September 27, 2017

The End of the Surgical Block and the Passage of Time

Our sixth block, officially known as Care of the Surgical Patient, is coming to a close already. I swear it just started the other day, and yet it’s already almost over. Like lots of specialist-placement blocks, it’s been a very self-motivated learning experience. This is something I wasn’t quite expecting about the course: as a student, we are given a framework of learning opportunities and then, depending on the block, we are expected to fill in some portion of our timetables by ourselves. This requires a very proactive student who isn’t afraid to get stuck in and talk to the right people, but can also take some getting used to as well.

I spent the first few weeks of the surgery block really enjoying vascular surgery (really, it’s very cool!) but then branched out to learning about other forms of surgery in the last couple of weeks. You really have to do this in the trust where we did our surgery block. I spent some time with colorectal teams and going to lots of follow-up clinics in other areas – breast surgery, urology, even the ENT (ear, nose and throat) clinic for an afternoon. It was absolutely fascinating to spend time in underexposed parts of medicine and surgery, and I’m acutely aware that these might be the last opportunities for a long time that any of us students get to see such a wide variety of disciplines.

One big surprise of this block was that, interestingly, it contains a lot less exposure to actual operations than I initially expected. This kind of makes sense, however. I guess that a lot of what we as students and foundation doctors have to know has far less to do with actual surgery and far more with knowing about conditions that would cause an operation to be necessary (and there are plenty), how to assess a patient immediately before an operation, how to treat them afterwards, and of course the anaesthesia care before, during and after as well. I don’t think foundation-year doctors even make it into theatre for operations, so that realm is basically reserved for registrars and consultants. Even though I found surgery really interesting to watch, I’m glad to have had the opportunity to gain knowledge in other related areas too as it feels much more relevant to our education at this level.

Soon we will be starting the acute block, which means that our seventh – and penultimate – block will begin. A new cohort of medical students (I remember when we were that young and excited!) will be starting and we’ll now be top of the heap. I’ve been interested in emergency medicine for a while, so this block is really exciting to me. Although we have our fair share of overnight and odd-hours shifts, I think it will be really accurate and a good opportunity for us to understand what emergency medicine is like – plus I want to see if it really is like 24 Hours in A&E! I am very excited about this next block and anticipate a lot of excitement.

September 21, 2017

Spending time in clinics!

Well, the pace of the fourth year hasn’t slackened at all, and things have picked right back up after our summer break. I’m still really enjoying the Care of the Surgical Patient block and am learning loads at the same time. I’m not only spending time in the theatres and on ward rounds, but also attend my fair share of clinics. A clinic is (usually) a half-day session where the doctor has appointments to meet patients alone in a treatment room and discuss their condition. Clinic appointments can be either new referrals or follow-ups; the nature of the follow-up appointments varies depending on the discipline. Some people with lifelong chronic conditions will check in with their doctor every six months or every year or something. But others, for instance after surgery or a broken bone, will come in for a meeting just to make sure that everything is OK before being discharged.

I like the nature of clinics and find them very useful to attend. It’s much easier for me to remember details of a condition when I can attach a person’s name and face to it. I can almost walk through the consultation in my head after the fact, which helps me remember investigations and management. You’re not guaranteed to see everything in a clinic, but you’ll definitely see more by attending than if you don’t go at all, and that’s what I like about them. In this block, we have the opportunity to attend a great deal of post-surgery clinics and some pre-surgery clinics as well – including vascular clinics (lots of foot ulcers and artery blockage), colorectal clinics, ENT (ear, nose and throat) clinics, breast clinics, urology clinics and more. It’s great that the organisers of the block are giving us so much of an opportunity to take advantage of what our huge hospital has to offer.

In addition to a main surgical consultant, we are also assigned to an anaesthetist (or two…) for the block and are given a lot of anaesthetics training and tutorials. I have had the privilege of spending some time in theatre with my assigned anaesthetist and have learned a great deal about the science of anaesthetics and how a lot of our physiology needs to be taken into account when anaesthetists do their jobs. It’s not all about making people unconscious and then waking them back up – so many things need to be monitored and kept within safe ranges whilst a patient is being operated on. The list of things to monitor and that can go wrong is really endless.

