), because this past month was an unexpected revelation. I still remember wincing when I got to know who I'm going to be working under, tales of their stern attitude had seeped through already. It seems the past interns in this unit had created quite a ruckus & the next batch would pay for their foolhardiness. The first thing that I was told when I started work, "I hope you interns will not cause us grief like the past batch. Work hard! We're gonna make them pay & if you bother us, we won't treat you any different." Gulp! And so we commenced what was expected to be a long month ahead, treading carefully, not wanting to step on anyone's toes. It took around ten days to realize that we're quite adept at what we we're doing, the junior residents were fun, even the seniors shared a few laughs. There wasn't any sense of terror that we'd anticipated. Instead, everyone just let us be. Scratch that, everyone pushed us to do more!

Every now & again, you'd hear someone shout out at you, asking you to wash up for the next surgery. They went out of their way to make sure our surgical skills were honed. It took them a few days to realize one needs basic skills in the first place to hone them! But, they were patient nonetheless. Eyes glued to the organs laid bare, there'd be a running commentary on what needed to be done next, why it was being done, why in that particular way. It made me wish everyone I'd worked for earlier had taken the same amount of enthusiasm. They need to be eager to teach to deserve an eager intern!

The most surprising aspect of this rotation though, was the women! Their beliefs, attitude & noncompliance were legendary! The humor in it all wasn't lost on any of us:

(Patient refusing a vaginal exam inspite of being 9cms dilated)

Patient: No, no, don't do that, it hurts, I want to go home!

Doc: Woman, how can I check if your baby is alright if you won't let me examine you? Don't you know where babies come from?

Patient: No!

Doc: Look, I beg you to please let me examine you, the baby will suffer otherwise

Patient: But, I'm scared

Doc: (whispers into her ears) You know something? So am I !

Patient: Look here doctor, its hurting too much

Doc: Listen, you're going through childbirth, we've already started your drip. This isn't your first delivery, you ought to know it's gonna hurt a bit.

Patient: It never hurt as much as it does right now! What should I do to make you give me a C-section? Should I get a pooja plate & pray to you?!

(Patient in labour since 12 hours, demanding a C-section, also since 12 hours, by far the loudest female we have in that room. Doc approaches to do a vaginal exam)

Patient: Ooooooh, Aaaaaargh! Doc, remove your hands, it's hurting

Doc: Why're you screaming so much? I haven't even touched you yet!

Patient: Oh, alright, I thought you had!

(The vaginal exam is completed, the patient doesn't squirm or scream)

Doc: Wasn't that bad now, was it?
Patient: But, you haven't even done anything yet.

Doc: Yes, I did. I'm done with the exam

Patient: Ooooooh, Aaaaaargh!

P.S: I almost forgot to explain the second part of my title - I start with my Pediatrics rotation tomorrow! 

The Pathology(cal) Inflammation

Ok, I'm sleeping in the side room while on-call. It's around 3am & I have this woman shaking my knees vigorously. "Anyplace else, any other woman", I pray half-asleep "Please let this be a part of my dream too". But, my resident doesn't find any of my mumbling funny & says, "Trace this patient's CBC & RFT report... STAT"

I've never liked this term - Stat! The only place it has any real use is in prescriptions or in nurses' orders meaning the meds have to be given immediately. But, this being a country of over-usage & customization, the term is now used as freely as a 14Fr Foley's; people have just stopped thinking. Some of the many improper uses I come across daily: 'Come back from dinner stat', 'Collect this patient's sample stat', 'Make this patient abscond stat', 'Finish reading this stat', 'the Head's coming up in 10 minutes stat' !?!

But I, as I so often do, am digressing. I slap on my shoes, put on my puppy-dog face & move to the lab which is around 300 metres away, but it sure does seem like miles. I look at the on-call technician & plead, beg, implore, beseech & request, then demand I get this report! I hate reports. That tiny piece of paper makes me want to dip into my family's savings & buy myself cell counters that I can carry around. Just imagine, patients queuing up in front of me every morning, bloody arms et al, being given STAT reports (Note the correct usage). And if I'm not tracing reports in the middle of the night, I'm definitely doing it bright and early every morning. But, my Intern Avatar is now 6 months old & I've learnt a few tricks to bypass these depressing situations altogether.

