CUT ME OPEN – The story of a clinical rotation in general surgery as told by an aspiring physician.

 

I look down at my blood stained hands. My mind races, thinking about the possibilities of how I got blood on them. Did I murder someone? Unlikely. I must’ve hurt myself. But I don’t see any cuts or bruises. How could a seemingly innocent person have blood on their hands? Doesn’t it seem mysterious? I could be tested for DNA, or worse, be thrown into jail for it, if the person that this blood belongs to is dead.

//deep breaths//
I’m okay. I shouldn’t panic. I haven’t done anything wrong. I trace back my steps to this morning.
Okay so I woke up, begrudgingly, at 6.30 am, showered and set off for the day by 8. Then someone asked me for the reports to an abdominal CT. I pretend not to hear them and walk towards the cafeteria because I didn’t have time to drink my morning coffee. A second person came up to me and asked me to write a discharge. This seems like white noise at this point, blaring in the background; mixed voices echoing about ceftriaxone and betadine and non healing ulcers.
I close my eyes for a second and look up at the ceiling. When I look down I find my hands stuck inside a patients abdominal cavity while the singe of flesh triggers my sensitive gag reflex. I am not in a super awesome mystery about an unsolved murder. The reality is that I am a surgical intern and I have to pretend like poop doesn’t smell every time my attending does an exploratory laparotomy (which is everyday). Also plot twist : that was poop on my hands not blood.

You know, my father is a surgeon, as are many relatives in the family. Surgeons pride on being surgeons. My father once said he doesn’t need my mother to sew on a button for him because he is a surgeon and he could (most possibly) do a much better job than she could. He always wanted for me to be a surgeon. My initiation ritual was to observe a radical nephrectomy at the young age of 13. It was spectacular in a way that it changed my life. I was never the same again.
What my first surgical experience did was, it taught me about vasovagal triggers. But the first five seconds before I fainted were definitely spectacular.

So I, being a bunch of vasovagal triggers to multiple things like the smell of a freshly excised segment of necrotic bowel, or a 10 blade, or any patient that lists main complaint as “pain abdomen” am forced to intern in general surgery. What’s worse is the surgical unit I am in-
1. Makes me dislike surgery even more.
2. Does not realise the difference between abdominal pain and constipation (inside joke.  Sorry if you don’t get it)
3. I would not trust one of them to even cut my toast in half.

How does one navigate this cat-piss ridden, foul-smelling, manic-depression inducing rotation without one turning into a foul smelling, cat piss soaked, manic depressive? They elect not to do surgery of course! But if you have impaired decision making ability, or are forced into a bonded contract of humiliation by multiple people with God-complexes, you can follow my guide to refusal of informed consent to the procedure (definitely an ex-lap).

1. Remember these words – Conservative management. They’re going to be your best friends. If at all someone mentions conservative management for treatment, jump on it and campaign for it. Because if that guy is posted for surgery, YOU will have to beg the anaesthesiologists to give him anaesthesia because there is no time for 700 chest X rays. YOU will have to face the attending if the case is postponed and he will scream at YOU because he thinks anaesthesiologists are incompetent even though you tell him you will never be an anaesthesiologist and agree to curse 10 generations in your family so nobody can dream of being an anaesthesiologist.

2. If you are a nervous fool like I am, don’t stand next to anything important or anyone important. If you do, you will be asked to do a million things like foley the guy or ‘reassure him’ while they’re DJ-ing his insides. Just be a fly on the wall. I once thought standing in the corner was a good idea so nobody would notice me. But as my terrible luck had it, I was asked to stand right next to the operating surgeon with the fumes of the cautery finding their way ONLY to my nostrils. I am perpetually put off by barbecues now thanks to that day. The other time I was standing behind everyone dry-heaving at the granulation tissue they casually minced, I was asked to adjust the lights so many times that I have permanent vertigo now.
I tried to run out of the OR but my semicircular canals failed me. I am trapped. Send help when you see me blink twice. If I blink once it means adjust the lights.

3. Chart everything. I mean everything. How much is the patient peeing, what’s his pain like, how many florals is he wearing for Spring-Summer ’18. Surgeons never care about charting but they love dissecting interns about not using a comma while writing an 8 part novel about the patient’s post-op condition.
I don’t even know half of the things they want me to chart. And they bark orders all the time, so I don’t understand what they’re trying to tell me either. This one time I saw the previous day’s rounds included “serous output” which was written horribly (because all surgeons use the pen like they’re welding a scalpel. The papers are filled with incision like pen marks). So OBVIOUSLY I thought serous output was actually ‘serious output’ and I spent half a day charting how the patient passes urine.
250 ml- serious
300 ml – happy
100 ml – crying about the indwelling foley’s.

4. Look around you. The surgical department is a treasure chest of knowledge and resources. All those blades strewn around? You could use them to chop someones appendix off. Or, you could use them to chop some beerakaya (bottle gourd?). Get creative! Your resident wants you to do the dressing while he gets to drink chai? Dress the patient up as an anaesthesiologist, complete with a constant ‘no’ for every question and the occasional ‘how much is his hemoglobin’. That will spook your resident into never making you do anything for him ever again.

