This blog will remain as an archive.
Update bookmarks and I hope to see you over there.
This blog will remain as an archive.
Update bookmarks and I hope to see you over there.
The guy who had had a zit on his forehead for three weeks and then decided, at 11.30pm, that he needed to see a doctor about it.
And the woman who wanted to complain because the cuff on her 24-hour blood pressure monitor had been inflating all evening.
Both on the same night.
I love coffee. It is wonderful. It is the sweet nectar of 6.30am alarm clocks and three hour lectures. My blog isn’t called becoming a doctor one cup of coffee at a time because I thought that it sounded like a snappy title, and my seventy-third thing (people who suggest that I should try giving up coffee [for Lent] are underestimating how much of a raging bitch I would be without my coffee) isn’t actually a joke.
In my world, there are four types of outpatient clinic:
1) The type where they take a proper break. There will be much coffee and a tray of nice things from the wee cafe, and the consultants will try to persuade you to take just one more cake. I have come across only one such clinic (and liked it so much that I went back five times).
2) The type where coffee is inhaled during the clinic. This category is very broad. It includes any clinics where the first question anyone asks when you arrive is how you take your coffee, any clinics where someone brings in a coffee for you halfway through the list, and any clinics where you are simply pointed at the kettle and told to help yourself. In the nicer ones, there are sometimes biscuits. This accounts for almost all of the outpatient clinics I have ever been to.
3) The type where there is no coffee. These are quite often fracture clinics.
4) The type where they take a proper break but are apparently not that keen on medical students. The consultant drinks his coffee and eats his ginger snap while the four medical students are not allowed such things and must sit, coffeeless and biscuitless, and watch him. This type of clinic is also known as the sixth circle of hell.
Now playing: The Hilliard Ensemble – Ave Maris Stella
At Glasgow, we sit our finals in February/March of our fifth year.
I’ve been avoiding our faculty library since September — not too difficult, that, as it feels as if my faculty have been going out of their way to put me in hospitals that aren’t in Glasgow. I was around last year, though, and I remember what the last cohort looked like by February and I remember wanting to give them all hugs and chocolate. I have no reason to think that the current fifth years looked any better by the time their exams rolled around. But it’s over. So far as I can gather, they spent most of last week having a very big and very deserved sleep, and then this week they learned that they really are going to be shiny new doctors.
In many ways, this is absolutely terrifying. It means that we’re next. It means that this time next year, I can expect my bloodstream to have been replaced entirely by caffeine. It means that I am expected to be competent to the level of an F1 in less than twelve months, which, if the passage of time over the last six months is anything to go on, can be fully expected to go by in a flash. And that in a very little bit more than that, I am expected to be an F1.
Mind, it’s not as if the semi-regular emails about FP application dates weren’t already reminding us of that.
In any case, all of those things are for tomorrow.
Because I ran into one of them today and we jumped in the air and hugged and screamed. In public. You might have heard me in Edinburgh.
We’re stupid proud of you all.
Now playing: Michael Ball – If Tomorrow Never Comes
It is a law of the universe that every once in a while you’ll have a day that is a complete disaster from beginning to end. A day that makes you think that you might have been better off not getting out of bed. A day that arouses in you the childish urge to pull the duvet over your head and demand a rematch.
Yesterday, I had just such a day.
It began when I left my travelcard on my desk, which meant £8.90 and a queue at the ticket office and led to the second disaster: jumping onto the train that was on the platform without checking to see that it was the right one. It wasn’t. It was a train that took me into the wrong train station, leaving less than fifteen minutes to dodge through the other commuters and run through town to the station that the connecting train leaves from. I had not planned to start my Tuesday with a half-mile jog across the city while wearing boots and a winter coat. On arrival at the hospital, I came to realise that I had an unexpected girl problem to take care of and this improved my mood not at all.
And so with these various disasters having already transpired to wreck my journey into work, the day began and I went to a meeting with my educational supervisor.
Do you know the difference between a perforated ulcer and a penetrated ulcer?
I had got it into my head that they were the same thing. I was presenting a case of a perforated duodenal ulcer. It went well until I started to talk about the emergency management of acute upper GI bleeds and the prognostic value of the Rockall score. My supervisor realised that I had gone very very wrong and proceeded to grill me on the blood supply to the alimentary tract, as all my anatomical knowledge fled from my brain and left me to sit there looking like an idiot.
