dimanche 2 septembre 2012

The one who was preoccupied about her toothpain at 4 a.m..

Accidents and Emergencies - Short-term care - Any hospital
Any training year

"- Good evening !
Er, Good morning !
Er, Good night !

Anyway, excuse me for that, what can i do for you ?"
"- Good Night. I am here because I have this horrible toothpain. Here."
"- Here ?"
"- Here."
"- Since... ?"
"- Since yesterday night. The problem was that it was saturday, so no dentist could have me in. So, i took painkillers.
And... Well, it doesn't work, i am in pain. So, here i am."
"- Mm."
"- Mm ?"
"- Mm.
Well, we are going to give you some painkillers.
And then, since it is sunday, monday actually, and it is four in the morning, well, i guess you won't immediately find some dentist to take care of you. Even here, in the university hospital.
Because, you see, i am not a training dentist.
The guy there, i mean my boss, i mean my senior, well, he isn't a dentist either.
In fact, the problem is that hospitals and emergency departements are unfortunately full of physicians but not of dentists."
"- And so, about my tooth ?"
"- And so, about your tooth, here is your prescribtion.
I wish you good luck for the rest of the treatment. With the dentist.
Normally, there are a lot of them available on mondays. Dentists, i mean.
Did i use too much the "dentist" word ? What time is it, already ?"
"- Four a.m. . Goodbye, Doc."
"- Actually, i am only a medstudent, as far as i am concerned. Only a medstudent. Under the resident stage, so not really important. But it is me who's pernickety.
M'am ? Hello ?"

Because i believe that everyone has already met The Ethereal Toothpain of the middle of night.

Like a scottish ghost never at peace, it goes from any University Hospital to any University Hospital, from any big hospital to any tiny hospital, from any "developed" country to any other "not-so-lucky" nation.
It cracks preferentially after the twilight, most oftenly in the last hours before dawn. Those exact long hours during when all the senses are shaken and the tiredeness is everywhere under the strained white coat.

Nobody have found a remedy to cure that Pain yet.

Legend has it that it will last until a dentist will be on call as well as a brave orthopaedic surgeon for the whole night.
Waiting for that we, unfortunate members of the medic-corp, are doomed to meet them wandering about in the Emergency departements in the middle of the night. Only equiped with our poor WHO grades of painkillers to fight back.

Oh, High Priests of the Health Board, do hear our humble prayer.

dimanche 22 juillet 2012

The one whose twisted ankle wheezed.

Emegency Room - Traumatic Care
6th year.

She is sitting in her wheelchair a sheepish smile on her face, sniffing now and then.
Her ankle is badly swollen but walking isn't that difficult.
There is no true diagnostic hesitation : the severeness of the strain will be, at most, medium.
I reluctantly fill the radio voucher.
One of my senior physicians informed me earlier that, on his shift, "Every single ankle strain coming into the ER will come out with an Xray. Even if the official recommandations are telling that it isn't necessary".
Why ? SIC ( Suing-In-Coming).

Strenghtened by my medstudent innocence, my will to do well and the total emptiness of the waiting list, i auscultate her.
They jump at my eardrums.
"- A little bit asthmatic, maybe ?"
She makes a shy smile and sniffes.
"- Yeah, not perfectly alright lately."
No kidding.

Twenty minutes later, when my senior comes in, he looks quickly at the ankle, doesn't even glare at the radio, approves my prescription and go straight to... The chest Xrays. He turns himself to look at me, his eyebrows raising.
"- She didn't sound really clear, i couldn't act as if i didn't heard."

He politely asks the girl one or two things, gives her her prescription and doesn't give her a thing for her lungs. "And if it doesn't get better, go and see your GP."

I know that the Emergency departement is there to take care about the casualties.
I know that in the trauma department the consultation motive leads straight to the prescription.
I know that the ER isn't there to take care of the common cold or the chest infections that are perfectly well (even if they occur on asthmatic people).
I know that the recording of the history and the clinical exam have to be quick because there is a lot of "urgent" people waiting for a further care and not a standard primary care of general medicine.

Nevertheless, this time I found a unstable asthma and a little chest infection going along with an ankle trauma.
What if, because of "care-optimisation" and SIC-abuse, I harvested unhelpful Xrays but missed much more critical things ?
What if i forgot the little questions leading to the current troubles ? The massive osteoporosis leading to a fracture, the badly located metastasis leading to the common backpain, the extensive melanoma  concomitant to the high bloop pressure ?

I know that we are not omniscient and that things will (hopefully) be done one step at a time.

