L A T E S T P O S T S
Maybe it’s just me, but the practice of medicine is/should be centred around patients. Why do I say this I see your mind box confusingly thinking? Well, one of the surgeons I had the pleasure of joining for consults forced me to remind myself of why I entered the profession.
When sent to shadow a doctor or specialist, students normally look to achieve two outcomes; one is clinically related and the other professional. The clinically related aspect of being with a mentor is the more self-explanatory. Students look to learn about the kind of work doctors engage in, the type of knowledge required to practice in that specific area and to reinforce their own knowledge in the specialty.
The professional related outcome is the more difficult to implement, describe or practice. As students, we look to observe the way mentors treat and interact with patients, as well as the manner in which they question, examine or acquire information. Much of this can be summarised by an often overused term; soft skills. This is the nuance that can be the difference between a non-compliant, aggressive patient response and a more smooth-sailing and beneficial consultation.
Why the whole charade about the details of shadowing? You’re now placed in prime position to understand the frustration of the following situation. While sitting in on these consults with my mentor, he had great clinical knowledge and really knew his stuff. However, his demeanour and overall mindset towards patients was quite concerning. He would finish what seemed like a normal consult to me, and come back to complain how rude the patient had been.
Seeing the confusion on my face, he would begin to elaborate, ‘Did you see how unappreciative they were? Unbelievable’ or ‘We really don’t get the respect we deserve, in other places the doctors word goes unquestioned, who do they think they are?’ or ‘They just don’t get it, they really don’t listen it’s so frustrating’. There are more along the same line, but I think you get the jist.
Here is poor old me, absolutely horrified that this guy in front of me is saying a whole lot of crap I can’t stomach to just ‘let slide’. I somehow managed to brush him off till his tirade was done and he’d had enough of either quizzing me about anatomy or being livid with the patient’s lack of respect.
I think it’s worthwhile to note that when it came to the way he treated me, it’s hard to believe but he was remarkably forthcoming and willing to assist. I still can’t quite work out why he opted for a passive-aggressive approach when with patients.
I think it goes without saying, despite this being quite a stereotypical case of what I’ve often heard called ‘arrogant doctor syndrome’ it is by far an exception to the rule. The vast majority of doctors don’t have a ‘chip on their shoulder’ and feel the need to constantly prove a point. Patients are their number one priority and come down on us as students, if we fail to keep that at the forefront of our minds. Some may see it as harsh, I see it as protecting the core of medicine and maintaining it’s noble purpose.
Despite his often lack of concern, I find there’s one of two ways you can think about what I’ve just explained. You can either look at it from an elitist point of view and begin to think about how you really do deserve to be treated better, or as a lesson for what not to do when you begin practicing yourself. The choice is yours
Learning is a lifelong process in which you encounter teachers and educators of all kinds. Some educators are etched into our memories, whether it be as a result of a pleasant experience or otherwise. I used to wonder why people would often differentiate between the term master and teacher. My thoughts were that a master was an exemplary form of teacher. Why create another word for the same thing, I left it at our willingness to be creative in the way we describe our surroundings. That was until a recent experience that contrasted two people of the same profession taught me otherwise.
During an anaesthetics rotation, I came across two educators with drastically different levels of competency in teaching. The first anaesthetist seemed to be quite competent, however as a teacher it was a different story. Initially I didn’t realise because I’d had no anaesthetics training prior. It was only until the next day that I met with ‘the master’ that I noticed the other was lacking.
The first experience was more a recount of what he did on a daily basis and operational matters that I wasn’t really privy to. Not to mention he lost me in the unnecessary detail for a student of my level and spoke to me for a whole of 10 minutes, if I’m being generous. In 2 hours of being in the operating room, he dedicated 10 minutes to teaching me what in the end was pretty useless information. In fact, the attending surgeon noticed my lack of activity and made a passing comment about ‘my thumbs working much harder than they should.’
