(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*

THE FAULT IN OUR SEMESTERS

I am in my final semester of med school. 5 months left. I can’t believe it. It feels just like yesterday I was a fresh faced 1st year, trying to memorise all the muscles of the flexor compartment of the forearm and trying to get through each day without dying from the sheer stress of studying anatomy. Now I’m in final year and
~I don’t even study 1/4th of how much I did back then
~I forgot what the flexors of the forearm are. One of them is flexor digitorum I guess?
~I should be knowing the flexors of the forearm though because I have my orthopaedics rotation now and it sucks.

I have 5 months left and I feel like I know nothing. I only know how to jump across spit puddles and used syringes expertly but that isn’t going to help me for my final exams. I feel like I need to go into a cycle of panicking and panic-studying but I still don’t feel as stressed as I was in first year. I mean who would be stressed? When you know that one of these days the ortho guys are going to drop one of those huge ass drills on your head and kill you, you’re not going to need to give finals. Right? Or maybe my professor would summon me from the afterlife to quiz me on CTEV. I need to be ouija immune. Are there antibodies for that?

 

So 5 months away from the biggest exams yet and I am still lazing around being complacent enough to take afternoon naps. Am I crazy? I might be. (note to self: read classification of antipsychotics)
First six months of rotations I didn’t do anything except sulk about waking up at 8 am and having to drive back home at a time comfortable for me and having no labs or classes back at college. I lead a tough life what can I say? Looking back at the last 6 months, I can only remember doing the following (apart from taking too many naps)

 

1. Gynaecology and obstetric rotations were a complete blur. I remember doing a 12 hour shift in the labour room and seeing a woman frantically pacing despite being told many times to lie down. She gave birth standing up and my resident had to catch the baby mid air in a sick, almost superman-ish swoop. It was amazing to watch, except I had to help the lady drenched in amniotic fluid and blood back up on the stretcher because I was supposed to remove her placenta. My shoes had placenta and amniotic fluid stuck everywhere. I incinerated them.

2. I went to medicine rotation everyday only to take hemiplegia case history everyday. One day our resident said he’d surprise us with a new case. Guess what it was? Quadriplegia.. WITH TB. Fml.

3. All Ortho surgeries make my head spin because its like carpentry but instead sawdust here is replaced by blood and bone bits? I was brushing my hair out after a knee replacement surgery one day (they made me scrub in just so I could take pictures for them) and I found enough bone bits in my hair to make a small voodoo doll out of them.

4. Even though I was the most enthusiastic about my general surgery rotation, I don’t remember what I did. I know I starved everyday because all the hydroceles and inguinal hernias and the oral cancers put me off any solid food. I think I also cried every time my professor asked me weird ass questions like “Why is the X-ray called the X-ray” or “ Why are you shaking so much examine the massive hydrocele case” and my favourite “Why do you think super specialists are better than general surgeons”
Excuse me while I deal with my PTSD in one dark corner of my room

5. My friend just reminded me I have a paediatrics exam in 10 days and all I know in paediatrics is that ‘growth’ and ‘development’ are two different things.
I mean they’re tiny humans, aren’t they supposed to be LESS complicated? ‘I must start freaking out at this stage because I haven’t even looked at the other chapters’- said she while breathing into a bag because of excessive CO2 washout during hyperventilation and hysteria.

6. I have noticed this more than I have noticed green sputum produced by TB patients, but it is so useless to wear make up on OR days?
I feel like the surgical mask manufacturers wanted to double them as makeup removers, because I try and do my makeup early in the morning so I don’t look anaemic and cadaveric when I go to hospital, but whats the point when post-surgery I take my mask off and with it comes my foundation, lipstick, and somehow even my mascara and that weird body glitter I was obsessed with when I was 12. So despite my herculean makeup efforts, I end up looking even more anaemic and cadaveric than usual because someone accidentally threw a used mop on me. I have blood on me but it wont help my anaemia. The irony.

