Smack in the Head

Fourth year eases you in gently with a Special Study Unit.  In this case, it's a three week block spent in one department, assessed by an essay to be handed in the following week.  The rest of my SSU's this year are all longitudinal ones, so I get the odd week on them here and there, but mostly we work on them in our own time to produce the assessed work required.  As they repeated like a broken record at the induction, this is to test our organisational and time management skills.

The SSU I have just finished was three weeks in the maxillofacial department.  Now I did pick it but it wasn't what I was hoping for from the list I submitted to the medical school.  The blurb was written very cleverly.  It sounded like a trauma SSU, as you can see from the title "A smack in the head" and glossed over the fact it was maxfax.  I think that's probably why it was a 'red spot', which means it's a hot favourite that lots of people pick so there's a lot of competition for it.

Despite being somewhat disappointed by the fact I wouldn't be spending three weeks in the Emergency Department and that our facilitator would be on holiday for the first of our three weeks, it was actually really good.  It soon became apparent that we have had no maxfax exposure in our course.  I had no idea where to start when it came to teeth.  Maxfax deals with dentistry, facial trauma, neck lumps, skull fractures and orbital pathology.  A lot of the clinics we saw were mainly painful wisdom teeth, temporalmandibular joint (TMJ) dysfunction (clicking, locking and pain of the joint where the jaw meets the skull by the ear) and teeth abscesses.

The head and neck MDT and cancer clinics on a Thursday were good although very harrowing.  I was moved to tears several times by some of the stories, as head and neck cancers only have a 50:50 survival rate at 5 years.  Some of the people coming to clinic seemed far too young to be getting that news, it wasn't fair.  I'm getting better with the tears though.  I shall have to really, I have a whole 9 week block in oncology and palliative care coming up this year.  If I don't improve, I'm going to dissolve!

We got to scrub into surgeries helping to remove teeth.  Teeth come out a lot easier than I thought they would.  I didn't get to pull any, and to be fair I really didn't want to, but I did get to inject some of the local anaesthetics to help make the patient more comfortable when they came around from the general anaesthetic.  We also saw some noses being straightened after trauma, and a couple of washout surgeries to flush out the contents of the TMJ.  By far the most impressive surgery however, was a 10 hour all day orbital exenteration.  The patient had cancer extending into the orbit and around the back of the eyeball, so the surgeon removed the eyeball and some of the surrounding tissues, packing the area with grafts from the skull, muscle from further down the face and skin from the thigh.  Because the surgery was so long, they were able to get frozen sections looked at by the histopathology lab to ensure they had clear margins and had removed all the cancer while the patient was still on the table.

I thought I would be quite squeamish, as the only other time I've nearly fainted in surgery was removing a tumour from a lady's face under local anaesthetic in dermatology.  I find it a lot easier to cope with when the patient is all covered up, it's harder to reconcile the reality of what you are doing to a real person.  With this one however, obviously the face wasn't covered up, but it just felt like we were performing surgery on a cadaver.  It didn't seem possible that you could do such drastic and brutal things to a person and for them to be alive.  I was pleasantly surprised with myself for not freaking out like I was expecting.  Once the cavity has healed, further down the line the patient will have a prosthetic eye area made for them, complete with eyelashes, eye brows and wrinkles.  The examples we saw were incredibly realistic, it was amazing.  The eye won't blink, but the passer by in the street won't be able to tell it's not real.

The consultant surgeon had a nice addition to the WHO surgical checklist where everyone introduces themselves at the start of the theatre list and the cases are discussed to keep everyone up to speed.  He gets everyone to rate themselves out of 10, so others are aware that maybe their colleague isn't on top form and needs a little looking out for.  We do a similar thing in our small group sessions, where we have a 'baggage check', so you can say if something has interfered with your work in the last week like illness or computer problems.  I thought this was a nice, elegant way that helps you tell people you're not 100% but means you don't have to discuss it if you don't want to.

Summer

I was in quite a bizarre situation over the summer and towards the end of last year.  I knew I had passed all my assessments along the way throughout the year, which meant there was absolutely nothing that I could fail on.  I was definitely a fourth year student, with no need to stress or worry about a particular day when exam results might be released.  It was an odd, uncomfortable feeling, and a situation I will never be in again.  

