“Ag man look at this, it’s disgusting! How’s a person supposed to read this?” Andries said, pointing to a note someone had made on the patient’s ICU chart, “And you guys are always giving me a hard time about my handwriting!” “No Andries,” I replied “When you’ve made notes we have to pass the file around in order to get some sort of a consensus on what it is you wrote.” “Nonsense man, when did this happen??” He asked looking shocked. “Every single time you make notes for a patient” I said, and at this point I could no longer keep a straight face and I may have broken into a giggle. “Ag piss off man!” He said when he realized I was having him on.
Andries is quite a character, somewhat of a legend actually in PE circles. When he was with in ICU with us I found working with this guy like trying to run alongside a fast moving train. He seems to have an endless supply of energy, doing everything at a 110%. If one didn’t know him one might describe him as brash. “Listen here, I don’t care I’m a surgeon I just want to cut!” He once said when I asked him about a patient’s electrolytes. That is obviously not the case, he does care very much about his patients. I used to hear stories about this guy before I came to Livingstone hospital. During my community service year at Dora hospital an intern once told me a story about how once when he was on call in surgical admissions he telephoned Andries for some advice. “Where are your seniors?” Andries asked. The two registrars both happened to be in theatre, operating. “Agg no man!!” Andries replied, uttering a few choice expletives. He proceeded to go to the hospital and on a day when he was not on call and should have been at home, he saw every single patient in surgical admissions with the intern and wrote out a plan for them, much to the junior doctor’s surprise and relief!
Then there’s Jonathan or Jon as we know him. Originally from Kwazulu Natal, schooled in Cape Town and now here in Port Elizabeth for the last 4 years or so, he is the archetypical coastal boy I suppose. His main interest like me, is internal medicine. He is quite literally one of the most intelligent people I have ever met. Insight, and lateral thinking are what come to mind when I try to describe him. He says things on the ward round that give the impression that he is thinking further than what has been presented about the patient. All of this is tempered by the fact that when dealing with Jon one on one I have found that it is always good to have one’s guard up, if only ever so slightly. This is because there is always a small possibility that Jon might be taking the piss.
He once walked into the doctor’s tea room and told Sashelin that there were three patients on their way down to ICU right at that moment, two of them medical and one surgical. They had been discussed telephonically earlier and needed to be admitted. Sashelin is another one of the doctors in ICU, he was on call that day. Jon delivered this message in the afternoon, just as the rest of us were getting ready to call it a day, leaving Sash on his own for the night call. Three ICU admissions all one right after the other is quite a bit of work for one doctor to have to get through on their own. One generally hopes to have that many over the whole night maybe, along with having to look after all the other patients already there.
“What the…?! Tell me a bit more about the cases?” Sash said, a little bit worried. Grinning Jon said “Had you a little worried there eh!”
Also, Jon has two accents: most of the time he sounds like himself, the coastal laid-back ZA boy, but every now and then when he is excited or wants to emphasize something he breaks out into what he thinks is a black African accent. Asides from being incredibly inappropriate it is a little funny at times, in doses. He’s a good guy though, we get along. In between work we’ve had a few good convo’s about the meaning and purpose of life, rugby and other such deep topics.
Sashelin is another character all together. Everything about this guy just screams linear and organized. Including the way he presents patients on the ward round and his approach to answering questions from consultants. He is also a budding surgeon. When he and Andries aren’t arguing about some or other surgical topic they can be found giggling (yes giggling) about something that is only clear to the two of them. Their respective personalities offset each other. Andries will typically storm into a room and exclaim “I just saw this patient,” and he’ll scrunch up his face “Absolute chaos, complete disaster!” While Sash is more calculating.
As one would expect from a perfectionist Sach thinks that anything that any other doctor does is below par. “They did what?…Slacking!” He’ll say while shaking his head disapprovingly. “You’re a slacker!” He’ll say to Andries, “Ja, jou bastard!” Andries will return.
I have mentioned before that I find it hard to (that is to say I don’t) write when I’m not inspired. This translates to not wanting to write when I’m unhappy. So I am much more likely to share the good bits about my Eastern Cape experience than I am to divulge on the times that are not so good.
I have been going through somewhat of a lull at work. I spent about four months working in ICU full time, and the last two months in the renal unit, while still doing my calls in the ICU. It has been quite an experience. My brain is constantly racing, or flailing I should say. Much more appropriate.
