Finishing Obs and Gynae

My final week in Essex was a short one.  We had the bank holiday on Monday, I went in late on Tuesday and left on Thursday.  I got my logbook (the bane of our lives) “finished” the week before, so all I had to do was a short piece of work commenting on the management of one case according to the literature and I could get signed off.  The rest of the time was for me to do whatever I wanted, and I’m pleased to say I did actually go in.

On Wednesday I got up early for an infertility clinic.  Quite boring, it was a series of couples coming in having failed to make a baby after a year or so of trying.  A few blood tests and fallopian tube check for the woman, a sperm count for the man, and they usually left with a 3 month appointment which would probably end in the woman being told to lose weight again or attempting to get funding for IVF.

For couples who have tried everything properly (weight, diet, enough sex etc.), and have never had a child and can’t conceive, I can understand the value of such a clinic.  But what I couldn’t understand was the obese couples coming in for their 3rd child, complaining that they’ve “tried everything”, and tying up resources.  Call me heartless, but I can’t square it in my mind.

After that clinic thankfully finished I watched a Hycosy procedure to check the patency of a woman’s fallopian tubes.  I didn’t feel particularly welcome by the all-female staff, but the patient didn’t seem to mind.  You’d think I’d get used to the archaic attitudes of some staff members by now, but it just smacks of discrimination to me.  Patients, who are vulnerable, can say no because I’m a man, yes.  Female staff members who disagree with men having anything to do with “women’s bits” cannot.

Later that night I joined the ST7 for her on-call shift in the hopes of maybe scrubbing one last time and seeing some cool stuff.  I was in luck – the umbilical cord had snapped for a Thai lady and she was bleeding steadily.  The midwife hadn’t been able to pull the placenta out and it wasn’t expelling itself, so she was given some syntocinon and the doctor called.  The reg literally just donned a glove and slid her hand up the woman’s vagina.  Her whole hand.  She managed to grab the remainder of the cord and out came a torn placenta and a shitload of blood.  The woman was screaming to high heaven, having only entonox as her analgesia.  Her husband was going quite pale and the baby had been left on the trolley.  I guided the guy to the baby and told him to take his shirt off and hold the screaming baby to his skin.  The midwives loved that.

An hour later and I was scrubbed, only me assisting the registrar repair a really long and 2nd degree tear for a hugely obese woman with the longest pubic hair I’ve ever seen (it was actually braided).  It’s the first time in surgery where I’ve actually felt like I was doing some of the surgery; I was holding back the relevant bits and swabbing as necessary while the surgeon sewed up.  I actually knew what was going on, all of it.  I got alot of teaching and felt great after (thought my back and knees didn’t); she seemed to appreciate the help given that she was the only doctor around and would have struggled without an assistant.

On Thursday I was told the consultant would sign us off.  Sign off means you can go home.  I was told he would be operating so I sought out his patients and took histories.  I followed the first lady to the anesthetics room and chatted to the anaesthetist about helping out.  I did her cannula and watched her drift off to oblivion.  I love that.  The other medical students turned up too but I was the one with the history, which went down well with our consultant.  The woman was having a laparotomy for adhesions and endometriosis.  Turns out she didn’t have endometriosis but her right fallopian tube was stuck to the sides so he took it out.  She was fine after.

The consultant took us to the tea room after and signed us off while simulataneously quizzing us on Obs and Gynae and singing our praises.  When asked what could be improved I told him honestly about the midwives in the first two weeks.  He assured me that things did get better and that he felt exactly the same way when he was in my position and that the situation with medical students and other staff members did annoy him.  Strangely that made me feel alot better.

Surgery; not for everyone, but fantastic with the right people.

