First concert event of the year the week before last.

Unusually, we had training earlier in the day before the concert in the evening – a nice touch, I thought – meant that we could practice on site. also, because it's hard to get mojo barriers (the crowd barriers that you find at concerts), and our mockup has been broken multiple times by larger members of the team. As I've found, I've found it hard to mock-up, or break down, the physical skills and movements for the thing that worried me most – crossing crowd barriers. so I've been winging it, basically.

As luck would have it, I was placed in a team with the tallest people around, both during the training and the actual event…

The height difference is usually nothing more than a funny quirk, a visual joke. Sometimes even a benefit. Tall members mean they can reach and see things I can't, or catch me where I'm weak. And it was good for those pesky barrier crossings because they could spot me.

Halfway through the main act though, I realised the two tall lads were talking to each other, then to me as an afterthought. It's easier for these tall guys to take up space, to be noticed, to be recognised as The Medic. More of an art to deflect attention.

MRT days make me mindful to be assertive. I am naturally quite soft-spoken and averse to conflict. But the more “go with the flow” I am in MRT, the easier it is to ignore me. Not that I must be heard at all costs. But this extends to being kept in the loop. As much as I can interpret my team's actions because we have a shared mental model, I appreciate sharing that communication…

*He's a student HCPs, and I find they fall easily into a clinical lead role. Those who started volunteering as first aider without necessarily a clinical background tend more to find the operator role more natural, I think.

When you're physically small, it takes effort to occupy space and be heard and lead. Especially when it goes against your own nature. It's not just an amusing look…

#crowdmedicine #MRT #volunteering #personal #reflections

“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

(he did not make the team)

#MemoriesUnbidden

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.

#pain #paeds #reflections

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

#surgery #career

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?

#career #fy1

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...

#surgery

as a junior

Out of hours, you're most likely to be called for hyperactive delirium, but your workup remains the same.

My finals notes: https://smolmedic.github.io/#Delirium

establish the baseline

• How do you know they're confused? Has anyone taken a collateral?
• “patient is a poor historian” just means you don't have enough sources of information
• Sources of information: NOK, carers (care agencies, sheltered accommodation managers), care home staff, previous therapists docs
• document who gave you the collateral

approaching the patient

• usual physical examination and secondary survey – looking for any source of infection, signs that they injured themselves as a result
• mental state examination (https://smolmedic.github.io/#Mental%20state)
• 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

Successfully diagnosed viral labyrinthitis in someone who had “failed PT/OT” (therapists declined referral due to no clear indication).

Very interesting conversations about AKI and delirium, as always

Got in touch with [external hospital] and discussed TWO patients in 20 minutes?! (I was once on hold to them for just under an hour)

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...)

#teaching #meded

• learned how to flush and remove a chest drain
• went to a suddenly unwell patient
• SHO was surprised that I was so calm with the acutely unwell patient, I attribute it to “request a chest X-ray, do an ABG then have a think”
• spotted a prescription error, carried out duty of candour ** the win not being the error but that I saw it and knew what to do to correct it

#wins