My Brief Encounter with Dandy-Walker Syndrome

On my call a week ago, I found myself doing my best to read up as quickly as possible on Dandy-Walker Syndrome/Malformation as we were preparing to insert a central venous catheter into a patient with this condition.

The purpose of a central venous catheter can be categorized based on the reason. There are therapeutic needs such as the administration of fluids or blood and its products, multiple blood draws and the administration of drugs such as antibiotics. One of the more common diagnostic reasons for a central venous catheter is to monitor the central venous pressure amongst others.

To be honest, I underestimated the conditions that exist within the population here in The Bahamas and what I would be exposed to upon my return home for my clinical years. I've seen the clinical presentations of Scleroderma, SLE and numerous patients with Rheumatoid Arthritis and now my first encounter with Dandy-Walker. I NEVER would have imagined seeing any of these here because I ignorantly thought that I would only be exposed to self-induced ailments such as Hypertension and its complications, Diabetes and heart failure.

So briefly, Dandy-Walker Syndrome/Malformation affects the development of the cerebellum-the part of the brain that is responsible for coordination of movement and is also involved with cognition and behavior. The development of the 4th ventricle in the brain is also affected; this is the fluid-filled cavity between the brainstem and the cerebellum and the posterior fossa.

Persons with this condition tend to have problems with movement, coordination, intellect and mood as well as other neurological problems.

The cause of this condition is unknown and it is a rare occurrence. Feel free to read up about it either at the site listed in the picture or perform a Google search.

I've been amazed at the conditions I've been exposed to so far. Such exposure has lead to a greater curiosity of what exists in the population of The Bahamas and what I will see as my future in medicine evolves granted the newfound diversity.




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Barb to the Back

“We are *all* we are, and all in a sense we care to dream we are. And for that matter, anything outlandish, bizarre, is a godsend in this rather stodgy life. It is after all just what the old boy said – it's only the impossible that's credible; whatever credible may mean...” 
― Walter de la Mare, The Return

The world of medicine has allowed me to experience the world through various facets of life. ON a daily basis, I interact with the young in age and the young at heart; delinquents and the elite and then there are those who walk on the wild side of life.

On my last call, lying in the trauma bay was a man who had been "stabbed" by a stingray that he was trying to spear. In its attempts to escape the ray stabbed him in the back which led to part of its barb remaining lodged in the lower part of the man's back. Throughout the course of booking an operating theatre (OT) and clearing the necessary requirements, it wasn't until 2 a.m. that he was finally able to be wheeled in to the OT.

After assisting with the insertion of a chest tube in a gun shot wound victim, I ran to the OT trying to get ready to scrub in on the procedure of the removal of the barb. The surgical area was neat and clean and there was no one in sight. I took off my white coat, grabbed a hair net and surgical mask and looked frantically around the area to which I had access for the foot covers-there was NONE in site or in any of the dispensers.

I made my way to the doctor's lounge and changing rooms and knocked hoping someone would be able to assist me with locating 2 foot covers. Unfortunately no one answered. So, stupidly, I made my way to the OT. I passed two, and as I saw surgeons and scrub nurses all fixated on their procedure,  it automatically became clear why no one was able to assist me earlier.

I approached OT 3, waved my hand in front of the monitor and the doors opened. I signaled to one of the surgical nurses to assist me with finding foot covers and after doing so I finally realized the error of my ways. One by one, they each turned around and looked at me in disgust, disbelief and anger.

Away they all went. "Are those outside shoes you're wearing?" "Where are your foot covers?" "Why are you here without them?" "Oh my Lord! are you serious?" "You should have asked someone in front to find them for you? Why don't you just walk into the OT just as you are? You're already this far?"

The tongue lashing went on and on and no matter how hard I tried to tell them that no one was out front to assist and that I didn't have access to the changing area, they did not care to listen or help. I allowed the doors to close, said good-bye to probably my once in a lifetime experience to see such a surgery performed and "hauled tail" out of the OT.

This week was not my best week in Surgery. It did open my eyes a little bit to the double standards that exist as it relates to the proper practice of surgical attire-I'm sure you've been in a hospital and witnessed surgical staff walking throughout the hospital in foot covers and heading right back into the OT without even changing them.  Needless to say, I won't be stepping foot into an OT without proper attire and I'll definitely be stepping my game up as the rotation advances.

I Survived My First Week of My Surgery Rotation

With my second week of my Surgery rotation on the brink, I can say that the first week of surgery was not at all what I had expected it to be. Yes the stereotype holds true as far as Surgeons equated themselves with a god, however, not all of them are that way.

From the inception, regardless of the fact that our team is predominantly male (we're the only females on our Team), I have yet to experience a lack of respect. Each member does he part to ensure we are learning, actively engaged and participating in the management of the patients on the service as well as corrected when we are wrong or going down the proverbial rabbit hole.

