a-small-medic

diary of a medical student // more personal thoughts at http://wordsmith.social/verity/

With the abundance of FOAMed resources, I realised I wanted a way to organise them, so here they are:

https://tagpacker.com/user/hc

Key features: * links are searchable by tag, and you can search multiple tags * uses my medical school's slightly artificial division of the curriculum, but that needs to be changed soon as “Mod A/B/C” doesn't actually mean much to anyone

That's it,really. I wish it could be collaborative – and perhaps there's a way to do that – but that would require moderation and I don't think I have enough time for that at the moment.

#links

More than a million people attended Notting Hill Carnival… I'm pretty sure this doesn't account for the hundreds of first aiders, healthcare professionals, logistics and communications staff and support staff from statutory and voluntary services – of which I was honoured to be one.

Our morning briefing highlighted the unusual nature of this event. Normal practices had been modified or delegated to optimise flow. Other measures indicative of a high capacity day: restricting access; strict triage; somewhat fluid procedures for escalation.

Apart from all that, one of the healthcare professionals assigned to the same treatment centre was a doctor I knew. Some students – medical or otherwise – sometimes have the reputation of sticking to doctors to chase the “interesting” cases. You'll know the type. The kind who displays open disdain for the boring, thinks they know the basics so well they don't do it, openly gleeful when they “find” something “juicy”, as if patients were prize specimens instead of distressed people trying to have a good day. I can't help having my interest piqued by stuff that I've learned on placement, but I consciously try to avoid that – pitch in with the heavy lifting, clean up after myself (not always…), fetch things for other people. Doesn't stop me giving that impression though, because I still ended up in “majors”, the section of the treatment centre which caters for one-to-one monitoring and more in-depth investigations such as ECGs, for most of the night. This was the area for more seriously ill people – yes, for things crassly referred to as “interesting”.

Out from the books (and hospital)

Almost by necessity, I have been learning medical conditions slightly in isolation. We learn about risk factors and start to make links between aspects of a medical history and a differential diagnosis. Rotating between departments, however, means that my differentials are easily restricted to the department I am at. Besides, in hospital, most patients have already been given a diagnosis or, if not, a list of issues.

Seeing truly undifferentiated patients challenges my diagnostic brain, and I'm not very good at that yet. When I saw a patient with pains all over, breathing fast, needing to go to the toilet, I hardly knew what to make of it. In the queue for the toilet, there was another EMT colleague waiting for her patient. She glanced at my patient – waved me over – “Does he have a UTI?” And I hadn't seen it until she suggested it!

Some of this diagnostic overshadowing and my resultant confusion was because I had been expecting intoxication with alcohol and/or drugs, and glass-related injuries. I hadn't been expecting “medical” problems – even though I had learned these for exams. Even if I had seen these conditions in hospital, my differentials would have been influenced by every other doctor's impression and in-hospital investigations. Working outside of these systems means one must have a good grasp of general medicine.

Getting a story

Now I start seeing patients by asking (them or bystanders) “Would you like to tell me the story?” That's essentially what a clerking is: the history of why they've come in, their health and social context.

One lady was carried in (over someone's shoulder, no less) in lots of pain. Another first aider tapped my shoulder, asked if we could do this together, so she did the paperwork while I did the preliminary examination and history. This lady's story turned out to be fairly complicated, so we got her into the area of the treatment centre where we could monitor her more closely, I had a look at what the FA had documented on the paperwork. It was... thorough. Down to who had done what. She also had documented that the patient had gone unresponsive without giving any further detail. In short, the paperwork was a minute-by-minute account of what she had been told.

Documentation is far more useful when it brings the reader through one's thought process. This has not been taught that much on my course, but I've come to appreciate it after reading other people's notes. For me, this reinforces my practice of taking a step back after getting a history to craft a coherent narrative.

“Fun” stuff

Having completed a year of clinical placement, I've been signed off on a number of basic procedures. In hospital, I can cannulate and take blood independently. Because it got so busy, the doctor asked me to do a number of cannulations. I think this was the first time I had cannulated pre-hospitally, too (and thankfully, nailed all of them)!

