Retirement brings revaluing

I retired earlier this year, a little earlier than one might expect (September 2025) three months ahead of the celebration of the age of 67. I have decided in my "dotage" (not weak as such, just experiencing the consequences of decades of sedentary lifestyle, perhaps even still strong on the basis of the resilience developed through decades of serving disadvantaged communities in Australia) to revisit the purpose of this Blog. Folia Medica was originally written (significantly after the fact) as a tool for emotionally debriefing, recovery and as a document I could share with other young doctors in training. Still somewhat remeniscent of Samuel Shme's profound contribution to the capacity of doctors in training to survive and potentially thrive, "The House of God." The new, perhaps evolved purpose is twofold. Firstly to continue the documentation of my life as a doctor but also as a document for my family so give themsomesnese of who I am and what I have spent the last 45 years doing. This will be a slow process, I am still formulating dirtection and content. Welcome back.

# 012 ... ( cut&paste)

I have reposted a blog of the early months of 2006 here. Partly for preservation, partly for those who dare can take a glimpse of where I came from and the intensity of my later (much later) reflections of those early years.

I left this journey unfinished ... for various reasons, but not for lack of desire to finish, just needed to put it aside for a while.

Perhaps me reposting this here will prompt me at some stage to resume.

Until then, those of you who have stumbled across this, please begin at post # 001 and work your way back to here ... if you dare. Just scroll right down to the bottom of the page.

# 011 ... Return to the City

The transition was rapid. Finish work in the country one week. Start work in the city the next week. Move us, and our belongings, over the weekend in between, with two and a half hours road travel between.

In the city, I was given the job I applied for. I deliberately chose the job rotation from the bottom rung of desirability in a peripheral suburban hospital.

So what was the attraction, you might ask. Well, the job included anaesthetics, a General Practice attachment outside the hospital, Emergency Medicine (of which I was becoming fond of) and “relieving” (i.e. cover for the holidays of the others working in the hospital). Nothing glamorous, but the following year in that hospital offered obstetrics and paediatrics training. There was no way I was going to be able to get the high-demand job of obstetrics/paediatrics as an unknown from outside the hospital and there was no way I was going to be given glowing references from my previous employ. So the only way in to the next year’s job was to be sure those who made the decisions knew me in a favourable light.

A desire to prepare myself fully as possible for family medicine, possibly in a rural environment lead me to consider the combination of the two years’ experience a good mix and a good opportunity. It was in this new place I discovered the value of mentorship. I also continued to learn, make mistakes and develop lasting relationships with colleagues. I will take you along for the ride next time we speak.

# 010 ... Goodbyes

Goodbyes I have to let go.

I could continue to randomly spout about my first two years of independent adult life devoid of any sense of reality, bearing planetarily proportioned responsibilities without the shoulders of Atlas to carry them, the unresolved bitter anger and resentment, near-death experience ... but at this point in time I must let go.

The experiences of those two years did profoundly contribute to who I have become, my emotional and spiritual evolution. It was my 40 years wandering in the desert.

I now metaphorically speaking stand at the threshold of a new jungle, unknown and foreboding but heading away from the wreckage left behind by the tornado that I, and some of my colleagues, managed to weather.

I wandered that jungle for another two years. It was a journey I valued and I will share with you soon.

I also need to learn to forgive the only man I have ever hated with a passion, not for his sake, but for mine.

# 009 ... Pepper and Salt

"Out here nothin' changes, not in a hurry anyway
You feel the endlessness with the comin' of the light o' day
We're talkin' about a chosen place
You wouldn't sell it in a marketplace, well
Well just a minute now"

Goanna : Solid Rock (Spirit of Place) 1982

There was a sense of endlessness in this place. Two years blurred and were punctuated only with chaotic emotion, anecdotes and meeting primal needs.

There were hard, black times and a few bright positive times. Mostly indeterminate in the milieu of life not infrequently punctuated by the basest struggles to survive.

"Feel goods" were hard to come by.

No one said thank you .. unless perhaps they did but we were too numb to notice. No one paid a compliment except when we generated a mutually supportive social intercourse. Many were ready to criticise purely to ensure that the pecking order was maintained. Some of us hovered between heaven and hell, in more ways than one.

One of my high points was at a time where I was covering for all the medical patients in the hospital. I was called to the ward to examine a patient who had been admitted for management of a painful, inflamed wrist joint. This was presumed to be gout and was treated as such. This patient, despite treatment, was experiencing increased pain and beginning to feel unwell. The medical registrar was off duty so was unavailable for advice. I made a decision to perform an aspirate of this patient's wrist joint (to take a small sample of joint fluid for analysis) and on pure speculation, started the patient on an antibiotic. The following day the medical registrar took me aside and thanked me. She told me that the specialist had instructed her not to perform the joint aspirate the previous day but was concerned that the initial diagnosis of gout was not correct despite blood testing being supportive of gout. As it eventuated, the patient had a septic arthritis and the joint aspirate confirmed the diagnosis. I had commenced the correct treatment, although without a confident reason for doing so, and had acted in a way that bypassed any potential conflict between "god" and "godling-in-training". That day I learned that registrars do as they are told because their career progression is "on the line". That day I also learned that one can feel good making the correct diagnosis, treating the problem correctly and producing a good outcome for a patient.

