I had an unbefuckinglievable day yesterday. I know I haven't written about the first half of the rotation yet, but I'll do that soon. I've got to get this down on paper first. The only background needed is that I'm with neurology these days...

The day started earlier than usual with rounds in A+E at 8. The first patient was a young German woman who was having some unilateral numbness, decrease in power, hyperreflexia, and some cerebellar signs. Unfortunately MS is high on the list of possibilities for her. She's going to need an MRI, and possibly a lumbar puncture to look for oligoclonal bands. It was interesting to see a possible diagnosis from the beginning. As for now her story is unfinished. Still waiting for the MRI.

Next we went on to see an young American woman with a crazy medical history. I'll have to remain vague in this forum as the details could theoretically reveal who she is to people who know her. She has a long history of a heart condition, and seizures are some of the effects of that. After her seizures she gets an atypical presentation of Todd's paralysis, which I had never seen before. It was interesting to get to talk to someone who is very familiar with her own medical condition, and I think she appreciated having another American to chat with. I think she's a republican, but I'm trying not to hold that against her! I also did a little research for her and for us as she used brand names for medications, and those are different from country to country. Another good reason to stick to generics. She had another seizure during the day, but was more or less OK. We don't know much more about her at this point either -- she'll need an EEG, though that's unlikely to show anything.

The third patient of the day was a young Polish man (are there any Irish in the hospital ?!!?!) also with a seizure history. He had had an attack, as he liked to call it, the day before, but was still quite confused. Though it's not unheard of for the postictal phase to last a few days, it's not particularly common either. His wife said this is normal for him, and that he was frequently confused, agitated, and slightly agressive. He, too, got an EEG, which luckily for him meant he didn't need a lumbar puncture. We got a phone call from the neurophysiologists while we were seeing some other patients -- the man in A+E was in a non-c0nvulsive status epilepticus! Never heard of that before, much less seen it. He was constantly seizing, though without motor involvement so it wasn't obvious. But it definitely explains his confusion and other neurological symptoms. Crazy.

After we got them squared away we went to do some consults that were requested by other doctors in the hospital. The first was a young woman who was brought in by the neurosurgeons because she was having headaches and spells during which she got "spacey". The MRI had signs that initially looked like a tumour to the surgeons, but is more likely to be a herpetic encephalitis. An unusually non-dramatic presentation of the illness, and also unusal because our patient had no other signs of a herpes infection. She should be well after two weeks of intravenous acyclovir.

The next man is another foreign natural who presented with a constant throbbing headache and a 6th cranial nerve palsy with very easily elicited eye-movement signs. His MRI showed a lesion of some sort in his frontal lobe with tons of oedema. As part of the work up he was diagnosed with advanced AIDS. As we were getting ready to leave the ward we got a call from radiology that his CT thorax showed what was likely to be a splenic lymphoma, so the lesion in his brain was likely to be lymphoma as well.

At the end of the day we went to visit another interesting, potentially exciting case. About a month ago a man fell and has been in hospital for the last three weeks with an enormous subdural haematoma, essentially in a coma. The night before last he started opening his eyes to command, squeezing our hands on command, and appears to be trying to speak. A most unexpected turn of events. It's still unlikely that he'll regain much function, but he also wasn't expected to do this well, so the neurosurgeons will reevaluate after the weekend. What was particuarly poignant was that at the same time as this man was making a recovery, a patient in a different bed in the same room was receiving his/her last rites. A perfect microcosm of the joy and sorrow present daily in a hospital.

I felt like I had had too many cups of coffee by the end of the day I was so revved up. I relize Ian may be the only person who finds this day as exciting as I did, but I feel quite lucky to have seen so many interesting patients and pathologies all in one day. I've been having a great time in the last month particularly, and I think it's a good sign that medicine is what is helping to break through the low mood I've been battling for the last few years.

More tales of my time with nephrologists to come....

"I know why North American students are outspoken. Tell me if I'm talking through my hat on this one. It comes down to one factor really, show and tell." This was early on in our last lecture of the day, which was from a geriatrician, and purportedly to be about delirium. A topic he didn't actually get to for 45 minutes. He went on to explain that while at first glance show and tell seemed to function as a way to teach about the life-cycle of hamsters and other such pets, really it was to get us used to speaking in front of people.

