Category Archives: Humour

Flying training vs. GP training

At the beginning of 2012,  I was fortunate enough to commence community based general practice training in rural South Australia with Adelaide to Outback GP Training. But before heading out into ‘GP land’ for a year, I interviewed at two practices in the country. Subsequently, I had this conversation with the second practice and GP supervisor:

GP supervisor on ground and air

GP supervisor on ground and air

Supervisor: “Just drive to Port Pirie and I’ll pick you up from there”

Gerry: “But I could just drive the whole way”

S: “No, no. I’ll fly there and pick you up”

G: “Oh, do you have a plane?”

S: “I’ve got two”

G: “Wow, flying is something I’ve always thought about doing sometime”

S: “Well we need to talk…”

And so I started my first GP placement and my flying training after generous encouragement from Dr. Scott. Following this first year of starting both country GP and flying training, I started to notice some similarities between the two. But GP training is not the first within the medical field to be compared to the aviation industry.

Biggles ready for takeoff (or cuddles)

Biggles ready for takeoff (or cuddles)

Anaesthetics has famously been linked to aviation in the past. And it’s not limited to both sharing the first letter of the alphabet. The obvious comparison involves the separate components of a typical flight and anaesthesia. Take off or induction, cruise on autopilot or maintenance and finally landing, or recovery. The other obversed similarity is that both professions can operate on the basis of 99% boredom, 1% sheer terror (or as one doctor so eloquently put, that moment of “S**T S**T S**T!“). The concept of anaesthetics learning from aviation was first described to me by a consultant as a 4th year student at Flinders Medical Centre. He discussed the case of Elaine Bromiley, who tragically died after unfortunately falling into the can’t intubate/can’t ventilate scenario. Her husband, an airline pilot, questioned the lack of standard operating procedures and checklists that were commonplace in his field. Dr. Leeuwenburg in KI commented in late 2011 on this association and brought to my attention an amazing analogy involving the dashing British flying ace Biggles found here (well worth a read).

But having completed some time in both GP and aviation fields recently, I would argue that general practice training has some similarities to flying training…

Ground/book theory:

In flying training, there is a substantial amount of theory that needs to be learnt prior to gaining a recreational or private pilot licence. These are often in the form of books and sometimes a discussion with the flight instructor. Many medical courses require a few years of theory and required knowledge before being ‘let loose’ on the patient population. In the past it boiled down to knowing the nuts and bolts of the field in question before taking to the air or wards. Nowadays the curriculum for both flying and medical training integrates both practical and theory from the outset.

Easier to read than Harrisons any day...

Easier to read than Harrisons any day…

Simulator training:

As a young lad I was a sucker for Microsoft Flight Simulator and took great (nerdy) joy in pretending to fly planes around the world. From top airline pilots to those learning to fly small aircraft, simulator training remains an inexpensive and safe way to practice emergencies. The same is true in general practice using mannikins, standardised patients and Observed Simulated Clinical Examinations (OSCE). These enable practice, honing of skills and assessment of doctors in a way that is safer for real patients.

I don't feel well doctor

I don’t feel well doctor

Difficult techniques:

In flying, it is important to practice difficult landings regularly. These can involve crosswind technique which need complex control inputs that allow the plane to land safely. Importantly, different crosswind conditions are tackled as no two landings or winds are the same. This is similar to GP where each patient is an individual, each one requiring different techniques. Especially ‘cross patients’.

Logbooks:

Pilots are very familiar with maintaining a proper logbook and it’s something that I started last year when I took to the skies. Logbooks are a great way to demonstrate your experience in a clear and consistent format. I have also found it good to look back and relive the journey, much as this blog has helped. We are also required to keep a procedure log for the different skills that we might be exposed to and learn during our GP training. This is an online platform and has been beneficial (and will continue to be good) in highlighting any deficiencies that need to be addressed.