Now, if I contrast this with my next anaesthetics training session, boy did my little brain get a shake up! Let me put it to you this way, I was in theatre for approximately 4 hours, in that time I think my mind rested for about 15 minutes in total and I wasn’t even complaining. I have never been so tired after a teaching session, but also so satisfied. It was a weird and wonderful journey in which he picked my brain and brought out archives I’d forgotten were even there. They had been covered in dust and he was able to wipe that thick layer off it and put it to good use. He went as far as taking me back to year 11 and 12 chemistry, which I thought would never be useful in real-life. In summary he took it back to principles.
In the image below, is a very good summary of the individual that I was grateful for having taught me:
When first learning anything, the foundations are the most important part of any subject as you will always refer back to them. This anaesthetist hammered that home. He said to me, ‘Stop, stop, stop! You keep throwing buzzwords at me, go back to first principles’ he repeated over and over. It took my thick head a little while to register, but when it did it was a light bulb moment. This is how any form of learning should be, the foundations are established and then built on.
The actual content of what was taught is not so important, the method of teaching is what I wanted to highlight. This kind of masterful teaching is available within every industry and even within specialisations. However, this level of engagement during a lesson is rare and not to be taken for granted. It takes a unique kind of teacher, a master.
Mr Henry Wallace (pseudonym) was a 70 year old gentleman who upon first impression I perceived to be a friendly, but world-weary man. He had a myriad of health conditions, of which he claimed his inability to walk to be the most important. We took his history, and in discovering he was a diabetic, was experiencing left foot drop, and loss of peripheral sensation, we began to suspect peripheral neuropathy. It was the ulcerated right toe however, that was the cause of his admission. Mr Wallace was responsive, eager to answer our questions, and after a while, it was quite apparent he was also eager to share. He stressed the frustration he felt at his inability to walk, which had developed some months ago. He was once an active man, and he was accepting of all his medical conditions, had no qualms managing them, but the debilitating aspect of his failing legs meant that he no longer felt independent. He lived in a building owned by a Church, and although he admitted he mostly stayed in his room, there were neighbours there that he was fond of. He had no wife, and no children. He mentioned no other positive social relationships. I could detect an undercurrent of sadness in his voice, and it soon became apparent that the source of such melancholy was his own history. It was during his response to one of our questions that he apologised and stated that he had a story he wished to tell us.
Many years ago, Mr Wallace was working for a big brand company. At the time of the story he had been an employee for 16 years. During this period, Mr Wallace’s father was residing in a nursing home, with the expectation that he was dying. It came then a day, which his father was not expected to live past, where his sister-in-law called the company for which is worked, requesting that Mr Wallace be excused of his duties in order to tend to his father. However the company’s response was that no such employee existed, and the phone call was over.
It was at this point in his story that Mr Wallace began to cry. I was already, in truth, fighting the urge to respond sympathetically. He cursed the company he worked for, the company who after 16 years of labour, were unable to acknowledge his existence, the company whose inefficiency or incompetence meant that he returned home from work that day to learn that he had lost his father. He shook his head as the tears rolled down his cheeks, regretting that he was not given the opportunity to say goodbye. “I hate them”, he said to us. “I will never use [the brand name] again”. We agreed. We responded in our own way, offering some form of comfort. But I believe the greatest comfort he took in our presence was the opportunity to talk, to tell his story. I suspected that it was not something that he came across often.
His second story was told in brief, yet it had an impact much greater than its length. It was not told to us by him, as we felt we had taken much of his time and thus we decided to leave him to rest. It was our tutor (his doctor), who was given permission to recount. This story, our tutor said to us, is perhaps the reason why our patient had no wife, and no children. At the age of 23, Mr Wallace was in a committed relationship with a woman that I will call Grace. It was a couple of days before Christmas and Mr Wallace was intending to pick Grace up from her house (where she lived with her parents) for dinner. He arrived instead to a scene of devastation. A fire had burned the house to the ground.
Grace, was inside.
Our tutor described how broken Mr Wallace appeared to be when telling this story. He stressed that patients will come in with more than one problem, and while we may not be able to fix everything, if there was something we could do for them, it was to listen.
