I'm still here

Still being a med student, too. More to follow.

How not to answer a question

Achievement unlocked: Completed first surgical placement
Status: Acceptable

Some consultants like you to stay quiet if you don't know the answer, some like you to take a guess because "I don't know is never right". But all of them like you to think systematically, to have a pre-programmed structure to your answer. There are some classic questions a surgical consultant will fire off and expect a quick, concise answer in reply - answer that can only be achieved by applying logical, systematic thought.

When we're taught this way of thinking it is generally with a smile on the face of the lecturer and a remark about how you can use the answer to avoid actually having any specialist knowledge in the topic or in actuality, having an answer to the question. If that sounds a little convoluted, allow me to demonstrate:

"What are the complications of this surgical procedure?"
"Complications of surgery can be divided into immediate, early and late, and further sub-divided into specific to a given operation or general to all surgeries. Immediate complications arise during the procedure or in recovery, early within 48-72 hours, late within weeks of the procedure..."

Do you see how that answer isn't an answer at all? And how it is completely right at the same time?

At first I thought it was a technique to bore the consultant and get them wave you into silence, firing off the next (and generally harder question) at the student next to you. But then when I thought about it a bit more, I realised this is such a useful way to manage your knowledge. Rather than having a randomly assorted list of things, you can partition them off, divide them up to help guide your care and treatment modalities with a clear understanding of the most likely cause and the relative seriousness of the complaint.

Whilst there having been important take-aways from this placement, such as the fact I don't think I'm going to be a surgeon, or how busy and yet elegant the anatomy of the hand is, the notion of systematic thinking and how to apply these kind of techniques to make me a better doctor is my top learning point form the past six weeks.

Poppin' my cherry

I couldn't see his mouth move, but his eyes were firm but kind:

"Is this your first time?"
"I want to hold this, and pull firmly up and back. Easy, not that firm"

His guidance was even-handed, congratulating my successes and admonishing my failings:

"When I want you to hold it, I'll pass it to you"
"No, you're holding it wrong, wrap your thumb and ring finger around it, and use your other hand for support..."

Oh dear.

Sorry, I thought of this post on the tube home and I couldn't resist. Today was my first day scrubbing in on surgery and it was brilliant. A lot of my coursemates have had negative experiences in theatre which has really impeded how much they get out of their surgical rotation. In medicine the classical educational concept is "teaching through humiliation"which is not without it's merits (I will never forget the complications of gallstones after a registrar took my umm and ahhh laden answer to pieces), but when you're in theatre, being told to GTFO because you didn't know the innervation of a particular muscle is just mean. Yes, you should bone up on stuff before your placement and doubly so if you know the operation you're likely to be scrubbing in for, but if you don't know the answer to a particularly esoteric question you shouldn't lose the rest of your potential learning.

I was felt so nervous scrubbing in but I think I really lucked out with friendly and helpful nursing staff and a my registrar being a great teacher. I was ended up in a procedure I wasn't expecting and hence couldn't answer a fair number of his questions (none of which were unreasonable), but my answers of "sorry, I don't know" didn't earn me a sound bollicking, but rather an answer and an explanation. I will not forget that the things I learnt, feeling like a plum and quietly turning red.

And I'm looking forward to the next time I get to scrub in.

The first cut is the deepest

I don't know who said it, but they were wrong. And also kinda right.

This week has been my first week on attached to a surgical firm at St Clabert's and it's been a reminder of what I know and what I don't.

The first point of call was that, until this week, I'd never been further than the anaesthetics room in theatres (other than as a patient). In ward life you know of theatre people and maybe have the occasional tussle in recovery, generally about how you're not taking the patient who is groaning in pain and who's BP is in their boots back to the ward. But I'd never before donned scrubs, clogs and a hat and walked into theatre. It is a strange, controlled, precise place compared to the ward. It was refreshing to experience this change of pace and bear witness to a kind of calm teamwork that I've not seen much of before now.

And the first cut. I realised, when I saw the scalpel go in, that I had never seen this happen before, either. Don't misunderstand, I've assisted in plenty of drain insertions, ascitic taps, biopsies, endoscopies et al, but never seen a person cleaned, draped and then surgically incised. It was amazing. I didn't expect it to be a notable experience, but it left me literally agape (and then when I realised, quickly stoical - I mean, no-one wants to look like a noob in theatre).

This week has quickly taken me out of my comfort zone as anatomy is one of my weaker points and being quizzed about specific muscles and their attachments and insertions and innervations and (god forbid) arterial supply or venous drainage is just awful for me. I've had to claim ignorance and face disapproval more this week than my ego is frankly comfortable with and had to accept I really need to spend more time with Netter if I want to get the most out of this placement.

The high points have (unsurprisingly) been history-taking, clerking, examinations and ward life (both pre-op and post-op). I fully expected this to be the case, given my previous life. I love being on a ward, talking to patients, sitting with them to take a history, busting out the stethoscope, percussing, palpating, the whole nine yards. Which I guess says something about my medical bent.

So far this has been a good placement and I have several weeks to go, so more time to get comfortable in theatre, maybe even scrub in and hold a retractor or two, more time to get my muscles and nerves straight in my head, more time to reinforce the ward skills I have brought with me.

Now if you'll excuse me I have an important meeting with the intrinsic muscles of the hand...

Getting hands on

Mr. McGuire: I just want to say one word to you. Just one word. 

Benjamin: Yes, sir. 

Mr. McGuire: Are you listening? 

Benjamin: Yes, I am. 

Mr. McGuire: Plastics. 

Benjamin: Exactly how do you mean? 

So we've had six weeks of PBL tutorials, statistics and communications seminars and clinical skills sessions and now, like so many baby birds, we're being let lose from the nest lecture theatre to fend for ourselves. For a bit.

My first rotation is 6 weeks of plastic surgery, allegedly with a hand specialist. Which carries all manner of silent terrors for me as I find the anatomy of the hand and forearm crazy complicated. And being in a theatre gives me all kinds of opportunity to fail to observe some anachronistic aspect of human interaction and get bawled out for my troubles.

But the upside is I have a fair bit of post-surgical HDU nursing experience and know the general tone of surgical ward life. And in many ways my current form was birthed on the wards of an NHS hospital. I don't mean that in a creepy "buffalo bill" kind of way (well, maybe a little bit...), but who I am now is very much the product of having lived and worked in the healthcare environment for quite some time. I hope I can fit back into the pace of things like a hand in a glove. No pun intended.

And then there is the undeniable fact that surgeons are the people who reach into the very living flesh of another person and fix them. This is something incredible to be sure. I can understand where the idea that surgeons sometimes see themselves as gods might come from - If you can make someone better with your hands and bit of know-how, you could forgive yourself for being changed from the experience, too. I look forward to seeing the fixing happen first hand (again, no pun intended) and to find out how the life of surgeon actually works, when they're not writing up post-op fluids or taking down dressings at 9am (don't get me started...)

I don't know if I am a surgeon (though I have nursing friends who promise to disown me if I become one!) or a medic, and to be honest, I don't know if it's relevant for me to wonder this without more experiences to form an opinion. To pass the first year without resit or hinderance showed me I can do this, that I am med student (hear me roar!). What I make of my opportunities and experiences waits to be seen, I guess!

PS There will be Malta pictures, once Flickr stops being in a strop with me.