Written and practical exams:

Flight computer and heart listening thingo

Flight computer and heart listening thingo

It goes without saying that both aviation and medicine require thorough assessment of candidates who are entering a high stress workplace that has very little margin for error. Therefore both fields undergo a number of both practical and written exams to ensure that these fledgeling pilots/clinicians are of a reasonable standard. Fortunately, aviation exams are infinitely more fun, but on windy days can be just as nausea provoking as medical exams.

First solo/consultation:

Then the time comes after hours of learning theory and practicing procedures, landings, consultations, takeoffs, examinations and stalling (applicable to both fields!) for the pupil to go it alone. [Side track: Go It Alone being a fantastic track by Beck with a guest bass guitar by Mr Jack White]. It’s time for the first solo flight or consultation! Both will always be memorable, a mixture of sheer terror and adventure. However in both areas, the supervisor or flight instructor is only a room or radio call away respectively. Fortunately in GP if things are going pear shaped, your supervisor can come in person to help. In the air, you’re on your own and may end up literally pear shaped.

Technology:

Throughout training in both fields there is a massive base of shared knowledge available. Increasingly, many of these resources are online and even use novel platforms like smart phones and tablets. YouTube videos can also explain difficult concepts ranging from crosswind technique to vertical mattress suturing. The advent of free open access information has started to take off in emergency and critical care medicine and I wonder if something similar might begin in flight training.

Worried when your taller than the plane...

Worried when you’re taller than the plane…

Ongoing review:

In private aviation, there is a requirement for a biennial flight review (BFR). This involves a check flight with an instructor to make sure that no bad habits have formed. Similarly, all GP registrars (trainees) within most training providers, a medical educator visit (MEV) takes place. This is an opportunity twice a semester for another doctor to sit in on consultations to see how the registrar is progressing and if there are any problem behaviours developing or major gaps in knowledge.

Acronyms:

CHF, CHT, PPL, PVD, RA-Aus, RSI, EFIS, ETT, GPS, GPRA, APO, APU…enough said. Both fields are often afflicted with what I like to call acronym overload or AO for short.

So as you can see, there are plenty of similarities. This probably highlights the fact that both fields need to produce highly trained practitioners that often work in stressful environments. Their assessments need to involved observed work so that their performance can be best judged. In many ways medicine has learn a lot from the aviation field. But I have certainly applied much of my medical knowledge or communication skills to aviation. Happy to hear your thoughts!

1 Comment

Filed under Aviation, General Practice, Humour, RA-Aus, Rural GP

Choosing a baby name 101

It seems in the past few years that baby names have taken a left turn at the common sense intersection. Those of us working with children (teachers, doctors, nurses, childcare workers) would have certainly noticed this shift in name trends. Of course, popular culture has always influenced the choice of moniker for our offspring. Unfortunately (in my humble opinion), our pop culture now includes such institutions such as Glee, Big Brother and the like. Parents are now naming their children to reflect their (often misplaced) love for these TV shows and movies. In the past, this choice of strange names was limited to the rich and famous: Moon Unit, Pilot Inspektor, Fifi Trixibelle and Sage Moonblood, the list goes on. But the general populous is catching on. Just have a look at the names that are apparently growing in popularity:

Girls                  

  1. Isla
  2. Adalyn
  3. Giuliana
  4. Olive
  5. Kinsley (too close to ‘Kinsey’ for me)
  6. Evangeline
  7. Paisley
  8. Vivienne
  9. Maci
  10. Kinley

Boys

  1. Bentley
  2. Kellan
  3. Kingston
  4. Aarav (clearly just to be at the top of alpha lists)
  5. Ryker
  6. Beckett
  7. Colt
  8. Paxton (as in the star of Twister? Come on)
  9. Jax
  10. Lincoln

A UK study found that 1 in 5 parents experienced resultant disappointment and regret in the different name they chose and wished they had done more research. That or not to have been drunk when choosing.  As clinicians and educators we must also consider the inevitable future Axis 2 diagnosis(es) that the poor child is lumped with.

