Valis

It's strange that when I hear an odd tapping noise I will turn to look at it, but when I see a strange flashing light I do not turn my head to check if it is making a sound.  But that's not what I'm going to talk about.

This is.  I'm currently reading Valis by Philip K. Dick.  I'm only up to page 50 but it's already a weird experience.  Any PKD book is a weird experience at some level, but this one more than any other so far.  What's weird about it is that he keeps diverting the narrative off onto seemingly random/arbitrary topics - but those topics are often things that have some kind of personal resonance to me.

I've started marking the pages where this happens so I can go back and check, since it occurred to me that maybe it's an artifact of me being really tired when I'm reading it.  Here's a partial list of statistically unlikely topics to arise so far:

• The concept of degrees of psychosis or delusion, where you get delusions about delusions.  You may remember that I queried my psychiatry teacher about this some time back and just got a funny look in return.
• Inguinal hernias, which I have previously ranted about.
• T-34 tanks, as used by Russia in the second World War.  I don't recall mentioning them in this blog but I certainly have played an awful lot of WWII war-games.
• The issue of Kevin's dead cat and the central question of its nonexistence before its own birth and how that is qualitatively different from its nonexistence after its own death, which is something that I have pondered at length in my offline life.
• Deus Absonditus, or the hidden God.  I have a book at home which uses game theory to analyse and explain why God doesn't just tell us all to our faces that he's right here, and related topics.
• Paroxysmal atrial tachycardia, which I seem to have discussed repeatedly with my Smaller Half recently because of a minor technical disagreement between us as to whether it really is a subset of the supraventricular tachycardias.  Yeah, we're dazzingly charismatic.

As mentioned, I'm only up to page 50.  What delights lie in store for me in the next 221?

It's a strange sensation - as if I'm reading a book that was written by someone who knows all about me and deliberately wrote a book that I would find appealing.  That kind of thinking, that the radio is broadcasting specially to you, or that there are hidden messages intended for your consumption in everyday occurrences, is known as a delusion of reference, and is a marker of psychosis.  Valis is all about the main character's drift into madness, unfortunately either initiated or accelerated by thinking too much about madness.  So I'm thinking that pretty soon now they're going to come for me.

Hopefully they won't take my book away.

Grayslant

The first album I ever bought was Paul Simon's Graceland, on cassette.  I liked the single Call Me Al and my Wise Elder Brother suggested that I should spend my money on buying it instead of some more Technical Lego, Dungeons and Dragons modules, or other such nerdy stuff.  Sure, Paul Simon is pretty nerdy for a musician, but you've got to start somewhere.  I gave him $12 and he bought it for me at K-Mart the next time he was in town.

I had a number of misconceptions about the album though.  Such as its name.  It wasn't until I actually had it in my hand that I realized it was called Graceland, not Grayslant.  Also, it wasn't until then that I realized that the little guy in the video clip for Call Me Al was Paul Simon.  I had assumed that Chevy Chase was Paul Simon, and to this day I think he may actually be him.

It was years before I realized that the National guitar that is mentioned in the first line of the first song is actually a brand of guitar.  I thought that the National Guitar was some of guitar monument, akin to the Big Pineapple.  I think I found this out while watching a documentary about Dire Straits and they mentioned the National guitar on the cover of Brothers In Arms.  It was a revelation to me.

It was also a long time before I found out that Graceland was an actual real Elvis-related place.  I thought he was just being metaphorical, as in a Graceful Land.  I think I realized this when I heard Mark Cohn's Walking In Memphis.  Spent a while wondering why everyone was so obsessed with Memphis.  That was around the same time I found out that Priscilla Presley also had an Elvis connection.  Huh - who knew?

The funny thing was that at the time I was great friends with a kid who grew up in Zimbabwe.  I played the tape one day while we played some Dungeons and Dragons, and he remarked that the music was heaps like the songs he'd heard in Africa.  I basically thought he was full of it.  Of course, turns out he wasn't.  How about that...

Anyway, that's all from this particular Human Trampoline.  Hope you're enjoying your holidays if you're on 'em and your work if you ain't.

Wisdom

I think it's true what the ancients said, that you can travel the whole Earth over but it's only when you finally return home to your electric toothbrush that your teeth feel really clean.