I got my email, as I was expecting to confirming that I had passed and progressed through to year 4.  Now I'm not sure I like this.  Fourth year is a little too close to fifth year for my liking.  Don't get me wrong, I really want to qualify and work as a Doctor, I'm just not sure I know enough about medicine to feel like a fourth year.  I feel there's much more pressure.  Third year was the start of clinicals, so we were still very much babies, but fourth year, that's way different.  To be honest, I'm not sure I ever will feel ready, and I think the fear is what keeps you motivated to work.  

The rest of the summer went well.  It was 10 weeks long and I went back to the pension administration company I usually work at over the summer holidays.  It was my eighth summer back with them so it's quite easy to slip back into that part of my life.  I've been there longer than most of the staff now, as they mainly employ graduates who use it as a stop gap when they can't find anything else.  There are some longer term members of staff and it's always nice to go back and catch up.  This year for the first time I spent all ten weeks downstairs covering the secretaries that work reception, as due to sickness, maternity leave and part time hours they were under staffed.  It was lovely sitting downstairs and finally being able to chat to faces that I recognise (there's a lot slower turnover of people downstairs than upstairs) but hadn't really gotten to talk to before.  

Twitter followers might, maybe, just recall that I had been selected for jury service starting the only week that Mr had free to take off work.  I wasn't too happy about this, as our holiday last year was cancelled because of the Olympics, and when you're in a long distance relationship, the novelty of being able to spend a whole week together is so precious.  I did manage to get out of jury service, although not in the way I'd hoped.  I had a phone call from the hospital asking me to come for tests, so I actually spent a large part of the summer holidays worrying that I might have cancer.  At the age of 25, despite looking after myself nutritionally, physically, medically, and not actually feeling like I've really started my life yet, I'm still working on getting there, this massive c-word flies in and basically just leaves the little bean in my head with tears streaming down her face, stamping her feet and pouting, yelling "it's not fair".  This is on top of the fact that despite having the least stressful periods of my life at university so far, I started developing numerous, fairly substantial bald patches half-way through last academic year, and have recently been confirmed as having the autoimmune condition alopecia areata.  I am awaiting blood test results to see if it is connected to anything bigger and nastier and was given the helpful advice from my consultant, that it isn't always stress related, but stress can make it worse, so try and stay calm.  So, going bald, query cancer and no holiday because of jury service. I must have some really bad karma I have to work through.  However, I try really hard to believe that you aren't given anything in this life that you can't handle so.... get on with it, you can do it.  

So the good news is that I don't have cancer.  Not in the traditional, spreads round your body sort anyway.  I do have the worst grade of pre-invasive cancer you can get though.  And the biomedic in me is stressing that if all of what they saw in the microscope was this bad a grading, then surely it's possible that a few cells in a section they didn't biopsy were the next stage on and then we have a massive case of the what-ifs and the big c-word still looming over you in the background cackling and saying I'll get you one day my pretty (a la The Wizard of Oz).  I go back in the New Year to see if they got it all.  The silver lining was that the treatment was scheduled for day 2 of my jury service, so I couldn't go, but Mr and I could have a nice mini break in Madrid (thank you Groupon).  

Now we are back at uni and there's the standard 'how was your summer?' and I find myself saying 'yeah, fine, it was good thanks, pretty boring, how's yours?' and inside I'm screaming cancer, balding, stupid army taking Mr from me, because no one really wants the truth when they ask that question, do they?  

Fourth year is the hardest of the lot.  Final exams, assessments coming out of my ears, practical exams, essays, presentations, posters, theory exams, elective to plan, and with the stress of this in the background as well?  This is going to be one tough year for me.  Oh yeah, and stay calm Bean, as otherwise your body might decide it doesn't need the rest of your hair on your head.  Marvellous.  *gulp*

~~Start where you are, use what you've got, do what you can~~

Pathway 3: Psych and Babies - Babies

I was expecting to like the NICU, but I found it really upsetting.  The latest research suggests that premature babies aren’t developed enough to be able to handle lots of stimulus from the outside world, so they are kept in warmed cots with blankets over the top in a silent room.  Any procedures that need to be done are co-ordinated to all happen at once so the amount of time the baby is handled for is kept to a minimum.  This means the parents sit and stare sadly at blankets over boxes whilst they wait until the allotted time when they are allowed to hold their child for a short amount of time, before being placed back in the box.  I can understand why this happens, and it was lovely to see the children progress from the sickest end of the corridor to the ‘almost ready to be discharged’ end, but I wasn’t expecting it to be like that so I found it really hard. 