Another night of Obs

Last week I tried again for another night, hoping to repeat the “sucess” of the previous one.  A 15 year old girl 34 weeks pregnant comes in with severe abdominal pain.  Her blood pressure is up and the midwives are rushing around.  It’s all very dramatic, and I’m told no about 3 times when I ask to get involved.  The doctors come along and I’m allowed straight in.  Sometimes I think other health professionals really do just get in our way on purpose.  It turns out she’s abrupting – the placenta is coming away from the lining of the uterus; she goes down for a crash c-section.  The surgeon opens up and out comes the baby.  It’s pretty small and they point that out to me as a sign of a pre-eclamptic baby.  The placenta comes away and has a huge clot behind it – where it had abrupted.  I see the baby after in the neonatal unit, looking pretty small and pathetic – I get told he has a big head and tiny bottom half because hes been growth restricted in the womb (IUGR) and his head has been spared at the expense of his body.  I go home, asking for a phone call if anything good should happen.  I get called back at 2:30 to a woman who has had 2 kids already – parity 2, they usually move fast.  I go into the birthing room with the midwife and the woman is in a big bath in her bikini, sucking down entonox.  After all the pleasantries I feel her tummy when she’s in pain and feel the contractions.  Quite amazing.  15 minutes later, and after a lot of bloody and pooey water, it’s all over.   My first natural birth – much better than interventional births.  I won’t be doing obstetrics for a career.

Two nights later I go back. I can deal with nights; there are less people, the atmosphere is better and it’s a good alternative to insomnia. After checking the board and sweet-talking a couple of midwives (very important as a male), I introduce myself to a lady who is 8cm dilated and get permission to come back for the birth. If the midwives really like you, they’ll call your mobile when things start moving so you don’t have to hang about pointlessly. On my way out I hear a scream from a side room and knock on the door (as you do).

The midwife comes to door looking fairly nonchalant and I ask if I can see the birth. I go in and catch the woman screaming again, sucking down entonox big time. Her partner is having his hand crushed, looking a bit pale. When she stops I introduce myself, the husband looks quite relieved to have another male around.

As the babies head starts to push out, the woman screams that she’s going to shit herself. This happens sometimes, and the novelty for me has worn off, so I just take off my jacket and put on a pair of gloves, much to the man’s amusement. Eventually a little face pops out and starts to gasp, the midwives tell the baby to shush and wait until she’s all out, and a minute later she is, squalling in that beautiful, relieving way that only fresh neonates do. I join the student midwife in checking the baby and placenta over after we’ve cleared up a bit. I congratulate the new family and leave to recheck the first lady.

She hasn’t done much, but another lady has just become fully dilated so I go there instead. I say lady; she was 17, her skinny partner looks younger than my youngest brother. They’re both quite pleasant, and she’s has an epidural so isn’t in much discomfort. Father Ted comes on the TV and the baby girl is born to the sound of “my little pony”. Excellent.

The girl tore a second degree on the way out so we set her up for examination and stitching. I stand at the end of the bed watching the midwife work and teach. “Don’t make that face, doctor! You’re putting me off!”, the girl shouts at me, laughing. Apparently I was gaping with mouth open.

I returned to the doctors room after that and have some pizza with the on-cal docs. My first lady still hasn’t shifted, and they go off to forceps deliver a really big baby, very worried about a shoulder distocia. I go home and tell the midwife not to call if the lady gets going. That’s the benefit of being a student; you can go home whenever you want and not worry.

General Practise

The other student didn’t show up today so it was just me and the GP sitting the morning clinic. Over the last few days I’ve sat in, occasionally taking relevant patients (psych or neuro) away to interview them before presenting them to the GP and giving a differential.  I’ve actually enjoyed it alot – the GP is a nice guy who’s been doing the job for years.  We’ve had several chats about the job itself and my aspirations (at the moment) to go into it.  He’s done a fair bit of teaching, with us listening to the odd chest or checking a stiff limb, and I usually ask several questions about each case which are happily answered. Admittedly we haven’t done so many systems exams but I get the impression the doctor has no idea what we’re competent to do.

The morning saw a really good range of patients, and I got to do a ‘flu jab on most of them (I like sticking needles into people). Most of the end of morning slots are reserved for emergency appointments, so of course it’s all worried parents bringing perfectly well children to the doctor. I shouldn’t be so harsh, but when the children come running through the door laughing away it’s hard to see how the parents saw anything to concern them. One day I’m sure i’ll get it as I bring my own little dumpling to another doctor with “the worst cough ever”.

