Friday, February 25, 2011

The Pleasures and Sorrows of Humiliation

I can never sleep on call. And I can never win: if the night is busy, with one emergency bleeding into another, I'm utterly miserable by 3 am, lusting after sleep like Garfield after lasagna and swearing at the (equally exhausted) surgeon for daring to question my iPod playlist. Conversely, on a rare call like tonight when Cape Town seems to be behaving itself, do you think I can get some shut-eye? Hell no. The hamster in my brain sees it as a clear sign to resume training for the Insomnia Olympics. I just realised I finished anaesthetising an appendicectomy at 1 am and now I've started this post past 5. I tossed and turned in the on-call room for three hours until giving up and trawling Wikipedia for essential information like the geology of Oceania and why the Turkish language could be related to Korean.

It's not that the on-call rooms are uncomfortable. I seem to have a knack for fund-raising and recently helped our department source hotel-quality beds for the registrars on night duty. (Frankly, I found it perverse that those who keep others asleep should be denied comfort in the rare chance they themselves could sleep.) For some reason, when a work night is quiet my body reacts as if I've won an espresso drinking competition.

I think it's remnant post-traumatic stress from med school where as a fourth-year I was thrown in the deep end during my first (and worst) clinical rotation and was brutally torn apart from the joys of nightly oblivion for the first time in my life. (There's a small scared voice running around in the labyrinth of my subconscious, feeling guilty because there's actually no work to be done for the moment.)

Let me take a deep breath and revisit a derelict side of Memory Lane. My fourth year obstetrics block was like being locked in a lurid Twilight Zone episode directed by Aronofsky, Hitchcock and Kubrick simultaneously, with a screenplay by Stephen King and shot in bad 80s direct-to-video transfer (for that extra fluorescent shine).  Contrary to popular belief, interns are not always the lowest form of life in the petri dish of medical academia. Not when there are students to abuse, as was the case at my alma mater.

In the labour ward, fourth years ran around in Shock and Awe, years before George W.'s regime used the words for military strategy. On paper we were supposed to assist and observe x number of deliveries. In reality our job was to do... everything, certainly everything boring or demeaning or exhausting, while being crapped on by the entire hierarchy. And no matter how efficiently you tried to do it, you'd be made to do it again, and then, when you thought you could finally sit down and possibly close your eyes for a bit you'd be made to do something inane to keep you awake - and everyone else went to bed. Our intern whom I remember as Mr Slick - he bathed in hair pomade - seemed to spend the entire call smoking and chatting up nursing staff - who, at this particular unit, were permanently on tea - pausing briefly to check up on (translation: rip to shreds) the 6th years who admitted new patients (actually, the intern's job). They in turn, riled and humiliated, would do everything in their power to make the youngest and most vulnerable students feel smaller and more fleeting than an antiparticle in a bubble chamber. All of this usually in front of a patient in labour. (On rare moments the registrar would appear to dispense wisdom to the intern.)

I'm not complaining about any of the actual work, understand, I'm just a little sore that since joining a different medical school for postgraduate study I've seen students (and interns) treated like... gasp... human beings for a change, and, shock, horror, they haven't automatically devolved into jellyfish for not going through some inane hazing ritual. There has been a sea change in the past decade with a gradual and refreshing realisation that letting exhausted medical personnel loose on patients is not perhaps the best standard of care. In my field it's been in practice for a while now. In the EU they've gone to the other extreme, with complicated working time directives regulating hours so strictly that trainees are not getting enough experience.

Not so when I was a fourth year. The final year students then, enjoying their first rush of superiority, were particularly cruel to their minions (us); it was high school all over again and we were newbies doing tricks and running errands for shits and giggles. Worse, it was a cowing conga-line of contempt: the intern would do the same to the final years, and the registrar to the intern, right up to the Professor broadcasting fear even as he slept in a hotel room thousands of miles away on some international congress. The law was a reversal of the Golden Rule: do it to others as it had been done to you. And so a succession of gradually lightening humiliation ensued until one day my undergraduate studies were over.

The sum of all these fears is that I don't remember anything about those twenty or so babies I delivered but instead a simpering tide of criticism and pettiness. The question was - would I do the same when I ascended the ranks to 6th year, intern and beyond?

No. And not that I'm a morally superior head boy either. Fate would have it that on my first final year call for obstetrics I pricked myself with a needle while assisting for a Caesarean section with an HIV positive patient and spent the rest of the block spaced out on antiretroviral medication and anti-emetics to counter the rolling waves of nausea they caused. There simply wasn't enough headspace available to even consider that there were others to humiliate. For whether the cocktail of AZT and 3TC fried my dictatorial neurons or not, I've never pursued the role of Great Dictator in any clinical scenario. Even today I am a Type B island in a Type A world. Difference is, where I am now - a thousand miles and seeming years from those student years - I'm generally tolerated; and the very least I can do is tolerate back.

