Sunsets, sunrises, stethoscopes, swimming and socialising
And taking alliteration too far.
It has been more than a month since I last sat down to write for this blog. I am afraid the relentless schedule and the weighty responsibilities of being a junior doctor have rather stifled my creativity or at least my motivation to stare at a screen when I could be sleeping.
In the four and a half weeks since my last post, the scenery has shifted. I have moved from the sheer chaos of Northdale to the tertiary environment of Greys Hospital, continuing my rotation in Obstetrics & Gynaecology. The sheer volume of daily new admissions in the labour ward is significantly lower than at the district level, but the clinical complexity has skyrocketed. Patients tend to stay in the wards much longer, meaning both our post-delivery and antenatal patients are being worked up for a myriad of complicated conditions. To give you a taste: we have had a pregnant lady with bilateral pheochromocytomas (prompting a deep dive into the multiple endocrine neoplasia syndromes), patients with congenital heart lesions like Fallot’s tetralogy, and numerous cases of rheumatic heart disease affecting various valves. Then, of course, there is the bread and butter of tertiary level obstetrics: pre-eclampsia and imminent eclampsia, including managing a seizure in a high-BMI patient weighing around 200 kilograms.
But it hasn't all been diagnostic triumphs. Recently, a patient presented with bilateral lower limb weakness about a month post-delivery. She turned out to have septic arthritis of the sacroiliac joint. In medical school, the golden rule drilled into us is "never let the sun set or rise on septic arthritis." Unfortunately, she endured quite a few sunrises and sunsets before we finally arrived at the diagnosis. To me it was a sobering reminder of the importance of a proper clinical examination for which no scan or blood test is a substitute - and certainly not the C-reactive protein or the procalcitonin!
Being a tertiary hospital linked to the university, Greys maintains at least the veneer of highly academic environment, and there is a lot of pressure especially on the registrars to stay on top of literature. Although there are several practices and protocols in place that I cannot help but think are clearly impractical and impossible to carry out satisfactorily - to the point where an alternative practice which may be inferior in perfect conditions, would actually give far better patient outcomes... the monitoring of anticoagulation in cardiac patients comes to mind. Though he may lack the skills of the specialist obstetrician, the logician would be better at managing the obstetrician's patients surprisingly often! (In my humble opinion based on weak anecdotal evidence).
Remembering Austin Flint
As a medical student, the enjoyment of a rotation the passion for a particular discipline in clinical medicine is highly dependent on the quality of the supervision and the opportunities given to you by your seniors. It probably helps most students if your seniors are amicable and approachable, but I have found that being able to respond to destructive criticism (rather than only to constructive criticism) is pretty useful. Anyway, I always try to take the time to teach the medics what I know both theoretical and practical. Though I am not paid for it I feel it is a very important part of my duty. I know that I learnt a lot on the wards in my early clinical years from very competent senior medical students at Stellenbosch, and that system of having students in different year groups rotating together doesn't seem to exist at the local medical school. Additionally, teaching a subject to someone helps you to find your own knowledge gaps and tests your own understanding. Occasionally, you might even realise something you hadn't before appreciated. This happened to me a couple of weeks ago.
During a rare free hour waiting for the handover round in labour ward, I gathered the two students assigned there and suggested we examine a patient. The patient was a young lady in her teens awaiting induction of labour; the ID board over her bed noted she was at the tertiary hospital because of known 'valvular heart disease'. Without biasing ourselves by reading the notes of previous examiners or looking for the coveted echocardiogram report at least until afterwards, I suggested that we examine the patient each in turn and then discuss our findings.
There is often a collective rush to unholster stethoscopes and attack the precordium when examining the cardiovascular system. But as we are taught in the common reference texts of Macleod's or Talley and O'Connor's Clinical Examination, and as I reminded the students, a proper cardiovascular exam starts at the hands. In fact, most clinical examinations start at the hands, right after your general inspection from the end of the bed. My schema for examination of the cardiovascular system is generally: hands, pulses, blood pressure, jugular venous pressure, and finally the praecordium, with auscultation of the heart being only the last part of the pracordium examination.
Our patient exhibited textbook clinical signs. She had a collapsing Watson’s water-hammer pulse, a wide pulse pressure, and a positive Duroziez sign - the whooshing to-and-fro murmur heard on compression of the femoral artery with the diaphragm. Her apex was displaced to the anterior axillary line indicating eccentric hypertrophy of the left ventricle. Additionally there was a parasternal heave palpable.
On auscultation, there was the classic diastolic decrescendo murmur of aortic regurgitation, accompanied by a systolic murmur and a subtle, low-pitched rumbling diastolic murmur both at the apex.
Initially, I assessed her as likely having rheumatic heart disease with aortic and mixed mitral valve disease. But on the drive home, I remembered Occam’s razor: Entia non sunt multiplicanda praeter necessitatem or 'Entities must not be multiplied beyond necessity'. Without using those exact words the professor to whom I owe most of my cardiology training, usually embodied this sentiment. What if there was only one primary lesion? If we assume she had primary, severe aortic regurgitation, the resulting volume overload would cause left ventricular dilation. That dilation would stretch the mitral valve ring, causing functional mitral regurgitation. And although I didn't remember it in the moment, the regurgitant jet from the aortic valve impinging on the anterior mitral leaflet would explain the diastolic rumble - the murmur described by Austin Flint (which I had never heard before). Finally, the backflow and increased left-sided pressures could lead to secondary pulmonary hypertension, explaining the parasternal heave.
I'd like to think the students really appreciated learning how to elicit Duroziez sign which is a pretty good clinical indicator of the severity of aortic regurgitation that does not require an ultrasound probe. Actually examining for it and hearing it makes a fairly obscure description absolutely unforgettable.
And miles to go before I sleep
Outside of the hospital, I have been trying to make the most of my free time. I've started playing football semi-regularly, struggled in a couple of rounds of golf and most notably, swam the Midmar Mile.
Calling it a "swim" might be generous. It was quite an experience, largely because I was late to my starting batch. I had to start about 200 yards behind the very last person, and to make matters worse, there were no functional flotation devices left. It was a bit of a disaster. I ended up dead-sprinting to catch up to the back of the pack. When I finally reached them, I gasped to the lifeguards, asking if I would make the cutoff. They confirmed I probably would, at which point I promptly switched to a leisurely breaststroke for the remainder of the race because I was completely out of breath.
Other than near-drownings, I have been socialising at every opportunity. I attended a pub quiz last week where we came in second. And another one a couple of days later where we came close to last. After getting a third question on KZN birds wrong I was pretty irritated - especially because one of them was a Martial Eagle which I have actually photographed.
One of my mentors in medical school once told me that it is better to be burnt out and having fun than burnt out and hating your work. That is a philosophy I am trying hard to subscribe to. It is difficult keeping up with old friends and I often find I let non-urgent messages go unanswered for days while attending to the numerous immediate responsibilities I now have. But I am making a point to call old friends and squeeze every drop of life out of my time away from the wards.