I did like gynaecology, for the most part.  I stayed late on several occasions, and happened to be in the right place at the right time to be invited to scrub in on some surgeries, again showing that diligence and hard work pays off.  I got to help remove an ovarian cyst the size of a baby’s head and invited to help on some research papers which was pretty cool.  I liked that there’s a lot of flexibility in gynae, apparently.  You can do surgery or clinics, or both, and pick and choose which bits you want to do and which you don’t.  So, you could not do any oncology if you didn’t want to.  It made it quite a viable alternative to A&E for my future career considerations.  I know, I know, and so close to when I had finally made up my mind for that specialty, I’ve changed my mind again.  Well I haven’t changed my mind, I’m just keeping my options open. 

 

I was fairly horrified in the colposcopy clinics were they assess and treat abnormal cells picked up by the cervical screening programme.  The severity is graded from CIN 1-3 with 1 being some cells are abnormal on histology, and 3 being all cells are abnormal at histology.  The next stage beyond 3 is fully invasive cancer, so it is important it is treated.  CIN 1 will probably return to normal itself, but 2-3 definitely won’t.  Plymouth has two methods of treating it in clinic – either burning it off with a probe, called cold coagulation, or cutting it out with a heated wire, called large loop excision of the transformation zone.  I got to watch both types and it was probably one of the most brutal things I have seen being done to an awake patient.  Now you may think I’m weird, but I think the cervix is quite cute.  It’s like a little face with a mouth that goes “OOoooo” if you haven’t had children and smiles if you have.  I know, I’m odd but, it’s cute.  I can’t believe you can be so brutal as to cut it and burn it and make such a mess of it, and for that to be ok!  What probably made it worse was the lecture we had about risk factors, which basically said if you were more promiscuous, had many sexual partners and were sexually active from a younger age you were more likely to get the virus that causes this and have it for longer to be able to make the abnormal cells.  So although I tried not to, and obviously showed nothing externally, it’s hard not to pass some judgements about the ladies we were seeing. 

I got to finish with pregnancy and labour weeks which were very cool.  It was hard to take histories as the ladies are somewhat preoccupied and aren’t ‘ill’, so it needs a different approach to the normal history we would take.  That took some adjusting to and tended to make conversations a little awkward as I tried to remember all the extra bits that needed to go into a maternity history.  I got to scrub into caesarean sections and deliver babies, and I got to help with a natural delivery too, and delivered a real life, squirming, slippery, squalling baby.  It was surreal, mind blowing, amazing and fantastic.  A fantastic end to an amazing year.  I never would have imagined the things I’ve been able to do 3 years ago.  

Pathway 3: Psych and Babies - Psych

The third pathway essentially boils down to psych and babies.  To be honest, after the buzz of A&E nothing was going to seem brilliant, and psych being so far from the acute medicine I saw on my SSU probably didn’t help, but I really didn’t like the third term.  There were some good parts, it wasn’t all bad, but it was fairly boring.  The themes for the pathway were adult mental health, child mental health, gynaecology, neonatal ICU and pregnancy and labour. 

It was quite easy to become disenchanted with the mental health placements as the consultations were all really long, spread really far apart over the city and nine times out of ten the patients either don’t turn up or they don’t consent to allow a student to watch.  If they did consent, I usually found that they got bored half way through the epically long history you have to take for psych and left half way through.  I had a placement with the community mental health team where they asked me to sit and wait for four hours doing nothing whilst I waited to go out on a home visit.  This was my punishment for the medical school giving me an afternoon placement there, whereas they prefer to have students in the morning.  I had no computer access, no text books with me and I wasn’t allowed to leave and return later, despite only living a 20 minute walk away. 

I also got placed at the MDT meeting that discusses the progress of children at a day school programme for children with behavioural difficulties.  The meeting was three hours long, but due to more fantastic timetabling from the medical school my two placement partners were the ones that had spent the day with children and meet them, I just got to sit and hear about them.  Furthermore, at feedback sessions, no matter what the patient story was, the answer always seemed to boil down to feelings of abandonment as a child causing problems later on in life. 