All in all, I'm excited to learn in light of the amount of reading that I have to do on a daily basis and I am eager to take part in the intellectual discussion that occurs at the bedside during rounds. This week will be the start of our presentations on rounds-I can already sense it won't be what I've grown accustomed to during my Medicine rotation.

Here's to a new week.

Two Months

"You don't always win,
but every time you lose, you get better."- Ian Somerhalder, Actor

Forgive me for my lack of explanation regarding how the Internal Medicine rotation really works and what my responsibilities are whilst on a team.

In a nutshell, the rotation lasts a total of two months. We are divided up into two teams based on the class size from each campus of the UWI; these teams are then broken up into smaller teams of 2-3 students who are then assigned to one of the five Internal Medicine teams. Each team rotates between two of the 5 teams during the 2 month rotation.

Some teams are structured which allows you to plan your weekly schedule and manage your study time and ward time; others, unfortunately lack structure and due to this, discipline and good time management are your saving graces as you try to learn as much as possible whenever, wherever you and from whomever you can.

We are  responsible for having our procedure book as well as attendances to clinics, ward rounds and calls signed off by a Supervisor by the end of the rotation. Procedures range from taking 10 histories and performing physical examinations and presenting your history during rounds or while on call to your Registrar, Senior House Officer or Intern. As we're all human, our immune systems have its moments where it just isn't up to par, and as such sick days are to be documented and a sick slip is to be turned in to Administration and your team members are to be notified.

Calls are every 5 days and during calls you are responsible for clerking at least 2 patients which you will be responsible for following until they are discharged along with familiarizing yourself with the other patients assigned to your team.

It helps tremendously if you either create a census for yourself that you edit daily to reflect each patient's progress, medication changes and decisions that are agreed upon during rounds and any significant clinical finding. This worked for me to ensure that I had something to read about each evening or to catch up on over the weekends or during calls. It also shows that you are interested in learning and understanding how to efficiently and more importantly, accurately manage patients.

The above is an example of how I organized my census using Google Sheets. The advantage of using Google Sheets is that you can share it with your fellow team members and you can access it from your mobile device if your hospital has an open internet service or if your service provider is reliable and you're able to get data during your ward rounds. It allows you to make changes on the go so you are always up-to-date on the management and decisions made at the bedside during rounds.

As far as the resources I utilized during my two months of IM I cannot say that I reached for one resource more than another.  My IM arsenal included the  Davidson's Principles and Practice of Medicine, Kumar and Clark Clinical Medicine, Oxford Handbook of Medical Sciences, Oxford Handbook of Clinical Medicine, as well as Toronto Notes and Up-to-Date.

As you transition to your next rotation, be sure to relish the journey. The experience is invaluable and the patients you will encounter will change your outlook if not for a lifetime, a moment. Don't take on every little criticism or beat yourself up if you answer incorrectly during rounds, just know that whatever it is you'll just have to work a little harder at it.

All the best for a new week!

A Hard Night

"The successful warrior is the average man with laser focus."- Bruce Lee

During our last call, I was able to clerk an elderly man who presented to Accident and Emergency due to loss of consciousness for one day, hiccups and complaints of left knee pain for a week. Long story short, his presentation of community acquired pneumonia and dehydration resolved however his hiccups were so persistent that sadly he left with them.

We did our best to try and treat the hiccups; first ordering Metoclopramide which seemed to do nothing so we discontinued that and the intern on call decided to switch him to Largactil.

Boy did I have a surprise the next morning when I went to SOAP him. He was drowsy, barely opened his eyes the whole time that I was there and no longer oriented to place.

After my failed attempts at waking him up,  and being rowed by him since he was convinced he spent the night on another island and was in desperate need of sleep, I took it upon myself to read the notes and orders and looked up the drugs that he was on that I was not familiar with.

Thanks to my handy-dandy Medscape app on my smartphone, I along with another SHO was able to find out that one of the most common side effects of Largactil is drowsiness and unfortunately for him, it didn't help that rather than starting him on 10mg of the drug he was started on 25mg.

Needless to say, we discontinued the Largactil after our morning rounds with the Consultant and sure enough he was back to his flirtatious, alert self again, anxious to return to the island to his wife.

This rotation has made me realize the importance of firstly taking a good history, paying attention to every detail and scrutinizing anything that may make your eyebrows raise.

At the end of the day, overlooking one small detail can be vital in the proper management and care of a patient. As a student it helps to question certain decisions when it comes to management especially if you've had the time to read up on management and care of your patients condition. I urge you to make it a habit early on especially if Internal Medicine is your next rotation as it will assist you throughout the course of clinical rotations especially as you study for your examinations.