Haematology (Block 6): Blood, sweat and, well, blood...

The end is nigh! Of GEMP I, at least. Well done! The last block is a bit of a thriller, I'm afraid... "Haematology and Immunology" or "Malaria and then some", as I remember it. This block is so hectic as a result of the very fine detail that is required to remember. And the devil is in the detail.

Just to note - you don't need an atlas full of pictures showing left and right shifts in neutrophils, or to know what a Howell-Jolly body is, you just need (yeah, you've guessed it) Google. It's got a plethora (get it? If you don't, just wait until after Haem and read this again) of pictures and info. The block is very well organised and if, like me, you didn't bother going to plenary sessions for the other blocks I would strongly suggest you go to these. 

Tired? Pale? Slight ejection systolic murmur? It's true that this could be a discription of your current state, with it being the end of the year and such, but it also describes an anaemic patient quite well. That's week one for you. The thing about anaemia is that it is extremely common. If you divide it into two broad groups - megaloblastic and non-megaloblastic (which is then further divided into normo- and microcytic) - life will be made much easier. 

Haemolysis (haem being blood cells, lysis being destruction) is common, and important. Week two covers this. To understand haemolysis you need to divide it into broad groups - intravascular and extravascular. Malaria is discussed here and was the topic of the SACS paper when I was in GEMP I. It sucked. Wow. Anyway... For a very well written piece on Malaria and its pathogenesis I would suggest you read it from the textbook used in MBBCh and BHSc II Molecular Medicine textbooks. It's way too much detail, but rather too much than too little. 

Haematological malignancies - myelo- and lymphoproliferative disorders are covered in weeks three and four. The clinical aspects of these diseases will be covered in depth in GEMP III, whereas the basic sciences, the molecular aspects, will be covered here. I don't believe in summaries. It doesn't work for me and I don't like rewriting other people's work; however, it was such a useful tool to have all the different malignancies with their specific cell lines and mutations on one page. Try it out.

Week five delves into immunology a bit. It's nothing that you don't already know, or at least vaguely remember from PCMS (I almost vomited whilst typing that). It was super fascinating. I remember that the course pack was the most interesting one of the block, albeit very long. The way that the T and B cells mature. Amazing! Sorry, I just realised my geek was showing. Moving along...

Okay, the course pack in week six was dreadful. The pictures used for the clotting cascade is not useful unless you already know it, defeating the point only a tad. So to understand the clotting cascade I asked my trusty friend, Google. He then referred me to YouTube and I finally got it. So check this video first, before attempting the course pack. It's seriously simple. Now you're ready for the course pack. 

The very last week, week seven, is really straight forward. Surgeons love talking about this in morning rounds, so best know it now. Deep vein thrombosis and Pulmonary emboli are the order of the day. Here's an important tip - when considering if you should get rid of the clot by breaking it up with thrombolytics, don't. Seriously. It releases a cascade of inflammatory agents and compromises the rest of the respiratory vasculature. The only time you should break up the clot is if the patient has a low blood pressure. 

This was, second to the block that shan't be named (as a result of prior emesis), the most difficult block. Hang in there though, almost there!

Renal (Block 5): If you don't study, urine trouble

First and foremost - the title. Sorry. It does beat the alternative - You're number one. Right, now that that is out of the way, here's a look at the Renal block. It's only a five week block, so don't blink or you'll miss it.

Week one has quite a monster of a course pack. Sheesh. As always it will introduce you to some basic principles - acid-base, sodium and potassium imbalances, diuretic use, etc. It sets the tone for the remainder of the block. The lectures... well, the lectures when I was in GEMP I, weren't exactly useful. The lecturer tried to use analogies as she taught, and that simply doesn't work for me. It will probably be very different when you're doing Renal, though.

Week two is, in my opinion, the most important week of the block. Here you will be introduced to acute kidney injury, acute tubular necrosis and how to tell the difference using, for example, spot urine sodium. Just a tip - patients who are oligo- or anuric often go through a phase of polyuria when the renal function is restored. The week flows quite well. Get it? Hmm.