Even if a student clearly doesn't even get basic physiology when you're metaphorically hitting them over the head with a textbook while trying to keep a patient asleep.

Even if a colleague interprets my lack of screaming and shouting during an emergency as being disinterested in my profession. (I may be disillusioned, but I've never thought I don't care.)

Even if all this is just a case of protracted sour grapes. If so, I think I've digested them well.

It's great getting this out there. It's going to be even greater to get into bed...

Wednesday, February 16, 2011

A Pale Blue Dot

Perhaps because I've been studying all week, buried at almost atomic level in cellular processes from "mitochondrial failure" and "remote ischaemic preconditioning" (it's ok - only I have to know about these things seeing that I'm just over a month from my final specialist exam... eish!) that my mind is urgently wanting to pan out, as far as possible, from inner space to outer space. And what I'm left with is a sense of smallness.

Consider the incredibly moving picture of Earth, taken at a distance of 6.1 billion kilometres by the Voyager 1 probe as it reached the edge of the Solar System in 1990. It's become famous as the "Pale Blue Dot", and that great man, Carl Sagan, campaigned tirelessly for it to be taken. Before entering interstellar space, Voyager turned its cameras back one last time and snapped this astonishing image of the tiny world it was sent from. We really are just a pale blue dot in the vast seething mass of the galaxy. As Sagan put it:

That's here, that's home, that's us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives.

... Think of the rivers of blood spilled by all those generals and emperors so that, in glory and triumph, they could become the momentary masters of a fraction of a dot...[our] posturings, our imagined self-importance, the delusion that we have some privileged position in the Universe, are challenged by this point of pale light. Our planet is a lonely speck in the great enveloping cosmic dark. In our obscurity, in all this vastness, there is no hint that help will come from elsewhere to save us from ourselves.

Perhaps for some, this evokes angst and loneliness; for me, however, our utter insignificance in the Western Spiral Arm of the Milky Way instills a great slow wave of awe. I am moved that we are placed, by evolution or a great deity (or, as I believe, both) on this Goldilocks planet, blanketed by a Universe that is ever expanding, while we hold the power to destroy or nurture our little bastion in the infinite. No-one can look at the stars and not wonder the primal, protean why in their marrow. I would go as far as to posit that this very thought unites atheist and believer, man and woman, scientist and proselyte, bunny-hugger and banker-wanker.

If we gaze deeper and deeper into the inky void, perhaps we could find comfort in E.M. Forster's words... "at the side of the everlasting why, is a yes, and a yes, and a yes." And even if the Universe gives us no clear answer, we will realise more and more that until, say, Kal-El crash-lands from Krypton there is nothing but ourselves. More humbling is that even without us, the Universe is not empty: physics has discovered that energy lurks, phantasm-like, in the very vacuum of space.

Could I go as far as to say that evil exists only because potential goodness never craned its head up and saw that vast silence? Or that, frightened and obstinate, it resolved to gaze at its feet instead? We will never know. But we can swallow our pride and yield our fear, and, one night, perhaps lie back on the grass and let the stars move us.

Wednesday, February 9, 2011

More Medical Mayhem

I'm (pleasantly) surprised that you all would find my misadventures as a patient entertaining. To continue, the sutures were barely a day out from my head's unfortunate encounter with our bedroom door when fate decided to zone in on my right index finger.

It was New Year's Eve and I was the lucky sod on call for a certain hospital that I can't name, suffice it to say that it's neither a private nor civilian institution. Ahem. I had always suspected that those working in the interests of national security are of a different breed... this was to prove an underestimation when I met my arch-nemesis.

It was hate at first sight. Sister X loathed me from the tip of her faux Crocs to the top of her badly-crocheted theatre cap. Her pasty complexion flushed peuce and her tiny dormouse eyes switched their built-in passive aggression beams to "kill" every time I entered her gaze, contorting her doughy face into expression that I like to call "The Blancmange With Teeth".

I could never do anything right. Whether I'd forgotten to put on my mask (contrary to popular belief, several studies have shown that only personnel directly over a surgical site have to don a mask) or a shoelace was a tenth of a millimeter too long or I'd forgotten to initial some copy of a copy of a form in triplicate, this Nurse Ratched on steroids would notice it and bark her disapproval. Did she have a vendetta against all doctors, or did the Spider-Man stickers on my textbook recall some traumatic memory? I'll never know.

While I resolved to make peace with her enmity, I was left speechless by her vitriol when I was on call on New Year's Eve... barely a week after my fateful encounter with the bedroom door that I rattled on about in my previous post. I arrived in the early evening for a minor surgical case and chose to ignore Sr X (who always seemed to be on duty with me) while I saw the patient and prepared theatre for the case. Soon the patient was on the table, monitors attached and ready for me to send him off to oblivion when I remembered one drug still had to be drawn up, so I reached for the ampoule and snapped it open... why I did it with bare fingers, and not in the usual safe way by covering the glass top with the edge of my shirt as I usually do, I don't know.

