Paradigm shifting

Once again I have been surprised by the Hatchling's ability to listen to me talking (ok, ranting) to my Smaller Half and distill from my words the true essence of my frustrations. I had been carrying on about a pet peeve of mine - that some patients find it nearly impossible to follow instructions. For example, I may ask them to have a blood test done and come back within a week for a long appointment. And then I don't see them for a month and they come in for a short appointment and they haven't had any tests done. And now they have a new problem or three as well.

So the Hatchling digests all of this and comes up with two great suggestions:

1. That I point over their shoulder and say, "Oh look, a beautiful butterfly has flown into the room!" And when they turn around to look, I should quickly lean forward and attach (using a clothes peg) to their shirt a list of written instructions for them to follow.

2. That if despite my efforts they don't follow my instructions, I should just solve all their problems in one appointment and say to them, "Seriously, why don't you go and buy a tablet or something to make you better?" And then I won't ever have to see them again.

And after she had made these suggestions she came up with a great idea - I should just invent a tablet that stops people getting a blocked nose and make it so good that you only have to take it once a year AND it tastes just like your favourite food. Then I can come home from work early and play!

This girl - she's a thinker!

Sweet cheeks

Here's a quick quiz for those contemplating getting into medicine as a career - complete this sentence:
"I wish to become a doctor because..."

1. I want to help people.
2. I enjoy challenges.
3. I got good marks at school.
4. I enjoy pushing people's guts back up into their bums.

Mark my words, if you're applying to medical school, you'll be asked that question, and the correct answer is 4. Bums is where it's at.  The panel will know that you're a pragmatist rather than an idealist and you'll be in like Flynn.

Almost everyone has a rectum.

Some people have prolapsed rectums that fall out of their bums.

A few people have rectum that flop right out if you so much as glance at them wrongly.

Which is fine, don't get me wrong.  Easy in, easy out, in general.  Problem is, if they stay out for a while they can start to swell up, then it's hard to push them back in.  It's like trying to thread a needle with a marshmallow.

If you find yourself having to push a swollen rectum back up someone's bum, here's a handy tip: if you sprinkle said rectum with some salt or sugar, water will be drawn out of the mucosal surface by osmosis.  This reduces the swelling and makes it easier to push it back into the bum.

Having said that, I prefer sugar to salt, for two main reasons.

1. You know how much it hurts when you get something salty on an ulcer inside your lip? The idea of giving someone that feeling in their bottom just makes me cringe.
2. I think using sugar instead of salt is safer, just in case someone walks by with a lemon and some tequila and gets the wrong idea about what's going on.  Could be an ugly scene.

So I use sugar.  A teaspoon or so will do.  Leave it on for a few minutes so it has time to shlurp that water out of that rectum.  But before you leap ahead and push it back into the bum, wipe the sugar off first.  You don't want to attract ants.

Any questions?

4 fattening foods to avoid this summer

Summer is coming, if you live in the northern hemisphere of Mars.  If you're worried about how to get that perfect spacesuit body, here are 4 fattening foods to avoid that you might not know about!

Lard

Lard is the big diet fad this year, as it's 99% sugar free.  Lardsicles, lardwiches, lardacinos - people everywhere are singing their praises.  But did you know that as well as being 99% sugar free, lard is only 1% fat free?  And scientists at Princeton have recently discovered that this may result in lard being up to 99% fat!  This may not sound too bad, but some of those scientist's friends have recently theorized that dietary fat may be an important contributor to total caloric intake, which itself is believed to be related in some as yet unknown manner to your energy intake/output balance, which Sanskrit manuscripts recently found in Paulo Coelho's underwear drawer attribute to how fat you are.  So try eating less lard and see if it helps.  You don't have to go entirely without though - colonic irrigation using lard is still okay.

Crushed Glass

Crushed glass is the big diet fad this year, as it's 99% fat free and 99% sugar free.  Glassicles, glasswiches, glassacinos - people are just munching that stuff up.  And sure, in the short term it seems like bleeding vigorously from the mouth and anus would be an easy way to lose weight.  But in the long run, perhaps in 2 hours, perhaps in 3, you'll end up in an intensive care ward getting parenteral nutrition while you wait for your entire digestive tract to be transplanted.  And do those bookish, bespectacled ICU-types really care about the state of your muffin top?  They do not.  They'll just pour those milkshakes into your veins and plump you up, up, up, up, up.

