My hands

My hands have tried to save lives

I never really liked them when I was growing up. I felt they were always a bit too big, the veins too prominent. My nails were never shaped neatly but always slightly ragged and cut hastily, a bit too short. I look down at them today, despite my efforts to touch-type, and notice that, still, the nails are a bit too short; the skin dried out by hand washing and now also a bit wrinkly. But now I take less notice of their outward flaws, as I remember what they have done as the tools of my trade for the last 13 years.

My hands have brought life into the world. They have been the first hands to touch brand new, warm, slippery, vernix covered skin. The first hands to write new names on tiny wrist bands. To stretch yellow knitted hats over tiny heads.

My hands have tried to save lives. Shaken as they applied the pads or paddles and pressed ‘shock’. Tapped to find a vein. Tightened a tourniquet. Tapped again. Trembled as the cannula pierced flesh. Hoped. Interlocked and compressed. Felt the rhythmic bounce of the sternum underneath them.

They had to stop their compressions; instead fold together, poised, beneath a bowed head. Touch a colleague’s shoulder to signal that their hands should also stop. They have felt cold flesh under their fingertips and drawn up the hospital sheet to cover the indignities of resuscitation. They have written in black ink to confirm the finality of a life passed. And paused to wonder what those hands had done in that life, what hands had held that person dear.

My hands have communicated as they helped me listen to stories. Stories of all things human - joy, anger, fear, grief, trauma, addictions. My hands have passed tissues, rested on other hands, arms, shoulders. My hands have embraced, because, sometimes, that is all that can be done.

My hands have prevented influenza, pneumonia, shingles, HPV, measles, meningitis, hepatitis, and more. How many deltoids, old and young, have they exposed and how many vaccinations have they administered? Applied band-aids and stuck stickers on sweaters. Tousled brave heads and signed green books.

And how many times have my hands pulled the curtains around the examination couch, palpated abdomens, pelvic organs, found elusive cervixes? Swabbed and smeared. Inserted IUDs, ring pessaries, contraceptive implants. Prevented and detected cervical cancers; imparted contraceptive choice.

I think about how my hands have managed acute and chronic diseases. Checked blood pressures, oxygen saturations, peak flow readings, dipped urine samples. Felt for a pulse: regular, irregular, too fast, too slow, thready, bounding or quickly collapsing. Feeling again. Necks, wrists, feet, knees, groins. Auscultated and percussed lungs and abdomens. Pricked fingers and toes; swung tendon hammers. Squeezed skin nodules, held dermoscopes, ophthalmoscopes and otoscopes; checked temperatures of hot foreheads, swollen shins, sore knees.

My hands have helped me explain anatomy, diagnoses and treatment plans. They have drawn pictures: diverticulae, enlarged prostates, vertebrae, mostly it seems (from an unofficial audit). They have written and typed notes, referral letters, medical forms, Centrelink reports, radiology requests; checked interactions, issued prescriptions. They have written instructions. And re-written them, more clearly.

My hands have been the tools for teaching medical students and GP registrars their trade too; passing on skills and experience etched in mine to hands that are less wrinkled.

And my hands have made mistakes. They have written the wrong doses of drugs, missed an important clinical sign. My hands have held my head in dark, lonely on-call rooms, blown my nose, wiped away my tears-and those of colleagues.

These are my tools-my hands, the hands of a GP.

Dr Claire Denness

First published on the RACGP History page, under Tales from the Tools

My stethoscopes

My stethoscopes. I had several. They were special, awe inspiring tools and badges of my new life and identity. I inscribed them with my name and learned to care for them - by trial and error. My first stethoscope – a gift from my proud parents - was usually crammed into a pocket of the short white coat I wore around the wards. One day, the tubing split. I learned the most durable way to wear it was draped around my neck.

I slowly and progressively learned to use it - to keep it clean, to not transfer infection and how to wield it without mutual embarrassment to the patient’s benefit. I built up a library of sounds in my own head and developed a sense of what was normal, what was not normal but not pathological and what was definitely pathological.

What episodes stick in your mind?

I remember when it did not work. When I could not get a BP reading because the BP was too low for Korotkoff Sounds, because I was in the back of an ambulance going lights and sirens to hospital, when I was attending to a patient in dire peril and the pounding of blood in my ears blocked out any other sound.

