Daydream Believer

I haven’t gone crazy, this is the title of my Special Environments SSU.  The providers like to try and give them humorous headings to entice people to pick theirs over another.  This SSU gives me the opportunity to spend three weeks at the Day Case Surgery Unit in Torbay Hospital looking at anaesthetics and surgery.  We have three compulsory sessions and a feedback session each week, and apart from that we are given the listings for every other surgery going on in the unit and encouraged to see as much as we can.  I’m like a kid in a sweet shop, it’s amazing! Everywhere we go we are proudly told that Torbay has the best Day Case Unit in the country and the second best in the world, so it’s a great place to be.  We are also only allowed one student in each theatre, and there’s only three of us on this SSU so we all get to see what we want and are getting to be quite hands on too. 

I’ve spent time in pre-assessment, recovery, breast surgery, orthopaedics, maxillo-facial, GI, gynae, eye surgery, general surgery and urology.  I’ve retracted breast tissue, sutured feet, been chatted up by sleepy patients coming round from their generals, set up drips, helped remove a testicle, inserted my first successful cannula on a real person, managed airways, intubated and inserted LMA’s.  It is such a supportive atmosphere; it’s a really great SSU to be given.  

Long days full of sniffles

Week 7 of acute care was my favourite yet.  It was called thirst, but was actually just a week on the paediatric ward.  After an induction session watching a video about how to examine children and a supervised practice examining a 3 month old we shadowed the ward round and were then let loose to clerk all the patients being sent up from A&E.  They have a very low threshold for admitting patients down there, so they tend to send them up to be triaged and dealt with by paediatricians just to be sure nothing important is missed.  We had to check the board to see who was due to be seen next, collect them from the waiting room and take them to a side room, take a history, do an examination, send them back to the waiting room, write up our notes and find a Doctor to present them to.  It wasn’t terribly difficult though, as most of the patients were toddlers or below with bronchiolitis, a respiratory infection caused by RSV.  The treatment is pretty much just monitoring. 

We were encouraged to stay for the afternoon handover at 5 and continue clerking until about 7 when it started to get less busy.  It was intense, but it was really nice because you really got to know all the patients on the ward and really feel useful and a part of the team.  It made for long days though, especially as Thursday I had an evening placement with Devon Doctors.  On that day I was in for 8am and the ward round and I didn’t get back home again until 11pm, taking 30 minutes for lunch and 30 minutes for tea. 

We weren’t actually timetabled for that much, but our facilitator was a little disgusted with how little paeds we did and politely suggested that we spend all the time we can clerking patients to improve our confidence with examining children.  You could also be cynical and say we were helping to keep the department running smoothly by adding free man power to the clerking side.  But I had a blast, so I’m not complaining!  Also, since he had to write a professionalism judgement on me, I wanted to be seen to be heeding his advice and on the wards as much as possible. 

Devon Docs is our out of hours system now that it is no longer compulsory for individual GP practices to be responsible for out of hours cover for their own population of patients.  Local GP’s sign up and according to a rota they are either based at the hospital triaging calls and seeing patients that are well enough to come to hospital, or they go out in a chauffeur driven car to see patients in their own home.  I was lucky enough to go out in the car with Devon Doctors.  It was great seeing the Doctor trying to work out if the problem was severe enough to be admitted overnight.  It’s quite intense as you are on your own in another person’s house with no back up if anything goes wrong or to support your diagnosis.  

Leprechauns in boxes

Week 6 was helpfully titled ‘Confused Drinker’.  I was a little apprehensive of this week, as previously, when we had been on MAU we had been kept away from confused patients.  Even if they had perfect signs, we were told to avoid them as we wouldn’t get anything from them.  I wasn’t sure what had changed in the few short weeks since that made them think I would now be ok to literally search these confused patients out.  It is a clinical manifestation of Wernicke’s encephalopathy which, if left untreated, develops into Korsakoff’s psychosis.  It is a result of a thiamine deficiency which, in alcoholics, is due to malnourishment and alcohol impairing GI absorption and hepatic storage of thiamine.  Korsakoff’s is irreversible but has been known to spontaneously resolve. 

We had a bit of a slow start to the placement as we were sent to a gastro ward to wait for a hepatologist.  There were 5^th year students also on the ward, so whilst the Consultant had rung the ward and told them to find us some patients, the juniors on the ward told us to go to the staff room and gave our patients to the 5^th years.  5^th years don’t normally see patients in the same way we do, so everyone was a little confused.  After nearly 2 hours of waiting, the consultant finally caught up with us and we were allocated a patient each.  My patient was having a bed bath so I went and read his notes while I waited.  This was just as well, because when I finally got to talk to him I couldn’t understand a word he said.  He mumbled quietly and had such a thick accent I was at a bit of a loss.  The few words I could catch didn’t make any sense to me either – something about going on a trip and it being all my fault he was here. 

I noticed that he hadn’t taken his pills that morning and looking around the ward, all the nurses were busy trying to keep a rather sprightly but deranged gentleman in his bed by bribing him with biscuits.  He was instead trying to clean the ward with rubber gloves.  I decided to forgo clerking for that morning and instead help this gentleman take his tablets.  He had a broken arm so he wasn’t co-ordinated enough to take the tablets himself.  Over the course of the morning we had quite a good chat as his world was pretty special.  There were apparently two leprechauns sat in glass boxes opposite him, and on the end of one of the patients’ beds there was a woman who later turned into a goddess.  He had kittens in his bed and their mewing kept distracting him from our task.  I stayed with him until it was time to go and feedback to the consultant, by which time a nurse and a doctor had come to give him a nebuliser.  It was quite upsetting to see the state he was in, but I was proud of myself for persevering as I previously would not have had the confidence to approach such a psychotic patient as I had no idea how to handle it.  It’s not something I had come across before, so I didn’t know what to do or expect. 

The rest of the week was spent on MAU and in endoscopy watching oesophageal varices being fixed.  It was quite a depressing week in all to be honest!  Some of the patients we saw were so young to have drunk themselves to such an irreversible deranged state, it was awful.  It’s definitely not a specialty I can see myself in.  

Lumps, bulges and how’s your bowel?

Abdo pain 2 started with a clinic for problem bowels.  This was quite good as I got my own little consulting room to chat to the patients with before presenting them to the consultant.  Unfortunately, most of the time I had no idea what was wrong the patient.  Thankfully, neither did the consultant, and most had to be signed up for further tests.  That was a little frustrating, as it would have been nice to find out the diagnosis, but it improved my history taking skills.  There was an intriguing case of a patient who had their appendix removed when they were little and 5 years later and for the next 10 years they were still getting pain in that region, although the pain was now increasing.  It was thought that fibrous scar tissue that formed after the removal of the appendix was being pulled on when the patient moved in certain positions or did heavy lifting. 

I spent an afternoon in a hernia clinic getting up close and personal with men’s testicles and palpating for defects.  My competency this week was on examination of a swelling and I was sent to see a patient in the surgical assessment unit.  The patient was sat in a side room waiting for me to assess them but I had no idea where to start.  Their whole arm from shoulder to wrist had an enormous, pulsating, swollen vein running down it.  I really didn't want to touch it in case it burst.  At its widest it was 4 cm.  It was so distracting it quite put me off proper examination technique.  After the exam I was told the patient had kidney failure and it was a fistula that had which is a communication between the artery and vein to help give haemodialysis.  They were about to have surgery to reverse it.  It wasn't something I’d come across before, so it was quite astounding to see.  

Abdo Pain 1 – Where Bean Stresses About a Patient

The weekend before abdo pain 1 I was mightily stressing.  A patient I had seen in ED minors had come in with abdo pain and bleeding and they were a few weeks pregnant.  Obviously, high on my list of differentials were ectopic and miscarriage.  When the Doctor saw them, they didn’t ask any of their own questions, they just listened to me present in front of the patient.  The patient was due to have an early scan in 5 days and the Doctor decided they would be ok to discharge until then.  I was terrified I had missed a really important question to ask that would have made the doctor spot a red flag symptom I did not have the experience to notice yet.  I was even more terrified when I realised I was due to be in the early pregnancy unit for the patient’s scan.  I had nightmares of the scan showing she’d miscarried and then her yelling at me that it was all my fault because I hadn't admitted her then and there.  What was worse, was that the ED Dr said it was fine because ectopics never bleed, but my feedback facilitator said that was wrong and ectopics frequently bleed.  I was so confused about the whole thing, and just kept thinking of the worst case scenario. 