I can still see it happening in slow motion in CinemaScope, but minus the cheesy Vangelis soundtrack from Chariots of Fire: the ampoule shattering into a kaleidoscope of shards like the planet Krypton finally yielding to the wrath of Zod; the largest shard slicing through my finger and the blood cascading forth in a small crimson fountain. Ok, not really a fountain but I'd sliced the tip of my index finger to the phalanx and I was soon looking like an extra from the prom scene in Carrie.

The poor patient nearly got up to help me. "Are you ok doc?" he asked - bearing in mind the poor man was in significant pain of his own. Sr X, already scrubbed for the case, stood silent, glaring, aiming her alcohol swabs at me as if they were flamethrowers. Several other nursing staff scattered around helpfully fetching bandages and making sympathetic noises. But first I had to get the bugger of a shard out.

The air-conditioning warbled slightly: Sr X spoke.

"Is this going to be long, doctor?" she said icily.

I was flabbergasted. What would get a sympathetic word out this dragon? A dagger through my eye or a telephone pole in my aorta? I shrugged, disengaged from my instincts to utter a stream of profanities and instead gave my own death glare back (usually reserved for projectionists who get the focus wrong during a movie) and excused myself from the theatre, leaving a trail of blood behind me like a scene from a bad detective thriller. In the scrub room I yelped as I got the shard out under running water. It would need sutures. But the case had to be done now. Fortunately the posse of nurses - evidently insurgents disobeying Sr X's totalitarian rule of the theatre complex - arrived with an armamentarium of bandages, gauze, swabs and crepe. Five minutes later a pressure bandage had been assembled around my poor finger and I walked triumphantly back into theatre.

The case proceeded uneventfully, with the patient - bless him - asking me on awakening if my finger was ok, never mind his own condition!

But the hospital had no idea to help a civilian injured on duty. There were too many forms to complete and they'd need authorisation from A who'd have to have it ratified by B who needed to countersign C and fax it to D who was in Pretoria and on leave. Enough was enough and I informed my consultant that due to a horrible ampoule accident he'd have to cover the call for two hours while I got myself sutured ... at the same hospital I had my head seen to on Boxing Day!

I was hoping the pressure bandage would be enough, but the SCW (Sexy Clever Wife) took one look at the wound and shook her head. So off it was for another bout of suturing. I wondered what accident I'd be having next.

An ancient but affable physician sutured me. It appeared to me that he'd last put in sutures during the sixties. It took a while, and the lignocaine hurt like ten circles of hell going nuclear simultaneously, but I didn't care as the SCW dosed me up on a cocktail of tramadol, paracetamol and diclofenac (Power-Myprodol, we like to call it) reserved for really really bad pain days like the migraines that strike me four or so times a year or when Chiv's back decides to flare up like a row of cheerleaders with gaudy pom-poms,

Both the trip for the head and then the finger surgery set me back a cool R2 000. And of course, like most medical aids, they don't cover casaulty cases except if you have savings.  Grrrrr.

But I would have the last laugh on Sr X.

The next day my war wound practically became a purple heart. Is it something about men in uniform who are injured that makes women all broody and caring? I practically had my own harem for the day, running errands for me, enquiring whether I lost a lot of blood or whether the sutures were painful, supplying me with care packages of coffee and rusks. It was awkward at first but quite pleasant for my ego. From her Dark Cave of Evil - sorry I mean office - Sr X watched with displeasure etched on her face.

Relaying this, I had to restrain the SCW from driving in from work and giving Sr X a snotklap. After all, in a few weeks I would leave this Gormenghast fiefdom and be back at the great, lumbering, happy, amazingly efficient chaos of my home teaching hospital - where doctors and sisters have minor hissy fits over silly things but share big hugs and rude jokes, and music plays in theatres and no-one thinks twice about a graphic novel or Sudoku compendium or the Confessions of St Augustine being on the anaesthetic machine next to the BJA and other august journals, provided the job gets done.

We are so shaped by the people we work with. I wonder what Sr X is doing now? Perhaps she has a secret lair next to the oxygen supply bank deep in the bowels of the hospital where she hacks into governmental agencies and feeds WikiLeaks their prime fare. Or is she training an army of nurse fembots who will go online during the next solar flare and eliminate all men? Or crocheting a blanket made of cyanide-laced spider silk and wool from her late Alsatian called Beelzebub? One will never know... but I'll be there, like Chloe in the Watchtower in Smallville, keeping an eye so that the streets of Cape Town will never be brought to its knees by the terrible wrath of her Total Passive Aggression! [cape flaring, standing on top of the Cape Sun building with badly scrawled "S" on T-shirt, peering queasily down the edge and wishing he had a double whisky before he attempted this stunt]

...fade out to the titles and rousing John Williams soundtrack...