I listened and no noise came from one side of the chest.
I took a slow deep breath and eventually learned to focus on the needs of the patient - my fear served no function except as a distraction.
I heard the wheeze of asthma, the rales and crepitations of infection and the pleural and pericardial rubs, the hollow echoes of cavitated TB. There were things absent that should have been present and vice versa. I heard the unilateral wheeze of a stone in the right bronchus, of a compressive cancer. Far too often, I heard nothing and having heard nothing I turned to the nearest table and completed the Death Certificate.

I remember the roadside trauma, the cricothyroidotomies I had to do. I recall the anaesthetics. Did I really do all that?

I remember all the techniques I was taught by those who had seen it all, done it all and were only too glad to have an eager pair of ears to finally tell. They had so many stories bound up in medical confidentiality that they could not share with family or intimates. Finally, as my teacher they could unload. Their passion imprinted their stories into my consciousness – I can see them still. May they rest in peace. In spite of my encouragement, they never wrote their life stories, which is probably why I have become a researcher, a teacher and now RACGP Victoria Historian - to see that they are remembered. They learned their craft by the trial and error of everyday practice. They had paid a high price for their knowledge - if I or any other doctor could be spared by their experience, they will rest happy. “Chris, experience is what is left when you survive your errors.”

Dr Chris Hogan

First published on the RACGP History page, under Tales from the Tools

Unk

Lionel Nicholls never married. He had grown up in Woolgoolga. He lived in a one room fibro shack next to his nephew Jack’s house, close by the beach. He had been a fisherman for much of his life, although he would have almost certainly have worked in the local timber industry intermittently, as well as on the Woolgoolga Jetty during times of peak demand. He was functionally illiterate.

His sole venture into the wider world was apparently his military service during the Second World War with the Australian Army. The story I remember best was his regular description of hair-raising trips through the mountains of Syria in a frigid winter, driving large trucks along perilous roads.

Unk’s fishing boat had been destroyed in the big cyclone of 1937. The same storm washed about 100 metres of Woolgoolga Jetty into the sea. Quite possibly he was still struggling to make a living when war broke out in 1939, so joining up would have been a logical enough step.

I don’t know whether the army managed to tame Unk, as he was affectionately known to all and sundry, but no one else seemed to have. He was singularly undomesticated. He kept cats and regularly seemed to have new litters of kittens. In later years it fell to his nephew to gather most of them up and despatch them in the traditional rural manner. There was no vet in town in those days. Unsurprisingly his home was rather chaotic, and yet exuded a homely character.

When I came to town in 1981, he had been a long term patient of my predecessor, receiving daily Fortral injections for reasons that I never clearly elicited. At first I wasn’t game to challenge that practice as a young solo GP trying to make his way in a small country town. However, as the months went by I became increasingly uncomfortable giving a daily opiate injection to an old man who still managed to live in his own home, however humble, on his own terms and had no need or wish to go to hospital.

It took a little while to summon the courage to substitute his Fortral with something more benign. I had already worked out for myself that there was no rational discussion to be had on the matter with my grumpy old patient. I tried some vitamins, reasoning to myself that they might even help him, B1 and B12 came to the fore. I didn’t alter the daily routine, he still presented to the surgery every morning around 8.00 am, waiting with the swelling numbers of patients for the doors to be opened at 8.30 am (In those early days I didn’t have appointments, it was “first in, best dressed”. Fairly soon I started afternoon appointments, but left the mornings as they had always been for the good folk of Woolgoolga.)

Six days a week, Unk would be on my front doorstep around 8.00 am (For the first six months in my own general practice we lived out the back. The arrival of child number two and the desire for some sort of respite on weekends saw us find offsite accommodation in the latter part of 1981.)

Sundays were different, I went to him. I would take whichever of our children were capable of walking to give their mother a break. They were shy at first, but quickly learnt that someone had suggested to him that little children liked lollies. He took delight in handing over small bags to them, whilst the cats hopped on and off the bed, or exited via the window. I could see that it became one of the highlights of his week, so carried on as before. Interestingly, he never seemed to notice any difference when I injected him with thiamine occasionally, mostly normal saline, so I was at least able to avoid opiates. He was clearly dependent on the injection process, rather than the contents thereof. I think he was a lonely old man, quite reclusive, incapable of normal social interaction, and in need of some reason to have regular human contact. This we were able to provide for several years until the inevitable happened. He stroked out, and fortunately did not survive his trip to hospital, exiting this world having lived it generally on his terms. For me it was an important early lesson into the many and varied ways of humanity.

Of course, it would be impossible to practice in this fashion nowadays – such things would not be sanctioned in the current millennium.

Assoc Professor John Kramer

First published on the RACGP History page, under Tales from the Tools