One kiddy wasn’t well, however, and I’m pleased that I clocked this as soon as I saw her. She was 3 years old and was carried in by her mum. Ironically this mum didn’t seem as hysterical as the last few lots with well children. The girl was quiet and pale, wrapped up well under a thick coat which I could see was moving noticably with her breathing effort. Hell, I could hear her breathing from the other side of the room. Occasionally she’d cough, a wet nasty kind of cough which makes you want to clear your own throat. The GP listening to her chest and then let me; bit of wheeze in the lower zones. Mum was instructed about the antibiotics and steroids and sent away to get an X-Ray and blood tests with a warning to go to AnE if things went more tits up.

The doctor explained to me the medico legal side of things in this situation. You don’t want to send a parent away with no clear instructions of what to do next if the child worsens; it’s got litigation written all over it.

A few cases of depression came and went – one was a particularly intense consultation with the doctor repeatedly having to raise his voice and stop the patient shouting.  It was actually a sad case; an Afghani guy was getting no sleep and was in constant pain.  Turns out he was non-compliant with his Vitamin D pills (he was severely deficient) and was seriously stressed out.  After claiming he’d done some violent things recently and was considering suicide, he went away with some citalopram and a psychiatric referral.  Apparently the case was way more complex than I could know at the time; he had a family to support and was unemployed, relying on a diagnosis of  any sort to get benefits.

I got to see a patient with Parkinsons I’d seen before, and I was happy he’d recognised me.  His medication change hadn’t helped much and so the next steps were up for review.  It was good to see how he was getting on; I so rarely get to see the same people twice anymore.

Many of the patients spoke poor english, so the doctor spoke to them in Hindi or Punjabi.  I saw so many I can actually say and understand a few bits myself now!  The funny thing with the languages is that they’re a flurry of words interspersed with totally english words.  This, along with the usual patient gesticulation meant that most of the time I could get an idea of what was wrong lol

An interesting point with many asian patients is their cultural expectations of seeing “the doctor”.  It turns out they always expect to walk away with a prescription: anything will do.  This explained why the GP was so often prescribing Ibuprofen and Paracetamol, much to my amusement.  When asked about the fact that they would pay £7.50 (or something) for that, the guy told me that most of the time they don’t actually cash-in the prescription; they just want something to make them feel they’ve been seen.  Also the local pharmacists knew the score and would do the right thing by explaining about buying the same drug over the counter for far less money.

During my medical school interviews I was shown a video about a difficult patient.  She wanted antibiotics for a cold and that was that.  The GP gave in.  When asked about this by the panel I enthusiastically stated that she should not have been given the drugs and that the GP should have stood their ground.  I asked the GP about this and he said that, like most things, it was more complicated “at the coal-face”.  Much of a GPs work can be made easier by having patients respect your judgement.  Putting up a brick wall regarding ABx does nothing to build on that, as the patient just thinks you’re being a nob.  What my guy says he does is explain himself and point to recent newspaper examples about the drugs.  He weighs up their response and if they arent happy still then he may give them a delayed prescription and tell them to give themselves (or their kids) a few days to see how they get on and only cash-in the script if things havent got better.

The patient probably knows they hassled him and appreciates him hearing them out.  This should build more respect for his future clinical decisions and, as most of the scripts wont actually be cashed-in, do very little harm.  It’s fascinating stuff, the real world.

Ophthalmology part 2

A chap sat in a cubicle on his own.  I was told this was the station I should sit at so I introduced myself and sat with him.  I decided to try and take a bit of a history, despite this being a probably fruitless cause for reasons explained earlier.  It turned out he’d had trouble reading and seeing details for about 2 years, with lots of “floaters” crowding his vision.  Numerous trips to his GP hadn’t gone anywhere and finally he’d referred himself to Moorfields.  He’d been here since 10am and it was now 4pm.  I felt I built up a good rapport with him (thanks Barts), and we had a laugh and a joke.  I must have done well because he started opening up to me.  He was terrified of going blind and thought that life wasn’t worth living if he ended up that way.  His wife couldn’t deal with the stress and had left him at the hospital on his own earlier on.  He told me he was really depressed about the whole thing, and almost got a bit tearful.

