III.II.VI – Guilty Pleasure
III.II.VI
GUILTY PLEASURE
Our time in Pokhara was not all spent on fun and games. Once there, we started a clinical placement in emergency medicine at Gandaki hospital. I was particularly excited for this rotation as I had no experience in emergency prior to that, not to mention that emergencies are the coolest thing to study when you’re a student (at least for me).
There’s only one way I can describe why it’s the case, and anyone whose job doesn’t involve life and death decisions might find it a bit hard to understand without showing some contempt. It’s kind of an unspoken feeling shared by most doctors; especially emergency physicians and surgeons. And of course, I’m gonna quote Grey’s Anatomy for this. Medicine is “like candy, but with blood. Which is so much better”.
To a doctor who’s good under pressure, medicine is like candy in the sense that it’s addictive and it gets you going. It’s the having to make a hundred and one decisions in a split second, the adrenaline rushing through your veins, the not knowing what’s gonna happen, the satisfaction of having saved a life. The virtues of medicine, I guess, are indisputable by all.
But then there’s also the blood. That same pleasure is also tainted with the guilt that comes along with getting off on another person’s pain. The cooler and rarer a patient’s condition is, the more excited we’ll be, no matter its repercussions. The patient that’s completely alert and communicative despite a knife that went completely through their head? Sad, true, but it’s also one for the books. Truly a medical marvel – only god knows how they’re still alive! But you know what? They also come with a story of their own, friends, family, an entire life. And even then, it’s not just about pleasure. It’s also about livelihood. Our profession thrives on tragedy. We need people to get sick or injured if we want to stay in business and earn a living. It’s not just a guilty pleasure, it’s also about living – at the expense of the dying. And, of course, medicine’s not the only guilty party. Firefighters need house-fires to earn their wage, lifeguards need people who can’t swim, police need gun laws to remain as they are. These jobs aren’t as noble as one might think they are.
Back to emergencies. When studying about emergencies, I always picture myself alone with someone who’s dying in the middle of a deserted island or a road in the middle of nowhere. Somewhere without any of the resources you’d find in a hospital basically. You’re left to your own devices; no seniors telling you what to do, no protocols to follow, no equipment or super fancy tools. It’s just you and your imagination and improv skills. That’s it, doing whatever is in your power to save the other person’s life. And this is exactly how I always imagined medicine in developing countries to be. Having the bare minimum and doing the best you can do with whatever it is that you have.
On my first day at Gandaki hospital that was what I was expecting. It certainly wasn’t the case. From weeks before I had been bracing myself; not knowing whether we’d be assisting with bare hands or with gloves, whether we’d be using clean needles or recycling used ones, whether we’d be putting ourselves at risk just by standing there. I was prepared for it. Turned out it wasn’t at all like what I had been picturing. Not saying it was a state-of-the-art, cutting edge hospital; far from it. It was run-down and dirty, disorganised and chaotic. And you know what that’s way superior to? A deserted island or a road in the middle of nowhere. I’m sure it must sound all kinds of condescending coming from someone who studied in a developed country and volunteered only for a couple of weeks just so he could say he helped the world out. I know that.
But it’s also true. Nepalese doctors who have experienced Western medicine themselves told us that. They are conscious of how far back they still are. They also know how far ahead they’ve come in little time with such few resources, setback after setback. One day it’s an earthquake, the next a flooding. And so, they count their blessings along with their gloves, and their needles. They don’t waste as much as we do. They appreciate the value of every single thing that’s available to them. Every pair of gloves, every needle, every alcohol pad. Every single thing. Because they know what it means to not have something we usually take for granted. They know all about it. We don’t – or rather, we don’t have to. Until we’re in a position in which every pair of gloves, every needle and every alcohol pad is indispensable, we won’t recognise how wasteful our practices are. How wasteful our lives in general are.
Over the course of a week, we got to see a little bit of everything one would expect to encounter in an ER. Literally. Snake bites. Spider bites. Dog bites. All kinds of bites really. Fractures and dislocations, falls from height and falls from clumsiness. From the very dramatic attempted suicide with rat poison to the boring, old appendicitis or simple lacerations that only required a couple of sutures.
But it’s only one case that will forever have me shake in excitement and awe. You see, by now you probably know that I’m a little into medicine. You know, just a teeny bit. A smidge. What you don’t know is that I actually have a top ten list of cool medical conditions I want to see at least once in my lifetime. It’s a list I update only very rarely, usually when something super rare that piques my interest comes up online or on an episode of a certain medical drama. There we go…
MARIUS’ LIST OF MEDICAL MARVELS
1. Epidermodysplasia verruciformis
2. Fibrodysplasia ossificans progressiva
3. Neurocysticercosis
4. Takotsubo’s cardiomyopathy
5. Harlequin ichtyosis
6. Diastematomyelia
7. Congenital insensitivity to pain
8. Ectopia cordis
9. Fetus in fetu
10. Leontiasis ossea
I can go on and on about all of these. Most I’ll be lucky to ever encounter, one is quite common and I’ve already seen in practice, a few rare but common in Malta given our tiny gene pool (guess there is a silver lining to inbreeding, huh?). Nonetheless, they have a place on that list for a reason. I’m not gonna go into all of them, and I know you must be thankful for that, if you’re still reading that is. Pretty sure it’s just a conversation between me, myself and I at this point. But that’s okay, I quite like myself. I’s not as cool, granted, but he’s great when you’re in need of a night out. Anyways. If ‘you’ wanna know more about them, there’s Google (and nowadays, ChatGPT). However, I am gonna mention two. First, it’s Takotsubo’s cardiomyopathy; and it’s on the list not because it’s rare or because there isn’t anything more interesting. It’s there simply because it got me into medicine. That’s it.