Good parts of psych included the children’s outpatient clinics where I got to see two cases of Tourette’s, which is apparently pretty rare.  I also got to spend the morning at Shekinah mission which is a day centre in Plymouth for the homeless, ex-offenders and jobless for whatever reason to come and get a cheap, hot meal, clothes, socialise, life skills training with the aim to get them into employment, access to healthcare and dentistry and connections to the housing agency to find them housing, plus a starter kit of bedding and kitchenware to get them started.  They put me to work serving teas and coffee and dishing out lunch.  I was really surprised to see a couple of my patients from my GP surgery clinics I have run there, and utterly humbled to see how happy they were to see me again.  In the space of a few hours my perspective changed from a naive how can things be so bad for you to have to come here to I’m so glad you have somewhere to come where you can get help and support, make friends and get your self-confidence back.  It’s lovely to see you looking so happy, and actually there’s a few more people I’ve seen at clinic who could benefit from coming here. 

One of my feedback facilitators tried very hard to convince me I’d make a really good psych Dr as she could tell from my patient presentation that I like the story behind the person, and that was just what I needed to be good in that field.  Unfortunately, A&E proved to me that although I like stories, I really enjoy fixing things quickly, and making a difference in a short space of time.  Psych really isn’t for me.  

Emergency Medicine SSU

For my next Special Study Unit I was lucky enough to spend 3 weeks in the Emergency Department at Derriford hospital, the trauma centre for the South West. I was in heaven, it was simply the best three weeks of the whole year. I had such a blast! We were completely immersed into the team. We had sessions we had to go to, but apart from that we could turn up when ever we liked, go and see whatever and whoever we wanted. It was amazing. Our brief was to get stuck in and see as many patients as possible. From the computer system we could see who’s next to be seen and what the triage nurse had said was wrong. Then we had to clerk them in with a full history and examination and then go and hover until the next free doctor is about to pick them up onto their case load. We presented back to the Doctor with a concise history, impression and management plan and the Doctor sends you off to get some bloods done. Then you go and see the next patient. If something exciting was going on in resus we could go off and help with that, or we could go and spend some time in minors clearing patients there. I saw and learnt so much over those three weeks. My examination skills and history taking skills improved immensely and I really didn’t want to leave at the end of the three weeks. It honestly felt like coming home, I have found where I fit in medicine. It’s the only place I’ve been to where you look up and four hours have gone by in a flash and you haven’t stopped but you still have plenty of energy and could keep going. I did an 8am-6am shift with a total of 5 hours off throughout the course of the day and could have kept on going. Although I do realise that if you do that everyday, you probably won’t still have the same amount of energy and enthusiasm. But for these three weeks, it was incredible.


Everything comes to the door and you get to be the first person to listen to them and say you know what, this is rubbish what has happened but I hear you, I understand and I will help you figure it out. We had all sorts, from strange rashes, drunken teenagers, fibromyalgia, epilepsy, pneumonia, fractured neck of femur… I could go on.

A few of the more interesting ones I saw:

- A gentleman with an irregular heart rhythm was bought in, and to differentiate between the different types we gave him adenosine to slow is heart rate right down to see the underlying rhythm. It was atrial flutter in the end, which has a characteristic saw tooth baseline on the ECG. Patients must be counselled before you give adenosine as whilst the heart is stopped they often report a feeling of impending doom which can be quite unsettling.

- An elderly lady tried to commit suicide by jumping from a third storey window. She broke every bone in her body but still survived.

- I got to be in charge of airways in a trauma call for a man that fell and hit his head. Because I was at the head end it was my job to keep talking to him and I felt so privileged to be able to be with him in what must have been such a scary time.

- A man with mental health problems was rushed in having stabbed himself in the stomach with a blunt dinner knife. He had done this so many times before his abdomen is full of fistulas and this time he was only millimetres away from hitting his aorta.

- A grandson bought in his granddad who’d had a cough for a few weeks and was now short of breath and off his food. The granddad had been refusing to see a doctor until this point. I stood next to the relatives as they were told the cough and shortness of breath was caused by fluid on the lungs from cancer of an unknown primary source that had metastasised all over his body. Hearing that diagnosis felt like I’d been punched in the stomach and it wasn’t even my family. It was so unexpected and heart breaking.

