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When you work somewhere as nice as the University of Otago you begin to look at things a little differently. Every November the School of Medicine in Dunedin, New Zealand runs a preparation course for Australian and New Zealand Basic Physician Trainees who are to sit their first part physicians exams the following February. The School is known amongst physician trainees for its entertaining lecturers and this year was no different. Below are some of the best analogies from this year's BPT training course: 1. Investigating ACTH-dependent Cushing's Syndrome ACTH-dependent Cushing's is like naughty children. If you shout softly with 2mg of dex and send them to their room for the night they just ignore you. But if you shout loudly with 8mg and ground them for 2 days then the pituitary ones feel bad and listen to you. But the ectopics are really naughty and they're usually cancer so they still don't listen. 2. Coronary plaque physiology Coronary atherosclerotic plaques are like Justin and Selena's relationship, they're rupturing and healing all the time and no one important pays any attention as long as they keep doing their job. But platelets are like Minions from the opening scene of Despicable Me 2. They just blindly follow each other attempting to serve their evil plaque masters by patching them up each time they rupture. But eventually there'll be a plaque big enough and a stress great enough that the platelets in their excitement block off the entire artery and kill the plaque, and potentially the patient. 3. Pre-eclampsia risk factors Getting pregnant is like getting a transplant. You'll feel better than you do now in a year's time, as long as you don't die in the meantime. Unless some cousins or siblings got up to something they weren't supposed to the placenta is a transplant that's 50% unmatched to the mother so of course the body's not going to react well and high blood pressure is the body's way of saying, 'Hey, I am not cool with this'. But we know some things reduce pregnancy-related hypertension. If the uterine macrophages see some paternally-derived placental antigens and are then like 'It's all good guys!' to the rest of the immune system, 'We've seen these proteins before. In fact, we see them most nights. They come in here, do their thing, then leave. Just ignore them.' then you don't get as big a reaction. Basically what I'm saying is, before you get pregnant, practice makes perfect. 4. Liver transplant donor-recipient matching Liver transplants are like clothes. They can be comfortable to wear or not, and look fashionable or weird. ABO compatibility is comfort for the body. If it matches, great, and if not, you go through some initial discomfort with desensitisation and after that you've worn in the clothes and they feel fine. Why would you do that? Well it's a small price to pay for looking good. HLA matching is like style and your immune system is a class of teenage girls, ready to pounce with vehemence on the slightest bit of non-conformity they can find. Have you seen 'Mean Girls'? Actually, even the immune system isn't that brutal. So wearing uncomfortable clothes is a small price to pay for fitting in. Extended-criteria donor livers are like factory clearance outlet clothes. They might look a bit weird and be a bit uncomfortable but when you're dying you'll take anything so they go just as fast. 5. Classifying Chronic Obstructive Pulmonary DIsease COPD patients are just like different types of fruit. Group A (mMRC 0-1, FEV1 >50%) are like berries. They are sweet as and everyone loves them. Start them on a SABA/SAMA and they'll be fine. Group B (mMRC 2+, FEV1 >50%) are like pineapples. They're prickly and difficult to get through to because they're always breathless and don't trust that you can help them. But when your LABAs and LAMAs do get through the tough outer layer of chronic breathlessness the rewards are just as sweet as for the berries. Group C (mMRC 0-1, FEV1 <50%) are like bananas. Have you ever bought a bunch of bananas from the supermarket? You eat one a day and the rest are fine, slowly getting more brown dimples until one day, bam!, the remaining three are chocolate-brown and you have to throw them away or make a banana smoothie or pancakes or something. Group Cs are sweet most of the time but every so often they fall off the perch and splatter on the floor and you have to put them through the smoothie-maker of a gen med admission to make good of a bad situation. Group D (mMRC 2+, FEV1 <50%) are the lemons of the fruit bowl, breathless at rest with frequent exacerbations. But when life gives you lemons make lemonade. So ramp up the steroids, list for lung transplant and cross your fingers. 6. Cancer prevention Preventing cancer is easy. You only have to avoid the IARC's grade I carcinogens (proven to cause cancer in humans): obesity, smoking, UV light, asbestosis, hepatitis viruses, diesel exhaust, air pollution, alcohol, oral contraception, red meat, and the 108 others. This of course means you have to be a tee-totalling, non-smoking pescatarian that doesn't have sex. You'd have to stay away from human settlements to avoid vehicle exhaust and have to avoid sunlight, so a cave somewhere is a good option. But fluorescent lights and even fires give off some (albeit minuscule) amounts of UV light, so it'd be best to stay in the dark all the time. So you see, we know what to do to prevent cancer... only problem is you'd be Gollum. 7. Ordering investigations Any test in medicine is like picking your nose. You need to have a plan for what to do when you find something. 8. Cancer therapy Advances in breast cancer over the years have been like being pecked to death by a flock of ducks. One duck by itself isn't going to hurt you. But if a hundred relentlessly gum you with their bills and scratch you with their claws and you're trapped in the park by yourself they'll eventually make you suffocate and bleed to death. Now imagine that you have a cricket bat. Well I'll just send 500 ducks. Oh, you've got a shot gun? I'll send 5000. We can always kill cancer if we send enough ducks. The problem is that some cancers develop machine guns and we need to send hundreds of thousands of ducks. All those ducks need to eat and drink and poop and by the time they're done with the cancer the trees in the park are stripped bare, the lake is dry, there's duck carcasses everywhere and the ground is covered in a layer of poop centimetres thick. So the park is cancer-free, but completely useless. Kind of like what happens when the US intervenes somewhere, 'We killed your dictator, here's your country back! Oh, everyone else may be dead too... yeah, about that.' 9. Colorectal cancer risk factors To remember the colorectal cancer risk factors just think of Santa. He's a fat, elderly male who's unemployed 364 days of the year so he probably drinks and smokes a lot. It's pretty cold in the Arctic so he probably doesn't get much exercise. And there's not much greenery up there so his diet is mostly red meat with few vegetables. During the winter months he doesn't get much sunlight and his vitamin D levels are surely pretty low. But that one's controversial. The low vitamin D being colorectal carcinogenic that is, not the lack of sunlight North of the Arctic Circle in Winter. That one's definitely a thing. 