I was not always right. Mostly I too did what I was told to do by my superiors without harm to the patient, but sometimes I made decisions that did in fact have an adverse outcome, either for my own emotional wellbeing or worse, to the detriment of the patient.


In the early hours of one morning (my night on-call) the nurses on the ward called me to seek advice on a problem with an intravenous line that had ceased to work properly. This intravenous line was a "central venous line" where the end of the plastic tubing placed inside the patient's vein was threaded along the length of the vein and into the major vein near the heart. Various reasons determine the need for such an intravenous line, needless to say, this patient had a good medical reason to have this line. Well, at 03:00am (or thereabouts) that line was discovered to be blocked and despite gentle irrigation could not be unblocked. I made the decision to remove the line and wait on its replacement in the morning. I had never inserted a central line, I was not going to start unsupervised in the middle of the night. The following day the specialist ranted and raved about the removal of that patient's central line. Worse was the fact that the patient was a "private" patient of the specialist.

A few days previously another patient had been admitted to the hospital's intensive care unit from a complication of a central venous line. I was not going to be responsible for creating a similar occurrence in a patient under my care. My mistake was not calling the specialist in the middle of the night. Perhaps if I did there would have been a cascade of other undesirable consequences ... I will never know. What I do know was that given the information I had at the time I made the right decision, it was a shame that "god" did not agree. That day I learned that with all good intentions and without adverse outcome for the patient, one still can suffer unexpected but unpleasant consequences from decisions one makes as a young doctor. I never worked directly under that particular specialist, although I was occasionally responsible for the care of his patients. At times, that specialist was the most arrogant, rude and obnoxious specialist one could have met, and certainly the most unpleasant I have ever met. It was a necessary evil that his medical skills made him a part of the medical team in the hospital and to be honest, he was to be trusted to be a very thorough physician - just lacked the necessary social skills.

I also remember the time that I was the lone senior doctor ("senior" as in "second year postgraduate") of the night. A gentleman who had just retired from one of the services (I can't remember if he was a policeman, fireman or in the armed services) had come in late in the evening with a very short-lived episode of chest discomfort earlier in the day. He was well and painfree on presentation to the emergency department. A cardiograph was performed and it seemed normal to me. The medical registrar, who was off duty, was in the resident's quarters on the hospital grounds so I sent the cardiograph over for her to look at. She agreed that the cardiograph was normal. I sent the patient home after a period of observation confident that the pain was not his heart, but uncertain of the diagnosis. Just before the end of my shift that morning, the ambulance arrived for a "certification" of a body - you see, people aren't actually dead until a doctor pronounces them dead, so given the emergency department doctor was the only accessible doctor in town overnight, the ambulance relied on us to pronounce death before a dead patient could be transported to the morgue.

That morning the body was that of the patient I had seen the previous evening. I felt ill. I was exonerated after an investigation however until this occurred, I suffered the unpleasantness of rumour and innuendo floating around the hospital that a "young doctor had sent an unwell patient home to die". That day I learned that despite doing one's best given the circumstances it is sometimes not good enough. I also learned that ruminating was not a healthy past-time.

Others of my colleagues had their own unpleasant visions brought in the back of the ambulance. One night when my wife was in the emergency department, it was her job to pronounce death. This body was bagged up in pieces (having been, when alive, laid down across the rail tracks just outside town - this means of suicide was not that uncommon in that town) and there was no earthly reason why it should take the "skills" of a doctor to diagnose the deceased. It was just for the "paperwork" ... as if the bits would somehow join up, reanimate and sue the mortuary for "false imprisonment"! Life's regulations are strange sometimes.

Other memories that jump out of the blur? Many ... but how many pages do I devote to them? Maybe this journal will be expanded into a tome at some stage in the future.Boat races, cocktail happy hour, bush bands and pub meals (loved the pepper steaks and salty chips), weekend resident's parties, weekend's off with my wife, working with a devout Jew who could not work on the Sabbath, defensive driving courses, holidays by myself, sleeping in different rooms to conserve my and my wife's precious sleep, food poisoning at a staff function, end-of-year "revues" ... all spring to mind if I let it wander.Black and white ... mostly grey with splashes of light and colour. Not as satisfying as a good pepper steak.

# 008 ... Day 17

I don't know why I decided it would be day 17 ... all the days were all a blur for the two years I worked in this parochial little town in the middle of almost nowhere, over two hours drive from what I still then considered to be my home.

Seventeen just sprang to mind ... and I have discovered that the number 17 is an important number.

Seventeen is comprised of the digits 1 and 7.

Seventeen is a prime number. It is the sum of all the first four prime numbers.

Seventeen is the maximum number of strokes in a Chinese radical.

Seventeen is the number of syllables in a traditional Japanese Haiku.

The number 17 is considered to be unlucky in Italy.

Despite this, the number 17 was chosen for no particular reason other than it seemed about right. Representative of the further anecdotal ramblings that spill from the rush of my first two years as a doctor.

Mid December that first year, my mother died. Yes, I mentioned this but I feel the need to elaborate. My mother's death and the events leading up to it were as sobering lessons in being a doctor as my intensive time in hospital.

