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Tag Archives: not a proper doctor

My Kingdom For A Cuppa

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.

 

my coffee mug

 

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.

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Now playing: The Hilliard Ensemble – Ave Maris Stella

 
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Posted by on March 30, 2011 in Blog

 

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In which Life only somewhat resembles Television

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.

 
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Posted by on February 28, 2011 in Blog, Medicine

 

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The Art of Clerking In

“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.

 
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Posted by on January 31, 2011 in Blog, Medicine

 

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See One, Do One… Teach One?

In one of my earlier rotations this year, I was landed with a work experience student for a bit.

Really, it’s more accurate to say that she was landed with me.

I am fairly obviously not even a little bit qualified for such a thing. I can’t tell anyone what it’s like to be a doctor, not really, and sixteen-year-olds do not go on work experience to find out what it’s like to be a medical student. If they’re anything like most of us when we were their age, sixteen-year-olds go on work experience harbouring the fond delusion that they might get to assist on brain surgery. So far as I can gather, her consultant thought that she’d learn more about what she might be getting herself into if she shadowed a junior doctor, and the junior doctor followed that thought to its logical conclusion and thought that she’d learn more about what she might be getting herself into if she shadowed, well, me. It might be true. It might even have given her something a little bit different to talk about in interviews and I hope it did.

On a purely selfish note, I do admit that it was nice to not be the most junior person on the ward round for once.

Still, watching me look lost and useless isn’t what I’d call the most inspiring sight. I was in my first five minutes on a new ward when she joined me — ‘lost and useless’ isn’t an exaggeration, the poor girl spent a decent chunk of time that afternoon watching me spin slowly in circles in the middle of the treatment room as I bemoaned an apparent lack of syringes. And even if I eventually stopped looking lost and useless, it’s not as though I was empowered to do much with her. I showed her how to take bloods and do venflons, and I showed her how not to do blood gases and demonstrated the art of giving yourself a needlestick injury with a heparinised needle. In spite of my best efforts to find her someone interesting to be with for a few hours, she ended up at one point in a tutorial on diabetic emergencies that included things that went over the top of my head.

It’s been a long time since I did my work experience, and an even longer time since I was sixteen. I don’t know if I had much of an idea what I was trying to achieve with it, back then The clearest memory I have is of the SHO who tried valiantly to teach me some radiology, asking what was abnormal about the CXR of a patient who was coming into outpatient clinic. “Well, I’m sure that this big thing in the middle of the lung probably isn’t supposed to be there, so I think he might have cancer,” I said, with the absolute certainty possessed only by someone who knows nothing but has a shiny new batch of good GCSEs and is therefore convinced of her brilliance. Of course, my brilliance was undermined somewhat by the fact that I was pointing at the left heart border. I tell this story to demonstrate that no matter how ridiculous you think you might sound, there is always someone who has said something stupider than whatever it is that you’re about to say.

In any case, it got me thinking: what do you guys want to get out of your work experience? I’m asking mostly out of curiosity; after all, I don’t expect personally to be faced with that question again for at least the next few years. I would really like to know, though. I feel like if I don’t know what I wanted from my work experience (and if I don’t know the answer to that now, I never will), then I’m hardly going to be in a position to make assumptions about what other people want from theirs.
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Now playing: Bruch – Violin Concerto No. 1 in G minor, Op. 26 – 2nd movement

 
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Posted by on November 25, 2010 in Blog, Medicine

 

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The Storytellers

Last week, I had dinner with a group of acute care physicians.

We are all storytellers. I tell the funny stories, the moving stories, the profound stories, and the ordinary stories. Sometimes, I tell stories that have been told to me by other people. I’m a blogger because there are stories I want to tell. I think we all do it, we all have a wee stash of good stories that we like telling and that we know get a good reaction from our audience. Of course, there are some that always get a good reaction no matter how they’re told or who they’re told to — I have a friend who likes to tell people about when he met the Queen and started talking about tampons — but, more often, stories are better when they’re told to people who have had common experiences. This is why you put seventeen Anglicans in a room and aren’t surprised when they start telling stories about funny things that have happened at funerals.

It’s no different with medics. If we end up around a table together, we will pull out all our best bits. We share stories about ridiculous things that have been done in the name of infection control (getting intercepted on your way out of theatre by an HEI inspector who wants to know when you last did handwashing training), least likely investigation results (a troponin level of 3.28 on a man who hadn’t thought himself unwell enough to come to A&E), most surprising greetings from patients (“um, can I have a cup of tea, please, doctor?” shouted from the room of a woman who had been GCS 3 every time we’d checked for the last week), and craziest experiences with patient transport (calling in a helicopter from the Ministry of Defence during the volcanic ash cloud). The fact that these are our best bits may explain why we make awkward dinner party guests.

In the middle of dessert, the conversation turned to funny stories about life support training.

I was the only person at the table who wasn’t an ALS trainer, so that was fairly predictable.

The only good story I have about life support training comes from my most recent OSCE. It all started well enough. I got the sticky pads attached and the monitor switched on, and I had identified VT and debfibrillated properly. I’d done all the things that we’re supposed to learn how to do in third year life support skills. The last part of the assessment is to demonstrate that you’ve not forgotten how to do all the rest of it. I tried to dash around to the other side so that I could take over from my “assistant”. I tripped over the Ambubag cable and took a nosedive onto the mannekin and expressed myself using words that my grandmother doesn’t know that I know. So, when third year OSCEs were mentioned, off I went into this story.

