Emergency medicine

Highlights from one shift in the Accident and Emergency department:

Brisk start with a cardiac arrest call. I am assigned to performing chest compressions - 4-5cm deep at 100 beats per minute. Hard work at the best of times. End up doing that for 23 minutes non-stop as due to another emergency, replacement never arrives. Great workout, but I found it difficult to hold a pen afterwards.

Next I try to stop a patient from self-discharging.
Tricky.
I end up saying there IS a point to saving his life because... his pet parrot needs him.
Did not work.

Finally, a lady who came in because her carers couldn't wake her up, wakes up when I try to cannulate her. She threatens to smack my face because my hands are cold. Then she tells me she's just kidding. And that she really likes my smile.
As I get on with sticking a needle in her arm, she erupts with "Going home for Christmas", really going for it with all she's got. She repeats the whole song four times and gets me to sing along. The nurse can't stop laughing. Finally, as I wave goodbye, the lady tells me "I love you dahling, you can come again".

I walk back home at 2am. The streets are so quiet and still, you can hear raindrops in the trees.



Oh, go on then, let's have one more New Yorker cartoon:

Fame and infamy in the search of lost youth

Fig.1 A century after his death Dr. Brown-Séquard
proves madness and disrepute will still get you
on a stamp. In Mauritius.

I have just been entertainingly distracted from my studies by a bizzare curiosity paragraph in the Oxford Handbook Of Clinical Medicine, 8th edition (2010), pg. 711:

"After his neurological experiments, Charles-Édouard Brown-Séquard (1817-94), the most visionary of all neuroanatomists and the grandfather of HRT (hormone replacement therapy), proclaimed he had found the secret of perpetual youth after injecting himself with a concoction of testicular blood, semen, and testicular extracts from dogs and guinea pigs. In the 1880's over 12,000 doctors were queuing up for his special extracts, which they used on their patients in various ways. He gave the extracts away free, provided results were reported back to him. 314 out of 405 cases of spinal syphilis improved, and his own urinary flow rate rose by 25%. Endocrinologists never forgave him for bringing their science into disrepute. To this day, no one really knows if his (literally) seminal work has given us anything of any practical value. But he might be pleased to know that testosterone is now known to have the urodynamic benefits he anticipated, at least in men with hypogonadism.
Like many brilliant men, he had a cruel streak, backing clitorectomy for preventing blindness and other imaginary complications of 'masturbatory melancholia'. Had he not been blinded by the 19th-century ideas about female sexuality, could he have found a marvellous use for his concoctions, for 21st century 'hypoactive sexual desire disorder'? Possibly, but only if he relied on placebo responses."

Fabulous. I wish we had more (any) classes on history of medicine...

Profanities

Profanities? I'm a big fan. Seriously, what honest person wouldn't struggle to avoid profanities when talking about the world today? It is hard to remain polite when describing the current state of affairs, the widespread socio-political insanity... Nasty words tend to be very poignant, and often refreshingly frank and sincere. In contrast, one may say, to the indirectness, roundaboutness and plain cotton wool lies that corrupt our bureaucratic institutions, politics and media.

To curse is human. The other day I was in clinic with one of the cancer consultants. During a break another member of the medical staff came into the office to discuss one of Dr.X's patients. This Mr.Y, we were told, wanted to withdraw from treatment which included chemotherapy and an organ transplant. This patient was very lucky to have found an organ donor match. The transplant meant a possibility of a complete cure for someone who was otherwise looking at a maximum of few years left to live. The consultant couldn't believe what he was hearing, and had to be told twice. He got up from his chair, paced the room, forgot I was there, and exclaimed "What the fuck!? What the fuck is he thinking???". A few moments later, when he calmed down, he remembered I was there, and sheepishly apologised for using "foul language" and "offending me" (he didn't). He was probably slightly scared I might report him for being unprofessional.
Well, obviously, I didn't. It was not an unreasonable reaction. I was actually impressed that after years and years of practice this consultant still invested his emotions, still cared deeply about what happened to his patients. It would have been quite different if he had this outburst in front of Mr.Y, but he didn't. By the time we saw him, the consultant was back to his calm and non-judgemental professional persona. Mr.Y's reservations were explored over a long chat, and in the end, the patient made the decision to go ahead with the treatment. Some clinics are less boring than others;)

In addition to all of the above, profanity-infused dialogues are funny. Not sure why, but they still are. The more absurd the better. If in doubt, watch Big Lebowski. Or this abbreviated version:

What's your favourite profanity?:)

Good news everyone!