I realised that while I am proficient at these skills, I still need a bit of finesse. I've been spoiled by the way I was taught, with someone handy to hand me stuff. What I'll try and take from this is to spend more time preparing the kit, and despite the chaos of anything pre-hospital, to spend time to do it right.

While setting up IV fluids, I realised I had to hang up the fluids at height to use gravity. My height… had me at a disadvantage. As much as I enjoyed using my skills, I realised that having another pair of hands is sometimes essential. I can't do everything alone. Sometimes doing things together means it's a lot faster and more comfortable for the patient. It was still weird to be doing these outside of hospital, though.

At the time I was focused on each patient at a time, but realised later that our doctor had been so busy taking referrals (basically), giving ambulance handovers and handling ambulance requests that all this possibly sped things up for patients. An unfamiliar sentiment for a medical student who feels she's being a burden half the time!

On a complete side note

The best moment of the night? Making my patient who had been in terrible pain laugh.

got something to say?

My ears are open on @hope_ucl on Twitter, or @noctiluca@scholar.social x

being a live model on a regional anaesthesia course

Was part of a point of care ultrasound (POCUS) course today, for the second time! While the first was for emergency medicine doctors learning POCUS in the context of trauma and looking at the heart, this was for anaesthetists hoping to take a post-graduate qualification in regional anaesthesia.

Regional anaesthesia refers to targeted injections of local anaesthetic into/around specific nerves. This can be used in surgeries, with or without general anesthetic (“being put to sleep”), to provide pain relief immediately or afterward. Ultrasound is used to find the nerves so people aren't just blindly stabbing around!

I was the live model for simulated vivas, where candidates got an anatomy question, demonstrate how they would do a specific nerve block, anaesthetic complications and demonstrate anaesthetic reasoning through a clinical case. All I really needed to do was to sit there while candidates scanned my neck or armpit or knee and talked about the anatomy they saw.

Listening in on the vivas and the feedback was oddly encouraging though: a surprising portion of the stuff, I already had, even in part, in my distant or not-so-distant memory! Compartment syndrome? Got it, got the buzzwords to go with it. Epidural haematoma? I actually know what that is! (Thank you anaesthetic tutor!) During today's session, anatomy actually mattered! Minutiae that I forgot immediately after second year were now being interrogated. Sometimes they even had clinical implications.

One of the things I picked up was exam techniques. If you're not sure, go broad, not necessarily deep: demonstrate your knowledge. Know the buzzwords? Use them. Prepare a few handy explanatory phrases to save time. Recognise when certain strategies can be used for multiple procedures.

As promised by the organisers, I got to play with the ultrasound machines, though with limited success... We looked for veins (especially the internal jugular vein). We looked for nerves in the arms, and the cervical plexus. I could not find them. I would use an artery as my landmark, move the probe a little, and immediately lose everything. It was like using Microsoft Word when there's too much invisible formatting: change one margin and the text disappears entirely!

Met Twitter medics as well, which was fun! It can be refreshing to meet people who are very certain of what they want to do, because while I know what corner of medicine I want to be part of, and I know what aspects I want to work with, I don't know what that job looks like. I quite enjoy learning about the technical complexities of anaesthetics and the problem-solving aspect, but don't fancy being in theatre all that much. I like the idea of emergency medicine, but haven't seen enough of it to be absolutely certain. I see the appeal of HEMS, wilderness/expedition medicine, military medicine... but I'm not the typical outdoorsy type.

So, you know what? I'll work on gaining lots of experience and being as good as I can be, rather than chasing a dream I've seen in someone else.

#notetoself #POCUS #reflections

Kinda impressed with myself that I just asked myself, “Is there anything that needs to be taken care of tonight, or can it wait til tomorrow?”

I do not need to work into the wee hours. I can go to sleep now with peace of mind.

I'm learning, I'm learning...

Originally submitted as a piece of reflective writing, edited for brevity and detail. There's another part of this which I didn't submit... for another day.