But it is hard to give up. Yet.
I want to believe a little bit more in the "extensive scan" provided by a standard consultation. I can't yet accept the agreement consisting of leaving a lot of untrated/undiagnosed pathologies around just because the patients didn't mention anything. Or because their physisian didn't ask.

Utopia, here i am.

mercredi 27 juin 2012

The One who swallowed clocks.

Visceral Surgery, 4th year.

"- So ?"
"- Easy one : clock !"

"- Right !"
"- What was his excuse ?"
"- Oh, this one doesn't really theorize things. It's not the first time, actually. He is coming from Saint
Gargoyle* (* Psychiatric Hospital of the area).
"- Oh, I see."
"- Yes. We're waiting for the clock to pass through the pylorus and then the cecal defile and he'll
be free to go on swallowing whatever he likes."

That awkward moment when you understand that it is the item more than the human being or the
reason he swallow strange things which matters to you.

That terrible moment when the simple sentence "He is coming from Saint Gargoyle" suits to undoubtedly justify nearly everything.

mardi 19 juin 2012

The one who drank caustic soda in order to forget.

Visceral Surgery rotation, 4th year.
Digestive surgery patient hosted in the high located E.N.T. service.

I quietly stare at her, waiting for any kind of answer.
It won't come.
Her blurred look insists on ignoring me, heading towards the window. We can't see anything else than the summer sky through this one. From her eighty-five years and her erratic medical follow-up, i am not convinced that she actually sees that sky.

I hold on to her file.
According to the nurses, the first thing she said to the psychiatrist was "I failed, but i'll do it again.".

I inform her that i am going to check up her scar.
She starts holding her lips and blouse tightly. With that strenght that can only be shown by the elderly while defending themselves against the White Coat Confraternity.
I instantly start reciting an endless flow of words in order to establish some kind of non-agression pact. Doing that, i brought back her record in my mind.

Eighty-five years old, social isolation, domestic violence lasting for more than half a century, eighth suicidal attempt recovered at the hospital.
Phlebotomy and defenestration didn't work out, neither the absorption of caustics. Unlike some others doing it again and again, it is not due to a lack of will.
This time, she drank two bowls of Destop(R).
As our Psychiatry professors say "When an elderly does a suicidal attempt, he or she usually succeeds."
She, indeed, stood close to self-dissolution.

She reluctantly accepts to show me her abdomen, rightfully hoping that it would make me leave quicker.
The scar is smaller than what I had expected. There is a  nearly clean draining pocket and a gastric tube for enteral nutrition. I follow the tube with my finger.
Indeed, compared to the other clinical cases I studied before entering her room, she "was lucky". I mean that the soda didn't have the time to nibble her stomach as it did for her now removed oesophagus.
The firemen, called by the family, came up pretty fast, which is of prime importance in the cases of chemical burning by strong bases.
She won't be able to swallow her saliva anymore. A little pocket on her neck is here to collect the limpid liquid.

I can't help thinking that she might be planning another suicidal scenario right now.

I step aside and let her button herself, ending the contact which was obviously painful for her.
I reach the door of the room and try a last glance. She is still huddled on her armchair, staring at the window.
"- The one who is always there to call the firemen, don't you think that he could prevent her from being beaten ?" would eventually spat my senior surgeon.

The occasional impotence of our caring system and the morbid grotesque of her situation still freeze me to the bones.

dimanche 10 juin 2012

The one who celebrated his cupper wedding with the kidney of someone else.

Daycare Hospital, Nephrology, Sixth year.
I grab the following file of the "Annual checks" pile and open it.

I like to picture the transplant physicians as a form of National Matrimonial Agency.
"Nothing will ever prevent us from finding you the perfect HLA-match, so let's sign up now !'

We have to acknowledge it, organ transplantation is a complex process requiring a huge amount of concessions.

The recipient, in need by definition, is accepting the graft by doing some sacrifices.
He has to rethink the notion of "self" and the idea of autonomy. Which, i bet, does not come that easily. He also have to make a clean sweep of his past, muting his immune system oftenly using heavy treatments.
And yet, even if they are sometimes grumpy, the recipients rarely refuse the idea of this planned matrimony. Their destinies rely on it. They eventually are the ones soliciting the services of the Transplanting Agency.
So, our recipient is in waiting (sometimes for quite a long time). And suddendly, one day, the Agency calls because it has a match and has set up a meeting.

On the other side, the story of the sweet graft is quite different.
Rarely spontaneously offered, it is oftenly torn from its homeland while things are seriously going crazy. It is seperated from its birth-organism, arteries cut, and bend to another body. Maried by force to a great machinery more or less functional requiring its urgent and constant services.
So, expectations towards the newcomer are somewhat huge. 