Lets roll back time a little ... four years earlier to be precise. My mother had a routine Pap smear test (as all women are encouraged to do) and the report on this test indicated cancerous cells developing. She was advised to have a hysterectomy and dutifully she allowed this to be done. The pathology test results after the operation indicated the complete absence of any cancerous cells. Being firmly religious, my family took this as a miracle. I was not convinced. My first thought was that the first test was wrong, but being a medical student in the great place of learning that my mother was being treated, I felt I was not in a position to question the authority of the gods of the place. The stress of the operation triggered an elevation of my mother's blood sugar that was diagnosed as diabetes, and with great aplomb the resident doctors of the hospital started her on insulin injections and discharged her home. Mum struggled with her injections and eventually (with a little inside knowledge from our training in another place) we arranged for her to see a diabetes specialist who weaned her off all medication and her "diabetes" was eventually controlled with diet and tablet medication.

First do no harm.


During the first year I was working in the hospital, my mother started to experience transient dizzy spells that she managed to hide from us for quite some time. Eventually the symptoms became so significant and worrying to her she sought medical advice. Her doctor investigated these symptoms and discovered that the main arteries in her neck that supply blood to the brain were severely narrowed and were likely to be the cause of her symptoms. Without treatment there was an accumulating risk over time that my mother would have had a stroke. My mother never feared death, but it was her greatest fear to become invalid and totally dependent on others for her care. She did not want to have a stroke. Having been advised that vascular surgery was necessary my mother was admitted to hospital for the procedure of carotid endarterectomy ... the purpose being to remove the narrowing and reduce the future risk of her having a stroke. One other patient was on that operating list for the same operation.


Both that patient and my mother woke after their operations to discover that they could not move one side of their body. The other patient fully recovered within a few hours, my mother never did. She lost fully her ability to speak and had a paralysis of one side of her body. My mother stayed in the acute care ward for two weeks and was then transferred across to a rehabilitation ward. Within 24 hours of her arrival in that ward, my mother suffered a heart attack and within another 24 hours she was dead. I knew in my heart that when my mother saw the other severely disabled patients in the rehab ward she decided she was not going to allow herself to live as she feared, totally dependent on the care of others. She gave up her will to live.

First do no harm.

One resident doctor covered the hospital that weekend so my wife and I could come back home to my mother's funeral. I don't even remember who that resident was. That makes me sad.

Christmas that year was also very saddening. My mother was well organised and had prepared gifts for the family in advance. Opening those gifts without her being present was a profoundly emotional time for us all. My mother had also left her secret diary for us ... she must have known the risk of the operation and had prepared for the eventuality of an unpleasant outcome. I will speak of the rest of the blur another time.

# 007 ... Day One

Day One ... I have to give my acknowledgments to Sr Lewis. She was the charge sister of our first ward. A lady that knew exactly what to say and do for us young resident doctors as we arrived for medical ward duties on our first day. The sense of dread was somewhat alleviated by her calm and controlled manner. I believe I owe my sanity to this God-given woman.

It is interesting that I remember not much else of the first few days or weeks of working, other than the overwhelming relief to have a weekend off and the incredulous sense of being "rich" associated with my first pay cheque. The hourly rate was not good, but the ridiculous hours we worked made the amounts we earned appear huge. Having financially struggled during the years of study, having money accumulating in the bank (and no time to spend it) was a novel experience.

So what are my recollections of my first year of working in hospital?

I learned the value of alcohol. I never liked being drunk - I have been inebriated only twice in my life. Once as a student deliberately at home to feel what it was like, and the second time unintentionally was in that first year of working, whilst drinking in a bus with many other hospital staff on the way to a restaurant meal. Drinking on an empty stomach was a bad idea. I felt so ill both times I have not had enough alcohol to be inebriated again. However, as a young doctor it was partly the social scene and partly the need to relax once a fortnight after the shift rotations brought a Friday evening free of work commitments that taught me that alcohol in moderation was a good thing. (What I know now and what I thought then are different, very different.)

I learned that arrogance came with the territory. Specialists (read "gods") modelled the behaviour, we tried to emulate it ... and it was always out of context, socially and probably also professionally inappropriate. However a problem developed that as one grew a sense of confidence within the workplace it was sometime interpreted as arrogance ... and if it was god seeing this in his understudy, it was perceived as a threat and quashed from a height. With hindsight I can only consider this behaviour pattern to be a means of self-protection, for both the "god" and "godlings in training". Perhaps reasonable theoretically in a primal sense, but entirely dysfunctional, and sadly some doctors never lose this behaviour pattern when the reality is that it is unnecessary and counterproductive.

I learned that when given the pedestal to stand on we "godlings" can say things that are given more power than they should ever be given.

I remember observing my colleagues look after a recidivist patient, an insulin dependent diabetic, who returned frequently (every few weeks) after overdose injections of insulin. She had been labelled as having a "personality disorder" by the psychiatrists (read - "patient with a problem we don’t want to deal with") and a multiplicity of social stresses unable to be resolved by the social workers ... its hard to deal with problems that are experienced by one with a lack of insight. The frustration affected us all. This woman eventually came in under my care. In a fit of arrogance I whispered in her ear, "If you ever come back to this hospital with another overdose I will have you locked up in a psychiatric ward and the key thrown away." I had no right to say this ... and there was not a valid medical or social reason for saying so. This woman did not return to the hospital for nearly six months. When she did return, she had deliberately chosen an isolated place to repeat the deed. Having created the circumstances where she would not be found for a long time and having given herself a lot more insulin than she normally would "overdose" on, she suffered permanent and severe brain damage. She never overdosed again ... she was never again physically capable of doing so. I wonder sometimes if what I said to her was "good" or "bad".

