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!

Only plastic surgeons should

I had a mandatory training review today, involving a fairly tedious 30 minute phone conversation with an Authority Figure to make sure I am Ticking All The Boxes.  It got off to an awkward start when the first thing he said to me was, "How was your morning?", to which I replied, "Pretty good, I spent half an hour BLANK". (BLANK, of course, replacing what I actually said, for reasons soon to be apparent.) He made a Concerned Noise and said, "I was once told by a plastic surgeon that only plastic surgeons should BLANK", causing me to execute a series of daring evasive manoeuvres to throw him off my tail.

But it made me think that you could write a good exam question about it.  Here goes:

Q314. Only plastic surgeons should:
(a) Wear shoes with such pointy toes that you are mistaken for an elf.
(b) Remove large sebaceous cysts from the face.
(c) Buy a Lamborghini rather than lease it.
(d) Sexually harass a subordinate.
(e) All of the above.

Feel free to leave a comment below with your guess as to correct answer, or to suggest a better alternative.

Mulch

Tonight I cleaned out my manbag.  No, that is not a euphemism for sexual intercourse.  I just figured that I looked like a bit of dill walking down the street towards work holding my stethoscope in one hand and balancing a sandwich, an apple, and a carrot in the other.  Well, to tell the truth, I had been thinking that for several months now, but I finally got around to cleaning out my manbag because my Smaller Half strongly advised* me to do it.

Which is nice, because as of tomorrow I will be able to put my stethoscope, sandwich, apple and carrot into my bag before I leave the house and my apple won't roll off the front seat of my car and onto the floor either, which can only be a good thing health-wise.  But, as I've already mentioned, first I had to clean it out.

My manbag management protocol is pretty much the same as the way my brain works.  I just jam into the top whatever seems useful or surprising that I've come across, and slowly things work their way down into the darkness below where they are forgotten or else take on a strange life of their own.
I found stuff in the bottom of my manbag going back to February 2013, which sounds bad but there is stuff in the bottom of my brain going back to the mid-70's.  Here's a highlist list:

• 8 pens
• 3 torches
• 1 tourniquet
• 1 butterfly needle
• 3 paperclips
• a document telling me that I officially don't have tuberculosis
• almost 50 pages of patient lists, notes and discharge summaries
• identification badges and access cards from 3 different hospitals, none of which I actually work at anymore
• notes and summaries I had scribbled about such diverse topics as sudden cardiac death, management of diabetic ketoacidosis, differences between atypical antipsychotic medications, and "cultural safety toolboxes"
• about a dozen phone bills, electricity bills, reminder notices, final notices, and termination notices
• 20 or so payslips, unopened
• "Where Late The Sweet Birds Sang", by Kate Wilhelm - winner of the 1977 Hugo Award
• A nice stripy blue wool scarf
• an empty shopping bag
• several used-looking tissues (shudder)
• a partridge in a pear tree.

About a third of it I kept, about a third of it needs to be shredded as its mere existence grossly breaches just about every confidentiality requirement I can imagine, and the other third I just ate with a nice chianti.

So tomorrow I will be able to transport my lunch in a snug, marginally hygienic bag.  It's exciting.  And I will start to fill it up all over again.

*directed.

How to just pop it back in

A lot of readers have been asking me for advice recently on how to reduce a proximal dislocation of the 5th metacarpal.  It's an unusual injury, the more common outcome being to simply smash the metacarpal into pieces - the so-called "auctioneer's fracture", but sometimes the metacarpal is simply too strong, too stubborn, or too ignorant to break, and a dislocation occurs - the so-called "meteorologist's dislocation".

It is easily recognized clinically by the appearance of firm lump on the dorsal surface of the hand, preserved motor function of the fingers, and an unequivocal description in the radiologist's report.

