Skills....

This has been a week of firsts.....................

• My first pleuritic tap...maybe next time my hand won't shake so much..... and the patient will have less excess soft tissue so I can feel the top of the rib - the tap needle must go along the top of the rib not the bottom because the neuro-vascular bundle runs along the bottom of the rib.
• My first 12 lead ECG which I managed to set up, record and then have a go at analysing myself....though I did need some leading through it. ECG's are one of my bogey areas.
• My first Arterial blood gases (sterile procedures) and blood cultures.
• My first dead body in a mortuary...technically it is my second, since I saw a PM during my BSc Honours year in 2004, but this was the first where I had known /met the patient.

Many of the patients this week seem to be either very, very sick, or alternatively just bobbing along getting better slowly...more to follow later.

................and those chicken sewing pictures

Initially we made a wound

then started sewing in our aseptic operating theatre
it was an intricate job

some of us did some nice stitches

others need some more practice.

OSCE-ness.

They came, they went, they happened. Probably because the OSCE doesn't count for me this year (formative only), I didn't really get too stressed about them. They seemed to go ok, despite having very little practice this year. I guess I will wait and see. I know I messed at least one of the 26 stations up, but thats life I guess.

The night out to celebrate the end of exams was a good one - with many of the year tehre, and a couple of the old year (class of 04).

Cartoonism

Today on my way back from my GP placement, I was reading the metro while waiting at the station and came across this cartoon. Anyone who has ever been grilled by a Med Student may know how the patient feels.

Do you mind if I examine you?

As mentioned here and here, today was my first day on my easter holiday clinical skills placement. It was bright sunny morning, if chill, and the train was even on time. The walk to the GP's was nice, past a park and sports ground and not at all what I expected that area of the city to be like. Maybe my exposure to UPA's in Edinburgh has coloured my views on what they are like?

The format of the clinical skills bit is that there are 2 students, and we get 30 minutes with each patient. We take it in turns to lead each consultation, and take a brief history, then do an appropriate examination, then the other person does the examination, then we get feedback from the tutor.
I was observing consultations 1 & 3 and leading consultation 2.

The first one was a man who was diagnosed with lung carcinoma 4 years ago, but the tumour has not developed in 4 years and the GP thinks it maybe carcinoma in situ. Either that or this was one of the 5% that deos respond to chemo and radio therapy and survives 4 years. He was breathless at rest, but surprisingly mobile for his age (80) and breathlessness!

The second one was one I was leading. The man had had breathlessness on holiday, then 7 days later woken feeling funny, and was admitted to hospital with an MI. He was also found to have a calcified aortic valve and AF (the 3 main causes of which are heart ischaemia, thyrotoxicosis and valvular problems - see I do listen in plenaries sometimes). Hew as quite difficult to pin down on history and was quite vague. On examination he had a quite striking ejection systolic murmur.

The 3rd patient had MS, and so we did a neurological work up, where I managed to miss quite a few of the reflexes...

Then we had 2 normal patients on whom we did BP while they were in seeing the gP. These were not planned patients, and so teh history was often very short - History of Presenting Complaint, a bit of local enquiry, and social habits, then hand them over to the GP.

The GP tutor is very friendly, so hopefully these sessions will mean that I go into the OSCE more confident than I feel now. Especially as I passed last year with a satisfactory, and this year the OSCE is twice as long as it was last year, and although I only need a formative pass, I would hope to do better than I did in 2007.

Due South, on Tuesday

Following on from my last post, I was looking at a map trying to work out teh ebst way to get to my clinical skills GP on Tuesday. The GP is in Pollok, next to a big roundabout.

It looks like I need to get a train, then walk through the Socialist Republic of Tommy Sheridan-ism, until I get to the roundabout where the GPs is. This involves walking past the local (huge) sports complex, always a haunt for Neds, however as yet I haven't been able to find a high school on the map, so either they are bussed out, or no such beast exists. However there are many (large) primary schools on the map. Google earth-ing the area is also quite good fun...