5. Try not to answer anything on rounds. I don’t know about the other surgical units, but the one I’m in absolutely hates it when an intern answers a question. Almost as if the whole point of doing medicine is to never learn anything.
If you do have the answer to something weird, say “why is nystatin not a statin” then they will bring their claws out. Or 10 blades, same thing.
I once knew the answer to a question about gall bladders and my attending followed up with “what was the size of Emil Theodore Kocher’s gall bladder” just to mattress suture my lips shut.

6. What is a consult? A consult is an elaborate ritual in which surgeons find the smallest thing wrong with the patient like hemoglobin being 10.9 instead of 11 and try to shuttle them off to other departments because they’re so tired of doing wound dressings and meshing hernias.
Here are some reasons to turf patients to other innocent departments.
Does the patient have a headache? Page neuro stat. Every headache is a subarachnoid haemorrhage to them so they won’t ignore you. Easy peesy.
Turfing the patient to ortho is a tad difficult as they are also always looking for reasons to completely empty their wards so they can make castles out of POP. If you have any non-emergent, geriatric patients, ortho will be more than happy to replace all of their replaceable joints with their shiny, new toys.
One of my patients said he was so in love that he was “blinded” by it and I called ophthalmology in a heartbeat because love is blind, and this kind might just be curable.

7. Do you want to impress your surgical residents/attendings? Do you want to turn their constant frown into an occasional half-smile? Follow these simple steps!

~Mention on rounds that at least two patients’ BP is over 130. They will convulse at the thought of sending them over to internal med for hypertension and having two less dressings to do.
~Always have some betadine on you. Surgeons love betadine. They even drink betadine flavoured energy drinks to keep them awake between wound debridements. One surgeon I know even threw a betadine themed party for his kid.
~Spend some time on mastering the ‘snap’ every time you wear gloves. This will both intimidate and impress your residents. “She’s one of us” they will whisper to each other as their noses pick up the unbeatable smell of glove powder.
~All that work and no pee breaks giving you kidney stones? Refer yourself to urology first, that’s one less intern off the hands of gen surg. Then beg your urologist about letting you keep your kidney stones. He might think you’re weird, as most gen surg interns are, but will most likely comply.
Then proceed to use your kidney stone in a ring to propose to your future husband/wife/10 blade. If there’s a surgical resident around, he’d most definitely let out a half-smile at your dedication.

8. If you want to survive general surgery you need to put up with diarrhea every single day. You see all surgeons hate cafeteria food and they frown upon vegetables and essential nutrients, stuff like that. They love eating food that’s from questionable places with questionable looking meat. Somehow none of the surgical residents get diarrhea. Maybe because they tag team with the patient for metrogyl. They love metrogyl. It’s like they play the ‘he loves me, he loves me not’ game but with metrogyl. ‘Patient gets 500 ml, I get 500 ml’.

9. Casual misogyny is always welcome in gen surg. There are so many wonderful female surgeons, but male surgeons love to make the occasional sexist remark to compensate for their imperfect suture technique. Here are some phrases to get you started with your misogyny 101.
“Of course I won’t be a surgeon! I’m too delicate and weak. I’d rather do something tailored for my gender like family medicine or dermatology”
“Yes I absolutely agree that all female interns MUST wear sarees. We can even get navy blue saree scrubs and spend 7 hours pre-op perfecting the pleats”

10. Surgeons are very serious about contamination. My father even complains about an extra LED light contaminating the cricket field. So it is in your best interest to be proactive about not contaminating anything and everything in addition to the surgical field.
You can’t be friends with radiologists because according to surgeons, they will contaminate your young mind with fancy MRIs and CTs.
You can’t cry during surgery because the OR lights hitting your retinas are making your eyes bleed. Because that will contaminate the patient’s clean-contaminated wound.
You can’t even eat a salad for dinner because that’s too clean and you need to contaminate it.
You can never win.

Hope this unhelpful guide helps you on your gen surg rotation, and hope I take my own advice for the rest of my rotation because I advised myself a head CT and some bed rest. And a repeat hemoglobin (because of anaesthesia).

(IM)PRACTICAL EXAMS – A GUIDE ON HOW TO EMERGE UNSCATHED

Tick tock, my watch ticks furiously as I wait in line to be guillotined (metaphorically) at the hands of the executioner in sheep’s clothing- the examiner.
My classmate asks me what the accommodation pathway is, but his voice is drowned out by the rhythmic, nauseating ‘ping’ of the many machines attached to the patient two beds away and the quiet sobs of the guy who forgot to study CVS but unfortunately picked that case for the practical exam.
Sweat beads on my forehead and plops down to my already disgusting apron which I forgot to throw in the laundry. But luckily, the examiner can’t see that because the wards here are only partially lit by sunlight and two 17th century lightbulbs.
I curse my luck for it must’ve played a major role in my picking the hemiplegia case and I curse (albeit silently) at the residents who won’t tell me the level of the lesion because “the CT results aren’t back”.

SHIT.
He’s walking towards me. And he looks pissed. Like he ate bad biryani for lunch and on top of that he had to listen to students falter when asked where the pons was. (It is in the brain right? I’m positive) If I do survive this tsunami of questions, condescension and humiliation, I promise I will go to church every Sunday mom, I promise. I will even feed stray dogs, or volunteer at a soup kitchen or.. or.. donate my clothes instead of hoarding them. I promise! Dear God let me just live this one out. I can’t bear to study for another six months if I fail this. And..
//lights suddenly start blinking//
//ominous music plays//
//sound of glasses crashing//

There is rubble everywhere. Papers with meticulously written case histories including the ‘mmHg’ after blood pressure readings, rubber tubings with which everyone contemplated faking their own death, punctuated with sphygmomanometers and the occasional mangled stethoscope.
It is a horrible sight, a disaster like you’ve never seen. “Survivors are unlikely” says one passer-by to another who nods his head mournfully.
I fight against all odds (of the patient having aphasia and not just refusing to talk to me) and emerge out emotionally and physically drained but I made it. I MADE IT!

