Living and Learning.

It happened, I missed a blog. I actually missed two. In the name of confession I also haven’t run for 14 days days and I missed 13 days of studying any medicine. Not ideal but fair given the circumstances I’ll recount below. Important to know at the outset is that this is indeed a long blog, apologies.

I write today about living and learning. Irrespective of circumstance.

I learnt a lot in the past fortnight. I learnt to listen to my body. To trust my intuition, even my inexperienced medical intuition. I learnt about the joys of a caring nurse, and the potential discomfort at the other end of the spectrum. I learnt a little about pain, a bit about dignity. I learnt that ‘eyes forward’ isn’t just about work or sport. I learnt that having family around at tough times makes them far more manageable. I learnt that the predictable ups and downs I’ve come to love when running an ultra is mirrored in illness. I re-learnt about smiling and accepting because at times there may be little else worthwhile.

A great photo on Twitter yesterday showed the normal squiggle of an ECG with a caption along the lines of ‘without ups and downs in life you’d be dead’. I had a down last week. I’m on the up again now. By definition, I am alive. As I write about these ups and downs I will maintain that this is not a whinge. I realise that the absolute level of ‘hardship’ here is low. I am incredibly fortunate and am very aware of this. I write simply and honestly about the things I have learnt. The little things. Read on and you might learn something too.

It started with a tummy ache. Boring I know. ‘I don’t have time for this’ was about the extent of the thought I gave it for the first two days. The ache persisted, it was now accompanied by tenderness. The medical brain kicked in to gear as I took my history. Bowel habits? Fine. Fever or any other signs of illness? Nope. Change in appetite? No. Localised or diffuse tenderness? Diffuse. Or is it….? I’m sure I’ll be fine.

That night I half-jokingly said to my wife Carly:

‘I think I have appendicitis, if I wake you up in the middle of the night with severe pain just chuck me in the car and drive me to ED.’

The basis for learning point number one – listen to your body and trust your intuition.

I carried on with life, wondered about a musculoskeletal cause for the pain. I was still running everyday, I stretched the crap out of my hip flexors, it was still a boring story. At most the pain was a 2-3/10, maybe a little worse with some poking and prodding. Starting to localise….? ‘No I’m being paranoid!’ Or maybe… ‘No don’t be stupid.’ I chastised myself.

Placement was going well, I was ticking off experiences, getting along well with my supervising doctors and seeing lots of patients. It got to Friday and a little relax time allowed me to slow down, perhaps to tune in with myself a little more. ‘Hmmmm… Is the pain getting worse?’ No it’s fine. What happens if I poke my appendix? ‘Ouch.’ Hindsight is beautiful but at the time I was in the denial stage. 26 years old with some lame abdominal pain. Must be a viral cause, a bit extra sleep for a few days and I’ll be fine.

I studied most of Saturday then hit the bush and knocked out three repeats up the nastiest black mountain trails. Hard hiking on the way up, bombing the downs – prep for that 100km ultra in May was going well I thought as I drove home exhausted. Arrive home and hold on a minute…. Pain started to climb. 4/10… Maybe 5/10. It was a little more local, a little more tender.

‘Could still be my hip flexors, hey babe where is the foam roller?’

Ah hindsight.

Sunday morning I was sore. ‘Ok fine, I’m going to the doctor.’ I was heading into the acceptance phase now. I tried to elicit rebound tenderness (turns out very hard to achieve on yourself), continued to poke and prod my right iliac fossa out of curiosity. I was headed to the hospital to study so I booked a 10:40am spot at the after hours GP. Sitting in the library trying to study, pain 6/10, sore to move, slow to walk. It was 10am on the 5th day of some boring abdominal pain and I brushed passed full acceptance. I called Carly, told her I felt like company at the doctors and went to pick her up. I love her and I love her company but this was about forward thinking, not loneliness – if I had appendicitis I would be bounced to ED and admitted for surgery whenever they could fit me it. What good was it if Carly was stuck at home without the car, I had better go pick her up. Carly later recounted her disbelief at how calm and collected I was that morning given I knew I was likely headed for admission and surgery.

The GP I saw just about giggled when I told my story and she examined me. Her smirk was so evident, ‘this is classic appendicitis, are you sure you’re a medical student?’ was the sum of the sentiment. I strolled down the corridor to ED, handed over the hastily typed referral and grabbed my spot in the cue.

‘So did you just ask me to come down because you thought you would be admitted?’ Carly quizzed with a cheeky grin.

Busted.

