Vitum's Field Guide to Hospital Grunts - Patient Edition

1. HHUUUUUUUNNNNGGGGHHHH

ID: Reproductus cornicopious, the common multip (i.e. multiparous woman, who has delivered a few babies already)
HABITAT: Maternity Ward
ACTION REQUIRED: RUN AND DON GLOVES. She is about to pop.

BACKGROUND: There is a saying on the maternity ward: “Never turn your back on a multip.” It is a known medical phenomenon these women, who have already had a few babies, have shorter and shorter labour for subsequent pregnancies, to the point where you better not ever be too far away or you’ll be picking baby up off the floor.

I have actually been trained that these multips often make a loud, primal, guttural grown the moment before the serious pushing begins. If you’re not in the room, and you hear this, hustle.

2. GAHHHHHHHHHH GAHHHHHH GAH GAH GAH GAH GAHHHH

ID: Narcoticus demandilus, the drug seeker
HABITAT: Emergency Department
ACTION REQUIRED: Holistic support up to and not including writing an opioid prescription

BACKGROUND: The loudest patients demanding pain medication tend to be the ones for whom Tylenol just doesn’t work, they’re allergic to the stronger anti-inflammatories, and gosh darn it your only option is to prescribe the good stuff. The ones who are bad at it are the ones who only seem to be in pain when the doctor walks by, and are easily fooled (i.e. “Let me examine your back.” “Ow ow ow! Even the slightest touch on my back hurts!” “Funny, when I felt your back earlier and didn’t warn you that I was examining you, you didn’t seem to notice…”
A good rule of thumb is the more convincing the patient, the more you should look for signs they’re trying to fool you.

Be careful, though. Every so often you’ll get someone who you are convinced just wants drugs, and then you are later corrected and find out with convincing evidence they are in legitimate pain. Looking back and realizing you denied a cancer patient some form of relief makes you feel really bad.

The hard part is, there is a legitimate argument that drug seekers need treatment too, just not the drugs they’re looking for. This is something I wish modern medicine could treat way better than it does.

3. MMGGGGNNNNNHHHHHHHHHHH

ID: Constipationaticus fecalis, the bunged-up ones
HABITAT: Old folk’s wards
ACTION REQUIRED: Grab a diaper. Just in case.

BACKGROUND: I was called one night to see an ornery elderly woman, and recognized her from seeing her in the emergency department, shouting at the nurse. “Closer, I’m deaf! Closer! Louder! I can’t hear you! Closer! WHY ARE YOU SHOUTING AT ME? *smacks the nurse*” I thought she was hysterical.

I’m not even sure what the original call was about, probably needing a sleeping pill or something basic like that. All I do remember is walking in the room, and she was moaning, as above. “MMGGGGNNNNHHH!”

“Why are you groaning?” I asked of the woman laying in the bed, gripping the siderail for dear life. “I’m POOPING!” she shouted at me. “I’m POOping in my DIAper!”

I was only a third-year medical student at the time, so not an expert in things medical. But I did know a few things, and took haste to correct her.
“Ma’am, you’re not wearing a diaper.”

The ruckus stopped. She looked down, and stopped to think for a minute.

“MMGGGGNNNNHHH!” I went and got someone who knew where the diapers were.

4. HUUNFGH

ID: Cardiovascularis joltishockus, or defibrillating a semi-sedated patient
HABITAT: Emergency department, cardiology ward
ACTION REQUIRED: Increase sedation!

BACKGROUND: Some patients who have a heart arrhythmia need to be shocked with the defibrillator, or cardioverted, to get their hearts back in normal rhythm. They are given sedation, then, under strangely close supervision, the medical student is often allowed to push the button with the little lightning bolt on it. One or two, sometimes three, shocks, and their hearts are back to happy beat (Yes, that’s what we call it when the patients are sedated and can’t hear us).

There was one patient who didn’t seem to have very much sedation. He had just barely fallen asleep, and the doctor turned to me and said, “Vitum, push the button!” “Uh, does he need some more propofol?” I asked. “No! Push the button!” So I pushed it, wincing a bit as I did, sending 100 joules of electricity through this young, muscular man’s heart.

The machine clicked, the patient jolted just like on TV, uttering a HUUNFGH, and his eyes went COMPLETELY wide open. And he turned his head, and stared directly at me. And stared. And stared. His eyes were bugging out of his head, and he was clearly sending the first silent death threat I had ever received, probably trying to kill me with his mind.

And then the doctor said the words I didn’t want to hear: “Hmm, he needs another one. Shock him again, Vitum.”

I asked the patient later if he remembered. Fortunately, the doc was right – he’d had enough sedation, which made me breathe a huge sigh of relief. I swore he’d be waiting in the parking lot for me after work.

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The best part of spending two weeks with medevac? Not what you might think.

As my third year was winding down last month, I had the opportunity to do a two-week elective in anything I wanted. Supposedly it had to be medically-related, but given that some of my classmates were approved for two weeks of wakeboarding or a 3-hour first aid course*, spending two weeks in paramedicine made me look like an overachiever.

The elective was pretty incredible from a medical point of view. Among the dozens of calls we attended, we picked up a young lady whose ATV had gotten away from her, crushing her leg to the point where she might never walk again. We also treated a few patients who had fallen off ladders or nearly drowned, and a nailgun injury. As well, there was a variety of medical patients too complex for the rural hospitals who needed to be brought to the big city for super-specialized care.

There were things that I didn't anticipate. There were heart-wrenching moments, like talking to one of our patients, a young lady who had been poisioned by carbon monoxide...intentionally. Sadly, she was not the only suicide survivor that we saw during my two weeks. As well, we went to a few car accident scenes and I saw some things, tragic things, that I wish I hadn't.

One thing about the elective really surprised me. Those of you who have read this blog for a while might remember that I have shadowed flight paramedics in the past. Back then, it was fascinating for me to see what the paramedics did...treat and transport the sickest patients in the province. What surprised me is that this year, my time with the paramedics served as a stunning eye-opener, revealing to me how little I knew about not only paramedicine, but medicine in general back then.

In other words, until I had completed my third year of medical school, I had no comprehension of just how sick the patients were that we were transporting. Not only that, but I had no idea the elite level of training of the flight paramedics. Back then, I did not understand the skill demanded when handling ventilator settings for patients with severe lung disease, or the implications and specialization required in order to keep alive a patient with bacterial infection coursing through their entire body. I only now realized just how sick these patients were, having been involved in identifying and treating sick patients myself, and also that some of the drugs that the paramedics were trained to prescribe are typically only used by intensive care specialists.

It was exciting to be able to understand at a deeper level the diseases affecting our patients, and to be able to have a new level of conversation with the flight paramedics, actually discussing treatment options with them. To put it another way, before I had completed three years of medical school, I didn't even know what questions to ask.

Needless to say, my understanding of the complexity of the patients and the difficulty of their management gave me a new level of respect for the critical care flight paramedics.

Retrospect, for me, is a valuable, meaningful experience. In fact, one of the reasons I started this blog was so I could look back and see how far I've come; in a program that is years in length and where you rarely realize how much you have learned from day to day, sometimes looking back is the only time you'll realize how much you are learning. It was a huge privilege to be invited back to spend time with these highly-trained paramedics, and it was a great surprise to discover that without realizing it, I had signed up for two weeks of seeing how much I have learned. Glad the $45,000 I've spent so far on tuition seems to be paying for something!