In light of these poor choices and the future psychiatric consequences, below is a handy reference tool that should help your steer clear of pitfalls in the name game. For our players in ED, you can keep this card and tick off each time you see an example during your shift. The doctor/nurse with the highest score ‘wins’. Enjoy!

Happy to see further examples of names….or additions for the flow chart in the comment section!

What's in a name?

What’s in a name?

References

1. Good or Bad, Baby Names Have Long-lasting Effects. Retrieved February 9, 2011, from Live Science.com: http://www.livescience.com/6569-good-bad-baby-names-long-lasting-effects.html

2. Flora, C. (2004, March 01). Hello, My Name is Unique. Retrieved February 9, 2011, from Psychology Today.

3. http://today.msnbc.msn.com/id/40461260/ns/today-today_celebrates_2010/t/glee-effect-baby-names-reflect-love-tv-movies/#.UOJPee3n00w

5 Comments

Filed under #FOAMed, Emergency Medicine, General Practice, Humour

Butterflies in the stomach

Swallowed foreign objects in kids

I was called to see a poor young fella up at our country hospital the other week and the case got me thinking about the above topic. As we all know, kids are delightfully inquisitive and adventurous. Of course Freud provided us with the five psychosexual development stages. The oral stage is first and spans from birth to around 21 months of age. Unfortunately this stage coincides with the period in which children become increasingly mobile and can evade the watchful eyes of parents. It follows then that the risk of objects being swallowed also increases. (Interestingly, our ED collueges tend to see many adults stuck on the 2nd and 3rd psychosexual stages presenting with interesting radiological findings….)

However a large observational study in 1999, found that the mean age was 5.2 years (Cheng, Tam; 1999). Although many objects will pass through unobstructed, there are a few cases in which emergent care and/or watchful waiting must be undertaken. Like any medical problem a proper history, examination, investigation and treatment plan is required.

History

The primary objective is to glean what the foreign body is and when it was ingested. Sometimes this isn’t always obvious as the parent was not present at the time. An important strategy is to bring a replica of the object. Especially when dealing with lego, disc batteries or hair clip if possible. Any reports abdominal pain or blood in the stool is important. A history of developmental or intellectual delay can also be associated with major complications given a delay in presentation and vague symptomatology. This extends to adults with such disabilities and should always be considered in any case of abdominal pain in this population.

A list of commonly swallowed objects:

  • Buttons
  • Bones (chicken, fish)
  • Coins
  • Keys
  • Safety pins
  • Drawing pins
  • Lego
  • Glass
  • Soft drink lids
  • USB sticks

Special cases:

  • Large coins (ie 20 and 50 cent pieces)
  • Hair clips
  • Button/disc batteries
  • Magnets

Examination

The demeanour of the child may provide hints as to how far the object has progressed. A child with an oesophageal foreign object may be in distress, vomiting, drooling, and irritable or refusing oral intake. Those with objects in the stomach conversely, may be asymptomatic. However these presentations are not the rule and further investigations sought. Palpation of the abdomen can be normal, but signs of peritonism or localised tenderness point to perforation. Generally, examination will be unremarkable.

Investigation

Plain x-ray (XR) is indicated for any metallic foreign objects. The role of XR is to demonstrate that the foreign object has passed the oesophagus. In this case, the object will be below the diaphragm in the stomach. Mouth to anus imaging is usually required.

Nasty battery, luckily in the stomach (NB fluoro light reflection, not chest tube!)

Treatment

Disc batteries

The alkaline nature of these batteries (used in watches and hearing aides) can erode tissue when in contact with moist mucous membranes. If stuck in the oesophagus as seen on XR, these should be removed urgently or the child retrieved to a centre that can perform endoscopy. The tissue destruction can occur in a matter of hours. On the other hand, asymptomatic children with subdiaphragmatic batteries can be observed at home. The stool must be searched and a repeat XR performed after 3-4 days if it has not passed.