- A blood curdling scream was heard from resus so we rushed in to have a look. A man had been bought in an hour earlier with a lambing band (used to dock lambs tails) that he had wrapped around one of his testicles. This had been cut off and he was waiting for a psych referral to come through. The only damage he had sustained was a small tear in the skin of the scrotum. Whilst being watched by a policeman and a nurse, he had managed to put his fingers in the tear, open it up and remove the testicle from the scrotum. Still attached, he rolled over and it was lying on his hip, where the nurse saw it, and screamed. He was taken to theatre where it was sewn back in and then transferred to a secure mental ward. His belief was that with his testicles attached his head would explode. He’d spent two weeks furiously masturbating, to see if that helped, and then decided this was the next best thing to do. On the psych ward, he later tried to tie them off with a shoe lace, but was stopped and I heard he is now feeling much better.

GUM Clinic

I got to spend a whole week at the GUM clinic which was certainly interesting. The week involved clerking the patients that come in off the streets for appointments, presenting back to a Doctor, taking blood for tests and then observing any examinations and treatment. It culminated in an informal teaching session from one of the Doctors with a lot of cake a lot of pictures and a lot of stories of items where they shouldn’t be. The GUM clinic is where anyone can come, with or without an appointment and talk to a Doctor about symptoms of a genital or urinary nature. It operates completely separately from the rest of the NHS records system, so nothing you say will ever come close to your normal NHS records, nothing gets sent to your GP and the staff don’t even know your name. You are given a number, which I found really bizarre walking into a waiting room and calling a number not a name.


In terms of the history talking, that’s simple as there is just a sheet of paper with questions to be asked and boxes to be filled in for every person, no matter what they come in with. This way, asking questions of a personal nature becomes more of a box-ticking exercise, which helps to take some of the embarrassment away. The patient can see there are questions to be asked, so it isn’t personal what we ask them, it’s just matter of fact. It also means you don’t miss anything.

I got to clerk a few interesting patients. One was a fairly young homosexual man who was coming for a regular check up, to find out about the free Hep B vaccination course he was entitled too and because he wanted to speak to someone about erectile dysfunction problems he was having with a new partner. I was really amazed on several counts. Firstly, I had no idea they could have the Hep B vaccine, what a good idea that is. Secondly, he was whipped straight through to talk to a psychologist about his problems, who gave him some new thinner condoms to trial, a pep talk with some really good, down to earth advice from someone who sounded like she really cared and understood and wanted to help him and an open invitation to come back anytime for a longer, in depth talk if that hasn’t done the trick. I felt really sorry for the guy, as he was so nice to have agreed to me observing, especially as it was such a personal problem and he hadn’t mentioned what he wanted to talk to the psychologist about. I’m not sure I would be that brave.

I spent Valentine’s Day (I told you I was far behind) holding the hand of and distracting a uni student as she had her genital warts frozen off which she caught after a one night stand. I was meant to be observing the procedure, but she was close to tears, really upset about the consequences of one stupid decision and it is really painful and pretty undignified. I felt I would be of better use giving moral support. My last interesting patient of the week was a middle aged gentleman who came in to get someone to take a look at a mole on the tip of his penis. As I was taking the history it became clear that this wasn’t actually why he had come in. His long term girlfriend had died of cancer a year ago. He had looked after her right up to the end and was still grieving and depressed. He had gotten himself into financial difficulties, making poor decisions about his mortgage and wanted a doctor to come with him to the bank to help explain his situation as he never remembered what they said to him and thought a doctor would be responsible and professional and help him get things sorted. He was taking advantage of the fact that you don’t need an appointment at the GUM clinic, so he could talk to someone when he was ready and capable of doing so. I felt so awkward and out of my depth. This wasn’t something I could help him with, the questions on my sheet were completely inappropriate but I was touched that even though I wasn’t who he was expecting to see, he still felt able to open up to me and talk about his problems. It goes to show that sometimes, you just have to listen and be there as there may be something else they want to say that’s really important to them.

And as for the teaching session, the most interesting item pulled out of somewhere it shouldn’t be? A lady came in with a yeast infection she wanted treating. The lady had had a positive home pregnancy test and so had been attempting a homeopathic abortion. She had picked some organic parsley, bound it with organic twine, inserted it like a tampon and left it for a week. She was most upset to find that she was still pregnant and couldn’t see how the infection could possibly be due to anything she might have done.

Saws and plaster casts

Hello, so I am really far behind in my blogging. Sorry! Last year got a bit busy towards the end, both academically and personally. Expect a few from me over the next few days highlighting some interesting things I got to do, but not one for each week.


