What a Day.

So like I said in my last post, my placement is coming to an end and because my supervisor is really good with slowly giving me more responsibilities as the weeks go by, this week has been a lot of fun. My last placement, Obs and Gynae, could easily be the highlight of my medical school in terms of all-round great placement. Yesterday could have EASILY been the highlight day of my degree so far and by the looks of it - this placement will probably become the best placement of my degree.

Anyways yesterday was theatre day and was expecting to have 3 patients on the theatre list but I was actually disappointed in the morning to find out that one of the patients were cancelled so we only had two patients on the list. It was also going to be my last orthopaedic theatre list for this placement so I was a bit bummed out that we were most likely going to finish early. First patient was a simple straight forward one man job so I didn't scrub in and just observed. Afterwards we had a good break prior to the next and final patient for the day. Had some good banter with my supervisor and then I went to go see the patient in the anaesthetic room. It was a bit weird as the anaesthetist had quite a bit of difficulty putting in an epidural and other things just weren't going right/straight forward. The anaesthetist and I had a bit of a chat and we agreed that we have a feeling this surgery is going to be FAR from straightforward. Anyways after the patient was put to sleep my supervisor came in and told me that I will be scrubbing in and will be a first assistant. My eyes lit up. Last few weeks, I was scrubbed in, but I was more of an observer who did a bit of suction here and there, but nothing really special/that helpful.

Brief summary of patient: 1st stage revision of total hip replacement. Reason: Infection

11.10 - first incision made

I am still a bit new to orthopaedic surgery, but I have seen a few now and I knew immediately that something wasn't right. Immediately after the first incision, the patient was bleeding a lot more than usual. As we went deeper, it was obvious that the bleeding is only going to get worse and by the time we got to the muscle layers...it was like the flood gates were opened. The patient was bleeding from all sides of the opening and it was difficult to find where the bleeding is coming from. I tried my best to keep up with the suction so we can identify where the bleed is coming from, but we couldn't find a specific source. At least we knew it wasn't an artery as the blood is darker in colour. Anyways it was just a big mess in there and slowly it became obvious that this surgery is going to take a lot longer than predicted. The anaesthetist was struggling to keep the patient's stats normal and eventually had to call in for blood. We took a break during the surgery to try and get the patient to clot by packing the wound with swabs and putting pressure. After a bit, we hoped the swabs did the trick and started removing the swabs (which also gave the anaesthetist time to catch up with the fluids) and 5 seconds after removing the swabs...the blood just came pouring out.

12.30 - removing the femoral stem component

This wasn't too hard and everything came out very easily as the bone was dead and very weak. The cement and the component came out without much difficulty...luckily. Then we had to remove the acetabular cup which proved very challenging...to the point we had to get creative. Anyways after a lot of creativity and trial and error we did get the cup out. Again the bleeding was still really bad and it was so hard to keep up with the suction and to keep the view clear. There were times where we were sloshing around blindly trying to feel for the anatomy instead of visualizing as it was far too difficult. At this point I was starting to lose track of time as I was completely focused on my job of suctioning and holding tissue out of the way, etc. As time went I could tell we were taking awhile as my feet were starting to hurt. My hands were starting to cramp up due to the gloves. My back was starting to stiffen up. Oh and I had to use the toilet...but guess what: too bad.

14.30 - making antibiotic cement beads

Essentially we leave these beads inside the patient to allow the antibiotics to work and to kill off the infection in the local area. After the patient has healed from this surgery...these beads will be taken out in the 2nd stage revision and a new joint would be put in.

14.50 - patient starting to really deteriorate

While we are operating...it is difficult to hear what is going on outside of the operating area as we are in a "tent" area with plastic walls, but you could hear the anaesthetist making a lot of calls for extra help. People were starting to come in and you know something isn't right.