Coins & Hair clips

If the offending currency/clip reaches the stomach, there is usually no treatment or intervention required unless symptoms arise. If the agent is stuck in the proximal or middle oesophagus, then semi-urgent endoscopy is required. Although they lack the chemical effect of disc batteries, they can still cause pressure necrosis and perforate. Distal oesophageal objects can be observed with follow up XR. Check stool for passage.

Magnets

The most important question apart from those covered above are: what sort of magnet and how many were swallowed. Recently, there has been a growing trend of ingested strong magnets causing perforation, obstruction and even fistulae. Fatal attraction indeed. So magnets may need urgent surgical intervention even below the oesophagus.

Humorous stories

A young man that I went to college with had skolled a pint of beer at a pub night that had a dollar coin at the bottom. When he presented to ED that night, the coin was found to be subdiaphragmatic. Palpation over the stomach was performed asking “are we on the money here?” and the patient was sent home to ‘pass the buck.’

Not so shiny anymore…

I saw the poor young girl in ED in late 2011, above, who had on her birthday accidentally swallowed her shiny new hair clip and inadvertently got butterflies in her stomach. I didn’t follow up as to whether she was given a replacement.

Another comes from Dr. Scott, my affable GP supervisor had this gem on hand:

God speed, little pendant

Dear Doctor,
‘James’ was brought into A&E this afternoon after swallowing a St Christopher medallion.  We x-rayed him and confirmed that this had passed the diaphragm. We have reassured the parents that the medallion should pass with time and without complication.  We have, however, advised them to see you or represent here should St Christopher’s own travels be unduly delayed.
Sincerely,
A&E Consultant

Final pearls of wisdom:

  1. Find out what it was and when it was swallowed
  2. Foreign bodies in the stomach or intestine should pass in 99% of cases (with normal anatomy)
  3. Most complications involve foreign bodies in stuck in the oesophagus
  4. Plain x-ray can localise a metallic foreign body and stratify into oesophageal and subdiaphragmatic
  5. Caution with disc batteries!

References: 

Murtagh, J. (2008) John Murtagh’s general practice.  (4th Edition). Sydney: McGraw-Hill Australia.

Cameron P, et al. (2012) Textbook of paediatric emergency medicine. (2nd Edition). Sydney: Elsevier.

Cheng W, Tam PKH. Foreign body ingestion in children: experience with 1266 cases. J Pediatr Surg 1999;34:1472-6.

1 Comment

Filed under #FOAMed, Emergency Medicine, General Practice, Humour, Radiology, Rural GP, xrays

Riding in harvesters with farmers

Cultivating primary prevention: the mechanised agricultural approach.

 

All aboard the combine harvester

Just the other day I was fortunate enough to visit one of our local grain farmers on their land. All over our corner of the Eyre Peninsula, hard working farmers are driving neat patterns in their combine harvesters (headers) collecting wheat, barley and other crops. Interestingly enough, our patient numbers have fallen steadily during this time. It seems that most of the community is too busy harvesting to be sick! Subsequently one afternoon, I only had two patients right after lunch. An early day! I’d spoken earlier in the year with a patient about visiting his farm and seeing what goes on around harvest time. After half hour driving east of town, I arrived to be greeted by a gargantuan green machine. There had been plenty of them parked in an empty lot next to the medical centre over the year, but when switched on and heading towards you, they are a different beast altogether!

ALL THE WHEAT!

chomp, chomp, chomp

Obviously things have changed a lot since the humble scythe, kyphosis and a headscarf. These days, the operator sits in air-conditioned comfort with a pre determined track and auto steering. The on board computers can tell the farmer the current yield of the crop and let him calculate (with SMS prices popping up continuously) how well they have done for each field. Looking out through the huge unobstructed windshield, you are able to see everything happening. From being plucked from the ground to being stored in the back of the header, a piece of grain has an amazing journey. When the comb at the front cuts the head of wheat, it is fed into the header by some conveyer belts. Inside, the stalk and the head are agitated so that the grain can fall below and be placed in the hopper for further use. The stalk and left over husks are then spat out the back into the field.