I am now the leader of all the survival guides, because even if you abandon me in a hospital full of hydroceles which WILL NOT show transillumination and patients with rheumatic heart disease who have physically willed themselves into not having ANY of the Jones’ criteria, I will diagnose them and present the case unlike Bear Grylls who will wither because he cannot tell the difference between alkaptonuria and coca cola. So it is only fitting that my final exam experience is shared with complete strangers on the internet along with survival tips because let’s face it, without me none of you would know that there are actual human beings out there who expect you to hold back tears as they scold you for not knowing the cellular mechanics of how aminophylline works. It’s true, I was there. (I cried)

So the most frequently asked question is, what is a good look for practical exams? Neutral makeup with nude lipstick or dewy with a nice shiny lip gloss?
The answer is – None of the above. Aim for cadaveric.
Try to look as deflated as possible, but alert, so they won’t catch you with your palms sweaty, knees weak, arms are heavy. There’s vomit on your sweater already- mom’s spaghetti. Actually it was idli. Same thing.

Coming to the actual exam format, first you must go to the ‘spotters’ section where you need to look at that guy sitting there and diagnose him on the spot without asking any questions. Why, you ask? It is a little known fact, but this was one of the torture techniques used in the Middle Ages to segregate the people based on their knowledge of “why do you think he has jaundice just because his sclera are yellow”. The ones that knew that bilirubin is an uninvited guest at the eye ‘Ball’ (get it? hahaha! If you’re reading this please be friends with me I have none) got to go to med school and the smart ones that didn’t know the answer went on to professions that did not make them acquire TB at any point in their long, happy, needle prick injury free life.

You must then walk quietly to the patient assigned to you where you need to take the case history, do a full general and local examination – that is if you can localise the system that’s affected. I chose solar system because if you think about it, if the solar system did not exist, I wouldn’t be here taking this case. But I decided against it because percussion of the moon was a bit time taking and a tad impossible. Although my best bet remains that the note is stony dull.
Unfortunately your diagnosis cannot be “patient is sick”, believe me, I tried. You need to say something fancy like ‘complete right sided hemiplegia with UMN type of facial paralysis’. But we both know that I wouldn’t know a UMN facial palsy if it hit me in the face *wink*

Your examiner will now walk over to your assigned bed and he will do it like he hates you and he hates his job (which is true). Recite all your findings to him and don’t forget to include that the patient is cooperative even though minutes ago he tried to stab you in the spleen with the biopsy needle. Now comes the fun part where you are asked to demonstrate reflexes. When you swing the knee hammer, the movement needs to be at the wrist, just like when you play badminton instead of studying the root value of the triceps jerk.
Don’t worry if you can’t elicit the biceps jerk. Try again, this time hit your thumb hard. The patient will flex his bicep in pity looking at you wince in pain.

You made it so far! We only have the toughest and the most avoidable part now. The part where you face off with the four horsemen of the apocalypse. A section each for drugs, instruments, x-rays and the part where we pretend like we’re on Dr. House.

Walk in to the first cabin, trembling as you do and take a seat in front of two people who would kill to be literally anywhere else right now. One guy has a huge tray full of vials of drugs, half of which you do not know and the other half is paracetamol. Surprisingly laughter isn’t on the tray. It must not be the best medicine as per general claims. I prayed for an easy drug like aspirin or penicillin. I would’ve been happy even with those cockamamie homeopathy sugar pills. They would’ve actually helped me with my hypoglycaemia. But alas. I was given aminophylline and I got an asthma attack. So my advice is, be prepared for the worst. If they ask you what propanolol is, say you have chest pain.

When it comes to instruments, try to hide a foleys in your pocket so when you are asked to pick an instrument you know to talk about, you can produce one with sleight of hand. But this never works because you are not Houdini, so you must face the dilemma of picking the lumbar puncture needle (and having to demonstrate the procedure of lumbar puncture on yourself because the examiner is never satisfied with any answer) or the other ones which are impossible to hold in the correct position because according to the textbook you are supposed to not hold the instrument at all but instead make it levitate mid air. You can never win.

Listen to me carefully. All x-rays in medicine are of pleural effusions and all x-rays in surgery are inevitably barium meals. So when handed an x-ray to read, confidently say it is pleural effusion. Unless it is not the chest and actually the skull, don’t say thalassemia because you see crew cut appearance. That is actually a picture of the examiner and he wants your opinion on his newest hairdo. Most x-rays used for exam purposes are super old anyway and they look like photographs from WW2 so nobody will be able to identify anything.

Next is my favourite part, the Dr House section. Here they just give you a card with a bunch of information and you need to connect it all and make a diagnosis.
For example : young female, anxious, palpitations, diarrhoea.
See this one is tricky because I know most of us would love to blurt out “THIS IS ME RIGHT NOW ACTUALLY” when faced with a case card like this, but you must think about more common conditions like hyperthyroidism.
After finishing every section, and surviving till the evening without a sip of water or a morsel of food, you can finally drive home and faint at the wheel. You might even crash into someone but hey, it was worth it since your demonstration of ankle clonus was A1.