15.00 - closing up the wound

We started closing up the wound and then I heard my supervisor tell the scrub nurse: "vicryl to the student as well please". I was a bit confused as to why my supervisor and I both each had sutures as usually only one person would close up while the other person uses the scissors to cut the stitch (which is usually my job). My supervisor told me to start on the bottom end of the wound and he went off and started closing up the top portion of the wound. Last time I sutured, my supervisor watched me and guided me. This being my 3rd (?) time suturing on a real person...no one is watching. Worst bit: I was also shaking like a leaf. No I wasn't nervous/scared...it was because the last time I ate was at 8.00am and was obviously starving. Anyways managed to close up the bottom of the wound and then proceeded to help my supervisor with cutting and pushing the skin closer together so he can close up properly. Other than the shaking...I didn't struggled with the knots or anything. It actually went fine and my supervisor said my sutures looked fine as well. Proud moment. Thank goodness for masks as I was probably smiling like an idiot.

15.30 - put dressing on the wound (which was leaking out with blood still) and clean up

As we took down the drapes and everything you really notice that the patient isn't doing well as hiding in the back were 4 other people helping the anaesthetist and the floor was covered with empty blood bags. At one point the patient's haemoglobin count dropped to 6 (normal is 12). Apparently the patient had no clotting factors as well and we suspected the patient had DIC (disseminated intravascular coagulation) as the patient was bleeding from the cannula sites and from her nose. By the end of surgery it was calculated that the patient had lost up to 10 litres of blood. Normal human has about 5 litres of blood. It wasn't good and the patient was obviously in a critical state. There was a student nurse watching the surgery so I went over to go talk to her. She initially thought I was also a surgeon and hadn't realized I was a medical student. I was a bit shocked as I thought it would be obvious as I'm the "clumsy" medical student that probably looked lost and clueless during the surgery. The student nurse quickly disagreed and said that she was amazed how it looked like I knew what I was doing and what needed to be done. She thought I was constantly on the same page with the consultant and I didn't need much direction. It was weird hearing that as I always though I looked like a clueless idiot when scrubbed in. Even the other theatre staff gave me a pat on the back and told me I did a good job. Definitely put a huge smile on my face and the surgery felt good. I really enjoyed it and it was exciting. The surgery was also definitely challenging so it was an interesting case for me.

Anyways first time being a first assistant for orthopaedic surgery and a good way to end my last theatre list for this placement. The patient ended up getting transferred to ICU, but she managed to recover so all was good. Definitely a very tiring day. By the time I got home it was around 1800 and I still had not eaten, but guess what...it was fine and I think it is something I have to get used to. My supervisor also hadn't eaten as well and he doesn't complain as I'm sure skipping lunch is a usual thing for him. What a day.

Orthopaedic Clinic.

A bit hard to believe but I've only got 2 more weeks of Orthopaedics left. It definitely flew by despite not being a very "intense" placement. Actually it was extremely slack...but it still went by very quickly as I'm still having fun and having a good time. With this particular specialty at my school, students aren't placed in Orthopaedics for very long. Through the regular rotations through the school we only get about 1 week of Orthopaedics so consultants/registrars don't get to know you very well. With me, because I had self-designed my placement to be in Orthopaedics for 6 weeks...consultants find it weird that I've been around for a lot longer than most people. Every week I attend early morning meetings to discuss about cases and I can tell that the consultants are starting to expect me in meetings and I'm becoming a familiar sight. They are all acknowledging my presence and are talking to me, which is a bit of a surprise as I haven't really followed any of them to clinics/theatre so in general the only time they see me is when I attend their meetings (once a week). 

Essentially I go to clinic twice a week, and we would see quite a lot of patients in a half-day clinic. When I first started out on my first week, I essentially just sat in clinic and observed. The week after, I was allowed to go take full patient histories and then present them to my supervisor in front of the patient, but I would watch my supervisor perform examinations on the joints. Third week: full patient history + joint examination on my own, then present to my supervisor in front of the patient. Fourth week (now): take a full patient history, full joint examination, differential diagnosis + formulate a management plan. I think my supervisor is doing a really good job in terms of allowing me to progress and allow me to do a bit more with every week. Finally getting things to do and a bit of responsibility, which is nice. It also makes the clinic a bit more enjoyable as sitting through a whole clinic and not doing anything gets fairly boring, especially in such a specialized clinic (lower limbs). Patients generally come in with the same complaints so when we get new patients, I get to at least get up and walk around and do a bit of talking/interaction with patients in a side room, while my supervisor sees a follow-up patient. I actually think it helps the clinic move a bit faster as we are seeing two patients at a time at some points and when I present my patient, it obviously takes less time than doing a history on the spot and my supervisor is starting to trust my examination findings so he only needs to quickly check instead of going through all the motions.