It got me thinking. Could we apply this same principle to primary health care and prevention? Watching the header bear down on me first and then seeing the wheat collected into the machine to get sorted gave me an idea. Often general practitioners, community nurses and health promoters have difficulty encouraging the public to connect and participate in health prevention strategies. One simple reason for this reluctance to attend may be that these approaches rely on self-directed changes. Eating less sugars/salt/saturated fats, exercising more, cutting out smoking and reducing alcohol. Stopping all the things that people can enjoy. But these are also all essential elements in reducing serious preventable health issues such as diabetes and CVS disease.

*duelling banjoes*

I propose this. Rather than relying on self-presentation, family members nagging or proactive health workers, we construct a transportable health prevention vehicle. “But Gerry!” I hear you exclaim, “such schemes exist already.” Ah yes they do (Harold et al), but never before like this. The Combine Health Harvester (CHH) will function in a similar way to the headers currently out in the fields surrounding our medical practice. Gathering then triaging the wheat from the chaff. The process by which the harvester can increase health officer access to patients with poor health lifestyles and then do something about it follows:

  1. Unsuspecting patients scooped off the street by scoop
  2. Channelled into the back of the harvester
  3. There, a BMI, blood glucose, blood pressure, and SNAP history taken, nicely.
  4. If enough risk factors exist, the patient will be kept inside the harvester for delivery to the local clinic.
  5. If the patient is healthy, they will be deposited back onto the street. Then left to continue their daily business with a healthy lifestyle pamphlet in hand.

How it works

Once dropped at the clinic, the patients assessed being at high risk can be tested further and referred to specialist care if needed. The technology and policy for the harvesting and patient education are already here. We just, in the words of the machine itself, need to combine them. Now just to pacify those civil libertarians….

============================================================

DISCLAIMER: This blog post is intended to be taken entirely as parody and humour. If it has not been, then perhaps you’d better go outside and get some sun. Our capture methods in Wudinna are currently much more crude than stated and will be refined in time. Thank you for your patients (sic).

1 Comment

Filed under General Practice, Humour, Rural GP

Bow-ties in medicine

“I have an opinion about men who wear bowties. They are mavericks; truly adventurous dressers who live on the sartorial edge. They are nonconformists and often seen as threatening to the establishment. Yes, look out for the man who sports a bowtie – he probably has an attitude.” – Chris Hogan, 2008.

Revenge of the Ner..Doctors

So I’ve been busying myself this year by watching online lectures as part of the Diploma of Child Health. This is run out of the Children’s Hospital at Westmead in the outer suburbs of Sydney. Throughout these lectures, I have noticed many of the doctors sporting natty bow-ties. During my time at Flinders Medical Centre and in GP land, I could probably count the number of docs setting this trend on one hand (free from polydactyly). But it seems every second professor or head of department on these web-based lectures are wearing them! What is going on? I propose this hypothesis: As one delves deeper and deeper into the sub-speciality crevasse, silent pressures force a required dress code. The most obvious and classic of these, the humble bow-tie. The graph below summarises my findings. Unfortunately elbow patches, jumpers tied across chests, pocket protectors, grubby white coats and mad scientist hair variables have not been investigated, but pose areas for future study.

Figure 1: Bowties verses subspecialty

Neurons or shooting stars?

Additionally, my off the cuff choice of neurologists at the pinnacle of this fashion statement seems to be rather accurate. In an article published in 2010, an American medical news outlet outlined neurologists penchant for wearing bow-ties. The American Academy of Neurology’s self-appointed spokesman on neckwear, John C. Kincaid, MD states that “Bowties suggest the wearer is ‘on the precise side,’ which describes many neurologists.” Yes it also describes the majority of people diagnosed with OCD. Perhaps suggesting a slight overlap in populations? The Academy is pretty serious about this caper, so much so that they even have an official bow-tie festooned with miniature neurons. But you are a renegade infectious diseases consultant, you want something slightly more relevant adorning your small piece of tied fabric. Well never fear. This website makes and sells bow-ties featuring microscopic lovelies such as: Anthrax, E.coli, Swine flu and Rhinovirus. Just don’t get any Syphilis on your neck….