The important things from that part of the story are: a) perforated ulcers cause peritonitis, b) penetrating ulcers cause haemorrhage, and c) blood vessels run behind the duodenum.
It is true that you learn more from looking like an idiot than you do from being right. Still, feeling desperately incompetent is never fun for anyone.
Today, a friend offered me a lift in and my commute became an hour of warmth and good conversation and Radio 4. I answered a question on the ward round. I spent some time with my F1, who made me a cup of tea and taught me how to prescribe vancomycin and gentamicin and warfarin. I passed my first nasogastric tube. I was complimented on my examination technique by a consultant surgeon.
And that’s the thing about bad days.
Last Wednesday, I came home from the hospital and watched an old episode of ER while attacking the pile of dishes that had accumulated. Flatmate and I are both on peripheral surgery rotations and seem only to be at home long enough to sleep and eat, and so the less important things have become less important. I was self-righteously smug when I was able to yell out the diagnosis (to the kitchen wall and the dirty spoons) for a high school athlete who presented with tenderness in the anatomical snuffbox. But my smugness was to be shortlived, for I learned that what I should really be doing on my surgery rotation is forging signatures on procurement paperwork, showing up at the clinical director’s house in the middle of the night, and being the first assistant on an LVAD implantation. I suppose all of those venflons and surgical clerk-ins have been a waste of time, then.
Incidentally, I have a non-medical friend who asked once why we watch medical dramas and this is the answer to that question: so that we can be insufferable when we get the diagnosis before the television doctors and so that we can mock the hell out of them.
And then with order restored to my kitchen, I sat down to watch Junior Doctors: Your Life In Their Hands. It’s a good concept for a documentary and one that hasn’t been done since the epilogue series of Doctors To Be back in the 80s, and the evidence from the first episode suggests that the BBC have done it well. I didn’t have the constant urge to say, “WTF, that is the most ridiculous thing I have ever seen in my life!”, although I admit that I’m not quite sure how a person can get all the way through medical school and remain blissfully unaware of the fact that the day job part of F1 will be almost entirely paperwork and bloods. It’s a good show and I’m looking forward to seeing how it all develops over the next five weeks.
The show has the added element for me of being based the city that I grew up in, those hospitals are the hospitals that I visited my family in and was treated for ridiculous childhood concussions in and did all my work experience in. Only not, because the RVI was never that shiny and A&E was at Newcastle General.
It seems as if my family are all watching it too, and so are many of the families of other students. It’s as if this is acting as a not entirely comfortable window into our world. My parents were freaked out by the rectal, but they were more freaked out by the cartoon lightbulb that switched on in their brains and said, wait, she’s going to be a doctor, like a doctor doctor, oh my God when did that happen, but she was only eight years old the last time we checked. In truth, I understand that reaction. It was a lot like my own reaction.
“Dr GP is sending us a patient to be admitted for pain control. Sefkhet, can you clerk her in?” Yes. Yes, I can. I’ve, uh, I’ve never actually done it before, though. “Oh, it’s easy. Just do what it says on the form.” And so it came to pass that I found myself on the medical admissions unit, looking like someone who ought to have known what she was doing and gripping the clerk-in form like a security blanket. And thinking that it couldn’t possibly be as easy as my F2 had made it sound.
First, to explain something of what I’m talking about. The “clerking-in” is what happens when someone is being admitted to hospital. It is basically a full medical everything. From the patient’s point of view, this means being asked lots of questions that either don’t seem terribly relevant or were already asked by their GP and/or A&E and then being used as a pincushion
The clerk-in form is a magnificent invention that: a) provides a consistent format for recording screeds of information, and b) acts as a prompt for all the things that you would otherwise forget to do. However, it is not quite so simple as “just do what it says on the form”. I had an exceedingly cooperative patient who was being admitted for pain control on her arthritic shoulder. I made her sit through a full neurological examination but didn’t dare touch the shoulder.
1. read the old notes
Or the GP letter. Or the SBAR from A&E. Or whatever. At worst, it means that there’s verification of what they’ve told you. At best, it means that you don’t struggle through getting a medical history only to find later that the patient who looked completely sane was actually completely demented and making things up as she went along. Oh, but I did.