Week three is pretty cool. It's all about nephrotic (protein in the urine) and nephritic (blood in the urine) syndromes. Another tip, don't think of these disease manifestations as isolated entities, but rather as two diseases found on a spectrum of disorders. That should make understanding what's going on much easier. Also, for most of the week you won't actually have an idea of what's going on. They don't give you a nice overview. "Hi, I'm Focal Segmental Glomerulosclerosis" is pretty much where it starts. Make sure you read the course pack ASAP.

Now that all the acute diseases have been covered, week four is all about chronic kidney disease (CKD). Remember that CKD is a manifestation of many other diseases, such as diabetes, HIV, hypertension, autoimmune disorders such as systemic lupus erythematosus (contrary to what House says, it is sometimes Lupus...). Glomerular filtration rate is also explained, and how to calculate it. Make sure you understand how calcium and phosphate metabolism is changed as a result of CKD (the long pathway involving vitamin D and PTH) and how anaemia can come about (decreased EPO production and of course anaemia of chronic disorders).

Ahh the prostate and it's issues. That's week five for you. It really isn't a tough week to get through. Unlike trying to get a urinary catheter passed beyond a prostate the size of a watermelon. Oh how I don't like Urology. Prostate cancer is really very common (in the elderly, at least) and many men will die with it rather than of it. Yay.

A final tip is to stay up to date. If there are any concepts that you don't understand ask someone. Ask a friend, a lecturer, Google, your mum or even me. I really enjoyed the internal medicine component of this block. Nephrology is really fascinating.

Almost done with GEMP I! Just one more block to go, well done!

Respiratory (Block 4): A breath of fresh air

The Respiratory block is really fascinating, albeit that it didn't stand out much at the time. Thinking back it was breathtaking! Okay, maybe not quite. I just felt a pun was in order and that's all I could think of. 

The first week was a real hit. By that I mean it was about a guy who got hit by a car. It is, like the other week one's of GEMP I and II, a case to introduce you to some basic physiology and other basic sciences. In addition it will also introduce you to a bit of Trauma (which is its own block in GEMP III). It's as easy as ABC (you'll see what I mean...).

The second week  is all about asthma. Asthma is a reversible form of obstructive pulmonary disease - well, up to a point. Understand the (predominantly) underlying immune mediated pathophysiology. If you understand this, the management becomes simple. When it comes to the drugs, just remember that oral corticosteroids aren't without risk. Oral candidiasis is quite common.

Week three will cover respiratory infections: upper and lower. Upper respiratory infections include otitis media (middle ear infection). No, you don't breathe through your ears, it just shares the same epithelial structure, and the bugs that affect your upper airways also affect your middle ear. When it comes to pneumonias the pathologists will hammer on the differences between lobar and broncho pneumonia. It doesn't really matter clinically. The importance is to know the difference between community and nosocomial (hospital, old age homes, etc) acquired pneumonia. The causative organisms differ greatly. Streptococcus pneumoniae vs Pseudomonas auruginosa for example. The CURB 65 score (Google it) is also important.

TB is the name of the game in week four. Sheesh, it's so common and some say that by the time you graduate, you're almost certain to be infected. Don't stress, that doesn't mean you will be symptomatic. Do be careful though, you'll hear of so many stories of doctors who got infected. This week is important for obvious reasons. Just understand how the body reacts to the tenacious bacilli and you'll be fine.

If you were a bad child it's said that you will get a lump of coal for Christmas and that sucks, right? Well, imagine being the miner who got that coal. He also got coal - on his lungs. That's what week five is all about. The effects of mining on the respiratory system and other restrictive lung diseases, not Christmas, unfortunately. Nothing much more to it really. This week you can catch up some work if you are behind.

Chronic obstructive pulmonary disease (COPD) is what week six is all about. Unlike asthma, this is an irreversible process. The terms "chronic bronchitis" and "emphysema" are a little bit archaic. Cor pulmonale is also discussed in this week. It's where the left heart is normal, but as a result of increased pulmonary vascular pressures, the right heart fails. TB is a common cause of this.

Few things in medicine we know for certain. The association between tobacco and carcinoma is one and that's what the very last week chats about. Smoking is a huge problem, and a difficult one to nip in the butt, as it were. If you're smoking now, try not to. Not because it's hypocritical, but because you're studying way too hard to die of cancer when you're young.