Roughly equidistant, as the train station, from the GPs are Ross Hall (private hospital), Leverndale Hospital (huge psychiatric unit) and Silverburn (huge shopping centre).

In the opposite direction from the train station is Bellahouston Park, where I spent a week in the summer of 2004, working in a tent....

Holiday, what holiday?

As most of the medical faculty wind down slowly towards the easter holiday, which starts tomorrow or Friday, I am preparing for a short weekend off!

You may remember (see here, and here) that the GP Dept had decided that due to a shortage of GP's taking students this year, they would be not giving placements to those of us repeating 3rd year. thus we do not have to attend GPO Community Practice, nor complete the LCP.

However, we still have to sit the OSCE (albeit formatively), and thus in order to give us some refresher training in the examination etc skills for the OSCE, we get to visit a GP practice for 5 2 hour sessions. Due to GP and student availability, the only time we are all free, is Tuesdays and Thursdays over easter.

So my easter break from Uni will be spent partly in GP land doing clinical skills, partly in the Med School doing the same, mostly in the Library/SL trying to notify all my PBL scenarios thus far, and partly house-sitting for a friend (more later).

Oh and hopefully also meeting up with some friends for food or coffee.

Due to the cancellation of tomorrow's PBL session (facilitator on holiday), my easter begins at 12.30 tomorrow, and ends at 5pm on Monday, when I get back from a weekend away.

Tea breaks

On Monday, when we arrived at the hospital, the new parking charges were in force and we spent ages going round and round, then parked in the staff car Park....well actuallym, the new shiny signs said 'Staff Permits Only' but teh smaller yellow plastic temporary sign said 'Patient / Visitor parking'. Similar yellow signs all round teh site are covered in moss, so they may not be the most recent.

Upon getting to the Education wing, we discovered that the decorators are in, and have requisitioned the med Students computer / PBL etc room as their own, as it has a code lock on the door. Thus the med students are displaced into a seminar room, which we can't use all the time, has a key lock, and which to be fair doesn't put up much resistance to a firm shoulder charge.

When we get there, the decorators are drinking tea, and have a tressel table with lining paper on it out in the hallway.

When we come back at the start of our break between teaching and PBL, they are still drinking tea, or maybe coffee, and a tub of wallpaper paste has joined the tressel table, but no obviously new bots of lining paper have appeared on the walls.

When we come back for PBL, having spent the intervening break in the canteen, as we can't use the library or computer room (the computers are piled up in the lecture theatre with no net access), the decorators are again drinking tea and moaning about no where cold to keep the milk....and asking us if we know where there might be a fridge they could use. We all resist the urge to suggest the mortuary......

By the end of PBL, in a freezing cold Lecture Theatre - after pressing lots of buttons i eventually found the heating controls and got the PC to turn on, one painter was painting the ceiling, and the others were packing the lining paper and wallpaper paste away as it was nearly 4, or as we might call it, 2.55.......

Meanwhile the teaching had a distinct cardiology bent to it this week, with the first half spent in CCU, talking to a patient who had had a stroke last year and an MI at the weekend, and the looking at many many ECGs and trying to ID an inferior MI of the posterior descending artery (ST elevation in II, III and aVf I think....) and then up in a Cardiology ward, seeing patients with murmurs and listening to them.

My turn to do the examination in front of the group came, and showed how rusty I am, and how nervous I am. According to the SpR, I was too 'questioning' and not definitive about my findings, and was doubling back to things I had forgotten rather than leaving it until the end and saying "I would also....".

Time...........

Have you seen the Virgin Atlantic 'Upper Class' advert? The one with John Hannah in it, where he talks about the importance of time, and how being able to have your own check in gives you more time to play Pool while waiting for your (delayed again) flight. Well today i had a lesson in time as well.

Lesson 1 - Carry extra stuff cos you might need it

For the second time in a week, and I think only the 4th or 5th time in Med School, no-one showed up to take our session this morning. It was to have been a 3hour session on Mental State examination, mental Health History taking and such like. But it didn't happen. After 20 minutes the course secretary came down to say that the lecturer was a no-show and he couldn't be reached at work or on his mobile.