I recently saw an operation on a patient who was having an adrenal tumour removed; an excess level of adrenaline and related hormones were being released by the adrenal gland directly into the patient’s bloodstream. So before the gland was removed, the anaesthetist had to administer drugs to counteract the effects of the adrenaline: the patient’s heart rate and blood pressure had to be brought down and kept within safe ranges to avoid the effects of high blood pressure. But – and this is where teamwork with the surgeons comes in – as soon as the gland was removed (and ideally a few minutes before), supplementary adrenaline had to be given for a while to counteract for the sudden deficit that the patient’s body was now experiencing. Watching the physiology literally in action was absolutely fascinating and an extremely worthwhile use of my time. I cannot wait to see more!

September 12, 2017

In Demand…

Having started my acute block on the acute medical wards, clerking relatively stable patients, I have spent the last two weeks on the Intensive care unit (ITU) and in A&E where stable is not a word used to describe many of the patients!

The ward round in ITU was one of most fascinating ward rounds I’ve been on as a medical student, many of the conditions you read about as a medical student thinking you will never actually see were there, as well as patients recovering from major traumas with multiple injuries. On ITU patients conditions aren’t just identified and treated, patients are only on ITU if one or more of their organ systems need support. That might be blood pressure supporting drugs in the case of a patient with life threatening sepsis or in more severe cases patients may require multi-organ support, for example, dialysis for kidney failure as well as mechanical ventilation to allow them to breathe. Patients in ITU have 1:1 nursing and are constantly monitored, as such a stay on ITU is very expensive and there are only so many beds, dictated by the number of staff available. ITU beds are in high demand; deteriorating patients around the hospital are referred to the ITU registrar who can then discuss potential new admissions with the consultant. In addition as UHCW is a major trauma centre there is also the possibility of a major trauma arriving that may require admission. Deciding who to admit to ITU is a murky area with no strict rules; does the patient need organ support right now, are they likely to survive even with ITU support? Unfortunately using a crystal ball isn’t an option.

Patients often get referred to ITU from A&E and while it’s much easier for patients to get through the doors of A&E, demand is so high that getting a cubicle to actually assess a patient is not so easy. In just a handful of A&E shifts I’ve seen queues of patients on ambulance trolleys, paramedics waiting to handover their patients to the nurse in charge while the nurse is frantically trying to find a space. Reading about this in the newspapers is disheartening but actually seeing it is shocking. Demand is so high and while some A&E attendances are inappropriate the vast majority aren’t and need to be seen. It was nice to feel useful as a medical student in A&E by helping the doctors clerk patients, take bloods and insert cannulas (my success rate has now improved to 50:50-good for me, maybe not so good for the poor patients!). Seeing a wide variety of presenting complaints was really interesting and used lots of different skills. In Minors I saw lively children injured in various trampolining /climbing incidents, a few sports injuries ranging from badly sprained ankles to fractured bones and even a builder with a chemical injury to the eye. In majors I saw first-hand what happens when social care fails our elderly patients, patients discharged from hospital one day and then back again the next. I was able to observe the treatment of an acute asthma attack, something which can be quite scary but didn’t seem to fluster the experienced A&E consultant. I was also excited to be asked to see a patient had been referred urgently by their GP for a possible stroke, which I correctly identified as Bell’s palsy-a relatively benign condition that will improve in time on its own.

I don’t think there is ever a dull shift in A&E and despite some of the problems with the system it was inspiring to see the Nurses and Doctors in A&E working as a team-and actually feeling like I was a contributing member of that team! I have more A&E shifts over the final two weeks of this block, here’s hoping my cannula success rate improves!

September 01, 2017

Finals countdown…

After a relaxing two week break I have emerged from my chrysalis as a fully-fledged final year medical student. Do I feel any different? Do I look any different? People certainly seem to be treating me differently, all the focus is now on job applications in October and final exams in February next year. Doctors teaching us in hospitals have high expectations and seeing students from the year above us now working as FY1 Doctors is inspiring fear rather than confidence! I don’t think I have felt this nervous since freshers week, nervous feelings about the task ahead have resurfaced now that my ambition to become a Doctor is almost a reality, with a few final hurdles to overcome.

I embark on my final year by starting on my Acute Medicine block. This block is split between UHCW in Coventry and Warwick hospital. We spend time in the emergency department and the acute medical wards, doing a variety of shifts so we can see as many patients as possible. I’ve spent the first two weeks of the block on the acute medical wards at UHCW. These are interesting places to be as a student as you get to see lots of patients presenting with common medical problems that will come up in finals. Patients are clerked in A&E and once its decided that they are stable and need medical treatment as an inpatient or are waiting the results of investigations they come to the Acute medical ward (AMU) at UHCW. The doctors on AMU then clerk the patient and then arrange or follow up investigations and start treatment. There is a huge variety of patients on AMU at any one time. Patients may have come in with chest pain and shortness of breath so things like heart attack or pulmonary embolism need to be ruled out even if you suspect a chest infection. Some patients may need to be admitted under a particular medical specialty and will move once a bed becomes available and for others they can stay on AMU and leave after a few days of treatment. As a student you can clerk patients, help take bloods, insert cannulas and attend ward rounds and because its AMU, every day there are new patients to figure out.