In the scanning unit I asked her consent to watch her scan and she actually seemed relieved to see a friendly, familiar face, rather than accusatory, which was good.  The waves of relief that washed over me as I saw the tiny flickering heart beat on the ultrasound is beyond words.  I later found out that she wasn't far enough along when she presented for the ED scanner to have found a heartbeat, so even if they did suspect something, there wasn't much they could have done and waiting for the EPU scan was the best option.  It just would have been nice to know that at the time so I didn't tie myself in knots at the weekend thinking I’d maybe missed something drastic.  I won’t forget that feeling in a long time. 

Most of the rest of the patients in the EPU scanning list were also happy endings.  They let us clerk in the patient and then watch them being scanned, so between us one was watching a scan and one was clerking the next patient.  One lady I was particularly worried about had been having really heavy bleeding.  When she was scanned, it transpired she had a bicornuate uterus, where the uterus is split into two lobes at the top and is sort of heart shaped.  She had a foetus in one half and the other half was having a regular period as it didn't know it was pregnant.  Very clever!

The rest of the week was spent in the Surgical Assessment Unit where I passed a competency in gastro exams and clerked patients.  We got to go to a lunchtime meeting for trainees where hospital staff from all over bring along an interesting case to discuss as a teaching aide.  That was actually pretty good, and I shall try to go to as many as I can.  They should be good AMK material.  

Shortness of Breath

Week 3 was Shortness of Breath.  There weren't really any focussed respiratory sessions, it was more a case of turning up and hoping that there would be a patient who was short of breath.  We had placements on the Medical Assessment Unit and in ED Majors and Minors.  The stand out experience by far was ED Minors, surprisingly.  When we turned up they were short staffed and really busy, so they told us to look at the screen, call the next patient through, clerk them, think of some differentials and management plans and find someone to present them to.  My partner and I looked at each other in disbelief.  Although this was similar to our ISCE’s only a few months ago, we hadn't been given the opportunity to do anything like that since and we were both worried we’d miss something important from being rusty.  It turned out to be the best afternoon I could have hoped for.  I had all the tools I needed to clerk patients, I just didn't have the confidence in my own abilities to trust and use them. 

The first patient I saw was a tricky one, as they had come in thinking they knew what the problem was, but what they were describing didn't fit with that at all.  On top of that, there was a significant language barrier, so they were having to type words into their phone to get translations so they could understand me and me them.  When I presented them back, the Doctor agreed with my diagnosis and that was the confidence boost I needed.  I stayed for four hours in the end, I was enjoying myself so much.  

Palpitations and Gunner Bean

Week 2 was palpitations and when I spoke to you last I said it hadn't been as exciting as the first chest pain week.  There was a trip to MAU, followed by what was supposed to be a cardiac catheter placement.  It turned out that had been cancelled because of a scheduled monthly departmental meeting.  It was a run through of all the statistics of the department for the previous month - how many operations, how many bed days used, how many complications, who was the most active surgeon, reg and anaesthetist and what barriers stopped patients from going home.  Then there was a mortality meeting where they go through who died in the last month and why they died.  It was interesting in a way, because I didn't know they did such things.  It was a bit brutal for the surgeons seeing all their stats up on the board for all to see and they were getting quite defensive with excuses like how their surgeries were generally harder and longer which is why they hadn't done as many.  I guess it sort of promotes competition within the team so they are all trying to be better... or faster, which probably wouldn't be a good thing if that made them make mistakes.

The medical school are doing a similar thing with us.  We have an electronic log book where we have to log all the patients we see, what histories, examinations and skills we did on them, what was wrong with them and what we learnt from them.  You can see your totals on a graph so you can see how many you are doing.  We are supposed to be aiming for 3-5 a week.  Also plotted on the graph are lines for the range of patients seen by 10-90% of the rest of the year and 0-100% of the year.  In theory, you can therefore see where you are doing against the majority of the class.  What it actually does is promote the feeling of 'I must be the best!!!!'  I don't want to be top, but I do aim for top 10% every week.  It's not possible every week, as sometimes the opportunities just don't come up to see patients.  There is also the inevitable moment where you finish logging for the week and think your top and then log in a little later to see everyone else just hadn't completed their logs yet so you're in a completely different place.  There are some people who still haven't logged any.  I hope they have good notes because I would never be able to remember if I didn't write them up that week.

Thursday afternoon of this placement week we were sent on a bit of a wild goose chase around the hospital. We were sent to find the office of a Consultant who had actually retired over summer.  Then we were told to go to his clinic, which hadn't been taken on by anyone else so wasn't taking place.  Finally we were sent to the cardiac catheter lab staff room to wait for a different consultant.  It was three hours before we actually started our placement, and it would have been the same as the Tuesday placement had that not been cancelled because of the meeting.  Pretty poor planning on the medical school's behalf.  After an absolute grilling by the consultant he lead us on a tour seeing exciting things.  On one cath lab table was a patient who was in multi organ failure and had arrested three times on the way down tot he procedure.  Everyone was on tenterhooks waiting to see if they would arrest again.  It was pretty much a last ditch attempt for them, and there was a bit of controversy as to whether they should have even been attempting the procedure in the first place as it wasn't likely to work.  Apparently the mother had been distraught and begged them to do something, so they decided to give it a shot.  We left half way through so I have no idea if it worked and the patient survived or not.  On another table they had just completed laser ablation of an accessory pathway in the heart and were all on their phones killing time waiting to see if the pathway would open up again once it settled down.  That was bit surreal.

Next comes the really exciting bit that I feel so guilty for.  My partner had seen a cardioversion the previous week but I had missed it as it was after a feedback session and I had to run to the Ladies Dinner Night.  The procedure is to shock the heart out of an unstable rhythm and into a more stable one, in this case atrial fibrillation into sinus rhythm.  It's not a lifesaving operation as you can survive in AF, just with a higher risk of developing blood clots, so you tend to be put on warfarin.  Quite a few older patients spend their time flicking in and out of AF, as it can spontaneously resolve.  In that case however, the patient was fairly young and fit and it was bothering them, so the consultant decided to cardiovert them out of it.  My partner had almost gotten to push the button but an F1 poked her head around the door at the last minute so the consultant gave it to her to do instead.  It is quite exciting; it's a different use for the 'charging, stand clear, shocking' defibrillator machines you see on the telly, just they don't use paddles any more  it's electrodes, wires and a button.

Because he had nearly gotten to do one, the consultant we were with had promised him that he would be able to do it this time.  It was explained to us that the person we were about to see was a private patient of the consultant and was fairly wealthy and important and had paid to be cardioverted out of AF as he had slipped back into it again.  The longer you are in AF, the harder it is to get you out of it and you are more likely to convert back into it again, so this wasn't a definite fix of a procedure.  As we entered the curtains the patient was put to sleep and the consultant turned to me and told me to dial up the right charge, push the sync button, say stand clear and push the shock button.  I blinked at him and he ushered me forward to hurry up while the patient was sleeping as it wouldn't last long.  Me.  Not my partner.  I am ashamed to say I leapt at the chance.  The gunner in me came out and I couldn't turn down the opportunity to do something cool.  But I feel so guilty about it!  My partner was really looking forward to it and.... ARGH!  I'm not that sort of person usually, I don't know what came over me.  But it was cool though :-D

We were ushered away quite quickly once it was clear he wasn't going to flip back to AF and then sent to look at a slide show on how to read ECG's.  It occurred to me after that I'm really not sure I had consent to do that procedure.  It was a private patient that I didn't even speak to and I'm pretty certain he didn't even register we were in the cubicle.  I'm going to blame the slinky green dress I was wearing for the fact the consultant gave it to me not my partner.  It's a professional dress, not low cut and appropriate, but slinky nevertheless.  I made a mental note to be sure to put my partner forward for the next cool thing we got offered the chance to do.

The Inevitable Sick Bean Post

The cold I'm nurturing has been with me for 2 and a half weeks now.  It's doing a tour from my tonsils to my throat, then nose and now chest.  My coursemates and housemates have all gotten sick, gotten better and gotten sick again, while I still have the same familiar bug proving that yes, I really can make more goo.
Despite that, uni is amazing.  I can't believe the opportunities I'm getting and I have so many stories to tell you.  I'm going to try and write shorter more frequent posts so I can share them with you.  It's October 15th soon which is the scary "this is it, I'm really doing this day".  Good luck, believe and just give in and embrace the fact that you will check track, new media medicine and the student room about 5000 times a day.