And you can meet someone and spend the entire day with them and know that there’s something familiar about them, something that’s tugging at the corners of your memory, something that you just can’t quite place…

I came to the end of my story and there was laughter, and the consultant who was sitting next to me put down his fork and said, “Oh, gosh. I remember that! I was your examiner!”

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Now playing: Barry Manilow – Somewhere Down the Road

 
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Posted by on October 14, 2010 in Blog, Medicine

 

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Well. Obviously.

You know, we don’t mean what we think we do when we ask about past medical history. First, there’s a handful of common conditions that almost nobody lists as part of their medical history, like hypertension and hypercholesterolaemia. Those are at least sort of understandable. But people don’t think that arthritis is a medical condition, especially if they’re quite stoical west of Scotland types like my patients tend to be. They never think that an ‘operation’ is a ‘medical condition’, even if it was a CABG. They often forget about their diabetes, and, unlike hypertension, that doesn’t naturally reveal itself from the drug history because insulin isn’t a tablet, so, in their heads, it might not necessarily count as a medication. My jaw nearly hit the deck the first time someone made it clear that they didn’t think of their COPD as an actual disease, but it turns out that that’s not so unusual. And on and on and on.

Then, you get the huge glaring gaps in medical histories that nobody could possibly have anticipated.

I was sent with the rest of my clinical practice group to speak with a gentleman who had been admitted to the stroke ward a few days earlier. There are few things more awkward than four people trying to take a medical history all at the same time, and so it was decided that one person would take the history and that the rest of us would observe. The gentleman told us that he had been feeling well throughout the day and had been watching television when he became aware of blurry vision and a heaviness in his right arm, and, thinking that he was having a stroke, had gone and knocked on his neighbour’s window. He had realised then that he couldn’t speak, but the neighbour had called an ambulance and he had been brought to A&E. The guy who had volunteered for the firing line asked about the specifics of his inability to speak, and then asked if there had been any symptoms in his right leg, if he had had a headache, if he had blacked out, if anything like this had ever happened before. It all seemed to be going well. He moved on, asked about any other medical conditions and any past medical history — it was after this that I started asking, “has your doctor ever told you that you have high blood pressure or high cholesterol?”, because we do need ways of getting around the obstacles in the first paragraph and I liked that question and it works. He asked about family history, about medications and social circumstances and smoking and alcohol intake and recreational drugs.

Finally, he asked, “Sir, can you take me through exactly what happened on the day you were brought into hospital just once more?”

“Well, I got home from my radiotherapy at about lunchtime…”

Collectively, we wondered if we had misheard that.

“Right,” he said. “Okay. Um. If you don’t mind me asking, what is it that you’re having the radiotherapy for?”

The patient looked at him as if he might have a screw loose. “Well, for my lung cancer.”

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Now playing: Leona Lewis – Run
via FoxyTunes

 
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Posted by on September 12, 2010 in Blog, Medicine

 

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Trial By Fire

My hospital is a remote DGH with a tiny staff. This is a good thing. The compensation for going to the arse end of nowhere is that this is where you’ll find hospitals with fewer students, better teaching, and much more opportunity for getting stuck into things. I was told before I came that at this hospital, I would be able to do practical stuff and improve my clinical skills.

I clerked in my first patients. I learned how to scrub in. I relearned how to take bloods. I stopped trembling when I had to sign patients’ notes, and pretended I wasn’t when I had to hold down a toddler for a blood draw.

At least twice a day, someone asked, “Are you a medical student? Do you put venflons in?” I always told them that I was a medical student but that I’d only ever done a venflon on a plastic arm (and that in my OSCE, I had failed to do even that — but I didn’t say that part), and they always balked and went to find someone else. Eventually, my FY2 found a man with excellent veins and herded me in to his room… and I gave up after the fourth attempt. It happened again on the next three patients. The patient who ended up being my first successful venflon got me because it was the middle of the night and the ward nurse thought that my burgundy scrubs indicated some sort of competence.

The patient didn’t ask if I’d done this before, and thank God for that. I’d not slept. I might have blurted out the thing about the plastic arm.

Although if someone’s putting in a venflon and they can’t work out the venflon dressing, it’s a pretty good indicator that they’ve never done this before.

I cleaned up the blood that I’d got all over her and apologised profusely to the nurses for the blood that I’d got all over her sheets, and I scuttled back to the doctors’ room with my heart still doing triple time. They beamed at me. “Oh, we knew you could do it. You just needed to be left alone to get on with it!” Well, I suppose. Yes. I feel better about them now — getting one in in the mostly dark at five o’clock in the morning does wonders for confidence, even if it doesn’t do much for actual technique. Still, I’d not have wanted to be that patient.

I’ve still not worked out how to get them in without spurting blood absolutely everywhere.

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Now playing: Woldemar Bargiel – Adagio for Cello and Orchestra
via FoxyTunes

 
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Posted by on August 10, 2010 in Blog, Medicine

 

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