Good news everyone! I've invented a device which makes you read this in Professor Farnsworth's voice!

I also got a (hypothetical) job!:D I have somehow managed to secure my first choice of training location! All I have to do now is NOT fail my final exams and I'll be moving down south in the summer! Fantastic! Apparently I can produce a deceptively good job application!:D

Twiddling my thumbs

Today is the day I find out which area of the country I will be swept away to on the great wave of semi-random quasi-fair process of job allocations. Of course, I can't find out anything, I can't even get the damn page to open! Even though the date of job allocation results publication has only just begun, the server has already failed to cope...:/ I guess this is precisely the reason why they didn't announce the publication time... Grrr...

Scenes from a sample week

Scene 1

In which somebody steals my phone at a party and sends everyone in my phonebook a message "I love you!x".
Cringe.
Cringe cring cringe!
The replies induced varied doses of successive embarrassment. The funniest reply being:
I received your text... but i
don't know who it's from?
Maybe I love you too? Maybe
youre trying to kill me and
eat my soul. I hope ur who i
think u are..

Scene 2

In which I stand over a birthing pool, watching a lady in labour. Mum-to-be takes turns between releasing deep primeval grunt-wails, and screaming obscenities. I am handed a small pink sieve for scooping out the poop, which inevitably shows its ugly physiological head. Well, it's only to be expected, what with all the pushing and contracting and spiking lower abdominal pressure. Still... not the most advertised part of the miracle of childbirth.
The baby pops out, and I'm brought to tears by the ridiculous sense of unreality. Pregnant belly one moment, slimy baby the next. Seeing it live is so bizzare and unbelievable, my brain fails to wrap itself around this momentary transition.
I get to cut the cord. Because nobody else particularly wants to, but hey!:)

Scene 3
In which I find out that the girl who I once dogsat a chiuaua (or was it a chorkie?) named Princess for, changed her name to Sunshine and is currently on Big Brother waving her beglittered Leicester Medical School badge on national tv!!! How ridiculous is that?!!
Having said that, the dog did come in a hand bag with a hole for it's head - surely a forewarning sign?

Scene 4
In which I joke that I will only accept peacock or badger meat for dinner, then turn down the invitation, only to find out badger meat is apparently a bit stringy.

Scene 5

In which I find out that the reason the pharmacist gave me weird looks when I asked him for citric acid, was because of its popularity with heroin users.
I need it to make elderflower wine. The lot behind my house is full of elderflowers in bloom, and a flower picking expedition was a very pleasant way to spend an evening with friends:)

Uuuurgh...

So this must be mentioned - the "interesting" times (in the Pratchett sense, of course:) of sweating my teeth out through my popliteal fossa and grinding my bloodshot eyes on the sandpaper pages of Oxford Handbook of Clinical Medicine are, for the time being, over. The Exam for which I've been revising for the last two months (chained to my radiator, feeding on what the cats brought in) took place. I showed up on time, and... it sort of went downhill from there. Still, the deed is done.
I should be relieved, shouldn't I? But after such an enormous adrenaline ride, the waves and tides of panic and elation, I just felt like... a used condom... left behind in a side alley... in a puddle of vomit.

Danae (white version), by Auguste Rodin

I am slowly recovering. Just sitting still and letting music wash over me, waiting for a sprout of emotion to break through the barren scorched ground of my psyche.
:)

Scenes in suspended animation

On the dangers of blending in with other medical students:
Between tutorials I grab a seat at a table with people in my year I loosely know. They kind of ignore me, but then somebody breaks the silence remarking on the impressive size of an orange I’m eating & I take this opportunity to start a conversation:
- Hey guys, you know how when you go to party and you’re the only medic there, people just start showing you their their freaky abnormalities and skin diseases and stuff? Isn’t that weird?
(a slight pause, then a young woman speaks):
- I never go to parties where there are no other medical students.
(Everyone sips their drink. I give up.)