I learned that we are all mortal. Some of our patients died. They died despite our machinations mostly because there was nothing we could have done anyway, some died because we did not know what was wrong until it was too late to do anything about it, some may have died because of what we did to them. A middle-aged man (yes I know that is subjective depending on one's own age, but that is how I remembered him) came into hospital severely unwell, with a high fever. He was complaining of back pain. I was the Emergency Department doctor of the day. I remember him for two reasons. One ... he had no legs. He was an obese diabetic with severe peripheral vascular disease. His legs had been previously amputated above the knees. Second ... I could not get an intravenous line into him. Having become most proficient in this most basic of medical skills, it was something that concerned me. The medical registrar eventually put in a central venous line and the patient was commenced on appropriate treatment and admitted to hospital. That night that man died. I remember the registrar being most distressed. She took it personally. Me, I didn't care ... I was too tired to care. At autopsy we discovered that the man had been slowly developing an aortic aneurysm (hence his back pain) that was small enough to miss clinically (remember he was obese ... and we didn't have the luxury of scanning techniques we have today) and in the haematoma so formed he had developed an abscess (hence the toxic, febrile patient). This man was going to die despite what we did for him. Not that it made any of us feel any different.

Others of our patients died because of what we did to them. Some were going to die anyway, but sometimes what we did could only have hastened their death. A young man (yes I know that is subjective depending on one's own age, but that is how I recall him being described) came into hospital severely unwell, with a high fever. It was on a weekend I had off, but I heard about him and his care. He had septicaemia (that's bacteria in the bloodstream) and was very unwell. He was rapidly assessed, treatment (correct in this case) initiated and he was admitted into the hospital's Intensive Care Unit. The medical resident, as part of the full assessment of the patient, performed a lumbar puncture (intending to take a sample of fluid from around the spinal cord for analysis) ... the patient died "at the end of the needle". "Coning" they call it. It happened because of the combination of raised pressure inside the patient’s head and the rapid reduction in pressure around the spinal cord caused by the lumbar puncture procedure. The pressure differential causes the brain to be forced down into the confined space of the opening at the base of the skull. The stuff of horror stories! Rare, and now these days "coning" is rarer because we now do scans before lumbar punctures ... but gut wrenching to have had it happen. I was grateful I was not the medical resident on for that weekend.

Some may have died because of what we did, or neglected to do, at a time when they would probably have not been going to die. None of us want to think about this ... nor talk about it, but we all will have recollections that have enough doubt about the circumstances of a patient's death to think that our own actions may have been responsible. Yes, I learned a lot about human frailty and mortality that year.

It was also that year my mother died.

# 006 ... 256

Monday 08:00am - Tuesday 18:00pm = 34hrs
Wednesday 08:00am - Thursday 18:00pm = 34hrs
Friday 08:00am - Monday 18:00pm = 82hrs
Tuesday 08:00am - Wednesday 18:00pm = 34hrs
Thursday 08:00am - Friday 18:00pm = 34hrs

This was a normal 2 week for interns doing a 1:2 roster in the hospital I worked at for the first two years post-graduation from medical school ... that is 218 hours worked per fortnight on a normal rotating shift. And that's assuming one actually could walk away from the job at 18:00pm on your rostered "night off" AND assuming your consultant didn't drag you in for an early ward round to start the day ... a 36 hour "day" was not uncommon. We were paid at a "normal hourly rate" for the first 120hrs per fortnight, then paid "time and a quarter" for "overtime hours" and nothing for hours worked that were not on the roster.

Insane? ... damn right it was!

We thought we were in heaven when worked a 1:3 roster so we worked only every third night overnight ... with the dreaded weekend shift only every third weekend.

We changed jobs every three months ... only one of those rotations was the 1:3 medical ward job.

Why such an insane weekend system?

You see, this was a small rural hospital that, in order to attract new medical graduates, offered a "country weekend". If you had a city job, your "weekend off" started at 13:00pm on Saturday (again, if you were lucky enough to actually get away on time) so you NEVER had a full weekend off. Most country hospitals started their weekend off at 18:00pm Fridays ... but the consequence was that those left behind to work the weekend started their job normal time 08:00am Friday morning and didn't finish until 18:00pm Monday ... 82 hours later!!

The hospital administration also claimed it could not allow us to have more than two weeks off each year, despite the fact we were entitled to six weeks holiday (our "award" gave us four "normal" weeks leave plus additional for all the "public holidays" and weekends we were required to work).

We worked very long hours.

I remember one fortnight's timesheet I signed off on 256hrs ... it was a change over of jobs and I got the short straw and managed to work two "weekends" in a row. Just to save you the calculation, there are only 336 hours in a fortnight. The "normal" working fortnight for "real people" was 76 hours.

We grabbed sleep when we could, we ate when we could, (desperately, and unhealthily fast in case we got interrupted - and we not infrequently were), we toileted when we could no longer hold on and we worked constantly ... and we made mistakes.

