Endings

I had passed my two AMKs, passed the SJT and passed the prescribing skills assessment.  I had been matched with my 6th choice on the FPAS list and had a job lined up waiting for me which would send me far from home to a DGH in The North  starting with a rotation in Emergency Medicine.  There was just one small hurdle to overcome.  I knew I couldn't do anything and what would be would be so I tried to keep busy for the three weeks of the holiday.leading up to results day  I spent a lot of time with Mum as I knew it was potentially the last summer holiday I would have at home, and I wanted her to really enjoy it as she would miss me if I was leaving.  We went shopping, we had crafty afternoons and we had lovely days together.  She wanted for nothing and I was determined she would have lots of happy memories from our last summer holiday together.  Mum was hopeful and she'd planned a celebration meal that family from all over the country were coming to.  It would be the first time she would meet Mr's parents.  She'd picked out a present of a new stethoscope she wanted to get me.  She had more faith in things working out than I did, after all, this is what I excel at.  I get so close, within touching distance and then fail at the final minute.

When the 2nd of July came around, the results would be released by an email at 12.  I was sick to my stomach with nerves and time went so slowly.  At 11:37 my phone binged:

RE: Outcome of Year 5 Progress and Award Board

         

Further to the meeting of the Year 5 Progress and Award Board, which was held on Monday 29^th June 2015, we can confirm that the decision of the Board was as follows:

Award of BMBS

Kind regards

Registry Services

I did it..... I passed! After all the stress, getting a standard email like that was a bit of an anti-climax, but I wasn't fussy, it had the magical words in it.  I could not believe that the thing I had worked so hard for for so many years had actually, finally happened.  I was now a Junior Doctor.  I would be moving in three weeks to start my new job as the only F1 in Emergency Medicine in a hospital on the other side of the country.

Mum had done a good job of inadvertently distracting me on that day as she'd woken up with a bit of a chest infection and so I'd spent the morning looking after her.  She was feeling a bit drained so I got the GP out who gave her antibiotics and I tried my best to keep her drinking and eating.  Within 10 minutes of the email coming she'd started vomiting.  It was getting to the stage where she couldn't keep anything down and her blood sugars were rising so I eventually persuaded her to go into hospital.  She detested hospitals and doctors and was refusing but I told her if she didn't she's be too poorly for my meal and graduation the following week.  Dad and I left her comfortable and looking tons better on AMU getting fluids and antibiotics.  We promised her we'd be back in the morning to visit.

At 0415 I got a phonecall from the ward asking if we could go back in.  Dad and I set off chuckling that she was being awkward.  We expected to find her sat up in bed refusing treatment and demanding to see us.  I knew something was wrong when they took us into a quiet room instead of straight to her sideroom.  They all looked so worried.  The Med Reg came to tell us that she'd gone into respiratory and then cardiac arrest after coming back from her chest X-ray at 0400.  She had been proudly telling anyone she came into contact with that her daughter was now a Doctor and so they thought I might like to watch the resuscitation attempt.  I couldn't believe it, she was fine, so I had to see for myself.  There were so many people in her little sideroom there was barely room for Dad and I to get in.  She was in PEA.  They were up to the 6th round of adrenaline and were discussing why the transcutaneous pacing wasn't working.  Someone was being sent to fetch and ultrasound machine.  She had access both sides and IOs in her shins.  The CPR they were performing was so effective at perfusing her brain, she was moaning and trying to climb off the bed.  Every time they stopped for a rhythm check she lay lifeless on the bed again.  I had a brief moment of surreal panic as I couldn't see where I fit into the team and what job I needed to do to help.  There was already access, there was already fluids being squeezed in, what could I do to help?  One thing was clear, they were doing everything.

The consultant anaesthetist who was leading the arrest call lead Dad and I outside and talked us through what was happening.  He asked if we knew Mum's wishes and if they got an output back would she want to be put on a ventilator?  Was there any reason we wanted her on one?  At that point I dissolved.  Of course I wanted her on one.  In 14 days time she needed to be sat smiling in the audience watching me walk across a stage at graduation.  She needed to go wedding dress shopping with me when the time came.  She needed to meet her grandchildren.  She needed to celebrate me becoming a consultant.  What sort of a question was that to ask?  Dad and I looked at each other and we knew.  No.  She'd hate that.  She always said it was the worst thing having make the decision to turn off Grandad's ventilator.  We knew what she'd want.  The anaesthetist was told the ultrasound was negative, no fluid.  All the H's and T's were sorted.  There was nothing more to be done.  The people quietly filed out and Dad and I went in to sit with her as she peacefully passed away.  In the space of 24 hours I'd had the happiest news and the most devastating news of my life.  What was I supposed to do next?