7. I feel like you need to carry 2-3 pairs of shoes any time you go to a hospital attached to mine, more so if it is a ob/gyn hospital, because I feel like instead of land mines and booby traps we have placenta traps. Here instead of being blown to bits and dying in an explosion, you fall into a sea of placenta and clamped umbilical cords, which is 10 times worse.
Or the other danger is running into a pregnant woman who thinks theres something wrong with her (which is 98% of them). They will physically drain you of your energy and extinguish you of your glycogen stores even after you show them that all their tests AND the repeat ultrasound is normal. Carry some candy along with those extra pairs of shoes or you will go into a hypoglycaemic coma from answering all their questions.

8. Its been a year since my horrible experience with orthopaedics and I still hate orthopaedics? I know surgical subjects are supposed to be interesting but orthopaedics is so repetitive and lumberjack-esque. And I’m pretty sure the C-arm is giving me cancer.
And also it’s cute when orthopaedic surgeons are taking a class and they have to explain something medical, and they’re just like “uhhh yeah so fuck that, we need to insert an intramedullary nail and thats all you need to know”. It’s very comforting to know that someone else is just as bad in medicine as I am.

9. I have become an expert in coordinating the time of my hospital entry to the time they mop the floors because otherwise I have to make faces and skip around puddles and run away from stray cats which sounds relatively benign but is extremely hard when you have to do it in corridors with no lighting (both artificial and natural) and you’re wearing heels.
Tbh running in a hospital corridor while simultaneously dodging stray cats which want to give you cat scratch disease and not stepping on used gauze or syringes should be an Olympic sport. Like an obstacle course, but even harder and even more deadly because MRSA is not an easy hurdle to jump. (cue nervous sweating)

10. Instead of learning important things for exams, like obstructed labour and stuff like that, during my obs rotation, I learnt that I have to rap battle the nurses for oxytocin. I tell them I need oxytocin for a patient and they will spit verses back at me telling me they are running on a short supply. Well i guess we won’t deliver this baby today then?
Its safe to say I won’t be pursuing gynaecology or obstetrics in my residency.

Study up kids. Don’t be like me. Or do. You could be an olympian one day. If the olympic committee makes hazardous obstacle race an event. Thank me later losers.

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.

THIRD WORLD MED STUDENT PROBLEMS PART-2

Picture this. It’s summer in the tropics, which means it’s pretty fucking hot, say 41 degrees C. You are forced to go to a hospital 4789236 kilometres away from home. You park your car in the crumbling semblance of a shed, bump your car around a few other frustrated drivers, trees bang in the middle of the road, and obvious manholes laced in between the intricate one-car lanes.

You are extremely tired and it’s only 9 am. Delightful. Then you have to do a 100m sprint from the parking to the hospital building and while doing so you have to dodge a few birds trying to take a shit on your white apron. You are basically an Usain Bolt who also does relay-runs. Why do you need to run you ask? The professor comes in at 11.45 am, but he will enquire when the students came in because he is trying his very best to invent new ways to torture us. Poor guy, A+ for trying.

Then you are barraged with questions, as soon as you can catch your breath. Mostly from residents because they are in a constant fight for power in the food chain. You try to answer whatever you can while also experiencing grade 4 dyspnoea. But tough luck, you trip on a bum tile and fall down in a tub of used gauze. Ha-ha. You laugh awkwardly. But inside you are dying.

Welcome to one day in my life.

In my previous post of third world med student problems, I made a lot of people laugh (sure, go ahead, laugh at my misery), but i spoke da real 100% truth. Though I might have left a few points behind, because you can’t really describe a third world hospital. It’s a museum, a zoo, a dustbin, a movie set and maybe sometimes, a hospital.

Third world hospitals are like a parallel universe. It’s like stepping into Narnia, only the white witch is Tuberculosis. In this strange world, we have endangered art work such as “Jai Telangana” splattered across walls, the ritualistic outdated surgeries using instruments John Hunter himself forged out of rusting metal. And how can I forget, the mesmerising sing-song voice of the nurses saying ‘pakkaku jaragandiiiiiii’ (translation : GTFO) . It’s all fun and games until your professor makes you examine a hydrocele case sans gloves. Why? Because it makes him inexplicably happy and don’t whine, it’s *practical knowledge*. It must be my damn birthday because the icing on the cake was that the hydrocele guy had TB too. Ha-ha-ha (crying slowly turning to tears) I want to switch places with the coma guy.