I hadn't brought any work to do today in an effort to now end up like the hunchback on Notre-Dame when I had my rucsac on. So I now had 3 hours to kill.................which I did, semi-productively reading sBMJ, printing off some useful looking bits from it, checking emails, and having a longer than planned lunch break (the planned break was eat a sandwich while going to the hospital for PBL - this way i ate my lunch sitting down).

Lesson 2 - If you have a plan remember it!

On Monday, some of my PBl group had discussed that since the tutor was missing on Monday, we would ask our Thursday facilitator to let us feedback both scenarios today (being the end of a teaching block, there were no new scenarios this week), however we all forgot until we were leaving today. Thus I found myself at 2.35 with 55 minutes to kill until my driving lesson, and even less work to possibly do.

Communication...

Yesterday was Comms skills, and despite Faculty knowing that there are only 5 roles per session, and only 4 sessions through the year, they put 6 people in each group!

Because I as off ill for our introductory session, I didn't have a role yesterday, so I watched the other 5 - who were really quite good, and tried to give useful comments in the spirit of our peer support curriculum.

I also noticed that faculty have been out spending money again. Not only do we have 3 plasma screens around the place with a list of what lectures / tutorials etc are taking place in which areas of the building each day, but we now have plasma screens in the Comms Skills rooms.

Until now, the camera / mic in the Comms Skills consulting room have been linked through to a small 24" TV/Video combi unit in the 'group' room next door. Soon though faculty wants us to move to a DVD based system. The idea is that each student will be able to record each consultation onto DVD for review later. In most rooms the DVD recorder's are in place, but in their wisdom, faculty have also purchased a 48" plasma/LCD screen (I can't tell which as it still had a cover on it) for each room.

My issues with it are:

a) why could the DVD recorder not just be hooked into the existing TV
b) how much are the plasma screens costing - my guess is about £8k for them all
c) if students are expected to record the stuff onto DVD, then the DVD will have to be finalised in that machine before it will play on any other machine, so this will be a 'cost' of one DVDR per session.
d) This outlay is despite the same department saying that copying all the Clinical Skills instruction videos onto DVD for students would cost too much.

Please note he is glued to the bed.....

Friday was our Clinical Skills session- the clinical skills course is a random combination of sessions which runs through 3rd Year, with no regular pattern, or real connection to current academic or clinical practice topics.

This one was loosely themed around Cardiovascular examination technique, valvular disease and an introduction to Harvey.

Harvey
We were introduced to Harvey as "The chap in the bed next door with no legs, and a bad haircut." He is also glued to the bed (so you can't really examine his hands), at a fixed angle (so you can't make him sit at 45 degrees) making him somewhat useless for the finer points of cardiovascular examination.

Harvey can mimic several types of heart condition, and has a nice chart showing the condition you want and the magic code you have to type into him to get it. He/it then can move their apex beat and heart sounds within the chest, though these at any time are only audible if you hold the stethescope directly above the area - there is no sense of it radiating or getting louder as you get closer. Also His rib interspaces are well marked out with dirty fingerprints!

Still I feel sure that I will be back to see Harvey again this year to listen and try to understand valve disease.

Block 12 week 1

The first week of this block was quite nervy really. I was a wee bit scared about being in hospitals - always am - I'm convinced that I will put my foot in it, mess up an examination or dry up completely. So much so that on Monday I couldn't eat any breakfast and felt nauseous until I got to the hospital.

I was also nervous about meeting my Clinical Practice/PBL group for the first time. In the event, the clinical practice group seems ok. They all seem so much more confident and smarter than I feel, but once we came to feed back, we all seemed to have got stuff at about the same level, which was good.

The afternoon PBL was interesting, especially in comparison to my 2 PBL groups in Year 3 last year. This year's group seems to have 2 or 3 groupings and is less homogeneous. This leads to interesting bits in the discussion of people ignoring each other (politely) and a general sense of chaos, as the questions end up not being in the correct order. We muddle through the scenario though.

