Out

As you may have noticed on your daily peregrinations to the shrine of this blog, I ain't been updating it much recently.  Reason being, we've moved.  Again.  You know how much I hate moving and also how often I've had to do it, so I won't bore you with the psychological background this time.  But the circumstances of this move are interesting (I think).

Way back in the dawn of time, in October 2010, we shifted into House Minus One (present house being House Zero).  At the time I had just had a nasty fall-out with my clinical supervisor, my exams were a few weeks away, and my beloved Smaller Half was about to give birth the Hatchling, and we had to find a house to live in.  Time was short, so when I found an airy, spacious house in the hills I signed on the dotted line and didn't worry too much about the little niggly voice in the back of my head telling me to be careful, especially since the landlord seemed so houseproud and promised that the collection of little maintenance issues would be taken care of pronto.

Fast forward 6 months and nothing had changed.  The landlord had gone awol somewhere in Bulgaria to star in adult films and as a result the curtains were still moldy, the paint was still peeling off the ceiling in the Hatchling's room, the fan in the bathroom still didn't work, and so on in that vein.  We kept hassling the real estate agent but she was helpless to act without the landlord's say-so.  When the hot water system leaked into the ceiling we could get that fixed.  And when the drains blocked up time and time again we could get that fixed.  But that was about it.

Then the landlord came back and started hassling the real estate agent about the fact that we needed a plumber every week.  Somehow this was our fault.  He'd done so much for us already, apparently.  Then the smell started.

The smell was more of a stench.  It started one day immediately after the plumber had come round to ream out the drains again.  Strangely, it was localized to one room only and got worse when we opened the windows.  We kept complaining about it and the agents kept saying that there must be a dead possum in the roof despite me telling them back that it didn't smell like a dead possum unless perhaps the possum had died of dysentery.

Eventually we cracked.  There was mold growing on the walls of our bedroom and on the curtains and windows all around the house.  The Hatchling's room stunk.  The drains kept blocking. And and and and and and.  So we bailed - we got a new house next suburb over and wrote to the agent saying that we were giving them two weeks notice to break our lease and we weren't going to pay a penny more because the house was a dump.  We also got a letter from our GP saying that mold was a health risk, just to put a nice medicolegal aspect on the whole thing.

The agents were a little taken aback but it turned out that they were so jack of the landlord that they wanted to ditch him too because it was more trouble than it was worth.  So they bullied the landlord into letting us not pay any more rent even though we had six months left on the lease.  The landlord pushed back a bit and insisted that we let a building inspector take a look at the place.  And his conclusion was that there was a leaky sewage pipe under the house.  Which would account for the smell, the damp, the mold, the blocked drains.  So ha ha sucked in Mr Landlord.  Take your smelly house and jam in up your cribriform plate.

Functional anatomy of the tongue

The muscles of the tongue can be divided into two groups, extrinsic and intrinsic.

The extrinsic muscles are named for their bony attachments.  Their function is to control the position of the tongue within the oral cavity.  The extrinsic muscles are:

1. Genioglossus, which attaches to the mental prominence of the mandible and acts to protrude the tongue,
2. Hyoglossus, which attaches to the hyoid bone and acts to depress and retract the tongue,
3. Styloglossus, which attaches to the old-school stylus and acts to scratch up some wicked beats,
4. Cranioglossus, which attaches to the head-bone, and acts in amateur local theatre.

The intrinsic muscles of the tongue have no bony attachments and are named for their function, which is to modify the political affiliations of the tongue.  The intrinsic muscles are:

1. Tyrannoglossus, which acts to increase centralized control of government,
2. Populoglossus, which acts to decrease centralized control of government,
3. Socioglossus, which acts to move to the tongue to the Left,
4. Conservatoglossus, which acts to move the tongue to the Right, particularly in New South Wales.

The innervation of the tongue is complex.  Motor control of the tongue is primarily via the 59th cranial nerve, the Diagonal Tongular Nerve (CN LIX).  Sensory afferent fibres from the anterior 2/3 of the tongue, carrying gustatory sensation for salt, sour and umami, course westwards along the state boundary, evading authorities for weeks before holing up in an abandoned farmhouse and dying in a shootout at the end of a protracted siege.  Sensory afferent fibres from the posterior 1/3 of the tongue, carrying gustatory sensation for sweetness, bitterness and elbo cheese, join the lingual nerve, before diverging acrimoniously and writing a tell-all memoir.