Super Happy Sleepy Bean

Well, I have survived my first two and half weeks.  I think I have survived anyway.  I am still here, in one piece, but I think my brain may be making a pilgrimage back to bed.  I started last week on a chest pain week.  Myself and my partner turned up at the required ward at the required time, slightly terrified and wide eyed but keen to learn.  We were met by a registrar surgeon who took us through some basic anatomy and causes of chest pain on a white board in a theatre and within half an hour I found myself peering over anaesthetists drapes into an open chest cavity watching a heart beating.  A real live, actual beating heart.  It's a good thing I was wearing a mask because my mouth was wide open in amazement for the next 5 hours of surgery.  We don't do dissection here, so this was my first encounter with the real thing, and no text book can prepare you for what it is like to see a patient splayed out on the table in front of you: vulnerable and beautiful and impressive.  The surgery was a double coronary artery bypass graft and aortic valve replacement.  At one point, the surgeon looked at us and said "Now, for the first time in 77 years, this patient's heart is going to stop beating."  It was all I could do to stand still and not jump around the room singing "this is so freaking amazing!!!!".  Also, I really, really wanted to poke the heart.  Is that bad?  I wasn't scrubbed up so I couldn't, but the compulsion was there. 

The rest of the week was spent on MAU and in ED and the heart wards chatting to and clerking patients and then Friday morning saw us back in theatre watching a CABG and aortic root replacement.  This poor patient's ascending aorta was about 7cm wide, a healthy one is normally 2.5-3.  They opened the chest and it was there, pulsating angrily.  It was decided it was too big to clamp, as every time the reg touched it to prepare the area for the consultant pin prick bleeding started.  Part of me wanted to duck behind the drapes, certain the thing was going to dissect and spray blood everywhere.  The decision was made to put the patient in full circulatory arrest.  This means they were cooled to 20 degrees C, put on bypass and their blood volume drained into the bypass machine.  This would then give the surgeon 15 minutes to cut out the aorta and attach a synthetic one.  Impressive is an understatement.  This surgery was mind blowing.  At one point, I was looking down into the heart from the top where the aorta should have been but had been dissected away.  It was unreal; a view point you should never be able to see in a living person. 

This week is Palpitations and has been rather less exciting, but then probably anything was going to be after that.  My partner and I have spent a lot of time waiting around for patients or placements, and one of our placements was cancelled completely in favour of a departmental meeting.  I am waiting right now in fact, for my next placement at 1.  Happily, I passed my feedback session last week and my competency and professionalism judgement.  I practised my competency on my housemates who are engineers and they were such big wusses, they were terrified, even though the worst it was going to be was a needle prick on the face.  I guess, since I know the examinations inside and out, it's easy to forget the patient doesn't and they might be imagining you will do awful things to them. 

Mr came down now he has a couple of weeks off.  After the amazing surgery Friday we bombed up the motorway to his mess for a Ladies Dinner Night.  It was so lovely to see everyone again at what will probably be my last mess function there as he's moving bases now.  It was a little surreal though, to go from scrubs and blood in the morning and then fine dining and fancy dresses in the evening.  My feet didn't really thank me either, after a 7 hour surgery (and that was just my morning!) and then mingling until 3.30am in heels.  The next day we had a leisurely breakfast and then it was down to a family wedding in Exeter.  It was Mr's turn to meet Dad's side of the family, most of which I haven't seen myself since I was tiny.  It was such a good weekend, filled with everything I love but I am really, really lacking in sleep at the moment.  The hospital is a 30-40 minute bus ride away, so I am getting up everyday at 6 to be there for 8, and my housemates all have their fresher's week at the moment so they are being really noisy both when I'm trying to get to sleep and then again when they all traipse home at different times.  I am dead on my feet.  Hopefully, this weekend I'll be able to catch up on sleep a little more.  I am having a blast though, third year is amazing.  People keep mistaking me for being a real doctor, it's unreal.  If there could just be a few more hours at night to sleep, then I would be a super happy bean.  Otherwise, you'll just have to make do with a super happy, sleepy bean. 

New term, new town, new start

I finished the summer job, had a couple of days in Cornwall with mr, packed up my stuff and moved to my new home.  I've been here a week now.  I haven't really done anything exciting, it's mostly just been induction lectures.  All I can really tell so far, is that 3rd year seems packed.  It seems exciting too, but I'm pretty nervous.  My first term is based around acute care so I'm on the wards a lot.  I have one week in each speciality focussing on a specific presentation and then I move on.  Mondays and Wednesday mornings are for lectures and clinical skills and the rest of the time I will be on the wards and in theatres on placement.  Friday afternoons I will have a feedback session with a Consultant where I have to present back a significant patient I encountered during the week to be questioned on.  This is probably the bit I'm fearing most.  The Locality Sub-Dean asked at our induction lecture if this was the bit that everyone was most afraid of, and if we'd heard the Consultants were brutal and would grill us.  All bar one in a room of 77 raised they're hands in agreement.  He said that wouldn't be the case, but how did all of us hear it.  I shall just have to go into Friday as prepared and as confident as I can be, and see what happens.  

I am starting with a chest pain week and I have placements in the ED, MAU and cardiac theatre.  I'm not enjoying the early starts much, I'm finding it hard to get sleepy enough to go to bed earlier, but tomorrow is my first proper day on placements on all day, so I'm sure adrenalin will help to get me up.  During the course of the week I have to clerk and examine a minimum of 3 patients to log in my clinical log book, find a patient and get assessed on a cranial nerve, higher function, eye and ear competency and find two patients to take to the feedback session on Friday.  It will be fine, I can totally do this.  Yeah, so send good thoughts my way please.  I can do this, but a little luck can't hurt.  

Summer's Nearly Over

I think wanna-be medics spend a long time waiting for something; waiting for exam results, waiting for UCAS, waiting for uni decisions. Now I'm on the course I was waiting for, I'm still waiting. This week finds me waiting for the uni to update their website and tell me what my timetable is and waiting for summer to be over.

I know, I'm odd but I really don't like summer. It's shorter than it's ever been for me before, only 10 weeks this year instead of the 15 I used to get, but it's still so long. I'm fed up of work. Grateful as I am for my job, I can't get away from the fact that I don't want to be here. Simple as that. This is not what I want to do. I am fortunate to do what I want to do for most of the year, but then it goes and takes a reeeeally long break. It gets to the point where I have to remind myself that this isn't forever, that I'm not a Pensions Administrator. That people's incompetence with page numbers in Word and their habit of breaking spreadsheets they commission me to make so I have to rebuild them isn't my life. I'm fed up of office gossip, although medic gossip seems to get me in just as much trouble since people are apparently only capable of talking about me, not to me. Honestly, it's worse than high school. Hopefully they grow up someday soon before they graduate. I'm fed up of the army changing mr's shift patterns and destroying our plans seemingly with the changes in the wind. I'm fed up of Facebook filling up with pictures and statuses of people's lovely holidays and trips to multiple countries - when is it their turn to join me in the real world? It's my seventh year at this company working.  I don't remember what it's like to have long empty summer holidays doing nothing.  Home is a bit stressful too as some of my family aren't very well.  It's frustrating, as when we call for an update, I get oh, well we're waiting for scan results. What scan? Not a clue, a scan.  Right. 

At work my boss has been seconded to another office for the next few months. He left me with a load of work to do. Unfortunately, the other five managers at work have realised he's not here and queue up to give me their work to do as well. Every time I refresh my work queue or email inbox there's more to do. I tried to give a bit back as I was just too busy and I had five different people going up the chain of command coming over and demanding why couldn't I do it, what else did I possibly have to do that was more important than their bit. Plenty thanks.

I got into an argument with one of my old housemates. They hadn't paid me bill money so I can close down the accounts, and when I reminded them about it twice, after ignoring me, the first thing they did was lie to me. When I caught them out at lying, they went all defensive and tried to make out it was me being mean and demanded an apology. After the third time they asked for an apology and said something completely melodramatic to make me sound like an awful person I erupted. I probably said some things I shouldn't have, but it just galled me that never once did they say anything in the way of an apology for lying to me in the first place, or even admit to it in fact. You don't take Bean on in an argument and then make her mad because you will lose.  I know it was a silly thing to do because they have a lot of friends and they will delight in telling them how mean I was and what an awful person I am. Even those these people have never really spoken to me before, it's going to be a little frosty next year I think. Hopefully they will give me a chance and see that actually, I'm a nice person. See? High school stuff.

Our landlord is trying to keep all our deposits and wants more money on top of that. Not because we damaged the place, but because the tenant he found to fill a room turned out to be a broke druggy so he lost a lot of money in unpaid rent. He also had to replace our broken boiler, rewire the lights as the switches didn't work, rewire the top floor as the fire alarms weren't connected and as he doesn't have any tenants for next year he's decided to knock the kitchen and the dining room together and put flat screen TV's on all the bedroom walls. I think new tenants would rather not have damp and mould not share there room with worms that come in through the hole in the wall, but that's just me, he's the Landlord. Rather than getting the unpaid rent from the guarantor he wants it from our deposits. It should work out in our favour though, because he never told us which deposit protection scheme he put our deposits in, and won't tell us now we've asked, suggesting he never did. This is illegal and we can take him to court for repayment of the full amount plus a fine of 1-3 times the amount of the deposit. We aren't the affable, clueless students he takes us for. Fingers crossed.