After falls and funny turns I was on orthopaedics. I got to spend quite a bit of time in fracture clinic clerking patients and looking at x-rays whilst a scary consultant stood over me waiting for my management plan. Thankfully most of them seemed to be, can you wiggle it, are you getting pins and needles, can you feel me touching here? Brilliant, come back in a few weeks. I got to spend a whole day in paediatric orthopaedic theatres which was amazing. It wasn’t entirely timetabled, but after one of the morning X-ray meetings a surgeon caught up with my partner and I as we were busy trying and failing to get a secretary to tell us what patients were on the theatre lists for the afternoon so we could go and meet them and get their consent to watch their surgery. “Are you medical students? Go down to paediatric theatres and get scrubbed, I’ll be down soon.” No one ever says they actually want us anywhere, so we leapt at the chance.

On the list for that day was a baby with clicky hips, a child with clicky hips whose first surgery hadn’t worked and a child with a broken arm which needed pinning. Watching the baby being operated on was surreal, it looked like a doll it was so tiny and still from the anaesthetic. The child’s surgery was ridiculous. The surgeon sawed off the front of the child’s pelvis and then inserted it horizontally like a wedge into the hip joint to change the shape of the joint space and hopefully help the head of the femur to stay in the socket and not dislocate. It was so brutal to watch, but I really liked the practical approach to trying to fix the problem. Plus it was good to see what actually happens once you’ve found clicky hips in your new baby check, and to be able to take your time to properly feel them in an asleep child with the problem.  The last case was the child of one of the surgeons in the hospital, so everyone was on tenterhooks a little in case anything went wrong.

It was really and truly multidisciplinary, which was nice to be part of. There was the usual theatre team, but then there were also radiologists, to image the patient on the table to check things were in the right place once they had been fixed, and some specialist nurses which applied the fastest plaster casts I’ve ever seen. We all had to wear these really heavy lead aprons and it was such a hot room it’s a wonder we didn’t faint. It was a good day though. They were a really friendly team, and apart from the fact that I’m not sure I could take a saw to people, it was a really interesting topic and I quite like orthopaedic surgery.

Diligent Bean Triumphs

Collapse, falls and funny turns week was mostly based at a smaller hospital talking to people who'd fallen and broken their hips and were under long term rehab.  It was my first placement of the week however, that really made my time special.  It was my eureka moment; my achievement to cement in my mind that I can be a Doctor, I do know what I'm doing.  It was quite possibly one of my favourite moments of the year.  I was sent to go to the Clinical Decision Unit ward round.  This is where people are sent from the Emergency Department if they need a little observation and so would break the 4 hour target, but aren't sick enough to be admitted.  It tends to be full of people who have fallen, head injuries and over doses. 

After the ward round I sat and chatted to a lovely elderly patient who had fallen at home while down visiting their children.  They were adamant they had just tripped on the rug and stuck to the story despite specific questioning about dizziness, light headedness or any peculiar feelings before the fall.  I always do a systems review after I have explored the presenting complaint and social history, just for completeness.  It was then that they admitted that actually, maybe, possibly they just might have been a tiny bit dizzy and that's why they missed their footing and tripped over the rug.  I moved onto the examination, and as I was listening to their heart something just didn't sound right.  There wasn't the normal lub-dub I had heard before, there was something else.  I was so excited by the possibility of hearing my first ever heart murmur, I quickly abandoned the rest of the exam to find a doctor to confirm that I was actually hearing a murmur.  There was nothing in their notes about a murmur and so I really doubted myself. 

The doctor confirmed my findings, a clear murmur suggesting aortic stenosis which was probably the cause of the the patient's fall.  I felt elated, I practically skipped for the rest of the week.  The best thing, was that the patient was called away to have a scan and their lunch after I had finished my history but before my examination.  I had seen the Consultant round on them so I knew the examination findings for the dislocated patella they had sustained in the fall and I was really tempted to go home and make up the other findings for the heart and lungs that hadn't been examined.  The weather was disgusting and my two partners had already long since finished and left.  The doctor I was due to feedback the patient to would never get a chance to meet them, so they wouldn't know if I had presented the correct findings or not.   I could just tell the Doctor about the dizziness and hope he followed it up later, althought the doctor was the only one covering the ward due to staff difficulties getting in because of the weather and he was due to go off on mandatory training at lunch time for the afternoon, when the patient would be discharged.  The only niggling doubt in my mind that made me wait an hour and half to talk to them again was that in their ED notes and their CDU notes, no one had listened to their heart.  Nowhere was documented heart sounds 1+2 and nothing else.  If there had have been, I probably wouldn't have stayed.  I am so glad I chose diligence over laziness in the end. 