*In defense of my classmates, they did have to write a 500-word essay relating their elective to medicine

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Part 2: Vitum Loses 85 Pounds...and the mistakes that kept me from doing it earlier

Continued from Never Trust a Skinny Chef. A Fat Doctor, however...

For several years, I was eating healthy, knew about the dangers of obesity, and yet found myself at 280 pounds... so overweight that I was considered class 2 obese. So why wasn't I losing weight?

There are three reasons - three mistakes I was making. Once I corrected these mistakes, and took on a lifestyle of a healthy, balanced diet and exercise, the results were amazing:

• In September, I weighed 280 pounds. By January, I was down to 230 - I had lost 50 pounds.
• In April, I met my long-term goal of running a 10 kilometer race, something I thought was a big deal
• In May, I blew that goal away - and successfully completed a half marathon. That's right, I ran for 21.1 kilometers. Never thought I'd pull that off. Ever.
• My weight now is 195 pounds. That's 85 pounds lost so far (I say so far because that puts me - believe it or not - still at an overweight BMI. 10 pounds to go.)
• Finally, I don't feel like a chump telling patients they need to lose weight to be healthy... and in fact, if I want to show them it can be done, I just point to the photo of me on my ID badge from September.

So, what were those mistakes that kept me from doing this earlier? Well, for three easy payments of $9.99 sent to.... just kidding! Here they are:

1. I thought QUALITY was more important than QUANTITY.


Healthy eating is important for disease prevention - I ate multigrain bagels and chose sugar-free fruit juice for years, never buying pop, chips, donuts or cookies... and only gained weight.

Consider this: I would go to Tim Horton's for a snack between morning classes and proudly ate a healthy 12 grain bagel with cream cheese, instead of what I really wanted - a chocolate glazed donut. Despite my choice being overall more healthy, I was eating 471 calories of healthy goodness instead of the 260 calories in the donut - almost DOUBLE! If I ate one of those bagels every day, and didn't jog for half an hour to burn off those extra 471 calories, I would gain almost 50...that's right, FIFTY... extra pounds in a year.

So, I changed my mindset to cut down on how much food I ate, instead of just choosing healthy foods. And wouldn't you know it, the pounds started coming off. That's why I like to tell people I started on the "put less stuff in me diet."

2. I used to only think of my weight when I stepped on a scale.

In order to actually make a difference and lose weight, my goal to lose weight had to become something I thought of every minute of every day, not just for the moment when I stepped on a scale in the morning.

I knew you had to eat less to lose weight, but I always found myself only thinking about this between meals, and forgetting about it when the food was in front of me.

So what had to change? Every decision I made, such as getting in the elevator, and every time I put something in my mouth, such as my morning coffee or cereal, had to be filtered through the perspective of "how could I change this to increase calories burned or decrease calories taken in?" The answers were easy - take the stairs instead, switch to milk in my coffee, only 1 bowl of cereal instead of 2 (okay, who am I kidding, 3). I just had to ask myself the question...dozens of times in a day, before I did anything.

My weight loss goals had to be something that influenced everything I did and every thought I had. Sure, it might sound a bit obsessive, but after years of unsuccessfuly trying to "eat healthy," for me, that's what it took - a complete mindset change.

3. I didn't use a simple strategy to overcome my hatred of exercise.

I hate exercising. I was able to run regularly for a while a few years ago, but that dropped off. I didn't really have anything to keep me going.

But now I found three things to keep me getting out there and exercising. First, I combined exercise with diet modification - and started to see results. Seeing the weight come off, and having people comment on it, is a great way to keep you excited about getting out and running.

Secondly, I began to time myself, and try to break my records. I got RunKeeper, a free app for my iPhone, and tracked how long it took me to run a certain time. The next time, I would try to run the same distance just a second or two faster.

Thirdly, I signed up for a 10k race. This gave me a goal to work towards, and an exciting event to participate in when the day finally came.

Now I just have to come up with a way to overcome my even more intense hatred of lifting weights...

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Never trust a skinny chef. A fat doctor, however...

U.S. President Obama with Dr . Benjamin, Surgeon General nominee. Source: The White House

Today's LA Times has an interesting piece about a new Surgeon General nominee in the USA, who herself is obese. Her nomination has generated discussion about whether or not doctors should be overweight.

Let me explain why this article caught my eye.

Last year, in a family practice rotation, I was in the room when my preceptor was counselling a patient on theimportance of losing weight to cut down his risk of heart and stroke (and countless other diseases). The patient was obviously feeling a bit sheepish about the lecture, and awkwardly tried to draw the attention away from his waistline. He pointed at me, and said, "Well, this guy will be needing to lose some weight too then, won't he?"

This was the first time somebody had said something about my weight since I was teased in high school, and afterwards, my preceptor apologized profusely for the behaviour of his patient. However, even though it was a bit more surprising and amusing to me than offensive, he did have a point.

At that point, I was 6' and weighed almost 280 lbs. That means my BMI was 38.0 - not just obese, but class 2 obese... and my disease risk for high blood pressure, heart disease, and type 2 diabetes was a few pounds short of extremely high.

If you think this is starting to read like a diet book, it actually does. I had always "eaten healthy," and had even done some jogging in the past. My list of reasons to lose weight was long...pages long. But not long enough to get me to have a healthy weight.

At the start of third year, my list of reasons to lose weight got longer. I began to spend over 8 hours a day seeing patients....most of whom were fat, and most of whom were dying or very sick... because they were fat.

In fact, every ward I rotated on showed me new ways people were suffering from obesity. I expected to see fat people with heart attacks on the cardiology wards, but I began to see obesity-related diseases and complications in ALL of my other rotations, almost ENTIRELY due to the patients' obesity, in other words, PREVENTABLE - in orthopedics, ophthalmology, surgery, maternity, emergency, dermatology, anesthesia, and scarily enough, even in pediatrics.

I knew that obesity caused disease, but that didn't really frighten me. Until I saw the complications of the diseases first-hand. They can lead to heart failure (which is a slow death with fluid in your lungs just like drowning), heart attack (pain and sudden death), stroke (paralysis and loss of ability to speak), dementia (to the nursing home we go, and hand in your driver's licence and memories of your family and friends on the way), permanent loss of sensation (can't tell if you stepped on a tack, so it could stay in your foot for WEEKS until you notice - yes I have seen this happen), osteoarthritis (waking up with pain in your knees every single morning increasing until you can't walk anymore), limb amputation (I have seen black toes and feet from the arteries getting so clogged with fat that they stop supplying blood to the feet) and blindness (a complication of diabetes). All because of obesity...all almost entirely preventable.

Seeing all this helped me get my butt in gear. I took a close look at my lifestyle and eating habits, and was surprised to find some mistakes that I was making. That's right - I discovered that even as a reasonably bright, educated medical student, there were simple things staring me right in the face, easy things to change in order to lose weight, that I was oblivious to (I'll talk about these in another post shortly).

And soon, I began to see results. Dramatic results. I've lost so much weight that people barely recognize me anymore.

Continued at Part 2: Vitum Loses 85 Pounds...and the mistakes that kept me from doing it earlier

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First do no harm...unless you haven't gone to medical school

Albert was on the phone with his sister on a sunny afternoon last week, telling her about the trip they had gone on over the weekend and his wife's bingo winnings at the local senior's centre that week, when suddenly she interrupted. "Albert, don't be silly."