Water

The list of people who don't know that water is fattening is so lengthy, it would be easier for me to just give you the list of people who know that it is.  But that's just what they're expecting me to do.  Shhhhh...  They're listening... Just think of it this way - eliminate all water from your diet and watch your hips melt like ice.  Do it.

Cancer

It's becoming increasingly common these days for people to think that they can lose those summer pounds and tone those abs simply by eating cancerous facial tumours from Tasmanian Devils.  Facialtumoursicles, facialtumourwiches, facialtumouracinos.  Big mistake - for two reasons.  First, they are so delicious, especially with a garlic and cayenne aioli dip, there's no way you'll be able to stop at just one.  And second, you will of course be infected with Devil Facial Tumour Disease.  And while you might think that this would be a good thing, because the enormous and disfiguring facial tumours will physically prevent you from eating, unfortunately the cells will also disrupt the glomerular basement membrane of your kidneys, giving you a raging case of nephrotic syndrome.  You'll retain fluid in all your tissues and will swell up, up, up, up, up. I can't believe it's not butter!

So those are the four surprising foods you should avoid eating this Martian summer.  I expect you'll all be slimmer, less haemorrhagic, and much, much drier the next time we speak. But that's just what they're expecting.  Arrivederci Roma!

The stone

So here I am - stuck at the hospital on a lovely day with not much to do.  I'm on cover.  "Cover" means you're stuck here all day on a weekend dealing with whatever random stuff the regular doctors forgot to do or didn't foresee or simply couldn't be bothered doing.  Today is bizarrely un-busy for me.  Hence the flurry of blobbing activity, which I've cunningly scheduled to be published daily over the next week or so.

All that is by way of getting to what I want to talk about which is superstition.  When I'm on cover I get hugely superstitious.  All of my superstitions are aimed at avoiding having my pager go off.  Over the last year I've developed a decent set of tips for avoiding being paged.

1. Do not go onto the ward, through the ward, or near the ward unless you absolutely have to.  If they see you there or smell you out, they will page you.
2. Do not read a book.  Opening a book is a sign that you're getting comfortable, and they will notice and page you.
3. Do not watch TV.  Watching TV is practically begging someone to page you.
4. Do not sit down into a comfortable soft chair and wriggle back and forth a bit then curl your feet up underneath yourself.  They will page you.
5. Do not attempt to eat any food which gets substantially grosser if you try to re-heat it later on, such as cheese on toast.  As soon as you've got it ready to eat, you'll be paged.
6. Do not ever send anyone a text message saying, "Today is AWESOME!  There's NOTHING to do!" - you know how this ends.
7. Do not attempt to do any of your own work, such as chewing through your backlog of discharge summaries or doing MMSEs on your own patients.  This will generate a singularity in the pager continuum that will suck you in for the rest of your shift.
8. Don't arrange to catch up with someone you know and love for lunch or coffee.  Your pager will go off so often that you may not even see them except as a rapidly receding silhouette in the sunset.

"But PTR", I hear you ask, "What can I do when I'm on cover and want to avoid making the pager gods angry?"  A good question, mosquito.  The answer is to be found in nature.  You must be like the stone, which weathers all that the world can throw against it.  The stone does not read books, or sit in comfy chairs, or meet up with friends for coffee.  The stone does not try to catch up on discharge summaries or eat a delicious lunch. 

No.  You must be like the stone.  You must lie low, very still, in the dirt.  Let the ants crawl over your face.  Let the rain run into your shoes.  Let the frost rime your beard.

Do this and you will be like the stone, whose pager never, ever goes off.  Be like the stone.

Pain or something like it

Medical bloggers love to bang on about the 1-10 pain scale, usually to comic effect.  Here's my contribution, but with cynical intern burn-out substituted for comic effect:

So, the 1-10 pain scale, eh?  In my experience, there's no need for anything so elaborate.  There are only 4 actual subcategories of pain.

