Saturday, March 31, 2012

O&G Labour Week Part 2.

Tiring second half of the week. No joke. Again I underestimated/didn't give labour week enough credit. I thought it was going to be complete crap...but this week has proven me wrong. I wouldn't say obstetrics is my cup of tea, BUT it has certainly earned a lot more respect from me. The midwives are so hard working and enthusiastic despite their ridiculously long shifts. I think the most frustrating part about obstetrics is that it is either very busy or very quiet. When it is busy, time passes by extremely quickly...but when it is quiet - holy is painful as all you do is just sit around and zone out.

Day 3 - Because I only had 1 thing left to be signed off on my log book (instrumental delivery) I was literally running around and broadcasting to the midwives and doctors that I need to see an instrumental delivery. Essentially showed up early...again struggled with arriving for 7am, but tried my best. The midwives suspected that one of the rooms will need an instrumental delivery so they told me to keep an eye out. Literally sat and waited for the whole day for this woman to deliver. So a bit of background.

27 year old woman
Prima Gravida (first pregnancy)
Been in labour for 48 hours
Admitted to hospital with cervix dilatation approx 5cm and severe contraction pains
SROM (spontaneous rupture of membrane)
CTG revealed an episode of deceleration of fetal heart - spontaneously resolved - may need C-section if re-occur
FBS (fetal blood sample) taken x2 (both revealed normal blood results)

Plan: Midwife to review every 2 hours for any more CTG decelerations.

Essentially I had been hovering around this lady's room and keeping an hawk eye on the midwife responsible for this lady as I did not want to miss an instrumental delivery. Sat around in the midwife room for hours. Time was ticking and it was getting closer to the end of my shift (5pm)...then 4:50pm - midwife reports that the lady is fully dilated and has tried to push for awhile but the baby was not coming out - called on-call registrar. It was determined that this woman will need instrumental delivery. I obviously perked up and was relieved that I will finally get to observe an instrumental delivery and get my log book obstetrics section completed.

Lady was brought into theatre as there was a bit of cervix which could be pushed back and she was given spinal. Realized that we cannot use the KIWI so we had to use Forceps. I had never seen forceps before and when I saw them it looked pretty crude but it doesn't really do any damage to the baby. Forceps delivery is just crude. The registrar was pulling quite hard and we had to hold the lady back as she kept sliding down the bed as we pulled. The husband nearly passed out as well. After several attempts, the baby was delivered and it was fairly large so I was not surprised why it took a few pulling attempts. Unfortunately, due to the baby's large head and that the lady was quite small, she ended up with a 3rd degree tear. 3rd degree tear = torn perineum and a bit of anal sphincter. Essentially tears are not pretty...seen a few tears now and it's not nice. Essentially the surgeon has to stitch your perineum back together which is pretty much  a mess. It isn't pretty. I don't even get how does the surgeon figure out what to stitch. To me it was just a bunch of flesh torn apart. Certainly looks very difficult to repair and requires a lot of skill and experience. Amazing though. Once that was done it was almost 6pm but the extra hour got me my final signature for my log book.

Day 4 - because my log book was filled and it was a half day as I have a night shift on day 5...i turned up late and observed 2 caesarean sections. Fairly boring day.

Day 5 - 16 hour on-call night shift. Start at 5pm Friday, finish 9am Saturday. I really didn't know what to expect...I like to consider myself nocturnal as I work well in the middle of the night. Unfortunately it was a VERY quiet night and time was crawling. I didn't know what is the proper etiquette for night I go sleep or do I stay awake with the midwives? The doctors disappeared midway through the night and I assume they went back to their office to sleep. So what do I do? Essentially I tried my best to stay awake and read 6 chapters of my O&G textbook. 4am - I was getting fed up. Bored to death. Nothing going on. 5am - told the midwives to bleep me if there's anything interesting/if they need to bleep the doctors to also please bleep me. I technically don't have a room but I reckoned the seminar room would be empty so I went to bum on the couch in there. Passed out for about 30 minutes and then my bleep went off. I was so tired...I looked at my bleep and was trying to get up...couldn't. 15 minutes later - woke up and sun was rising...obviously hardly knew where I was...very dazed. I could hardly open my eyes and zombie stumbled to the ward and the midwives said they were trying to bleep me and that there's a patient in theatre. Went to theatre to see the consultant repairing a 3rd degree tear. I'm pretty sure he knew why I was late...but he didn't say anything. Phew. 8:30am - doctor handover. I packed up, got changed back into clinical clothing, and then stumbled to my car. Managed to get home in one piece. But wow WHAT A TIRING/BORING NIGHT. Brutal. Never again - 16 hours. Doctors and midwives only do 12 hour shifts...why the heck do students have to do 16 hour shifts?! Trying to kill us?! At least give us a room or an office instead so we can rest.