I think I'm actually learning a lot as my history taking skills and examination skills can always be improved on so with all this practice, I believe I have improved a lot. Taking a pain history is quite easy now and it is something I don't really need to think about anymore and I hardly miss any questions out as I'm seeing so many patients and getting lots of practice in. This is definitely giving me a bit of a head start compared to other students as other students use their "self-design" placement as a holiday by applying to do a project in "sign language" or something really random. With my placement, it is almost like a regular rotational placement that we get placed in and I'm doing a lot of clinical things which is obviously helping me improve and giving me a lot of opportunities to practice and formulate management plans (which aren't really taught to us...it is something we have to learn on placements).

Overall, really enjoying my time in clinics (can't believe I am enjoying clinics) and they go by fairly quickly as well. My supervisor asks me questions from time to time so he keeps me thinking and he teaches and shows me a lot of x-rays throughout clinic as well. Like I said about my last O&G placement, supervisors definitely matter and they can make a huge difference in your placement. Can't believe only 2 more weeks left...I could do another month of this! Starting to become a routine and I'm starting to feel a bit more comfortable. Best bit is that I'm not in every single day from 9-5, so I get to work on a project/audit at the same time so it keeps my week interesting/varied. Plus I'm getting some free time to enjoy the odd sunny weather here in the UK. Loving it.

Empathy.

Empathy is probably one of the most popular answers to medical interview questions such as "skills required to be a doctor." Empathy is essentially the skill to be able to feel another person's feelings. To be entirely honest...it seems like it is a skill that you LOSE, not gain as your career progresses. As a medical student, I treat the patients with a lot of respect and take the time to listen to them and try to empathize and sympathize with them. It is definitely not an easy task. There are countless amount of times where I found myself fake sympathizing/empathizing with patients as I sometimes find it very difficult to place myself in his or her shoes. And some of you may think why you "lose" your empathy skill as you progress through your career. Obviously this is a generalization and there are definitely lots of consultants out there who are really good at empathizing with patients; however, there are some where you start questioning their bedside manners.

I really don't blame the consultants for not empathizing with patients. After doing your job for 30-something years, you might not be as interested in it as you were 30 years ago. Some consultants have extremely busy schedules and it is a shame they don't take the time to empathize with patients. With an aging population, we now see a lot of elderly patients on the wards with chronic conditions. These patients might be in for their 10th surgery on their hip, for example. Sometimes it is unfortunate that surgeons/doctors don't acknowledge these things. Yeah you need to fix a patient's hip, but after having so many surgeries, it is obviously going to affect the patient psychologically and socially. I know there are some doctors who believe in holistic medicine. These doctors would tend to all the needs of the patient: psychological, physical, and social. I feel like the patients who have these sort of doctors feel like they are cared for and sometimes I guess it is pretty frustrating to be tossed between 5 different teams in a hospital as consultants won't know you as well.

Then we start to asking the question: are doctors too specialized? I mean just under orthopaedics, we've got consultants who specialize in only hip replacements, or hand surgery, etc. With such specialized doctors, we start to realize that these doctors start to lose knowledge about other systems in the body. In hospital for hip replacement but have a breathing problem so the orthopod has to refer you to the respiratory team. Are we becoming too one dimensional? It's definitely a tough argument. By having such specialized doctors/surgeons, we get people who are excellent at their field. If we have a bunch of doctors who knows a bit of everything...well we get doctors who are just good at everything and not excellent in anything. It's a tough argument, but to be honest, I would much prefer having a very specialized doctor as I would know for sure that he or she is fantastic at treating a certain condition or performing certain surgical procedures. If my life is at risks...I would obviously want the best and only the best.