The frightening thing, is that the heart murmur was quite clear and so the problem was fairly advanced.  No one else had done a cardio exam, even though they definitely should have done, and no on else had the time to sit with the patient and build up the relationship enough for them to confide in them about the dizziness that might make you suspect a cardiac cause.  They told a very convincing story otherwise that would have you believe it was entirely mechanical.  If left untreated, something much worse could have happened, so it shouldn't really have been down to me to spot the murmur.  But it goes to show that medical students can be useful on the wards, that you should always trust your judgement and be thorough.

Guardian Angels

My Peri-Op Collapse weeks had me mainly based in ICU, apart from a seemingly unconnected trip to the urology wards on Friday.  I though t I would quite enjoy ICU.  The paediatric conference I went to in Brighton last year had featured a talk from a paediatric ICU consultant, and he'd made it sound really appealing and something I had been seriously considering.  Whilst I did enjoy me week, I don't think it is a specialty I can see myself doing as a full time career.  Plymouth is the second largest ICU in the country, beaten only by Birmingham Selly Oak, but the turnover in patients is the same, despite Birmingham having 4-5 times the number of beds.

The day starts with a ward round where a roaming computer and a team of Doctors goes from bed to bed discussing the patients progress with their designated nurse and amend any management plans as necessary.  Each patient is surrounded by a multitude of equipment - monitors, syringe drivers, dialysis machines etc, all hissing, beeping and blinking.  A nurse is responsible for watching over the patients, making a note of how their vitals change over the course of the day and this is fed back to the ward round.  For the majority of patients, this was fine, but I felt a little sorry for the ones who were awake, as twice a day a collection of people gather at the end of their bed, peer at them and discuss them from a distance, and then move on.  It didn't appear that they were included in the ward round, and it was mostly left to the nurse to explain if they felt it necessary.  I imagine it is bad enough to be that sick to be confined to an ICU bed, your friends and family kept from you apart from a few hours a day, being watched over constantly by a stranger, in some cases stripped of your voice by being intubated or having a tracheostomy, having no control over any aspect of your life and then to be peered at and discussed twice a day by more strangers that still don't talk to you.

I found it all pretty heartbreaking.  My patient I was allocated to had come in for a simple checkup in the liver clinic.  They have a condition that is currently baffling liver experts and so they come for regular tests to try and get to the bottom of it.  It looks like damage from fatty liver disease, except there's not enough fat in the liver to have caused it.  They came in with a bit of a cough and had to be persuaded to keep their appointment by their partner, as they felt too sick to go.  After the Consultant saw them in outpatients and some routine bloods were taken they were admitted for rehydration, treatment for community acquired pneumonia and then developed signs of organ failure and had to be sedated, intubated and admitted to ICU.  From having a bit of a cough to fighting for their life with their family crying around their bedside in the space of hours.

I spent hours by this patient's bedside.  I read their notes cover to cover, I knew everything about them medically, and had constructed the rest of the picture of what I thought they would be like around the medical facts I knew and insinuations gleaned from the language used by the various doctors they had seen in consultations.  I helped care for them, wash them, change their bed sheets, but what I really missed was being able to talk to my patient.  I admit it, I'm nosey, I love chatting to my patients, finding all about them, what makes them tick, how they got to be where they are.  Mr will tell you when we go to public places I'm forever eavesdropping, looking around, wondering how these people got to be in the same place as me under different circumstances.  I love people.  I couldn't work in ICU forever, although they are a fabulous group of guardian angels.  And if you were wondering, the last I heard, my patient had turned a corner and was getting better.

Surgery loses its glamour

Week 2 was entitled 'Fever in the Post Op Patient'.  It started with a placement watching open heart surgery with an important Professor and Consultant.  Whilst I should have been amazed, as it was exactly the same operation as I had seen in the first pathway I found it a little difficult to muster the same enthusiasm.  I was quite surprised at this, as, don't get me wrong, I love what I do, but it wasn't new and exciting.  The placement is there because sometimes in the Major Elective Surgery week, the timetable works out that the students don't actually get to see any surgery, so the Consultant has tacked this by providing a session in this week.