I grieve that I probably made many mistakes, and not all I became aware of. I hope I learned from my mistakes ... we all made mistakes, some that may have resulted in the premature death of the patients in our care, certainly some that added to the already profound level of stress we all felt, and many that added to our own work load and that of our colleagues.

The stress taught us how to consume alcohol, a lot of alcohol - we didn't have much else to spend our hard earned money on.

The lack of sleep strained relationships.

The lack of sleep also took the life of one our colleagues. She was heading back to the city (two hours drive away) for her weekend off ... in the failing light and no doubt, with overwhelming fatigue, she missed a corner and drove herself off the road.

It was this year that our state Health Minister decreed that the normal working week for hospital-employed doctors was to become 48 hours replacing the 60 hours. It didn't immediately reduce our hours, but we were paid a little more for what we did. Slowly that extra wages cost ate a hole in hospital budgets so over the next few years, the rostered hours for hospital doctors were gradually reduced to reduce costs.

This eventually made life for young hospital doctors a little more bearable, at least for when they had the time off.

I wonder if it made life harder for those left behind to do the work.

Our older colleagues would say that we lost our experience when our working hours were reduced.

I would ask - what experience did we lose that was worth more than the life gained and the iatrogenesis prevented?

# 005 ... Primum non Nocere

i·at·ro·gen·ic adj. Induced in a patient by a physician's activity, manner, or therapy.

My first exposure to the dangers of modern interventionalist medicine was that same year I think I saved my first life ... the guy with a shard of glass in his groin plugging a laceration in his femoral artery. Well, okay maybe I didn't save his life, but my instinctive choice to not remove that shard of glass certainly contributed to my not killing him.

First do no harm.

During my two weeks of attachment to a vascular surgical unit I was involved in the care of a man who travelled from interstate with his suitcase ("positive suitcase sign") for an outpatient consultation. He suffered from poor circulation in his legs, producing a condition called intermittent claudication. Basically he could only walk a limited distance before his legs became painful and the pain was only relieved by rest. By all rights his symptoms were in fact not too bad and could probably have been managed conservatively but because the vascular registrar felt sorry for the man she admitted him to the hospital and booked an angiogram. For that a needle was required to be inserted directly in to the artery of his groin so a radio-opaque dye could be injected and X-rays of the legs (with the dye highlighting the arteries) performed.

The angiogram result confirmed the clinical impression that the arterial disease the man had was mild and surgery was not going to be required in the near future. Plans were set in place for his discharge home the following day.

Seven o'clock that evening the nursing staff reported to the consultant that the man's right leg had gone blue and cold and no pulses could be felt below the knee ... typical of a full below-knee arterial occlusion. As the registrar had left to go home (one of her rare nights off) I was the only extra pair of hands to assist the consultant with that man's emergency surgery to save his leg.

A piece of internal artery wall had been dislodged by the angiogram needle and found its way down the leg to a resting place of its own choosing. The vascular surgeon found it, removed it and the man's leg rapidly returned to its normal colour and foot pulses, although weak, were again palpable and probably in their normal state of semi-vibrancy for that man's vascular disease state. The man left the operating theatre with a viable leg and I with a sense of achievement.

Two hours later the nurses made the same phone call to the same consultant about the same patient who had redeveloped the same acutely ischaemic leg.

Back to the operating theatre. The whole mid-thigh main artery had completely clotted. The man's leg was severely compromised and in order to save it a bypass with plastic tubing was required.

That man eventually safely left hospital with souvenir groin-to-knee scar, plastic tubing, and persistent intermittent claudication in his untouched leg.

First do no harm.

In that same hospital, same year, same rotation I was the student of a unit that was looking after an elite level footballer who had become unwell. His diagnosis was Hodgkin’s disease, a malignancy requiring aggressive treatment. In order to decide on the "best" treatment regime a "staging" had to be done to determine the extent of the disease and which organs were involved.

In those days staging was done via laparotomy, a major abdominal incision, physical visualisation and palpation for lymph nodes in the abdomen and the performing of a liver biopsy. The liver biopsy was performed under direct vision, with the correct technique, by the surgical registrar.

The biopsy needle hit a blood vessel in the liver and the anaesthetised patient, oblivious to the event, bled profusely. Because the biopsy was done at laparotomy where the bleeding point could be surgically attended to, the patient survived. Normally liver biopsies are done by passing the biopsy needle through the skin and abdominal wall under local anaesthetic. I dread the thought that similar profuse bleeding can occur with such a "closed" biopsy. Liver biopsies are mostly done in patients with liver disease. Liver disease by itself can increase the risk of bleeding. Being my first "liver biopsy" I will always wonder how many liver biopsies done for any other of my patients now and into the future will result in a bleed that requires emergency surgery to repair.

First do no harm.

Years later I spent three months as a trainee anaesthetist and as one does, we talk about latest cases to learn and hopefully avoid adverse outcomes. I remember one day my mentor talking about a young woman who was at that time being cared for in a long-term care facility in a semi-vegetative state. She was a young mother of two young children at the time of a "routine" D&C performed as a diagnostic procedure for erratic menstrual bleeding. She suffered an anaesthetic complication but due to the diligence of the anaesthetist she survived. I finished my anaesthetic term and chose not to further any training in that area.