All in all...labour week wasn't too shabby. Obviously Monday and Tuesday were my highlight days as I got to assist and scrub in for elective sections. Very good experience as I enjoy surgery so any opportunity to scrub in is an honour for me. Next week is my final "timetabled" week which is Ward Week; however, it is more like 50% ward, 50% clinic. My summative assessment is next Tuesday as well. It involves taking a full Gynaecological history and answering questions about investigations, management, and treatment. Quite nervous as I haven't had time to practice history taking as I haven't had my ward week. Next Monday = catch up time. Probably going to try my best to talk to as many patients as I can on the ward. Final stretch of placement: 2 more weeks. Ward week then "catch-up" week. I'm actually kinda sad that this attachment is ending. Having a blast. Unexpected. Wow.

Tuesday, March 27, 2012

O&G Labour Week Part 1.

I'm only 2 days in to my labour week and I'm already struggling. I'm supposed to be in for midwives handover at 7am every day. Day 1 - alarm clock for thing I knew I woke up again and it was 6:30am. Didn't get to the hospital til the time I got changed into scrubs for labour was like 7:20am. Day 2 - alarm clock for 5:45am...actually got up this time. Arrived at the hospital at 6:55am and traffic wasn't bad. I actually tried really hard to make it to handover...ran to get changed. By the time I got out...I had apparently missed handover already and the midwives said I should aim to arrive for 6:50am tomorrow. In my head I was like "6:50am?! Yeaaahhh right." Dreading it already. Also I have been sooo tired. I would sometimes catch myself dozing off in the ward because I start so early in the morning...but still get off at 5ish pm. Brutal. And when I get home...I hardly have the energy to eat and all I want to do is sleep. So unproductive.

Pretty exciting first day though. Saw 2 normal vaginal deliveries. Also assisted as a first assistant on 2 caesarean sections (aka I got to scrub in and actually do proper surgical stuff...not just hang around and watch - just the consultant surgeon, me, and a scrub nurse - what a dream). Also witnessed an emergency caesarean section as the baby was stuck. When the emergency button was pressed it was like a TV show. It was crazy. Loads of people ran in within 5 seconds of the buzzer going off and everyone knew what they were doing. Anaesthetist was already making his way to theatre and some of the theatre staff darted to theatre to prep. About 8 of us were racing the bed down to theatre. It was really surreal. Obviously there was a sense or urgency. The mother had to be put under general anaesthetic (most caesareans is under spinal so the mother stays awake and just can't feel anything down below). Staff was frantically prepping the theatre with the was just organized chaos. I was so scared to get in the way so I just crammed myself into a tiny corner of the room. I obviously couldn't scrub in as it was an emergency and the registrar had turned up.  Eventually we managed to get the baby out and I finally got to see the link between the paediatricians and obstetricians. The paeds team was already waiting for us ready for the baby and for any resuscitation as it was a complicated birth. Baby came out floppy and wasn't crying/breathing. It was a very tense moment as we handed the baby over to the paeds team. Unfortunately I'm with the obstetrics team so I couldn't go watch the paeds team work their magic. Finally after a few tense minutes we heard the baby cry and you could see the relief on some of the staffs' faces. I'm sure it was pretty scary for the mother herself as one minute she was just about to give birth but the baby got stuck..the next minute she's asleep. Also the father is left waiting outside of theatre after seeing a bunch of people wheel off his wife. Pretty scary situation for the family in general I would think.  I couldn't say I had as much fun  in the afternoon though. Immensely boring after a frantic morning. But the morning certainly made my day though.