And so the lectures continue. They range in topic from international paediatric care [as an aside, I'm listening to Leonard Cohen sing about being KY Jelly. WTF?] to blood-borne viral illnesses to the biochemical principles of blood lab tests. Ooh. and forensics. All sorts of pictures of dead bodies, taught by a woman who I believe is the model for every medical examiner you have ever seen on screen. All in all a pretty good deal. Most of the lecturers seem pretty glad to be there, and do a great job making the subjects interesting and make sense. I've found the lectures that are the best are when the lecturer clearly has respect for his/her profession, patients, and us. It really makes a difference.

For instance, this doctor who is in charge of the blood lab. We're all used to radiology as a specialty, but don't really think about the lab as anything but a place where you send icky stuff and get back useful numbers. But of course, it's actually the same as radiology, in that the doctor uses clinical information we provide him to help make sense of the information that the tests produce. Much of the time it's straightforward, but there can be times when results are equivocal or something, and it takes a specialist to make sense of it. He actually got me wanting to know more! The same thing has happened for me with obstetrics and neonatology. I'm feeling very fortunate to be in a position to be exposed to so many different things and excited by most of it. Helps me to see the light at the end of the tunnel.

Another interesting thing about this week has been the hospital's response to the election (pause for cheering). EVERYONE here is excited. Well, there are some American republicans around who aren't, but only two of them, and I like them anyway. But doctors all over the hospital were talking about it with excitement. Pretty cool.

I should probably head to bed. Another 7 hours of lecture tomorrow...

Good night, Gracie

I'm nearly done with the World's Most Disjointed Attachment.  As you know, I spent the first week in plastic surgery.  The following week I spent in ophthalmology, which I have to admit I found far more interesting than I expected to.  There's something about looking the wrong way through people's eyes that is amazing, and getting the visual information about various disease processes, both opthalmic and systemic, is fascinating.  Though I dabbled briefly with the idea of going into ophthalmology (it encompasses some surgery too, which is amazing) ultimately I think it is too focused a specialty for this bouncy attention span of mine.  Not to mention I don't like the idea of spending 5 years in medical school only to focus all of my further training on those 2 little globes in your face.  Last week was spent in Dermatology.  Quite dull.  I know, it's important for a number of reasons, but still dull.  Luckily we only had half days there, so I got to go to the gym and do lots of yummy cooking and baking as well.

We had a long weekend this week (some sort of bank holiday as they're called here.)  It was also the Guinnes Jazz festival and the beer festival, so there was plenty going on in Cork this weekend.  Had some Belgian beer (Pater, it was called) and chatted with a fellow named Barry who is heavily involved with the beer world in Ireland.  He told me about a liquor store that carries beer with hops in it.  How exciting!  It was a great opportunity to have some beer that wasn't a stout or bland European lager.

On to two days of anaesthetics this week, where we'll learn about pre and post-op assesments, and probably some intensive care medicine as well.  Then there are these academic half days at the end of the week, but I don't know what those will entail.  They haven't bothered to tell us yet.

It's been appropriately cool and rainy here.  Today there was a lone rain cloud (isn't there a chapter in winnie ther pooh that relates to this?) that rained on me for much of my walk to the grocery store, and then even gave a little hail once I got inside.  Luckily it had cleared up for the walk home.  Though there are some trees turning colors, particularly on campus, they don't compare to what I imagine I missed at home.  Sigh.  Soon I'll get to smell and hear the leaves crunching under my feet once again.

I'm feeling like this wasn't a particularly interesting post.  Sorry.  If I come up with anything more thrilling I'll let you know.

Ciao 

It's been a full week.  I spent the last 5 days with a plastic surgery team.  At the very least, it was good to see what non-cosmetic works they do in plastics.  Lots of nerve and tendon damage in the hand and wrist.  Breast reductions and reconstructions.  Lacerations of various sorts, repairing fingers that have been crushed by hammers or gates.  Removing skin cancer, cleaning wounds, making skin grafts for burns.  Seeing such a wide variety was great.  The team was fantastic -- friendly, and happy to teach. 

