jenniferhawke.com

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dearest Nevis,

new month and a new pool and a new view and a new roommate.

life just gets better and better.

hurricane Omar blew through in the middle of the month, but nobody noticed as much as the beachside resorts like the Four Seasons. there have been vehicles piled up along both sides of the road for the past two weeks and we can only assume a veritable army has shown up to get the grounds and rooms back in shape again.

and not a moment too soon.

tourist season is just around the corner. the days we are flying out after MED 4 will be some of the biggest days for tourists flying in.

personally, i can hardly wait to get home to some snow… !

“Will you walk into my parlour?” said the Spider to the Fly,
‘Tis the prettiest little parlour that ever you did spy;
The way into my parlour is up a winding stair,
And I’ve a many curious things to shew when you are there.”
~ Mary Howitt

we like the spiders and lizards more than the flies, mosquitoes and cockroaches. so they stay.

have a creepy crawly halloween.

i know i said in my last post that i’m tired — and i am — but i’m happy. there still isn’t any other place in the world i would rather be.

i probably won’t have the energy to bend over and tie up my shoelaces for a little while, but i think that’s okay. as long as i don’t trip over them and fall on my face.

“A mind too active is no mind at all.”
~ Theodore Roethke

i’m the one stuck at the watering hole with a plastic cup of Gatorade in my hand and a glazed look in my eyes. my number is skewed and crumpled and barely pinned to my sweaty shirt. my shoelaces are coming undone. which direction was the finish line.. ?

my brain is tired. you could probably call me mentally burned out right about now. and i think at least part of it has to do with the fact that i have been off this island for a grand total of 2 weeks in the last 14 months.

i need my mom.

i spent a couple of hours at the old place yesterday afternoon sweeping and cleaning and defrosting and mopping and chasing a lost goat off the porch and saying goodbye. final walk-through with my landlady should be sometime this week. keeping my fingers crossed for a friendly deposit return.

after posting yesterday’s photo of my grandpa’s medical tools from 1952, Brandon commented that he was surprised at how little things have changed. and it’s true. even the trusty stethoscope evolved a bit, but has remained largely the same since the 1940s. i found myself wondering if the lack of technological advancement in physical diagnosis tools is a reflection of the fact that doctors are relying more on other diagnostic technology. technology that has come giant leaps and bounds in the last 50 years.

then, yesterday in Physical Diagnosis class, our professor handed out an article from the New England Journal of Medicine.

I remember well my first course about physical diagnosis, which took place at the beginning of my second year of medical school. The preceptor was an intense but likeable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. Of course, he dutifully trained us in the appropriate mechanics — palpating for lympahdenopathy, performing a comprehensive neurologic examination, and the like — and uttered the usual homilies about their importance. But the emphasis at our weekly sessions was on the normal findings. Once, in response to a question, he scoffed that it would take two days to perform the physical exam described in our textbook. Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it.

I encountered similar attitudes toward physical diagnosis throughout my internship and residency. We residents were apt to regard the physical exams as an arcane curiosity — after all, who had the time to concentrate on proper technique when you had to round on 15 patients? Even if you said that you’d heard a diastolic opening snap or a midsystolic click, no one believed you, or people thought you were showing off, or they assumed your observations were derived from something other than a physical exam. Technology ruled the day, permitting diagnosis at a distance. Some doctors didn’t even carry a stethoscope.

In a 1992 study at Duke University Medical Center, 63 residents were asked to listen to three common heart murmurs that had been programmed into a mannequin. Despite being tested in a quiet room and having all the time they wanted — hardly conditions encountered in real practice — roughly half could not identify mitral regurgitation or aortic regurgitation and approximately two thirds missed mitral stenosis.

Not surprisingly, medical educators whose job it is to ensure the proper transmission of medical skills, have found these results troubling. They worry that a vital art, as they like to call it, is being extinguished. But is the demise of physical diagnosis a crisis or a natural evolution?

~ Sandeep Jauhar, M.D, Ph.D. from “The Demise of the Physical Exam” NEJM

two of our instructors in Physical Diagnosis lab are local practicing doctors here on Nevis. they are wonderful women with strong personalities and wry senses of humor.

and their hands-on technique is impeccable down to the finest detail.

i watched Dr. R take a precise blood pressure in milliseconds flat like she could do it in her sleep. and Dr. N carefully (and oh-so patiently) corrected my chest percussion over and over and over until my awkward fingers started doing what i wanted them to. i would probably trust these ladies to make a diagnosis based on physical findings alone more than most doctors i have met in North America. they may not be high-level super sub-sub-specialists, but they are experts at the fine art of hands-on diagnosis.

is it because they don’t have the opportunity to rely on the same technology that we have in North America? even if there was an MRI or CAT scan machine on the island, most folks couldn’t afford to pay for that sort of confirmatory test. they trust their doctor’s touch because they have to. their doctor’s have made diagnoses based on physical findings alone over and over and over again because they have to.

i will never argue that Wenckebach’s method of identifying arrhythmia is more accurate than a EKG. or that abdominal palpations more true than an xray. but i am very happy to be learning this vital set of medical techniques from such detail-oriented instructors. even if i don’t get to use these skills as often in a noisy, bustling high-tech hospital back home, i feel it’s a basic foundation essential to my education and understanding of the human body. besides, i may end up back in Africa someday. and there certainly aren’t a lot of MRI machines out there.