Second one’s… I’m gonna tease this one out a little bit longer. We were in the ER when this patient in his thirties comes in seizing. Cool, right, whatever, another seizure. Even as a student, there’s only so many seizures that will have you tremble with excitement before they start losing their panicky charm. We helped stabilise the guy, brought his parents in, asked for his medical records and waited. And then waited, waited and then waited some more. Then in comes a nurse with his chart. We voraciously went over the whole thing, trying to find something which could explain the fitting. We read a previous MRI report which stated that he had multiple, well-circumscribed hyperintense lesions in his brain, with the characteristic dot sign suggestive of “NCC”. As I read through the Klingon gibberish, I felt as clueless as the first time I had sex. Luckily, that’s when our supervisor stepped in and and explained that basically the scan showed various cysts that were consistent with… And out of his mouth comes the sweetest, most mellifluous, euphonious word that has ever been uttered in the history of language:
“NEUROCYSTICERCOSIS”
NEURO – CYSTI – CERCOSIS
BRAIN – CYSTS – TAPEWORM
Neurocysticercosis… What a mouthful huh? Man, I never get tired of saying this word. Neurocysticercosis… Just like honey; smooth, soothing, soft… That’s right; friggin worms in the friggin brain. Just like candy. But with blood. And yes, this is the same thing the teacher had in the first episode of House MD and what Addison’s brother had in Grey’s. I’m gonna go a bit into it, so if you’re the kind of person who gets queasy when talking about creepy crawlies and poop, just skip the next part and move onto the next; which is definitely easier on all the five senses. For those resolute and unrelenting in their quest to pursue further knowledge, keep reading.
Tapeworm infections are pretty common. You eat undercooked pork that’s riddled with larval cysts and that’s it. In the intestines, the baby worms hatch and then mature into adults that cling onto your gut wall; absorbing all the nutrients that would otherwise be satisfying all your bodily needs, thereby allowing them to thrive and keep on growing.
While most people would be asymptomatic, some can become anaemic (low blood count), some dyspeptic (indigestion) and some even lose weight (hence their mindless use in dieting), amongst many other presentations. But, if you’re asymptomatic, don’t count your blessings just yet. Even so, you’ll go on to poop parts of the worm which carry the eggs. And, if you happen to live in areas where sanitation is not so great, contamination of food or water with said poop means another unlucky soul will get to feast on those eggs. That’s one sucky thing. Then there’s also the fact that the same larvae can enter the host’s bloodstream, invade other tissues and mature into cysticerci. What do I mean by other tissues? I mean muscle, skin, the nervous system, and… wait for it… the eyes. Insert smiley face here. Yes folks, that’s right. Eyes.
But as cool and disgusting and cringey as that may be, it’s the brain worms that get me going. Cysts in the brain can cause symptoms simply by compressing adjacent structures, by blocking the flow of cerebrospinal fluid thereby resulting in increased intracranial pressure, or via a major inflammatory reaction once the worms die and the cyst capsules rupture; usually within four to five years. The symptomatology depends on the location and number of cysts and the size; ranging from half a centimetre to a whopping six centimetres, according to my infallible source (Wikipedia). Symptoms include anything from headaches, blindness, meningitis, dementia, death, or, as in the case of the poor guy at the ER, seizures.
Treatment? Well, prevention is better than cure. Treatment and vaccination of pigs, adequate cooking of pork, proper sanitation and education are the only way to break the chain of transmission. If infected, antiparasitic agents are the mainstay of treatment, together with steroids if there is extra-intestinal infection and surgery as a last resort. The problem? Well, most countries suffering from poor sanitation; mainly Central and South America, Asia and Sub-Saharan Africa, cannot afford the pharmacological therapy that is required to treat the infection. However, while it is still considered as being one of the so-called ‘neglected tropical diseases’, it is also classified as a ‘tools-ready disease’ in the sense that the disease is quite possibly eradicable by means we already have. Unfortunately, till the day that this is no longer neglected, millions of people will keep on dying every single year. Just like the guy at the ER.
Like I’ve said many times so far, medicine is my one true love. But even the greatest love affair, I’m sure, has its periods of frigidity. And that too, happened to me during the course of my studies; multiple times. My passion has always been a constant wave of crests and troughs. On some days I’m flying on a high, excited at the prospect of learning new things, on others I feel as if my fire has been all but extinguished. But always, every single time, something comes my way that manages to bring me back to that high, reigniting my fire.
This was one of those moments. This was one of the few moments that made every single low seem like a high, one of those few moments that makes you realise you’re in it for the long haul, one of those few moments you realise you’re right where you should be. Candy. But with blood.