***

On the dangers of living in the library with your life pushing the lower limits of boring:
Sitting in the library I occasionally check my facebook. My friend recommends a game. I join and get instantly addicted. It’s a superhero role playing game and my character is called Thunderwoman.
When she fights duels the layout looks a bit like Street Fighter. I can’t find any instructions on which buttons to press to make her attach/kick/whatever so I vigorously press any and as many buttons on the keyboard as I can. I keep winning but can’t figure out how. People are giving me looks (it is the library).
P. passes me a small folded piece of paper.
- Can you take this piece of paper, read the instructions and follow them? (a witty reference to the Mini Mental State examination we were practicing earlier)
I open it. It reads “DO SOME WORK”.
I eat it.
I actually put the paper into my mouth, chew and swallow it. I’ve never eaten a piece paper in my life.
P. is baffled. So am I.
Also at this time I realise that my game plays itself out. The battles are just short clips and I don’t need to press anything.
I feel retarded.
I do some more work. But not before signing up to a free trial on lovefilm.com in order to receive 260 merit points for which I purchase Thunderwoman a bracelet which gives her +65 to defense. Yeah.
Then I read about heart attacks.

***

***

Remember to dress for sex offenders

With my semi-final exam only a few weeks away, I do find reading beyond the scope of my immediate curriculum has taken on an extra "spicy" flavour. Even reading about psychiatry feels a bit naughty, but being slightly bad in a very geeky way feels… good:) And keeps me sane.
So anyhow, there’s this book I am reading at the moment: Personality Disorders in Modern Life by Theodore Millon, 2nd edition. It’s a bit hefty, but let’s be realistic, any attempt to explain the most debatable of the diagnosable disorders from scratch should be, really. It does cover a lot of basic principles, which a person with no psychological background (me:) may well find extremely helpful and refreshing. It’s written in a clear way with a smart narrative that’s easy to follow and it summarises convoluted issues in a very illustrious, graceful way.
While reading about the classical foundations of personality disorders I found many intelectually/reflectively inspiring passages, such as this one, on the fundamental difference between social and natural sciences:

“Theory and experimentation are given equal weight in the natural sciences. Sometimes in the history of science, as with the theory of relativity, theory outpaces the capacity of science to make observations. Black holes, for example, were a known mathematical consequence of relativity long before scientists began to figure out ways to observe their effects. Alternatively, new technologies may make possible observations that are more detailed, more precise, and more abundant than ever before, challenging existing theories to the point that entire fields are sent into chaos. The ready availability of new observations allows testing to progress unfettered, quickening the pace of theory formation in turn. Thus, the science matures. The yield of the Hubble space telescope, for example, is so vast that the cosmologists cannot yet assimilate everything their new tool allows. Because there are usually multiple competing theories for any given phenomenon, determining which account is correct depends on the construction of a paradigm experiment, one designed to produce results consistent with one theory but inconsistent with the other. In this way, research tends to close in on the truth, whittling down the number of possible theories through experimentation over time.
The social sciences, however, are fundamentally different. Whereas investigation in the natural sciences eventually comes to closure through the interplay of theory and research, the social sciences are fundamentally open. Here, advancement occurs when some new and interesting point of view suddenly surges to the centre of the scientific interest. Far from overturning established paradigms, the new perspective now exists alongside its predecessors, allowing the subject matter of the field to be studied from an additional angle. A perspective is, by definition, just one way of looking at things. Accordingly, paradigm experiments are either not possible or not necessary, because it is understood that no single perspective is able to contain a whole field. Tolerance thus becomes a scientific value, and eclecticism a scientific norm. In personality, the dominant perspectives are psychodynamic, biological, interpersonal, and cognitive. Other, more marginal conceptions could also be included, perhaps existential or cultural. Some offer only a particular set of concepts or principles, and others generate entire systems of personality constructs, often far different from those of the DSM [Diagnostic and Statistical Manual – the international psychiatric rulebook:)]. Hopefully the most important ways of looking at the field are already known, though it is always possible that alternative conceptions remain undiscovered.”

Cool, huh?:) It just struck me that the way I understand things is completely social-scientific:)

So maybe, just maybe, if I get through enough of this book before the 7th of Feb, I will be able to actually navigate my way through the medium secure psychiatric unit during my 5 day placement there. I should mention perhaps, that this venture was inspired by my friend N. The lovely man that he is, and a self-proclaimed control-freak, he was full of tips and useful advice, about how I should prepare and what will happen once I’m there. It was so detailed, at times it bordered on insulting, which is where the message “remember to dress for sex offenders” comes in. A text like that just has to make you smile. I also liked another exchange which went something like this:
N.: Let’s do dinner after work one day that week
me: Let’s:)
N.: Well, some of my women may put you off your food...!
me: That will make me a cheap date then:)

I’m sorry, but my life rules.