First do no harm.

# 004 ... Rollback

Having had time to take a breath and recover from blog entry #003 I ruminated on other memories as a medical student.

I discovered, or rather rediscovered, a few memories from the previous year ... my first year in clinical school.

After three years of attending university campus, the clinical apprenticeship starts in earnest, an apprenticeship of a further three years of rotations through as many of the generalist and specialist fields as the training hospitals can get their hands on for us.

The beginning of that year, before our studies started, I went out west to the farming district with my wife-to-be and stayed with a mutual friend on that friend's parent's sheep farm.

It was haymaking season ... the old style, with hay bales like Lego blocks that were tossed up into the back of a tray truck for stacking into a barn for the upcoming winter. None of those modern, new large rollup bales that would sooner roll over you and grind you into fertiliser as stay well behaved where placed.

It was an adventure when it started, but I over the few days became more and more irritable and it strained relationships. Two days later, after arriving back home, the fevers and rigors hit. I was not well. My throat burned, my body ached, my mind was poisoned by the high fever and I could not connect to the real world around me.

My parents took me to my family GP who diagnosed glandular fever, took some of my blood for testing but "just in case" it was tonsillitis gave me an injection of penicillin ... to all intents it looked like I had tonsillitis, I was toxic, had large angry tonsils covered in exudate, tonsils that almost met in the middle of a throat struggling to swallow - all this despite that fact that I was supposed to have little or no tonsillar tissue left following a tonsillectomy at the age of five years. We all had tonsillectomies then ... the conventional wisdom was that it was good for us.

The tests for glandular fever came back negative. My dear doctor (who incidentally was a very good doctor, one of the few, and is still a very good doctor in practice in the same location now despite being past retirement age) arranged for daily penicillin injections. I still remember the deep, visceral discomfort of those injections. I learned to dread the visits, despite my rational mind telling me that they were helping me get better. Every time I give an injection now I connect with that time.

I recovered, in more way than one, but slowly. Six weeks later, still somewhat fatigued, but now in the full swing of my first clinical year of study, I attended the student clinic at the hospital I was studying. I still had a palpable spleen and generalised lymphadenopathy ... the young doctor (probably a junior resident) looked concerned and ordered more blood tests.

This time they came back positive for glandular fever. I continued to recover without the need for any further attention, but I did not perform as well as I might like for the first three months of my clinical training, and my need for sleep exceeded my normal requirements.

First Lesson learned: trust one's own clinical diagnosis - if the test results are unexpected, then the diagnosis is right and the tests are wrong.

That year as a student I spent many hours in that teaching hospital trying to learn what was being taught. It was a struggle, especially those lectures where the professor would breeze in, put up lists of topics on the overhead projector, replace them with more lists, finish the lecture by saying "These are what you need to know about" and then breeze out again. Bastard! A fucking lecture giving us lists of things we needed to know about but no true dispensing or sharing of knowledge. That same professor gave us a series of "lectures" ... all the same, all as frustrating.

Most of what I did learn in my first clinical year was found in odd places and odd times. Every morning a list of patients admitted to the hospital was posted onto the medical student notice board. The conscientious students were up early to see that list, and were off to see the patients with good signs. Patients in the hospital were referred to by their sign or their illness. Over morning coffee the chatter was along the lines of ... "Did see that spleen that was admitted to 4East?", "Did you hear that murmur that came in overnight into 6West?" I was never a morning person, and I never could be bothered to be the first to see that list in the morning.

However it was a ward round very early in the first week or so, which confirmed for me how dehumanising it was to be a patient in a teaching hospital. During that ward round, relatively late in the morning the group of 6 students, registrar and resident were lead by our teaching consultant to a patient in the wards. It happened that the patient who's bed we were swarming around had been a "good sign" to see and had seen the normal early morning queue of students and been the object of three other group ward rounds already. As the patient began to complain, the consultant stood menacingly over that patient and asserted that because they were privileged enough to have the best hospital that could be provided they had the duty to allow medical students to learn from him. I cowered, and when it was my turn to auscultate the patient's chest to listen to classical sounds that were indistinguishable from the mess of normal and environmental sounds I looked at the exhausted patient and thought a sincere apology that I dared not give voice to.

That day I gave myself permission to sleep in to a normal time in the morning and not join the vultures of the pre-breakfast sign hunt.

Lesson Learned: respect the humanity of the patients we work with.

I remember one night I had a phone call from the emergency department to come down and "do some suturing". Great ... I needed the practice. I extracted myself from the lounge in the student quarters and headed over to the hospital.

The patient was a male, drunk and had tried to walk through a plate-glass window. He was already placed on the table in the emergency department operating theatre. I, and another medical student, were directed to find, clean and stitch all the lacerations. My colleague started at the head end, I started and the feet. We measured out the maximum amount of local anaesthetic that was non-toxic for the patient (not that any local anaesthetic was needed given the inebriated state of the patient), shared the measured amount, scrubbed, gloved, masked and gowned and started.

An hour later my colleague was approaching the patient's chest area and I was just about to start examining the patient's groin area for wounds. We had already run out of our allocation of local anaesthetic and suturing without it did not seem to distress the semi-conscious body on the table. The nurse had already been in twice to re-stock us with gauze and suture silk. We were both confident and looking forward to finishing.