In conclusion, I wish I could tell you that it was easy, that you will overcome, but it wasn’t and I have nightmares even today. Nevertheless I survived. I finished med school.
I hope I did because if I don’t pass in all the subjects I am quitting this to pursue a life in a monastery away from the mitral stenoses and the hydroceles that orbited me for the past month.

HOW TO INTERPRET EVERYTHING AS A MED STUDENT

Picture this.

It is 9’o clock in the morning on one very ominous day in a very badly lit hospital. You are extremely tired and it is way too early to think. *smack* what’s that? Your professor just slapped you with a million investigations to decipher. ‘Is this the Da Vinci Code in real life?’, you ask. ‘Somewhat’, I tell you. ‘You have five minutes before he comes back and you better be prepared with the answers because having a stroke/MI right now is a little impractical’.

Hey you! Yes, you. Does your patient’s ECG look like modern day hieroglyphics? Does it bother you that you don’t know where the heart is on a chest X-ray? Do you often miss the liver on an abdominal CT? Well friend, look no further! You don’t have to be an expert in symbology like Robert Langdon! I have prepared a comprehensive list for you after 4 years of intensive research as a med student in one of the most over populated hospitals in the universe. So brush up on your X-Ray/CT/MRI/ECG/clinical signs interpretation as I teach you how to be an absolute expert in reading an X-Ray while expertly dodging that patient the X-Ray belongs to. (heads up: He definitely has TB)

1. How to interpret a few important clinical signs in the head and neck

(PSA: to be very honest I do not know the myriad clinical signs in the head and neck because I am never going to be a neurologist, and I am most certainly never going to be an ophthalmologist or an ENT surgeon. No sir, I am not a masochist)

Does he have a head? Check.
This is going really great.
Is the patient staring at you? 9 times out of 10 it is Stellwag’s sign.
Differential: You have spinach stuck in your teeth.

You know the textbooks will tell you to check for corneal and conjunctival reflexes, but the day a patient will let you poke him in the eyes with a cotton wisp is the day you will revolutionise medicine as the guy who actually does a complete physical examination.

Invite the patient for lunch. Is he drooling? What must you think of?
That’s right, facial nerve palsy.
Differential : My mum makes really good biryani.

Look at his general facial expression.
Is he grinning? What’s so funny?
SHIT! Is this risus sardonicus? I thought the textbook authors only wrote that as a prank.
Does your patient say he has a headache? It’s because the damn nephrologist next door WON’T stop suggesting dialysis, even if my patient only has a paper cut.

I think we can all agree that doing the fun tests like the smell test and the taste test are cool, whereas doing impossible things like testing the pharyngeal (gag) reflex by tickling the inside of someones throat is not cool and I really don’t want to get vomited on I have a hard life as it is.

2. How to read an X-ray better than the radiologist who is minting money faster than the Indian Government right now.

Start with the date on the X-ray. Is it really today? I joined med school four years ago. How did time fly by so quickly.
Don’t get carried away like radiologists who are on a perpetual vacation in the confides of their air conditioned CT scan rooms.

Next, look if the film is lateral view, PA or AP.
It isn’t AP anymore you uninformed doofus. It is Telangana now. Be very careful around KCR’s AP view X-rays.

All that empty space there is the lung. If you see hilar lymph node enlargement, it is TB.
If there is a cavitation, it is TB.
If you see a silhouette sign, it is pneumonia (but it is actually TB)
Can you see the heart hiding partially behind the sternum? It’s too shy to come out and say hi.
If the heart does come out and say hi, it might be ventricular hypertrophy. But you can never rule out TB.

3. How to get into the mindset that ECG is actually legit and not a toddler’s attempt to draw a straight line.

This one is really hard, I have PTSD from the transition.
So you need to know 3 things about the ECG. P wave, QRS complex and the T wave. If an ECG has all these three waves then your patient is alive and kicking.
Cardiologists will tell you about axis deviation and stuff but it’s totally fake. Do you want proof? Ask a cardiologist about axis deviation and watch him sweat buckets and mumble vaguely about it being left or right.

4. How to read lab reports and not freak out.
So you have a bunch of papers with numbers on them and you can’t figure them out?
Let me help.
The first one is random/fasting blood sugar – look around you. This is India. Everyone has diabetes. You don’t need to look at a lab value to figure it out.
Full Blood Screen – This one is standard. If you see malarial parasites, don’t freak out. At least it’s not TB.
Kidney function tests – Whatever you do, the nephrologist will most definitely start steroids and dialysis. STAT.
Liver function tests – He might/might not be an alcoholic. If you pretend to look away your patient will do a shot of vodka and act like nothing happened. Cirrhosis confirmed.

5. My favourite part of this list – Clinical signs in the abdomen.
Most of these signs have become obsolete after the advent of the ultrasound and CT, but internal medicine guys love to torture med students in a last bid to seem cooler than the general surgery guys.

Does the patient have tenderness in the Mc Burney’s point? Wheel him away to surgery. Internal medicine guys just lost one patient from their ward.

That one patient keeps throwing up from second hand stress every time he sees the professor grill the students about the grades of clubbing (serioulsy, why do you guys do that?). Congratulations, your patient now has a Mallory Weiss tear and he must be wheeled into surgery.