I walked away from that session with an overwhelming sense of sadness. It was sobering to realise and remember that there are hardships people experience that I (selfishly but hopefully) never will. How different we people are, the paths we take, yet somehow we end up here, on two sides of a bed (terrible way to put it, I know). We may all be cogs in a wheel, but hell, do we have a story to tell.
“Oh hello, I’ll find you one of the registrars, I’m just the resident.”
I scurried after him with an internal sigh, wondering who I was going to be palmed off to next. I was in an Orthopaedics Fracture Clinic, and was hoping to get something practical out of my session (such as ticking off necessary examinations in my logbook). But it was starting to look like that might not be the case.
We wandered over to one of the rooms, where three of the registrars were sitting together discussing something I was paying very little attention to. “Hey got a medical student here, anyone want one?”
They stopped talking. No-one responded. “No?” the resident asked. I was getting the idea that he wasn’t particularly interested in having me sit in with him either. “We’ve already got the other medical students.” (note: the medical students were actually with none of these doctors). The resident continued to stand by the doorway until another registrar piped up: “She can go to the plaster technician-that would be useful for her.” The resident straightened. “Good idea.” He turned to me. “They might let you do something.”
The plaster room was no good. She appeared as genial as I felt, though it was not directed at us. “Just not today, I’m sorry.” We backed out and I mentally prepared myself to return to the common room and reassess my plan for the day while indulging in feeling just a little sorry for myself.
“Hm.” I turned to the resident: “That’s ok, I can just come back another time.” To his credit (considering he didn’t seem very interested in the situation) he shook his head. “No no, come with me.” We walked back to the room assigned to him for the day and he sat down. He began setting up the computer. “Yeah, it’s just I’m just the resident, everything I do I have to run it by the regs, so it’s probably better if you were with them.” I quietly wondered if I should fake a tutorial and spare him the pain.
I made some agreeable noise I think, and stayed silent. The less I spoke, I thought, the less annoyed he might get for having been stuck with me.
“So what did you want to get out of this, Priscilla?” I dithered, and shrugged. “To learn, to do a few things.” I told him about the items I needed ticked off on my logbook. He nodded. “Well we probably won’t get the hip and back exams. But we can probably get a shoulder one in.” By then the patient was walking in and so it was left at that. Midway through the clinic however, he turned to me and said: “Ok, you’re leading this one.”
I blinked. “What?” He grinned. “You’re sitting in the chair, and you’re taking the notes, I’m not telling you her story, it’s your patient!” At that moment, I had no time to wonder wildly what my plan was, I had to just do. I sat down awkwardly. The patient had been called in, but as it turned out she was a 92 year old delightful woman who was stuck with a walker thanks to a patellar fracture. “I’m walking as fast as I can!” she said light heartedly, and we watched. “No, no. This is part of our exam; we just want to see your walking.” The resident said. “Now this is Priscilla, she’s going to be in charge today, is that ok with you?” She laughed as she sat down. “She’s going to be in charge? A woman in charge, of course I’m ok with that!” With that comment, I knew I was going to survive the consult.
She was an amusing historian, and also a very independent and determined woman, with an incredible amount of eagerness to resume her two daily walks a day. Once the resident had taken off her Zimmer knee splint and I’d performed both a quick knee and shoulder examination (she had a history of two shoulder replacements and the resident thought that was the perfect opportunity to ask), she was up and walking around the room. “What are you doing mum?” the daughter (who had accompanied her) asked. “Testing it out of course!” she retorted, as she resumed her seat. We left them for a moment to consult the registrar who did not glance at me at all even as I reported back.
We relayed the news to the patient. She grinned. “Oh thank god, I can go for walks now?” The resident reassured her that she could, however to be safe she should take her walker and continue to use the splint for one to two weeks and slowly wean as she pleased. Thanking us profusely, we watched her leave, and I daresay I almost saw a spring in her step.
