Pointless Arguments

So today I was having a “discussion” with someone who had recently become a doctor, about a patient I saw in my GP clinic. This discussion quickly turned into an argument and that was not cool.

Basically, I saw a man who had metastatic melanoma and after undergoing chemotherapy he was declared to be palliative. He came into the clinic because he had felt some slight discomfort in his tummy last night and this morning he woke up and had a glass of water, felt the discomfort again, and vomited up everything from his dinner last night. He had some more water and vomited again. So he had 3 episodes of vomiting at 7 am. He then was no longer vomiting, his nausea had settled and he was able to have sips of water. He came into the clinic at 2:30pm. He hadn’t eaten since his vomiting episodes.

So anyway, I took a history and did an examination and my registrar and I decided that he had had a bout of food poisoning or was in the early stages of a viral illness. We sent him home with some anti-emetics.

I recounted this story to this person. Her immediate reaction was “did you give him some IV fluids?”. I was in a rural GP practice. There wasn’t really much opportunity to provide bags of IV fluid for someone like this patient.

But more importantly, when I examined him, I was looking for signs of dehydration. He had a blood pressure of 150/70 (which is high), he was passing urine, tissue turgor was good, his JVP was 3cm (which is normal), his capillary refill was less than 2 seconds. (Oh God sorry about this. I’ve just practiced writing all these examination findings up in notes that I’ve just spewed them on here)

Basically, He was not dehydrated. He had been having sips of water all day. I didn’t think he needed fluids.

This person I was talking to however, did. She said that I should have at the very least, given him dextrose. For “energy” apparently. I had never been taught that you could give someone dextrose for “energy” so I said I didn’t think it was indicated as he seemed quite well and was likely to go home and eat and drink normally. She started to get annoyed. She said that it didn’t matter whether it was indicated, and that if I thought about it “logically”, I would see that giving dextrose was the best choice. And that she was giving me advice to be a “better practitioner”. She went on to say that in other health systems they do give dextrose to these patients. I said that I have never been taught this and no one else suggested it at the time and he looked quite well. She said “Well you’re wrong. This is good advice”. And that I should follow it if I wanted to be a “good doctor”.

At this point I got quite annoyed.

I’m sure I’ve mentioned somewhere before that in medicine it is so hard to decide who is “right” and who is “wrong” regarding diagnosis and management of a patient. Everybody takes away something different from their learning and have been exposed to different things, and as such, they are all inclined to practice medicine differently. To say someone is “wrong” because they don’t do exactly what you would do in the same situation seems a bit silly. Of course, this is what always happens. There is no department in hospital you can go to without hearing the doctors there trashing other doctors and their care of patients. It’s just the way it works.

I’m just frustrated at the futility of it though. To get angry because you think yours is the Right way and someone else didn’t know that? When realistically, neither approach would have done much harm or benefit to the patient in that setting. As long as neither approach severely damages the patient in some way, there should be some grey area between this “right” and “wrong” thing. Shouldn’t there?

Why do people walk around thinking they’re way is the right way? Surely we’re all working to make people feel better.

Giving him IV dextrose would mean pricking him and making him sit around for an hour in a small GP practice when he was likely to go home and eat and drink something normally. This was my opinion. And my registrar, who had also seen this patient felt the same.

Her opinion was different. Which is fine. But for her to say that I was “wrong” and wasn’t a “good doctor” for not loading him with fluids, seemed a bit much to me. It seemed arrogant.

I guess this is how it’s going to be in this career. Everyone has their own “right” way. Even me I suppose. But I wouldn’t be calling someone else wrong or a bad practitioner unless they actually did something awful to a patient.

Well maybe I might. Someday.

But I hope not. Blech.

I Am Not A Fish

4 weeks into this gastroenterology rotation, I’ve found that it’s quite specialised again.

I’ve found this on many rotations before and I’ve mentioned it on here. I don’t know what it is about being in a particular department that suddenly means you are wearing horse blinders and can only focus on one part of the body.

As in, you are admitted under gastro so therefore for the time that you are here, you are nothing except your liver and bowels.

One of the other med students and I admitted a patient together. As part of admission we completed the standard history and examination. This patient was being admitted for bowel preparation before a routine colonoscopy. While examining him, I found that his pulse was abnormal. The other med student confirmed this and we were concerned that he may have an arrhythmia. When we reported this back to our intern as part of the admission notes and said that we would like to request an ECG, she gave us a very pained look.

“…Really?” She said. “I mean. He’s just here for a colonoscopy. His pulse doesn’t really matter.. You can request an ECG if you want, but it’s just an extra thing to do…”

We were both a bit disappointed by this. Yes it probably isn’t relevant for a colonoscopy. But if it’s a heart rhythm that could descend into VF at any time during the anaesthetic administration for the colonoscopy, I would imagine the anaesthetist would question why the patient made it this far without anybody picking up his irregular heart beat. The chances of this happening are very low of  course as we did request the ECG and he had a benign RBBB. But the chance exists and I would hate to be the one to fall in that percentage. I wondered why my intern didn’t feel the same way.