Internal med guys lose 2 patients from the ward.
Why does your patient have bruising around the umbilicus? It’s not because someone punched him square in the gut for asking to split a 1000 rupee bill, it’s the Cullen’s sign. Sorry but this patient has to be wheeled into surgery too.

What are the internal med guys left with? That cirrhosis patient who won’t stop drinking behind their backs.

This list could go on but by the time you’re done reading the X-ray your professor will be either raging with anger at your incorrect diagnosis of TB or terribly disappointed at the fact that you are holding the X-ray upside down.

True story : My surgery professor quizzed me on the life of Wilhelm Röntgen when he ran out of questions to ask and then proceeded to look devastated when I could not answer his questions about what Mr. Röntgen’s favourite breed of dog was. And then he started blaming the medical education system.
So I hope you learn from my extensive and extremely detailed guide on how to decipher the complexities that are investigations and clinical signs.

PS. The differential is always TB.

A FINAL YEAR MED STUDENT GUIDE TO PERFORMING A PHYSICAL EXAMINATION AND CASE TAKING

A good physical examination, as repeatedly told by my professors from the first ever clinical rotation I attended, is the biggest clue to diagnosing a patient. But when I got to the hospital after a close encounter with death at the entrance i.e., physically wringing out of the grip of a patient who wants to leave AMA , I was only shown a few clinical signs and watched as my professors sized up the patient and told me his diagnosis. So as a naive second year med student eager to absorb clinical knowledge like a sponge after being released from the clutches of cadavers, dissection hall and the biochemistry lab, I thought all I needed to know was how to read a CT/MRI/X-ray/ECG.

I wasn’t wrong, but I definitely wasn’t right. We were taught how to write case histories and recite them to our professors who paid irritating attention to details like negative history of every condition ever known to mankind and measuring the JVP which I’m sure is only a myth and no man has ever measured the JVP before, much like how no man has ever seen the loch ness monster or the bigfoot. The people who tell you they’ve measured the JVP, and worse told you about how clear the Kussmaul sign is in the patient in bed 3, are LIARS and conspiracy theorists.

So this, my fellow batchmates and underclassmen, is a guide on how to perform a good physical exam, and simultaneously impress your professor while also learning about the complete sham that is JVP examination (seriously, I stopped using a scale back when I was in 5th grade. What makes Hutchinson think I have TWO scales at my dispense and the time to cry my eyes out every time the JVP is normal/ definitely NOT raised/ invisible in every right heart failure patient)

시작합니다 – That’s Korean for let’s begin. Physical examination is hella confusing so what’s one more notch on the confusion scale amirite?

GENERAL DETAILS:
Ask the patient his
1. Name : don’t be a dick and call him ‘that mitral prolapse guy’ every time you need to address him.
2. Age : Definitely going to be lied to about this. Tell him you’re not here for a rishta and this is not a Swayamvar. You don’t care if he did his MS in the USA at only 23 years of age.
3. Address : So you can tell his mom when he sneaks out in the night.
You can then ask for additional details like – does he have a dog? What kind? What’s his name? Is he a good boy? Is he a very good boy? Who’s a very good doggie?
Sorry I get carried away but this is 100% the best way to impress your examiner from the very start. Show him pictures of cute dogs.

PRESENTING ILLNESS :
Start by asking him when he first started noticing the symptoms. He will definitely give you a ball park range, for example :
Me : So when did you first notice the cough?
Patient : When I was 3 years old.
Me : But.. you’re 37 years old now.
Patient : Baba Ramdev said I can cure this with deep breathing.
Me : …
Patient : *Starts deep breathing out of one nostril*

After writing everything in chronological order, and describing the fever in 782 different ways like low grade in the morning, high grade at 8.37 pm and now in a hectic picket fence pattern, move on to asking about negative history, which means asking questions to rule out other conditions. Ask about trauma, weight loss, blood in sputum, syncopal attacks etc. You can also ask who will kill Cersei Lannister in the next season and why you keep watching GoT when you have so much to study.

PAST ILLNESS : Same as above, but like in the past. Before that guy got that cough when he was 3 years old.

FAMILY HISTORY : Does the disease run in the family? Does the father also show extreme displeasure while being asked for medical history by undergrads? Why was the saasuma (mother in law) fuming at the bahu (daughter in law). Stay tuned to find out.

 

VITALS : Is the pulse even present? Okay good. The patient is alive. Makes it easier to diagnose this way. Did you count for a full minute or just for 15 seconds and multiplied it by 4? Is it pulsus paradoxus or pulsus bigeminus or pulsus tardus et parvus? You need a minute to read about those for the first time? Cool. You’ll need a crash course on Latin for that. Good luck.
The respiratory rate is always 17/min even though he is tachypneic, bradypneic or apneic.
Just like how the BP is always 120/80 mm Hg even in someone with severe hypotension. As long as you write mm Hg, you’re good.
Temperature – afebrile/febrile/ you’re hot then you’re cold, you’re yes then you’re no, you’re in and you’re out, you’re up and you’re down – as described by Dr. Katy Perry.

GENERAL EXAMINATION :
This is supposed to be a head-to-toe examination so you don’t miss anything in addition to the disease you’re trying really hard to diagnose without looking at the patient’s case file.
Did you check for PICKLE? I mean did you check if the patient is carrying any pickles on him? I’m starving and I could use some, thanks.
But don’t miss the clubbing on the chain smoker’s fingers. Don’t accept his invitation to go clubbing either. No thanks, second hand smoke.
Look at his gait. Is it wobbly/trendelenburg/ moon-walk? He might secretly be Michael Jackson. Oh wait..