Vascular supply to the tongue is via the lingual artery, a branch of the external carotid artery, which is a branch of the carotid artery, being the twelfth exit from the Southern Expressway, but only between the hours of 2pm and 1am.  Venous drainage occurs in the reverse direction between 2am and 1pm.  This schedule is inverted on weekends and public holidays when the tongue is expected to be more active in the evening.

Clinical spills

It's kind of hard to believe, but soon I'll be a doctor. 

I've done all of my assessment.
I have eleven days left on the wards.
Two weeks after that I'll graduate.
In January I'll start working.

And yet, frighteningly, I am unable to diagnose a simple case of tonsillitis.
Despite having been in the ear-nose-throat team for just shy of a month.
And it was in my own child, the Hatchling.
I shone my torch down her gullet and said, "Nope, those tonsils look fine".
Well, apart from the exuded pus, apparently.

I'll give myself part marks for actually thinking of it and checking for it, but zero (obviously) for my actual clinical skills.

Majestically swept back

Here's a time-saving tip: you don't need to keep track of whether or not you need a haircut because eventually people will start reminding you themselves.

I was late yesterday morning and intercepted my team halfway through the ward round.  I apologised for being late and said that I'd been racing around trying to find them.  The Big Boss said to me, in his kindly voice, "That's okay PTR, we can see from your hair that you can walk very fast indeed."

A nifty quote

"It is interesting to note that patients who have been stabbed do not usually describe the pain as stabbing." - Pocket Clinical Examination, Talley & O'Connor, 3rd Edition.

Confidential

A couple of weeks ago I got roped into a teaching session for the 2nd year students by my surgical team.  They were running a rotating series of 5 or 6 learning stations for about 8 students per group, and since one of the registrars was away they got me to run a station instead of him.

In the other stations the big boss surgeons sat the students down and presumably taught them surgeony things like the best bottle of red between $50 and $75, and who the best trainers for racehorses are.  My station, bizarrely, was a test.  Tough luck if you got the test first before you'd been taught anything.  Not that it really mattered because the test didn't count for anything.

It seemed to me to be a pretty pointless exercise.  Also, watching people do tests is not my idea of fun, so as each new group came into my room I would explain that they could choose between doing the test by themselves or having us all sit around and talk about the answers.  To their credit (I thought) the groups all chose a middle path and had a crack at it themselves before having a discussion afterwards.

The discussions were good. I would let them air their theories about what they thought was the right answer and why, and I made sure that everyone contributed at some stage, before I would tell them what I thought was the right answer (note the important caveat there - I was not given the answers) and why, and then we'd discuss it some more.  I got the impression they all found it kind of useful and somewhat interesting.

I was told to collect the papers but made an executive decision that the students might as well take them home instead, seeing as I pretty much told them all the answers anyway.  As a result I had this almost surreal conversation with one of the surgeons:

Indignant Surgeon

Where are all the test papers?

PTR

The students took them home.

Indignant Surgeon

How will the students know what the right answers are if we don't mark their papers?

PTR

I suppose they could always look things up.

Indignant Surgeon

But they'll pass the information on to the other students in other groups who haven't sat the test yet!

PTR

The test doesn't count for anything, right?

Indignant Surgeon

We'll have to change the test.

To recap, he was upset that students might go away and learn something, and even worse, might help other less motivated students to learn something too!  Silly me - I forgot that medical education has nothing to do with educating people.  It's actually all about making sure that people feel bad about how ignorant they are.

I was discussing this with my Smaller Half and she pointed out the additional absurdity that there is no way in hell that a surgeon is going to sit there and mark 50 exam papers that don't even count for anything.  I suggested that it would probably have been passed down to the Fellow, who would dump it on the Registrar, who would delegate it to the RMO, who would handball it to the Intern, who would sling it to me.

So not only was I able to actually teach people something, I also thwarted a stupid plan and saved myself some dull work in the process.  Win-win-win.