1-4. Bearable pain.  Take paracetamol (known in the USA as epinephrine.  No wait, that's something else. Forget it.).
5. Unable to articulate character, site, severity, onset etc etc etc.  Refer to a general medical team.  They love these guys.
6-10. Severe pain. Give opioids and request a general surgical review.  They'll need a baseline before the patient re-presents with constipation from all the opioids you gave them.
11. Drug seeker. Or renal colic.  Either way, some indomethacin up the butt will give someone some relief.

Ha.

Win at emergency

It's taken me a few weeks but I've figured out the secret of success in the Emergency Department.  First, some necessary background.  There are two halves to the ED: A side and D side.  On arrival, all patients are triaged into either A or D.  You go to A if you are likely to require admission to hospital.  You go to D if you are likely to be discharged after being seen.

My secret is this: always discharge everyone on the A side and admit everyone on the D side.  It doesn't matter how flimsy your justification is, or how ludicrously risky it is for the patient - the important thing is that you are creating a vibe, a persona, an imago, that will live forever and guarantee you'll pass.

Of course, you won't always be successful in executing this plan, since you need consultant approval.  But again, the key point is that you go into that conversation with the consultant with this firm recommendation and really shake things up.

Scenario #1, A side: Little old lady who lives alone with chronic renal failure comes in having been nauseous and ill for the past week.  Her potassium is up the wazoo, ECG changes, uraemic flap, confused and disoriented.
Your position: Discharge.  She'll be less confused at home, she has a renal clinic appointment next week anyway, all she needs is a litre of fluid over half an hour before we send her on.
Impression: You're a strong minded independent thinker who isn't afraid to voice their own plan.  Possibly somewhat confused and disoriented when it comes to clinical work, but at least you have the courage of your convictions.

Scenario #2, D side: Man comes in with bruise on toe that he dropped a block of wood on last week.  No disability but he had the day off so he thought he'd come in and get it x-rayed because he's never had an x-ray before.
Your position: Admit under orthopedics.  No wait, under plastics.  Get a CT foot done, then a follow-up MRI to assess for soft-tissue injury.  Run a panel of thrombophilia screens to alert the surgeons to your awareness of how serious DVT is.  Get three or four large bore cannulas in and a flatus tube for good measure.
Impression: You're a strong-minded independent thinker who demands the absolute best for your patients and won't take no for an answer. 

If you're not in ED at the moment, the general principle is the same.  Do the unexpected.  Nobody remembers the guy who was always boring and playing it by the book.  Step out there and make your mark!

Awaken the giant within

Every now and then someone remarks to me that they wonder how I can cope with doing my internship at the same time as my Smaller Half whilst also trying to look after the Hatchling. The answer is of course that I don't. Cope, that is. I spend most of my waking hours desperately trying to catch up to where I'm supposed to be and never quite making it. And my sleeping hours I spend having bizarre dreams about imaginary medical conditions suffered by fictional patients that I have to try actively to forget upon waking lest I blurt out something insane sounding on the ward round the next morning.

"Mr Upendis hasn't had his brain biopsy yet so we still don't know where the chocolate is coming from!"

Be that as it may, it is made easier than it might be one you realise that caring for patients is almost exactly like looking after a one year old.

Patients: did they sleep well?
Hatchling: did she sleep well?

Patients: do they have a temperature?
Hatchling: does she have a temperature?

Patients: have they had their bowels open?
Hatchling: has she just made a special delivery?

Patients: how's their fluid balance?
Hatchling: has she had enough to eat and drink?

Patients: have you checked the gentamicin levels?
Hatchling: would you like me to read you Hairy Maclairy From Donaldson's Dairy?

Patients: can you get the neurosurgery registrar to review them ASAP?
Hatchling: you look so cute in those little purple trakkie-daks!

The similarities go on and on and it makes everything so much easier. So for those of you embarking on medical careers, my advice is to have children right now. Especially if you might be competing with me for jobs in the future. Yeah, that's it.

And if you already have small children, why then, enrolling in a medical degree and working 7 day weeks for some sociopathic overseer will be just the ticket to sharpen up your parenting and really bring you closer to your family.