His english wasn’t perfect, but I assured him I could understand him.  But he was very concerned that he couldn’t understand what any of the doctors were saying to him – a mixture of jargon, speed, and, as it turned out, absurdly thick accents themselves.

I asked if I could have a look in his eyes with my direct, and he obliged.  I couldn’t see a thing.  At first I thought he had a high refraction index and I wasn’t using the right lens on the dial, but he didn’t wear glasses.  The disc looked blurred regardless of the dial.  I sat down and shrugged saying I was just a student and couldn’t see anything.

Eventually the doctor came back, or rather the consultant came through with about 8 doctors in tow.  Must be something interesting going on here.  But they didn’t come back to the patient; they squeezed past him without a word and went straight to the computer screen full of angiograms and retinal images.  At one point the consultant examined the patients eyes with a slit lamp – again, without so much as a word.  Lots of talk followed with words that I struggled to keep up with: this guy didn’t have a chance.  The basic story was that he had a lot of cells in his vitreous and they didn’t know why.  Rather than start treatment with steroids empirically, they wanted to sample the vitreous at surgery and get some pathology done – this would also hopefully improve his vision a bit in the meantime.

I looked over at the guy who now was turning grey.  Clearly what he had understood hadn’t reassured him.  I gave him a friendly look and (hopefully) a passifying face.  The consultant went to leave but the other doctor looked at him, “Ok, I’ll tell him”.  And so followed a big stream of basically unintelligible english toward the patient.  I struggled to understand the guy for Gods sake.  The consultant got up and left and I asked the patient, aloud, “Did you understand that?”.

“No.”, he said, dabbing his eyes.

The more junior doctor asked for a second to write up the notes and then he would explain.  The patient looked at me and asked if there was any hope.  I put my hands on my chest and told him I was just the student.  After a while the doctor  turned around and proceeded to explain.  Again with complicated words, a thick accent, and no allowance for comprehension.

This finished the patient off and he started to cry, saying how he had explained everything to me, he didn’t understand, was depressed and worried about going blind.  The doctor just repeated himself and told him not to worry.  Then he told him to wait outside again.  I was not impressed.

All the guy needed was a few minutes for a slower explanation: “we don’t know what’s wrong but we need to sample your eye at surgery to find out.  I can’t say if you’re going to go blind before we have the sample but please don’t worry about this for now.  I can tell you’re upset but we’re going to look after you.”  It wouldn’t have taken much.

I asked the doctor, who now seemed a bit down-trodden, what was wrong with the patient.  He said they didn’t know, but to give him a minute while he arranged to tests and he would explain.  He went off; so did I.  As I got outside I saw the patient sitting there still dabbing his eyes.  He saw me and smiled so I went over to him.  I shook his hand and said I understood how upset he was.  I told him to try not to worry and that they would look after him.  It’s all I could do before I left, depressed and upset myself.

Ophthalmology part 1

I can’t believe I ever wanted to be an optometrist; it really is one of the most boring jobs ever.  And that’s the nice hospital kind where it’s actually about healthcare!  Not the commercial, high street, variety where patients with anything even slightly out of the ordinary are immediately referred to a place like Moorfields on an emergency basis so they can return ASAP to buy that expensive pair of spectacles.  It happens.

Moorfields is very much a centre of excellence, but I couldn’t work there.  It’s an ancient building which has been stuffed to the brim with clinical stations – each subsequently the size of my cloak room.  There’s no real privacy and the place is constantly noisy and dim as patients are asked what they can see in the dark.

Yesterday we had a fantastic teaching session in the morning by one of the Fellows.  After getting good (a relative term) with the ophthalmoscopes, we had a 6 minute lunch (seriously) and then were whisked off to watch the optometrists in action.  Very boring.

