Slow Week - Anaesthesia

To be fair, every placement has a "slow" week. Mine is usually the first week...somehow out of my 4 week placement, I managed to have another slow week. Last week, I spent most of my time checking out the intensive care unit and the high dependency unit. I'll just say in my opinion, it is probably the "less exciting" part of the job. Lots of ward rounds! I really don't know what to take away from this week. Having said that, I did manage to get a lot of physiology teaching from a consultant anaesthetist. It was actually a really good refresher. The way he taught was based on quizzing (which I hate, but love at the same time). I was picked on most of the time as I was the only medical student and that the knowledge should be "fresher" in my mind. It made me realize that I actually haven't really forgotten about physiology. From the quizzing/grilling, I realized that I just lack confidence in my answers and should just be brave and say what I think the answer is. It's a shame that it takes massive pushing and pressure for me to get an answer out. Guess it's one thing I need to learn and obviously shows I need to hit the books a bit harder to build some confidence in my knowledge. The foundation knowledge is definitely there and I just need to "go for it".

Thankfully to end the week, I got to go back to theatre and was placed with a really good anaesthetist who let me do a lot of skills. I was putting in all the cannulas, holding the oxygen mask, and inserting LMAs. It felt really good. In the first week, despite being very determined to get some hands on, I was quite scared and nervous performing these skills. Now, I'm on it the minute the patient comes to the anaesthetic room. Gloves on. Equipment ready. Ready to go! It also showed me that with practice, you'll get better at the skills. I had to cannulate a tricky patient. I missed the vein on entry, but managed to salvage it and got the cannula in without needing to try in a different spot. Added bonus was that the consultant complimented me on it, so it was a definite boost to my confidence level! Thinking back to the last 2 weeks and seeing my placement come to an end - I think I've made leaps and bounds in terms of clinical skills. I built a lot of confidence in my clinical skills and in general feel just a bit more competent. My day in theatre really showed me how far I have come from the beginning of placement and I think I have accomplished what I have set out to do - to improve on my clinical skills.

I do realize that my posts have been fairly short...as to be honest - there's not much to really talk about. I don't get to speak to as many patients as most are asleep. This placement was mainly refreshing my pharmacological and physiology knowledge and improving on my clinical skills.

Sorry for the boring read! I promise the end of this week's post will be more interesting!

Back to Work.

So I'm back from my winter holiday and have had a week of lectures which was an introduction to Specialties and Acute and Critical Care Medicine. Essentially how this year works is that I will go through 4 core rotations: Acute and Critical Care Medicine, Specialties, Community and Palliative Care, and General Care Medicine. Each core is about 8 weeks each. Within each core there will be sub-attachments/sub-specialties. Anyways I'm starting with Acute and Critical Care Medicine and my first 4 weeks will be in Critical Care so I will be getting to know the anaesthetists! Then my next 4 weeks will be in A&E/ED (emergency department). I am quite excited about this year as this year is quite focussed on specialties and I will have plenty of opportunities to be in theatre this year. Yay!

To give you an idea what sort of lectures we had this week - we went through topics in Urology, Opthamology, Haematology, Anaesthetics, Dermatology, Trauma, Oncology, Infectious Diseases, and ENT. To be fair, covering all of that in 5 days was ambitious and tiring. It just stresses the importance for you to go home and do some extra reading before you go into that specialty placement as a 1 hour lecture is not going to cover enough for you to get through the placement. Because of this, I spent my weekend reading up on Anaesthetics and Critical Care. In a way I am really excited for this attachment as I am placed in the main hospital and it is quite busy so I know I will be able to get a lot of hands-on experience instead of swivelling in my chair. I also spent the weekend trying to get as much sleep as I can (12 hours today!) as I'm starting at  8 am every day. I felt a bit of me cry, but at the same time if it's a good attachment I don't see waking up being an issue.