And while you're at it, write some damn blog posts on your phone using the stupid touchscreen. Ow! My arm!

Status idioticus

Thanks for your supportive comments to my previous post.  Since then things have improved a billion percent plus or minus 999,999,999 or so.  I'd like to think that it's because I am a winner, but that's only partially so.  Sadly, I still haven't managed to have any Vitamin C(ricket) but life can't be perfect.

Monday was not good.  I was there for 12 hours straight, didn't get to eat anything, didn't get to drink anything, if I hadn't been running around like a madman you'd have thought I was fasting for surgery myself.  Perhaps I'd be more productive if I wheeled a drip-stand around with me, with cool refreshing sea-water flowing into my veins, and a nice fat urinary catheter to cut out those pesky bathroom stops.

Things got off to a poor start when the Hatchling woke umpteen times the previous night.  I then managed to somehow miss half of the plans during the round and never quite caught up.  It didn't help that my RMO (the person between me and the Registrar, who is the person between the RMO and the consultant, who is the Big Boss) is away this week and there's no reliever so I'm kind of flying blind.

I failed to arrange some urgent consultations from cardiology and anaesthetics to prep a patient for surgery on Wednesday (today) because I simply couldn't get anyone to return my pages.  Either that or I wasn't in one place long enough to actually take a phone call.

Then the consultant surgeon came and asked me some questions about my patients and it turned out I had no idea about them because again I sleep-walked (slept-walk?) through the round, so he deservedly rebuked me for that.

Then I had two code blues (dramatic emergency for crashing patients) in 4 hours plus another patient started having massive rectal bleeding so I had to quickly arrange a whole bunch of stuff that I previously had no idea about.  And because of that, I fell further behind and the consults never got done and as I was sitting at my desk at 8pm scribbling out blood forms for the following day my Registrar came in and revved me about needing to get my shit together.

So I went home and the Hatchling was screeching because she hadn't eaten and was sick and was driving my Smaller Half bonkers because she's been just as busy as me and by bedtime I was pretty much ready to run away and join the circus until I realized that I already lived there.

Tuesday was better though and today was better again.  Here's some tips for new interns on how to make it so:

1. Get a student to write the notes.  Concentrate on trying to figure out what the plan actually is.
2. Review your patients yourself.  For surgical patients you need to listen to breathing, check IVT/fluid balance, check calves for DVTs, check the surgical wound is clean and ensure that they have correct anticoagulation.  This will put a cap on how much of an idiot you look like when the consultant starts quizzing you.
3. When your registrar starts flinging around multiple, ambiguous or conflicting instructions, make him clarify himself (or indeed herself).  He may in fact get annoyed that you "waste his time" by doing this, but if you don't you'll regret.  This is no time to be meek.
4. Page people once.  Give them 5 minutes to answer, then go through Switchboard to call their mobile.  Why we have a paging system when I am the only person who seems to actually use it is beyond me.
5. DO NOT LOSE YOUR PATIENT LIST WITH YOUR JOBS WRITTEN ON IT.  Seriously.
6. Ask for help within a few seconds of getting baffled or confused or being unable to find something or not knowing how to do something.  Sure, you might look silly, but at least you'll be able to go home at a sensible hour.  This is no time to be proud.
7. Write down everything you do in the notes.  Writing it down often makes you remember what else you should be doing as well.  Which may well make you yoyo back and forth between the patient and the notes, but hey, what's the alternative.  This is no time to be super-organized and work hard through med school so you know what you're doing.  It's too late for that shit.
8. Drink lots of water.  Do not eat the junk food in the office.
9. Stand up straight.  Sniff the morning breeze.
10. Be strong.  Be energetic.  Be determined.  Know yourself.  Be the ball.  Keep left.  Buy low.  Sell high.  Take the All-Bran Challenge.  Squeal like a pig.  Something's gotta work!

I just wanted to say good luck, and we're all counting on you.

Horse artillery

Like you, I've always been unsure how to use horse artillery effectively.  I've been doing some research on the matter, and it seems that the way to handle them is to gallop right up to the enemy infantry and use your cannon to shoot large iron balls at high velocity into their ranks, rending limb from limb, soaking the ground with blood, and tearing the veil from Death's face so he stares them right in the the eye.