10. HIV transmission risk Getting HIV from an infected pt's oral and ophthalmic fluids is difficult. And I mean really difficult. You'd have to remove so much saliva from the pt to find a live viral particle that a passing rheumatologist would think they have Sjoegren's syndrome. You'd have to pay through the nose for a private performance by Justin Timberlake playing 'Cry Me a River'. Basically, you'd have to be more unlucky than an Ashkenazi Jew with consanguinous parents. 11. Multiple sclerosis treatment A normal nerve is like a windy, meandering highway system. Action potentials are electric cars meandering around the hairpins on their axon lanes to wherever they want to go. The glial cells are tunnels, nice and close together as the highway's going through some mountainous terrain, and every time cars get to tunnels that go through a hill instead of around it they speed up immensely and the information gets to where it needs to go much faster. Now multiple sclerosis is a band of roving dwarves looking for gold, who overhead in a tavern there was gold to be found in these tunnels. Every so often they come out of the mountain caverns and block off a whole lot of tunnels in a particular region while they dig for gold. The more they block, the more cars are stuck and the worse the symptoms. Warm weather brings them out because it's cold underground (Uhthoff's phenomenon) and when it's a lightning storm the electric cars get a boost and travel so fast down the highway it's painful (Lhermitte's phenomenon). But we don't just have to sit and beep at the tunnels whenever the dwarves are out. Prednisolone is an army of roving orcs who eat dwarves for breakfast. But you only want to pay them until they clear the dwarves out. If you keep them around just in case the dwarves come back they start eating the countryside and who wants to drive through a wasteland. Interferons and glatiramer are elven outposts on the tunnels. Dwarves hate elves and will stay away but when they get desperate enough they'll come and try their luck, and you need to call your orc mercenaries again. Natalizumab is the dragon Smaug. There is no dwarf who isn't afraid of Smaug and they have to be so desperate they'd eat mithril before they try gold-mining with him around. So that's all well and good but the problem is that every so often Smaug gets bored and decides to roast the entire highway from end to end and you're fresh out of black arrows. So you only hire Smaug if you've got a really big dwarf problem. 12. Lymphocyte development The story of lymphocytes is like police academy in Russian without the nudity. They're born and raised in the leafy green Eastern suburbs of the bone marrow, sheltered from the world by their stem cell parents. Then when they hit 18 it's out the door to the University of Thymus. They're put through their paces and at the end have to present a project to Professor AIRE. What they don't realise is they're actually being selected into the KGB and if they don't pass they're killed quietly and their families sent a fake letter saying they defected to the West. That's not entirely true; the B cells are all children of oligarchs so their parents can buy them a second chance and if they fail their first project (kappa Ig) they get to try a second (lambda Ig). If that fails then even money can't save them and they're knocked off. 13. Amiodarone-induced thyroid toxicity Amiodarone-induced thyrotoxicity is like war in the Middle East. If there's an extremist regime oppressing their people and exporting terrorism or a dictator threatening mass destruction, then the big guns get called in and amiodarone gets thrown about like it's, well, an ICU. The problem with bringing in an army is that once you're in you bring in weaponry, military hardware, and ammunition, and all this hangs around for a long time. Some of it goes to the local rebels or interim government's armed forces, and from there inevitably gets to the wrong people and you get increased levels of guerilla warfare (Type 1 AIT). IEDs mean your bowels are a mess, the rockets being fired into your base mean your heart's racing all the time, and you're so edge your reflexes are always primed. You're so used to looking up at the sky for warheads that when you finally look down even your lids lag behind. The treatment is what should have been done in the first place (thionamides); aid, education, empowerment of the people, and a slow withdrawal. Sometimes, however, your army's presence makes a local warlord angry, and you provoke small-scale battles (Type 2 AIT) that are a real pain in the throat. Unfortunately when it gets to this stage your usual approach won't work and you need a scorched earth policy (steroids). Of course once that's all over there's no more guerilla warfare, but there's also no infrastructure and people are depressed, puffy from all the crying, and have no energy to go about their lives. So you need to spend a long time re-building their shattered country (thyroxine). 14. Lupus screening Being a rheumatologist is a bit like hunting. Hunting for lupus is like hunting a wolf in the woods at night when it's pitch black. Not only do you need to kill the wolf, once you do you need to find its carcass by following the stench of fresh blood. You've got a choice of three weapons. You can use a machine gun (ANA), which is very likely to hit the wolf but the problem is there're so many other dead animals around that it's difficult to find the wolf's carcass once it's been hit. You can use a shotgun (anti-dsDNA), which is less likely to hit the wolf but there's less collateral damage so it's easier to find the wolf once you've killed it. You also have the option of a sniper rifle (anti-Sm); your chances of hitting a wolf in the dark are very slim but if you do you're guaranteed to find it. The choice depends on what sort of hunter you are and whether you can differentiate which wolves will be easy to kill precisely from which will need a scorched earth approach. |
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