"What are you talking about?" he replied.

"Albert, I can't understand you, what's going on?" He was confused - he was speaking perfectly fine, as far as he could tell.

His wife walked into the room, and noticed that he was indeed slurring all his words, and rushed him to their naturopath. The naturopath saw his mouth drooping on one side, and told him he knew exactly what was going on. He promptly gave him a glass of water, into which she had mixed several spoonfuls of salt, and told him to drink up, and encouraged him to do this over the next several days. Why?

Because, as the wife explained to me, "Well, when the left side of the mouth droops, he has a deficiency of sodium. And when the right side droops, he is low in potassium, you see. When both droop, then he needs more calcium."

Sure enough, in about half an hour, his droop had resolved, and his speech returned to normal. So the naturopath was right, right?

Unfortunately, in this case, his naturopath was wrong. Because he'd had a heart attack in the past, and his heart muscle didn't contract the way it should anymore, giving salt to this patient was a bad decision. In fact, research shows that patients with heart failure have worsening of their symptoms when they have salt in their diet, and the most recent heart association guidelines recommend low-salt diets for these patients.

And why did he get better? It had nothing to do with chugging brine. He'd had a TIA, or a transient ischemic attack, exactly like a stroke except it's just that - transient. The brain is starved of oxygen for a short time because of low flow or a small clot blocking an artery, but then the flow is restored before brain tissue dies. Had this lasted long enough to kill the brain tissue, it would have been called a stroke; in his case, the symptoms - temporary paralysis of his facial nerve innervating the orbicularis oris muscle, causing a mouth droop on one side - went away about half an hour after he drank the salt water. Though it looked like the natural treatment worked, it in fact had nothing to do with his symptoms resolving.

But, because of this advice, his wife faithfully gave him several spoonfuls of salt every day, causing more and more water to build up in his blood vessels. And it wasn't long before his failing heart couldn't cope with this excess salt. He soon could walk shorter and shorter distances without having to stop for air, and would wake up gasping for breath in the middle of the night. His heart muscle's ability to pump blood, which had been measured right after his heart attack as still being still quite reasonable, couldn't cope with the extra water in his blood vessels and took a drastic turn for the worse.

I saw him when he came into the hospital with his wife, unable to breathe, but it was too late. Despite receiving massive amounts of diuretics, vasodilators, and being placed on a breathing machine, it was too little too late. A few weeks later his heart gave out completely, he died with his lungs full of water instead of air, with a look of panic on his face, gasping for oxygen, because of the misinformation the wife had been told naturopath.

It doesn't worry me that naturopaths provide a whole-person approach, and attempt to treat the cause of patients' ailments rather than the symptoms.

It does worry me when they cause harm to patients, and make their health worse.

Any doctor that prescribed salt to a patient with heart failure... not to mention miss the diagnosis of a stroke... could be sued, successfully, for malpractice.

It also worries me that out on the western coast of this country, in British Columbia, naturopaths have been given the right to prescribe medications,which not only seems to go against their entire profession's objective of treating things naturally, but is possibly dangerous given that they are quite simply not trained in this area.

But going back to the story...you know what the worst part is? Had he seen a physician earlier, this could have been avoided... but the wife didn't see it that way. She left the hospital, without her husband, thinking that traditional medical treatment had failed to save her husband, when in fact the damage had been done long before he got to the hospital. Hopefully, her stronger belief in natural therapy doesn't kill her too.

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That poor, poor transcriptionist. I almost admitted it was my first dictation.

I picked up the phone with a shaky hand, and slowly dialed the number for the hospital dictation system for the first time.

"Welcome to the Excelleris Express Dictation Service. Enter User ID , followed by the pound key," a cheerful voice said.

Good, I thought. She doesn't yet know that I have no clue what I'm doing.

I keyed in the number for the doctor who was dumb enough to ask me to dictate for him. 6-2-1-0-9-#.

Enter hospital ID. 1-6-#.

Enter work type. 1-0-#, specialist consultation of a patient.

Enter patient number. 2-1-6-2-7-8-1-#.

Beep beep. . . . beep beep. . . bee- okay, are you going to make me wait all day? this is where you start talking, idiot. Fortunately, it didn't actually say that to me.

I pressed 2 to begin, and slowly began to talk.

"This is Vitum Medicinus, M-e-d-i-c-i-n-u-s, medical student intern, dictating on behalf of Dr. Doe, a consultation note on patient James Smith, S-m-i-t-h, unit number 2162781, date of birth 02/20/1949. "

This isn't so bad, I thought. I picked up speed.

"Copy to Dr. Doe, copy to Dr. Wilson. Date of consult March 6 2009, date of dictation March 6 2009. New heading, patient identification. Mr. Smith is a previously healthy 60-year-old Caucasian male who presented to the emergency department with his wife and daughter. Period. New heading. Chief complaint. Open quote, I passed out in the McDonald's parking lot, close quote."

I was doing it just like all the doctors I had seen dictate before! I was dictating! How exciting! I went on.

"New heading. History of presenting illness. This afternoon Mr Smith was getting out of his car at McDonalds when he began to feel presyncopal, period, before he could stop himself he fell to the ground, period, he described his presyncopal symptoms as open quote I was light headed comma I felt like I was going to pass out, close quote, but denied vertiginous symptoms, period. he lost consciousness for approximately ten seconds and in this time did not have any tonic clonic movements comma nor did he lose control of his bowel or bladder or bite his tongue period."

Okay, it didn't go that smoothly. My actual transcription went something like this... or at least what it would have looked like if I hadn't known how to pause, rewind, and re-record:

"Uh.... um.... uh... consult...dictation.... on ... patient .... copy to... Dr.... heading...new heading.... History of, uh, no wait....go back... Mr. Smith..." ... well, you get the idea.

Starting to dictate on behalf of the physicians has been really helpful. I've done a fair bit since that first one, and the process has made me realize that as far as taking the history and presenting the physical exam goes, I've started to really get the hang of it. It's when it comes time to dictate the assessment of what the patient has going on, and the plan of how to treat them, that I kindof fall apart and realize that I still have a lot to learn; with my first dictation, I had a fair bit of trouble with it even though I had discussed the case with the doctor already. Obviously, that's what I'm here to learn in third year, and throughout residency.

After I finished my first dictation, I sat the phone down, and began to gather my notes. I took a deep breath in and out. I noticed that one of the other emerg docs had sat down at the same desk about two-thirds of the way through my dication, and turned to him and asked, "Do you remember your first dictation?"

He smiled really big, and laughed, as he replied, "I try not to!"

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The strangest thing said to me during a pelvic exam

She had been fairly relaxed about the whole situation, considering, and after taking her history and doing the rest of the physical examination, I was standing at the foot of the bed. She had assumed the unpleasant position, and I was cautiously brandishing the well-lubricated speculum, when she said to me,

Don't lose your gum, Vitum!

Hope I didn't look that eager...

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Make sure you know what you are getting into... [part one]

One of the pieces of advice I was given as a pre-med, and that I frequently give to pre-med students (it's #7 on my Top 10 list of advice for pre-med students) is,

"Make sure you know what medicine is like before you sign up for it."

That was ringing quite loudly in my mind when I started my call shift the other night. I had had a busy week in surgery. There were some really long days of showing up on the ward at 7am then a full day of office then going straight to the hospital at 5pm and seeing emergency patients and eventually taking them to the operating room and getting home well into the wee hours of the morning... with a full day in the office after that.