I did manage to get away with Mr for the weekend in London, which was nice. We went to watch the women's triathalon and finally got to the Hunterian collection at the Royal College of Surgeons. I've wanted to go for years, but it's always shut at New Years when we get to go to London. It was lovely to be in London at Olympic time, everything was so colourful and happy. I loved the medals hanging from the trees in Leicester Square. Hopefully in a couple of weeks we're having a mini break in Cornwall since we had to cancel our main holiday. If the army change his shifts again, I'm kidnapping him.

I am so excited and nervous about next year. I'm quite looking forward to exploring a new city now I've gotten used to the idea. I do feel a little lost and forgotten about though. If I was a Fresher I'd have been sent a welcome pack, or I'd have one waiting for me in my Halls of Residence room. Because I'm a third year, I won't get that, yet I still don't know anything about the uni or town and we start two weeks before they do, so there won't even be anything around on campus to pick up.

I want to say thanks to all the people that commented on my last post, I really appreciate them, they made my day.  I only have one more week left a work and then one week at home, four days of which I'm in Cornwall. Summer's nearly over and I can't wait. Normally, happy posts will resume when I'm back at med school. 

Results: AMK's, ISCE's and Progression Decisions

So I have been my usual big stressy ball self recently. I've been saving my results post until I knew the outcomes of all my exams - I really didn't need to share my neuroticism and what if's with the whole of the internet. I think you get enough of that from me normally! We sat the final AMK, which I thought went quite well, but everyone else came out saying 'that was awful', which worried me somewhat. I answered more questions than ever and felt really confident. The results came out a couple of weeks ago now. I'm super happy to say I passed. I got 42.3 which is my highest score yet and still in the top half of the year. I got 60 right, 30 wrong, they binned one and I didn't answer the other 34. I'm pretty chuffed with that. It would have been nicer to be a little higher than my apparently fluke 41 in the first test of the year, but I really can't complain, it's a good score.

ISCE results were due out at 10am on the 5th July. At 9.45 I thought I would throw up. I couldn't concentrate on work, I was shaking, I had palpitations, I was pretty stressed. This was all that stood between me and passing the year. Mr had a couple of days off the weekend of the 7/8th but I wouldn't arrange to go and see him in case I'd failed as there was only 4 days until the re-sits from results day. He wasn't too impressed. By 10.05 only the professionalism judgements were out, not the clinical results. I called the admin office who asked the assessment database team who apparently had no idea there was supposed to be another bit of the results. By 10.45 all the results were up and I passed! I got a satisfactory overall and satisfactory professionalisms with one excellent. I was so over the moon I nearly cried, big sop that I am. In the breakdown of the results there's a real mix of borderlines, satisfactories, low and high excellents. I was a little annoyed at the respiratory lady who said I seemed like I was distracted and I wasn't in the room, after she was so off putting. She also said I didn't sign my peak flow document, which wasn't true, I know I was completely anal about signing everything. At the end of the day, I passed and that's all that counts.

I got the email yesterday to say that the Progressions Board had judged me and decided I could pass and progress through to year 3. I still can't quite believe it. I wasn't going to apply for a third time, and now look, I'm actually not bad at it, and I'm a third year! It's my half way ball next year. Half way! Wow. I used my leaving present money from the GP surgery to get the Oxford Handbook of Clinical Diagnosis and I'm going sale shopping this weekend for some short sleeved shirts that fit as mine are long sleeved and much too big now.

In home life I have 6 weeks left a work and 7 at home. I'm back in my element as an Excel geek at work making spreadsheets to interrogate data and provide management information. Unfortunately mr got the longer posting that is closer to home but comes with a leave ban so we've had to cancel our holiday which is beyond rubbish. We had it all booked and paid for, and he'd had the leave approved. We had no idea he'd be called to do this posting. It's been a really hard year and I was so looking forward to a week in the sun being a normal couple to have a break from everything. He gets a couple of days off every 15 or so, but most of his are week days when I'm at work. I'm looking for a two night city break for the end of August some time when I have a week off work to pack and he has two days off, and in a few weeks I'm going up to visit him when he has a weekend off.

I filled my memory box where I keep all our tickets to things and business cards of places mr and I have been and things we've done. Well it has been nearly five years. I've started scrapbooking them now. I've also started making the Christmas presents for family in the evenings: one done, six to go. They are getting decopatched notepaper block holders with paper and a pencil. They're looking really good and it'll leave me with just mum, dad and 4 more cousins to buy for as mr's is sat put away in a drawer already. Organised or what?! :) Now I just have to find a job in Plymouth, preferably something outside of normal working hours to fit it in with studies. It's a bit difficult though, I can't really say 'Hi, I'm bean, I'm good at admin, data mining and fixing problems. I can't work many hours and I have to be super flexible as I don't know my timetable and I'm a clinical years medical student but I will work hard for you when I can. Please hire me.' I don't know how to market myself, or what sort of thing to look for. I though a Devon Docs admin/phone answering person would be ideal but they don't have vacancies without me having to drive for 40 minutes get there, which really isn't practical. Any ideas greatly welcomed.

So that's about it. I hope your Summer's going well despite the despicable weather.

Bean
(3rd yr Medical Student, Peninsula Medical School)
*Runs around the room, screaming, whooping, cheering and doing a happy dance*

PS.  Also, happy 100th post to meeee!

ISCE debrief

In the middle of June I sat my ISCE's (Integrated Structured Clinical Examinations), integrated because we have to do a history, exam and skill all in one. We had six 25 minute stations to do in two groups of three split over two days. We were given 12 scenarios a few days before of which 6 would be our exams and the other 6 would be the re-sits if we failed. Last time I mentioned this, I had a comment from someone saying it wasn't fair if we knew what was coming up. The rumour is we get the scenarios because dyslexics complained a minute outside the station wasn't enough time to read and put them at a disadvantage. It wouldn't be fair to just give them the blurbs and no one else, so we all get them. Find a few friendly dyslexics and persuade them to complain?


Day 1

Gastrointestinal and urine dipstick with documentation
First station and I was pretty nervous because I didn't know what to expect. My examiner was jumping all around the room, peering over my shoulder, getting really close, interrupting me and was completely off putting. I later found out he was the head of ISCE's, so I guess he had a vested interest in making sure I was doing everything right. My patient was a real one with irritable bowel disease I think, which flares when she gets stressed or angry. Luckily for this one I don't have to give a diagnosis or management plan. I took a full history, did a gastrointestinal exam and then I had to do a urine dipstick and document the results. I missed a few bits from the history and the examiner got me flustered closing at the by interrupting me to tell me the things I didn't do when I hadn't actually finished yet. I had to politely tell him I just wanted to close with my patient and then I could answer any of his questions. I had plenty of time left, I think he was just over excited and I was emanating waves of calm. He wasn't supposed to ask questions anyway. He also made me wash my hands for a third time after taking off my gloves because I'd done a urine dipstick so now had uriney hands. I don't think he noticed I actually took my gloves off inside out so that wouldn't happen. He told me off for not taking proper notes, but was happy enough when I said I could write down all the details if he wanted them, they were all in my head. I wasn't being examined on that bit of documentation. All in all it went fine and I finished to time.

Diabetic review with cardiovascular Exam and BP with documentation
This was a weird one. I had an examiner, a real patient and a moderator marking the examiner. The case was a diabetic review which I did fine, taking a BP which also went fine, though I completely forgot how to document it and how to put it on the obs chart. The graph had a space for resp rate and pulse. I'd done pulse but didn't bother with resp rate so I turned round to check it. The patient looked a little expectant, as I was literally just staring at him, so I told him I was checking his breathing rate. I then remembered from class you really aren't supposed to say that as he'd start focussing on his breathing and I wouldn't get a natural result so I thought I'd better distract him. Unfortunately, the first thing I could think to say was "Don't worry, I'm just checking your breathing rate, erm, think about cats!" Cats, really brain? Brilliant. I just hoped my examiners had a sense of humour. I then had to do a cardiovascular exam on him, which was odd, as it didn't really follow from a diabetic review supposedly carried out in a GPs surgery in my opinion. It went fine, I even noticed he had some arthritic nodules on his hands so did some screening questions and got him to agree to go to his Doctor about it. Not sure I was supposed to do that, but hey, I'm thorough at least. I finished with masses of time left, and the two examiners stood in the corner comparing their notes on me and "hmm-ing" to each other which was awful and made me so nervous.