2. the end-of-the-bed test
There are some patients who just look sick. Like, really sick. Sometimes, it’s all right to stop your clerk-in and go to find a doctor.
3. sit down
It’s not a five minute job. It isn’t made more comfortable either for you or for the patient when you spend the entire half hour looming over them.
4. the form isn’t a substitute for knowing what to do
I’ve used clerk-in forms that have prompted everything — where the section for GI examination includes a blank schematic of the abdomen and space to comment on organ size and bowel sounds. And I’ve used clerk-in forms that have “GI Exam” and then some empty white space. Besides, being reminded to comment on the spleen only helps if you already know how to palpate for it. (I was worried about causing pain, but my bigger reason for not examining that patient’s shoulder was that I didn’t know how.)
5. presenting complaint
The presenting complaint is the thing that is wrong with the patient, in their words. Generally, appendicitis is not a presenting complaint — stomach pain is a presenting complaint. Mind, I once had a patient whose actual presenting complaint was atrial myxoma, but I suppose there are exceptions to every rule.
6. the concept of background history
The taught format for taking a medical history is very very structured. It works. In real life, things are a little more flexible. You’re allowed to record relevant details from other parts of the history under the presenting complaint. If a patient presents with crushing chest pain, their history of unstable angina and previous CABG is part of the presenting complaint. Yes, you have to write it down again under past medical history, but that’s okay.
7. the art of medicines reconciliation
If the patient offers a plastic bag full of their medications or a copy of their last prescriptions, take them. It’s a much easier and much more reliable way of getting an accurate drug history than expecting patients to remember the names and doses and times of all their drugs. Of course, not everyone is on seventeen different drugs. But the ones who offer usually are.
8. when not to do a neuro exam
As a general rule, everyone gets their heart and lungs listened to and a hand laid on their abdomen. As a general rule, not everyone needs to have a neuro exam. If they aren’t presenting with neurological symptoms, “grossly intact” or “alert and oriented / moving all four limbs” is usually enough.
9. think about getting the bloods first
Yes, they are at the end of the form. It doesn’t mean that they have to be done at the end. This is especially true when you’re at a hospital in the arse end of nowhere and there aren’t out-of-hours lab facilities and your patient turns up at 4pm on a Friday. Similarly, sending off the x-ray request first means that the patient might actually get their x-ray before all the radiologists go home. Again, especially if you’re at a hospital in the arse end of nowhere.
10. find someone to present it to
It is not quite so simple as “just do what it says on the form”, but that’s the only way you ever really learn how to do it. You do what it says on the form. And then you present it to someone so that you can learn how to do it better next time.
A thick blanket of freezing fog has descended across the city. It’s nothing like so cold as in December (I have not yet forgotten walking to an MDT meeting when it was minus twelve degrees outside), but there’s a distinct bite in the air, enough to make me shiver and walk that little bit faster if I need to pass through the main lobby of the hospital. It feels all the colder for the few days of almost autumnal weather we had last week.
It’s the second week of my second SSC, which was supposed to be on haematological malignancies and has ended up being on general haematology. I’m rethinking my career choices.
I am not alarmed by this. I always do it. I work in a field for a little bit and enjoy it so much that I cannot help but think, “I want to do this for a job!” I spent two days in October thinking that I would really rather enjoy being a cardiologist, even with the seven hour ward rounds.
I don’t know, I think there’s something different about this. I think there are a lot of things to like about haematology, a lot of things that seem to add up to the sort of doctor that I’ve been working out that I want to be. I think the thing is that I want to do oncology, and this isn’t not oncology. It’s more specific and yet more generalist than that, but it still is that. In America, haematology and medical oncology are one specialty and I suppose in my ideal world we would do something like that. I understand why we don’t, though; it seems like a dauntingly enormous specialty. I think that this is one of those paragraphs that maybe made more sense inside my head.
Truthfully, it’s the fact of it involving lab work that makes me think twice. The lab and the MRCPath, oh God.
And a little bit because I should perhaps not make these sorts of decisions based on what nice people all the haematologists are or how happy I am to be back in medicine after five weeks of mostly surgery.
I have time to make my mind up. Years.
I do, though. Now, at this moment. I want to do this.