INSPECTION : You’re supposed to look at the patient and ‘inspect’ him before touching. Does anyone do this anymore?
Imagine staring at him until you check off all the boxes under inspection.
Scars – check
Sinuses – check
Swellings – check
Engorged veins – check
Mild awkwardness progressing to extreme awkwardness – CHECK.

PALPATION : Did you touch the patient with your ice cold, nervous, quaking hands? Good job, you’re one of us now. This is your patients encounter with frost bite #1. Spend the next five minutes playing tag with the patient around the hospital because he doesn’t want to be touched by you ever again.
Did you feel for thrills/apex beat/tactile vocal fremitus? Feel for organomegaly – close to impossible, but your professor will always say “There’s massive splenomegaly! Look! Feel right here”, to which you will say “yes yes there is massive splenomegaly” while jabbing the poor patient with your cold hands and finding that there is actually NO splenomegaly. There might not be a spleen present too. This is all an act.
Run away whenever someone mentions Murphy’s sign.

PERCUSSION : Percussion is by far the hardest thing I have ever done and I have helped a woman give birth on the floor while she screamed and yelled at me. What is the note you hear when you percuss the lungs? Resonant/hyper- resonant/ dull/ stony dull/ emo/ very emo. Talk about how you heard a resonant note when you don’t even know what the ‘pleximeter’ is.
If everyone in your class cooperates, all of you could play a song out just with percussion.

 

AUSCULTATION:
Your patient’s encounter with frostbite #2 – the harsh, sub-zero temperature of your stethoscope diaphragm.
Did you listen for the first and second heart sounds? I have finished at least a million clinical rotations and I still say “lub-dub” out loud to differentiate the first heart sound from the second. The heart is weird man. It murmurs and stuff too. You have to then grade the murmur. Grade 1 – very faint to Grade 6 – very loud, very Arnab Goswami, very tantrum-throwing teenager-ish.
If you hear a gallop sound its best to bribe a resident with some food and actually confirm because everything sounds like a pathology to your underprepared, over enthusiastic ears.
To complicate things even further, there are some signs that combine the already complicated auscultation with other things – like the liver scratch test where the patient tells you his skin itches and you have to scratch him or he won’t let you examine, or the puddle’s sign which is impossible to perform and has joined the leagues of the JVP and the loch ness monster.

After finishing your case taking and examination, you must arrive at a diagnosis.
To summarise my case,
“37 y/o male patient who did his MS from the USA, a resident of Westeros, who sneaks out regularly in the night through the left window on the second floor, has a dog named snickers who is the cutest, won’t stop doing yoga (consult psychiatry), won’t tell me who will kill Cersei, never walks, only moonwalks (consult ortho), has invited me to go clubbing with him, has a grade 6 murmur yelling at me from across the room, most definitely a case needed to be taken up by Dr House”

*drops mic*

FAQ : HOW IS FOURTH YEAR?

How is fourth year?

Can you perform surgeries now?

Why are you wearing block heels to hospital?

Why is your makeup so blended?

Where did you get time to buy that outfit?

Hello friends, remember me? The mopey third year? I am in final year now. Which means I am invincible and I have all the time in the world to watch Captain America : Civil War TWICE. That’s right, twice. Can any other med student perform this staggering feat? I don’t think so.

To answer all the questions above, yes I look amazing because I get enough sleep and I have all the time in the world because fourth year is like all hospital and no classes. I don’t have to shuttle back and forth from the hospital to classes in sweltering heat. I finally have a life!

But I know that even though I say I am free, I really am not. I’m supposed to be reading Bailey and Love/ Davidson but I guess I’ll stick to my method of panic-reading everything before my semester exams and crying about how little time I have. Up until now I’ve only had my medicine and general surgery rotation and even though I’ve hated them they were really comfortable and I got to go home early and sleep 🙂

I first had my surgery rotation which was a breeze (not). Instead of rollin’ into the surgical wards at 10.30 am like the other kids, I had to go at 9 am because my attending was a little cray cray and he got a kick out of seeing students being punctual. So my daily routine in the 6 weeks of general surgery was something like this,

Walk into da club (general surgery male pre-op ward) at 9 am and look at wound dressings being done.
Study about hernia/hydrocele
Present a case of hernia/hydrocele
Listen to general surgeons talk about how they’re better than super- specialists while they’re teaching a hernia/hydrocele class
Being the official discarder of used wound dressing materials. Mostly suture dressing after hernia/hydrocele surgery.

But I am a surgery fan so it was bearable for me. In medicine all we do is cry about getting TB because even the CVA guy has TB and I can’t escape it.

So here are some of the frequently asked I (or any other med student) face. I will answer them once and for all, so please don’t trouble us.

1. (Q) All my relatives : Can you treat me now? You’ve been studying for the past decade.
(A) No I can’t treat you. I can tell you the procedure of gram staining and I can give you a band aid. Do you want some aspirin?
Also that one cousin, you cannot have a prescription for medical marijuana sorry.