Words of wisdom

This is, apparently, everything you need to know about emergency medicine:

• Assume nothing
• Trust no-one
• Give oxygen

I think I just need to work on the second one.

Catching earworms

In response to THIS COMMENT I simply wanted to say that the best treatment for an earworm is to use a juicy piece of bait to lure the earworm out.  This usually happens at night when you are sleeping, so the trick is to enlist the help of a close friend, jailmate, casual sexual acquaintance, or ideally someone who is all three at once, to catch the earworm when it pokes out its head and twist it around a short stick which can then be used to gently wind out the earworm over several days.  The best bait to use is a stinking piece of rotten meat such as Tubthumping by Chumbawumba.

Slow learner or slow teacher?

Deranged Old Lady
Ooh, what a gorgeous baby!  How old is she?

PTR
Almost 7 weeks.

Deranged Old Lady
She's beautiful!  I was a midwife for 27 years at the old hospital over there so I've seen plenty of little ones like this.  I'll give you some advice.

PTR
I love advice.

Deranged Old Lady
If you stuff some stockings and pop them under her legs, it'll stop her wriggling down under the blankets in her cot.

PTR
That's a good idea.

Deranged Old Lady
Yes, it stops them wriggling down under the blankets.

PTR
I see.

Deranged Old Lady
Yes, if you stuff some old stockings and pop it under their legs, it stops them wriggling down under the blankets.  I did it with my children and they've done it with theirs.  It stops them wriggling down under the blankets.  You just stuff some old stockings and pop it under their legs.

PTR
Yes, I think I understand.

Deranged Old Lady
If you stuff some old stockings and put it under their legs, it stops them wriggling down under the blankets.

PTR
Excuse me, I have to call the police.

Serenity now

There comes a time before each exam when you must find the balance between learning and de-stressing.  For me, that time is now.  And the balance is learning 0%, de-stressing 100%.

This is particularly true of studying medicine because there seems to be no limit to what we might reasonably be expected to know, even though in actuality what we are expected to know is quite reasonable and sensible.  In fact, to put it in the words of an Esteemed Colleague, "They just want us to be sub-lethal".  Just make sure you know Plummer-Vinson (Paterson-Brown-Kelly) Syndrome back to front.  Sure, it's rookie stuff, but you'll look silly if you haven't reviewed it.

Everybody de-stresses in different ways.  Some people hit the gym.  Some people meditate.  I like to behave like an effete retired dilettante.  So here's what I do:

• Feed the birds.  Tut-tut over the crows that have been pushing the rosellas around.
• Put some string quartets by Mozart on the stereo.
• Slowly nibble some avocado and smoked salmon on whole-grain ano-bread while sipping my eco-coffee and browsing The Guardian online.  Tut-tut over government spending cuts in the UK.
• Gaze vacantly out the window at the garden, thinking about where I might plant some bulbs for the winter.
• Put some waltzes by Chopin on the stereo.
• Go to my blog and dispense some patronizing and sanctimonious advice to my long-sufferering readers.
• Do some tai-chi in the front yard where the neighbours will be sure to see me.
• Throw open all the windows in the house and stand in front of them with hands on hips breathing deeply and saying, "Aaah, it's a beautiful day!  Feel the air in your lungs!"
• Put some Bach violin sonatas on the stereo.
• Idly wonder what might be on the OSCE tomorrow.
• Hurriedly snatch up an excrutiatingly detailed textbook and attempt to memorize specific gene defects for a range of rare diseases for the best part of an hour before collapsing sobbing into a corner.
• Put some Rachmaninoff piano concertos on the stereo.
• Tell everybody on Facebook how bored I am.  Tut-tut over the young folk these days.

The next time you have a big exam looming, why not try my method?  It's never failed me!

Expecto Patronisum

No.  No no no no no.

We had a practise OSCE this evening.  Oh how we laughed.  Eight stations, five minutes each.  All pretty straightforward stuff.  Or it would be, if you had any freaking idea what you were doing. 
Case in point: x-rays.  Now I know all about x-rays.  But clearly I don't know much about anatomy or pathology because I tanked that station.  Really badly.  But hey - that's why we have radiologists, right?  I mean, apart from having to find somewhere to put all the oddball graduates.