Most of the surgeries were routine, but some came with the emotional stress of having to tell a patient and their family they had a 50% chance of dying on the operating table, and a 50% chance of us opening them up, finding that we could do nothing, and closing them up to face their death within the next few days. (One patient's response to that speech? "Bloody hell." Yeah, no kidding.)

I also had a long academic half-day full of lectures on things that I need to know but had no energy to learn, that also went late into what was going to be my evening relaxation time.

I had to try and fit in studying for my two upcoming exams in between all that, and then on top of that I tried hard to make time to get some exercise and spend some quality time, either on the phone, online or in person, with the people in my life who mean a lot to me. And no, there was no time for going to my buddy's poker game, watching the Leafs get their butts kicked (I haven't watched one game this season!), an afternoon round of golf, or any of the other things I would have enjoyed doing that resemble this "having a life" thing I've heard so much about.


As soon as I finished work in the surgeon's office for the last day of this tough week, I headed to the hospital to get my pager and start call - and within five minutes of my call shift starting, my resident and I had five patients to see, all of whom were pretty sick. Just as we were trying to figure out who to see first, the pager went off two more times. We didn't get a break longer than ten minutes until 2am, when I got a bit of sleep before the pager started going off again (getting a bit of sleep means it was a lucky call night).

I'll admit when all those pages were coming in right at the start of the shift, I was feeling the stress of the whole week on top of having a lot on my plate all at once, and I fell into a rut I find myself in once every year or so when all the negative thoughts come rushing to me. I find myself seriously asking if I am in the right place, if I made the right career decision, if I will ever be able to treat patients on my own, if I really knew that medicine was like this before I invested all that effort and money into pursuing it.


Fortunately, the five minutes the resident gave me before I had to meet up with him on the ward was just enough time to break down, almost re neg on my no-crying policy, and beg for some strength from heaven.

Fortunately, God was listening and obliged. And all in all it ended up being a really good call shift. For me, that means a night with some varied, useful cases that are important for me to learn how to manage, and with some good opportunities for me to see patients on my own, evaluate their situations, and develop a plan and present it to the resident for their approval and questioning. We triaged those first cases well, and got through them and all the other calls throughout the night, and put off studying for just a few more hours in order to do those therapeutic things like write this post and sleep in late for the first time in a while.

::: part two to come... :::

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Poking a screaming child? That'll put hair on your...

"Bet you feel the testosterone surging through your veins now, eh?" the ER doc supervising me said. "That'll put hair on your chest."

Then again, I'm sure everyone else in the ED (and all the other wards on that floor) also had a snappy comment for me, seeing as how each and every one of them could hear the screams of my patient.

A young girl had gotten a huge gash in her arm after falling through a plate-glass window, and the emerg doc took one look at her chart and handed it to the resident, who handed it straight to me. At that point I was still unsuspecting, super keen to sew up yet another wound. Boy, was I naive.

After looking at the wound I flattered her quite nicely about being such a trooper, such a large gash and all and so little crying.

Turns out that all my buttering up was for nothing, which I found out as soon as she asked if she would be needing a needle.

That's where I went wrong.

She sensed my instant of hesitation before my answer, and took that as her cue to start screaming at the top of her lungs.

The screaming didn't stop. We tried everything from distraction, to warm blankets, to massaging her temples, to topical anesthetic and intranasal fentanyl, all of which seemed to only fuel the screaming, which lasted well into the procedure, despite the gallon or so of lidocaine I used to freeze the wound.

Even though I have sewed many a wound with very little fanfare, this whole experience actually stressed me out a lot -- much more than I expected it to.

You see, I still have enough compassion left that it makes me feel REALLY bad when I know I'm hurting a patient, especially a child, and I get uncomfortable when I see a pouty look, let alone screams of bloody murder and "PLEASE STOP! NO MORE NEEDLES! OH FOR THE LOVE OF...' Yeah, I didn't know 11-year-olds knew that many swear words. Kids these days.

It was made even better with the parents shooting me the look of death the entire time for causing harm to their little angel. Fortunately, the father's claim that he wouldn't be bothered by the blood soon proved to be quite false, and the emerg doc saw him starting to reel and whisked him away, saying "OK, come with me, you are sitting down over here. Put your head between your legs."

As well, with all the the flying fists and limbs I was pretty scared of buring the syringe or suture needle in my own hand.

In fact, I was even more stressed that I'd be poking the care aide holding the child down. Keeping this saint happy had risen to a very high priority ever since she set aside one of the leftover hospital meals for me (which, despite being hospital food and looking like it had already been digested once, was still food).

The procedure finally ended, and she finally went home, and a strange calm fell over the emerg. In fact, with the young girl gone I could only really hear monitors beeping, ambulance sirens, nurses shouting, and other patients yelling, which was so much more quiet than when that girl was there.

Later on, one of the doctors told me that he used to feel bad poking children because they would cry so much. "Then," he said, "I had my own kids, and realized they cry all the time... even if you are not doing anything to hurt them."

That did make me feel a bit better. But I was still so worked up when it was all over that I considered going to the homeless gentleman and ask if he was gonna finish that bottle of rubbing alcohol he was using to get drunk (tuition is due soon, so I am trying to get all the free hospital food and free alcohol - of any form - I can get). I figured if dealing with the screaming child didn't put my hair on my chest, perhaps some isopropyl alcohol will.

Either way, any more shifts like this and I think I'll start losing hair rather than growing any more.

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She was one of those 'natural' people, and the odd x-ray terrified her.

She was one of those 'natural' people, who always wanted to do things naturally, and even the odd x-ray terrified her. Too much radiation. She once wore a cast on her arm for 6 weeks after falling off a horse, for what could have been just a sprain, just to avoid the two x-rays it would have taken to rule out a fracture.

So, obviously, getting a mammogram was out of the question.

Her doctor tried over and over again to explain to her that a mammogram gives you a very minimal amount of radiation, the same amount as living in a city for 7 months (0.7 milliseverts) - the average U.S. citizen is exposed to 3 mSv per year of 'background' radiation.

The mammogram would have picked up her breast lump long before she felt it, long before it was diagnosed as cancer, and long before she would have to get her breast surgically removed.

A few years later, she started losing weight suddenly, then one day coughed up a startling amount of blood. She had never smoked, so lung cancer never even crossed her mind. Fortunately the radiation dose of 1 chest x-ray (0.1 mSv) no longer scared her, given her past experience, so she got the x-ray her doctor recommended to check it out. Unfortunately, however, breast cancer can spread to the lungs, which is what her doctor found on the x-ray. She died a few weeks after I met her in hospital, surrounded by her family, and countless beautiful flowers and cards showing how much she would be missed.


The week before she died, she said to her doctor over and over, over the sound of her oxygen and between short, gasping breaths, "I should have listened to you. I should have gotten that mammogram."


I had a conversation with another patient last month who is younger than my dad, an incredibly friendly and cheerful man, who is dying because he was too afraid to have a doctor stick a finger up his bum. Had he done that, his prostate cancer would have been discovered a long time ago, long before the it had the chance to spread to his spine, ribs, and legs, forcing him to live his last few months unable to get out of bed and suffering from excruciating pain every time he tried to take a breath. While you are celebrating Christmas with your family this year, his family will be celebrating their first Christmas without him.