Smiling the resident turned to me. “Perfect. Well done.” It was three words, but I knew they were genuine and was feeling incredibly proud of myself, and satisfied with my morning. Thanks to the kindness of one resident, I was actually able to do something I had never done before. I could have just left in a huff after being rejected by the registrars but I stayed, and it definitely paid off.
“So Priscilla, what can you tell me about cirrhosis?”
As per usual, my mind went blank. Two months into placement and my brain had yet to successfully retrieve and open fire responses to questions within a reasonable amount of time. To confuse it even further, I had just finished a cardiovascular and respiratory rotation and was now doing a stint with gastroenterology unit. I was still stuck on murmurs and hyper-resonant lung fields.
“Cirrhosis?” he nodded at me kindly. My mind raced. Think, Priscilla, what does cirrhosis sound like? I might add at this point, that whilst I’ve spelt the word perfectly on paper, at the time, I received it phonetically and thus you must forgive my next response: “Is it…inflammation of the serous membrane?”
He looked at me. I’m sure I had the most dumbfounded expression on my face and he smiled. “…cirrhosis?” was all he said and suddenly it clicked. “Oh my god no, I’m so sorry, I don’t know what happened to my brain there, permanent scarring of the liver?”
Here’s the kicker. I was sitting with a gastroenterologist in what was specifically called the Liver Clinic.
He laughed and nodded. “Don’t worry, I have those moments all the time, but yes, that is cirrhosis. Now can you tell me why that might occur?” I spent the rest of the morning with this kind and absolutely willing to teach doctor, and whilst I did learn, my mind continued to revert back to that dunce moment I’d had. I was thankful that he was the only one who had heard my response. If this occurred in the middle of the ward in front of the gastroenterology team there would have been a high likelihood of me becoming too embarrassed to show my face in that ward ever again.
It might interest you to know that my ambition in medical school is to never become a funny topic of conversation during morning tea in the breakroom.
Mistakes though, do happen. And it’s necessary to remember that they happen to everyone, whether they are a consultant or a clueless third year medical student. But since I am not (yet) the former, my musings are perhaps more relevant to the latter.
It’s hard to forget that our peers don’t actually know everything. Group tutorials are a constant reminder that someone knows more than you. But we have been told time and time again that this is never the case. Your colleague doesn’t know more, they simply know different things. Medicine is too broad for one person to be an expert in everything, and too varied for them to have a vested interest in all topics anyway. Often what we know best is what we find to be the most intriguing as there arises a desire to learn more. So often we sit (or stand) in these tutorials, a mounting panic growing as we realise that someone seems to have memorised the whole CHADSVASC score and the whole treatment plan for deep vein thrombosis and are now appearing to be infinitely better than you are. When in fact, you happen to know COPD like it was your own child and they can’t even distinguish between Chronic Bronchitis and Emphysema. Perhaps poor choices in examples, as both of these topics should be a staple in a medical student’s diet, however I think I’m making a valid point.
So while it is easy to say and hard to do, try not to panic too much when you feel as if someone knows more than you do. Note down that gap in your knowledge, and fill it in (also something that is easily said and harder to do). Sometimes you are going to be embarrassed by blurting out a completely incorrect response. The Liver Clinic incident was only one of the many times I’ve said something that has been completely off the mark. Funnily enough I’ve found that my confidence has been slowly growing at just attempting to answer questions with only a vague idea as to the correct response. Trying is never the wrong thing to do, and sometimes you just might be correct.
Besides, think of how inwardly envious your peers would be when the doctor smiles and says: “Yes, you’re right.”
Life, for all of us, has always been about balance. It might, I say with exuberant sarcasm, surprise you to know that this is certainly the case for a medical student. All aspects of one’s life comes under a certain amount of strain for this select group of masochists, whose sole purpose appears to revolve around making it through 4 or 5 years of relentless studying without losing their minds. Coupled with the fact that we all know perfectly well that studying does not stop with the title ‘Doctor’ and we have actually subjected ourselves to a lifetime of pressing our noses against books (or computer screens), stress is a constant presence in our lives.