Day 2 - quiet morning. Waited til 9am for elective caesarean sections. Again was really lucky and got asked to scrub in and help out...but not to the certain extent of a first assistant. Still makes a huge difference when you're scrubbed in. I even got to transfer the newborn to the crib after we pulled him out. It was really cool. After the sections...again went quiet again. Saw 1 normal delivery and that was it. Next thing to knock off my list: Instrumental Delivery (eg. using Forceps or Ventouse Suction). Really need to get that signed off tomorrow.

Labour week to be continued.......(if I'm still alive by the end of it)

Saturday, March 24, 2012

The Grind.

Clinic here. Clinic there. What a brutal week. I don't mind clinics...but I do mind them when I have 2 clinics per day from 9-5pm. I have now grown to fear Antenatal Clinics. It is essentially an overbooked clinic where you talk to high risk pregnant ladies and just following up on their pregnancy. It's nice as you spend about 10-15 minutes with each lady; however, after 5 pregnant gets very boring.

Not only did I have Antenatal Clinics, but I also had to attend Gynae Clinics, which I admit are a bit more exciting/interesting. Gynae Clinic is where patients come in with problems downstairs. This could include menorrhagia, dymenorrhoea, discharge, etc. Because I was with my supervisor, Mr R, I was able to carry out a few examinations and after being taught how to use a Cusco Speculum in theatre, I was finally able to try it out on a patient who is awake. I gotta admit...I was extremely nervous as I obviously don't want to cause any pain and the Cusco can easily cause pain. I managed to find the cervix in the first go and I felt a sense of pride come over me and Mr R was complimenting on my technique. It definitely filled me with confidence and to be honest...inserting the Cusco wasn't that difficult. I don't know why I was pissing my pants about it. I also really appreciate patients being so tolerant with students. I mean if I needed to get my downstairs checked up...the last thing I want in clinic with me is a medical student...and no way the student will be going near my bits. I mean these patients who allow us to practice our skills really need to be more appreciated. It's one thing to practice on a plastic mannequin but being able to practice on a real patient is a whole new ball game and it really helps build confidence. It also helps when your supervisor is keen to allow you to practice skills and perform examinations. Overall I enjoyed my clinic with Mr R as he was also in a good mood and we finished clinic on time (RARE!). Learned loads, got to do examinations + Cusco, and had a lot of good banter and many good laughs.

Unfortunately, I cannot say that I had as much fun with the rest of my clinics. Note to self: READ UP before attending special interest clinics. I literally got wiped all over the floor by another consultant when I went to Colposcopy and Gestational Diabetes Clinic on Tuesday. Because I had an evening meeting, I did not have time to read up on the clinic and I wrongly assumed that the consultant I was going to have wouldn't quiz me like Mr R does. To my demise...this consultant LOVES quizzing and I got my butt kicked. It was so embarrassing. I have never felt so dumb either. I kept blanking out and my heart was racing with every question. Worst bit is that I know the answers to the questions...or more like I SHOULD know the answers but I couldn't spit it out as I had not done any revision. Definitely taught me a good lesson and ever since Tuesday I did some reading prior to clinics especially clinics with consultants I haven't met yet.

On top of all the clinics this week...hands down...I have never worked so hard on placement...ever.  I was putting in so much extra time. Usually we are expected to be in 9-5pm on a standard day.  Monday...technically didn't have to go in until 10:30am for a tutorial. I went in at 9am to take a full patient history for my case study report. Tuesday: 9am clinic...went in at 8am to get a different patient history as the patient history on Monday wasn't good enough for my case study (ended up not seeing any patients as there was a ward round going on). Then had clinic in the afternoon which did not end until 5pm. Went to the ward to see if there are any more interesting patients...didn't leave until 6pm. Wednesday: 9am start for clinic...but stayed until 6pm...when I could've went home at 3:30pm (clinic finished very early) - was chasing after some patient notes I had requested for as I forgot to copy down info. Thursday: 9am start (clinic). Gave up my lunch hour to go read up the patient notes that I had requested for. Then had teaching from 2pm-3pm. Went to clinic...which didn't end until 5:30pm. Friday: FINALLY a normal day - 9pm-5pm.

