My best placement ever as a medical student was a four week attachment to the A&E department at Blackburn in my third year and I have since looked forward to returning to this hospital. Enthusiastic and motivated students get a lot out of this hospital as the staff are ever willing to allow students to get involved. Over the years, I have met many senior students who spoke highly of this hospital in delivering high quality fifth year placement, and I thought I have to see what the fuss is all about for myself.
It was an 8 week placement - 4 weeks of GP and 4 weeks of general surgery. I thoroughly enjoyed both. I have written about my GP placement - on being given responsibilities that I've never been entrusted before and being challenged. The two GPs supervising were very competent and hardworking doctors but not without a life, and I aspire to be like them. It has revived my interest for general practice and now I can just about imagine myself enjoying GP as a job for the rest of my life.
The hospital placement was equally satisfying, even with my deep-seated dislike for surgery. I got stressed out when clerking in new patients because I wanted to do them properly fully, not like my previous clerkings which had always stopped at 'history and examination' and neglected the impression and management plan, putting in cannula and taking blood, arranging imaging, reviewing the results, writing up drug chart and presenting it to a senior doctor. I have finally understood and experience the need to PRIORITISE (like cooking for my family, really!) Seriously, I was stressed out, but the doctors were very encouraging and kept said I was doing well. I also had a go at presenting patient at a shift handover (which was a station examined in last year's finals) which involved lots of palpitation and butterfly in the stomach. When not on-call, I helped look after the patients perioperatively. On the second last day of my placement, I surprised myself by actually enjoying a day in theatre. I saw gallstones in real life, assisted the surgeons and the anaesthetists and properly examine a hernia.
There is always a few patients that every doctor remembers forever. For me, there were three this time. I was the first to see them and I diagnosed all of them correctly: they all had cancer, the scans confirmed it. While I couldn't resist the excitement of being the one to have elicited the important symptoms and signs on the history and examination to bring such important diagnosis to light, the people looking after them and I know that there is nothing to be happy about because there's basically no cure as their diseases were far too advance. They could well be dying as we speak. Which is why, I think, I will remember them forever.
The most unusual feature of all is the structured teachings that we received while on placement in Blackburn. There is weekly orthopaedic, surgical and radiology teachings as well as lectures on various specialties and practical clinical skills sessions for revision (not that I attend all of them or that they were on every week). On every Tuesdays, about 10 hospital and community tutors come together for our bedside teaching, PBL session and student grandround. The tutors knew us by our names, something that, as Manchester students, we are not accustomed. There was this award for a member in every PBL group for being, not the brightest but the one who contributes the most and did all the work (akin to the man-of-the-match title), and I received the award for my group! I knew they created this just for a laugh. But still, it's nice to be recognized and I'm really proud of my contribution! So that was the Blackburn tale. It's a shame that I won't be returning after the exam. Suffice to say, if I pass my exams, I have Blackburn to thank.
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Tuesday, December 29
Saturday, December 19
I read this very moving article in the theatre coffee room. Have a look. It's a long one, but I wish it had been longer.
Necessary Angels - National Geographic December 2008
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Necessary Angels - National Geographic December 2008
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Friday, December 11
Bones, stones, groans and psychic moans
Since my secondary school days, at the beginning of each day, I will decide if a day is going to be a good or a bad day. If it is going to be a good day, I'll be as productive as possible and make risky decisions. If it is going to be a bad day, I will keep my head down and let the day would pass uneventfully. I decided that last Wedsnesday was a bad day on the morning ward round. I knew the theory of the hernia orifices inside out. But when the consultant asked me explain and draw it on a piece of paper, I confused myself (between the mid-point of the inguinal canal and the midinguinal point) and consequently made a fool of myself in front of the entire surgical team. All day everyone from house officer to registrar was teasing me by saying 'so have you learn the hernia orifices?'
Just when I thought of leaving the unit, this lady comes along for me to clerk in. She presented with a week of lethargy, general malaise, constipation and left sided abdominal pain, and the GP sent her in because he was worried of her very high (>100) WCC. On examination, I found a mass on the left abdomen and in the rectum. As well as the physical signs, I thought she was withdrawn with a general apathy and was slow to answer questions. I thought something was really wrong, along the line of haemotology or GI malignancy. The registrar reviewed her and agreed with my findings. He told everyone that he was impressed that I managed to pick up the signs as they are quite subtle. To add to the excitement, the lab later on phoned urgently to inform us that this lady's calcium was 3.9 (sky high!). This is a medical emergency that surgeons are not used to dealing with, so they double checked using the internet. We then realised that this lady has essentially presented with symptoms and signs of hypercalcaemia, well, not really bones and stones but certainly groans and psychic moans! How exciting! Never thought a line like this in the bible of medicine (Oxford Handbook of Clinical Medicine) actually occurs in real life!