Party people

When you get to the party, the very first people you see are the people near the door who are the very people that you are anxious to avoid talking to, so you walk right by.  Immediately afterward you are accosted by the people are keen to talk to you even though you have never had anything much to say back to them.  Shaking them off, you then become enmeshed in a conversation with the people who you'd like to talk to but who you can't hear because the music is too loud so you are reduced to nodding, smiling and laughing at what seem to be appropriate moments.

In order to get out of that mess, you strike out across the room but are waylaid by the people who are very drunk and sling their arms around your shoulders and mouth breathe through their winey teeth at you and tell you how very drunk they are.  Simultaneously you are trapped by the people who stand too close to you and never break eye contact.

Fortunately you are able to direct your attention towards the people who you'd like to talk to some more but can't find again after returning from the bar.  Instead you briefly talk to the people who you'd like to talk to some more but don't seem very interested in returning the favour.  That awkward situation is interrupted by the commotion caused by the people who only turn up to parties to undress, but in the confusion you are carried away and thrust against the people who are spouses or partners of boring and unpleasant people and who turn out to be even more boring and unpleasant than them.

You manage a brief interlude with the people who you feel like you could be good friends with, if only your relationship could progress beyond the point of making the same stupid in-jokes to each other every time you meet.  Standing with them are the people who tell the same limited repertoire of stories to you over and over again.  Finally you are able to take a breather with the people that you get along with so well that you don't actually have to talk at all. 

Later, you find yourself stuck with the people that you would like to talk to some other time but but at the moment are too preoccupied with getting stupefyingly drunk.  So instead you talk to the people that you feel obligated to talk to because of some tangential social connection rather than genuine interest, so you're counting every minute until you can find a decent pretext for escape.  This is provided for you by the people who sidle backwards into you and force you up against a piece of uncomfortable furniture.  So you make your excuses and talk to the people who you don't want to talk to at all but do because otherwise there would be nobody to talk to and you don't want to stand there alone.

And finally you have a quick chat with the people that you always assumed were idiots so you've never bothered to talk to them before but have only now discovered how interesting they are and that they're leaving town forever tomorrow.

What a night.

Go slow

Ayyy!  Since I finished on Wednesday I've been simultaneously rushed off my feet and going as slow as I can.  Life is good with no deadlines but I've been flat out getting away from it all.  So sorry for the lack of posting interesting things.  That may continue for the next little while.

Blogging as a stress relief valve from the pressure of studying works really well for me.  But once the pressure comes off, there's no steam to jingle that little bell any more and I find myself with not much to say.

But I will say this: I'm re-reading a book I last read at least ten years ago and it's really interesting how I have changed since then.  Some of the things in it which I thought were profound and insightful back then now seem plain obvious or even wrong, while other things that I skimmed over and ignored then now seem fascinating.  It will be interesting to see what I think of all this stuff I type out here on my blog in ten years time when I am totally different person.  No doubt I will be ashamed of some it and find other parts fantastic.  I hope I have the courage to leave all of it as it is rather than try to go back and excise out the parts that I find uncomfortable or embarrassing.

Move along!

Bravo X-ray November

It's hard to read x-rays.  The darn things just shoot straight through your eyeballs!  Ha ha - stick with me, it gets better.  Since we might have to interpret some x-ray films in the next couple of days, here are some tips from me on how to Get It Right!

The very first thing to do is to figure out which side of the film is the left and which is the right.  My preferred technique is to guess while watching the consultant's eyebrows.  If the eyebrows twitch, quickly correct yourself and laugh at your slip of the tongue.  A quick excuse such as, "Ah but of course, we're in the southern hemisphere here!" will cover up your ignorance.  Other excuses that I find useful are, "Wait, you have no goatee - that means I'm back on Earth 1", "It's all been so different since Obama", and "I have a neurological condition that means I'm unaware of whether I'm saying left or left.  So if I mean left, I'll say left, but if I mean left, I'll say left instead.  How about I just point?"

Next, you should determine if the film is AP or PA.  AP stands for armour piercing.  This is a film that has been shot with pointier x-rays than normal so they can punch straight through armour.  AP is useful if your patient is wearing a flak jacket or is riding inside a Sherman tank.  The heart always appears enlarged on an AP film because the armour piercing x-rays are making it explode.  PA stands for personal assistant.  A film that is shot PA is one that was done with some extra help there, so it will probably have been done better than other x-rays.  The heart is the right size on a PA x-ray.