One particular surgeon has left an impression.  He is an Iraqi man, in Ireland now for a little less than a year.  He has been a surgeon for over twenty years, but at some point recently a group of militants started killing cosmetic surgeons.  So he's in Ireland, where he has to work for 2 years as someone much less qualified than he is, at which point he will be fully registered.  Fortunately his previous experience will allow him to have a private practice.  Otherwise, due to the politics and economics of the irish medical system, he wouldn't be able to advance very far in the hospital setting.

Next week I'll be doing ophthalmology.  It used to be 2 weeks, and the doctors try to cram all of the same stuff in to less time.  It sounds like the tutorials are interesting, but the ouutpatient clinics are fairly dull, as it's mostly watching doctors look at patients eyes.  I'll actually have to study this week!  They give us a written and a clinical exam.

Friday night an old friend of mine from Timberlake was in town with his brother, on a tour to support some work they do.  You can check them out at www.foundmagazine.com.   It was great to see him again, and get to show him around Cork.  It was a helpful reminder that I do have a life, and personality, and experience that goes beyond my time in medical school, or even my time in Boston.  It was a reminder I need more frequently than I'm getting.  Since I'm having trouble finding extracurrculars here, it is easy to forget about all of the other things I enjoy doing in life.  One of the good things about having this difficulty is that it is making me much more aware of the fact that I have to make some conscious decisions about my future in order to get some of my other interests back into my life again.

Good night, and good luck.

My parents' last request before they went galavanting about Martha's Vineyard was that I should update them on the goings on of last week. I spent the last 2 weeks in the emergency department of the Mercy Hospital in Cork. It's a relatively small hospital in the middle of the city, and provides emergency care mostly for people in poorer sections of town. Not a ton of major medical or trauma cases, but very steady musculoskeletal injuries, asthma, COPD, abdominal pain, overdoses, and paediatric cases. It proved to be an interesting time. The two consultants in charge seem to enjoy their roles as teachers, and the registrars and SHOs did for the most part as well. The figures for the number of ER visits in America, Ireland, and the UK are all about the same, and end up with an average of 1 in 3 visiting and emergency department each year. That's astronomical. The Mercy is no different, though has fewer resources than many at it's disposal since most of its patients have public insurance which means inadequate resources. So the idea of the ER there was very much "first aid." Even if a patient had complicated or unknown medical problems, they wouldn't be sorted out in the emergency department. The role of the ER is to make sure the patient can breath, help a cut to heal, find the infected appendix, etc. While this is generally the idea of emergency departments in the States, the Mercy operates as an extreme example of it in order to stretch their resources as far as possible.

What did I get to do? During day shifts I was generally with one of the consultants, seeing patients or practicing reporting on patients to the doctor. The evening was when I generally got to do things like take venous and arterial blood sample, do ECGs, and suture wounds. It was educational and fun. Though lately I have been thinking more about intensive care as a future for myself, I appreciated the fast-pace nature of the emergency department. I got to work with doctors from all over the world, including Ireland, Malaysia, New Zealand, Austrailia, and Sudan. I got to see a little girl's hair used to hold togther a scalp laceration, and the finger of a sterile glove used as a tourniquet for a man who accidentally planed his finger instead of the door he was working on. I'm not sure I would have seen that if all of the doctors had been from fully industrialized nations with relatively adequate resources.

We also had a day of lectures about the fundamentals of emerency care, set up in the "ABCD" paradigm of medicine -- Airway Breathing Circulation Disability. The main speaker was the chief at the CUH, which is effectively the best ER in Ireland. A very cool man. He started the talk off with a picture of a man whose face had been shot off. A useful demonstration of the importance of a good airway, no?

I'm sorry to be moving on. Just as I was starting to get comfortable there and develop relationships with the nurses, doctors, medics, security guards, etc, it's time to move on to a dry couple of weeks discussing how and why to do research. I'll probably show up to the ER a couple more times to tie up looses ends, which will be nice.

In the mean time we're trying to have some fun when we can. Yesterday was beautiful (as is today, much defying the odds) so we lit up the grill. Almost felt like a normal person again.

