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!

The Dead and the Dying

Few things in life are certain, and that we all have to die is one. If, of course, you are reading this from the year 2242 and civilisation has figured out how to put consciousness into computers, please ignore that sentence. In medicine we come across a lot of suffering and death. I would like to share a story which really touched me and how I handled it.

I was on call during my surgical rotation at Bara. Nothing special, really. A couple of botched circumcisions, tender McBurney's points, gangrenous diabetic feet, etc. That's when a lady, we'll call her Patricia, came in. I looked at her file and it said "Abdominal swelling". That could be anything, I thought. I took her history and it was evident that she was the picture of health. In summary: Patricia was a 59 year old female with no chronic medical conditions who presented to us with a 6 week history of abdominal swelling. Examination revealed a large, firm, nodular, non tender hepatic mass. Nothing else.

"I'm so excited," she said, "in two weeks' time I turn 60 and get to retire. I look forward to resting and spending time with my children."

As time went by the diagnosis became even more apparent. Patricia had a diffuse hepatocellular carcinoma. Imaging revealed that the mass could not be excised. The prognosis? Very, very poor. How is this possible? Just a few days ago Patricia, with no discernible risk factors for liver disease, came in with a mass in her abdomen - now she's been given a death sentence?

Over the next few days I saw her deteriorate. She became terribly jaundiced, encephalopathic and delirious. Still though, just the other day she was O.K! She passed away exactly two weeks after being admitted. Two days before she passed away it was her birthday. I remembered. I bought her a small gift. She loved it.

This whole situation had me doubting why I was studying medicine. If Patricia had stayed home the outcome would have been exactly the same. We did her no good, whatsoever. Not because we were incompetent, but because of her disease. This hit me so hard. It was very tough. Then came the realisation - I made her smile and laugh and enjoy her birthday, her very last birthday. I prayed with her in her last moments and made her feel comfortable. That's what I could offer this wonderful lady.

Perhaps the biggest lesson learnt was that we aren't only here to save the lives of people, but also make their last moments tolerable, even enjoyable. Try to remember that... Her last words to me as she dipped in and out of delirium was, "You are a good doctor."... Words that I will never forget.

You will see a lot of sadness, pain, suffering and death. Find a way to deal with it. Speak to your colleagues about it, pray about it, cry about it. My favourite form of therapy is laughter. Often you have to laugh like you're insane to remain sane.

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.

To Textbook, or not to Textbook - GEMP I & II

Textbooks are awesome. But they're also ridiculously expensive! So I thought I'd give you some advice as to which textbooks were very useful to me, and which of those on the booklist I didn't think I required.

Going into GEMP I and II there are really few textbooks you'll need. The one you absolutely have to have is Clinical examination: A systematic guide to physical diagnosis by NJ Talley & S O’Connor (or as everyone calls it - Talley's). This is what you will be examined on in your GEMP III Internal Medicine rotation, so it's a great buy. For the Graduates who didn't do Anatomy I would advise you to get Clinically oriented anatomy by KL Moore & AF Dalley (Clin Anat). It's very useful, but also readily accessible at the library. If you haven't done Physiology, don't stress. The lectures are sufficient.

Porth's pathophysiology: Concepts of altered health states by C Porth & S Grossman (or Porth for short) is very useful. I used it a lot and it really does help. But again, it's accessible from the library and the notes are great that lecturers give.

For Anatomical Pathology Dr King will advise that you get General pathology: Illustrated lecture notes, AKA "Rippey". I thought Rippey was fantastic, but not a requirement. It's pretty much exactly what you will be taught in the Path lectures, just laid out nicely. For people who have brains that require order and structure and not your own scribbled writing (like mine), get the book; otherwise, you'll be sorted!

Now let me chat about the other textbooks on the list.

Anatomical pathology : Robbins and Cotran pathologic basis of disease, and General and systematic pathology - I have both, never really used them at all. I wouldn't suggest it. The lectures are sufficient. If you need to see what caseating necrosis looks like, just Google it (not before, during or at least two hours after eating cheese, you'll thank me for that!).

Anatomy: I've mentioned Clin Anat. It's far better than Gray's for students, in my opinion.
Histology: a text and atlas - Nope, you really don't need it.
Fundamentals of human embryology by J Allan & B Kramer - This is quite a nice book, but Prof Kramer teaches word for word what is in this book. As can be expected, she wrote it! If you find that you struggle to follow her lectures (she goes through it very quickly), get this book; but I'm more than certain you will be fine without it. Check the library first, too, and make copies of the important sections.

Chemical Pathology: Clinical chemistry by WJ Marshall & SK Bangert - They say it's great for your Renal block. It isn't. It it, however, very useful for your first block in GEMP II, Endocrine. I used it a lot.

Community Medicine: Epidemiology: a manual for South Africa - Just... no. Don't waste your money!

Family Medicine: Handbook of Family Medicine by R Mash - You don't even need this book in your Family Medicine block in GEMP III. I wouldn't advise it.

Haematology: Essential haematology by AV Hoffbrand, JE Pettit & PAH Moss - This is an interesting one. Many people found it very useful in the Haematology block. Apparently it has nice pictures and stuff. To be honest, I didn't use it, but it might be worth a look.

Immunology / Microbiology: Medical microbiology: A guide to microbial infections - Seriously, why is this even on the list? It's not necessary.

Medicine: Clinical medicine by P Kumar & M Clark - You don't need it, but if you can afford it, why not. It's not a bad textbook.

Obstetrics: Perinatal education programme (maternal health) - WASTE OF MONEY! I'll tell you which one you need to get for GEMP III in another post.

Pharmacology: Basic & clinical pharmacology - Again, no need. If anything, get Medical pharmacology at a glance. The lecture notes are really all you need. Also, Google is for free...

Psychiatry: Primary health care psychiatry: a practical guide for Southern Africa - I didn't even know this book was on the list. It's not needed, trust me!

In general, before buying a textbook use one from the library first. Do this in week one though, don't wait until two weeks before the exam, because then everyone will have taken it out. All textbooks were not created equal, and what might be an easy read for your friend, turns out to be useless for you.

I hope this was useful! Happy reading!

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!