More boring shit

These are reflections from yesterday and today. But first, I yoinked my mad professors' comment to the first entry:
"Sweet dreams tonight Germbuster. Do not let the nightmares in future nights during this exercise put you off. Soon you may wish you are getting lots of articles and analysing them. Nevertheless, I am glad that you like the diarrhoea. I will see if I can get more shit coming your way. Getting organised and being resourceful will stand you in good stead. Also, foregoing tea breaks may be a luxury you will enjoy."

Day 2...

... and the pressure is ON!

So today we learned that Health Protection Agency's job is HARD. In the morning we became one big buzzing think-tank gathering and evaluating information. We learned how a given amount of information can be "not enough" and nearly "too much to handle" at the same time. A nice juicy piece of information can be treacherous: it can bring you closer to a conclusion or lead you to a dead end - so now we know that it is useful to be weary try to tell the two apart as early as possible.

I think time pressure and limited resources caused us some frustration today. At the same time these limitations meant we had to prioritise our efforts, go into not too much detail and invole all members of the team in our work. Which I suppose reflects reality - with a threat of a potential outbreak HPA needs to move fast and multitask. And, of course, each day could bring a completely different threat so they can't be experts in everything and I suppose quite often have to improvise.

The task today was significantly more complex and very much outside of our area of expertise (or so it seemed :). Our process was definitely more labour intensive compared to yesterday, going on in fits and starts.

I think if I had another go at today I would make the roles of our team members more discreet (division of labour!) earlier on and brought in at least one more computer so that we could research different angles simultaneously. I think our organisation and communication suffered a little under today's time constraints (it was evident in our somewhat under-prepared Q&A video conference session with our sibling hospital). But we will learn from that.

All in all we arrived at some reasonable conclusions by ourselves, and starting from scratch that has to count for something!;) I think what also matters is that we all took part in brainstorming bits where we tried to form conclusions, which was great because the more of us spoke, the more good ideas we had and the faster we could move on.

Go Germbusters!

Day 3...

... and my team mates took some interest in this blog. Much to my embarrassment. Oh dear, I'm meta-reflecting. This blogging stuff is freaky...

Let's move on to the ramblings proper.

I am proud to say we all took some time last night and did our homework which meant our job today was much easier and more focused on analysing information rather than gathering it. And we had ample time to agree on our presentation and lines of argument.

I think we did a reasonable job communicating with the team in Burton, utilising the wonders of modern technology (email! speakerphone!). The speakerphone use turned out to pose similar difficulties to the videoconference. It felt artificial and it wasn't at all easy to discuss ideas. We had to be specific in our questions to be legible. We were positively surprised with how well the other team did their job and felt our input was equal and satisfactory.

I was a bit disappointed with the level of grilling at the videoconference meeting though. I was hoping to show off more of our handsome background research ;)

As for tomorrow... I hope learning about the ins and outs of the water supply and treatment will be a bit more spectacular than it sounds.

PS. The CSI moments in the Clinical Skills unit were much appreciated :)

A day with diarrhoea

Ok, please don't laugh but I volunteered (I know!) to write a daily reflection blog for my team during our Infectious Diseases course. Reflection (related as it is to being wise after the fact) comes quite naturally to me. Alas, just as I suggested I'd do it, our lecturer added that the thing has to be entertaining. ENTERTAING! I masz babo placek, as the polish say.
I tried to make it funny but gave up and submited this instead.

Day 1...

... began innocently enough. Not entirely put off by our foldable beast of a timetable and much invigorated by the promise of a fierce competition, the members of the G team assembled. Not unlike panthers, we sprung to our first challenge: coming up with a name for our team. Two minutes later the matter was settled. We had become the Germbusters. Our other ideas such as Germs and Ghostbusters were also brilliant, but something had to give way...

I think we all made some interesting discoveries today (like where room MSB223 is located, and what Ashby-de-la-Zouch is). We learned how to approach a patient with a potential travel-related illness and that seems like a powerful practical skill to have in your clinical arsenal. Making links such as that between incubation period and the pathogen type felt like a neat piece of detective work. I think it is fair to say we all enjoyed the clinical scenario-based format.

