“had a group task with someone [...] and halfway through I literally told him, “please can you stop talking for a sec and let [another group member] speak””
still can't believe I did that. my sharp comment was probably the sharpest thing I'd said all day because I was much nicer back then...
this was selection for a certain team in early 2020, scant months before first lockdown in the UK, and this remark was towards a good acquaintance – who, as much as we get along, has an unfortunate tendency to talk absolute rubbish
searching for guidelines for an audit for children with learning disabilities and it's low key depressing how many of those guidelines are focused on * behaviour that challenges *
many times I feel like a lot of health and school measures are for the convenience of the adults, but this is saying it as someone who doesn't need to stop these children from throwing things or hitting/biting/kicking other children.
there are also precious few guidelines on chronic pain in children that aren't condition-specific, which is vaguely interesting.
was with the same reg on my last set of on calls! lucky me.
unfortunately one of us is turning out to be a magnet; had plenty of unwell patients. was this the on calls where he decided a very frail patient needed a relook laparotomy? maybe. he seems to have at least one going to emergency surgery every time I'm on call with him.
if you wonder why healthcare staff have such superstition: we have so little locus of control it feels better to blame it on someone saying the Q word or someone being a magnet rather than a strained system.
nonetheless.
have seen many people's bums and carefully squished many people's abdomens. learned a lot. got some pointed but well meaning feedback from said reg.
the ol' career instnct is pointing towards ICU as a way to:
* maintain medic diagnostic skills
* airway skills
* much physiology
* learn some surgery-adjacent skills
UK medics will appreciate: ARCP season is upon us. My ES does not know how to fill the forms in properly. Which begs the question, if there are so many hidden tickboxes, what measure of clinical competence is that?
my registrar and I sat in ED at 3am and he just went “I want to cry”
I made an unintelligible sound and we moved on
heck of a night to finish on, first he went to theatre and left his bleep
cue loads of angry referrers leaving passive aggressive mesages in the notes
then the urine analyser stopped working, then the BLOOD analyser stopped working????
then a crash bleep for “cardiac arrest in CT” and the reg thought it was one of our patients
it sure beats the night where three people got unwell the hour before handover tho
or when I went to assess a patient, left the ward, and was bleeped 5 mins later with a much more worrying update
overall still enjoyed it though, much better vibes than medical nights – I guess partly because we know what's going on with each person on the list, the chance to go between the wards and ED, and seeing patients get better...
can they tell you about any delusions or hallucinations? voices/noises/telling them to do things? seeing people/things/animals? are these frightening? these can contextualise behaviour, help you reassure the patient and risk assessment
the last one can help you step into their world for a bit
bedside investigations: aim to rule out reversible causes
think U PINCH ME
retention – bladder scan
hydration/nutrition – fluid status, bloods
metabolic – bloods, blood sugars
environment – environmental stimuli can sometimes be a focus for a delusion/hallucination (i.e. misinterpreting stimuli) – hearing aids in, glasses on!
bedside paperwork: working with nursing staff
bowel chart – they must poo. nuff said. “type 7”/watery stool may be overflow
food chart – if not eating, look in mouth (easily missed) – mouth care? thrush? cognition = needs prompting to finish food?
behaviour chart – full of incredibly useful information. are they sleeping at night? consultants might like sedatives, but as a junior, making sure they have adequate pain relief can be an easy win
suggestions for management
family visits can help re-orient/reassure esp with paranoid ideation
1:1 may be needed if very very hyperactive
MHLT can help +/– old age psychiatrists to help with antipsychotic dosing, weaning of psychotropics, follow up/discharge planning e.g. for dementia unit
Meds a geriatrician might use (from local experience): risperidone/olanzapine esp with violent behaviour, quetiapine with PD patients (less anti dopaminergic effect I believe), sedatives to even out sleep pattern
sometimes I find myself at a loss with a keen med student. I don't want to ignore them, but I don't always (or often!) have a structured tutorial to pull out of the hat
this often varies by specialty and ward anyway
EDIT 29/07/2023: to add stuff
Suggested
at the bedside:
examine a friendly patient
pt with a rare condition? tell me what you can about it – better, what can the patient teach you about it?
when asked to review a patient, do an A-E together, or get them to lead the A-E examination
observe a blood transfusion
do a MOCA/ACE etc. (other patient questionnaires exist) talk about the advantages and limitations of those tools.
procedures:
take a postural BP then talk about risk factors for postural hypotension
take and interpret an ABG
any other procedure in the GMC core procedures is game obviously
troubleshoot a catheter/NG tube/cannula
prescribing:
mock prescribing – antibiotics, gentamicin (grrr)
let's talk pain relief...
let's talk antiemetics and their mechanisms...
let's talk parkinson's meds...
take a medication history
do an admission meds reconciliation
do a meds reconciliation for discharge – why were meds stopped?
teamwork:
ask a friendly AHP if the student can shadow them – e.g. specialist nurses, therapists, pharmacists
follow a patient down to scan
ask a friendly specialist if the student can shadow them
write a referral together
calling micro for a specific question
take a handover
doctoring:
write a scan request together → discuss why this modality
chat about on calls
do they know how “the take” works?
doing a DNACPR? write the “red form” together
investigations:
describe an ECG/scan systematically
look at some bloods, ask them to tell you what it means
parse reports, historical or otherwise (I was asked to look through 6 years of clinic letters once...)
I have two days off after a weekend on call with a steep learning curve, so my brain does need that break.
Just writing some reflections and portfolio sign offs now and thinking
It was pretty fitting that one of my first big learning events was recognising when people were actively dying. That was something I was afraid of, starting off – knowing what was reversibly unwell and what wasn't, and with all the things around that: discussing when people might not survive resuscitation; when to make the call to involve palliative care.
Being in Frailty has helped with making these conversations much more common, and led by seniors used to making these decisions compassionately and sensibly.
Listening to the palliative care team was an education. Listening to how they navigated difficult conversations and family dynamics helped show a way that was calm and clear about uncertainty. In medical school, palliative care teaching was often about generic “breaking bad news” and prescribing. Let's be frank, most of my “palliative care revision for finals” was 80% prescribing, 20% “soft skills”. Learning about palliative care in FY1 has been 20% prescribing, 80% communication skills and styles of patient assessment.... like most other clinical specialties, really!
I have no answers. Coming alongside people and talking about this with them is becoming a bit easier with practice, especially when I know it can be done with compassion and gentleness.