TTFN

Greetings and salutations. I have finished my whirlwind first two weeks of lectures. They were doozies (they were a doozy? hmmmm. apologies to grammerians reading this.) Generally 7 hours of lecture a day, covering reproductive physiology, embryology, birth, neonatal health, neonatal ill-health, parental ill-health, psychiatry, ENT, opthamology... probably some others I'm forgetting. For a complete rundown feel free to read my schedule which is linked to the side of the blog. Most of it was really interesting and well taught. The obstetricians were so enthusiastic and such good lecturers that a number of us started wondering if maybe we were interested in that after all. Not likely for me, but good stuff. I'm looking forward to my time in the maternal hospital.

Monday I start my 2 weeks in emergency. We are the first class to get a dedicated rotation in emergency (in Cork, I mean. It's quite normal in the States.) which is exciting. The schedule they've given us ahead of time doesn't make too much sense so I'm not sure exactly what I'll be doing, but at the very least will include some casting and wound management. From what I can gather the clinical teachers in the hospitals are prepared to make us work hard, which is great. It seems like rather than simply letting us loose unsupervised all the time we will have more tutorials and practical teaching along side the patients and house staff.

After emergency (or A&E as it's called here) I will have two weeks to work on my research project. This project was traditionally done in final med, but do to years of feedback and a new faculty member in charge, it is being split into two tears and actually assigned credit and dedicated time. I'm not sure what I'll be researching yet, let me know if you have any ideas! After that I'll have a mixed month of special surgery (neuro/plastic/orthopaedic),opthlamology, dermatology, and anaesthetics, with a week for each. Then another couple of weeks of classes and a month of renal medicine and neurology to take me through til Christmas. Should be a good, busy term.

Thanks for stopping by!

Part two.... The Common Areas


The Kitchen
Our back yard
Our grill, kindly left to us by our friends who graduated

I have a picture of our living room too, but the blog seems to keep swallowing it.

This will just be a quick post. Got into Cork Friday morning, to an empty house. No worries, the rest of the roomies are to show up soon. Thought you might like to see where I'm living now...


The entrance
My room
My room some more. It's not actually big enough to necessitate two shots, so that may be misleading.
Upstairs. My room is on the landing.

The top two pictures were taken on the street next to my house a block away from each other. Despite my affection for both tofu and pax I am not responsible for either demonstration of anti-social behavior, or whatever it is people call graffiti.

I don't know that the bottom shot needs much color commentary. Surprisingly, the pay parking fills up quite quickly. That's at the South Tipperary General Hospital for an inquiring/nosey minds.

The 10 days after I returned from Clonmel were busy spent learning about chi squares, one-way anova tests, and other drool-inducingly boring statistics. I sort of learned some things about statistics, though they kind of skipped the beginner level stuff to get straight to the intermediate which is the stuff we'll actually need to know when we do our final med project (which may be done in 4th year, but probably won't change the name). So really I have no idea what those tests are, but I sure can make some cool looking graphs on the program SPSS.

This is the view from South Tipperary General Hospital (I'm pretty sure it was the inspiration for the American soap), where I spent the month of February. It was always nice to leave the hospital after a long day and be greeted by that view, especially at sundown. I'm not sure how the rest of the populous feels about being able to see the hospital from every part of town, though.

All and all it was a great month. Of course, traveling back and forth between Cork and Clonmel had already worn itself thin, but in terms of teaching I couldn't have asked for anything more. One of the cool things is our main contact there is the first Irish woman to both summit Mt. Everest and hike to the South Pole. It's a small hospital, only 6 physicians in medicine (others in surgery, pediatrics, and obstetrics) and very few students. Because of this the consultants can take the extra time to actively teach us during rounds, and some of the other meetings for the entire staff were expanded to make them useful as well. I was with a geriatrician, and because of a general lack of specialists in the hospital, her patients had everything under the sun. Parkinsons, stroke, heart disease, kidney failure, and of course pneumonia. I was finally able to learn a little about disease and patient management, which was great. I got to interview and examine patients in Dr. Pillay's outpatient clinic, see how tilt-table tests are run, learn how to do an arterial blood-gas, do venesections, and spend more time with anaesthetists.