Anyway, that's not what this blob is about.  This blob is about the post-OCSE feedback session in which we were ruthlessly patronized by our supervising doctors who marked us.  Here's what went down...

First, we were subjected to a lengthy mealy-mouthed pep talk which actually contained nothing of substance whatsoever.  "The best advice for the OSCEs is to go into each station and genuinely try to address the clinical problem that is given to you."  Swerving that violently to avoid colliding with actual content left me reeling with mental whiplash and in no state for what was to follow.

We were then given a little finger wagging lecture about how if we are ever in the position of not knowing something we should always ask for a little lesson on it right then and there to "close the gap" rather than just shrugging and saying, "Meh, I can haz brains L8R", presumably because we are all adolescent dipshits rather than responsible adults.  At this point I bit my tongue and refrained from pointing out that, in my experience, asking questions of doctors leads to one of two possible answers:

1. You should know this by now.
2. It's not my job to answer questions that you can look up in a textbook.

Then, we were told in feedback for one of the stations that it was disappointing that so few of us knew the dose for drug X.  There were two marks available for knowing the drug and the dose but if you didn't know the dose you got zero.  Right. 

We did point out that we've been specifically told that we don't need to know the doses of drugs, to which the response was the evergreen and fanciful idea that we can get some kind of mythical "bonus marks" for impressing the examiner with knowledge like drug doses (as opposed to the cruel reality of disappointing your examiners by being unable to distinguish the bum from the elbow).  Buddy, the day I start spending my time planning ways to "impress" my examiners is the day I'm not devoting enough time to my stamp collecting.

Seizing the opportunity presented by our collective stunned silence in response to the feedback about the dose of drug X, I asked a question.  "Oh wise practitioners", I asked, "To enable me to close the gap and to ensure that I learn something from this encounter, couldst thou in thy wisdome inform me of the correct dose for drug X?" 

There was widespread hilarity.  My Esteemed Colleagues laughed because they know me well and recognized that I was being at least somewhat of a Smart-Arse.  The doctors laughed because I should know this by now and they are not here to answer questions that I could look up in a book.  I kid you not - the doctor next to me said, "You'll remember it better if you look that up yourself when you get home".  And then another doctor said, "The correct dose is one ampoule", and chuckled to himself behind his little doctor's beard.

I love it.

Words of wisdom

Which reminds me to pass on the excellent advice given to me recently by a general physician:

"Never go drinking with a painter.  The solvents in their paint induce their liver enzymes so they'll still be going strong when you're flat on your back and half unconscious."

Insomnia

Every now and then I have trouble getting to sleep.  Usually it's because I slept in really really late that day so I was only actually awake for 12 hours or so before going to bed again.  Sometimes it's because my mind is racing with something interesting or challenging or upsetting or disturbing that happened during the day.  And sometimes it's because the Secret Cat is stomping all over my face trying to make herself comfortable.  Regardless of aetiology, it's annoying.

So I've developed a great method for focusing my consciousness and getting myself off to sleep.  It seems to work well, for me at least.  If you have insomnia why not try it and let me know if it works for you?  Here's how it works:

1.  Visualize a sphere floating in front of you, about the size of a tennis ball at arm's length.  The ball is smooth and matte and shining against a dark background.
2. Now change the colour of the sphere from however it first started.  The colour you want depends on your current emotional state.  If you are angry, make it red.  If you are agitated, make it purple.  If you are sad, make it blue.  If you are happy, make it green.  And so on.  The colour doesn't really matter, the point of it is to identify your current emotional state and make the sphere an appropriate (for you) associated colour.
3. Just focus on the sphere now it is that colour.  It will probably try to change to a different colour or maybe even a different shape but just gently nudge it back to what it should be.
4. Now, visualize the sphere gradually changing colour to a pale silvery grey, over the course of several seconds.  Hold it there.  Feel your mind relax.
5. Repeat the previous steps in order about ten thousand times until either you're asleep or the goddamn sun comes up and it's time to get out of bed.

 If I get a positive response to this maybe I'll record some CDs of the instructions and sell them in hippy shops.