Mental Health with a mini mental exam and mental state exam
This was an actor with early onset Alzheimer's or dementia of some kind I think. She was really forgetful, thought she was in London not Exeter, thought it was a couple of years ago, had big lapses of memory like not being able to remember how to get home from town, couldn't remember her children's birth dates or what her husband had died of and her family were worried about her. This one was going quite well. I got a really good history and remembered all my questions for the mini mental and was writing up under the headings for the mental state exam just in case the examiner wanted me to present back, which luckily she didn't. Then I thought I'd blown it when I was trying to assess if she'd accept help by telling her it wasn't 2009 it was 2012 and she was in Exeter not Devon. She started getting really upset (understandably), but I managed to calm her down and get her consent for help. Again, I finished early, but it went well. I could over hear other people with the same case and could hear them getting really frustrated going round in circles with their actor who was playing at forgetting what they'd just said. All of a sudden they'd switch back to 'who are you, where am I?'. I'm so glad mine didn't.

Day 2

Respiratory with peak flow and documentation
I was much calmer and did a pretty thorough history. I was really pleased with this station. This was a real patient with a history of COPD. They'd also had breast cancer twice, a double mastectomy, stomach cancer, rheumatoid arthritis, ankylosing spondylosis and was a carer for their equally sick husband. She was an amazing woman to talk to. She had all this wrong with her, but she was still so cheery and upbeat about it all. I did a pretty good history but when it came to the exam the examiner was a real pain. She interrupted me and asked if I could talk through what I was doing and what I was looking for. It completely put me off and I lost my train of thought. I started to, but had to stop as thinking of all the differentials and possible signs was really putting me off my flow. She said it was all right if I didn't, just that it helped some people. She then looked really grumpy at me when I asked to do the peak flow on the examiner like we'd been told to and not the patient. I don't think she wanted to get up from her warm corner under a blanket (it was really cold) but I was supposed to explain to the patient and get the examiner to do the peak flow, so, tough basically! I finished this one perfectly on time.

Sexual health history and giving information about Chlamydia with documentation for an MSU request
This was an actor who was worried about a one night stand she'd had following a split from her long term boyfriend. She'd heard the guy she slept with was a bit of a lothario and so wanted to be checked out for Chlamydia. I actually found this one quite difficult. The sexual health history was fine and filling in the form for her to drop a urine sample back later was fine, but I found the giving information bit really hard. She didn't have any questions or concerns, she'd come to get checked out so it wasn't as if I had to convince her. I didn't want to scare her too much because I felt it wasn't necessary. She was smart, she knew already about the fertility problems, so I really didn't have an in. I told her the basics, gave her a leaflet and closed. I could hear other people drawing diagrams so that worried me a bit, but I still don't think it's a good thing to be all doom and gloom and worst case scenario and scare the patient. That was frustrating; I wish she'd had questions to answer. I finished really early.

Ophthalmology with cranial nerve exam and ophthalmoscopy
This was an actor whose history pointed to a pretty standard migraine with aura. I was happy to end on this one, it was nice to have a clear diagnosis. I took a complete history and moved on to the exam and skill section. This is where it all went a bit wrong. Because it was a standard migraine, doing a cranial nerve exam really didn't fit. I forgot papillary reflexes and I forgot to examine the external eye. At the end I went back and did the papillary reflexes when the examiner asked if there was anything else I wanted to do and what hadn't I used yet. Panic! We had to do ophthalmoscopy on a polystyrene head with ping pong balls for eyes. They have blood vessels and clock faces in them and we had to read the times on the clock. Because it was a head held by the patient I completely forgot the whole 'don't look in the light, look at a point on the wall behind me until I tell you', but I did get all the times, even the ones on the clocks that were orientated diagonally. At the end, the patient asked if I'd finished, and though she meant finished all my stations I thought she meant in the exam and was wracking my brain for anything else I missed. External eye exam didn't present in this search. I said I hoped so and she smiled, looked at the markers sheet and mouthed I'd done really well.

All in all, I thought they went alright. They weren't perfect, but I wasn't looking for perfection and we'd been told neither were the examiners. We just had to be safe and polite and competent. I thought I'd done enough to pass. I also needn't have worried, I didn't have any examiners I knew, although I did see their names on the sheet, I didn't have them. Once ISCE's were done, that was it, second year over. I did one more week at the GP surgery and then moved back home and went back to the Pensions Admin company.

Old Bean

I am sitting in my favourite coffee shop in Exeter.  I'm  really going to miss this place next year.  It's full of big tables, comfy sofas, free wifi, amazing food and drink and lots of different types of people.  I used to have English classes in here when I was at college, and it's Mr's favourite place when he comes down to visit.  It is a chain, but it feels independent.  I'm here because we'd agreed as a small group to come here and do our final PBL session of the year.  Our facilitator is on holiday and we have a form to fill in, so I suggested we end the year where we started, as our first ever session was here when it was a bank holiday.  Everyone thought it was a lovely idea.  Or so I thought.  None of them have turned up, just me.  So, I thought I'd sit and have an indulgent lunch (parma ham, pesto, mozzarella, sun blushed tomatoes and basil in an artisan white bread baguette with a butterscotch steamer) and blog instead. 

I'm celebrating.  It was my birthday yesterday.  Because of the two bank holidays, I had Mr down for a whole four days, it was wonderful.  We went hiking 10 miles up the canal banks to a pub only accessible by foot, we went to the cinema, we had cocktails in teapots, we baked brownies, we went out for a birthday meal with my parents and we laughed a lot.  If all goes to plan I won't see him now until the end of August, which sounds strange, but is a good thing.  I'm also celebrating because I've been named secretary of the Plymouth branch of PUPS, the paediatric society at uni.  I didn't think I would get it because I figured if it went to a vote I wouldn't be popular enough to win.  But happily it didn't go to vote and I was successful.  Whether that was because I was deemed the most appropriate candidate by the current committee or because I was uncontested I'll never know, but I'm happy. 

I've been a bit glum the last few days.  Facebook shows me all the things my school friends have done and how they are doing and it just feels like everyone my age has so much more to show for their time on this Earth than I do.  They are married, have kids, have jobs, have houses, and what do I have?  Letters after my name and mountains of debt.  Mum tried to point out I have my career, but I don't actually have that yet.  I'm still living in awful student accommodation, still years away from settling down, no clue as to where my future will be, no back up plan, still not a real person yet.  I am feeling old.  My first act as an old Bean was to drive an hour and a half to meet mr half way as he'd driven off with my keys at midnight.  So I'm no wiser for being older. 

I'm in full panic mode for ISCE's now.  I told myself I'd give myself the bank holiday weekend off to enjoy my birthday guilt free with mr, but all I saw was my housemates studying and I just kept thinking, oo, I don't know that, I should look at that.  I think I'll be fine.  My history taking is quite good, I just need to sit down and remind myself of the specific system questions to ask, the mini mental state exam (although I've pretty much got that), the mental state exam to report back findings, obstetric booking history and diabetic review.  The exam is six stations split over two days.  Each station is a history and a skill on real patients or actors.  Each station lasts about 21 minutes.  One station will be written, so either a medication review, a genetic family tree or interpreting an ECG.  One station will definitely be a mental health station on either a depressed, anxious, OCD or manic patient.  Some people in our year know the stations because they've seen a copy of the list sent to GP's in the area that will be the examiners.  They aren't sharing the info though.  Some time this week though, we'll be given a list of twelve stations, or which we'll have six.  Then I'll have the weekend to polish up history taking and run thorough skills in my mind before the exams on 12th and 13th June.  I know my boss, my academic tutor and my PBL facilitator are all examiners.  It might work in my favour as they know me, but then it might not because I won't get to make a first impression.  I'm most worried about my boss.  He's one of the GP Partners at the surgery I work at, and one of our marking criteria is a box they need to tick to say I can see this person as my Dr.  I hope he can disassociate me from being his secretary.  I definitely have the fear. 

End of Term Feeling

As usual with me I have been busy-busy.  We finished the MS case unit, thank goodness and have also done an alcoholic liver disease one.  We are about to start our final case unit of the year.  Final case unit?  All ready?  How is that possible?  It's on Parkinson's and should be pretty light as we've done most of the extra stuff they wanted bundled in when we did the MS case unit.  I had a placement at the GP surgery for the day and completed my final competency for the year in history taking, which I'm pleased to say I got an excellent grade for.  I got to take lots of blood and do some INR tests and blood pressures - all pretty standard now, though I remember how excited I was on my first placement to take blood.  I've come so far in just a year.  It's sad, it's all going by so fast and I'm changing so much.  Not that change is bad, just that I can see the change in me when normally it creeps up on you over time and you don't notice it so much.