I won't lie, I was sick of the round trip every week. This is my first week in Cork since the middle of December. With my 3 week vacation coming up, I won't have spent very much time in this apartment, or getting to see my friends before the somewhat hellish build up to summer exams. To make it even more ridiculous, our first week up there coincided with something called coursing. Some activity where greyhounds chase bunnies through a field. In today's world the dogs are muzzled, so the rabbits are only subject to abject terror, but very little, if any physical harm. People come to this year after year, so all of the b+bs are booked well in advance. We stayed with Bernie, who is a pal of the woman who runs the place we were in for the bulk of the time. Bernie was very nice. Somewhat strange to be staying with just a random woman (she is not an inn keeper). She is also the aunt of one of our biochem lecturers, as it happens. So the beginning was a little crazy, returning from my trip to Boston, starting in a new hospital, and hanging my hat in so many places. But for these two weeks I'm sleeping in my own bed, cooking my own food in my kitchen, and generally having a slower time of it.

I'll leave you with some pictures of the place I made home for the month of February

January 17, 2008

The second week here in Clonmel have flown by. Pretty much more of the same, as far as the medicine goes. A lot of sore throats and coughs, rashes, joint pain/injury, a well-baby check… I’m wondering if anxiety is as rampant every where as it is here. A lot of people very anxious about their health, or that of their children. Even in parents whose children are older, there are a lot of very nervous people around.

Once again we got to see very few of the female doctor’s patients, even fewer than last week. I understand why women might be uncomfortable having extra people in the room for a pelvic exam or Pap smear, but it brings to the foreground some of the frustrations of getting trained in a Catholic nation that is still very squeamish about gender relations. For our classroom based clinical teaching, they only want men to volunteer to be patients. I’m beginning to wonder if I’m ever going to really get to treat a woman. It turns out not just to be in training, either. Dr. Lynch almost always puts his stethoscope underneath a female patient’s clothes, rather than ask her to take her shirt off.

I’m noticing this week I’m frustrated about a few things. I think the pace of this experience isn’t agreeing with me, so I’m generally irked. It may be that most of my training at this level will feel slow to me; I’m pretty much just a fly on the wall, so my day is filled with standing around listening and watching. I’m learning, but I really prefer hands on stuff. I feel like I need to be learning practical skills and differential diagnoses, not just getting better at communicating with people. Perhaps because I don’t feel like I’m really learning all I could be, it’s easy to let the aggravating things about this rotation get to me. It’s a lot of travelling. 1.5-2 hours each way, every week. Having to buy lunch and dinner every day, while trying to maintain a somewhat healthy and affordable diet. Scarce internet and phone access, making keeping in touch with friends and family difficult and/or expensive, depending on which solution I choose. This week I bought a loaf of bread, and some cheese and mustard that I keep with the milk for coffee and some vaccinations or something at the office. I supplement that with a Pot of Noodles (which actually has tvp in it, so I’m getting some protein with the fat) or yogurt and fruit or something. Dinner continues to be a search around town. Last night I found a place to get a decent felafel for cheap. The guys who run that restaurant are from Bagdad.

Another thing that is beginning to grate on me is Dr. Lynch’s disdain for all treatment outside medicine. He continually disparages chiropractic, acupuncture, rehab, and all forms of mental health treatment that don’t involve medication. WTF? I have yet to tell him that both my parents are therapists. I’m just not interested in having that conversation.

I’m not really this cranky, actually. I’m enjoying meeting people, and having fun on our little sojourns into town. I’m already more used to the routine, and I imagine will continue to get more accustomed to it. It’s only a couple of months.

I was going to take some more pictures of my life here, but awoke to a nasty rain storm that involved a lot of wind, some thunder and lightning, and about 1 minute of ferocious hail. It mostly cleared up over the rest of the day, but my camera-phone isn’t exactly high tech, so I’m waiting for a little more sun. Stay tuned.

To quote Calvin, more news as events warrant.

January 9, 2008

Last night the 4 of us (there’s two more at a B+B around the corner, and John has a car) went into town to find dinner. We’ve been a little spoiled living in Cork, I’d say. Not much open in Clonmel, even at 7:00. There were a few restaurants of varying quality and price, and we eventually settled on a chipper. Why, you ask? That’s an excellent question. If you come up with an answer, please let me know. It was fine. Not great, not terrible. It was dinner, and it had protein, which were about the only criteria I was aiming for that night. Tonight will be a similar scenario. Only The Nose knows what we will find.