2. (Q) My boyfriend : Why are you always studying? Do you like have an exam or something?
(A) Do I have an exam or something? DO I HAVE AN EXAM OR SOMETHING? I only know that my paediatrics textbook is lying somewhere and they’ve finished teaching half of whatever it is they teach in paeds.
So no, I do not have an exam. I am just catatonic I will fail this year and forever be stuck in a loop of trying to look for my book and failing ❤

3. (Q) All my non-medical friends : Why are you throwing up?
(A) From the stress of a pancreatic pseudocyst rupturing and the weird green liquid spilling all over my brand new scrubs in the OR.

4. (Q) My mom : Why do you only eat foods with absolutely no nutritive value? You read about nutrition in community medicine right?
(A)Because I am training my body for surgery finals. Also, what even is nutrition 🙂 ?

5. (Q) Also my boyfriend : Why don’t you emote?
(A) I was forced to watch 15 episiotomies non stop pls don’t do this to me I can only take so much.

6. (Q) Everyone at the hospital : Why do you park like you’re a blind fruit bat?
(A) I never learnt how to park properly because I was learning the urea cycle.

7. (Q) Patient : Sister. Excuse me. Ma’am. Lady. Lady in the white coat. Nurse.. (basically everything except doctor) Why won’t you turn the fan on for me? While you’re at it, can I have the menu for dinner?
(A)This… this is not a hotel!

8. (Q) Professor : What did the author of this textbook say in the preface about his take on the meaning of the Hippocratic oath?
(A) *wiping tear from cheek* I can recite the steps of hernioplasty. Will that do?

9. (Q) My classmates : Why did you go on a holiday and then cry about not being able to study gynaecology?
(A) You fools I know what menstrual cycle means I think that’s enough to master gynaecology.

10. (Q) Underclassmen : How are you so calm when you have massive subjects this year to study?
(A) Water-proof mascara, concealer, caffeine, a lot of waking up at 4 am and panic-reading, and a boyfriend who thinks IV antibiotics are stage 4 antibiotics and who also offsets your psychosis.

HOW TO SURVIVE THIRD YEAR OF MEDICAL SCHOOL

After what seemed like the longest hiatus, I am back, this time equipped with the knowledge about how to survive third year of medical school. Surviving second year was like surviving the apocalypse, so the tiny subjects of third year were a welcome change to me.

Third year for us in India has only three subjects- ENT, Ophthalmology and community medicine. When I was buying my ridiculously overpriced textbooks, I noticed ENT and ophthalmology were really tiny books. So right there in the book store I did a happy dance because I was so tired of reading Robbins which weighed more than I do.
So picture this, I, a stressed out, maniacal, fresh out of second year student, enter into the vast nothingness and freedom of third year. I went mental with happiness because all I wanted was to rest and while my time doing nothing. And I ended up studying one years worth of medicine in 1 month which is a terrible idea. But if I could pull it off, so can you.

So with experience, I have drafted a list of how one can survive third year which is seemingly benign but actually really really scary.

1. First clinical posting of third year- Eat a lot and get buff. If you’re skinny and frail, God be with you.
It was in the chest hospital I think. Chest hospital sounds weird I know, but it’s just a hospital to treat the 2180747815 new cases of TB we see everyday. And as per my general suckish bad luck, the chief of the hospital was crazy and the opposite of a hypochondriac. He would examine a child visibly coughing out green sputum, never would he mind a bit about getting sputum all over him, and would expect us to do the same. He never would even let us wear masks, because he said and I quote “I never got TB and I’ve worked here for 25 years. You won’t get it too”
So of course I wailed like a baby when we were made to examine the MDR TB cases sans masks
Doctor language decoded : MDR stands for Multi Drug Resistant TB which is essentially terrible and imagine being frightened day in and day out that you’re going to get it and die of it before you even graduate.

2. Don’t worry about the other postings like dentistry (highly unnecessary for med students I think) , psychiatry etc.
You won’t care, nor will the professors, nor will the patients.

3. Do you feel like you just got hit by a truck ? They were actually your semester exams, which are even worse.
You are expected to write a full 5 pages about fungal corneal ulcer and otitis media without attending a single day of hospital teaching.
Calm down, hook yourself to an IV line because you’re going to be throwing up with the stress of studying the anatomy (again) of the ear and nose and eyeball which is all very confusing.
Relax, nobody knows what aqueous humor or lamina papyracea means.
If the question is corneal ulcer, write c-o-r-n-e-a and a-n-t-i-b-i-o-t-i-c-s in big, decorative font and you will be through.
Same goes for otitis media. Except now you only write m-i-d-d-l-e e-a-r in fancy lettering.
You’re welcome. *drops mic*

4. NOW you have your first ENT clinical rotation. Have you already seen the surgery for deviated nasal septum 500 times? No problem. Watch it being done 7209 times more in one week.
Do you know the steps of cataract surgery by heart? Still gotta watch the surgery being done until you slip into a coma. It’s a slow torture.

5. Now what? Community medicine ? Haha you thought it was only vaccines?
Think again honey. Here’s a list of the myriad fascinating and also utterly nonsensical things I learnt in Community medicine.
~ How to build a sanitary well
~ How to disinfect said well with bleaching powder
~ The anatomy of a flush toilet
~ Criteria for group discussion
~ Treatment of sewage
So every answer looks like this “In the community……. vaccination…… sanitation….. prevention….. community medicine”
Mind blown.