Hmm...think I got a bit off topic there. Anyways empathy. It is a shame that some doctors lose this skill and overlook a patient's social/psychological well-being. But like I said earlier...I really don't blame them. I hope I will still be good at empathizing with patients 30 years down the line, but I know it will be something I will have to keep reminding myself to do. What's the point of being rude to patients? You gain nothing. Might as well be nice and listen to them and make their stay at the hospital better. Easy to say...hard to do.

Too slack?!

Some of you have probably noticed that I am back from holiday due to my recent post. Anyways you must be thinking what placement I must be on. Essentially we get 6 weeks where we can either design our own placement or select a project that the school offers. Most of you probably know that I am interested in Orthopaedics, so I designed my own placement and have chosen to spend 6 weeks in Orthopaedics. So far...well so far I haven't really done much as my supervisor has been taking quite a few annual leaves. I've been in for about 3 days in the last 2 weeks. I've been to 2 clinics, which were quite good. My supervisor is quite good at teaching so I'm definitely learning lots...just wish I was in more often. Yes I am whining about not having enough to do. It doesn't help that my last placement was quite busy (in from 9am to at least 5pm every day). Now I'm in for a half day here and there. I got 1 theatre day which was alright. For the first surgery I didn't get to scrub in because the nurses didn't realize I was attached to the consultant and no one helped me scrub in. For the rest of the list I got to scrub in and it was definitely interesting. Looked ridiculous though fully decked out in gear as in Orthopaedics they are quite anal about cleanliness as they want to prevent infections. If the patient gets an infection, the only way of curing it is to take the implant out so we all want it to go successfully. No one wants to go under the knife more than once. My supervisor was really good at getting me involved though. I mean scrubbing in was already good enough but my supervisor also let me use the drill, hammer, etc. It definitely put a smile on my face and I really enjoyed it. I also got to learn how to stitch (finally) and I got to help close up at the end of surgery.

Anyways there isn't much to post about unfortunately as I haven't actually had a proper full week yet. It's quite frustrating. I'm actually keen to do some work and stuff, but I haven't even really touched base with my supervisor so I hardly know what is going on. I mean I've gotten to know the registrar which is good, but with going into theatre, the consultants are generally quite picky about having students in and I haven't had a chance to meet all the consultants on the team yet. Really difficult to keep my motivation up to go into placement at the moment. A bit disappointed as well, but once my supervisor gets back I'm sure everything will get going again (I hope).

Taking Notes 101.

Attending lectures is one thing. Paying attention during a lecture is another...but taking notes during a lecture is almost like an art. Essentially, note taking is a unique thing. Every one takes notes differently. Back at school, everything was spoon fed to me. What the teachers wrote on the board, I would copy it down. This method doesn't exactly work in university...unfortunately. When I got to university, I was pretty confused about how to take notes during lectures. Fortunately, my university uploads the lecture slides ahead of time, so I usually print them out and take them to lectures. What notes do I write down? Well it depends. It helps to read the lecture ahead of time so you can pay more attention to what the lecturer is talking about and you'll know when to add to the slides.

For me, I bring a laptop to lectures as I think it is easier to type my notes as I don't need to really pay attention to my typing and I can pay more attention to what the lecturer is saying. Plus, I type quickly so I can take down more notes. If I know I have a brief/not detailed lecture, I would tend to write down most of what the lecturer says. Some people find it difficult to follow lectures, so some people bring a dictaphone to record the lecture and to listen to it later when they have time and to take more notes. I think it's a good method ONLY if you go back and listen to the lecture. I'm a bit of a lazy bugger....so I know this method wouldn't work as I wouldn't go back and listen to a lecture and make notes.

Then again, some people don't take any notes and rely on their recommended/extra reading to get the notes. Also you need to know what kind of a learner you are. I'm not a great oral learner...I'm much more a visual learner so I need to see things written down. I can't remember things that are told to me. I have to either do it or write it down; therefore, note taking is a very unique thing and only you'll know what is best for your learning.

I wish I can tell you in more detail how to take notes, but this is something you have to try and discover yourself. Try different methods...and eventually you'll find what works best for you.