Since I am discussing this, I'd also like to talk about the nurses. Some junior doctors recently told me that nurses are stupid. And I thought what a very rude thing to say, not least because most of them are much more experienced than us when we just qualify. Now I can kind of understand what they mean. When this lady come in with a WCC of >100, the nurse wrote in her admission notes ?sigmoid abscess (I don't know on what basis because there wasn't a GP letter, maybe based on her left abdo pain and high WCC?). She said to me that she is septic and we need to get her onto the septic care bundle (a set of tick box protocol for patients with suspected sepsis). That was even before I had a chance to assess this lady. She shoved that form to me and asked me to take blood for lactate and blood culture as dictated by the form. After seeing the lady, I looked at the obs and the blood result, and along with the clinical picture, I thought sepsis was unlikely. When I expressed my opinion to the nurse, she patronizingly said 'It doesn't matter love, I've checked with the registrar'. Well, she's conveniently not informed the registrar that the lady is apyrexial and was haemodynamically stable with no sign of sepsis whatsoever and her main worrying symptom was the general malaise. I was bullied by this nurse into sticking multiple needles into this poor lady to fulfill these septic bundle tickboxes. When I then went on to present the case to the registrar, and he agreed that this lady was not septic and doesn't need to go down the sepsis bundle route. I wish I could smirk at this nurse and said 'I told you so' to her. Nurses doing the doctor's job is currently a big debate among the medical and nursing community. I personally think doctoring (ie decisions on diagnosis and management) is best left to doctors for many reasons, one being diagnosis and treatment is not as easy as ticking boxes.
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Just when I thought of leaving the unit, this lady comes along for me to clerk in. She presented with a week of lethargy, general malaise, constipation and left sided abdominal pain, and the GP sent her in because he was worried of her very high (>100) WCC. On examination, I found a mass on the left abdomen and in the rectum. As well as the physical signs, I thought she was withdrawn with a general apathy and was slow to answer questions. I thought something was really wrong, along the line of haemotology or GI malignancy. The registrar reviewed her and agreed with my findings. He told everyone that he was impressed that I managed to pick up the signs as they are quite subtle. To add to the excitement, the lab later on phoned urgently to inform us that this lady's calcium was 3.9 (sky high!). This is a medical emergency that surgeons are not used to dealing with, so they double checked using the internet. We then realised that this lady has essentially presented with symptoms and signs of hypercalcaemia, well, not really bones and stones but certainly groans and psychic moans! How exciting! Never thought a line like this in the bible of medicine (Oxford Handbook of Clinical Medicine) actually occurs in real life!
Since I am discussing this, I'd also like to talk about the nurses. Some junior doctors recently told me that nurses are stupid. And I thought what a very rude thing to say, not least because most of them are much more experienced than us when we just qualify. Now I can kind of understand what they mean. When this lady come in with a WCC of >100, the nurse wrote in her admission notes ?sigmoid abscess (I don't know on what basis because there wasn't a GP letter, maybe based on her left abdo pain and high WCC?). She said to me that she is septic and we need to get her onto the septic care bundle (a set of tick box protocol for patients with suspected sepsis). That was even before I had a chance to assess this lady. She shoved that form to me and asked me to take blood for lactate and blood culture as dictated by the form. After seeing the lady, I looked at the obs and the blood result, and along with the clinical picture, I thought sepsis was unlikely. When I expressed my opinion to the nurse, she patronizingly said 'It doesn't matter love, I've checked with the registrar'. Well, she's conveniently not informed the registrar that the lady is apyrexial and was haemodynamically stable with no sign of sepsis whatsoever and her main worrying symptom was the general malaise. I was bullied by this nurse into sticking multiple needles into this poor lady to fulfill these septic bundle tickboxes. When I then went on to present the case to the registrar, and he agreed that this lady was not septic and doesn't need to go down the sepsis bundle route. I wish I could smirk at this nurse and said 'I told you so' to her. Nurses doing the doctor's job is currently a big debate among the medical and nursing community. I personally think doctoring (ie decisions on diagnosis and management) is best left to doctors for many reasons, one being diagnosis and treatment is not as easy as ticking boxes.
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