Reduction of the dislocation (or more colloquially, "popping it back in") can be achieved by following these easy, easy steps:

1. Ask your boss to help you.
2. When your boss tells you to simply do an ulnar nerve block at the wrist, tell him (or her - this technique works equally well with supervisors of either gender) that you have not done this before.
3. When your boss suggests that you use Google to learn how to do it, use Google to learn how to do it.
4. Ideally, your source of instructions on Google should be a PDF document, preferably authored by a doctor-sounding person.  Watching videos on YouTube lacks gravitas, while learning medicine from a blog post is simply preposterous.
5. Print out the instructions and place them out of your patient's eyeline but within your line of sight.
6. Locate the distal flexor carpi ulnaris tendon.
7. Using a 22 gauge needle or smaller, penetrate the skin deep to the tendon on the medial aspect of the wrist and advance the needle approximately 10-90 mm.
8. Infiltrate 3-5 mL of a mixture of 1% lignocaine and 1 tsp cream of tartar.
9. As the patient's vasovagal response begins, slide them gently onto the floor.  When supine on the floor, ensure airway patency.
10. Press the emergency button on the wall.
11. While the patient is unconscious, grab their 5th digit on the affected side and pull firmly and steadily while applying firm pressure on the dorsal surface just distal to the wrist.
12. Feel the bones crunch as they slide back into place and vow to never eat turducken again.
13. Revive the patient.
14. Reassure staff who are now arriving in response the emergency alarm that everything is progressing exactly as planned.
15. Apply an ulnar gutter slab from below the elbow to even more below the elbow, applying three point pressure to keep the metacarpal enlocated, or better yet delegate this to a nurse, student, or nursing student.
16. Write a blog post about it, making it seem like it really happened. 
17. Profit.

Boustrophedon

The other day I got a call from my doctor.  It might seem strange that I, as a doctor, have a doctor.  But it's actually a really good idea.  As I like to say to people who are easily confused, "The barber cuts the hair of everyone in town who doesn't cut their own hair. Who cuts the barber's hair?"  If the barber cuts his own hair, then he doesn't cut his own hair, then he does cut his own hair, ad infinitum.
Obviously, the barber lives in the next town over and travels to a third town to have his hair cut by a barber friend of his who is completely hairless, and he also owns one of those creepy hypoallergenic cats that feel like they are made of scrotums.  So it makes sense for me to have a doctor because that way I have two doctors looking after me.  But that's not what I'm here to talk about.

So my doctor called me, and asked me to come in because my latest cholesterol test was abnormal.  Now this was a surprise because I had already checked my result through the simple expedient of many years ago romancing and marrying a person who had ambitions to be a doctor themselves (not a barber - and thus making a third doctor who is looking after me) and asking them to look up my results, and so I knew that my results were completely normal.

Nevertheless, I dutifully went to my GP. I sat down in the consulting room and she told me that she wanted to see me because my cholesterol had suddenly and unexpectedly increased to a dangerous level.  I expressed my surprise at this, and she pointed to the computer screen where the pathology results were displayed in serial form:
Total cholesterol
7.8    7.2    4.8
and at that point, she said in a horrified voice - "Wait, I think I was looking at the wrong one.  4.9 is the most recent one isn't it? Since you started the statin."

What she had done was assume the results were listed from newest to oldest rather than oldest to newest.  On the face of it, this seems pretty dopey, especially as each column has the date printed at the top.

But it's actually an easy mistake to make, as that is indeed the way that some pathology companies list their data so she would have been used to just looking at the leftmost column, whereas I am used to the one I am familiar with from work, which does it the logical way.

I say logical because we read from left to right, so it makes sense for new data to be added to the right of the old data.  You may accuse me of cultural imperialism, but if you usually read my blog from right to left, esnes ekam t'nod sekoj ym rednow on s'ti.

In fact, I have made the same mistake in the past, but in reverse.  I was working in ED and got a different company to fax me some old results.  I read them the wrong way around and rushed off to try to figure out why the person's blood tests just made no sense at all.  How embarrassing.

But not as embarrassing as the time I checked a patient's blood test results, which gave a reading of 55378008 ng/L, but I had glanced at the paper upside down, so unfortunately broke the news to the patient that they were boobless.

Once again, German has an unexpectedly apt word for what you have just experienced

Blutschlauchüberraschung (n.) - A feeling of wonder, as that elicited when emptying your pockets upon arriving home after an evening at work only to unexpectedly find a tube of blood, unlabelled, whose origin you do not recall.

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?

German is an incredibly versatile language

Manfraurektumverwirrung (n.) - The disorientation felt by the medical examiner during a rectal exam when they realize that the man's rectum feels much more like a woman's rectum because the man has had a total prostatectomy so there is no anterior firmness, so for a brief moment the doctor is concerned that they have made a terrible mistake and is fact examining the wrong patient.

