A high T3
"doesn't he remind you of Tigger?" said Jasmine, as Dr. T left the room to fetch his next patient. Dr. T is elderly, tall, imperious, and always impecably dressed. I guess it is his easy grin - so broad that his eyes vanish and his chin doubles in size - and his spriteliness that is Tigger-like. He is undoubtedly one of the old-school consultants ("back in the days when we did 5 terms of anatomy...") - patients are expected to do as they are told, and students to know their place. He has his own brand of humour ("i'm cleaning your neck with this alcohol wipe, not because it's dirty, but because we like you to leave hospital smelling of hospital") and he digresses to the discussion of politics at every opportunity. Unfortunately, consultants like Dr. T seem to be a dying breed - few doctors are able to truly put a patient at ease in a small consulting room with 3 students looking on. This requires a delicate balance of friendliness and authority. In addition, by listening in to Dr. T's dictations, one discovers that he has arranged beforehand for his secretary to book all his 'favourite' patients - those with interesting goitres who are agreeable to having their necks prodded - for the Thursday teaching clinic. The others he sees on his own during the rest of the week. A simple but clever idea.

And so, in 3 hours of thyroid clinic, we saw nearly the entire spectrum of thyroid disease, from Grave's to Hashimoto's, to a solitary nodule, to a biopsy for possible thyroid cancer. We felt smooth goitres and lumpy goitres and heard a thyroid bruit. And the patients left smiling, 'happy to help'. This is how medical teaching should be.

futility
"316, 401, 480...hrmmphh. " The consultant turned around. "80. Lovely. The average age of our patients today is 80." He had a raging cold, and I know from experience that it is difficult to be sympathetic when you have a cold - even though it is the patient and not you who is dying. It was a grim ward round, with largely moribund patients, and the smell of hospital caterer-curry mingling with that of used commodes and sick bowls. Of course, I had to Clerk in the sickest patient of all. She'd come in with left-sided weakness and an obvious facial droop. She was accommpanied by a puffy-eyed daughter and a 30-something grandson, who both lived with her. The grandson had an awkward demeanor and a squeaky voice and laughed at the most inappropriate moments. This made my skin crawl, but I could hardly tell him to leave. After having to ask the two of them lots of irrelvant questions for the sake of filling in the Clerking Sheet, I had to examine her. At this point, the porter arrived to take her to CT - she had already been seen by a senior doctor, who had ordered the scan as it was obvious she'd had some kind of brain injury, most likely a stroke. The scan showed an intracerebral bleed. The only treatment for this is urgent neurosurgery, but it was decided that because of her age and other medical problems that it wasn't appropriate. Her GCS (Glasgow Coma Score) was falling by the second, and she was obviously upset. I really didn't want to be there because 1)the patient just wanted to be left alone 2) I was contributing nothing to patient management and not least 3)she was DYING. This woman should have been left alone with her relatives in a quiet room.

But everyone who comes into Combined Assessment has to be Clerked. Even if they are going to be dead in a few hours. And if you are a final year medical student, it is your job to Clerk them. So there I was, checking her reflexes. It made me feel sick. I finished up and left as quickly as I could. I couldn't look the relatives in the eye, because I felt as if I had as good as killed her. I had stolen a full 20 minutes of their last hour together. Once I was done, the nurses came and moved them into a side room, and one of the doctors (who I'd reported to about her declining GCS) went in and did the 'Breaking Bad News' thing. By this time she was so far gone, that the ward round didn't even stop in her room. So I didn't get to present my hard-won Clerking (we have to chalk up 8 Clerkings each) to the consultant. Nobody seemed to care that I was upset, so I just went home. I told Youee about it, but he's too young to understand. I told one of my friends, who is a House Officer, and she said 'don't worry, you'll get used to it'. I guess I have to try and not be upset by patients dying on me, but I think it will be a sad day when I am able to just walk away and forget.

hmmm
The fact that I am writing again so soon says something about how slow things are at Combined Assessment today. Which is lucky for the patients as the PRHOs have just changed over. I've decided that it is possible to guess a patient's age (to the nearest decade) by their first name - that's how bored I've been! A "Margaret" or "Wilhelmina" (yes, this IS a common name in Scotland) is likely to be about 70, a "Veronica" 40, and a "Leanne" in her teens. Boy's names are a bit harder, as half the male patients (of all ages) seem to be called "James". Hence the 'Jimmie' hat , I suppose.

My favourite patient of the week has got to be Mrs. H. She is a tiny, stooped elderly lady - so stooped, that when she stands up, she can't see straight in front of her. The four of us approached her as she hobbled back to her bed-space. Her grossly twisted hands somehow gripped her crutches, allowing her to swing herself forwards a few inches. It was excrutiating to watch. Finally, she made it - the full 10 metres in about 5 minutes, and boosted herself onto the bed - high for her, though already lowered as far as it would go. "Can we have a look at your hands, Mrs. H?" "Oh yes, you've got to learn haven't you?" she smiled. We crouched or squatted by her bed, trying to make ourselves smaller. Her eyes were bloodshot and the whites were a daffodil yellow. She put her hands out in front of her. It was a spot diagnosis. "How long have you had arthritis?" "Since I was 6," she replied. She'd had her right wrist fused at the age of 8 "so I can get my change, see?", two inches taken off her right leg because her left wasn't growing, and many other operations over a lifetime. "The arthritis seemed to get better when I was a teenager, and I went away to college, got a job, lived it up in London," she said. "What did you work as?" I asked. "I was a milliner." Pause. I was sure I knew what a milliner was..."made hats for the Queen" said Mrs. H, helpfully. No doubting the function of those devastated joints, then. The question that remained was, why was she the colour of Marge Simpson? Perhaps her liver had been damaged by the arthritis medication? It bugged me, so I returned to the ward afterwards to have a look in her notes. It turns out she has pancreatic cancer - completely unrelated to her arthritis. It's always the nicest patients who have the nastiest diagnoses.

Finals fever
Day 7 of acute medicine. The word on everyone's lips is 'finals'. Somehow, in the space of 8 weeks, we have to become proficient at examining every system of the body, able to give a differential diagnosis for any complaint, to know (in theory) what to do when someone comes through the hospital doors in extremis. Returning from St. Anthony, I begin to appreciate how rich the wards of the Royal Infirmary are with 'good signs' - heart murmurs, enlarged livers, twisted joints. Well, good signs for medical students, not for those on which they are found. We feel like vultures, circling the wards, ready to descend on any patient with a lump or a wheeze.

Finally handed in my elective report. It turns out that the strike that started just after I left St. Anthony has turned into the biggest strike in Newfoundland's history.