If I’m honest, the whole thing was a little underwhelming. For perspective, in an ultra last year my right knee hurt easily two times as bad as this for the final 60km of the race. ‘Surely appendicitis should hurt more than this?’ was the thought circling my head. This was quickly put to rest by the ED doctor, every nurse that heard the story, the surgical registrar who came down to consult with me, and the two interns in ED who had been my senior classmates last year.

In the hope you might read this full post I had better speed this saga up. Although it is far from the climax.

Admitted on Sunday, fasting fasting fasting for surgery tonight right? Guys… Hello? I was kidding myself, it was a long weekend and I was a boring story that would be easily bypassed by a busy theatre. Fasting fasting fasting for surgery Monday. Ok cool, surgery done. No trepidations around this aspect. Past broken bones mean this was nothing new so bring it on, ‘fix me!’. All seemed to go well. ‘Crunch down endone for a day or two after discharge and I’ll be away again’ was the idea in mind as Carly drove me home.

Tuesday night and Wednesday weren’t fun. The endone (3 every fours hours in addition to the panadol and nurofen) wasn’t cutting the mustard. Mild concern. It felt so lame to be so incapacitated, Carly had to help me get up from a chair, get down to a chair, get into the shower, sit up in bed. I had to close my eyes and block my ears when we were watching a comedy show on TV, laughing was unbearable. If I coughed I winced and broke out in a dramatic sympathetic sweat. It appeared that abdo surgery was a different recovery process to shoulders and wrists…

I woke in a daze about 9:30pm on Wednesday night. A new symptom had arrived, overwhelming nausea… I did the complicated manoeuvre to get myself from lying to sitting and lurched to the bathroom. The vomiting started. Coughing had been bad, deep retching and vomiting was far worse. I sat on the floor and filled the base of the bath with what looked like everything I had eaten since the surgery. Semi digested food, bile. Lovely. I didn’t want to wake Carly so I went to the dining room table and tried to sleep sitting upright with my head on a pillow on the table top. I woke an hour later in a puddle of drool and lurched my way to the bathroom again. I filled and re-filled the sink with more internal contents. Again, lovely.

My medical brain started churning about the new predicament, attempting to put the pieces together. Abdo pain worsening steadily (now worse than that blasted knee pain in the ultra), recent surgery, profuse vomiting, no bowel motions since before the surgery, now unable to urinate either. Hmmm SBO? SMI? I wonder if I have any bowel sounds? A quick listen with my stethoscope said no to this question. I gave in.

‘Hey Carly, I think I need you to take me back to hospital.’

Basis for another learning point number two – having family around at times of hardship makes them far more manageable.

She was great. ‘Ok no problem, give me 5 minutes to get dressed.’ We got to ED about midnight, every bump on the way there gave a corresponding cringe and more vomiting soon followed. I filled a plastic back with what was surely the last of whatever I had within me. Unfortunately we arrived to a busy ED, about 15 people sitting around displaying the full spectrum of discomfort. The triage nurse listended to my story, gave me some ondansetron to settle the nausea and asked me to take a seat.

For fear of a rant breaking out I won’t go into my thoughts around this part of the story.

I alternated between a hunched ball on a chair and an absent figure perched over the sink in the bathroom continuing to empty my guts. My mate Aidan once drove me 2.5 hours from a remote farm to the hospital with a suspected dislocated shoulder. Upon arrival the ED doctor tried for 10 minutes to ‘re-locate’ my shoulder. The subsequent x-ray showed I had a broken humerus rather than a dislocation. The pain during the ‘relocation’ was indescribable. This ED abdo pain was climbing to those kind of levels. At 3:40am we were asked to come through…. Under the four hour mark. Again, I won’t go into my thoughts on the triage system in practice there – eyes forward.

By 4:30 I got to see a doctor and was administered some IV morphine. Pain below 10/10 again, winning. Examination showed guarding, diffuse tenderness again localising to the RIF, afebrile, few bowel sounds, peripherally pretty shut down. Thankfully an X-ray showed no big dilated bowel or signs of obstruction, winning again. ‘Surely I’m too young for SMI’ I remember thinking. ED doc heard the story, intern heard the story, surg reg brushed past for an opinion, I even got to see the consultant surgeon. A catheter went in and a litre of urine poured out, ‘Well there goes part of the problem’ I remember thinking. I was a bit more comfortable now so it was off to CT to figure this thing out.