Tiling, Seville, Spain

Sticky dates

Centrelink, from whom all benefits do flow, is ever so slightly frustrating because their payment timetable does not accord with my Smaller Half's pay week.  This means that I need to analyse her paysheets and divvy them up into the overlapping fortnights into which Centrelink carves up time.

A similar situation exists in the unit that I'm with at the moment at the hospital.  Rather than having a weekly schedule so that I can turn up to the operating theatre and say, "If it's Wednesday you must be Mr Farkas", they have a four-weekly schedule.  So there are meetings that happen on Wednesday of Week 2, or Friday of Week 4.

Although this complicates my life slightly, I can cope with it.  It gets annoying though because there are other meetings/events that happen on the third Thursday of the calendar month, for example.  So there are clashes with the four-weekly timetable which means that things are Never As They Seem.

Again, this is something that a somewhat intelligent and sophisticated person such as myself should be able to deal with.  Unfortunately the Big Boss Surgeon is quite old and grew up in Tsarist Russia and still denounces the Gregorian calendar as a communist conspiracy.  As a result, whenever he's around we all have to pretend that it's thirteen days in the future.  This meant that not only did I have to come in on a Sunday, I also missed out on my birthday.

I got so fed up with this that last week I didn't bother to go in at all.  When I turned up this week I was going to tell them that I'd been at home preparing for the Mayan apocalypse, but since I'd been using a reconstruction of Antikythera Mechanism to calibrate my diary I'd erroneously thought that it was going to happen on November 3 2011 rather than December 21 2012.  Unfortunately I'd forgotten that it was Daylight Saving so I was an hour late and they'd already finished the ward round and gone off for coffee so I missed them entirely.

Frosty

So today's lesson for beginners is this: when the surgeon walks up to the team and asks, "Is everyone good?", the wrong answer is, "I'm great thanks!"

They are not interested in you.  They are asking about the patients.

Timing is everything

Registrar

So what structure do I need to be careful of when operating just here, PTR?

PTR

The facial artery?

Registrar

No.

PTR

The external carotid?

Registrar

No.

PTR

The cervical branch of the facial nerve?

Registrar

No, the marginal mandibular nerve.

PTR

?!?

[Enter Consultant]

Consultant

So, PTR, what structure should the Registrar be careful to preserve in this area?

PTR
Hmmm.  The marginal mandibular nerve?

Consultant

Yes, that's right. Excellent!

[Exit Consultant]

PTR

So - what's this marginal mandibular nerve then?

Bohemian rhapsody

People often ask me why I decided to study medicine.  I usually lie to them and tell them that I wanted to help the helpless, bring hap to the hapless, and so on, especially if it's an interview panel or they are dressed like the Three Amigos.  But the truth is that I did it because I really like funny names.

Medicine is chock full of conditions, diseases, syndromes, body parts, microbes, and devices that have been named after people.  The number of things is so vast that all of the Bakers, Browns and Smiths got in early, meaning that the field is wide open for people with unusual and sometimes amusing names to be enshrined for all posterity.

So it helps me while away the hours thinking about how Reiter's syndrome is different to writer's block, or why Kawasaki disease has nothing to do with motorcycles, or how Wohlfart-Kugelberg-Welander disease has the word "fart" in the middle of it.  Snigger.  This is PTR's First Law Of Comedy: funny names are funny.

The problem comes though when you find out that the condition that you're laughing at the name of is serious, horrible, and generally dire for all concerned.  This is PTR's Second Law Of Comedy which contravenes the First Law: dead people aren't funny.

Fortunately, I have recently discovered PTR's Third Law Of Comedy, which contravenes the Second Law: dead people are funny if they happen to have been officers in the Prussian army during the 1866 campaign against Austria in Bohemia.

As evidence, may I present Exhibit A:

• Verdy du Vernois
• von Wartenleben
• Schlotheim
• von Tumpling
• Finck von Finckenstein
• Prince Kraft zu Hohenlohe Ingelfingen

These names are fantastic, and in fact I feel a bit disappointed that they chose the military life rather than the medical.  Just imagine finding out that you've ruptured your Ligament of Ingelfingen, or that your doctor was about to slot home the Schlotheim speculum.  Now that would be worth the pain.