MCQs

We had a practise exam a few days ago.  It doesn't count for anything, it was just an opportunity for us to have a go at the type of question that will hopefully turn up at the end of the year.

There was a fair bit of stuff in there that I had to guess at but I'm feeling reasonably confident that I won't crash and burn because I am a pretty good guesser.  Guessing isn't just about closing your eyes and stabbing your pen at the page (no, that's how you get IV drips in) - guessing is a game that you play against the evil genius who sets the exams.  If you know how he thinks, you can beat him.  And thus I present PTRs Incredibly Useful Guide To Doing Well In Multiple Choice Questions When You Haven't Really Bothered To Prepare Properly (tm).

The key fact to remember is this: one of the answers is right.  Another key fact is this: another one of the answers will be clearly wrong.  And finally, the other two or three answers will be there to confuse you.  My approach is to first identify the answer which is clearly wrong.  Then, one by one, eliminate the answers which confuse you.  Whatever remains, no matter how improbable it seems, is correct.

A brief example is in order.  Here is one of the questions from the practise exam that I used my photographic memory to capture:

A fifteen year-old boy presents with sudden onset severe scrotal pain.  Your best next step in managing this problem would be:

1. My first is in anaphylaxis but not in diarrhoea, my second is in Cushing and also in Parkinson, my third is in spleen but never in lymph and my last is in both E. coli and S. aureus.
2. Inject adrenaline straight into his heart. 
3. If three and a third surgeons can insult three and a third medical students in three and a third hours, how many medical students can two surgeons insult in four hours?
4. Take a detailed biopsychosocioeconomicopoliticogeometrical history.
5. Antiquis temporibus, nati tibi similes in rupibus ventosissimis exponebantur ad necem.

What do you think the answer is?  Apply my technique, figure it out and submit your answer in a comment!

Agony Aunt 3

Dear PTR,

I'm in agony!  My head hurts, my back aches, my toes and fingers feel like they are burning up!  What can I do?
(signed)
Idealistic in Adelaide

Dear Idealistic in Adelaide,

Take two aspirin and call me in the morning.

Sincerely,
PTR

Agony Aunt

Dear PTR,


I desperately need your advice!  I'm bored with my current job and need help deciding what to do next. 


My current job is extremely boring and predictable - I want something with a little more excitement.  For example, I enjoy getting confusing and contradictory feedback on my performance depending on the whimsy and caprice of whoever happens to be in the room at the time.  In particular, I like being taught six different ways to do the same thing, with each new teacher emphasizing how terribly mistaken the previous teachers were.  I also like to be given ambiguous tasks in language which is easily misinterpreted.  When I fail to complete the task adequately because my telepathic powers failed that day and I was unable to read minds, I would like to be scolded for being timid or unreliable.


I don't have many friends, and I don't like the ones I do have, so it would be convenient it this new job could suck up as much time as possible and, if possible, destroy my social life by making my schedule irregular and unpredictable and by otherwise making me feel extremely guilty if I do attempt to enjoy myself.  In fact, the guilt thing is very important - my ideal career would be one in which success is difficult if not impossible to measure, thus leaving me a neurotic mess as I have no idea when enough is enough.  Needless to say, the added benefits of my new job being completely unpaid would add a certain je ne sais quoi.


In order to remind me that it's a job and not a hobby, it would also be good if many of the people in this new job were unpleasant, egotistical, arrogant, abrasive, selfish, or just plain mean.  Naturally, a majority of people will not be like this at all, but it would be nice if the awful people were SO awful that they SEEM like the majority.


Please let me know if you have any suggestions.
(signed)
Idealistic of Adelaide


Dear Idealistic of Adelaide,

You should enrol in a medical degree immediately.  Good luck!

Sincerely,
PTR

Mock OSCE

We had a mock OSCE on Wednesday night.  (An OSCE is a oral exam where you interact with either actors playing patients or real patients and you have to be the doctor.)  There were only five active stations and two rest stations, but the organisers had structured it so that it was excellent preparation for the real OSCE at the end of the year.  Here's an overview of what each station was testing.