Hmmm....to be honest there isn't much to talk about from this week as it was really dull and I won't bore you with the details. Hopefully next week will be action-packed and hopefully can give you all a more exciting read!

End of GP Placement.

Oh how much I looked forward to typing the title to this post. It could have easily been the least brain stimulating placement I have yet to have. Not only that, I couldn't go make myself useful elsewhere unlike being in the hospital. Looking back on the last 6 weeks, it was definitely a struggle and a challenge. It was mentally draining as it was just so much harder to get the motivation to work. After throwing my arms in the air when stepping out the door of the practice...I realized I have another GP placement next year. Joy. BUT, I know it'll be more useful as I'll have my own surgery and get to see my own patients. This placement literally has redefined work experience. It was 20 days, 10 hours/day of work experience.

Also in other news - crisis averted with all the deadlines as you would remember from my "Walls Closing In" post.

1 report - completed and submitted.
1 audit report - completed awaiting for submission.
1 audit poster - 90% complete.
1 audit abstract - completed and awaiting for submission.

Cannot feel any more satisfied and proud of myself managing to get everything done in time. I think it has been a long time since I was really sure I was not going to make the deadlines.  Miracles do happen. Actually it's more like: Efficient...and very late and long nights...

Oddly enough, in my final week of GP placement, I saw the most interesting case. It was a case of a man with an end-stage disease and the GP needed to start the palliative care pathway with him. This man is quite young (40 years old). Initially when I heard about his medical history, I did not know how old is he. In my mind I imagined him to be an elderly man. Surprisingly when I went to go meet the patient, he looked frail and skinny, but young. What really struck me was that he also has two very young children (ages 8 and 3). Unfortunately, the patient has not really told his children what is wrong with him. They are aware that their father is ill, but do not know the extent of his illness. With his condition, no one really knows how many more years he will live. His condition has been progressively getting worse and the GP told the patient and his wife that there would be one day where he does a nose dive and his health severely deteriorates. We discussed the various options for support and care. In my mind I knew the GP was trying to find the right moment to bring up the "Do Not Attempt to Resuscitate" (DNAR). Eventually we had to talk about it and only until you come onto the topic you then come to realize that the patient is still in denial. To be fair, he has a young family and he himself is quite young. Worst bit is that there is no cause for his condition - as what doctors like to call it: "Idiopathic". He was adamant that he wants to be resuscitated when it comes to the end of the line despite the GP fully informing him about the benefits and harm of resuscitation. As we were talking about his palliative care plan, his children were happily running outside - no clue what is going on in the room. It was definitely a very "grim" consultation. Before leaving, the GP advised the patient to find some support for his end-stage disease and to have someone help him to explain his condition to his children as they will have to know at some point. The GP was right that it is better for him to talk to his children while he is still well and still able to versus down the road he might not be well enough to explain - leaving his children a bit puzzled.

In all fairness - my experience in GP has not been the best, but the GPs who I have worked with are all really nice people and some are great at teaching. Guess it just wasn't my "cup of tea". Had a good feedback session with my supervisor though and I suggested giving students a bit more responsibilities and letting us see our own patients. Hopefully they'll take my feedback on board as I really think it'll improve the student's experience. All in all though, 7 weeks...that was painful.

Psychiatry up next...don't really know what to expect...actually I have no clue what to expect. At least it is hospital based (in a more familiar environment). I'm sure it'll be interesting seeing these sort of patients. Hopefully it'll be better than my GP placement and get back to the happy-go-lucky medical student.

Dull.

If I could describe my GP placement with one word I would use the word: "Dull". Dull might even be an understatement. I have caught myself so many times zoning out during consultations. Again my frustrations are growing as I still cannot do anything in clinic. The most I can do is maybe do manual blood pressures. I guess the only thing I can take away so far from GP is the difficulty of immigrants. My practice sees a lot of immigrants and most of these people can't speak English.  You realize that it is very difficult to get a patient history and even more difficult when you have to talk to your patient through an interpreter.