It takes a lot to wrap my head around the fact that I am meeting and treating patients who will be dead very soon.

It's harder to accept the fact that a good number of these patients, who drink litres of alcohol a day, smoke like a chimney, don't get off their couches, and especially those who don't bother getting screened for cancer, could have had much longer lives.

Yeah, the screening tests we have aren't perfect, and some of them are uncomfortable and seem a bit undignified. But they do save lives, and so if you are in that age group, there is no excuse to not get them done.

This is not the place to get medical advice, so talk to your doctor about getting a prostate exam, a pap smear, or a mammogram. Sooner rather than later, please.

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When patients try to fool doctors - four interesting types of fakers

Most people have heard of Munchausen's syndrome, a fascinating condition in which patients try to fake a condition in order to draw attention or sympathy.

There are a few syndromes that doctors need to keep in mind, some of which are quite fascinating, in which the patient tries to fool the doctor for various reasons. Here are some of those conditions, how the patients fool the docs, and how the docs avoid being fooled.

1. Drug-seekers

What are they –
In a sentence, the bane of any ER physician's existence. They're either addicted to pain meds, or obtain and fill prescriptions then sell them on the street to addicted people for a huge profit.

How they fool doctors -
Drug seekers can be very slick. I have seen a patient had another doctor vouch for them, one who wore their full police uniform, an adorable 80-year-old church organist, and even nurses and doctors ... all of whom were found to be getting prescriptions for pain medications and selling them illegally.

How doctors recognize them -
Besides being highly suspicious of any patient who asks for narcotics, some regions have databases that doctors can use to determine if a patient has filled a suspicious number of pain prescriptions. However, some drug seekers raise a lot of suspicion on their own. They'll claim to be allergic to every non-addictive type of pain medication, which is statistically unlikely. Others are just bad actors. They’ll shriek and cry at the lightest touch when a doctor pokes their back to find out which part hurts… then later, the doctor will give them a friendly pat on the back, and find that the supposedly painful spot no longer seems to hurt.

2. Malingerers and Insurance Hopefuls

What are they -
A "malingerer" is defined as a person who fakes an illness with the intention of avoiding duty or work. I'll lump these in with patients who fraudulently fake or exaggerate illnesses to try and get insurance payouts.

How they fool doctors -
Malingerers will seem to have a lot of pain, and some actually are suffering from very real pain. They use this, however, to prey on a doctor’s empathetic side. They can also be quite convincing actors when they demonstrate just how incapacitated they are.

How doctors recognize them –
By knowing the physical exams and anatomy very well, doctors can get suspicious if the results of a few different tests of the same joint or muscle aren’t consistent. Some malingerers, though, can be fooled quite easily. Even I have had my suspicions raised with a patient who struggled to raise her arm a few inches when I asked her to demonstrate her range of motion. When I then asked her to show me how high she could raise it before her accident, she effortlessly shot her arm up high above her head!

3. Psychogenic nonepileptic seizures

What are they –
This is a term for people who appear to be having seizures, but it turns out that they are actually not suffering from epilepsy – for various reasons, they’re faking the seizures.

How they fool doctors –
Anybody in a doctor’s office or emergency room who is having what appears to be having a violent seizure, will obviously get the benefit of the doubt. In fact, in some cases, it is many years of investigating and giving high doses of seizure medications before a doctor realizes that the patient has been having nonepileptic seizures the whole time.

How doctors recognize them –
Research has shown that nonepileptic seizures occur more commonly in a doctor’s office or waiting room, or when there is a witness around. Some medical textbooks suggest giving such patients a sugar pill or an injection of water while telling them that this medicine has been known to cause seizures, and seeing if the patient starts shaking. While this can seem deceitful, the lie isn’t usually necessary: some patients still have these fake seizures even if they are told that they are being given something that can induce both real and fake seizures. Other things doctors look for are things such as where the patients bite their tongues, which is often in a different location for real and fake seizures, and the length and frequency of the seizures.

4. False comas

What are they –
Hopefully I don’t need to explain what a fake coma is. I will mention though, that people fake comas for a variety of reasons. Some people with psychological conditions feel safe in a hospital, and fake a coma so they are surrounded by doctors and nurses. Others have been found to fake being knocked unconscious on a ski hill, because they can’t afford a bus ticket home and would instead prefer taxpayers pay for a helicopter to fly them to the nearest city.

How they fool doctors –
By laying very, very still.