The thing with eye medicine, in the ophthalmologists own words, is that it’s not really so much about the history.  Most patients will probably just say that their eye hurts or they can’t see very well anymore.  Therefore most of the information is gathered by examination.  This is totally different to any other kind of medicine which is very much the other way round.  For us students who get beaten into submission with lectures on the importance of communication, this is a bit of a shell-shock.  And it isn’t conducive to giving us much to do either, as we obviously can’t use the equipment quickly or skillfully enough to get anything done.

Today I sat in AnE triage – two desks with nurses quickly clerking an endless queue of patients leading out of the door.  I decided to go further down the line and ended up with nurse practitioners (a very nice bunch of people actually) who used a slit lamp, tonometer and eye drops (phenylephrine or tropicamide to dilate; fluorescin to stain) to examine the patients eyes before they got shipped off to the ophthalmologists.

Further down the line still I sat in with more optometrists and the doctors who were doing vitreal injections for Macular Degeneration.  I got to examine a lot of dilated eyes with my ophthalmoscope.  I then moved on to the retinal medicine area and this is where I really went off the idea of ophthalmology as a specialty for me…

Paper D – The OSCEs (Di)

Yesterday hailed the end of third year (subject to a pass on all papers) with the second OSCE day.  I convinced myself I wouldn’t get anxious about it but failed miserably, being unable to eat any breakfast or lunch before we started.

There were 7 stations, 10 minutes each.

I started on a history station, which was not ideal given how nervous I was.  The only thing worse than a history station to start is a rest station, of which there were none this time around.  The lady was in obvious pain (or as believable as the actor could make it) and had a 3 days history of constipation.  Like Monday, I was confident I got all the salient points but probably didn’t empathise enough or ask her concerns.  I like to think that doesn’t make me a bad medical student or, indeed, person.

Next up was an abdo exam followed by a PR (digital rectal exam – finger in the bum, on a mannekin I should add).  As with cardio on Monday, I went into auto-pilot and bashed out a decent exam and presentation.  Having never done a real PR before, I had furiously read up on it over the last two nights and did my best.  I ran out of time just as I was “inspecting” my finger for blood and poo.

Next up was a patient discharge after a pacemaker.  I had no idea what to do with him, opting for checking how he was and asking what he was concerned about.  I was asked by the examiner who would need to see him at home, and opted for social services and occy health.  No idea.

A PNS lower limb exam came next.  I thought I smashed it.  On questioning about the diabetic foot though, I got most of it out but felt I spoilt things a bit by saying, “hmm, they might have a few toes missing”.  The examiner didn’t seem to mind though.

Another simulated patient consultation about non-adherence next.  The guy was a diabetic, had a lot going on at home and forgot to take his pills.  He was starting to show signs of end-organ damage and I had to explore the reasons behind his lack of motivation.  Again, I found it hard.

Next came a male catheter insertion.  I got a cath kit from the hospital a couple of nights before the exam to practise at home with my housemates (not actually inserting the thing, mind).  This caused a great deal of mirth but I did feel it was helpful.  I think I did ok but didn’t actually get the catheter past the “prostate” on the dummy.  I just said what I do in that situation in real life.  My aseptic technique wasn’t too bad but I probably made a few mistakes.

I finished off on a resp exam which I felt I did well.  This was presented to the examiner, then followed by doing a peak flow on the guy and working out if he was normal or not.  Very straightforward.

And that’s me done for this year.  Results next Friday, more progress testing on Monday.

Paper D – The OSCEs (Dii)

On Monday I had the first of my third year OSCE exams.  Di is seven 10 minute stations, Dii is ten 7 minute stations.  I initially thought one would be comm skills and the other practical skills and examinations, but this proved to be wrong.  The longer stations are reserved, logically enough, for tasks that tend to take longer.  For example a cardio exam is a 7 minute station, while resp is a 10 minute one – as you have to do the back as well and a peak flow.

I had Dii on Monday, and I was very nervous.  I don’t take anxiety particularly well anyway, and the morning before the afternoon test I was almost vomiting and passing out.  Eventually I got my shit together and made my way down to Barts.