We had one patient who was from Slovakia and could not speak very much English.  It was requested that an interpreter come, but he/she did not show up so the patient attempted to tell us her problem in broken English. Unfortunately, her problem was a mental health related problem so patient history is really important and there was no way we will get what is the problem as her English was not cutting it. We resorted to using the phone interpreter. I swear those things are not user friendly.  The interpreters aren't that great and it is really awkward having a phone in between the patient and you and the phone is on speakerphone so it is quite difficult to hear what the interpreter is saying.  Even weirder is that you lose a lot of rapport with the patient as both of you are trying to talk into a phone. Very confusing stuff.  After 45+ minutes (when it should've been 10 minutes), the GP gave up. It got far too complicated and too difficult to get a proper patient history. I felt like we wasted a lot of time and it obviously makes the clinic run quite behind. We asked the patient to bring an interpreter next time and you just can't help but feel a bit annoyed that you wasted 45 minutes only to get nothing accomplished.  The next few patients weren't too pleased either as clinic got quite delayed. When one patient sees that you spend 30+ minutes with one patient, they think they have the right to have 30 minutes as well and it's hard to cut people short and to keep them on topic about their medical problem/presenting complaint.  When you're running behind, the last thing you want to hear about is what the patient did on the weekend.

I have no problems admitting that GPs are extremely patient people and their job is certainly not easy.  I just feel like I would have a lot of difficulty maintaining my composure during consultations especially when it gets quite frustrating.  I do consider myself quite patient, but I guess not patient enough for GP and probably the main reason why I'm having a difficult time enjoying this placement.  Worst bit is that I still have another 5 weeks to go. Thankfully I am only in 3 days/week so my weeks won't be too long. I'll take it that I have 15 more practice days.  That doesn't sound too bad...I guess....

1 down, 6 More Weeks to Go.

What a shock to the brain. I've tried my best to prepare myself for my next attachment in General Practice....and actually had very little expectations. My main fear prior to starting my attachment was the prospect of just sitting in the corner of a clinic from 9-5pm and not really do anything practical/talk to any patients. I have never had a rotation in GP before so I am obviously out of my element. I have always been in a hospital and there are a lot of advantages of being in a hospital such as if you don't find your attachment particularly interesting/useful - you can always go to another ward/department and there will surely be someone who will be willing to teach. The problem with GP is that you are stuck in the same building and there is no where to run. I am a type of medical student who likes to venture off to find more interesting things if I find myself getting very bored. There is a sense of "freedom" in a hospital as you aren't bound to a single area for the whole day. It is seen to be acceptable for us to roam to other wards to learn about different things while we are in the hospital so no one would really notice you not being on your assigned ward (unless there is scheduled teaching). In terms of GP, it is VERY obvious if I do not turn up as I am the only student in the practice and the GPs who I am attached to can see on their own schedules that they should have me, the student, in clinic with them. Very difficult to escape.

So I had a short week...had 2 days of lecture and 2 days on placement + 1 day off. Despite only being in the GP practice for only 2 days...it still has managed to knock my motivation completely over. My last attachment in orthopaedics probably was the highlight of my degree and my motivation to work was at an all-time high. I could wake up for early morning meetings. I rarely found it boring. Just everything clicked. I was truly happy. I was hoping all the happiness and motivation I managed to build up in my orthopaedics attachment will get me through GP. Wrong. In 1 week....my motivation level is at an all-time low. I am not interested in doing anything. Can't wake up in the morning. Don't feel like doing any work. Do not feel like participating. According to my friends, I am in a horrible mood. I am actually really low at the moment. On my first day I walked in with a very open mind and told myself it will be a good change as I'll get to see various different type of conditions and get to relax a bit more.