6. Just when you were regretting not studying the whole year, you are faced with practical examination where you are supposed to
a) Identify all the instruments used in surgeries
b) Read an Xray that looks like a child drew on it with a white crayon
c) Answer 500 questions in a rapid fire round : you vs your professor

This was me and my professor in the face-off. Hope you can learn from my experience.
Professor : What’s this instrument *holds up a shiny steel scissors like thing*
Me : *overly confident* Medium artery forceps.
Professor : (unfazed) what is quinsy?
Me : (slightly nervous) ulcer.. haha.. of the.. haha… tonsil?
Professor : (now establishing dominance) Read this X-Ray in less than a minute.
Me : Sinus. Maybe *looks at smudged writing on hand* this is an X-Ray of…. I think… Um… *Gulp*
Me : Has a stroke and dies.
Professor : Me 2- You 0

7. This is how to handle the community medicine viva if you ever survive the massive stroke during ENT and Ophthalmology exams.
‘How do you manage an epidemic of cholera’
~ Community diagnosis
‘How do you treat malaria’
~ *cough* Community diagnosis
‘What is your name’
~ Haha this is an easy one. Definitely community diagnosis

May the odds be ever in your favour, my third year children.

HOW TO STUDY FOR MED FINALS 101

Everywhere in India, depressed students are even more depressed than usual because finals are approaching. I’m particularly stressed because underclassmen keep asking me how to study for pathology, microbiology etc. Brother I barely made it hanging by my fingernails, how can I give you guidance? I might look calm and collected on the outside, carrying a community med textbook like a wailing infant, but on the inside I’ve been screaming for five hours straight non-stop.

Exams are stressful man. In fact they’re so stressful that I’ve run out of cortisol and I am functioning on caffeine alone. (for ignorant first years, cortisol is the stress hormone. Now go back to dissection). I feel like exams are more stressful when you’re in med school because it’s not just knowing the answers to a printed sheet of questions, you have to face tobacco chewing patients and ask them for their medical history while they shoot tobacco spit missiles all around you, then present the history to an attending while he tears you apart with things like “You must never say the patient is not anaemic. You must always say he doesn’t have anaemia. I’m sorry I’m going to fail you. TTYL”. And if you’re an unlucky second year kid, you’ll have to go to the lab and test a myriad of urine samples while trying not to get any on your hands.

But I’ve passed all my finals up until now. If you want to know how I did it, read this in your break time between reading GIT path and Antidepressants because that’s when you’d have found an all time low.

1.Don’t sleep.
I know it sounds simple. Like what is she saying? Of course I don’t sleep during exam week.
But hear me out. No sleep means you have entered exam week, and already running on zero sleep. Your eyes have such huge bags under them that your parents don’t recognise you anymore. Your DNA is slowly transitioning from human to zombie as you pull your hair out in every vain attempt to learn the classification of cephalosporins.
But it’s really dangerous. I tried this thing where I studied ALL night without even dozing off for a few minutes for my pathology finals and I went straight to the exam. I mean I did well and everything but I’m pretty sure after I got home I passed out/had a seizure/ mental breakdown/ all the above.
I thought it was worth it though. Which means I might be a masochist at this point I don’t even know.

2. You have to cry.
Because who else knows the pain of not knowing even the basics of epidemiology of measles ? Only you. Cry your eyes out. Then realise its all just vaccination and community med is a bitch.

3. Practice cringing, a lot.
Now this isn’t for the theory exams. This is a special tip just for practical exams.
I don’t mean cringing externally, because if you do that your examiner might fail you in a heart beat. Cringe internally. Let your heart slide down into your abdominal cavity, overdose on cortisol and get goosebumps while sobbing internally.
You have to hold cadaver testicles in the correct anatomical position WITHOUT gloves? Time to cringe.
You have to check a patients stool for parasite eggs in microbiology and the stool leaked onto your hands because you weren’t careful? (and let’s be honest, it’s a really watery diarrhoea consistency) – Cringe like a boss.
Your patient threw up on your apron because he couldn’t see the vomit pan right next to him? Cringe with class.

4. Your diet must contain 99% saturated fats.
You know that moment when your parents are tired of your continuous sobbing and whining about how weird ENT is and they stop paying attention. Who is going to love you without judging you for not showering for 48 hours? Not your textbooks. You think Guyton and Hall or Robbins and Cotran care about you? They don’t. You’re just a fling to them.
Who really cares about you are saturated fats. That’s right. Every comfort food imaginable with melted cheese on it.
You might get an MI while writing your exam though but at least you know your atherosclerotic plaque loves you so, so much.

5. GET READY FOR YOUR EXAMSSSSS
And I don’t just mean buying a new set of pens.
Here’s a checklist for med school exams. Make sure you have everything before you go. Or risk stroking out mid-exam. I mean it’s your choice, really.
~ Pens, pencils, industrial level highlighters (with a one litre refill tank), etc, you know these.
~Fresh frozen plasma because you might get massive attacks of epistaxis every time you see ‘anatomy of’ and ‘explain why’ on the question paper
~ Some sedatives are always advised
~ A continuous IV line
~ Adderall
~ One Big Mac with extra cheese, extra large serving of fries, extra extra large coke, and some tissues to wipe your tears with
~ Whale mating call noises to calm you down when you have a panic attack or a seizure.
~ A life sized poster of Ryan Gosling because he will love you even if you don’t get a 99% on that test.

You should be fine if you follow all these tips. Thank me later.