Here's a list of things to do to make sure you never get sent out to trace ever again:

1. Forge a report!
   I know this sounds kinda insane but there're times when you know the result (usually via phone) but can't get your hand on the signed report. Don't be afraid to forge it, there're plenty of desks in these labs with report sheets lying around. Better yet, call the friendly "private" path lab fellow & have him make you one instead.
   
2. Over-diagnose
   Never be afraid to write a 'killer' diagnosis. And it must be absolutely horrendous if you aren't going to go deliver the sample yourself. Here're some of the ones I frequently use:
   HIV induced encephalopathy (?Query) with past h/o STI
   Acute drug-induced Hepatitis (preferably due to ART or AKT)
   DIC
   Acute necrotizing glomerulonephritis with patient to be given Mag.Sulf (100% success rate)
   Incomplete abortion with post-curettage hemorrhage
   Septic peritonitis with hepatic encephalopathy
   ? MDR-TB
   
3. There's a budding actor in all of us:
   I usually start panting as soon as I get to the blood bank or emergency-lab, ask the technician to run the sample. I put on my sternest, most constipated face, and mumble, "Didn't even have time to write up a request form". Thank them profusely and run the hell outta there.
   
4. My newest book's title: "Letters to the the E-lab"
   Dear on-call E-lab technician,
   Kindly send reports of patient xyz in Wd.123 urgently as the patient is already being induced & we need to know the counts before we start blood transfusion. Also, the patient has developed drug toxicity requiring steroids, we could use the LFT, RFT reports as soon as you can process them.
   Thanking you,
   abc
   (Senior Resident under Dr.ABC)

Another useful piece of advice from my recent misadventures; whenever on-call, sleep in the adjacent ward. The residents are usually too lazy to go call you themselves & the cellphone reception in our hospital is horrendous to say the least (God bless broken promises by cellphone operators).

The Guess-work Amplification

I've always loved Viva-voce (oral) exams, I really miss them now. They not only give you a great chance to show off just how much you know, but also how well you can communicate with the examiner. No two examiners are alike, and neither are any two vivas that an examiner takes. There're so many variables involved, there's no way that one can be "totally" prepped for these exams. Not a lot of fellow med students appreciate vivas; a lot of them know the matter but are unable to formulate a differential diagnosis, argue their points etc.

Some of the wackiest situations are when the examiner starts off on a completely different path than what you have taken, now he/she expects you to not only justify why you weren't wrong, but also why the examiner could be correct. Another is when some examiner says something outlandish & grossly wrong, leaving you to correct them. It's made for some damn interesting stories over the years.

One thing remains constant in every exam though, your ability to guess & exaggerate in front of the examiner. There's a lot of slang that's used to describe this phenomenon, "Butt मारना ", "Globe मारना " etc. I know they don't make sense at all,  but they've reached a level of national acceptance in med schools! You can either wow the examiner with your special gift of nonsense or frustrate them to new heights! Like all the crap we pull in exams, its a double-edged sword, with a shit-ass barbed handle to boot! 

There was a time last year when all of us were so apprehensive of identifying a particular sign, giving a definitive diagnosis, living a rough line of treatment. We all second-guessed ourselves, confused as a hound in  a meat factory about what we were about to say. It definitely didn't help when we had to invent symptoms, signs & diagnose a patient who wasn't a classical presentation; better yet when we tried to "Globe".

Things have changed so dramatically its insane. We now give spot-diagnosis without batting an eyelid, notice signs & argue clinical findings without giving it a second thought. There's something magical about internship because you're never worried about anyone grading you, never really worried about the patient because the hierarchy above you is always around to check on what you do. Vicarious Responsiblity (Respondeat Superior) is one of the few perks in internship, meaning that if we screw up, we're not held responsible. It's given us wings & pushes us to diagnose more often, report irregular findings with greater confidence & try things that we would otherwise never have the guts to do! I wanted to leave you with a quote on how the practice of medicine revolves around an intelligent guess; but somehow I just couldn't find it. Well, here's a funnier one instead:

"The reason doctors are so dangerous is that they believe in what they are doing"

- Robert Mendelsohn