It is quite something to be in a ward round or sit in in a discussion where after every few beats I’m thinking “Wait, what was that? Wow is that what we think it is, ok… but what does that actually mean, and how on earth did we get to a point where we’re considering a diagnosis of..? Man I’ve gotta read that up (picture scrunched up face emoji). So as I mentioned before I made lists, of topics. EVERY. DAY. It was crazy. I tried to keep that up. The list is as long as my arm right now (and I have long arms!) I can’t honestly quite say how far I am with that…
It’s one thing to look up something but quite another to know it. I very much doubt that I’m the first medic to wish that I could read something once and know it (If only!) You have to see a case, discuss it, go read up about it, see that same case again then see another similar case again later, be reminded of what you read, have the discipline to go back and read it again. This may be over a period of a couple of weeks, months, maybe even years and then, only then can it maybe be said that you know a few things about said condition, maybe… And even then there’s knowing something and there’s knowing it, with all the nuances that it can’t go without. I say it’s advanced HIV and the response is “Stage it, three or four? then I know exactly what we’re talking about…” I say it’s nephrotic syndrome. “No, it’s renal dysfunction with nephrotic range proteinuria, not quite the same thing…”
Herein lies my little conundrum. I have been comparing myself and my level of knowledge (or lack thereof) with the guys that I’ve mentioned above and others like them. We’re all roughly about the same age but they all have at least a couple of years on me in the profession. Sash and Andries have both recently written and passed their surgical intermediate exams and are well on their way to becoming surgeons. Jon has worked in the renal unit where I am currently and in ICU previously and he has just started a masters research degree in anticipation for starting as a registrar some time soon. I finished my year of community service just a few months ago. The difference in experience, and my lack of it, goes a long way towards explaining my sense of inadequacy.
“The first 2 months you’ll feel like you have no idea what is happening, then the next two months you’ll think you know what’s happening but the truth is you’ll have no idea what you’re doing and the next two months you’ll carry on, you’ll feel much more comfortable and you will know exactly what it is that you don’t know…” This was my buddy Gareth breaking down the phases one goes through when starting in a new place of work. “It’ll take you like three days to get into it…” one of the consultants said before I started. “You’ll be fine in about three months…” another doctor had assured me. I had admitted to feeling a little nervous before starting in ICU. Take all of those estimates, average them out and add in the ‘slow learner’ factor and the fact that my learning curve in ICU was truncated after four months and you might get an idea of my slight sense of disorientation and not-knowing. “You don’t have to know everything bru, you just need to have an approach.” Jon said once…
I read somewhere that to live a creative life we must lose our fear of being wrong. In the art form that is medicine however we prefer to be as exact as possible. Given what is at stake most medics would prefer to get as little wrong as possible. This comes with time. With time there is more learning. With time there is experience. I can say with absolute certainty that I am a better doctor today than I was about six months ago when I first arrived at Livingstone hospital but even so I am far, very far from the finished product. The further one goes in the profession the less we can be forgiven for not knowing. The buck stops at the specialist really. Ideally once they have spoken there should no longer be any need for continued discussion about the diagnosis right? Yes, and no. The time factor still plays a role I think: The difference in experience and exposure between the specialist physician who qualified a short while ago one who qualified a few years ago (and continued to learn-it must be added) means that there really will always be some room for a question or two.
This is acute kidney injury secondary to new onset sepsis. It will resolve with the systemic infection. A week or so of antibiotics. Me thinking last week while we were going around seeing the renal in-patients with the consultant. I smiled and claimed a personal victory (however small it may have been) when the consultant looked up from perusing through the file and voiced out loud almost exactly what I’d been thinking. There is something very satisfying about nailing a diagnosis. “The patient was on Tenofovir though,” (a nephrotoxic antiretroviral) I hadn’t picked that up. But the creatinine levels had been normal before the infection…
We each of us run our own race. Some will fly out of the blocks and we may not even see them along the route because they’re so far ahead. They may have been blessed by nature with the right combination of traits that make them really fast, or they may have had a look at a route map before setting off making them better prepared. Others may find the course a little more challenging, what with the hills and other obstacles (those that are part of the route and others that we make for ourselves😋) Some of these strugglers will learn along the route, gaining momentum as they go, gathering pace. A marathon I have found-is all the more enjoyable once one ‘finds a rythm’ so to speak.
We each of us run our own race. At the road races I am one of that crowd that starts out fast. I lose pace the further I go, and I have to fight to finish with a nice time. In life however (at work-in medicine more specifically) I have found the converse to be true, a typically slow start with a slow but sure upward trajectory.
It is probably not entirely correct to liken running to a career as a medical doctor but hey each to their own-frame of reference. I love my job, and I love my running so here goes: It took me over four years of road running to figure out what I had to do to get my body to a level where I could do a sub-4 hour marathon and along with that a sub-5 hour 50km race. Once I had done that it changed the whole game for me, I broke 3hrs 40mins just the other day, but more on that later… I have come to understand that it is going to take me longer than four years to get to a point where it is being said that the buck stops by Pascal, he’s the go-to physician in these parts, no need for a second opinion.