“Every patient carries her or his own doctor inside.”
~ Albert Schweitzer

learn. do. teach.

we are finally on step 2.

this week, we were graded on our first hands-on patient-interactive exam. we had to dress up in professional clothes and wear a white coat and drape a stethoscope around our neck and stand in front of someone sitting on an examining table as if we might be able to figure out what’s wrong with them. i played the doctor once and the patient twice and found both roles to be equally educational.

here’s an (abbreviated) overview of what you’ve probably seen in your doctor’s office a zillion times.

introduction: name, medical student, purpose, wash hands

vital signs: ask height and weight for BMI, take pulse & blood pressure

skin: general survey, colour, temperature, moisture, turgor, etc

head: hair, scalp, temporal arteries, masseter muscle, temporomandibular joint

eyes: eyebrows, eyelashes, conjunctiva, sclera, pupils, optic disc, visual acuity

ears: mastoid process, auricle, lobe, canal, tympanic membrane, hearing acuity

nose: septum, inferior turbinate

mouth: lips, teeth, gums, tongue, parotid & sublingual glands, uvula (“ahhh”)

neck: lymph nodes, trachea, thymus

chest: inspect, palpate, percuss, auscultate

the exam ended with listening to the lungs in 6 spots on the anterior chest. we haven’t learned anything beyond that yet, so it sort of felt like examining half a person.

oh wait. it was.

i have to say, this sort of test anxiety is different than the palpitations you can get filing into a classroom and staring at a scoring sheet. no matter how well you feel you know the material, the fact that someone is staring over your shoulder is more than a bit unnerving.

but after several years of an undergrad career where you are just a number in a lecture hall, it’s really nice to get immediate and detailed feedback on your personal performance.

————
note: the photo is of my grandpa’s gear from his med school days in the early 50′s. i didn’t bring any of it down with me because i was worried about transit damage, but plan to replace the stethoscope tubing when i get back home and will hopefully be able to use it. right now i have a Littmann scope, Omron sphygomanometer and ADC pocket otoscope opthalmoscope set. all of my equipment was delivered by the wonderful marvelous Kev when he came to visit in August. i recommend each name brand and prefer ADC over some of the other oto-opthalmo sets that i have seen that look particularly complicated.

yes, we spent pretty much the first 48 hours straight doing laundry. with a dryer!

other than that, we are settling in. cooking dinner at home. enjoying the gym and new internet connection and generator when the power goes down.

life is good and school remains crazy. today i had my Physical Diagnosis practical midterm with the head and neck exam. i should probably write about that. or write about something to do with school, but i’m flippin exhausted. having classes canceled last week due to Omar was nice, but we’re just making up the time with extra hours this week and even a bit on Saturday.

51 sleeps till Christmas break. thank goodness.

there was a bit of water to be cleaned up in our new place from Omar last week (and all the rain that came after he left) and the power at my house hasn’t been on since Thursday evening.

so, we spent an hour adventuring around the island on our way to grab breakfast at Nevis Bakery Saturday morning. we stopped at a few local landmarks to check out how they fared Omar’s visit.

Oualie Beach before:

Oualie Beach after [dock demolished and the Sea Bridge car ferry washed ashore]:

Pinney’s Beach before:

Pinney’s Beach after:

Four Seasons before:

Four Seasons after [hotel was evacuated and may be closed for months due to sea surge damage]:

unfortunately, i don’t have a photo of Chevy’s before, but it is a wonderful Nevis landmark and was one of Tiffany’s fave spots when she came to visit. sadly, the iconic celebrity-worthy patio bar on the beach has been all but erased. Sunshine’s is mostly still standing.

thankfully, no one was hurt in the hurricane and most of the damage was due to sea surge and high water levels on the west side of the island. the hit to the Four Seasons is a big one for local tourism economy and we’re all hoping they can get back up and running in top condition for the big winter season.

how on earth does a girl that arrives with 4 legal airplane weight suitcases end up with so much stuff in just over a year?

thank you for all the wonderful care packages! i saved every box and boy, are they coming in handy.

i have un-hung and folded away my kitchen curtains made of material that won the 2006 Zambian fabric award. the fridge is (sadly) white and postcard-free. i took down the hammock before Omar zipped through. clothes and books have been divided into “take home at Christmas” and “take home in April” and “give away” piles.

we are picking up keys to the new place (and new gym!) first thing tomorrow morning.