As for organisation and time management I think we did quite well (not letting our inability to remember each others names spoil the fun). We each took on a patient but discussed differentials together, delegated one person to read out the laboratory results to save time and presented each case to the group to open it up for changes/suggestions. Also, our resourceful minds were rightly not put off by the idea that using the internet might be considered cheating.

We even ventured somewhat beyond the task at hand by wondering about possible connections between the cases and questioning the reliability of the printed information. We even got a bit philosophical in a short stimulating digression on what it is that makes Swine Flu so frightening (humans fear what they cannot control).

All in all it was a fun day, even if it did revolve around diarrhoea. As one of my team mates put it "I thought it would be more like getting lots of articles and analysing them, you know? Thank god it's not! (laughs)"

I wanted to finish off with a diarrhoea joke, but failed to find a good (or bad) enough one.

Goodnight.

Ethical dilemma...?

Over the years I have probably fooled many into thinking I have a "scientific brain". There are at least 2 arguments to the contrary:

1) I use phrases like "scientific brain"
2) I actually prefer tackling dilemmas to problem solving.
I can live happily without clear-cut answers as long as I can take pleasure in the process of seeking them.

It started with a general ethics course I took in years 7 and 8 of my primary education. Somewhat ironically, the most formative course I've ever taken was a chat-based extracurricular class run by a teacher who in her infinite wisdom and kindness decided to volunteer. And thus I achieved the greatest objective of the educational system: I learned to question what I think I know.
Sadly, this meant that I found ethics disappointing and repetitive for years after. During the 'ethics week' in the first year of University I eloped to Ireland and came back just in time to sign my name on a poster produced by my group. Which makes me wonder: is it the case that the better you are at mastering the ethical process, the less ethical you become? Probably not. I was a cocky teenager.
However, since joining the world of clinical (hands-on) medicine, I'm faced with a new generation of ethical dilemmas. Turns out I was just tired of weird hypothetical scenarios where you have the power to telepathically manipulate planes but not, say, make a phone call. It was the pragmatic world of nitty-gritty disease business that sparked my interest anew.
Recently I completed two exercises in medical ethics - one as part of a Clinical Genetics seminar and one as part of an online research survey. It felt... refreshing:) Below is a sample if you fancy a go. Answers welcome (you can post anonymously), if you feel like sharing:)

Skin Cancer Survey.
I like this scenario because the more you think about it, the more complex it becomes. What gives me the right to invade an individual's privacy? What ethos am I bound by in this grey area between my lay and professional identities? And even if I decide it's my duty as a medic to be proactive, how do I ensure that above all, I "do no harm"? By interfering I take away the patient's right to choose - bizarre as it may sound, some people do not want to be told they have (or are at high risk of) cancer.
In question 3 the kids are added as a twist. Talking to the individual concerned is one thing, saying something where you are sure to be overheard (especially by family) is another. Even if you are officially the patient's doctor, you are strictly not allowed to dispense their medical information to the family without the patient's clear permission. So, if as a result of your actions somebody gets the patient's information against the patient's will, you'd be, as it were, in a whole world of shit. And because the modern commodity of information is so precious you could even end up defending your job and future career in front of the General Medical Council...
But enough of my blabbing. Here's the raw material:

My seminar exercises will be up in a few hours ;)

