Thursday, 28 February 2013

Elective Major Surgery

This was the first week of my new pathway 'Ward Care'.  I was looking forward to it, as I'm giving surgery serious thought with regards to my future career path.  The week was a bit jumbled though, in the end.  Although, it's such a vast topic to cover in just three days, it probably always would have been.  It started with an introduction by an anaesthetist   He split us up into three different placements for the Friday, as apparently some re-arrangements in the departments meant the pain service had been downsized so 'there wasn't enough pain to go around' for all of us to be on the pain ward round.  Quite an intriguing way of looking at it I thought.  He told us he expected two patients, fully researched and written up and a presentation on any basic area of medicine.  We were then packed off to pre-assessment for the afternoon.

The pre-assessment team were lovely, and not just because they gave us cake! It was a little boring for me just watching, because having just spent three weeks in day surgery it was something I knew about already and had seen many times.  I was therefore very happy when the nurse asked if I wanted to do the next patient.  Pre-op is a really important part of the patient journey.  It helps to identify any barriers to the actual surgery going smoothly such as care at home afterwards, airway difficulties or allergies.  It also gives the patient a chance to ask any questions they may have thought of after their initial consultation with the surgeon when they were told they needed the operation.  It's not the best place for the questions, as it's done by pre-op nurses who aren't experts in the surgery the patient will be having and so aren't best placed to answer the questions, but they can listen, answer if they can and give them a booklet to read which probably covers their question.  It's a chance to show the patient that we are an organised team who care about them and will look after them now they have made the decision to have surgery and trust their body to someone else.  That all sounds a little dramatic, but basically, I believe it's really important.  It's not difficult to do, there's a form to be filled in so you just ask the questions to fill in the form.  But I really enjoyed being able to do it.  It made me feel useful as a medical student for once!  I'm asking the questions for the benefit of the patient, not myself.

My patient for the week was someone who had undergone a Whipple's procedure for jaundice.  It's normally done because the patient had pancreatic cancer, but all my patient's biopsies were clear so I never did get to the bottom of why they had the procedure done.  I spent quite a long time with them and at the end they admitted they were in so much pain that if they knew it would be this painful before, they never would have consented for the procedure.  I didn't really know what to do then, I felt so awful for the patient. As I was reading their notes in the corridor, I heard the morning ward round discussing them saying how poorly they were doing and the surgeons and the ICU team should be paged as the patient may have internal bleeding and need emergency surgery and be taken back to ICU.  They didn't look well, or comfortable, but I didn't think they were that bad.  It was quite shocking to hear.  It really didn't sound as though they were going to pull through.

I went to visit them a couple of days later, relived to see their name on the board meaning they were in the same ward and not dead or in ICU.  As I rounded the corner to their bed, they were sat in their chair, eating lunch.  They looked at me and smiled, saying "Ooo, hello love. You here for a free lunch?"  They looked so happy when I said I'd come back to visit them and see how they were doing.  They were much better now, and hadn't needed an ICU stay or surgery, thankfully.  Seeing the smile on their face, then I realised that's another way I am useful as a medical student.  I am a friendly face and a listening ear not constrained by visiting hours.  I make more of an effort to visit my patients more often now, until they are discharged.

Feedback was postponed, after all that work we'd done preparing presentations and patients! Apparently the consultant had a family emergency, which was fair enough.  Later, we discovered the family emergency was that the builders had bought the wrong stairs in his house renovations.  Not amused....

I got to end the week on my individual placement arranged at the start of the week - watching caesarean sections.  How absolutely, mind-blowingly, amazing!  I stood my ground when they'd asked if I'd rather see the epidural complication clinic as I had been looking forward to this all week.  And it certainly lived up to expectations.  When the end of the world was supposed to be happening (yes, I know, I'm really behind writing up weeks) I was watching new life starting and that is a sight that will stay with me for a long time to come.  I didn't get to help, only observe, but I made myself useful keeping the Mother company as she was being closed up after Dad and baby had been taken through to recovery leaving her alone, awake, under a green drape splattered by her own blood in what must have been a very bizarre moment for her.  Wow.  I can't wait for my pregnancy and labour weeks!

