Updates

Hi to anyone who still reads this, that was a bit dramatic to end with.  I ended up doing what most other people I used to read did - get to foundation year and have no time left in my life to blog.  :( Sorry guys.  That really wasn't my intention.
From where I left off I had three weeks to plan a funeral, pack up Mum's stuff and my stuff and move half way across the country to start my new job as an F1.  Thanks to a lot of help from my family and Mr I did it and I threw myself into my new job with gusto which helped a lot to distract me.  Now I find I'm coming to the end of my foundation years and about to uproot and move again and I can honestly say that I believe I have the best job in the world.  Medicine is everything I hoped it would be and more and I truly, truly love it.  It is hard work, rewarding, back breaking, exhausting, thankless, exhilarating, comical, lonely, supported, terrifying and great fun and I have made such good friends.  I have been lucky enough to have stayed in the same DGH for 2 years so I know most people and how thinks work in it.  I have rotated through Emergency Medicine, Diabetes and Endocrine, General Surgery, General Practice and Cardiology and I'm now in Trauma and Orthopaedics.
I've had

• on call shifts from hell where everyone tries to die at the same time in geometrically opposite ends of the hospital
• bizarre shifts where I'm bleeped because a patient is stealing other people's jumpers
• delirious shifts where we crumpled on the floor maniacally laughing at 0400 because there's nothing else to do
• winter pressures that lasted 6 months
• sole responsibility for 3.5 wards of patients and a strong desire to hurl the bleep out the window and go cry in a stock cupboard
• a posting stripped of its juniors after I left because it was so bad and poorly supervised
• a letter written into the local newspaper from a grateful patient about how pleased they were with my care

I have loved every minute of it, even the awful bits because every shift does end and I can make a difference to something, someone, somewhere and that is enough for me.  At the end of every shift I go home to this little girl, who is just so happy to see me and doesn't care what I have done or not done she just wants chin rubs in this particular spot until my finger drops off, and a comfy lap to sleep on.  That I can do.  

Recently I completed a really long form and went for an interview which I was certain I bombed. Remarkably, I am thrilled to say I got my first choice training job.  In August I will be starting back down south and a lot closer to home as an ST1 in ACCS Emergency Medicine.  Things are coming up Bean!  Here's hoping I have enough time to take you guys with me on the next bit of my adventures.

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

Fourth year round up

Do you remember that I said fourth year would be busy? Well it certainly was. To cut to the chase, I passed fourth year and am currently on elective but it was challenging on an academic, personal and financial level, so much so I still can't actually believe it all came out well in the end. Placements were on the whole, fantastic. There were a few iffy moments including a GP facilitator that really didn't like me (when presenting the case of a 6 year old mute child complaining of bleeding from the ear, he marked me down for not including malignant melanoma in my list of differentials) and a surgeon whose sexually inappropriate names for his instruments left me feeling really uncomfortable in his presence. On the whole though, placements have been brilliant. My SSUs went well and culminated in me ambushing an unsuspecting group from my year and teaching them to sing a simple round to prove to them that singing positively affects mental health.  I surprised myself by not dissolving into a teary mess on my oncology and palliative care weeks and actually really enjoyed them. I will admit to shedding some tears at the funeral of one of my long term patients I'd known for the year and shadowed all his appointments.  He was an amazing man, so strong and determined to fight his cancer to the end. He always had a smile and a joke for me and really made me feel like family. His funeral was packed to the rafters with people, a testament to how popular he was and being a devout football fan he had 'you'll never walk alone' as his final song. All his work colleagues started singing along, though through their tears it sounded more like howling and I couldn't hold back the tears anymore.

On a personal level, my bald spots all grew back, and though I have new indents on my nails indicating there is still an autoimmune process going on in my body, I haven't found anymore new ones. Yet. Investigations for that showed I have thyroid auto antibodies,  so I'm waiting for thyroid symptoms and having regular blood tests. The scary c word was treated successfully thank goodness. Unfortunately, my Dad was taken into hospital with a suspected stroke which turned out to not be a stroke but neurology cannot work out what is going on. As they explained it to him, it's like half his nerves have just decided not to work. All their tests are coming back as normal, so they've decided it's not common or bad, so they've discharged him from follow up which I'm not terribly happy with as he's had the symptoms since Christmas now and they aren't improving. The same weekend Dad was taken in to hospital a close relative of mine attempted suicide and was thankfully unsuccessful but we had no idea they were in such a bad place.

To top it off, the week of my final exams mr was deployed on tour to the hot sandy place with a three month window in which he might be back at least six months later. Suffice to say, I failed my final exam. By 0.9 points. Grrr.  Our final exams are similar to what I sat at the end of second year. They are ISCEs and are 6 stations over three days with each station being 45 minutes long. We have 10 minutes to take a history, 10 to do a relevant examination, 5 minutes to put our thoughts together and 20 minutes to present the patient, differential diagnoses, investigations, management plan and answer knowledge questions.  Each station is marked on 10 areas with each graded out of 5.  I went to Phase 2 ISCEs which is 6 new stations in one day. You have to get the pass mark plus enough extra points to make up the difference between your phase 1 mark and the pass mark, so luckily I didn't have much to do. I had passed everything else, so the ISCE was the final hurdle to getting in to fifth year. Had I failed, I would have had to resit fourth year, which I wouldn't have been able to afford as I had splurged my savings treating myself to an overseas elective which I wouldn't have been allowed to go on. I had worked part time during fourth year as a driver for the local out of hours GP service, but money was still tight due to not having a job in third year. Despite everything riding on it, I actually walked into phase 2 ISCEs with a smile on my face and really enjoyed them. The results came out a few days before I was due to fly and I don't think I've ever been so relieved in my life. To have come so close and fail by such a tiny amount was heartbreaking.  Thankfully the exam gods smiled on me, and oh boy am I looking forward to a fifth year with less drama!