The exam stations themselves were a mixed bunch.  I started on an ABG station which included a result you had to interpret, which wasn’t so bad.  The next was taking a history from a lady in AnE who had haematemesis.  It quickly became obvious she was an alcoholic and this had happened before – she wasn’t very cooperative or forgiving.  I only just managed to present it back to the examiner in time.

Onto a thyroid exam which I found relatively straightforward.  It was followed by questions about thyrotoxicosis and further tests and treatments I’d want.  I forgot Beta blockers but probably got most of the other stuff.

The next station was a venepuncture one.  Very easy in itself, except the instructions were convoluted and they wanted the paperwork filled in.  At one point I had to be told to calm down and take a breath.

The CNS station next was a bit unexpected but I think I’m fairly slick at that by now.  The questions afterwards were quite hard though – describe what I’d find if the patient had an MCA infarct.  Beyond the obvious I was struggling.  Eek.

The IV fluids station next was just awful.  I’ve had one hour of teaching on the practical aspects of “putting up a bag” and wasn’t prepared.  I got through it fairly well to start with but the paperwork was confusing and I was convinced there had been a mistake.  The examiner kept telling me to read the instructions again.  I got the bag up (the easy bit) but then had to calculate the drip rate which I got wrong as I misread the giving-set packet (20 drips to the ml, not 15).  The paperwork already had a fluid bag prescribed which I didn’t realise was from yesterday and that I was meant to prescribe this new bag.  Oops.  Left that station feeling very stupid.

Next up, a cardio exam.  Went into auto pilot on this one, having done it so many times before and only missed the collapsing pulse (I think).  Unfortunately I ran out of time halfway through presenting my findings.

Staying on the theme of cardio, I next had to take a history of angina from a lady.  I think I got all the salient points, but most probably didn’t empathise enough or ask her concerns or expectations.

The next station stayed in theme and was just me and an examiner asking questions about an ECG, Chest X-Rays and cardio drugs – all related to the previous station (the lady had been taken to AnE after she spoke to me).  The ECG was, frankly, easy.  But the X-Ray was printed on A4 with the ink running out – useless.  Taking the previous history into consideration I decided on pulmonary oedema and this seemed to get a nod.  Explaining the oedema, however, was a bit of a struggle, and at one point I crossed my arms, huffed, and said I didn’t know.  The examiner told me I did know it and to just calm down.  Eventually I got through it.

The last station was a patient discharge on warfarin.  Bizzarre setup – “this patient is going home on warfarin and is concerned about his treatment – he has asked to talk to the third year medical student about it”.  Aside from asking how he was and explaining the drug and it’s side-effects to him, I wasn’t sure what I should do with him.  Eventually the station ended with me telling him about pregnancy and warfarin.  Sigh.

Quite a kerfuffle

As I stood with one of the nurses and hassled her to sign my little booklet, I spied another nurse filling up a tray with cannula stuff.

“Ooh, don’t suppose I could have a go?”, I ventured.

She was really quite happy to let me do it.  It turned out that the drip was for a African lady who came in with a sickle crisis and had pulmonary hypertension with oedema and as such was struggling to breathe.  I thought this was a golden opportunity to listen to a boggy chest (my own term) so I grabbed the nearest other medical student and off we went.

The lady lay there with the 02 mask on and was clearly a bit distressed.  I did all the intro and asked her if I could quickly listen to her chest before I put the drip in.  Sure enough I heard the fine crackles and even a bit of a wheeze.  Result, onto the needle.

She had a nice straight vein which I could see had been used before.  The nurse assured me this was fine to use so in I went.  And got nothing.  For a good 30 seconds I moved the needle around getting nothing, very aware that the it hurt the poor woman and the other student and nurse were watching me.  As I was about to give up I pushed a bit deeper and felt a little tug before the flashback, the bloody lovely flashback, filled up the needle.

The nurse, student and now visiting CNS all breathed audible sighs of relief (for some reason).

A bit of a commotion ensued as the nurse fumbled with the syringe to draw off some blood and a bloody mess (forgive the pun) developed on the patient’s bed.  She wasn’t best pleased and I apologised unreservedly.