I will certainly not dispute that GPs see a lot of different things, and actually props to them for being such patient people. Some of the patients who come through the doors really....erm....there are no words to describe it. GPs are given 10 minutes per patient...but some patients come through the door expecting to get 30 minutes and talk about everything and anything. I can obviously tell in between patients that GPs get frustrated and they have to put on a mask whenever another patient comes through the door. As a student (who is sitting in a corner), it's just painful. If the GP finds it frustrating and boring to constantly have to reassure and listen to life stories...think about the poor student sitting in the corner who can't do anything but sit and watch. There is only so much I can learn by sitting and listening. I learned from my last placement that you won't learn anything until someone pushes you into the deep end of the pool. I was very hesitant in my first week of orthopaedics to go see new patients on my own as I had never done that before...but very quickly I found it very useful and eventually became quite good with taking patient histories. I don't think you can learn communication skills by just observing. It is something you have to learn by experience and I think that by making your student sit in the corner and listen is not very productive/a good way for he/she to learn.

I personally think that medical students can actually be very useful if used correctly. At the moment I feel like an old piece of furniture which isn't being used. I literally just sit there and watch. I don't even get to interact with the patient. I just try my best to not fall asleep and smile. I don't want to look not interested in what GPs do so I have to put on a face. I was so bored in my morning clinic today that I was desperate enough to offer to get things for the GP or make him a cup of coffee/tea, but nope...was told everything is fine and to just sit there. I haven't been so frustrated with a placement in a long time. I mean paediatrics wasn't my most favourite placement....but at least I was in a hospital where I was given the freedom to walk around and go to other wards...go see other things. I feel trapped at the moment. How am I going to survive next week. I don't get how I'll stay sane by the end of this attachment. All I want to do now is just sleep the day away. Props to people who want to be a GP...don't think I have the patience/tolerance to be one. Need to desperately find a way this weekend to pick myself back up or else I won't be able to bring myself in to the practice on Monday.

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).

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 smokes...it 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 shifts...do 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.

End of Placement 3.

What a placement. It actually went by a lot faster than I thought it would as I hated my first week of placements. In the end, it wasn't too bad. Definitely found out colorectal surgery is not for me. I can never seem to orientate myself in theatre especially during laparoscopic procedures. Everything looks the same! Just bowels here and there. Clinics were alright - completely understand why consultants hate it though. It's usually the same old things - over and over again. Only been to 2.5 clinics - and to be fair - it was starting to get repetitive and boring. I must admit, I am a bit embarrassed by the fact that I only turned up to ward rounds ONCE in the entire 4 weeks of placement. Oops. 7:30am ward rounds are too early - Note to self: don't get admitted as a patient to a hospital with 7:30am ward rounds - no wonder most of the patients we saw on ward round were cranky. You're ill/in pain and you're tired - 7:30 am a team of 5+ doctors (have seen teams of 10) crowd around your bed - doctor takes a feel/ask a few questions and then disappear. As a patient, that would really tick me off, but then again I'm not the most cheerful person in the morning.

What else have I learned on this placement? As previously mentioned in an earlier post - common sense takes you a long way. Oh and some consultants are actually human and love to talk about other stuff other than medicine. And again especially at busy hospitals - medical students are probably the least important things in the hospital - be prepared to get ignored/no one caring about you. That's reality and you just have to be proactive and be responsible for your own learning.

Next placement will be in endocrinology. Don't know what to expect; however, I don't even think I will have time to go into placement as exams are around the corner (December). Need to really study and start focusing. Can't tell you how stressed I am - it's mental. Like most students - I hate revising. The only thing that keeps me going is the future. I keep telling myself that once these exams are over I can slack off again and it'll be a year before my next exam. Can't wait as we just had our year-end exams in May - so it's only been 6ish months. The thought of 2nd year exams/revision still scares me - it was tough/a nightmare. At least this year's December exam will be more clinical (what I like) and not as science based. Still a bit lost as to what to study. Just hoping the best and hoping that I'm studying the right material as this year - we've hardly had any guidance. Eep.