Worst bit about this case study I was chasing around for a whole week - I ended up writing up on the first patient history I took Monday morning. Most annoying bit: of ALL the patients I could've picked, I picked a patient who was under the care of my supervisor (who is also marking my essay). I didn't want to do up a report on my supervisor's patient as he would know the patient history well so I definitely have to write accurately. This unfortunate coincidence doesn't end there. I thought I could get away with this patient case study as my supervisor had no idea which patient I am writing up, but also this patient presented with a fairly common problem (urinary retention post-op total abdo hysterectomy) so it could easily be anyone. Because the patient was discharged later in the afternoon on Monday and I needed to look at the notes, I requested for the notes to return to the ward so I can read through them. They arrived on Thursday, but were delivered to my supervisor's secretary. No problem right? Wrong...the secretary shares the same office as my supervisor, but luckily my supervisor was called to cover a clinic for another consultant for a few minutes. Perfect - quickly ran to fetch the notes, except the secretary forbid me from leaving the office with the notes. I knew my supervisor had just left his office as his computer was still on (screensaver wasn't up yet), and his chair was still warm. I predicted that my supervisor would be back in 30 minutes so I quickly went through the patient notes. supervisor returned in 10 minutes and found me lounging on his chair and working at his desk and I had moved all his stuff to the side to give myself some room to write. Doh! I quickly stood up and moved over to finish up copying out important info about the patient's operation. My supervisor got curious as why the heck was I in his office, and who's notes was I looking up. He knew I have been working on my case report...and obviously his curiosity took over and he was trying to see the patient name. I kept my hand over the patient label on each page; however, in the 2 seconds I bent over to pick up my pen, which I dropped, my cheeky supervisor took the notes and found out which patient I was writing about. I was obviously a bit annoyed as now my supervisor definitely knows who I am writing about, but now also knows what I will be writing about in my report. He promptly refreshed his memory by flipping through the notes while I stood next to him giving off a dumb face. Guess I really have to do a good job on my essay now that my supervisor knows I'm writing up about his patient and the fact he remembers the patient as well. Great. Bonus bit: my essay is due in 3 days...2 weeks earlier than everyone else. What a tiring week. Hopefully all this hard work will pay off in the end. Next week: Labour Week. Going to be VERY tiring. Long shifts. Lots of waiting around. Yikes.

Saturday, March 17, 2012

O&G Theatre Week

So far so good! I'm enjoying this placement 100% more than my paediatrics placement. I feel much more comfortable and it's a nice feeling to be looked after. Yes it is annoying that someone is keeping a hawk eye on your progress and your work, BUT at least someone cares. In my last placement I felt like I could get away with anything and there wasn't enough motivation/pressure for me to work hard. I'm working much harder in this placement and I am learning loads. This week was my theatre week and as you probably know - I'm a bit biased towards surgeries as I really enjoy surgery. If you tell me to stand in theatre from 9-5 and watch surgery all day...I will happily do that - no complaints. If you tell me to stand in the ward from 9-5...I'm pretty sure I won't be as happy about that. I don't know what draws me to surgery so much. It's just nice being able to fix things immediately right there and then.

Anyways all in all the week had its highs and lows. Monday and Thursday were my two highlight days of the week. Oddly enough these two days were the two days where I had theatre sessions with my supervisor (Mr R). Right before joining Mr R for theatre, I was told by his registrar that he enjoys quizzing his students in theatre. I found it quite weird as when I was in clinic with Mr R, he didn't seem to be the "quizzing" type of consultant. Before surgery even started, I was grilled about common gynaecological problems. Luckily the questions weren't too challenging and Mr R seemed fairly impressed with my knowledge. I was just lucky that I had clinic prior to theatre which covered the conditions that Mr R quizzed me about. Phew. After the grilling, Mr R invited me to scrub in and to assist in the surgery! I was obviously very excited and it was nice being right at the table and I got to actually assist. I felt a part of the team and I felt like I was helping out. Unfortunately, this gave Mr R the opportunity to quiz me on the pelvic anatomy (which was VERY rusty). My lack of knowledge in the pelvic anatomy was not exactly impressive and I was promptly told to review my anatomy. Oops. Other than that I was able to get my hands in and I learned quite a lot as I did not get a female cadaver dissection specimen during my 2nd year so it was nice to be able to actually see the organs. I was also lucky to help out in a total hysterectomy as it was an open surgery so I got to see the organs more clearly. As the days went by I realized this was the only open surgery I will be watching as the rest of the surgeries I saw were laparoscopic surgeries. Pretty lucky to be honest. When surgery finished I had a good time and had some good banter going on during the surgery. Got to know my supervisor and the registrar better. No joke I really felt welcomed and I didn't feel so much like a medical student. I didn't feel like a joke in the theatre. People were taking me seriously and the nurses were all very friendly to me and I got along with everyone. Definitely a good start.