So I have to express my incredulity as to how so many of my peers seem to be able to competently accomplish their academic goals whilst in romantic relationships, maintaining friendships and family relationships, working shifts, keeping up with their hobbies and, if social media tells me anything, go out for a drink or two at a reasonable amount of frequency so as to not be classified as a hermit. The level of admiration I have for their expert juggling skills is simply immeasurable.
I myself am committed to only a small handful of pursuits. As I creep slowly towards my mid-twenties I’ve come to the realisation that there is only one question one must ask when encountering another individual, whether it be in the hallway, or at a social gathering: “How are you?” And often the standard reply would be: “Good, how are you?”
Now in the off chance the conversation must continue, the follow-up question is: “What’s been happening with you?” or variations thereof. Unfortunately for myself, I’m quite limited in my response. I perhaps have two priorities in my life and that is my medicine career and the gym. If (and we must touch wood for this) I were believed to have gone missing there are really only two places to look. Three, if you count my home.
So consider me flabbergasted that one of my best friends is not only at placement every day, but works a couple of shifts, exercises a few times a week, maintains her two year relationship and still has time to go out with me for brunch or dinner every now and again. The idea of being booked in for two social events in one week stresses me out more than it should if I have to be honest. I do love to socialise, but I become quite highly-strung if I cannot make it to a gym session.
It all comes down, in the end, to priorities. Lately there has been a lot of coverage on burn-out, where medical students are struggling and failing to feel mentally and physically able to handle the stresses that come with medicine and maintaining a balanced life. We all, not just medical students, have many things we value, and wish to prioritise, and keep in our lives. But an expert juggler can still drop their pins after a while, not because they are incompetent, but because they are exhausted. Overstimulated nerves, become exhausted and fail. Overused muscles break down, and fail. An over-activated heart, will fail. We humans are not made to last forever.
I reached this topic in such a roundabout way to demonstrate that we are all different. We have different limitations, we value different things, and we have different strengths and capabilities. What one person can do, is not necessarily what you can do. This does not make you, or them, lesser. Sometimes it is difficult to remember to do what suits you best. Sometimes it is easy become caught up in the ever-increasing chaos, to forget to stop, take a step back, and reassess your surroundings. And it’s much easier to forget to take a look at yourself. Am I sleeping less, becoming more irritated, worried, stress, frustrated? And if so, what can I do about this? Perhaps it is a selfish thing to say, but I am my priority. I want to be mentally and physically capable to face what is in front of me. And I paint myself as a strong character, but I know there are others for which this self-evaluation is harder, or they are so focussed on their goals they forget to look after themselves.
There is nothing wrong with saying you are drowning. We shout and scream for help in an ocean when we feel like we are going under, because we know we need the help. I wrote this piece in the hope that it may serve as a reminder for those who have neglected their own health to remember to give themselves a perfect OSCE-worthy history and exam. Are you ok? And if you are not, find some help. Your family and friends are there for you. Your tutors and mentors are there for you. Professionals are there for you. Asking for help is a simple piece of advice, but for some it is difficult to follow.
Take a step back. Look after yourselves.
The clock ticked. Through the windows I could see the beautiful inner suburban scenery, a patchwork of old Victorian roofs amongst the shiny new architecture. The city skyline rose above it, glittering in the light of the low-hanging sun. It was a beautiful view. And a beautiful room. Pale, creamy and crisp, the carpet looked freshly steamed and vacuumed. The furniture was modern and minimalist, exuding just the right amount of welcome, but not enough to encourage a prolonged stay.
It was, by now, nothing short of expected for a suite in a private hospital. Having spent four rotations at a major public hospital, I needed a small amount of adjustment. It was at first novelty to me to find that virtually every single clinic came complete with spectacular views, magnificent décor, a coffee machine and a tray of glasses with jugs of water and a dishwasher. Walking the wards the world seemed much quieter, and I learned that there was scheduled in the day a ‘rest period’ from 1-3pm, where visitors were discouraged and patients were encouraged to rest.