Sincere gratitude

Thank you for laughing at me when I needed help.
Thank you for being incredulous that I couldn't read your mind.
Thank you for making me guess when you knew I didn't know.
Thank you for answering my question with a question
Thank you for questioning my answer too.

Thank you for being too busy for me.
Thank you for having heard more interesting stories far away, in another time.
Thank you for not meeting my eye.

Thank you for wandering and hiding and making me chase you.
Thank you for your affectation of indolence which told me what I needed to know.
Thank you for dismissing me.

Thank you for monitoring me.
Thank you for checking up on me behind my back.
Thank you for offering. I agreed, but then the offer changed.  Thank you.
Thank you for making me feel like I could do this.

Thank you for staring at me in disbelief.
Thank you for mistrusting me.
Thank you for threatening me.
Thank you for trying to take away my options.

Thank you for talking and talking and talking.
Thank you for not listening.
Thank you for not trusting me.
Thank you for bragging and strutting and pouting.

Thank you for grinning and smiling and acting like my friend.
Thank you for seizing the opportunity to belittle me.
Thank you for asserting your dominance.
Thank you for your misperception of my admiration.

Thank you for being lazy.
Thank you for making me do your dirty work.
Thank you for mocking and boasting and preening.

Thank you for trusting me.
Thank you for thanking me for what I have to give.
Thank you for listening to my opinion.
Thank you for sympathising.
Thank you for making me feel like a human.

Thank you for interrupting.
Thank you for correcting.
Thank you for not listening.
Thank you for looking so bored.
Thank you for making your obligations seem like favours.
Thank you for showing your contempt.

Where have all the nurses gone?

Doctors are a superstitious, cowardly lot.  So my disguise must be able to strike terror into their hearts.  Errr, no forget that.  Just think of the superstitious, cowardly bit.  There is no disguise.

Doctors are so superstitious that they do. Not. Ever. Use. The word. Quiet.  It's never a quiet day.  It's never quiet in here.  Even patients aren't allowed to say these things.  People will be quickly corrected.  It is in fact "steady", "ok", "not too bad", or (for the extremely bold or naive) "a bit slow".  Everyone knows that saying it is quiet invites the attention of the Gods, who will smite you most unjustly and spitefully.

Yet some things, when examined with the might and majesty of science, turn out to be not superstitions but cold hard facts.  Take, for example, the observation that when the nurses are hard to find, it means that the shit is about to hit the fan. After lengthy investigation I have determined that this is true, a truth that shines brighter than the sun, casting shadows on our minds so we knowest it even while our backs are turned from the light.

Sorry, got a bit florid there,

The facts are these.  Nurses, with their superior sense of hearing and touch, are able to sense the low-frequency vibrations caused by distant shit hitting the fan.  As the shit and the fan grow closer, the nurses become agitated and distressed, and will find ways to escape the impending disaster.

For example, today I saw a herd of fifty nurses galloping wildly in circles, biting and kicking at each other in dismay, before they suddenly veered away and plunged off a great precipice to fall hundreds of metres into an icy mountain river and were swept onward to the sea.  Soon afterwards, a busload of bespectacled teenage girls who were unable to weight bear on their mildly sprained ankles presented to triage.  With their mothers.

Another anecdote, if I may, for while the plural of anecdote may not be data, it certainly is "blog":

Last year, I myself witnessed a dozen nurses leaping above the water of their pond, shaking their golden tails in the sunlight.  Very soon, they were all lying helplessly on the bank of the pond, their scales glittering while their gills gaped and flapped as they slowly suffocated in their thirst for oxygen.  I stood above them and sang an old Scottish dirge but kept my sextant ready.  Sure enough, soon it was reported that there was no more instant coffee in the break room, and it was the weekend so the cafe was shut.

As you can see, even seemingly inexplicable occurrences have their origins in physicks.  The modern man of science must eschew superstition in all its forms if we are to struggle up beyond this primal muck in which we wallow.

I'm Bat-Man!

Alternative pain scales

Fahrenheit Pain Scale:
If your pain was a number between 32 and 212, where 32 is no pain at all and 212 is the worst pain you've ever had, what would it be right now?

Complex Pain Scale:
If your pain was a number with a magnitude less than or equal to 1, where 1 is the worst pain you've ever had, and i is defined as the square root of an immense sense of well-being and fulfillment, what would its magnitude and phase be right now?