If you study hard in this block it will help you in the lung run. See what I did there? I just felt inspired! Okay, now I'm just typing random stuff with Resp puns. I'll stop right here, promise.

CVS (Block 3): Lub Dub

The Cardiovascular (CVS) block. Here you'll learn that the heart wants what the heart wants - and failure is not one of those things. This is a pretty cool block in terms of doctory things. You'll learn how to read an ECG (or EKG for our friends from the States). So next time you watch Grey's and McDreamy or McFlurry, or whoever, looks at an ECG, you can be like "Pfft, that's not how it's done!" To be honest, you'll still not really know how to identify pathology on an ECG strip, but you will know what the deflections mean, which is a start.

CVS consists of six weeks. Here the topics flow from one week to the next, which is quite neat. Week one is meant to teach the basics of cardiac function - physiology, anatomy (cadavers, yay.), pharmacology (same stuff from PCMS, again), etc. The physiology is really important. It forms the basis of the rest of the block. Week one delves into syncope a little. That means "passing out". If you get asked - the commonest cause of syncope is vasovagal. People love this question for some reason. (Google it)

Week two... ahh heart failure! Probably my favourite topic in GEMP I. I enjoyed it because it really is logical. Once you understand the normal cardiac cycle, heart failure becomes a breeze. Not for the patient, of course. I remember tutoring this topic quite a few times, so if you need any help, just send me a message via the Facebook page. You will learn some interesting new terms such as orthopnoea and paroxysmal nocturnal dyspnoea (PND) - described as awakening very short of breath at night. For those who are interested: PND is NOT because the patient lies flat; this is archaic. It's as a result of the diurnal variation of antidiuretic hormone (ADH) which increases at night. In the exams though (and this is important), just say whatever the notes say.

Hypertension is the topic for week three. A huge burden worldwide. The course pack is really very good for this week, so make sure you understand it very well. What's important is to understand what contributes to the systolic and the diastolic components of blood pressure.

Ahhhh good ol' myocardial infarctions (MI)! Week four will teach you all about heart attacks. The classic crushing chest pain and pain in the arm. Interestingly, the pain in the arm is as a result of referred pain. As the inflammation reaches the pericardium is involves the phrenic nerve (which originates in the cervical cord roots 3, 4 and 5). C3, 4 and 5 also gives sensation to the area of the arm which hurts during an MI. I doubt that anyone will teach this to you, I just kinda logically thought it out.

Week five goes into Rheumatic Fever (RF) and Rheumatic heart disease. As Dr King says: "RF licks the joints and bites the heart." In this week the structure of the heart valves are important. RF is caused by Group A Beta Haemolytic Streptococci. This friendly bug is found in many a pharynx, but doesn't cause RF is everyone. An underlying autoimmune mechanism plays a role (M proteins and such). Oh, and this week also dabbles in pregnancy and the heart. I'll chat more about that when I post about Obstetrics (ohh the horror!!).

The final week. By now you should be stressing, not too much, but not too little. Juuust right. Exams are around the corner. Don't worry though, if you've been working consistently throughout the block you'll be fine! Week six will cover the Paediatric aspect of the CVS. You will learn more about the Tetralogy of Fallot (silent 't') and some embryological considerations. Don't miss those lectures! This week is unbelievably important for your GEMP III Paeds block. I seriously wish someone had told me that...

And that's CVS in a heart beat. Good luck!

LOTS (Block 2): Life on the - wait, this is the title of a block?!

Life on the Street (LOTS). The content of the block is pretty much as random as the title. There is no real flow to the block, like there is in the Cardiovascular block; however, the content is super important. I'd advise you know each week before entering the next. Seeing as science has yet again failed us and we still don't have a machine that can stop time, that means working from day one.

LOTS consists of five weeks after which you'll write a couple of exams. I'll chat about exams in another post. PBL's will now be the order of the day. The first week starts with Little Anna. What a depressing topic to kick off with - Protein energy malnutrition (previously known as kwashiorkor and marasmus). This is such an important topic - it's basically what most of your Paediatrics block in GEMP III will be about. Wish someone had told me that... The lectures were very useful, so were the theme sessions.