Station 1: Panic
The first OSCE skill to master is panic.  If you go into your first station and you don't panic, the patient and the examiner will know that you are a clueless noob.  For this reason, getting a good panic on for the first station is essential.  Some things that may help are to drink too much coffee, imagine how your life will be wrecked unless you perform perfectly, and to glance at advanced textbooks immediately before the start of the OSCE to ensure that you are fully aware of how much you don't know.  If, despite your preparation, you find yourself unnaturally calm and relaxed, you could try hyperventilating to induce lightheadedness.  Alternatively, try bluffing your way through by moistening your palms and brow with water to give others the impression of fear.

Station 2: Disorganisation
This skill is most usefully displayed during a station which combines history taking and examination.  You should immediately commence examination, and if possible arrive at a firm diagnosis immediately.  This allows you to suggest management, preferably something which would be contraindicated by common conditions with similar presentations.  Thus, you then are compelled to ask a few history questions which then trigger something in your mind to test by examination, and thus the cycle begins again.  It would be good if, from time to time, you then leap back to history taking by asking some general systems questions.  The effect you're looking for is something like this: "The patient is tachycardic, it's almost certainly a pulmonary embolus, I'd recommend thrombolytics, oh wait, maybe it's blood loss, have you noticed any change in your bowel habits?  The abdomen is tender in the right iliac fossa, how are you sleeping?  And your parents, do they have any history of epilepsy?"

Station 3: Time mismanagement
After station 2 you will realize that you need to be more thorough.  Thus, station 3 is the one where you can delve step by step into the minutiae of the patient's condition.  With any luck, you'll still be only halfway through taking a history when the bell rings for the end of the station.  A good place to get bogged down is when asking about medications - few patients can remember the correct names and doses of their tablets, so this gives you the opportunity to spend a long time trying to pin them down.  "Are you sure it was atenolol?  Not metoprolol?  Or nebivolol?  Or carvedilol?  What colour is the tablet?"  Alternatively, a good chunk of time can be burned up by an inquisitorial style when asking about smoking and alcohol.  Believe nothing that the patient tells you and scold them for not telling you the truth.  With luck you'll not only waste time but antagonise them so much that the rest of the station is complete disaster.

Station 4: Compensatory euphoria
By this stage of the OSCE you're past the halfway mark.  Soon it will all be over, so it's traditional at this point to relax a little and lapse into compensatory euphoria.  Thus, the fourth station is there to test your ability to urge the patient to make sweeping lifestyle changes while assuring them how great the results will be with just a little willpower, and babble at great length in order to show the examiner how wonderful your interpersonal skills are. A useful technique is enthusiastically agree with everything the patient says and then continue talking as if they hadn't said anything.  Another good trick is to dump on the patient all of the detailed pathophysiology that you learned in first and second year.  This will baffle them into stunned silence and ensure you have maximum talking time.  Again, hyperventilating while reading the instructions on the door before you enter the station can be invaluable in getting you into the right frame of mind!

Station 5: Exhausted confusion
This is one of the easiest OSCE skills to master once you know the right approach.  The key step is to begin preparing early on.  Don't eat anything since the night before.  Sleep badly.  If you have any notepaper to write on, keep notes for all stations on the same piece of paper.  Make sure you don't write any names or other identifying material.  This will allow you to keep asking, "What's your name again?", and, "I know I've asked you this before, but where is the pain?"  Hopefully you will have performed terribly on each of the previous stations so you'll be tired, demoralized and sick to death of the whole thing.  Sigh deeply.  Stare down at your notes and shake your head.  From time to time, glance despairingly at the examiner as if begging for help.  If you are unfortunate enough to have to recommend management, try being unable to recall the names of drugs, or unable to pronounce them properly.

So that's how you do a mock OSCE!  If you practise these skills at every opportunity, you'll be ready to savour the full richness of the real OSCE at the end of the year.  Of course it's hard to extrapolate from just 5 stations to the full 20, but keep in mind that these techniques can be used not only in isolation but in combination.  When you're first starting out it's advisable to master them one by one.  By November, however, I expect you'll be able to use these notes to play a beautiful symphony of underperformance in the key of F.

I just wanted to say good luck, and we're all counting on you.