Raised Blood Pressure

The theme for this week was renal and in studying for this week it was actually the first time the kidneys made proper sense to me.  We had some very good teaches during the week and things just started to click.  It was quite exciting.  The week started with an hour and half wait for the first placement, and I really wish I was exaggerating.  I remember reading something on twitter or a blog about how medical school was actually just training you to be good at waiting, and how particularly in your clinical years you mostly wait around for things to happen.  I thought at the time, how can that be?  Our days a timetabled and choreographed to the smallest detail and wards are full of things happening.  Maybe our medical school will be different.  Nope.  I turned up at 9.15 as my timetable said to be chastised by a nurse for being 45 minutes late as all the Doctors were in a meeting.  Our introduction was only supposed to last 15 minutes before we were expected somewhere else so I was a bit antsy about waiting.  Two others from my class turned up, but they weren't my partners, they were from another week also based on the renal ward.  When my partners turned up, I had now been waiting 30 minutes, and was 15 minutes late for the next slot.  The Doctors still had not emerged form their morning meeting.  My partners and I traipsed around the hospital looking for the renal transplant team the timetable said to find, but not where to find.  Eventually we gave up and returned to the Renal ward, just as the Doctors were finishing up.  One approached us and seemed to be expecting us, saying "wait over there, I'll be back in a minute".  30 minutes later, he was.  He told us to go home, and we would see him in the afternoon.  Successful morning.

Day two was spent in a diabetes clinic, which was interesting,but the theme seemed to be patient has poor blood sugar control and feels awful, patient goes to Doctor to make them feel better, Doctor recommends tablets and insulin and lifestyle changes, patient accepts, patient is non-compliant, patient has poor control and feels awful.  Repeat.  I'm awfully cynical, aren't I?  It reminded me of a lecture we had on breaking bad news, about how patients sometimes go through the grieving process when they are diagnosed with a chronic disease, as they mourn the loss of the life they dreamed for themselves that did not feature this disease, and this disease means they cannot have any more.  Not without medication and lifestyle changes, anyway.  I guess what they really wanted, was the magic wand to wave and take their diabetes away.  Variations on the theme included patients bringing any ache, pain or niggle to the Doctor, diabetes related or not.  And mostly not.  Things that GP's should really deal with, but they were relishing the chance to sit in front of a consultant with their issues, even though it wasn't his area.

The thing I mostly learnt from the week, was a greater appreciation of how fragile the kidneys were.  My feedback patient had been hospitalised because after having diarrhoea and vomiting for three days, their kidneys had started to shut down.  They were usually fit and well, and although no spring chicken, they were pretty ok for their age.  I was really surprised and shocked at how ill they were and how quickly it got so bad.

Sepsis and Singing

The next two weeks of term introduced us to the three long term projects we will be undertaking this year, one on research in action, on based in medical humanities and one about doctors as teachers.  For the doctors as teachers project we can do anything we like, but we were allocated themes for the other two.

My research in action project is working with a team at the University looking at new biomarkers for sepsis. They are working on the premise that maybe sepsis is like cancer, and there are different types.  You wouldn't treat all cancer the same way and maybe that is why sepsis treatment doesn't have brilliant outcomes.  They are working on ways to differentiate between different types of sepsis, whether there are any biomarkers that predict certain outcomes or complications, and whether there are ways to tell who is more susceptible to it.   At some point this year we get to go into their lab and use lab techniques to get data of our own and then we have to present it in poster format and write a research proposal for future research ideas.  I passed the first part which was a presentation of a literature review into the topic.

My medical humanities is looking at music, the brain and medicine.  I am a fairly musical person, sort of.  I like singing, and have always sung in theatre groups and choirs since I was very small.  That said, I cannot read music, I don't know any music theory, and I don't have that much confidence in my singing ability, but it does make me happy so I persist.  We are on to a winner here!  I am hoping to approach and expert patient group of some form and teach them a simple song that will sound quite impressive for an afternoon.  I am hoping that the act of singing in a group will make some of them at least happy, the way it does me.  Fingers tightly crossed.  I have to come up with something to display at a conference later on in the year and write a technical or reflective essay about the topic.

This leads me nicely on to Doctors as Teachers.  I figured, since I was teaching something for my medical humanities, I'd just tweak that a bit and focus on my teaching style and specific techniques.  I have to make a resource, display something at a conference and keep a portfolio of my teaching exploits and reflections.

It should be quite interesting, albeit a fair amount of work.  I'm quite nervous, as these things will require me to be much more extroverted than I normally am, but hopefully they will all work out in the end.

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.