Result – first surgery left a ‘normal’ stump of appendix. This stump was now misbehaving. It appeared to have an appendicolith within and was surrounded by heck knows what. There was fluid all over the place. The surgical report would later talk about an abscess, omental adhesions, pus and fluid through the paracolic gutters. All the fun stuff.

Thursday morning in a busy ED had me out and into a ward by 10am. I went back to my brief home from earlier in the week, I was kindly welcomed back by the nursing staff, consistently facing the light-hearted question, ‘did you miss us?’ The CT results meant another surgery, a second appendicectomy (or appendectomy for any American readers). Moreover, it meant a slow recovery, an extended stay with more fasting fasting fasting both pre- and post-surgically.

Gosh they were quick this time. I was in the OR by early afternoon. I was in a recovery daze with two lovely nurses not long after (the joys of general anaesthetic). Back in the ward I was sore. Carly was there by my side but I was hopeless. Consistently and completely reliant on her to do everything. My dad had come to town when I first headed into the hospital. He would later come down again when I was going through the joys of this recovery. Dad oozed kind eyes and practical help while he was there. He brought down a motorbike mag for me to read, sat with me in the hospital as we watched the F1 beaming to us from Melbourne. Yep, family is a necessary component. When neither Carly or Dad were around I prayed for nurse Kim to be on duty.

The basis for learning point number three – a caring nurse is a true angel, their value cannot be underestimated.

I want to detour here momentarily to explore this. I’m a people watcher by nature, always trying to be attentive to that and those around me, to ‘Be here. Now.’ as it were. Anyone who has been in hospital will likely speak of a spectrum of nursing care, or all medical care for that matter. There are outwardly and obviously caring nurses, and at the other end of the spectrum there are those that are unintentionally less caring, less compassionate. I bring this up not to whinge but instead to plea that you, in your role as a health professional or a family member of someone unwell one day, try to aim for the rosy end of the spectrum.

I reflected a lot during my hospital stay about what things defined good care. I went round in circles as I thought about this. I dismissed all the frequently quoted ideas about type of training, age, ethnicity, or sex. I think these things matter little. Instead, I came to the simple idea that a good nurse (or any health professional, or family member) has one simple empathic desire at the top of their list – to give people comfort.

Let me explain.

My beloved nurse Kim would come to take my middle of the night vitals in a completely different fashion to other nurses in the ward. In a way which left me as comfortable as I had been before she came in the door. This involved no single bit of technical skill, instead it focused on doing the required job and leaving me comfortable again. Kim would knock quietly and spread the curtains. She would gently wake me and ask how I was feeling. Kim would explain what she was doing, help me manoeuvre myself appropriately then do the jobs needed, heart rate, blood pressure, temperature, respiratory rate. Kim would ask if I needed anything else then explain when she would be back next. Lastly, Kim would shuffle out quietly and close the curtains again. I would drift easily back to sleep (well, as easily as was possible), having not been startled or worried for a second. If I’m really honest, the closing of the curtains was the most distinctive action that caring Kim, and other nurses in her realms, did over the other-end-of-the-spectrum nurses. This was the bit that showed she wanted to leave me as comfortable as she had found me. It was empathy in an action, it was compassionate.

Again, I write all of that not to whinge. Instead to express concern for the people stuck in hospital for months on end with truly terrible health conditions. I also hope to educate and in that vain I urge you to be caring and compassionate when dealing with patients. Think about, and even ask them openly, what they need to be comfortable. Close the curtains when you leave. I will be trying to do all of these things when I get see patients from now on.

My stay progressed slowly. If I’m honest, the two days after the surgery were shit. I was exhausted and couldn’t get comfortable. I don’t want to belabour this point though, instead I mention it so I can talk about turning the corner and feeling better.

Basis for learning point number four – ups and downs in physical and psychological state aren’t just a feature of ultra’s.

If you’ve ever run very long distances, or completed any really long distance events for that matter, then you may know what I am talking about. In my first ever 100km race I had a bad patch that literally lasted hours. Everything hurt in this patch. Feet hurt, so did knees, hips, back, shoulders, neck. My running slowed down and even walking became hard. Then the strange thing happened… I  started feeling better. The crap patch lifted. My legs started to loosen and my pace picked up. I was smiling again. I went from thinking there was no way I could make it the full 100km to knowing that I was going to make it.

As you go further into events like this things get more interesting. You won’t keep your high. Instead, you’ll drop low again, even lower than before. Then you swing wildly into the sunshine and rainbows again, higher than you were last time. The further you go the faster than mood swings occur and the more extreme they are. When you go beyond 10 or 12 hours in an event like the mood patches can last only minutes before the next swing. You learn to smile your way through the crap patch, grasping tightly the knowledge that if you just keep putting on foot in front of the other it will pass.