Vintner's Pain Scale:
If your pain was a volume of wine, such as a gallon, rundlet, barrel, tierce, hogshead, puncheon, tertian, pipe, butt, or a tun, where a tun would be the worst pain you've ever felt, how much wine would it be right now?

Sagan's Pain Scale:
If your pain was a number between 1 and billions and billions, where billions and billions was the worst pain you've ever had, what would it be right now?

Hertzsprung-Russell Pain Scale:
If your pain was a letter from the sequence M, K, G, F, A, B, O where O would be hot, luminous pain radiating in the ultraviolet, what would your pain be right now?

It's all Welsh to me

Had a med student trail me around for a few hours this evening.  He seemed like a decent guy, in that he was interested in discussing things other than medicine.  As a result, when he asked me to sign his "attendance book" (to prove that he bothered to turn up, a program probably instigated as a direct result of students like me who took the university's unofficial slogan of "Teach Yourself Medicine" rather too literally), I wrote some feedback in there to the effect that I thought his pronunciation was excellent and that I appreciated his willingness to contribute anecdotes from his extensive and esoteric background knowledge.

We had this strange conversation where somehow he ended up explaining the etymology of the word "dysdiadokinesia" to me.  Because it relates to Alexander the Great and his successors, I ended up talking to him about Ptolemy, and because that sounds vaguely like Potomac we ended up talking about the American civil war and Washington crossing the Delaware river.

Interestingly, when I got home I attempted to verify the etymology of dysdiadokinesia and found it less easy than I expected.  I ended up trying to use Google Translate to translate the word "diadochos" from Greek into English, but Google insisted that "diadochos" is actually Welsh.  Welsh for "diadochos" in fact.  However did we live before Google?

So then I tried translating "diadochos" from Welsh into Greek, and got "Διάδοχος", which I then translated back into English and got "successor".  The Diadochi were indeed the Macedonian successors of Alexander the Great, like Ptolemy (who ruled in Egypt).

But I'm still not so clear on what that has to do with dysdiadokinesia.  Oh well.

A word of advice

In a recent comment on my post regarding pain scores, the indefatigable Lumpage asked, "Uhoh, I set my pain scale between 0 and 10. Am I doing it wrong?"

No, Dr Lumpage, you're not doing it wrong.  You're just doing it different.  Which is my way of saying you're doing it wrong.  Stop - collaborate and listen.

You see, I don't offer the patient the option of a pain score of zero, for the following three reasons:

1. I have already asked them if they have any pain.  And I only ask them for a pain score if they actually have pain.  If they told me that they were in pain, and then told me that their pain score was zero, I think my brain would haemorrhage from sheer frustration. The medical history is a battle of wits.  Patients will delight in flummoxing you at every opportunity.  You must learn to close off every avenue of potential nonsense, building up your innate feel for these types of simple traps so you can conserve your energy for the real battle ahead: presenting the patient to your boss.
2. Having a pain score of 0 to 10 is actually an 11 point scale.  This sort of thing works well for humorous effect in rock 'n' roll mockumentaries, but isn't very practical when it comes to taking medical histories from patients at 4am when neither of you can think good.  Say the person's pain score improves from 10 to 5 after 4mg of IV morphine.  In my system that is a 50% reduction in pain.  In your system that is 5/11 or a 45.4% reduction in pain.  Which is frankly absurd. Especially since if the pain drops again by another 5 points to zero, that's another 45.4% drop, for a total of 90.8%, and they are now pain free.  What the fuck? Where did the other 9.2% of their pain go?
3. Is the patient alive? Then they are in pain.  Life is pain. Only the dead feel no pain. Or people that you've put a really good ring block in - you can just rip their nails out using haemostats and they don't feel a thing.  It's full on.  But aside from them, everyone else feels the exquisite pain of living, every waking moment, swimming in the agony of existence until they can swim no longer.

So, yeah, you're doing it wrong. 1 to 10, my friend. 1 to 10.

Non-renewable resource

"I'm so sorry for wasting your time."

It's surprising to me how often people say this to me at work in the Emergency Department.  Actually, it's not - it's surprising WHO says this to me at work in the Emergency Department, and WHEN, and WHY.

