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.