I found a wound in the groin, with a small piece of glass protruding. No big deal, we had removed almost enough glass already from wounds to reconstruct a beverage container. Clean, window drape, prepare my position for exploring the wound, remove the glass and suture. It didn’t feel right ... something didn't feel right. I stopped. I looked at the wound and waited. The glass was twitching, only so slightly but noticeable if one paid attention. No, I just didn't feel good about it.

I called the senior resident of the emergency department to look. He called the surgical registrar who consulted with the vascular registrar who took the patient into theatre and repaired the lacerated femoral artery that had been plugged by the fragment of glass.

An approving glance from the vascular registrar the following day was enough to give me a glimpse of the good things that could come from being a doctor.

Lesson Learned: find your instinct, foster it and trust it.

# 003 ... Holding Hands

Obtuse : slow to learn or understand; lacking intellectual acuity.
Obtuse : of a leaf shape; rounded at the apex.

Bizarrely this term that popped into my head as I wrote the title was not what I thought it meant ... but it is profoundly more relevant to this posting than I could have imagined.

Last time I mentioned being a medical student attached to a "labour ward". Simply that term conjures a palpable sense of dread ... the reality reinforced a headiness to the point where it was intoxicating. It was mostly the smell. Only those who have been there before can understand the all-pervasiveness of that smell. There is no other place in the world that it can be found.

My role? I never really knew. The midwives were the gods of the ward. The three cubic metres around the exposed vulva of the woman (who somehow, despite being slung between stirrups, melded with the elevated delivery bed) was sacrosanct. Midwives and midwifery students ruled the domain with iron hand and stainless steel blade.

I was rostered to the labour ward to learn, to observe, to assist in the delivery ... in the two weeks of the shifts I shared with two other medical students I was present at the actual delivery of two women. Now, that was not because only two women delivered their babes in that two-week period. Far from it. Many women served their time in that labour ward while I was supposed to be there.

However, the midwives who considered their own training more valuable than our own (and why not, we did not rate in their eyes) conspired for us to never be around at the time of the delivery.

Now it was not that I wasn't present during the labour of many women. I was. I attended to as many of the labouring woman's needs as was socially acceptable. Helped change bedding, empty pans, comfort, hold hands. I don't remember a woman's partner ever being present ... maybe they were once or twice, but in an unnoticeable fashion. I do remember that partners who wanted to be present were discouraged from being so. With the same aplomb that the midwives diverted the attention of the labouring woman's partner, they crafted the absence of the medical student for the point of delivery. Not because it was socially unacceptable, but to ensure the ability of the midwifery student to perform the actual delivery.

Oh, it was not like I was ever not called to attend when I was encouraged to be absent from the ward to eat, or drink, or attend to the necessary personal ablutions, but it was always timed so I would arrive too late.

They always did that in this place of excellence ... and it was not just medical students treated this way, it was also the O&G Fellows who were attempting to become competent GP obstetricians. They too were "left out of the loop". A lifetime later when I did my own fellowship job (in another place more respectful of the needs of trainees) I completed my six-month logbook with over 120 deliveries performed. My colleagues who were blessed with an attachment to this very labour ward of which we now speak, struggled to get their minimum of 40 deliveries performed.

So what if I arrived late? ... well true. I was a medical student and should feel privileged just to breath the air of the labour ward. After the delivery ... it was here and now was where I appeared to be valued. It was here I could imagine a sense of personal worth.


I did the stitching. Stitching? Yep ... for the benefit of the training of the midwives (no one could ever convince me that it was for the safety of the woman delivering) every woman shackled to that delivery bed had an episiotomy. Everyone. So once the midwifery students had enough of the laboured, and now exhausted woman, I was called in to repair the damage.

Was I ever supervised as a student repairing this most precious of a woman's anatomy? "See one, do one" was the adage. So yes, my first time was observing the registrar repairing the gaping wound caused by the midwives' steel, my second time was my own with the registrar looking over my shoulder ... the rest was me, myself and I ... and this woman, placidly laying there legs still in stirrups with me sitting there (anonymously gloved, masked and gowned) in the sacred place vacated by the gods.

Did I feel like a god? No. I did feel privileged though. And terrified. The result of my handiwork was going to be a permanent reminder of that day for each of the women who I attended. Well, just a part of them repaired. I wondered if those women ever recovered from the experience of being in that place. At that time, I did not know that the profound physiological changes that occur in labour seem to have an amnestic effect. I soon learned that most women didn't remember much at all.

I thought that a beautiful (any woman who is pregnant and happy that they are pregnant, glow and are the epitome of the most beautiful creature in God's creation) .... I thought that a beautiful woman's genitals were supposed to be attractive somehow. The freshly bloodied wound, the swollen, bruised labia ... and that smell of fresh liquor ... I wished I too had the brain chemistry of that woman who exposed all to me. In retrospect, I could not have done a good job suturing an episiotomy as a student. I learned in another place and time, from a revered and respected consultant, how to do this task well. And as a doctor, I did do that task well when occasionally required. I still hope that those women I attended while I was a student were not left deformed by my hand.