On Wednesday, we started the day with Lectures at 1 (I hate early starts like this!?) which was a standard afternoon with a plenary on Statin's and one on Medical Statistics, focusing on likelihood ratios. We also had an OSCE briefing (its longer this year) and an introduction to the block, and exams. Focussing on teh exams now already has me feeling very nervous. Oh well.

Community Care?

Well the Medical faculty are certainly being interesting this year......

It had been said that although not having to do an LCP coursework this year, I would have to attend the Clinical practice in the Community section of the course. this is basically attending a GP's one full day every fortnight in pairs and practicing clinical skills, history taking and observing the Primary Healthcare team in action.

However, when the list of allocations was published yesterday (for allocations starting next Tuesday), my name wasn't on the list. In a mild panic, I emailed the administrator, and she said that she had been advised by the faculty that I didn't have to resit that component, and that as such, and because they are short on GP's to take students this year, I was being taken off the list, and would get a chance for skills revision in Springtime.

This means I now have alternate Tuesday''s free, and potentially more time if i do not have to attend the Communication Skills sessions as well.

Elective - day 2 (maternity)

Today was my first ever visit to a labour ward. I was there to see what the anaesthetists do, although I also got to see 2 C-sections as well. It's much more umm, well, eerr, brutal than I thought. However, either way, 2 7lb babies were born fit and healthy so it can't be bad for them.

I don't know if today was a slow baby day, or if it's normally quiet, but there were only 4 ladies required anaesthetic intervention - either for a C-section, or for epidurals, so I got 3 or 4 tutorials on different aspects of anaesthetics. I got to spend time with an SHO, SpR and Consultant and got to see their different styles but also the high degree of teamwork they have.

1. The difference between a spinal and an epidural anaesthetic.
2. What the things to look out for when anaesthetising someone who is fit, healthy and awake.
3. How they manage a patient who has an 'allergy' to one of the commonly used drugs.

The most useful one, long term!!! How to be a good JHO - all about being organised, knowing where things are, what tests to request, how to request them, when to take them down personally and when to just put a card in, remembering to check up on results, knowing how to do all the minor jobs - ECG, venflon, taking blood before you become a JHO etc.

SHO Teaching & careers advice
The SHO I was with for that part of the day was really helpful at explaining why these things are important and why it is good to pick them up as a medical student, and not wait til you are a JHO. She also explained some of the simpler things about anaesthetics and the anatomy of where the different needles go. She also gave some advice on why Anaesthetics is a good choice as a career and also how to manage your FY1 choices and accepting that you are an admin clerk and spend most of your time monitoring things, checking up on things or ordering test fro other departments, She also said about knowing the patients on you ward because more senior staff are off at clinics, research etc, and it is down to you to know who slept well or didn't, whose birthday it is, whose family members are away and haven't been to see them, and things like that which help you to explain things to the consultant. Also getting to know some patient history and circumstances is important.

Seeing tomorrows patients
In the afternoon we were a bit quiet, so the SHO took me over to see the 2 patients who are being operated on and whose anaesthatist I am with tomorrow. Both are having heart surgery, so I had a look in their notes and noted the drugs they were on and went to see them so they would know who i was and why I would be in theatre tomorrow (if they care at that point!). Upon coming home and checking the drugs they are on, one patient is on Clopridogel, which is a drug which aims to prevent your blood clotting (an anti-platelet). The BNF and other textbooks recommend stopping it 7-14 days prior to surgery unless it is needed for anti-platelet reasons. So that case may be a little interesting anyway. When I went to meet that patient, who is having an aortic valve replacement, and potentially a CABG - the consent sheet and referral letter said different things! - I had a listen to her chest and the murmur was really loud and obviously diastolic. Even the SHO said it was one of the best she had heard.

SSM Week 2 (1)

Tuesday
We spent the day with a Speech and Language Therapist, who was telling us about deaf children, and deafness in childhood.

Neonatal screening
One of the interesting bits was the new "Neonatal hearing test" which measures the brainstem response to sound. It does this using small electrodes stuck onto the baby, and by playing a sound into the ear. this basically tells you if the pathway from the ear to the brain is working. If the child does not pass the test, they do not 'FAIL' but the test is repeated, and if the same result appears, they are referred to the audiometrists who assess them further.