Week two deals with genes. Levi's, Polo and Guess. (Okay, wow, that was lame even by my unusually low standards...) So the topic of the week is genetics. Although the PBL of the week is on Albinism, that's not the focus. The lectures will cover other genetic disorders, too. And for those who wanted to know: the opposite (so to speak) of Albinism is Melanism.

Week three is perhaps the most important week of LOTS, for our setting at least. The great imitator of our times - HIV. HIV can change the presentation of any disease, it can mimic many diseases and affects every single organ in the body, either directly by virological damage or indirectly via autoimmune manifestations. There simply is no way of getting around it - we all must know HIV. Although not a huge part of the week, treatment guidelines can be accessed readily and should be known. (Just Google the SA guidelines)

Week four... a difficult one. Perhaps not in terms of content, but certainly emotionally. Rape and sexual assault. This week is the only opportunity, most likely until Internship, that you will have to learn how to fill in a J88 form. This is the form we as doctors fill in when patients present after assault. I clearly remember the lecture on abnormal genito-anal findings. It's difficult to look at, but this is the reality of what happens in our world. Remember to treat every patient that has been assaulted, sexually or otherwise, with the utmost sensitivity and respect!

Ahhh... week five. For those who have not yet had the privilege to meet Prof Duse, will do so here. What a legend. This week is about infections - and a little on old folks. The PBL is about an Afrikaans farmer who hurts his hand on a gate. I got excited here, because I am Afrikaans. I don't sound it when I speak English (apparently) so don't read the posts in an accent from now on.

Apart from the above, you will get to learn some basic clinical skills this block. If you see me in the wards (just look for the really tall guy, I'm just under two meters tall) you can ask me to help you out with any skills you might be struggling with. Also make use of friends and parents to practise skills on. Not all skills though - avoid prostate exams, people don't like them...

PCMS (Block 1): Welcome to Medicine!

Congratulations!! You've either survived second year anatomy (and can now watch Grey's Anatomy and be like "Hey, that's not right!") or you've passed the WAPT (like a boss!) and are now going into in GEMP I. You're going to love it.

"What should I expect in GEMP I?" I hear you saying? (Auditory hallucinations on my part?)... So GEMP I is divided into several different "blocks" lasting a couple of weeks. Sounds like a long time, but it goes by so fast!

You start off with what is known as (enter dramatic Stars Wars music here) PCMS. PCMS officially stands for Preliminary Concepts in Medical Science, but I think it's some Latin acronym that loosely translates into Death by Studying. This will be your greatest challenge in GEMP (at least, I thought so).

In PCMS you are expected to learn a LOT of new things in a very short period of time. You'll be covering Pathology (Dr King is great, just sit close to the front in his lectures, you'll see why...), Pharmacology, Microbiology, Ethics, Immunology, some Stats and other random, but important, stuff.

The trick to tackling this overwhelming block is to remember one fundamental principle - you are always behind. Even before you've registered, you're behind. I don't say this to scare you, instead, to motivate you to start studying from day one. As clichè as that might sound, it's honestly the biggest tip I can give you.

The importance of PCMS is that it forms a base for the blocks to follow. You will notice that in all the other blocks the same Path, Pharm, etc. comes up in addition to the new material covered. So if you work hard in PCMS it will make subsequent blocks easier. In fact, I used my PCMS notes to study for a 5th year exam just the other day. Oh how I wish I studied Pharm harder... Sigh...

One last tip: I believe in goal directed living. I apply this to my studies as well. Set short, medium and long term goals for yourself and write them down. Short term goal - study pages 1 to 35 in Rippey's (you'll get to know Rippey's well) before 18h00 tomorrow. Medium term goal - Revise the first three weeks' work next Saturday. Long term goal - become ruler of the world by the year 2035.

Your goals will change day to day, but it's important to have them. Take it one day at a time.

Okay, last tip (I promise): remember to laugh and have fun (a synonym for cake). Life is short and isn't all about your studies, or medicine. My fiancée was in my GEMP I class for 6 months before we met. Don't be that blind.

Anyway... the next entry will be about the Life on the Streets (LOTS) block. Hope this was useful!