But I have left behind my snobbish ways of wanting cleanliness and wanting to NOT die from fright every time I trip on the ghoulish winding staircases with no lighting whatsoever. From my last post on third world hospitals, up until now, I have come to realise that,
a) I cannot change anything
b) All pigeons are going to want to poop on me
c) I need to get waterproof makeup because I cry a lot whenever I am confronted with a patient and his family who all have a coughing contest on me.
d) My professors expect me to love this hospital and worship the ground they walk on. Which I cannot because it is inevitably covered in dust/pus/blood/urine of animals or humans/all of the above

So while I cannot change the fact that I have probably stepped already on someones urine and/or blood, I can at least help you, if you ever have the misfortune of going to a hospital in India. You must first remember that bravery is key.
You cannot run like a pansy when you see poor med students being harassed and asked to feel for axillary lymph nodes in someone who has not showered in 10 days and is sweating like an Indian bride on the day of her arranged marriage .

You must instead give them moral support and stay with them till they regain consciousness. Okay here is your survival kit : Updated

1.How is your hospital back in the west with your beautiful shiny, expensive things and your spotless scrubs? All good? I thought so too.
While you lead a life of rampant luxury, we fight gladiator-style for the last pair of OT shoes . It’s cool 🙂
Also, must be nice to have a hospital stocked with ESSENTIAL things like hand sanitiser and soap and surgical masks.
You know the last time I walked into an OR and I forgot to bring my own surgical mask, I had to run around the entire hospital asking in each department if they could spare a mask for a poor child like me.
One nurse in the medicine department finally took pity on me seeing how I was close to tears.
I am free.
Master gave Dobby a sock.

2. Where do you go for your summer vacation? The theme park? Or probably the beach?
I go to the hospital.
When it is dangerously hot outside, it’s even hotter in the hospital. Because we have maybe about 10 ceiling fans and 2 out of them work on a good day.
So you are sweating half of your body weight and finally faint and fall into a puddle of your own sweat out of sheer dehydration. Only to be rudely woken up by the colossally inexperienced interns poking you with IVs, who can’t find a vein if it slapped them in the face.

3. There are a few words you need to know to get out of any situation in each department.
Surgery – ‘Pain and suffering’
For example,
Professor : What are the symptoms of acute appendicitis?
Me : Pain.. and suffering.
Professor : Ok. What are the symptoms of hernia?
Me : Pain. Maybe suffering too. Definitely pain though.
Professor : (Impressed) Good job. You can assist on the next surgery.
Me : OMG THANK YOU!! Which one?
Professor : Lateral anal sphincterotomy
*cue PAIN AND SUFFERING*
Likewise, the important word for internal medicine is ‘hypoxia’, or basically any word with a ‘hypo-’ prefix. It will give your attending little shivers of excitement.
For Ob-Gyn it is obviously ‘emergency C-section’, or if they’re feeling particularly risqué, ‘Bladder injuries’, ‘I-thought-the-ureter-was-the-fallopian-ha-ha’
For paediatrics you just wail along with the other children.

4. Why study about symptoms when you can demonstrate them on yourself?
Do you want to know what hypoxia is you silly child? Run from the OR to the blood bank because your attending surgeon wants to *make sure* you have enough blood, and then back to the OR from the blood bank because the blood bank lady won’t give one unit of blood to the patient. Try explaining to her that it’s redundant to call it a blood bank when they REFUSE to sanction blood to patients. She barks at you without ever breaking eye-contact.
What you feel right now is dyspnoea, hypoxia and pain and suffering.

What is the puddle’s sign? You don’t need a textbook for that! You’re already constantly in the knee-elbow position to prevent the blood-thirsty residents from seeing you sobbing because you got told off for showing slight displeasure at doing all those per-rectal examinations actually to be done by them.

5. When you see case files for the patient’s case history, don’t stroke out if you only see three words in the chief complaint, present and past history, combined.
Our precious residents and interns have other major things to do, like drink chai 792 times a day, always borrowing your stethoscope, and asking you to “man up” when you have an MI because you almost stepped on the maze made out of discarded needles.
So if you see something like “pain in chest”, assume immediately you will have to say drug names like ‘metoprolol’ without stammering even once, or you will be thrown to the wolves, i.e, casualty department.

 

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.