How doctors recognize them –
While there are some non-invasive tests that can be done to determine if a coma is indeed real, sometimes doctors aren’t even trying to “catch” a fake coma when they do their neurological exam and find that some results don’t add up. Also, patients who appear to be in a coma but resist the doctor opening their eyes, or flinching when the doctor’s stethoscope swings close to their face, obviously raise suspicion. Obviously to determine legitimacy it’s important the doctor knows what is normal, because strangely enough, patients with legitimate comas have been seen to do odd things such as cross and uncross their legs.

~~~~~

It goes without saying that doctors need to be careful when they suspect such occurrences. If a doctor confronts a suspected drug-seeker, malingerer, false coma patient, or psychogenic seizure patient, this can result in a very upset and sometimes even abusive patient. Two sentences that I know of that have resulted in a doctor getting punched in the face by a patient: “For the last time, I am not going to give you strong pain medication,” and “This isn’t a real seizure!” Even worse, if a doctor is wrong, they will be withholding care from people who are suffering very real medical conditions.

That’s not to say, however, that these “fakers” don’t need help. While the financial gains for drug-sellers or insurance scammers are usually based on greed alone, people who are addicted to drugs, or feign comas and seizures, can have very real and complex psychogenic conditions (to give you an idea of how complex these conditions can be, some patients may not even be aware they are faking). While they can make a doctor’s work more challenging, at the end of the day all of these people do need real treatment – not with narcotics or anti-seizure medications, but with psychological counselling to determine the underlying reasons that are compelling them to fake these conditions.

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Join me on my first on-call shift, and find out why I slept so little

For the future (and pre-clinical) medical students out there who are wondering what being "on call" is, I have just completed my first call shift. Therefore I am now a reliable source for information about what being on-call means. Here's how my night went:

5:00 pm ::: Start of on-call shift. On the phone with a friend in residency asking for some on-call tips. #1 tip: While on call, eat, sleep, and pee when you can. You don't know when your next chance will come.

5:21 pm ::: Fell asleep on the toilet while eating a granola bar.

5:36 pm ::: Woken up by a patient who claimed I was sleeping in his bathroom.

5:37 pm ::: Patient's claim corroborated by nurse, who is kind enough to explain to me what an "on call room" is, and where I could find it in the hospital.

5:41 pm ::: Changed out of my scrubs into pyjamas. Realized scrubs are more comfortable and changed back. Fell asleep.

6:12 pm ::: Woke up. The pager they gave me is making weird, loud beeping noises and has stopped showing the date and time. Now the display was just showing "911" and a few extra random numbers. Must be broken.

6:22 pm ::: Finally figured out how to make the pager stop malfunctioning and making such loud noises: take out the battery. Able to sleep again.

9:38 pm ::: Woke up abruptly. Some dude is banging on my door and shouting something about being "my resident" and how they have called me "100 times" in the last two hours. Must've had my phone on silent. Turned up the TV so I couldn't hear him, going back to sleep.

10:26 pm ::: That same dude got hospital security to unlock my door and wake me up. He is telling me to go to the sixth floor to "see a patient" with "delirium." Not sure what that means. Not sure what delirium is, either.

10:34 pm ::: Saw the patient - turns out the he is actually just a really nice guy who is a government agent, and he explained to me that he is being held against his will and that the nurses were trying to poison him. Helped him find his way out of the hospital so he could get back to being a secret agent.

11:17 pm ::: Back in the on-call room. Spent an hour propping all the furniture against the door so that my resident and the security guard couldn't come wake me up again.

12:19 am ::: Jumping on the bed.

2:54 am ::: Removed the pile of furniture from my door when I started getting hungry. Roaming the hospital looking for unconsumed foodstuffs on patient trays.

3:19 am ::: Found half a brownie and some cold soup on a patient's tray, and drank some apple juice that a patient thought they could hide from me by putting it in a pan under their bed. The apple juice wasn't very good, but it was free.

3:40 am ::: Running from the paediatric nurse who caught me drinking all the infant formula.

4:51 am ::: Back in the on-call room - can't sleep. Damn ambulances keep going by my window.

7:36 am ::: Woken up by security, who came in through the window this time, clever fellows. They told me to get out. Figure that means my call shift is over - going home to bed.

Turns out this call thing isn't so bad. It's basically watching TV, eating and sleeping. I think I could get used to doing this every fourth night.

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Casting - learn by doing (and making mistakes)

It is being made very clear to us, in our orientation to our third year, that in medicine some mistakes result in deaths.

Others result in really annoying tiny chunks of fiberglass on your fingers for a few days.

At a practical clinical conference I went to recently, one of the workshops offered an hour of putting on learning about various fractures and practical casting and fracture re-setting tips, followed by an hour of putting casts on each others' arms.

We learned some neat practical tips to make slightly casts, from how to cut the material so it doesn't bunch up between the thumb and pointer finger, to how to apply a bit of extra padding where the cast is likely to have a few extra pressure points.

For example, we learned "a good cast is an ugly cast" - if the cast is made properly, and is applying enough immobilization at the right area of the bone, there will be knobs and finger indententations from where the person applying the cast moulded it correctly (I don't think that the teacher was referring to a "really" ugly cast, like the one in the picture, that my friend Jordanna moulded... unlike me, though, at least she remembered Step #1...see below).

Or, we learned that any forearm cast - even for a single broken tiny bone in the wrist - should go up to within two fingerbreadths of the antecubital fossa (elbow crease). That way, if you fall on the cast, you don't end up with a radial/ulnar double bone fracture halfway up the arm where the cast ends (which could end you up in surgery) - instead the elbow joint can take the brunt of the force.

When it came time to apply the casts, though, I unfortunately forgot step #1.... put on gloves. I've had some experience applying plaster casts, where you can easily wash your hands afterwards with no residual... uh, residue.

However, for fiberglass casts, if you don't wear gloves, your fingertips get coated in tiny chunks of fiberglass cast material. Try as you might to wash it off, it's there for good for the next few days to wreak havoc on your sensory nerve endings and make your hands feel like they're desperately in need of moisturizer.

Fortunately this mistake didn't kill anybody. All the same, it's still one that I'll chose to not make again.

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He barely made it out alive

The rain was pouring into the windshield. The headlights may well have been candles, since they did barely anything to light up the dark night, especially around the corners and over the crest of the upcoming hills.

And of course, it had to be in these horrible driving conditions, was when he heard and felt a definite THUMP. He'd hit something. His wife started shrieking. "You killed it!"

After slowing down to a stop on the side of the road, he sat and took a breath and thought in apprehension about how cold it would be stepping out into the rain. As his wife's yelling got louder, he realized that no matter how cold it would be outside the car, at least it would be quiet, and he jumped out into the rain.

First was the priority of seeing if his car was damaged. Great, he thought to himself. That bumper is going to be at least a thousand bucks.

Then was the important part of checking on what he had hit. Groundhog? No, it seemed bigger. A deer, perhaps?

As he walked towards the black figure on the road about twenty yards back he could tell it was injured, but definitely still alive. Any doubt of that was eliminated when his wife made the assessment from the safety of the car, at a loud volume - "Oh noooo! It's still alive! It's suffering!"

She begged him to put it out of its suffering. But what was it? As he got closer, the figure, barely lit up by the red taillights of his car, started to take on a familiar shape... that of Jeddy, his favoured teddy bear from when he was a child.

Oh my goodness, he realized. He ran over a baby bear cub.

"Dooo something!" his wife yelled, as he watched it trying to lift its broken body, to drag itself to the side of the road. It was clearly suffering. What should he do? Run it over again, he thought? No, that's inhumane. Hit it on the head with a shovel? Maybe, if he had a shovel.

Going back to the car, and rummaging through the trunk, the rain now soaking completely through his dress clothes, he found that no, he definitely did not have a shovel, and that the only suitable tool of humane death in his trunk was the noble tire iron. "Come on, honey, let's just go," he pleaded. "It will die on its own."

"Nooo!" she protested. "You have to do something!"

Back he went to the dying creature.

"I can do this with one swift blow to the head," he thought.

After one blow, he knew his estimate of one blow was way off. He hit again. Not enough. And again.

It was somewhere between the fifth and fourteenth blow, from what I'm told, that the bear cub's mother lumbered onto the road. She saw this unfortunate this man leaning over her baby, beating the last breaths of life out of the cub with a tire iron. And so, rearing up on her hind legs to her full height, she reacted, in the way that only a mother grizzly bear can.

And that's the story of how I, working a nighttime ER shift, got to see a patient who had been attacked by a grizzly bear.

People were handing me bags of saline to squeeze, in an effort to restore his blood volume as quickly as possible, as the machines pumped donor blood into his body. Doctors were scrambling to put in chest tubes, central lines, and stop the bleeding from where his arm and shoulder used to be. After about fourty minutes, we stabilized him, in a manner of speaking, and sent him off to surgery. And six hours after the surgery, they're saying he's gonna survive.