Tuesday I was with a different consultant for surgery and then realized to appreciate my supervisor as this consultant did not teach me at all. We were performing laparoscopic excisions of endometriosis and these were fairly complicated surgeries in general so the consultant was busy concentrating and I felt forgotten. I casually stood at the the back of the team as I was not offered to scrub in so I just observed. It was horrendously boring and I was getting fairly restless. After a fairly boring/dull Tuesday morning I went to look back at my schedule and realized I have the same consultant that I had in the morning on Thursday. I did a bit of snooping around and found out Mr R had a day theatre list Thursday morning so I decided to make amendments to my schedule and decided to follow Mr R. You would think why would I want to follow Mr R as he loves quizzing and it's quite a lot of pressure as this is my supervisor who will be assessing me at the end of my placement. After following a different consultant on Tuesday, I realized that despite all the quizzing, I learned a lot more with Mr R and in general had a lot more fun in theatre. Yes it's nice not needing to use your brain, but because I'm interested in surgery I rather get quizzed and learn things. On top of that Mr R lets me scrub in and help out so it really makes my experience a whole lot better. I guess it's a give and take situation.

Unfortunately I caught Mr R on a bad day on Wednesday and managed to "anger" him as I didn't know I was scheduled in for an audit in the afternoon as it wasn't on my schedule. Because I had my schedule in advance I decided to arrange a few meetings on that day in the afternoon as I assumed I had a half day. I had to explain to Mr R why I cannot attend the audit and he was not impressed whatsoever. I was properly pooping myself as we have been getting along and he's been pretty chill. I didn't think he would care that much about me missing an audit. I obviously felt really bad on Wednesday so I knew I had to redeem myself on Thursday. Wednesday night I decided to dust off my anatomy text books and revised my pelvic anatomy very well and read up on various gynaecological conditions. I also found out that Mr R consents his patients at 8am on Thursday prior to starting theatre so I decided to head in early and join him in his consent clinic. Let's just say he was pleasantly surprised that I was there so early and I managed to get consent from all the patients for the list in order to allow me to do examinations while she is under general anaesthesia. When in theatre I was promptly grilled on common gynaecological problems and because I had done my revision I was able to answer his questions with ease. To be was extremely satisfying. On the first patient I was told to put on a pair of gloves and to quickly do a vaginal examination. I was a bit disappointed I wasn't asked to scrub in, but I assumed Mr R was still annoyed with me from the previous day. Fair enough. I was essentially ignored for the rest of the procedure and then I guess Mr R remembered about me and then quizzed me on the pelvic anatomy. Again having revised anatomy the night before, I named all the parts with ease and Mr R was very impressed. He gave me the nod of approval and again I got that sense of satisfaction. It felt really good. Had a bit of banter in between patients and because I had "passed his test", I earned the right to scrub in for the rest of the list. It was amazing. I got to move the uterus into position for the procedures and the quizzing stopped. Yes it may sound daft "maneuvering the uterus"...big deal right? But something that small can make a huge difference to your experience in theatre. Yes I was doing a pretty dull job, but I knew I was making it easier for Mr R to perform the procedure with his registrar. I was then taught how to properly do a vaginal examination and was also taught how to do a speculum examination. I think this was the first time where Mr R took the time to teach and explain things thoroughly. Usually Mr R briefly explains things and is usually quite vague, but this time he was detailed and was really patient with me. He made sure I got a hang of it and made me do all of this with all the patients in the list. By the last patient I was doing the examinations with ease and was getting good at maneuvering the uterus. Haha. Was in a VERY good mood for the rest of the day. I was really proud of myself and it was nice getting praised by my supervisor. He seemed very impressed and I felt like I redeemed myself from the previous day's mishap. What a day.