People never say this AFTER I have finished with them.  They always say it BEFORE-hand.  And the people who say it are usually the people who are absolutely not wasting my time.  These are the people that emergency departments exist to help.  They are most often elderly people who are quite frail and live alone, polite to a fault.  For example, they may have fallen down during a dizzy spell and been unable to get up again for some hours until they were discovered by chance.  You know - the people who could easily have turned up (or not) the next day - dead.

The other big pre-emptive apologisers are parents of very small babies, only a few months old, who have been dropped on their heads or have some kind of mysterious raging fever.  Again, people where things can go seriously wrong very rapidly, so coming to the hospital for a safety check is an entirely sensible thing to do.

Or the guy who broke a bone in his leg but didn't come to hospital for 9 days despite being unable to walk AT ALL because he thought it was just badly sprained and hadn't even taken any painkillers.  That guy apologised for wasting my time until I showed him his x-rays.

On the other hand, nobody has ever apologised for wasting my time when they have come to hospital on a busy Saturday night complaining of itchy arms.  And nobody has ever apologised for wasting my time for telling me that the pain in their ankle is so agonising that I can't even touch it, let alone expect them to bear weight on it, but who then, after being cleared of fractures with an x-ray, stand up from their wheelchair and walk unassisted out of the department.  And nobody has ever apologised for wasting my time when telling their child, who has bumped their arm and has a bruise, not to move it around like I am asking them to, just in case they hurt themselves.  These people do not apologise.

However, I can't complain too much.  Well, I can, and I just did.  What I really mean is that it is hypocritical for me to complain.  The person who wastes the most of my time is me.  And I don't even get paid for it.

Donate now.

There's a word for it in German

Zehennagelschnurrbartangst (n.) - The experience of, having hours earlier extracted an infected ingrown toenail from a patient, smelling the pus again, and worrying that perhaps some of it has squirted up onto your moustache without your knowledge.

Obligatory blog post about pain scores

PTR

So if you had to give your pain a score between 1 and 10, where 10 is the worst pain you've ever had, what would you pain score be right now?

Mrs Lumbago

10

PTR

So this is the worst pain you've ever felt?

Mrs Lumbago

No, it was worse this morning.

PTR

Ok, so if it was 10 out of 10 this morning, what score would you give it now?

Mrs Lumbago

10

PTR

So it's just as bad now as it was this morning?

Mrs Lumbago

No, this morning it was much worse.

PTR

Right. So the pain was at its worst this morning, 10 out of 10.  If 10 is the worst, what's it like now that it's a bit better?

Mrs Lumbago

10

PTR

Excellent. Excellent.

Corrosion

You laugh at me when I need help.

You act incredulous that I can't read your mind. 

You make me guess when you know I don't know. 

You answer my question with a question

You question my answer too.

You're too busy for me. 

You've heard more interesting stories far away, in another time. 

You won't meet my eye. 

You wander and hide and make me chase you. 

Your affectation of indolence tells me what I need to know. 

You dismiss me. 

You monitor me. 

You check up on me behind my back. 

You offered, I agreed, but then the offer changed. 

You made me feel like I could do this. 

You stare at me disbelieving. 

You mistrust me. 

You threaten me. 

You tried to take away my options. 

You talk and talk and talk. 

You don't listen. 

You won't listen. 

You don't trust me. 

You brag and strut and pout. 

You grin and smile and act like my friend.

You seize the opportunity to belittle me. 

You assert your dominance. 

Your perception of my admiration is all too wrong. 

You are lazy. 

You make me do your dirty work. 

You mock and boast and preen. 

You trust me. 

You thank me for what I have to give. 

You listen to my opinion. 

You sympathise. 

You make me feel like a human. 

You interrupt. 

You correct. 

You don't listen. 

You look so bored. 

You make your obligations seem like favours. 

Your contempt is showing. 

Oh my god, it's full of wax

So the med student had been off to assess this 1 year old, who was fine, and I'd gone in afterwards to check him out.  All was ok, but the kid certainly did have waxy ears (the patient, not the student).  No biggie.  The main task is to dissuade the parents from trying to prise/scrape/plunge/burn the wax out in future.