Rural medicine can be pretty interesting, that's for sure.

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Every doctor has a needle story or two

If you ask any doctor to tell you an interesting story from administering an injection, they probably have plenty. Most of them involve patients with countless tattoos and piercings who have to get one small needle to freeze a wound before it is stitched shut, but the fear of the needle is just too much, and the patients protest violently.

I was reading a needle story at Scalpel or Sword, along with the additional stories in the reader comments, and was reminded of a few of my own.

One of them did involve a huge, burly motorcyclist with a very, very worried look on his face, who kept asking the paramedics, "I'm not going to have to get a needle, am I?" He had too many tattoos to count. I'm not sure how he survived getting those if his fear was that intense.

Another involved a man who must have had more than half his body weight consisting of metal from piercings. He had cut open his arm with a grinder at work, and was placed in the minor procedures room at the ER to be stitched up. By the time I was in to see him fifteen minutes later, he was clutching the sheets, face down in the pillow, crying and screaming at the top of his lungs. As soon as he saw me, he shouted, "Get me out of here! There are needles in here!" I looked around, and didn't see any. I told him they were all put away, which didn't console him at all. "I don't care!" he screamed. "I know they're in here somewhere!"

While the freezing can burn a bit when people are given needles in a wound, vaccinations don't usually hurt very much if they're given properly. I've gotten 16 needles in the past five years or so, and given many more than that, and have hurt or been hurt hardly ever. While technique is most of it, anecdotal evidence is strong that a good portion of it is in the way you prepare the patient - if you tell them that it won't hurt very much, they often shout a lot less than the ones you tell them "this is really going to hurt."

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Medicine still amazes me...and still lets me down

As I learn all the physiology, pathology and pharmacology that medical school has to offer, sometimes there are unique things I see during my medical training that really, really impress me.

Whether it's the capabilities of a 3D reconstruction of a CT scan of a bone or the heart, or watching a patient's debilitating tremor disappear instantly at the press of a button activating a microelectrode in their brain, or re-starting the still heart of a dead person inside the chest of someone else, I occasionally find myself with my jaw on the floor when I learn things that medical practitioners are able to do and see that, only a few years ago, were an impossibility.

Then again, judging by something that happened earlier this month, perhaps I'm just easily impressed.


The doctor I'm working with was called from his office to go see Catherine, a pregnant woman in the hospital. She is early in her third trimester, but started having contractions. Of course, he explained, calls like this come right at the end of the lunch shift to provide the maximum inconvenience to him and the patients waiting in his office. He also explained that disruptions to the office like this are a part of the reason many other family practitioners don't do obstetrics anymore.

We're taught that a lot of information from a patient can be gained from the first part of the physical exam - from "five feet away," or the first glance of the patient at the foot of the bed. This patient was a great example of this. We had barely entered her room, and right away, we knew that Cathy was not doing well.

More than anything, Cathy was incredibly anxious, and for good reason. On the drive over, the doctor had explained to me that Cathy had never been pregnant, and it had been her dream to have a child. She and her husband Dale had been trying for years. No reason for her and her husband's infertility could be found, and finally, after several tries of drug-assisted and then subsequently in-vitro fertilization attempts at a high financial and emotional expense, this woman was now pregnant. And at 41 years old, Cathy knew just as well as we did that if something went wrong with this pregnancy, there likely wouldn't be another chance.


The doctor did a quick exam, and was convinced that the cervix had not begun to dilate. The baby's heart was still beating normally, and monitoring of the uterine muscle contractions revealed uterine muscle activity, but it wasn't clear if this was due to actual contractions or more minor uterine irritability.

Just a few years ago, Cathy would likely be admitted for observation, at a cost of a couple thousand dollars a day. She might not end up being in labour, and might not end up delivering for weeks... meaning a long, expensive stay in the hospital, with an expensive air ambulance transfer to a big-city hospital, with little benefit. On the other hand, she could be sent home, then suddenly go into full-blown labour, and deliver a premature infant away from the hospital after being sent home. How do you spell "lawsuit" again?

I was surprised to hear that this dilemma is not faced nearly as often thanks to an expensive but convenient lab test looking for fetal fibronectin. This protein, made by the fetus, is found in the mother's cervical secretions only if the mother is likely to deliver within the next four weeks. By taking this swab, and getting the results from the lab a mere twenty minutes later, we were able to conclude with resonable certainty (the lab test is correct 15 out of 16 times, according to the packaging) that Cathy was not going to have a premature delivery, and that she could safely go home.


Despite the things I learn that amaze me, large or small, there still times that I am disappointed by the failures of modern medicine. So many diseases cannot be cured, and many can barely have symptomatic relief.

Earlier this week, I had to look into the eyes of a 83-year-old woman in a wheelchair who was begging me to fix her legs. She could no longer walk, and she desperately wanted to be able to. After she had left, my supervising doctor told me that she lost the use of her limbs because of a progressive neurodegenerative disease for which there is no cure, and she often forgets that this happened years ago because of her long-standing dementia. She has two diseases that, despite all of the advances in medicine these days, it still seems as though we can't do much more for her, and the millions with similar conditions, than apply a band-aid.


I'm told that throughout my medical career the advances in medical technology are expected to be staggering. Who knows what clinical decisions will be made much easier because of medical advances, or which devestating diseases will soon become relics of the past. Waiting to hear what the future will bring, and the chance to put these discoveries into action to change peoples' lives, is yet another exciting part of living a life of medicine.

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Sometimes it seems as though the world's greatest people are dealt the worst hands in life

Happy birthday Dad!!!

The flight paramedic I worked with this week started his job the year I was born. He has seen patients of all sorts, at all stages in life, with all sorts of background stories. Yet, the story of the patient we flew into the big city, and what she did right before we loaded her onto the helicopter, he told me later really moved him.... something that means a lot considering how hardened he is and how much he has seen.

Actually, considering the several shifts I've had with the flight paramedics over the years, I have been surprised at how sensitive they are to their patient's needs while serving in a job that could have the tendency to see them slip into the mindset of a courier transporting inanimate packages. Even in the little things. "You're gonna feel a poke here" is something the lab tech should have said (many times) when she was digging to find a vein; instead, it was the paramedics who were keeping an eye out for the patient in that time. Treatment of a patient like a pincushion is something you never want to see... it is even harder to watch when the patient receiving the bludgeoning had been admitted for treatment of a suicide attempt.

But back to this inspiring patient.

It was a sweltering day in the city, and I had been regretting trying to dress nicely to impress the paramedics beacuse in my pants and long-sleeved shirt I was doing more sweating than shadowing. I wished we could stay in the air-conditioned ambulance station at the airport but instead when the pagers went off. I was hoping for an exciting scene response trauma call, but no, we had to head to the helicopter to answer yet another boring transfer call.

Rachel, a 33-year-old mother of two, was being brought in to the big city to see a specialist for a growth in her throat. It hadn't been biopsied, but it was pretty obvious to everyone that it was the cancer coming back.

You see, ten years ago, after a dental procedure, she started having trouble swallowing some foods. She ignored it for a few days because she assumed it was inflammation left over from her root canal, but it didn't go away, and finally looking in the mirror with a flashlight revealed a growth that made her weak at the knees. Her worst fears were confirmed when she was given the diagnosis of cancer.

The tumour grew incredibly fast, and she soon lost feeling in her face, control of her facial muscles, and had to soon start eating through a tube. That seemed like a minor inconvenience when she had to have a tube put into her throat because the tumour was blocking her airway. Surgery was attempted, followed by chemotherapy and radiation, which took the pressue off her trachea and allowed her to breathe again, but left her bedridden.

Then, miraculously, her strength began to come back, and so did the feeling and control in her face. She soon was talking, sitting up, then standing. Nobody seriously expected the day to come when she would leave the hospital, but she did... walking entirely on her own.

Unfortunately, the road to recovery soon came to an end. Three years after that, shortly after the birth of her second son, the cancer relapsed, this time much worse. It had spread to the bones in Rachel's vertebrae, paralyzing her from the waist down. Again, she had to undergo surgery, chemotherapy, and radiation. And, amazingly, against all odds, she again had a complete recovery, more miraculous than the first - all of the feeling and mobility in her legs returned. She could walk again!