E.coli (not to scale)

But this lighthearted choice of bow-tie material brings us to an important point in medicine. Infection control. Millions of healthcare dollars are spent around the world trying to reduce the number of hospital acquired diseases. Instead of regular neck ties dangling around in purulent exudate or hospital food (equally as nauseating) ready to be transfered to the next vicitim/patient, bow-ties remain high above strangling the neck of the treating physician. Neck ties have been shown to carry nasty bugs such as Staph aureus, Klebseilla and Pseudomonas as shown by a study of New York doctors in 2004. But obviously it depends on the specialty of the wearer, as you wont see much patient/doctor interaction from a radiologist. On a recent Twitter discussion it seems that along with neurologists, gynaecology and urology have higher proportions of bow-tie wearers. Whereas neurologists may be keen to avoid a long tie tickling a patients face during cranial nerve examination (albeit a nice quick way to check CNV sensation), our friends working below the umbilicus may well be avoiding ‘bits’ on their attire. (I chose the word ‘bits’ as the alternatives have been getting too much coverage in the media of recent days and I thought it rude of me to slipper them in.)

White is the colour of purity….

I can also see the benefit of bow-ties in paediatric populations as a way of breaking the ice. Whether the use of novelty ties that spin or flash lights would entertain the children as much as the wearer remains to be seen. Another avenue of research that may be followed. Until then, myself like many rural docs are happy with rolled up sleeves and the occasional boardshort/thongs combo. US readers should note the Australian use of the word ‘thong’ unless you have a confession KI Doc?

7 Comments

Filed under General Practice, Humour

Bogan Medical Terms

Benign – What you be, after you be eight.

Artery – The study of paintings

Bacteria – Back door to cafeteria

Barium – what doctors do when patients die

Cesarean section – a neighborhood in Rome

Cat scan – searching for kitty

Cauterize – made eye contact with her

Colic – a sheep dog

coma- a punctuation mark

D & C – Where Washington is

Dilate – to live long

Enema – Not a friend

Fester – quicker than someone else

Fibula – a small lie

Genital – a non-Jewish person

GI series – world series of military baseball

Hangnail – what you hang your coat on

Impotent – distinguished, well-known

Labor pain – getting hurt at work

medical staff – a doctor’s cane

Morbid – a higher offer

Nitrates – cheaper than day rates

Node – I knew it

Outpatient – a person who has fainted

Pap Smear – A fatherhood test

Pelvis – second cousin to Elvis

Post Operative – a letter carrier

Recovery room – place to do upholstery

Rectum – darn near killed him

Secretion – hiding something

Seizure – a Roman emperor

Tablet – a small table

Terminal Illness – getting sick at the airport

Tumor – one plus one more

Urine – opposite of you’re out

Varicose – nearby / close by

Leave a comment

Filed under Emergency Medicine, General Practice, Humour

Google Assumptions

Have you ever started typing a question into to Google search and some clever autofill decides to automatically populate the search bar? There have been some great ones on meme sites, but here are some that I have found on random searches. They have recently that have left me thinking….”No that’s not what I meant….Google, actually…” I will try and update as I come across more:

Always a problem when travelling in the Orient, I wake up one morning and…….

And then while Im here in Japan and huge, mmmm…I might like to move that 12,000 ft mountain…

That damn pig gang, just let me grab my switch blade and work out….

 

Some real life lessons here…..

Some people obviously missed the Health Education part of school….

These all seem a bit too related….

 

How cool would a fox be???!!!

 

Leave a comment

Filed under Humour