After that, comment on the exposure.  X-rays can see right through people's clothes, so you can almost always say that the exposure looks great!

The voice that you use is important.  Most radiologists speak slowly and ominously in sonorant voices so you should mimic them.  The more you sound like Gandalf, the better.  Try this phrase with chest x-rays: "I see a shadow in the East."  If you're looking at an abdo x-ray, you could try this one: "You shall not pass!"

A great tip is that any horizontal line on the film indicates a fluid level.  This can be helpful if you are hanging pictures, putting up shelves or building a fence and need to make sure it is straight.  Just ask the patient to hold the relevant item in place, take a quick snap with your x-ray machine, and adjust as needed.  Note: this doesn't work if you are putting up shelves made of radiolucent material such as glass, cholesterol, or air.

Another important thing to know is that it's calcium that makes bones show up so well on x-rays.  So if there's something unusually bright in a funny place on the film, it's probable that the patient ate something will lots of calcium in it.  For example: hyena faeces, milk, cheese, calcium tablets, limestone, cement, teeth, and/or eggshells.  You should be able to tell by the shape.  Limestone, for instance, will resemble the profile of a 19th century aristocrat, whereas cheese will be in large triangular wedges with holes in it.


Finally, it's very important to have a system.  For example, after a run of four or more tuberculosis cases, the odds of getting five in a row are miniscule, so at that point I would always switch and bet big on sarcoidosis.  It's easier to do this if you're back-betting someone else since your funds won't run out while you're waiting for the good run.  On the other hand, it will be very easy for the house radiologist to notice what you're doing, and most hospitals will throw you out quick smart.  Still, you might have been able to get some free drinks while you wait.

I hope these tips on interpreting x-rays will be helpful to you.  Until next time, try to cut down on the hyena faeces.

OSCE tips

Before exams I sometimes post up some tips on how to pass (eg: here).  Seeing as we have OSCEs on this week, I thought I'd better change tack and offer some advice oriented to them.

Don't be afraid to ask for advice from the examiner!
Sure, we're told that they won't help us, but if you get really stuck, just turn to the person assessing you and say, "Sorry, I really don't know what I'm doing here".  If they start to tell you that they aren't allowed to help, just say, "No no, I meant I don't know what I'm doing here in medicine.  I always thought that being a doctor meant being able to help people, but lately I've found that it all seems too abstract.  Do you think I should volunteer overseas for a while just to get my head straight?" and then burst into tears.  Take great gasping breaths and say something like, "Think of the children!".  They'll be so impressed with your deep compassion for all living beings that you'll get an immediate pass.

If you don't know what to ask in a history-taking station, treat the patient as a drug-seeker!
It's bound to happen at some point - you just run out of ideas, or your mind goes blank and you can't think of what else to ask.  You can save the day by glaring at the patient suspiciously and asking them how long it's been since their last fix, how many other doctors they've visited today, and did they really think you were going to believe this cockamamie story?  The examiner will know that you've been doing it tough in the bad parts of town and you know how things are in the real world, and no amount of fancy-pants book-learning can make up for that!  Immediate pass.

In any station where you are asked to do something even remotely clinical, refuse to do it until you've reviewed the local protocol!
Injection technique?  "I'd like to see the protocol that you have in place."
IV cannulation?  "Where's the protocol?"
Rectal examination?  "Protocol please."
Chronic care self-management plan?  "I'm afraid it would be unsafe for me to continue until I've reviewed the protocol."
Rest station? "Protocol."
Immediate pass.

If you're required to use a fundoscope to read the tiny leetle words out of the ping pong balls, bluff.
Try this: "klaatu barada nikto".  They may or may not be the words in the ball, but when you've just stopped a giant alien robot from destroying the Earth, who's going to quibble?  Immediate pass.

When you get to a rest station, make good use of it!
Hyperventilate.  This will ensure you are fully oxygenated for the next station.
Review.  Think about all this things you should have done two stations back.  Go back and fling open the door and let the examiner know the extra things that you missed out.  It all counts!
Relax.  Do some knee bends, sing a song, have a quick micro-nap.  A hip flask may be handy, as well as one of those neck pillows for sleeping on planes and buses.

Carry a small Yoda figurine at all times.
Immediate pass.