Tags: #reflectivewriting


This was fracture clinic, and the registrar and I had a plan. The orthopaedic registrar, H, and me looked through files in an odd-shaped room. The air hung still and muggy despite cracking open the door to the side room. Today's patients had mostly been referred from the Emergency Department, and so were new to H.

“Why don't you talk to this patient, take a history, then when you're ready to present, come in and tell me what you found?”

I went out to the waiting room and spotted the first patient immediately. Not a difficult task, as he was the only patient there. I had my standard spiel ready to go: a self-introduction, asking if I could take a history. Most patients are told early on that they should expect students to do this, and most are amenable, if slightly amused. He, however, adamantly refused. I took him in to see the registrar directly, to the registrar's bemusement.

As with all other patients, the registrar started taking a history – but the patient was oddly bristly. He was vague about how he had injured himself. When asked about his occupation, the patient interrupted: “No! We are wasting time! What I do is not relevant!”

“That's fine, let's move on to the examination. Could you take your jacket off please…”

H began inspection, but narrated what he was doing, as was his habit with medical students.

The patient interrupted: “I am in a lot of pain, you are wasting time by explaining to the student!”

The patient was physically imposing, and at that moment he stood between us and the only exit. I forgot the stuffiness, the traffic droning outside; I could only focus on the space each of us was taking up. I offered to leave, but H stood his ground. He explained that students were a welcome part of the team. He explained that this kind of behaviour was unacceptable in the clinic. The patient started shouting: this was his right to have whoever he wanted in the clinic, and if he wanted me to get out, I should get out.

I never felt physically unsafe during that aborted consultation, but I did feel threatened by his aggression, even by the size of the room. However, what contributed most of all to the feeling of threat was the divergence from the usual pattern.

Placement is supposed to be a safe learning space. We are often supervised by experienced clinicians, and can get immediate feedback if we make mistakes. Placement is inherently unpredictable, though, because any clinical encounter is unpredictable. People are complex, both patients and staff. While I initially treated events such as cancelled clinics and over-running ward rounds as nuisances, I realised that this stemmed from an understaffed system with many moving parts. These were, at least, benign, something we would laugh off.

This unpredictability meant that there were occasions during placement that genuinely made me feel threatened or fearful. Fear sneaks in during the seconds between approaching an intimidating nurse or consultant to ask for a favour. Fear sneaks in, in the moments before doing a procedure – hitherto only practiced on mannequins and anatomical models – on a real patient. Fear sneaks in when encountering a completely new situation with no clear solution, with no clear way out.

In that stuffy fracture clinic, fear snuck in, in the seconds between realising something was wrong and this patient being aggressive, because there was no telling what he was going to do. What if I had been in one of the side rooms alone, or H had gone out to run an errand, or if I had misunderstood the patient's intentions?

H never managed to calm the patient down. Instead, he got myself and then himself to leave the clinic room because he realised the conversation was going nowhere. The nurses got the other consultants in clinic – all as imposing as the patient – to talk to the patient.

When we returned to the now-empty clinic room, the patient had left with a new appointment with a new consultant. H did not immediately move on to the next patient on the list straight away, though: we talked about what had just happened. H spoke about the times that he had to disengage because he knew he was going to lose control. We discussed tactics for recognising when it was time to leave. We talked about de-escalation, from using non-verbal communication to choosing your physical position in the room carefully. It was humbling to realise that, with the same communication skills drilled into us from first year, a potential heated argument could at least be cooled down enough for myself to leave and escalate to someone more senior.

I realise now that our conversation was a form of debriefing. It helped separate the fear and perceived threat from the actual event history, and it was a chance for me to ask questions about why H did what he had done. More importantly, it was a space for me to formulate an approach if I ever found myself in a similar situation.

In an overstaffed, underfunded system fraying at the seams, there is reason enough for patients to be anger, justifiably so. I know meeting angry patients is inevitable. So when I next step into a room with the atmosphere electrified with hostility, I think I will see the same stuffy room again, and I hope I remember the gentle but firm way H tried to talk the situation down. If I find myself with a student encountering the prickly end of clinical unpredictability for the first time, I hope I remember what H did, and help them navigate these situations with grace and good humour.