I went to the BSMS first annual medical student paeds conference over the May bank holiday weekend and had a blast.  I met loads of twitter friends in real life which was surreal and left the conference on the Sunday evening feeling inspired and shattered.  I had always fancied myself as a paeds neonatologist, but I'm now leaning more towards paediatric general surgery.  It's so exciting!  I've always thought I wouldn't be clever enough to be a surgeon, but the talks we had were so inspiring and fascinating, the little bean in my head was jumping up and down shouting "that's so cool, I wanna do that, that's so cool!"  So there's a good excuse for me to pick up the knitting needles again to maintain my dexterity.

I sat the final AMK of the year last week.  I started off thinking that it was really hard, and there was all sorts of stuff that I should have revised and didn't and I panicked a little.  From about half way through I found my mojo again though, and when I went back to do a final sweep of the questions I was iffy on I was much more confident.  I've answered 91/125 in the end.  I knew I didn't answer enough last time, so I've definitely answered more this time around, and the last time I answered that many I got my excellent.  However, it's easy to tie yourself in knots going round in circles about whether I was too confident, took too many risks, made silly mistakes, thought I knew more than I did, or made calculated judgements, know more than I think I do and should have more confidence in my abilities.  So, I'm going to stop torturing myself, accept that I can't change anything now, be happy that I've passed the other three of the year so I've passed the knowledge module and this doesn't matter too much, and just focus on the fact that I came out of the exam smiling.  I am happy with my performance, whatever happens.

I've made my SSU choices for next year.  I should hopefully get one from minimum access gyneacology, orthopaedics with a special interest in paediatrics, daydream believer (aneasthetics) and when does a normal labour become an abnormal labour;  one from surgery in children, A&E in Plymouth, A&E in Torbay (inc ambulances) and military medicine on the naval base in Plymouth; and finally, one from hyperbaric care, cardiopulmonary bypass, cystic fibrosis and healing the 'hole' (wound management and healing issues).  Because I'll be a third year these will all be in theatres or on wards and they are all so exciting I'll be disappointed whatever I get because I'll be missing out on the others, but that's awesome.  I've gone for kiddies, ortho and a&e because they are the three specialities I could see myself doing.  Paeds general surgery has my heart for now, but it's important to keep an open mind.  The other options were ones I thought looked really cool or that I didn't know much about.

Now we've done the AMK and the sun is here it just feels like the end of term.  I'm finding it hard to settle down and start panicking about ISCE's coming up in a few weeks, but I think so it everyone to be honest.  It's just as well it's nice weather because I've broken my toe and can't wear normal enclosed shoes, I'm living in flip flops.  Silly bean.  Mr came down this weekend to celebrate his birthday a little late because I was exam cramming, and we had a lovely day sat by the canal in a pub in the sun drinking cider.  I made him a death by chocolate ganache cake and we went out with friends for steak and cocktails in teapots.  It was perfect.  I have my fingers crossed at the moment because mr finds out his posting for the summer soon.  He either goes really far away, back to where he was in winter for two months (which was what we were expecting) and so we can go on our holiday we have booked, or he gets pulled off that and sent somewhere else in this country for three months, and has a leave ban so we can't go on holiday.  I've got my bags mentally packed and little bean has her floppy sun hat and bikini on, I really need this holiday.

I'm Back!

It has been far too long since my last post.  Constant reader I'm truly sorry.  We had a consolidation week where I worked at the GP surgery.  Then we had two weeks of Easter break where I worked at the surgery.  Next came three weeks of SSU, where I worked at the surgery.  Spot a trend?  I've done a lot of work at the surgery and not much else.  We're back onto the normal timetable now and our case unit back is MS, which seems to be full of Neurology and cranial nerves, which I hate.

My SSU was called 'Wot you chattin about'.  I thought it would be about neuro-linguistic programming, but it turned out to be about active listening, being present/in the moment, quietening your internal narrative and finding your place in the world.  I had to write a diary everyday for three weeks about my observations and feelings, write a monologue that was my truth about an important moment, or something I want to say to someone but can't, learn and perform a monologue from Shakespeare and write a final report which I did as a self exploration of active listening and presence and their place in a healthcare setting.  It was a bit fluffy, that I can't deny, but actually I really enjoyed it.  I haven't done any amateur dramatic stuff for years, and the sessions were all about trust exercises and team building.  It was good fun, as long as you were happy to look silly for a few hours.  The facilitator encouraged us to try active listening on three people a week, and do some things differently to the way you normally do them - walk on the other side of the road, cross your arms the other way or take your jumper off a different way.  The active listening was pretty good, as I did it at work a lot and some of the conversations I had with the patients I could tell that it really meant a lot to them to have a stranger really listen, and they went away visibly happier.  It was great that such a simple thing could make such a big difference.  It felt like we'd make a deeper connection, and was lovely.  I should stop wittering about my SSU in case you all think I've turned hippy on you.  Anyway, the short story is I haven't posted because after writing a diary every day for three weeks I was all reflected out and I really liked the SSU and think I may have done well in it.

My results came out and I passed all of the competencies.  That was a relief because I was certain I'd failed one of the competencies.  All of them were satisfactory with one excellent for 2 person basic life support.  So now all that's left is one more AMK and my ISCE's which are like OSCE's - lots of competencies all on one day.  *Shiver*

Mr came home!!  He's been away overseas for four months and he finally came home.  We had a lovely couple of weeks doing not a lot and it was awesome.  We did go and see Cabin in the Woods which is an awesome film, I was bouncing up and down for a good few hours after loon grinning and repeating 'Ahhh, that was amazing!', but I am a bit of a Joss Whedon-o-phile.  We went to the christening of my cousins beautiful twins, the funeral of my two up boss at the pensions company - a wonderful, inspirational, kind hearted, legend of a man, cruelly taken much too soon.   We also found and booked our holiday for this year.  I've handed in my resignation for the surgery and confirmed my dates to go back to the pension company in the Summer.

All in all I'm a pretty happy bean, and that concludes the whistle stop tour of my last six weeks.  It sure is good to be back with you all.

Hell Week Debrief

Hell week is over and I'm a week through Easter Holidays.  I got my AMK results back and I'm very happy to say I'm back on track.  I'm up from 28.4 to 38.4 and back in the top half of the cohort.  I was a little more cautious this time and answered less questions; too few to be honest.   They say you should aim for half right and half wrong, and I got 54 right and 24 wrong, so I should attempt a few more next time.  I'm still waiting for the results of the competencies.  I think I've passed all bar one but it might work out ok in moderation.  I was so annoyed with myself because it's the iv cannulation one I've probably failed - the one I practised over and over until I had it down slick.  I made such a silly mistake, worse because I didn't know it was a mistake.  I got flashback and it started dribbling out the end so I put my thumb over the hole to stem the flow.  I had gloves on and the last thing I touched was an alcohol swab so I thought it would be fine, but apparently that's still contamination.  So frustrated with myself!  I've heard Plymouth people got failed if they didn't get flashback so I'm hoping when they moderate the scores I'll come out all right.  I'm not too worried about it because you get several chances to pass and that was the only mistake I made so I'm sure I'll rock it next time.

Hell Week

This coming week I'm asking for all your good thoughts my way please, we're about to enter what we are affectionately calling Hell Week.
Monday: PBL feedback session presenting our findings to our small group
Tuesday: Competency exams in IV cannulation, cranial nerves and motor examination
Wednesday: PBL feedback and the third AMK of the year
Thursday: Competencies in choking baby, choking child, paediatric basic life support, basic airway management and adjuncts and basic life support with 2 rescuers
Friday: Part 2 of PBL feedback, if we haven't done it Wednesday morning because we are trying to reschedule it so it's not the morning of the AMK.

Not looking forward to this week much.  It's a spectacular fail in timetabling, or it's just a ploy to test us to see how we cope under pressure.  Either way, not a happy bean.

Differential Diagnosis Of...

After the nice break for study week we were straight back in with cervical cancer this fortnight.  It was quite a light case compared to the last two, which should be nice, but just gives me a feeling of unease that I've missed something.  Our PBL facilitator is a consultant at the hospital and normally rips it out of us each week.  He talks really quietly, and it's not unless you listen carefully you realise he's just said something sarcastic about what an utter moron you are for deigning to offer such a ridiculous answer.  It's good practice for next year on the wards, but until now every facilitator we've had has been sickeningly sweet and lovely.  Well, with the exception of my last one of course, whose reply to me being 10 minutes late for class and hopping in on crutches was "I've sprained my ankle and I still managed to cross London with three tube changes to get to my lectures on time and I didn't need crutches".  Well bully for you.