At the same time I was a bit sad that it was my last proper theatre session for the rest of the placement. I will miss it a lot. My whole of next week are clinics and I'm not a huge fan of them. Will be a hard change and I'm sure I will be craving to go back into theatre. It was a shame I only got 2 sessions with Mr R in theatre as I learned so much. And with his quizzing, I realized I remember things much better. I guess in the end he ain't that bad of a teacher. I guess first impressions aren't always that accurate.

Saturday, March 10, 2012

Obs&Gynae - Initial Thoughts

So I have completed my first week of placement for Obstetrics and Gynaecology. Initial impressions? Fairly interesting. It's nice to see adult patients again. When I took my first patient history on this attachment, it was weird being able to speak directly to the patient and receiving specific information. Also in Obstetrics (pregnant women), you can't really call these people 'patients' as most of them are healthy and essentially are only in hospital to give birth. It's quite a nice change of environment from seeing ill children. In Gynaecology, one has to be quite professional as this specialty deals with quite sensitive things. You have to ask personal questions and you really need to gain the trust of your patients in order to get such personal/sensitive information.  Again a huge contrast from Paediatrics as I have to put on a "fun" attitude when approaching children; however, with gynaecological patients, I have to be composed and essentially act professionally. It is a nice change and I haven't found the transition too difficult...yet. We'll see in the next few weeks.

Again I am in a peripheral hospital, but this hospital isn't actually that far away. For me, it is actually closer than the central hospital so I'm not complaining. It's great to be in a hospital which has a good reputation for teaching. They pride themselves in teaching and on day 1 it was very noticeable. The supervisor and secretary was very organized and were expecting us. We felt very welcomed and we received our schedule for the next 6 weeks! I was not expecting a schedule as in my previous attachment everything was done ad hoc and we received little guidance. Huge difference for this attachment and it was definitely a change I welcomed. It was nice knowing what you will be doing in the next few weeks and I could actually plan my life as I will know when I will be free and I can prepare ahead of time for clinics/teaching.

On top of that, I have come to realize how patient some people are. I went onto the wards to help out and was given the task of clerking in 2 new patients. These 2 patients have not seen anyone yet, so I was excited to go talk to them. The first patient I saw was having severe pain and to my surprise, she had been waiting to be seen for 4.5 hours! Talk about patience! I would've left ages ago and I found it quite ridiculous someone in so much pain has been waiting for so long! After taking the patient history, I realized this patient was in a lot of pain and a doctor had to see her soon. In addition to that, the patient was not impressed with the care so far (not surprised) so I quickly went to go get a senior doctor. It was found that she had surgery a week ago and the stitches were infected and some of it has come away. This patient was promptly admitted to the ward and was finally given stronger pain killers and a surgeon was called to review the case.

Then I went to go talk to my next patient...who actually arrived earlier than the last patient I saw. She had been waiting for 5 hours and I felt really bad for her. She had come to A+E the day before and due to the long wait she left and decided to come to the ward the next day. Because the ward was fairly busy, no one has really seen her and again I was the first person to see her. This could of easily been the longest history I had ever taken. After introducing myself I asked the standard question: "What brings you to hospital today?". This patient went on and on with a very extensive history of her presenting complaint and I was overwhelmed with information. She did not stop talking for a good 10-15 minutes and I was completely lost. I slowly had to work my way back through her history to get a more clear idea what was wrong and this clerking felt like it took ages. It didn't help that this lady's first language was not English so I had to word my questions differently and I had to try and figure out some of her medical conditions as she didn't know the names. It was the few times I actually struggled taking a patient history and this is the first time where there was a bit of a language barrier between the patient and I. It was a good challenge and it was new experience. It definitely taught me to be patient and to take things one by one. Luckily the patient was patient with me as we worked our way through the problem and her history and after 40 minutes I finally got through the history. Mind usually takes me 10-15 minutes to get a full patient history.  After presenting the history to a doctor I  had to leave so unfortunately I could not follow up with the patient.  When I came in the next day she wasn't on the ward list so I assume she didn't need to be admitted to hospital, which I guess is good news.

All in all...interesting week. It was an introductory week so it was quite light and I took things slowly as I found my bearings around the hospital. Next week is my theatre week so lots of surgeries! I can't wait!