Teaching Point

One of the great advantages of my current life is the ability to see/think/learn and/or shamefully forget something new every day! For example today, in a CLL (Chronic Lymphocytic Leukemia - as in: cancer of blood) clinic, me and my fellow students were in consultant territory. What I really love about consultants is their unique ability to digress and get away with it. Even saying things like "you are a beast" randomly to a patient and then laughing manically at yourself don't really get you in trouble because, well, you are so good a doctor. So, as a species consultants may appear very... random and very often just plain crazy, but it's really only because they are in the position where they get away with having a personality. This is an example of how we interact:
Consultant: Never get old, never! It's no good.
Me: [pause, then shyly] I like this saying that it's not how old you are but how you are old.
Consultant: Haha, that's too deep, too deep for me!
Later in the day...
Consultant: So, you see, this [and at this stage I have no longer any idea what he is refferring to as "this"] is a little bit like the discovery of penicillin!
We: [plain looks, some nodding of heads]
Consultant: Now, can anyone tell me who discovered penicillin?
S.: Florey.
Consultant: Brilliant! Yes, dear Howard Walter! And what did he do?
We: [silence]
S.: He was Australian.
Me: Did he leave dirty petri dishes lying around?
Consultant: [to me, with disgust] Nooo! You are thinking of Flemming! His contribution was purely accidental but of course the Nobel prize was between them and Chain...
S.: I've seen a chamber pot they used for their experiments.
Consultant: Ah, yes! They were very interesting, very interesting indeed! Of course they had to have just the enamel on the inside and they were all made in Stoke. Because during the war, well you just couldn't get them anywhere... Remarkable, remarkable. [turning to S.] Tell me have you worked in a lab?
S.: No.
Consultant: Because, you see, the dishes we use now are all based on those chamberpots aren't they? And when I was a student they had a plaque in the hospital in Oxford, a wooden plaque on the ward that said: this is where penicillin was first administered. Remarkable thing. And cephalosporins! The work was also done in Oxford.
S.: I think they are now converting that wing of the Infirmary into some research extension...
At which point I'm looking at S. with a mixture of fear and bewilderment. The conversation then moves on to viruses, Occam's razor and then...
Consultant: You should all come and do haematology! It's brilliant! We actually get to cure patients. Some of them.
Other consultant: The ones that have the right cancer [chuckles slightly]
Consultant: [to us] What other specialty can you name that actually cures people?
S., future paediatrician, begins to open his mouth...
Consultant: Apart from paediatrics.
We: [silence]
Consultant: [chuckles] Come on?
Me: Musculoskeletal surgeon?
Consultant: Bah! They're just carpenters!
Me: GI [gastrointestinal] medicine?
Consultant: What there?
Me: Well, um, tumours? GI cancer?
Consultant: Peh! You lot always come up with these! They don't count! Come on!
Me: Respiratory medicine?
Consultant: What in respiratory medicine?
Me: Well, TB? [TB = tuberculosis]
Consultant: Oh! You are very close!
H.: Infection?
Consultant: Yes! Infection is the other major area of disease we can actually cure.
Consultant scribbles in notes.
Me: [shyly] ...but of course one could argue that you can never be cured of cancer, I mean we're always just waiting for it...
Consultant: [laughs a bit maniacally]
Me: ...because the "cure" is just taking your risk down to the level of the general population and it may still come back and...
Consultant: Yes, yes, but tell me this: if you're on a transatlantic flight and one of the engines in your plane breaks down, what are the chances that the other one will too?
We: [staring at him blankly]
Me: well, the same as the chances of the first one!
S.: No, because there is more strain on the remaining engine!
Me: Really? Don't they use just one engine at a time anyway?
We: Hmmm...
Consultant: [laughs - definately maniacally this time] But what if... the same mechanic repaired both engines?!
S.: Well...
Me: Well...
Consultant: [laughs some more]
Me: I think this analogy is too... complicated.
It is worth adding that during the course of the day we also learned that the Consultant's favourite comedian Eddie Izzard was on tour soon.
For comparison this is the interaction we had this morning with a doctor a level below a consultant (a Specialist Registrar). See if you can spot the difference!
SpR: I would like you to examine the patient's abdomen. Observe each other and look for areas of improvement in your technique.
We examine the patient one by one.
Patient's wife: We should be charging for this!
C.: How much would you charge?
Patient's wife: Hahaha, 10p?
SpR: [to C.] what did you feel?
C.: Hepato- and splenomegally?
SpR: What was the extent?
C.: liver about 5cm, spleen 10-15cm
SpR: Right, you'd need to use a ruler for a start. And 5cm from where?
Me: Costal margin
SpR: Subcostal margin. Subcostal margin where?
Me: Midclavicular line.
Spr: Yes. [turning to me] You might find it easier to palpate if you use the whole of your palm. And you may want to kneel next to the patient but that's optional. You just have to work on your own technique. [to all three of us] Now remember that feeling the liver subcostally does not neccessarily equal liver enlargement. It could be pushed down in lung disease - like emphysema, which this patient has. So ideally you do not report hepatomegally untill you measure the liver size with percussion. Now who can tell me 5 things to help you differentiate between kidney and spleen enlargement on palpation?

As you can see, the "matter-of-factness" (and some might say "relevance") factor in the two conversations is very different. But both are unique and colorful forms of didactic teaching I simply couldn't live without! Also: can't wait to be a consultant...