I think it was also not quite so interesting, because over the course of my three weeks in Day Surgery, I had gotten used to playing a more active role in the theatres, and we weren't allowed to do that in this case.  It felt strange, as I even though I had the ability and experience to help, I hadn't proven myself to this theatre team and so was allocated just an observatory role.  The theatre team were lovely, getting me a stool to stand on and peer over the anaesthetic drapes into the chest cavity as I am a little on the short side and I was able to answer all the questions the surgeons posed me, even daring to have some opinions on things when that seemed appropriate.  But because we are only in places for a short amount of time we cannot be tested and proved worthy, so we cannot participate.

I had been thinking that I quite fancied the idea of surgery as a career, but I wonder if I would eventually get bored of performing the same surgeries over and over, as I had with just watching them.  Or, whether because I was taking an active role, surgery wouldn't lose it's magic.  I like the idea of the responsibility of being in charge to decide how to perform the surgery, the artistry involved with making incisions and dissecting through tissues and being able to fix things with my hands and be the one to make things better.

After a fantastic teaching session examining a patient with the Consultant, we were let loose on the wards to find our feedback patient for the week.  This was rather strange, as the objective was to find patients with complications following surgery, ideally, patients with infections.  It felt almost treacherous in a way, to be patrolling nurses' stations asking if there were any patients where things had gone wrong.  I know that things do go wrong and surgeons aren't gods, but it felt odd to assume that complications were so common place that we could go onto any ward and find a case straight away.  We aren't taught about complications, and our lecturers are all surgeons and doctors and revered, so the notion that they could have ever made a mistake or had a complication is unthinkable.  The notion is slammed in the media, it is drummed into us, complications are bad and should never happen, if one arises then mistakes have been made.  By the time I am an F1 (exam gods be willing) cardiac arrests will be 'never events' in a hospital, as in the signs should be monitored and actions taken before it can happen, with consequences should cardiac arrests take place in a hospital, which is a bizarre idea.  Happily however, it was quite difficult to find patients with post-op complications, and impossible to find ones with a fever.

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!

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.

The one where bean is a little [all right, a lot] frightened

Week 8 was right sided weakness and was focussed on neurology.  Constant reader will know already that I hate neurology.  I don’t understand it and to be honest it baffles me.  Tuesday did not start well.  The consultant we were told to report to was away on annual leave, as was every other consultant we were then told to find.  Eventually we were told to go and find the ward round and shadow them.  This involved following a team of doctors around the hospital seeing all the new referrals to their service.

We were sent down to the clinical decision unit to see a patient who were told had seizures each night and would be post ictal when we saw them having spent the whole night on CDU so that his wife could have a nights peace.  We congregated around the bed and pulled the curtain.  The consultant sat on the bed and leant across to the patient sat in the chair to shake his hand and introduced himself.  With a broad grin the patient stood up, exclaiming “Oh yes, I know just what to do with you” and promptly punched the consultant squarely on the nose.  A little bit shell shocked I was acutely aware that I was stood right next to this patient, who suddenly seemed very large and very imposing.  The ward orderly ran around the corner and asked why the patient had done that, to which he replied “Because I want to go to hell!” and went to punch him too, thankfully, unsuccessfully.  Luckily, at that point Security came around the corner and we were able to escape to the corridor.  It turns out that the patient wasn’t having seizures, he was psychotic and our consultant had to be admitted to the ward for stitches in his nose, disbanding our ward round.

On the stroke ward I was pointed towards a patient I was told who was suitable for me to clerk and introduced myself and what I was proposing to do.  It quickly became clear that the stroke had left the patient unable to speak and that I was not going to be able to get a history from this patient.  This then left me in what I found to be a really awkward and embarrassing situation, having to explain to the patient that I had just asked to sit down and chat with that I was going to have to go without taking the history.  It felt so transactional, that all I wanted from them was one thing, and they couldn’t give it to me because of an illness.  From the look in their eyes, they probably would have liked a bit of company and I didn’t have time to give it to them.  I felt so guilty, and a little upset with the Junior Doctor who told me they would be good to talk to and put me in that position.

I passed my competency that week in testing motor, sensation and co-ordination, but the rest of the week was a write-off for me as I came down with a horrible ‘flu and had to take to my bed for the rest of the week.  I can’t say that there wasn’t a little part of me that wasn’t a tiny bit glad that I skipped the rest of the week.

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.