And as usual, I got the med student to do the write-up which I then counter-signed.  But, as always, I like to read what I'm actually signing, and when I got to one particular sentence I did a double-take:
"Unable to visualize tympanic membrane due to excess ceruleum"

From the context, waxy ears, but what the hell is ceruleum?  I'm 99% certain he meant to write "cerumen".  So I show it to my colleague Dr Rmo, and we have a good old chuckle about it.  Then it occurs to us that ceruleum might be a real thing rather than a typo, so we google it.  And it turns out that:

"Ceruleum is an energy source in Final Fantasy XIV. Ceruleum is a refined form of Aether, obtained by draining elemental Crystals of their energy, usually in processing factories. It is a powerful yet highly unstable source of energy, mainly used by Garlean Empire to power Magitek engines."

At which point we basically pissed our pants laughing. 

But honestly, it's not the first time this kind of thing has happened.  I remember when I was an intern on nights, trying over and over to get a nasogastric tube down into an elderly lady with a bowel obstruction.  Eventually I sent her for a lateral neck x-ray and, sure enough, she had a retro-pharyngeal deposit of dilithium which was almost blocking her oesophagus.

Then there was the guy whose prostate was jam-packed full of unobtanium, preventing me from forcing a urinary catheter through.  I would tell you about the young woman and her vibranium but that might be sailing too close to the wind.  Suffice it to say that a day without an orifice filled with imaginary power sources is like a day without sunshine.

Med students = softcocks

My latest shift in the ED was made more awesomer than usual by the presence of some med students.  Med students can be a mixed bunch.  I'm not very keen on the ones who are both diligent and knowledgeable, because they often ask me questions that I don't know the answers to, which requires me to respond by crushing them like helpless ants.  The ones who are neither diligent nor knowledgeable are also useless, because, well, they are useless.  You can't effectively delegate anything to them because they'll either stuff it up or wander off because they saw something shiny.

I suppose that in theory there could be med students who are not diligent, but are knowledgeable.  For a moment I was going to pretend that I was one, but that would be stretching the truth too far even for the interwebs.  Which leaves the diligent but not knowledgeable students.  Eeeeexcellent!

These are the guys you can send off to do stuff and they'll actually do a good job.  Usually better than I will do, actually, at least in the sense that it will be more thorough.  And as a special bonus, I often know how to answer their questions.  And if I don't, they can't detect my bullshit.  Or at least they aren't confident enough to call me on it, which is effectively the same as far as I'm concerned.

So it's great if you get the right students, because you get them to do all your work for you while you sit back on the couch eating bon-bons and sucking down all the Imperial Dust instant coffee you like.  It's prudent to go and actually check the facts for yourself at some stage, but you still save a bunch of time.  Presumably the students get something out of it as well.  I have vague memories of being a student and having nothing but respect and admiration for the junior doctors who exploited my labour so ruthlessly - yes, that's it, respect and admiration.  Made me the man I am today.  And I'm sure the respect and admiration flowed in both directions, as it most surely does still.

Having said that, a couple of the student were total softcocks.  One of them did a really good job of history taking and examination and writing up his notes, but I was shocked, SHOCKED, to discover later on that he had forgotten to list the patient's medications.  Instead there was a forlorn empty paragraph beginning (and ending) with "Meds:" - it took me at least a minute to enter the patient's four medications there.  Sheesh.  Next time I see him I'll crush him like an ant.  But not before I guilt trip him into buying me a coffee and giving me a footrub.

Another student was an even bigger softcock.  She found out from the nursing note that the patient has tested positive for parainfluenza by her GP, and then didn't want to see that patient in case she got sick because she had exams coming up.  In how long?  Six weeks.  Six.  Weeks.  If you don't recall, I actually gave birth to triplets DURING my med school exams while recovering from breaking the land speed record wearing sandpaper undies.  Honestly, if you're going to get frightened of parainfluenza, maybe you need to rethink being a doctor.  Or at least buy me a coffee and give me a footrub to make up for being such a softcock.

My day was lightened though, by the aforementioned patient. She said to me, "Parrot influenza? I don't have anything to do with birds!"

Gold.

Great Old One of the Cthulhu Mythos, or Pharmaceutical?

1. Lythalia
2. Rokon
3. Cynothoglys
4. Lapatenib
5. Inpesca
6. Romiplostim
7. Cyproterone
8. The Worm That Gnaws In The Night
9. Zindarak
10. Irinotecan
11. Zonisamide

Answers
Great Old One: 1, 2, 3, 5, 9
Pharmaceutical: 4, 6, 7, 10, 11
Both: 8