Monday, 25 February 2013

Dr Bean will see you now

The last week of my pathway was GP week.  I was quite lucky with my GP placement as it was only a 15 minute walk from my house.  Many people I know have horrible train journeys and bus journeys as they have been scattered around the county.  We go in ones and twos to a GP's for a week where we should in theory have at least three of our own clinics where we get to see patients.  I have signed up to a pilot scheme where I stay at this GP surgery for the next two years, so I'm doubly glad it's not difficult to get to!  I figured if I got to know the GP better they would let me do more things as they would trust me more.  It also means I am supposed to have a few patients I follow over the two years to experience what it is like to live with a chronic disease over time.

I turned up to the first day of my placement to find I would be observing the Doctor for the morning clinic, but apart from that the rest of the week I had my own clinics.  7 clinics, full of patients, all booked to see me.  Mind blown.  :) I even get my own little ( and I mean tiny) room that says Doctor on the door.  It's a tiny little practice, run by one Doctor, with one other GP that job shares.  The lead GP's wife is the Practice Nurse, and then there's one other nurse and a phlebotomist.  It's in an inner city, rough/poor-ish suburb mainly full of students and pubs and so quite a different population to the idyllic country practice I was in last year.

And boy did I notice the change in patients. It seemed like every one of them was there to be treated for depression.  I saw students, new mothers, Russian housewives, alcoholics, heroin addicts... all for depression.  There were a few ear infections and an eight year old with "tummy ache" that was actually bullying at school, but mostly I saw mental health issues.  It was so draining.  I feel completely out of my depth dealing with mental health patients.  I just don't know the questions to ask.  It's not that I don't think depression is an illness, because I do.  And it's not that I can't empathise, because if I'm honest I think I have depressive tendencies myself that I try and bury behind a smile or some loud happy music.  It's more that I don't know how to approach it.  I can do a basic SOCRATES, family history, social history, drugs and medications, ideas, concerns and expectations history for diseases or injuries, but it just doesn't seem to fit for mental health issues.  Plus I can't help feeling that whilst I am privileged to hear your story, hardships and innermost feelings, you should be telling this to your actual Doctor, building that relationship and trust as this is a long term issue you need to work on together.  Mental health is my last block, which may explain why I feel so uncomfortable dealing with it as I haven't had the training yet.  I definitely puts me off being a GP though.  I like to be able to fix you and send you away happy quickly, and you can't really do that with mental health issues.

I get given half an hour with my patients to take a history and then send a message to the GP's computer to come in and hear my presentation, impression and management plan.  I tended to run ahead of time though, so often he gave me some of his emergency patients to see to fill in.  One in particular I was a little wary of, as a massive violent patient notification came up on the screen.  As I mentioned, my room was very tiny and I had not yet found the panic button in it.  I'm only a small thing and I was at the end of the corridor not backing onto anything if I were to yell for help.  I put on a brave smile and called him from the waiting room.  It turned out he had been in a fight at the weekend when some youths had set on him and his girlfriend.  He'd knocked one of them out and they'd hit him, but the police had only been interested in the damage he did them and hadn't taken any photos of the injuries he sustained.  He wanted them checking out and photographing and had been let out of house arrest with an electronic tag especially to come and see me.  When I pushed the button to tell the GP I was ready, he sent back an 'acknowledged, 2 mins' reply, meaning his consultation wasn't finished yet.  The patient had gotten himself a little worked up re-telling the story and I wasn't too happy the GP wasn't coming immediately.  I managed to distract him by talking about hobbies from his past and it turns out he used to be a keen gymnast so we were discussing him possibly taking up coaching to give him something productive to do since he couldn't find a job.  The GP burst into the room suggesting the patient might like to wait in the waiting room until he was ready to see us both, presumably assuming the patient had become violent and I wasn't safe, which was lovely of him, and reassuring for any future similar scenarios.  I said we were fine and we continued chatting.  I was so proud of myself.  It was a situation I didn't want to take on, with a challenging patient and it gave me so much confidence to talk to different types of people and handling myself in difficult situations.

I did enjoy my week as a GP though, which is just as well as I have many more weeks there to come.  It is a nice practice, with friendly staff and a nice way of working.  I got a lot from it, even though one of those things was a firm decision that I definitely don't want to be a GP.