Rest in peace Mum, sweet dreams.

5th Year

I had been really looking forward to relaxing in fifth year and just enjoying it.  There were only two AMKs to sit and supposedly the only real way to fail 5th year is on professionalism.  Given my track record, do you think it was that easy? Ha! No.....

My first block was GP.  I was apprehensive as I hadn't enjoyed GP before but I was pleased to get the block over and done with.  As it turned out, I had a great rural practice, 20 mins drive away and I was working with a lovely bunch of people.  My GP facilitator was very clear that the reason he chose GP was so he could surf in his lunch breaks and he was keen I made the most of mine by going for walks or to the beach.  I had my own patients booked in to see me, I had one protected two hour teach a week with my facilitator and in the afternoons I was free to go home or pick from the emergency list of same day appointments.  It was great!  Not enough to convince me to be a GP, but I enjoyed it more than I thought.  It was a very friendly practice and I got on really well with everyone.  Picking off the emergency list let me see some more acute things as well, which appealed to me.  One day a week I was scheduled to follow the on call GP so we did home visits in the lunch break.  With one GP this meant sharing a car ride with his soppy dog, and with another it meant bacon baps on the beach.  It was wonderful.

Second block was where it began to fall apart.  I had GUM and I had been looking forward to it because I enjoyed my GUM block in Plymouth.  I found the staff to be very friendly and because it was mostly nurse led it had the same sort of team feeling that I find in ED, where everyone mucks in together.  Here, not so much.  I was given a timetable that had me at another site on a Monday and then only in for 2-3 sessions for the rest of the week.  If I tried to come in at other times when I wasn't scheduled I was told they had no room for me and the nurses looked at me like I was being awkward.  Once a week I had a scheduled clinic with my facilitator where I would see alternate patients on their list and present to them.  This invariably made them run late and a bit stressy.  This was the only time I saw my facilitator during the week.  Half way through my block just before the Christmas break I was told that complaints had been made against me by some of the staff.  They said I was cold and not approachable and they were worried about me.  What was I going to do to fix it?  I assured my facilitator I had never heard any feedback like that before and I couldn't see what I had done, but I'd work on it.

After the break I baked cakes, I went out of my way to be friendly and talk to everyone.  I went the long way around the building to leave at night so I could say goodnight to more people.  One of the nurses gave me positive feedback from a patient while standing right next to my facilitator... who wasn't listening.  I handed out 360 feedback forms to everyone.  I'd been told at my initial meeting I didn't need them because my facilitator would collect their own feedback but I wanted some evidence for my portfolio.  I only got 3 back and when I went to chase more they said they'd asked my facilitator who told them not to hand them back to me.  At my final meeting my facilitator told me people hadn't handed them back because they didn't want to write mean things about me.  I was failed on my professionalism and was told I hadn't done enough to improve my behaviour.  I was competent to be a Doctor as I had the knowledge, just not capable to be one.  I was handed a clinical skills assessment form which had been completed about a male genital exam I had done in front of my facilitator on which they had failed the professionalism judgement section saying I made the patient feel uncomfortable.  My facilitator said it wasn't slick and although I had done all the right things I hesitated.  I also hadn't given the patient enough eye contact.  They had put the date as the first week of my block, so it pre-dated the successful form I'd already completed with another supervisor and handed in and therefore superseded it.  In one fell swoop I was teetering on the edge of failing. We are only allowed two negative professionalisms so everything for the rest of the year had to be perfect.  I was furious as it felt like nothing I could have done would have changed the situation.  My facilitator had made up their mind and that was that.