Since Romeo and Juliet have finally met, the transplant physicians pamper them.
They do all they can in order to put on soft mood music (peaceful immune environment), make sure that everyone feels comfortable (clinically and paraclinically) and then hide in a corner (behind some computer) and do what every matrimonial agent would do : wait.

Sometimes, none of the main characters can suffer the other one. The first one is attacking the second evoking some old love story (aka transplantation) that had gone mad. The weapons are an immune battery able to recognise every graft that more or less looks like the previous one. And on the other side, the second is panicking because it has suddenly understood that he wasn't home and is so terrified that it tries to burn everything down.

Sometimes, it goes softly. The protagonists can understand each other. They cohabitate by doing some concessions and go every year to the Agency for their "Annual Check up". Then, they do the  together. This kind of relationship usually lasts for a decade. Ten or fifteen years of good services, then the two of them get tired and the story ends.

And sometimes, rarely but sufficiently anough for a chatty student to meet them, it is love at first sight. The recipient end up living with the graft longer than his own previous organs and the graft feels so comfortable that we can't tell it apart from the host.

The smiling man and the zen kidney i met this day were of these misfortune lovers. When i opened up the file that day, i saw the pre-filled column saying : "Annual Check up of the thirty-two years".

I looked up to the transplant physician still hiding behind his desktop, his finger on the mood music prescription, and raised a thumb. Well done.

samedi 26 mai 2012

The one whose HIV-positive status was fortuitously discovered.

A consultation room, i don't remember which one. Sixth year.

The next patient is about to enter.
I bend to read her file so that I will know her better before she takes place in front of the desk. The physician who is my tutor let me do it, clicking on his computer.

Then, I read it. On top, among the antecedents.
This infectious diseases specialist's sentence : "We do recall that this is a patient of X years whose HIV-positive status was discovered fortuitously".
I frown and turn tawards the physician when she enters.

Thirty-something, comely, a round and smiling face. She sits to discuss about the topic of the consultation, which as nothing to do with her random serologies.
I try to picture her later, when things might not be as steady as they seemed to be.
The consultation is over, she leaves.
I have absolutely no idea of what they talked about.
I was obsessed over and over again with those two words "fortuitously discovered".
How is that even possible ? How can someone turn a sentence like that ?

I sometimes meet one of my friend in the street fortuitously. Sometimes, i decide fortuitously what i am going to have for dinner.
Casually. By chance.

And however much I think about this sentence over and over again, if one day my physician happens to announce me that he has fortuitously find out something about me like HIV, hepatitis C, syphilis or, I don't know, pregnancy, well, I am not exactly sure about what might fortuitously cross his desk right in his face.

I know that I absolutely don't know this woman, who she is, what she thinks or what she feels about her sickness. And I am usually one of those who likes to ease things off.
But this very sentence shocked me. And I think that, no matter what I do, i will always find it highly disturbing.So, until I figure it out, be careful about what could, fortuitously of course, happen to you after you've read that note.

dimanche 20 mai 2012

The one whose life was saved by a mushroom.

Summer in the Visceral Surgery Service. Operating room.

I attend a diverticulitis surgery. It is a complicated inflammation of a part of the intestine which is called the colon.

A patient is there, lying down somewhere under the surgical drape.
I've never met him because he came in by the ER. I will never see his face because he won't be in my area of the service.
As usual, i am holding the operating tools to remove the tissues and the little device to draw of the body fluids. I am quite good at it actually, drawing of. It is tidy, it is meticulous and it doesn't need you to overthink at all. The main difficulty being the task of keeping the operating field clear for the surgeon and the resident, i think i can handle that without any overwhelming difficulties.

This patient is kind of a riddle.
The CT scan tells us that he is suffering from a perforation of the digestive tract leading to a start of peritonitis, an inflammation spreading in the abdomen, but the clinical aspect of this man is actually quite good.
Several minutes and a incision running from the sternum to the ombilic later, here we are, in front of the trouble-making gut.
"- Er, it's..."
"- Do you believe... It seems... I think..."
"- Nurse, take my iphone !"

The beaming surgeon smiles at me over his procedure mask. He cuts the gut and put it on the operating field so that we can examine it.
There, forming what is litteraly called in french a "perforated-then-patched-diverticulitis", is a... Mushroom.
A real one, a button mushroom, full piece, with its stem and its little cap. Cutted in half in the lenght side, it blocks the hole, preventing the intestinal content from pouring itself where it shouldn't.

I don't look at the mushrooms the same way anymore.
First, because i know the fungus' secret : the fact that we can't process them at all.
And secondly because they remind me the fact that, sometimes, you just need to be the right one in the right place to make the difference, no matter what brought you there.