Our current facilitator doesn't like fluffy stuff, hard science and management plans only please.  It's not enough to know what drug to give in a situation, we have to know dosages and timings as well.  Don't get me wrong, I love him and wouldn't have anyone else.  I feel like I learn so much more, it's just taken a bit of adjusting too.  He always prepares a slideshow of real life cases he's seen relating to the topic for the fortnight, and we play a what's wrong and what would you do game.  Gynae though, is really far from his speciality and he's been eerily quiet this time.  We'll give an answer to a question and cast a sly glance his way to see if he's about to erupt or if we've done well.  He's just been sitting there nodding silently.  His only contribution was to dissolve into fits of giggles and ask us differential diagnoses for a female with pneumoperitoneum.  We hesitently suggested trauma or infection.  Parachuting apparently, something he remembered from his med school days.  The air goes up and out through the tops of the fallopian tubes.  I just have images of fimbriae flapping in the breeze.  I know, I know, there's fluid, but that doesn't make such a pretty picture.  Colposcopy is apparently more likely to cause this through the same mechanisms though.

Study Week

For the first time in my uni career I've had the luxury of a study week.  At Southampton I enviously watched all of my house mates and friends having their study/reading weeks and I have just finished a whole week off.  No lectures, no deadlines, it's been bliss.  Now don't get me wrong I LOVE my course.  I love being a medical student.  I cannot wait to see what's coming up next, I don't take for granted any of the opportunities I have but oh my hasn't it been nice to have a break.  Constant Reader will know that it's very unlikely that I took this week off to sit in my room twiddling my thumbs, that's just never going to happen.  I worked at the surgery, I did some bits with Mum and I had a life and went to the pub to see a school friend I haven't seen in 9 years who's been bugging me to meet up with them for months, and every time I say yes, and then the next time I look up weeks have gone by.  I didn't do any work and I feel very guilty about that.  On the other hand, it was amazing! Everything I have to do fit into my time.  Apparently I can only fit three lives in my one.

Coming up I have sooo much to do, I'm really feeling the pressure, which is why I feel so guilty for not studying during study week.   In my defence I was ill for the whole week, which didn't help.  I have two presentations, an AMK, 6 competencies, PBL and 2 essays.  I used my study week to catch up on my life, can I have another to catch up on work now please?

Under Pressure

This year our GP placements take the form of a full day in the same GP surgery and we get to go about once a month.  We go in pairs, and mine splits us up, so we have a morning each with a different GP and then we swap over.  It depends on the GP you're with how much you get to do, but it generally works that if you answer all their questions correctly and seem keen you get to do some hands on stuff yourself.  That's aside from the competencies we have to demonstrate and have assessed over the course of the year.  My last placement went very well.  I was with a GP in the morning who let me be very hands on, which was nice.  At one point I thought she was going to ask me to do a vaginal smear, but as she was asking me questions about it I pointed out we hadn't been taught that yet, so she did it and let me assist instead.  She had me fill three tubes of blood from a person, which I got first time and was very pleased with myself, as I struggle in the clinical skills lab when I swap over the tubes and lose the vein.  I rocked my competency and got an excellent in it, so was feeling on top of the world really.

In the afternoon I went in with a GP I hadn't sat with before.  We had a couple of problem patients come in and I really admired his patience in dealing with them.  One came in to clarify the medication list they'd been given when they came out of hospital.  From listening to them, it sounded more like they understood the medications, they just wanted a healthcare professional to make a bit more fuss over them.  They'd enjoyed all the attention in hospital, as they'd been  pretty poorly but then got better and was sent home and they just wanted the fuss to continue a little longer.  Another patient came in and I swear they must have been actuary because they wanted to know the rates of MRSA and C Diff in the local hospitals as they had to pick somewhere to have their knee replacement done.  They'd only go somewhere that had never had those diseases.  Then they tried to 'test the system' and get the GP to tell them when they'd had an investigation done and what the outcome was so they could be satisfied the record keeping was good enough.  I understand it's probably just they were scared about their operation, but I'm not sure that wasting the GP's time in that way was the best way for them to deal with that.  I did love the way the GP dealt with the stress though.  Once the patient had left the room he stood up and said 'I think we need a chocolate coin after that one, don't you?' and chucked me one from a little stash he had in a cupboard.

The final patient that came in was a bit of a worry though, and I really want to know how they got on.  The patient presented with a three month history of a cough, night sweats, putting on a lot of weight, bowel movements of normal frequency but varying consistency, anorexia, stomach bloating and feeling sick.  They'd been for a chest X-ray for the cough and that had shown what was possibly a small shadow behind the clavicle, but may have been artefact.  They had come for the results of the X-ray and to tell the GP about the anorexia, weight gain, night sweats and bloating.  The patient was due to have an ultrasound of their liver at the end of that week, as a previous examination had shown it was enlarged, but the liver function blood tests had come back normal.  Now, all sorts of alarm bells and big red flags are flashing and waving in my mind, as this sounds like textbook cancer of some sort.  I exchanged a couple of glances with the GP, and the look on his face told me he thought the same.  I felt so bad for the poor patient, and really uncomfortable,  They had no idea.  They'd just been through a really messy divorce, had a whirlwind holiday romance and gotten remarried, this was the last thing they needed.

I wasn't sure how the GP would handle it, whether he'd tell the patient what it might be, or whether he'd wait until there was conclusive proof.  What I didn't expect was what the GP said next: 'Do you mind if the medical student examines your tummy first?'  The patient was more than happy and jumped up on the bed and removed their shirt.  Then I really felt the pressure.  I knew there was something to find, and I really wanted to find something, to give this poor patient the answers they'd come to their GP searching for.  Normally we do exams on each other and there's never anything to find,  We go through the motions and can answer the questions of oh I'm looking for this to indicate that, or that to indicate this, but we know we won't actually find anything.  I was an idiot and completely missed out the whole, stand at the edge of the bed, observe, start at the hands and work up business.  I've done it so many times, but I knew the answers weren't there, so I skipped those bits.  Luckily that wasn't my competency test.  I was just so anxious to get to the cause.  I felt their stomach and there was general tenderness, not localising to anywhere, a massively enlarged liver, no fluid,  and the whole abdomen was firmer than it should be.  Not tense, but not normal.  Apart from that there was nothing, no obviously palpable mass, just a generalised, feeling of something being not right.

I was so disappointed.  I know what the answer will be, but I wanted to give them something real to take away with them then.  Instead, the GP just had to tell them that there may be lots of causes, some sinister, some not, and to wait for the results of the ultrasound.  Medics amongst you will be familiar with the five F's that make up the differential diagnosis for distended abdomen: foetus, food, fluid, flatus and f*in' big tumour.  Is it best to keep the truth from the patient when it's glaringly obvious what the problem is, even though it's scary, or is it best to have them worry about it sooner before any definitive proof?  Or is that one of the really good parts of being a GP? That you have a get out clause for giving bad news.  I guess it depends on the patient and how much you feel they can take, but it felt so tense in the room with the GP and I sharing the same suspected diagnosis and the patient being so anxious.  Especially since if it has metastasised to their lungs that's a really bad sign for their prognosis.  That said, it was on the wrong side for that.  I thought stomach cancer went to the top left lung, and this was top right.  They were very tender in that area when palpated so there's a small chance it could be something else, but it's not likely.  I will try to find out what happened to them next time I go.

The Dreaded Phone Call

When I was at work the other day I got a phone call and for a moment my heart stopped beating.  I don't get a lot of signal at work, so I didn't really catch what they said, but the conversation started with:
Them: Hello, is that Miss Bean?
Me: Yes...
Them: This is xxxx from mr's battalion, corps

My heart stopped and I immediately thought the worst.  Although I am his person, if something were to happen to him, it likely his parents would get the smart men in suits to the door to break the bad news.  Though they may send me some too, I would probably get a phone call, which was what I thought this was.  Mr is far away at the moment, out of the country, in another time zone for 4 months.  Although he's had the odd couple of weeks in the EU on exercise it's the first time he's been away on tour, so far away, for such a long time and out of contact.  We do pretty well with our long distance relationship, but this is tough.  My best friend has left the country, I can't just pick up the phone and tell him about my day, or hear about his.  We normally ring each other everyday from bed before we fall asleep to talk to each other and he keeps me grounded and sane and makes me laugh and smile everyday without fail.  I am so lonely without him.  It's about 81 sleeps until he comes home now, but we don't have a definitive home date yet.  Then he's back for a few months and then off out again for a couple more months.