My next two blocks passed without a hitch.  I did gastro surgery which allowed me the freedom to come and go when I pleased.  I did ward rounds, went to surgery and clinic.  I spent a lot of time on surgical assessment unit clerking and I did a lot of night shifts.  The juniors I worked with were great and I really enjoyed it.  I didn't enjoy block 4 as much.  It was respiratory and I found it quite boring and repetitive.  Every day was the same, patients stayed in for weeks and I did nothing but bloods and cannulas.  I passed both blocks and was home free to my favourite and final block - Emergency Medicine.

I had the best time in A&E.  I could come and go when I pleased, I was encouraged to see patients and present them and I was treated like a real member of the team.  I had amazing support and a fantastic facilitator.  It was perfect, I didn't want to leave.  In the final week of my block I was called to see my academic tutor.  I expected it to be a pat on the back, well-done-you-got-through-it meeting but it turned out my tutor wanted to see how I was feeling.  We have one wild card professionalism judgement that is the locality judgement.  If you get an on-the-spot positive or negative which is usually formative, the locality judgement makes it summative and so count towards your final grade.  It is decided on by a panel lead by.... the facilitator from my GUM block.  I hadn't had any on the spots and not everyone gets a locality judgement so I hadn't thought anything of it.  The school office hadn't told me told me but my GUM facilitator had given me a negative locality judgement.  My tutor broke the news and assumed someone had already informed me.

That was it, I was done.  I had failed medical school.  I had come to the end of my money, I couldn't afford to resit the year.  All my friends were celebrating finishing and I had to call my parents and tell them I'd failed.  I was utterly broken.  I had worked so hard, for so long and it all came down to one person not liking me.  I threw my all into that last week at placement.  I figured if it was the last time I was going to be able to work in A&E I was going to make the most of it.  My facilitator took me and my partner out for lunch on our last day and I told her then.  She was outraged and submitted an on the spot excellent judgement for me, hoping to negate the locality judgement somewhat.  I had one final chance to pass.  Because I had failed the year, my case would have to be discussed at the Progress and Awards Board.  I would have to wait three weeks to find out their decision.

Elective

For my elective placement I spent 8 weeks in Malta working in the A+E department.  It was incredible.  I had really wanted to do an overseas placement to make up for all the summers spent working in an office, so I recklessly splurged my savings and loved every minute of it.  That said, Malta is actually a really cheap place to go, in terms of overseas electives.  Flights, admin fees, accommodation, bus passes, travel insurance and very generous spending money all came to just over £2,000.  I also didn't want to stay in the UK as Mr was deployed on tour while I was away.  I wanted to be completely immersed in whatever I was doing to take my mind off of worrying about him.  I didn't want to have to stop myself from picking up the phone to talk to him when I forgot that he wouldn't just be able to answer like he normally would.  I did kind of shoot myself in the foot with that plan though, as it turns out the free 30 minute phone call they get per week only works to numbers in the UK, and as they were closing down to come home they turned the internet off half way through so no skype calls or email either.

The Malta healthcare system works like the NHS and the case mix is exactly the same as the UK one too - lots of diabetes, chest pain and RTCs.  All of the medicine is written in English, most of the patients speak English as a second language, they follow NICE guidelines and use the BNF.  The major difference is that patients don't have a named GP, they can go to any one they like at any time, so no one keeps notes about the patient.  They would come in clutching their yellow cards to say what drugs they were on, but there would be no one to follow up on chronic conditions in the community, and lots of "inappropriate" ED attendances.  Because of this, there were 5 tiers of triage, and a nurse and a GP picked patients from the waiting room to say.  I stayed in the top three tiers.  The other big difference is that Malta is beautifully sunny and warm!  It was in the 30's for most of my trip, which is perfect for me.

I stayed in Sliema in the south in an apartment rented by the Malta Medical School.  The ground floor and second floor were occupied by the owners and their daughter and the top three floors were for medical students on elective.  Each flat had three bedrooms that slept 6 people.  They were lovely apartments - 3 mins walk to the beach, bus stop and shops and I could see the sea from the balcony.  It was great meeting medical students from all over the world and comparing training and hospital life.  There were students from Australia, New Zealand, Tunisia, Greece, Poland, Germany and the UK.