Then today, a patient who had an endoscopy for a bleeding ulcer was found by the gastroenterologist to have something pressing on her stomach externally. He had ordered a CT scan to find out what this was. My gastro team received the result and it appeared that the patient had multiple large cysts in her abdomen. There were multiple cysts in her liver, and some pressing on her stomach. My registrar was satisfied with this finding and was glad that we found what was pressing on her stomach. I asked him what would have caused the cysts. He told me he had “no idea”. “Some people just have cysts. We just don’t touch them. We just need to know what was pressing on the stomach”.

I just…. Eugh.

What if those cysts were hydatid? Caused by parasites? What if they become infected? Again, super low chance of this happening. And I appreciate that. But no referral, no plan to monitor further, nothing really.

Ie. Let’s just wait ’till it becomes a gastro problem that needs fixing.

What is this mentality? I’m seeing this in all parts of medical practice that I have experienced. And it really bothers me. I appreciate that once you’ve confined yourself to a specialty, your priorities are the problems that come to that specialty. But surely that doesn’t mean you have to intentionally ignore the patient’s other problems? They bang on and on about ‘holistic’ patient care in med school. I wonder how people interpret this. I am still a student so obviously I’m trained to think about every possible issue a patient presents with. But I’d like to believe I’m not just trained that way for the heck of it.

For me, if you’re the sort of doctor that says “they’re only here for a colonoscopy, don’t worry about their heart”, you’re just not providing good enough care for the patient. Like it’s just not multi-dimensional.

Okay I understand that people are busy. I understand that you cannot possibly be expected to fix every problem someone comes in with. It would be super stressful and will probably shift focus from the problem you’re supposed to fix, but it’s just the attitude. It’s just the way you’re doing your job. Why would you tell the medical students to be just as uncaring about these things?

It’s broken as Seth Godin would say. This sort of thing would come under the “I am not a fish category” Whereby the person who designed the water exit for a fish placed it one foot above the water level. The fish can’t even get up there. Why did they guy design it that way? Because he’s not a fish. He just did what his job description said: To build an exit.

Really interesting talk if you’re interested:

 

Anyway. Point of this is. I want to know which field of medicine I need to be in for doctors to not shrug off certain problems just because it’s not part of the body that they are assigned to. I wonder if there even is such a field.

Maybe I just have to try to maintain my student training mentality.

I don’t know.

Sunrise And The Day

sunrise with birds.jpg

I’m a pretty early riser. But lately I’ve been waking up earlier than usual. Don’t worry I’m not an insomniac (yet), something’s just been keeping me up.

But one of the perks of waking early is that you get to watch the sunrise. Especially in winter where the sun is also lazy and rises late and slowly such that there seems to be more vibrance and colour in the sky. 

Only in June in Auckland can you find a sunrise like this. Having an East facing house with a pretty good view is always a plus. And with a little bit of photographer’s luck, I was able to capture some migratory birds as they fly away to a warmer place right over the sun.

I’m actually very partial to sunsets. Sunsets in the West in Auckland – actually sunsets anywhere in New Zealand are pretty spectacular all year round. The multiple colours mixed together as the sun sinks over the horizon is something I could marvel everyday. But as I said, in June, from my house, the sunrise is worth appreciating. 

Pretty happy with this photo.

With a start like that, it’s kind of hard not to be motivated and hopeful for the rest of the day. 

You know what’s weird? 

When someone asks you a vague question with just one possible answer in mind…

Dr: So how do you check a child’s development? 

Me: Um you can check if they’re meeting the milestones for their age.

Dr: *silence* *staring*

Me: Well there’s gross motor, and fine motor, and social and communication..

Dr: *eyebrows raised*

Me: And you can ask the parents if they have any worries…? 

Dr: Mhmm you just have to say “use the Denver scale”. Bosses will think you’re really smart if you do. 

Me: ….. -__- I see. 

Why do people do this? Eugh. Just why. 

City change of scene

So today I decided that being depressed about everything was not achieving anything and I just had too many negative thoughts going through my head.

I needed a change of scene. So I ventured out into the city. There’s this place in Auckland city known as Silo Park. I’ve heard many people talk about it and I wanted to know what all the fuss was about. It seemed like the perfect opportunity to do so.

It’s actually a rather enchanting place. With a perfect view of Auckland’s own sky tower, the wharf with all the big yachts, the harbour bridge, etc. And at nighttime, it’s perfectly illuminated to give that calm yet vibrant city scene vibe.

This scene for me of course meant I had to take photos! …But being in my current scatterbrain state, I left my lovely Canon DSLR at home safely locked up and was left at the mercy of my crappy phone camera. So do excuse the quality of these photos. Believe me, it was an enchanting place.

Silo sculptureSilo sky towerSilo walkwayViaduct bridge

Basically it was an exercise in angle perspective shooting. Not one of my strong suits in photography. But basically I was going for different ways to see the same thing.

Moral of the story, the walk to this scene made me feel better. Just gotta keep doing more things that make me happy. I feel it’s the only way to keep going. I’ll consider this, my little win for the day. 🙂