Another area we have been assigned to is the Medical decisions unit (MDU), where patients are referred in by their GP for tests or treatment only available in hospital. These patients are usually not acutely unwell or unstable but they have presented with a problem that could be serious. For example if a patient presents to their GP with central chest pain that came on after eating a large meal, the GP simply doesn’t have the tests available in the community to rule in or rule out a heart attack even if it sounds like heartburn, that patient needs to come to hospital for further tests but they don’t necessarily need to come in an ambulance and wait for several hours in A&E. In MDU the tests can be done quickly and so patients can either be reassured confidently or brought in for further treatment. MDU is one of my favourite places to be as a medical student and it is great practice for finals. You can take a fresh history and examine the new patients and decide what your differential diagnosis is and what tests you want to do and then present it to one of the junior doctors who will agree (or disagree!) with you and who can organise the appropriate tests. Over the course of your shift you can chase up the results and actually find out if you were right and can decide on the management with the juniors and consultants. It’s a great chance to present cases to seniors and get feedback on your clinical reasoning skills and management.

Aside from getting to grips with the acute block I have also made a revision planner for finals, having the next 20 weeks before my first exam planned out and stuck to my study wall is terrifying! Hopefully when I start my A&E shifts next week that will provide a welcome distraction from my revision planner and the countdown to finals!

August 31, 2017

Care of the Surgical Patient – and the Beginning of Year Four

When I first became a medical student, being a fourth-year student seemed such a distant place to be. Before getting there, we had lectures to sit through, ward rounds to attend, and – who can forget? – exams to pass. I used to look in awe at the fourth-years I knew and think, “Wow – they must know so much. I wonder how I’ll ever learn enough to make it into the fourth year.” Well, odd as it may seem, last week we started our fourth year – it’s a bit anti-climactic, however, as it’s really a continuation of what we’ve been doing in the third year. Nevertheless, it’s hard to believe that I’m in that position now. I certainly don’t feel as confident and knowledgeable as those fourth-years seemed to me, way back when. But maybe I just don’t realise how much I’ve actually learned in the intervening three years. I’ll have to wait and see how I do on finals!

Along with our fourth year of medical school, we have also just started our sixth Specialist Clinical Placement block – this one is the CSP block (Care of the Surgical Patient). I’m thrilled about it for a couple of reasons. First, my clinical partner and I are at the largest of our teaching hospitals. I am taking full advantage of the huge variety of cases and the opportunities for teaching that are sometimes present at smaller hospitals but are definitely routinely present at ours. There’s just so much going on here. Second, I’m teamed up with a vascular-surgery team for most of this block. In previous blocks, I’ve spent time in orthopaedic surgery, colorectal surgery, urological surgery, gynaelogical surgery and loads of other disciplines, but I’ve never actually spent time watching operations on blood vessels, so this is an area entirely new to me.

So far, it’s been really interesting. I thought a lot of vascular surgery was occupied with conducting bypass operations, but there’s so much more to it than that! A lot of the patients we’re treating are elderly people who have diabetes and/or a smoking history, as these are two of the many risk factors for peripheral vascular disease. The issues that the surgery team deal with are much more varied than I expected: there are lots of bypass operations, some toe/limb amputations, a lot of wound debridement (removing dead tissue from wounds that have not healed fully) and lots of other things that you probably wouldn’t discuss over the dinner table with your mother – unless she is a vascular surgeon. Let’s just say there’s more gangrene than I expected.

And of course, although we’ve had our fair share of shadowing operations (I even got to make a stitch the other day!), there’s much more to the CSP block than just time spent in theatre. We have post-take ward rounds, clinics and lots and lots of teaching around surgery-related topics. We’ve had anaesthetics sessions, suturing workshops, teaching on wound dressing and care, and many other topics. I wasn’t too keen on a career in surgery before coming into this block, but who knows? There’s still time to change my mind!

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Our Med Life blogs are all written by current WMS MB ChB students. Although these students are paid to blog, we don’t tell our bloggers what to say. All these posts are their thoughts, opinions and insights. We hope these posts help you discover a little more about what life as a med student at Warwick is really like.

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