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.