It would have been nice if it could end there, but the story goes on, and not in the direction anybody would want for her. Earlier this week Rachel was having dinner with her family when she got some food stuck in her throat and started choking. She was unconscious for some time before anyone could revive her, and the preliminary tests suggest that not only was the cancer returning, but she had lost some cognitive function while her brain was deprived of oxygen.

Right before we picked her up to take her to the big city for some more tests, a few more results came in. It seemed as though the tumour was growing around some crucial arteries and veins, and that surgery would not be able to reach it. Treatment this time around, if any, would likely be palliative.

Despite all of this, she was one of the most genuinely nice people any of us had ever met. She thanked all of the paramedics profusely, and didn't complain about anything. "Thank you for serving me," she said to the paramedic I was shadowing as we took her into the hospital. He replied, "No, you have been the one serving me."

When it comes to life, it seems that sometimes it's the world's greatest people that end up getting dealt the worst hand. I don't know how I would cope if I had to go through everything she had in the past ten years. She truly put a face to courage and grace, and since then I have found myself remembering her every time I think I have it rough with traffic or something else minor in comparison.

Like I said, though, the paramedic told me he was also really moved by something she did right before we loaded her onto the helicopter. As we pulled her out of the ambulance, and were readying the aircraft's stretcher support, she did something that made me regret cursing the sun the whole day. She was strapped in to her stretcher, but her arms were free, and she spread them out and looked into the sky. "It is such a beautiful day," she said. "I love the sun!" And, knowing full well that she would likely be on a cancer ward for the next several weeks or months, and that this could be the last time she would be at home, she added aloud with the most beautiful smile on her face, "And who knows when I'll see it again."

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The failed mandate of our family practise course

Our medical school has a strategy to fight the sagging number of doctors choosing family medicine as a profession: expose students to the profession through a mandatory course in family medicine. Unfortunately, if you ask anybody in my class, it's quite apparent this strategy is probably doing more harm than good.

It involves exposing us to family medicine by arranging for us to shadow family physicians for a few hours per week in our first two years, assigning various time-consuming projects, and providing a number of family medicine-related lectures, attendance to which is encouraged (with limited success) more by sending threatening e-mails to the students than by providing interesting topics.

Then, we are given an exam for each of our first four semesters, asking medically relevant minute details from the lectures, such as, "How many people died in Somalia last year?" "Which of the following is an example of grey literature?" and "What does the E stand for in FIFE?" (the latter of which I know quite well after getting yelled at by a patient for using said technique).

I'm not sure who thought making medical students write exams on boring lectures that they've been guilted into attending would develop in us a passion for the field, especially when we're already overwhelmed with the study load for our other courses. It's a good thing we are instead able to develop this passion by spending time with family doctors, right?

Well, it's not that simple. Personally, I lucked out, and ended up with outstanding tutors. I'm among only a few people who had an excellent experience with all my various tutors, getting the chance to regularly see patients on my own and conduct histories and physical exams, and fill out prescriptions, referrals and lab requisition forms.

Unfortunately, for many people in my class, the taste of family medicine they got from this experience is a very bitter one.

First of all, urban family practice is very different from what family medicine used to be. While rural doctors still do a lot of procedures and deliveries, most of the doctors we shadow have cut down on the amount of these extra services, including following patients in the hospital.

Secondly, with the increases in class sizes, only a small number of students are one-on-one with the doctor, and even after grouping students, the faculty is still having a hard time finding
doctors willing to teach.

So, the preceptors they do sign up aren't all doing it out of a love for teaching, and the students suffer for it. Two students that I know spent most of their shifts with one physician sitting at the end of a hallway, called in only once to see patients. Two others I know spent a semester watching the doctor perform alternative medicine such as waving his hands over the patient (all of which he billed the government for), and they even spent a whole shift punching out pieces of aluminum foil, to build up the doctor's supply of tinfoil confetti to tape on to patients' hands as an (undoubtedly ineffective) alternative medicine method.

However, despite the lectures, exams, and poor shadowing experiences, the course is by no means a complete failure. Some students, like myself, have a fantastic experience with the doctors, getting to do and see a lot, including surgeries and infant deliveries. And even if it didn't convince anybody to become a family doctor, the amount of clinical and patient experience we got will give us a step up for when we start our medical student internships in the fall.

Additionally, the course also gave us the chance to practice a few office procedures, such as prescription writing, suturing, biopsies and excisions, which is the fun 'doctor stuff' that everyone looks forward to in med school. Unlike the medical students from some Canadian schools, though, we never got the chance to learn how to place IVs in our first couple years of med school.

As well, everybody in the class was exposed to the huge variety of sub-specialties of family practice that exist when we spent time with two specialized family physicians. Family doctors can tailor their practices with a focus in prenatal care, oncology, surgical assist, inner city medicine, emergency, hosptialist, sports medicine, and many other fields, something I didn't know before med school, and a realization that definitely piqued my interest as I search for a specialty that satisfies my desire for variety.

Finally, the rural exposure component of the course is one that is apparently a lot of fun. After two years of medical school, we get the chance to spend some time in a rural community, an experience I'm looking forward to right before I start my third year. This is evidently one of the redeeming factors for this course, and hopefully when I'm shipped out, I'll have a few interesting stores to share... and not spend the whole time punching out tinfoil confetti.

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Blinded by the silver lining

As I've mentioned before, some people seem to be much more willing to open up to you about their medical details when they hear you're a medical student. Often this involves unpleasant details, such as elaborate depictions of fungating lesions and uncontrollable bodily functions. Once in a while, though, I get a response I don't expect.

I was at a coffee shop a couple weeks back - to relax, not refuel, unlike during the school year - and was served by a cashier whose competence at baristing I immediately called into question. After she dropped a few things, had difficulty counting out my change, and made something other than what I ordered, I admittedly made some silent judgments about her intelligence too, which I assumed were related to the lack of natural pigment in her hair.

It was a slow day, and so when I went to return my dish before I left, she started making conversation. "You're a student around here you said? What are you studying?" "I'm taking medicine," I replied, and braced myself for the "Oh, let me show you this rash" or something of the sort.

"Oh, neat, do you know much about Alzheimer's disease?" she asked. "My dad has had that for the last seven years or so. It's pretty interesting, isn't it, with the tau protein deposits and the beta amyloid plaques, and all that."

I think my jaw noticeably dropped. She wasn't so blonde after all!

She went on to impress me with the other things she had learned about the disease, and talked about how she had moved in with her dad to take care of him when he got considerably worse, so that he wouldn't have to go to an old age home. She had left her job as an accountant and found the coffee shop gig which didn't require her 9-5; that way, she could spend more time with him.

Alzheimer's is a terrible disease. Many people get upset as it ravages the cognizance of their loved ones, feeling as though they can only stand by helpless as the person they love is taken away from them, a bit at a time, leaving an empty shell of the personality they once knew. Some even choose to not deal with the stress of the disease by moving their parents to an old age home and not bother visiting.

With this in mind, I asked, "that must have been difficult, I imagine, watching him change so much over the years?"

Her response to that question surprised me even more.

"No, no! It's the best thing that could have happened. You see, as he loses more of his memory, he's been becoming more and more like a child. Now we hang out and make jokes and play in the backyard like kids, and have so much fun. If it were a heart attack or a stroke that took him, then it would be instantaneous - I wouldn't have the chance to say goodbye. This way, though, it's been slow... and so I have had many years to accept that he'll no longer be with me soon, and I've been able to say goodbye."

Not only did I learn once again to not judget a book by its cover, but I also got the chance to see someone who embodied the "acceptance" phase of grief more than I had ever seen before. Perhaps it was because I was expecting her experience to be the same as the others I'd heard of, that she was full of anger at the situation because she had to watch this disease degrade her father to the point that he now is fully dependent on support from others. Instead, she embraced it. The amount of positivity she had for a disease so ruthless was truly inspiring.

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