The corridors were carpeted, and footsteps were muffled, adding to the air of calm. It lacked the disorder, the chaos and hustle and bustle I was becoming used to in the public hospital. And frankly, I quite missed it. I was once a catering waitress and team leader, and feel quite at home in bedlam. I simply found the quiet a little unusual.
The doctor cleared his throat quietly. He sat by his desk in one corner of the room and had swivelled his chair around to face me. I had actually met this surgeon before, having visited his operating theatre just one week earlier. He had asked me a few questions, however it was the assistant surgeon who had taken me under his wing at the time, and provided a genuinely enjoyable experience. His specialty was spinal surgery, and I was sitting in his outpatient clinic, waiting for his first patient to arrive.
As we waited I kept my eyes primarily at the windows, pretending I was taking in the view. He appeared as if he wished to say something, but was unsure of what, and thus sat there, hunched forward, elbows on his knees looking mildly uncomfortable. It raised in me the question of whether the stereotype about surgeons was true: that they were less skilled than their physician counterparts at being chatty, being much more talented in the operating theatre.
“So you were with me in theatre weren’t you?” I said yes, I was last week. “Remind me again what we did-I had several days in theatre last week.” I tried to elongate my explanation without dilly-dallying about my response; however I inevitably ran out of words and fell quiet. He nodded. “Ah yes, the coccygectomy. It’s not very common; you don’t get to see a lot of that.” It was actually quite fascinating that operation. The patient had experienced a fall off their horse 18 months prior, which had resulted in her coccyx being angled at 90 degrees to their sacrum.
The operation removed the coccyx entirely as it was at risk of perforating the rectum, was giving the patient pain and was actually protruding slightly outwards, leaving a bump on her back. He asked me several more questions, such as what university I was a student of, and what I did as an undergraduate. The response to each question was accompanied by a moment of silence.
Many of his patients were post-op, meaning that they had come in for a check-up after having undergone surgery by the doctor. Most were congenial, however there was one that was quite difficult.
He was a little overweight, accompanied by his non-English speaking mother, who greeted us with a wide smile. The briefing the doctor had given me was that this man had undergone multiple surgeries (the most recent being an L3/4 disc prolapse), was under work cover but would visit his suite with multiple complaints and he believed that the patient was unlikely to return to work. He had-as the doctor described it-a litany of questions, which included his potential for having sleep apnoea, why his breathing was laboured, what he should do about his bad knee, and most unusually: “What surgery did I have doctor?”
I am personally a very impatient person. As I watched the doctor work his way through the patient’s queries, I admired his ability to keep his frustration under control. Despite having informed him that respiratory medicine was not the forte of a spinal surgeon and he should really be consulting a specialist, the conversation about his breathing continued for at least five minutes.
Where I would have most likely become a little bit short in my manner (I am endeavouring to overcome that, I promise), he remained calm and patient. It was fascinating to watch. Once the patient had left however, the doctor breathed a sigh of relief and turned to me with a look, and I laughed. He needed no words. Difficult patients definitely was testing to one’s temper.
Our story starts with folk hero and investigative genius, Sherlock Holmes. After walking in for our customary weekly tutorials with the Intensive Care Unit (ICU) registrar, we were surprised when we heard we were going down to the ICU. Not privy yet to the details of what would happen next, we wait anxiously to see what is in store.
It is a well-known fact that medical students have very little, to no business in the ICU. It is a complex environment that operates on thin lines of balanced give and take from the various machines, to which the ICU staff carefully attend to and calibrate.
Upon arrival, we gather near a row of patient beds, the whole 10 of us. He first asks if any of us knew the author of Sherlock Holmes, much to his disappointment none of us had any idea. Proceeds further to quiz us on the profession of the author, I say to myself he must have been a doctor of sorts and sure enough, he happened to be a surgeon.
I await with intrigue where he is leading us and then comes the order of the day, ‘there is an unconscious patient in this room, you are to walk in there and work out what is going on with her, by merely inspecting her and the room’. We collectively look at each other puzzled, but we enter nonetheless to see what we can make of the task at hand.