Multidisciplinary team
This seems to be an MDT that works, involving, SLT, audiometry, teachers, social workers, psychologists and Doctors. It is quite a community based specialty, and a lot of the consultations and work goes on in the child's home or school environment.

We also got to see some videos of deaf children and noticed that the ones who had had their hearing aids for the longest had the better spoken language skills. In the afternoon, we had a visit to a grou for parents and their deaf babies which was being addressed by a health visitor about baby behaviour and their developmental milestones. The babies were lots of fun, although one toddler did whack me in the face with a toy. I think it was an accident.

Wednesday
We were away at the Cochlear Implant centre getting an introduction to cochlear implants from a medical physicist, then watching the programming of a cochlear implant and finally the ENT Surgeon explained the surgery to us and explained what we would be seeing at the Implant operation on Thursday.

SSM Week 1 (2)

Ear volume and pressure chart

Yesterday we visited the Hearing Aid clinic and sat in on a session with the Audiologist. Since he had two Audiometry students in, who have clinical exams coming up, he let them practice their examination techniques on us to give us an idea of the procedures and how they feel for a patient.

Audiogram of Right ear

Shown here are my charts for my right ear audiometry, both ear volumes and pressures (indicating that my hearing is normal and that I have un-perforated ear drums). They also took a mould from which a hearing aid ear mould could be made. This is done by injecting blue silicon into the ear canal them leaving it to harden. The picture does not do this wonderful toy any justice.

Mould of the inside of my right ear.

As we left, the Audiologist told me I looked too happy to have these exciting toys and souvenirs of my visit, but did tell me that the world needed people who got excited that easily. We are back next week, when we get to sit in on a session on programming a new type of hearing aid. I think I;m starting to like Medicine again.

Selling my body

I am selling my body, well technically I am renting it out, to the Medical School. Having last year volunteered to be a Guinea Pig in a research trial, my altruistic action this year is to be a model for the second year OSCE (in second year, all the patients are 'normal' and the OSCE assesses examination technique). I have been assigned to a DGH about 25 miles from home which means leaving the house at 6.55 to get there by 8.30am.

I get paid £30 for the day, thus valuing my time at a little over £3 an hour!!!!

Being male, I will be doing any of the examinations:-

• Cardiovascular
• Respiratory (front & back)
• Abdominal
• GALS / Musculoskeletal
• Blood Pressure

Resuscitation

Oh well, I failed this station in the OSCE ( a stand alone station0 and thus have a retraining and re-assessment day in mid June.

O S C E (to the tune of YMCA)

Exams are over!

Well for the moment, I might have a recall exam for my OSCE, if I was in the gap between PASS and (PASS + 5%). Hopefully I am not. I would like to think that the OSCE went well

1. Ethics station - a man with a sickline which says Alcohol (10 min)
2. Blood Pressure measurement
3. History of a jaundiced patient
4. History of a suicidal patient
   
5. Peripheral vascular examination of lower limbs
6. Respiratory examination of the back
7. GI examination of a jaundiced patient with hepatomegaly
8. History of a rheumatoid patient
9. Difficult circumstances with pregnant woman drinking alcohol
10. Comms Skills station - woman with a cough - followed by information giving for bronchoscopy. (10 min)
    
11. Neurological examination of upper limb
12. History of a woman presenting with headache
13. Resus with a Defibrillator
14. History of a woman with weight loss.
15. Breast examination of a manekin.
    

And another 1 I have forgotten since this afternoon, and 2 5-minute rest stations.

If I was going to revise for the exam, I wouldn't start here

Hmm with less than 48hrs to Exam 1, I started makinga list of teh areas I was worried about

• Bones (Always hated bones)
• Haematology
• ECG
  
• Cariology
• Renal
• GI / Liver
• Respiratory
• Psychiatry
• Neurology
• Ethics
• Antibiotics
• Infectious diseases
• Ethics

So basically the whole curriculum.

Argh!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!