When we were done, the nurse gave me the syringe and paperwork to fill out.  I did so, only to be told that I had done it wrong and that the lab would now not accept the blood bottle.  Balls.  To compound matters the nurse somehow managed to spill the entire (apparently useless) bottle of blood over another nurse which somehow became my fault as my initial error had caused that to happen.

To make things yet still worse, we now needed to retake the blood.  Fook.

Luckily the nurse took pity on me (which I only half needed, remember) and decided to take the blame when explaining to the patient.  Who was actually not that fussed about the whole thing now she could breathe.  Thank God for that.

Yeh, it wasn't this bad...

Breast exam

Yesterday, as part of a week off from firms to learn new clinical and communication skills, we were taught how to do a proper breast examination with the help of simulated patients.

I had never done a breast exam before, but I thought I knew a little bit of what to do from reading and general clinical osmosis.  As it turned out, I knew nothing.

The problem with breast exams, and almost any other examination in medicine, is that there is no one tried-and-tested fool-proof approved way to do it.  It seems everyone has their own way of doing it, from consultants right down to the the juniors.  And of course whoever is teaching you believes that their way is the ONLY way to do it.  So us medical students really have no chance of getting it right.

So after being shown one way of doing it by a consultant breast surgeon, we broke up into smaller groups and went behind the curtains with one of 6 simulated patients.  These are basically actresses who specialise in being a patient.

I went first and started badly with a “bloody hell your hands are freezing!” after I’d inspected the woman’s breasts and got her to put her arms up.  I did palpation as I was shown 5 minutes previously (but probably without the consultant panache) but was immediately told to stop by both the patient and the supervising doctor.

After 5 minutes of telling me what I had done was ridiculous, they showed me their way and I got back to it.  Aside from possibly taking a bit longer, I couldn’t see much difference in what I was actually doing.  Maybe I missed the point.  Or maybe you just have to do as they say until you’re experienced enough to develop your own way of doing things.  I don’t mind much, but it was a little intense being effectively told off for 20 minutes while I had my hands on a complete stranger’s breasts.

Anyway, overall it was good and I feel a little bit more clinically experienced and competent now.  Which is never a bad thing.

So here’s a video of yet another way of doing a breast exam.  The way(s) I was taught are really nothing like this, but who am I say who’s right?

On-Call

My current firm has been a mixed bag.  I haven’t been to theatre in weeks because 1) the theatre nurses are just plain rude, without fail, and 2) we just stand around anyway as we don’t get told anything about whats going on.  An early ‘telling off’ by the consultant for my cheek at asking if I could do sutures at some point put me off being more proactive.  So my experience with consultants and regs’ is not great so far.

My FY1s, however, are holding the firm together.  They are spectacular.  There are two guys and I couldn’t ask for more from them.  They let us follow them and keep us informed.  They teach us anything and everything they can.  They let us do cannulas and bloods, even though they could do it so much quicker themselves.  And they’re just really nice chaps.  And they sign us off.

Anyway, last Sunday I took the opportunity to shadow one of them on his on-call shift.  Before I left on Friday I asked him if he was sure it was ok – I didn’t want to be a burden.

“No, really, I like having you guys around.  It helps me out, and teaching you means that I’m learning too.”

So I rocked up on Sunday afternoon and did my bit.  I averaged a cannula every hour and got just about all of them, first time, on my own.  I managed bloods several times, too.  Being an FY1 on call seems stressful – they’re constantly beeped and never get a moment’s peace.  Among other things, I saw:

• A dehiscing wound being cleaned and re-dressed
• Several patients undergoing a septic screen (massively useful thing to get involved with, for many reasons)
• Lots of fluid balances (colloid or crystalloid?)
• An obstructed patient who I had to clerk and present to the surgical SHO

It was a great shift and I learnt so much.  I’m planning on doing another at some point, as it seems to be the place to get involved.  But it wouldn’t be half as good if it wasn’t for my trusty FY1s.  I only hope that when I qualify I can give as much time and attention to whatever medical students get stuck with me.