At first sight, we begin to comprehend two things; the power of observation and a picture telling more than a thousand words. None of us spoke a word for a good 5 minutes, before we were all called to gather and share one thing observed that could not be repeated by someone else. We eventually were able to get it all out and summarise the clinical picture of the woman in front of us.
In brief, she was a young lady who had been involved in some sort of accident. She had bruising and scratches all over her body, but worst of all was the severe trauma to her head. How did we know this? Well, she had to have part of her brain removed, partial craniectomy, which would have been an urgent procedure to reduce the ever rising pressure inside the skull.
Moreover, it seemed that all her body functions were being operated by machinery. Her body temperature, her breathing, her nutrition were all externally supplied. Moving over to the monitors, there was a close watch on particular measures that would give the doctors an idea of the pressure in her brain and how well blood was reaching parts of the body. There was even the slight, but ever important detail of the bed being completely on about a 30 degree incline to allow gravity to lessen the load on the head.
Once we had been through all of that, we were all in awe of the power of observation and its implications for our careers. We rounded the session with a few cases in which we took a few rather arbitrary figures and tried to paint a clinical scenario. From there we could proceed to putting into practice what had been drilled into us through our course so far. For a different, but equally intriguing teaching experience, stay tuned for my most enjoyable teaching experience to date.
It is often emphasised by our tutors that you learn by teaching others, and by doing. Often the ‘others’ I happen to be teaching is whatever inanimate object within eyesight, however I am definitely a person who learns by doing. Practice questions are more useful to me than textbooks, real patients are better than plastic models. I am perhaps not the most dedicated medical student (I don’t spend every hour of my day hanging around the wards for one thing), but I see the merit in what they preach.
As if she had an ear into my thoughts, the anaesthetist wheeled the next patient in, turned around to me and said: “Come, you’re going to intubate.” She was a brusque woman, but kind, and having spent the past three hours with her, and hearing her explain to another patient why she became an anaesthetist, I already admired her. However, the only thing I have ever intubated is the head and shoulders of Alan, a clearly plastic, inhuman model with no pain receptors.
I scuttled over nervously as she bagged the patient, waiting for the propofol to take effect. “Have you ever ventilated someone?” I said no, but I was willing to try (it’s a very good phrase to use, just as a useful tip). She nodded. “Good, now this is what you do.”
I began with some difficulty, since a plastic model’s mandible is incomparable to a real human’s, and I was struggling to jaw thrust whilst holding the mask one-handed. Once the patient had settled, the mask was removed and the anaesthetist inspected the vocal cords with the laryngoscope. “Can you see the vocal cords?” I stayed silent as I searched. I have never been the kind of person to automatically say yes, as I would rather be stupid than caught out as a foolish liar. “Well, can you?” she asked again impatiently. I was lucky enough that I spotted them just as she spoke, since beads of sweat were already threatening to form along my hairline.
I said yes and she nodded: “Now feed the bougie in.” I looked up, frozen. What on earth is a bougie? Should I know this, did I learn what a bougie was? How do you even spell it? What does it even look like, how do I find a bougie?
I probably only had this minor panic for about 5 seconds because to my left appeared this long thin blue tube carried by the anaesthetics nurse, James. I could feel my tachycardia regressing as I thanked him, took the bougie and carefully fed it past the vocal cords and into the trachea. She grunted. “Now the tube.” Again the tube appeared to my left, the work of the heavenly James, and I carefully guided the tube down the bougie, hyper-aware of the fact that vocal cords are delicate and this tube was plastic and thick.
All you have to do, Priscilla, is not ruin this patient’s life.
Easy enough, really.
“Push a little harder, a bit harder, otherwise the tube is going to bend and you are not going to be putting it in the right place.” I mentally crossed my fingers and toes and added a just a tiny bit of strength.