Today was a little slower medically. There was a different doctor there in the morning, a younger woman. She was quite friendly, and had a really calming, competent air about her. Unfortunately most of her patients didn’t want us in the exam room. My hypothesis is that younger patients are generally shyer than older ones. I doubt I will collect the data necessary to prove or disprove that idea. I don’t have any striking memories from this morning, so I guess that I’ll skip the color commentary. The afternoon was interesting. More back pain, chest colds, and the like, but also a couple of more interesting things. One was a man with a likely haemorrhoid. The GP actually had a simple proctoscope that he used right there in the office, through which he was able to see some internal piles. I was once again struck by how comfortable Dr. Lynch is at doing a number of different procedures in different parts of the body. Injections into joints, a ring to support a prolapsed uterus, injections into piles, foetal ultrasounds… I’m not sure how much all of those skills get utilized by urban GPs, either here or in The States. The last patient was a young woman of 19, on what I believe is her second pregnancy. She was grinning the whole time, which I interpreted to mean she is quite excited to be having a baby. He did an ultrasound on her, which was really amazing to see. I think it is the first time I’ve been in the room for a foetal ultrasound. At 24 weeks, we could see its limbs, heart, liver (those things are giNORmous in foetuses, by the way) and head. There may have been some boy parts, but we weren’t sure. Very cool.

Since it was raining pretty hard the secretary (or Hub, as Dr. Lynch introduced her as) gave us a ride home, which was very sweet. Just chilling at “home” now, waiting to hear back from our friends about dinner plans. The three kiwis moved out today, but I suspect we’ll see them next month at the hospital. I think the Simpsons are on. I’m Eli McKenna-Weiss and you’re not.
Here's a behind-the-scenes view of a medical student's bedside table and dresser while he's on a placement in Clonmel.

January 8, 2008

I’m writing to you now from my room at the B+B. There’s no internet here, so this posting is likely to be a compilation of several days’ ideas. Or I’ll separate them by day. still, though, perhaps too long and boring to anyone but my mother. It’s the end of my first day on location in Clonmel, only my second full day back in Ireland. How strange we can change locations and lives so quickly. One minute I was enjoying my vacation in Massachusetts, the next I’m learning to be a doctor in ruralish Ireland.

I hopped on a bus Monday evening, glad to have some quiet time to myself to try to get my brain and body less lagged behind the jet. Put some Josh Ritter on my headphones and… took a nap. Sean, one of the proprietors of the B+B picked me up at the train station (yes, you read correctly. Don’t ask me why I can’t take a train from Cork to Clonmel, but the bus stops at the train station. It sounds like something they would come up with in Russia.) I quickly got settled in. The other inhabitants of the inn: 3 women from New Zealand doing some of their medical training at South Tipperary General Hospital, where I’ll be next month, a GP from Capetown filling in for a few weeks, and 2 medical students from UCC. Arguably one of the safer places to be in the area. My room has a double bed, a little t.v., a closet, a dresser, and a sink. Both mirrors in the room were either designed for small people, or tall people who like to look at their torsos. There’s a shared toilet and shower (separate rooms, also a la Russia) with a comfortable sitting room downstairs. Breakfast was also a group affair, with people coming and going as their schedules necessitated and their breakfast arrived. Sean couldn’t stand for any of us to have to go to work in the wet weather, so he made a couple of trips with the various people to where they had to be. I feel like I am in one of those English comedies that have no apparent plot, barely move, and yet are utterly charming.

The G.P. we’re with, Paddy Lynch, is a great guy. Talks a mile a minute, and is a very patient teacher and doctor. Today was mostly about observing, but found little teachable moments. Today’s patients were varied, as they seem to be in a GP’s surgery outside the big city. A woman with symptoms that appear to be intermittent claudication, an infant in for some immunizations, some adolescents with ear aches and chest colds, some adults with chest colds, some routine blood tests, cryosurgery for a sebaceous keratosis, a prolapsed uterus (or womb, as the doctor said, which does have a friendlier ring to it), a woman with a as-yet undiagnosed nerve problem, a few folks with lower back/disk pain… You get the idea. We felt some pulses, listened to some chests, got to see how ESR is measured. Then off home, to change and relax. Somehow very tiring, despite the fact that we didn’t actually DO anything.