I also discovered in this place that when a young woman signed a consent for a pregnancy termination, nowhere on that consent form was it written that she was giving permission for 6 medical students to perform a vaginal examination while she was anaesthetised. I know we had to learn. Somehow this just didn't seem right or proper to me.

This same place I also learned the feeling of professional impotence. In the emergency department late one night a young woman was brought in by "friends" and dumped at the front door. She appeared to be having a fit, but was fully conscious and her eyes screamed terror. While the nurse and ED doctor assessed and worked on the patient I observed. This young woman's eyes pierced my own ... and I did not know what to do. I was standing, in my white coat, at the side of the ED trolley she had been placed on, she looked at me as if begging me to do something unable to speak, body contorted in pain, eyes more afraid than I had ever seen before nor seen since. I did not know what to do. The doctor gave the woman an intravenous anti-dote to the overdose that she had taken and the seizure left her body and the fear left her eyes. I stood by watching, relieved this woman was no longer in such pain ... but she and I were both drained. The fear I shared with that woman that day was mine alone ... if only I had held her hand, it may have helped us both.

That same year, in that same place of excellence, I sat with my mother holding her hand as yet another of the gods explained to her and our family my mother's diagnosis of cancer of the cervix.

# 002 ... So where do I start?

I guess the beginning ... isn't that what everyone who is being sociable and conversationally astute says to prompt someone who is pondering what to say, "Why not start at the beginning?"

Well, to be honest, I actually don't know where to look for the "beginning" ... or even define what beginning I should be seeking.

If I slosh around in the miswired memory banks this is the first recollection of emotional significance.

It was as a student. The lowly medical student. Not even acknowledged as having the bottom rung in the pecking order, more the mix of chicken faeces and discarded feed scattered around the bottom of the pen ... yes, that's what it feels like being a medical student.

And why does this happen? I don’t know for sure but I have my suspicions. Most doctors are men. Most men need regular sexual fulfilment. Most doctors are too fucking busy and too fucking impersonal to have any woman who is willing to have a committed sexual relationship let alone love a doctor. So what happens is that we bastardise our juniors to help relieve those sexual frustrations.

Consultants fuck with their registrars' mind and soul ... who fuck with their residents' spirit who, if they are lucky, get to fuck the nurses.

And medical students? Well they just get the "collateral damage" ... you know, when friendly fire kills one of your own. Just like that, only you don’t die -you get to live on with the emotional wreckage that was never your own, but gets thrust upon you in such a way that it becomes like your own, to love and cherish ... and learn to measure your personal value by.

So here it was, me with 5 other medical students on a ward round in the gynae ward. A ward like the ones you see in the old war movies. A long, very long ward with a row of beds all along one side and another row of beds all along the other side. Dark, dingy with the light provided by small electric bulbs strung from the 30-foot ceilings. The sort of wards that no woman could have her privacy anything other than invaded. Curtains pulled around in a ward with 19 other women who knew exactly what was going on behind those curtains (because every other woman patient there has also had the indignity of 16 or more goggling eyes fixated on her exposed vulva at least once that day).

The smell was, well ... definitely clinical. I guess "clean" ... must have been clean. Would have to be clean ... after all, the nurses were in their nun garb ... they wouldn't work in a place that wasn't clean would they?

At the beginning of the round, perhaps 2.00 o'clock in the afternoon, the consultant looked down at me over the top of his spectacles. Now, "down" is a relative term. I was of a similar height but being a medical student my actual physical presence was dwarfed by the presence of god, so yes, down it was.

"Next time you come on my rounds you will shave young man or you will never be on my rounds again!" "But I did shave this morning sir", I whimpered inaudibly. Inside my head I screamed "FUCK YOU SIR!" but because it wasn't in the rules I didn't ... I couldn't ... I valued my testicles, and my studies, more than my sense of self worth. Fairly you might say that I was being irrational. I guess I could have ignored it, perhaps even acknowledged that it wasn't important and I really was over-reacting. But no. That simple derogatory remark, with the voice tones and the body language ... it was demeaning and made me feel unclean. I suddenly felt ill. It was probably fatigue, but my body told me that the demigod towering over me had spoken truthfully and I was to tremble in his presence. So I did.

You see, I had been awake since midnight ... I went to sleep at 8.00pm but woke at midnight so I could have a free meal. Hospitals used to do that for their staff, back in the days when it was thought a good thing to do. On a meagre study allowance one ran out of money before the next monthly cheque arrived so one got used to having a main meal at midnight ... and taking a few pieces of fruit from the fruit bowl to eat the next day.

So being the student of the labour ward for that night (oh god, that’s another tale to tell!!) I got up at midnight, had a shower and shave (with the old blade that I could not afford to replace), ate ravenously the long-awaited meal and then wandered down to labour ward.

So comes the 2:00pm ward round, 14 hours after I woke ... 7 hours before any other civilised person would have contemplated facing the world. Of course I looked unshaven but with my fatigue, my addled brain and my overwhelming gonadectomy phobia there was no response other than the meek, inaudible reply.

Afterwards I debriefed with my colleagues ... it helped, it always helped ... it always helped us all. I can only thank my other God that I hadn't yet discovered the embrace of alcohol.

Medical student survival ... it was a pack mentality ... no, it was more a "flock" mentality. Protection in numbers. Huddled together we hoped that a few of us survived.

Some of us didn't ... but that too is another story.