My days were 8-2 in the hospital with the afternoons and weekends to myself.  They also had lots of bank holiday Fridays they didn't expect me in for so I did some evenings and weekends to make up for it.  I could do what I wanted, so long as I felt comfortable.  They were very keen to have me involved.  I would wander around majors and look for interesting things going on, or pick from the list and clerk the patients first.  I would go to the resus calls and help site cannulas or manage airways.  Their medical school curriculum is like a UK one, except they don't get a chance to practise skills like blood taking and cannulas until F1, so they were very impressed I could.

In the afternoon I'd go to the flat rocks Sliema calls a beach and snorkel and at the weekend a group of us from the apartments would go site seeing.  Malta isn't very big and the bus pass for the week is very very cheap so it was easy to see the whole thing while I was there.  We went to all the beaches on Malta, which were beautiful but very crowded.  We went to Valletta - the capital, Mdina - the walled city, Gozo - the neighbouring island, we went hiking the cliff top path way and on my last day I went to a secret beach on Gozo on the advice of my supervisor that was completely deserted.
There were a couple of differences in terms of patients and the way cases are treated.  Being just off the coast of Sicily, Malta gets it's fair share of immigrants fleeing from Africa.  Boat loads turn up and live in refugee camps.  I never saw any out and about around the island, but I saw plenty that had gotten into fights in bars and come to ED.  We also had casualties evacuated from the war in Libya. These patients had no ID, didn't speak the language and were referred to by a number only.  They had life changing injuries from bullet and blast wounds and I spent a good while holding the hand of someone who had lost most of his bowels.  According to the translator, he just kept repeating "Don't leave me, don't leave me" over and over.  So I didn't.  He'd had a stoma bag fitted by Red Cross doctors in Libya, but the reality is he will never be able to eat well enough to overcome the malnutrition he will face by having poor absorption.  Another patient had blast wounds so severe, I could see the white of the bed sheet in a hole sized bigger than my fist that went through his abdomen.  When I got home that evening Mum told me of an attack in Afghanistan that had left several soldiers dead, including and American General.  The thought that my Mr could be lying on a bed in a similar situation to the patients I had treated that day was.... devastating.  I hoped that if he was injured, he would have someone there to hold his hand and smile at him, the way I had done for the gentlemen in my care that day.  I did hear from Mr that day eventually.  A single line to say he'd seen a lizard that day.  I could have cheerfully shot him myself, worrying me like that.

Malta is very religious.  It is one of the few places that still does not allow abortions, even if it costs the mother her life.  If you attempt suicide and are heard to say you no longer want to live, you are no longer deemed competent to make decisions about your medical care as you do not have your best wishes at heart.  On several occasions I watched people having ng tubes fitted to pour activated charcoal down because they'd taken an overdose.  On my last day, I saw the case of a holiday maker who'd taken an overdose but couldn't afford to pay the hospital fees.  The hospital had to treat them because of the overdose, unless their parents flew over to sign paperwork so they took control of her medical decisions as she was underage.  Unfortunately, it would take too long for them to arrive in terms of the window to treat the overdose and minimise liver damage and the patient was refusing to call them.  Furthermore, Malta does not have DNRs or TEPs, so CPR is always started, even in futile cases.  Unfortunately, the paramedics start CPR and bring them to hospital where they are either pronounced dead in resus or they get a rhythm back.  They are then taken to the corridor outside MAU to die because ITU won't accept them as they won't recover and MAU is full.  Equally, the general public do not like to start CPR because they are afraid of doing it wrong and they are not widely taught first aid like we are here.  So in younger people die because they do not get early CPR and older people have an undignified death because paramedics always do start CPR.

Malta was awesome, I had a great time, I met loads of new friends, I grew heaps in confidence and saw things I never expected.  If you like ED, go to Malta!  If you wanted to go there to do something else, others didn't enjoy it quite as much as clinics are held in Maltese and the other Doctors weren't so keen to translate.  So, if you want sun and a relaxed elective, it's perfect.

Heaven is a good book, a cup of tea and the most amazing cake with views over Malta at Fontanellas in Mdina 

Sunset at Cafe del Mar

Blue Lagoon on the island of Comino

The view from my balcony in Sliema

Partying with the locals at a village festa. That's the village church.  Each village has it's own day of celebration with all day fireworks that can be heard all over the island, church services and a procession through the streets behind the local brass band. 

The secluded bay at Wied Il Ghasri on Gozo