I keep seeing everywhere happy couples, pregnant ladies, slushy film plots, my housemates nipping off for the weekend visiting their other halves and it's Valentine's Day coming up - all just reminders that my mr isn't here and isn't going to be here for a really long time.  It's worse in a way to being single, because at least you don't expect anything then.  But we haven't broken up, we're really happy, it's going well and still he isn't here.  Because of the ridiculous time difference and his insanely long working day hours if I'm lucky there's a five-ten minute window when I can skype him in the evening and it's his lunch break.  If not, I can stay up really late/early in the morning to talk to him when he's finished work, or he has to get up even earlier to talk to me before he starts work.  It's pretty impossible to work with.  Safe to say, I'm not a happy bean at the moment.  I'm not doing bad, but I'm so lonely.  Friends that I talk to keep saying how they don't think they could do it, mostly because it's too long, but some said it was because they couldn't trust them.  Thankfully, we don't have that problem.  I laughed when they said two weeks away was too long.  Ahh, to be one of those normal couples where good bye means I'll see you tonight, not I'll see you in a month or three.

Happily, what it actually turned out to be was an invite to a Ladies Night Dinner his mess are holding for all the wives and girlfriends of the guys who are overseas. And breathe....  I can't make the dinner night because it is a school night for me, so I kindly declined the invitation.  With that, the nice man on the end of the phone told me that if I needed anything at all while mr was away I only had to ask and they were all there to support me, even though I don't live on base.  Or any where near base, for that matter.  That, surprisingly, made it all a little better.  A slight admission from them that they are being real b*****ds splitting people up like this, and that there's a support network there to do whatever they can to help to apologise.

So, although this has been a bit of a mushy post from me, hopefully it's enlightened you a little into the life of an Army Officer WAG.  I certainly never thought about the other halves when I saw bits about the army on the news until I was one.

Results

So, I've been putting off writing my next post because I know Constant Reader would be waiting for my exam results.  Now, I know I knew they'd be going down, but I was hoping they'd surprise me and hold steady.  I wasn't even asking for an improvement, just a steady.  Obviously, from my silence you can tell that hasn't happened.  I went down to 23.4, which is only 0.1 above what I got at the end of year 1.  So I'm pretty disappointed in myself to be honest.  I feel miles better than I was then, I know so much more, I don't know what happened.  Even more annoying is that the class average was 24, so I'm below that too.  Absolutely gutted.  I know I shouldn't, because it's a pass, and it's nigh on class average.  Plus it's not a massive dip from my last but one test, so it's not an indication I'm dropping too much.

I got my SSU result back - the essay I wrote in 24 hours through the night because a peer stole my idea and the one I came up with on the spot in the consultant's room really wasn't working.  I got 19/20 so I'm pretty pleased.  The only negatives were that I didn't elaborate enough on some of the studies, but I couldn't because of the word limit and that something I wrote about procedure was wrong, but it isn't my fault if he doesn't follow procedure.  So a negative and a positive, but being realistic, they are both good scores so I shouldn't complain.  The lowest mark in the AMK this time in my year was 6.9, and someone who spent all Christmas break posting clever lines about how complicated their essay was (in other words, how clever they were in that particular subject to understand such clever things) only got a 13/20.  Taking that into consideration, Bean's not doing bad :) With that in mind, I'm just gonna forget it, bop away to some funky music and rock the next one.

My first time

My friend and I are sat with all our equipment prepped in a sterile dish, gloves on, surveilling the patients in front of us apprehensively.  Introductions done, procedure explained, consent obtained and the area swabbed with an alcohol wipe - one wipe top to bottom, and we could put it off no longer.  I reached for the cannula, removed the cap, wiggled it to check it wasn't stuck, put the bung to one side and willed a vein to jump out and dance at me.  Vein selected, palpated and pinned I advanced the needle through the skin which was tougher than I thought it would be.  Nothing.  I wiggled a little, still nothing.  I looked at my friend who peered and said "you have to pump the thingie to make the pressure for the flashback".  I dutifully reached around the back of the severed rubber arm and pumped the balloon but still no flashback.  My friend reached over and gave a few more pumps for luck while I advanced the needle a little further.  Just then, "aaaarrrrghhhhh!" I shout, as bright red fake blood squirts out of the end of the cannula all over me.  "Oooohhh, tourniquet off, needle out a touch, advance the cannula, pinch the vein, needle out, thumb over the end, needle in the bin, bung on!" yells my friend, helpfully.  I try and comply and wish for a few more fingers and pairs of hands to do all of that at once, as blood continues to spurt everywhere - a little too much pressure added maybe?  I got in a bit of a mess with the sticky thing, as it doesn't stick well to rubber but I got the gist and before long I was looking proudly at my first ever cannula, happily splattered in fake blood.  I looked at my friend who was trying to flush his with saline.  He was having a little difficulty and the saline wouldn't go in, so he put more force behind the syringe.  The saline squirted out around the port, spraying us both.  Despite our mishaps, job well done and we've been told it's much easier on real people.  I did get some odd looks at work later though, with my hands stained in cherry red blood.  Totally worth it though.  And now, if I'm asked if I'd like to try putting a cannula in I can honestly say it's not my first time.  I just won't tell them about the bit where I screamed in the middle.

Exam post mortem and my new friend

The exam went ok, I think.  I'm not really sure.  I haven't found any yet that I got wrong through overhearing other people discussing questions.  I fall in the group of people that doesn't like doing post mortems on exams.  I am very competent all on my own at beating myself up and second guessing my answers, I don't need any help thank you very much.  I can't change what I did so it's best for my sanity and sleep cycle if I just forget about it.  I answered less questions than last time, which could mean I have done better as I will have gotten fewer minus points for getting questions wrong, or worse as I didn't answer as many so didn't have a chance to get points.  Aargh, see? Neurotic about Track, neurotic about exams, maybe it's a medical student thing?  Or me, just me :)  My last minute cramming sort of worked.  There was a question about B symptoms in leukaemia.  I read a little about B symptoms, but only that they existed, I didn't read what they were.  If I'd just have read the rest of the paragraph!

I have moved back home for two weeks whilst my parents are away on holiday to cat sit.  This weekend was the loneliest time in my life.  The two people I talk to every day, Mum and Mr have left the country, and I had to move back to my parents house.  Normally I like to be on my own but it's different because in my house I can always hear the noises from other people.  Here it's just me and a cat that hates people.  She had very little human contact and she's only two, so she doesn't really know how to be a domestic cat.  Every time I stand she runs away.  I enter a room and she leaves it.  She sleeps all day then yells at me to go to bed so she can play all night with me gone.

Today, we had a breakthrough.  My computer is set up on the dining table and today she has come to sit next to me on the corner of the table, staring at the computer screen.  I've been watching the streams of our lectures, and the take the form of a split screen with a view of the lecturer and a view of the powerpoint.  Freya keeps watching the lecturer and every now and then bopping them in an "Ah, shut uppa ya face" sort of way.  It's hilarious.  Now she's weedled her way into the space between my bum and the back of the seat.  She's curled up in a little ball, very happy and purring.  There's a big bully cat who keeps coming in and eating all her food and she just yowls at it, terrified.  Every time she yowls I come running with a water pistol, whether it's 3am or 9 am (and believe me we've done all times in between).  She runs away, I see off the cat and she creeps back to make sure it's gone.  I think that may have won me some brownie points.  That and I haven't actively tried to eat her yet.  I've gotten back into my normal routine and done my big cook for the weeks' evening meals and lunches (pork and mushroom stew and a vegetable pasta, if you wondered) and so with that and Freya's offering of friendship, today hasn't been quite so glum.  Also, it turns out the boiler in my student house has broken and they haven't any hot water or heating, so it turns out this was all timed quite well after all.

The Fear

So, as is usual with me, it's the night before the AMK and I have the fear.  I have the fear so bad, I'm pretty numb with it to be honest.  I am about 99% certain I won't be able to beat last time's score, so I'm just psyching myself up to telling my family and friends I've gone down.  It doesn't even really feel like there'll be an exam tomorrow.  I've got PBL in the morning with a new facilitator who's pretty strict and pro-science/anti-fluffy stuff so hopefully he'll impart some pearls of wisdom as there's literally 15 minutes between finishing the session with him and the coach leaving to take us to the exam venue.  Before an AMK you'd usually find me pretty spaced out doing last minute cramming in my room, on the walk to the coach, going up the stairs to the exam hall, to the very last minute.  People tell me it's not good and if I don't know it by now I never will, but I know for a fact that I got at least one mark last time because of last second cramming - an odd sentence I read in a dermatology section about livestock handlers and skin diseases, and a question about orf came up.  It works for me.

Mr is now ridiculously far away for a stupidly long time.  It's not even really worth counting sleeps it's so far away - 108 sleeps.  I can't even comprehend how many fingers and toes and noses I'd need to count all of them :(  New Years was lovely though.  It filled up really early, so we were there in the rain from 7pm and my evening included a fun hour long queue for the loo.  The fireworks were worth it though - absolutely amazing.

I'm off to go cook tea - squash gnudi om, nom, such a student diet.  See you on the other side, and happy new year.