On Saturday morning, two days after the second surgery the pain seemed to drop. My in-dwelling catheter came out. The daily heparin needles seemed to hurt less. I had my first shower in days. My mood shifted upwards and a light flicked on at the end of the tunnel. I got my good patch back. It’s now a few days post discharge and I’m clear of the race it seems. I did manage to come out with 10% less body weight, a few new scars, and horrible attempt at a beard but I’m better, and that’s the main thing I believe. In summary, I learnt four key lessons in my time on the ‘other side’ of health care.

  1. Listen to your body and trust your intuition
  2. Do not be afraid to ask for the support of those close to you
  3. Give the patient what they need to be comfortable, be empathic, kind and compassionate
  4. The bad patches will come, and then they will go, smile to let them pass

I’ll stop here for now. This is by far my longest blog and if you’ve read this far I thank you. To me this period of time assured me that there are things to learn in all circumstances. The tricky part may be to tune in to this.

See you next week.

Back to medicine.

Getting back to medicine is a nice feeling. I say this because when juggling a few others balls study time isn’t at a leisurely pace, nor is it ever as long as I’d like. When I do sit down, with my email switched off and some music going, I feel more at ease. I can focus on the patient’s complaint from earlier today, I can choose the learning objective to focus on. It’s like switching gears, and gosh it feels good.

I’m not one to stop readily. Nor are you I suspect. Modern times appear to demand a high pace, there is the expectation of a state of urgency, of always being available and ready to act. Some people thrive on this (ED doctors??), others prefer meticulous work with all of the same importance but stripped of the urgency (anatomical pathologists??). Within the medical world we see a stark contrast when comparing the demeanour of the pressure seeking retrieval medicine specialist to the anatomical pathologist. There also appears to be this same contrast between different roles held by the same person. Or between different tasks within the same role. Let’s explore.

I recently read a few articles describing tasks on two intersecting spectrums. Heading in one direction we have the urgency of a task. At one end, those that must be done yesterday, at the other end the ‘when I get to it’ jobs. The intersecting spectrum consists of task importance. This is equally diverse, at one end the really important things. And I mean really important, like planning your life goals or marrying your long-term partner (urgency often at play here I suspect…). At the other end is to buy that spare box of paper clips because you’re halfway through the current one.

The above idea then defines four categories for tasks:

  1. Both urgent and important
  2. Important but not urgent
  3. Urgent but not important
  4. Neither urgent nor important

So to today’s reflection. Today I write about changing gears to suits the tasks in different categories. Specifically, how to get into the right gear, the slower and more thoughtful gear, for category two. I find this hard given it is surrounded by urgent tasks.

Take now as an example. I sat down for some category one and three time. These require the same high gear so I figure it’s best to aim to knock some over in the same sitting. The intention was to spend an hour in that gear, in the midst of the urgency, before knocking back a few gears and getting some category two tasks done (yep that’s right, category two is all about learning medicine). How wonderful a plan that was. Oh how my intentions were pure….. Oh how I missed the mark. Three hours have gone by and I am still in urgent territory.

This is what happens when you don’t change gears properly. I got caught up in urgency, forgot all about importance and now it’s after midnight. I’ve got buckleys of getting decent study done now (so I might as well blog?). I’m sure many people experience this, grand plans of knocking over those few urgent jobs before getting down to important things. I’m sure many medical students do this, quick trip to the shops for supplies before swinging by Joe’s to pick up the… and while I’m out I’ll just… and then I swear I’m gonna study this afternoon. Urgent gears are hard to get out of sometimes.

So what do I need to do to prevent this happening again? I plan to use stop signs. I accept that it’s fair to knock over category one first. These are true priorities that do have time pressure so go ahead. But if you plan, like I did, to make use of the high gear by doing some category three jobs you must put a stop sign in place BEFORE you start. This stop sign might be a time limit, “i’ll do 30 minutes of…”, or a specific number of jobs, “ten emails and I’m done”. I didn’t set a stop sign tonight and guess what, I never stopped. Urgency grabbed hold of me, and yes I do love this feeling at times, but tonight I got dragged along for a ride. I missed my chance at getting important work done, I missed my chance to visit category two – getting back to medicine.

Whether you’re the ED doc, the pathologist or the medical student you have tasks that need different gears. Don’t let urgency ruin your chance to have a crack at importance. Spend more time getting back to medicine.