“Good. You’re done! It’s a bit too far down because you got a little bit too excited, but I can just bring that back up again. You see these markings on the tube? If you’ve pushed it down too much you’ve almost certainly gone down the right main bronchus and then you’ll get collapse of the left lung because you’re only ventilated the right. Ok?” I nodded in understanding. She smiled. “Very good. Well done! You’ve bag masked someone, and you’ve intubated! You don’t get to do that every day do you? Well done.”
Like a puppy who has just been informed they’ve been a ‘good girl’, I beamed and felt an instant sense of accomplishment. She was a busy woman though and turned away to ready the patient for the operation and begin the paperwork. I was left to stand with a slightly more confident air by the wall, where medical students tend to be, waiting for the surgeons to return. It is one thing to successfully intubate one quarter of a mannequin. It’s quite another to say that you have successfully intubated a real patient (albeit with the assistance of an anaesthetist and the nurse). And I think having been able to do that once on my first attempt, I would be a little more confident for my next. Doing, is indeed more useful than reading.
My first encounter with a patient at a new hospital ends up being while they are unconscious; in theatre. I have been in the operating room multiple times to watch the skilled surgeons and accompanying staff at work. However, this time was more memorable due to the complexity of the patient at hand.
Our patient was a man in his 60’s, who unfortunately happened to have all the necessary complications to put him in this current position. He had what is called an abdominal aortic aneurysm (AAA), which was being closely monitored so it doesn’t burst and potentially send him into a life threatening situation. Just a bit of background to assist with understanding of the condition and how this man’s complications got him tot his point.
The aorta is the major blood vessel in the body. The abdominal aorta is just the part of this artery that supplies the organs of the abdomen. An AAA is where a laxity in the artery wall is exploited by different types of cells in the body such as elastic, fibrous, fatty and inflammatory cells that go to work on forming a home. This home continues to build in size until it starts encroaching on the area where blood flows through the artery, resulting in impaired blood flow and no surprises as to why that’s a bad thing.
Moreover, with this aneurysm continuing to grow, it can start to put pressure on other structures that are next to or around it. Therefore, not only making it harder for blood to flow to different parts of the abdomen, but also impacting the function of other structures in the abdomen. Below is a picture to help put it all together
Back to the man about to go under the knife. His abdominal aorta diameter was measured at 5.8 cm, which is higher than the 5.5cm standard for surgery. Typically, this procedure is no longer done in an open surgical fashion. However, I walked in to witness a rare procedure nowadays and that is an AAA open surgical repair. The reason the doctors felt this would be the best for the patient was due to the risk factors this man had, which included: being a chain smoker, having high blood pressure, having peripheral vascular disease, being overweight just to mention a few.
These days, most AAA repairs are done under the guidance of some sort of imaging to put in a stent. They clean out what ever is clogging the area of blood flow, also known as lumen, and place a stent that reinforces the wall of the artery and stops it from rupturing. The procedure is called an endovascular aneurysm repair and a clearer visual of the final product is shown in the image below:
This procedure is much more comfortable for the patient, no need for all the potential harms that come from surgery. It also doesn’t have the same recovery period that one needs post-surgery because it’s normally done when you’re awake! This type of procedure, use of a stent has been developed to help minimise the typical harms associated with surgery and to help people get back to normal life as soon as possible.
Despite all of this, the surgery seemed to have gone well for the man so hopefully he can appreciate the importance of taking care of his health. Making the adjustment to be health focused can often be difficult, particularly in the situation of smoking and adapting healthy lifestyles. The problem often lies in trying to help people through the process of changing old habits, which is no mean feat.
Sometimes people see the impact of their lifestyle on their health, yet can’t seem to quite get around to making it a priority. The barriers to making these changes are both mental and physical, hence being of assistance in this process is always much better than being of an opinion. One day just maybe, the individual sees for themselves that prioritising their health has nothing to do with taking away from their other commitments, but rather it will enhance their ability to fulfill their other commitments.
Just to fulfill the curiousity of those among you who may want to see what the surgical repair may have looked like, I’ve embedded a video of an AAA surgical repair below. Actual AAA repair occurs from time 1.30-6.00 minutes