Into the abyss

Back in bedlam, the chaos ensues. The ward I am currently working on has a number of different types of patient; some transient cases - fresh faces recently admitted and soon to bode farewell, whilst others have been lying in their beds for far longer than I have been in clinics. As I tag along on the morning rounds, I notice we become a point of interest. They lay there helplessly chained to their drips, watching silently as we continue the daily ritual. I carry on listening to the doctors, occasionally picking up an obs chart or scribbling an unnecessary sentence on my patient list in order to look preoccupied, all the time acutely aware of the row of screaming eyes only metres away.

Later on I am summoned to take blood from a patient down the corridor. Fearing failure I eagerly oblige with face full of false enthusiasm. Slowly, I gather the venepuncture equipment and make my way to the bedside. Rapport it seems, is unnecessary in certain situations. For this particular patient - dosed up on drugs could barely stay awake long enough to provide consent. As I tied the tourniquet around their arm, they broke back into a thunderous chorus of snoring. The concerto continued, as the first few attempts at striking oil proved futile and went seemingly unnoticed. A change of tactic and I tightened the tourniquet to a maximum possible tension. Their veins courteously came into play. As I took the needle and slowly forced it into the target I realised my mistake. A quick puncture of the surface and a jet of high pressured blood squirted out, leaving a large bloody mess on their white top. Panicked, I continued to force the needle through and took as much blood as possible, removed the tourniquet and applied a dressing. Sheepishly I scanned the opposite beds, and noticed a patient that I had nicknamed ‘The Walrus’ lying there watching as he gargled on his aspiration pneumonia. With the walrus being neither compos mentis, nor able to speak I breathed a sigh of relief. Another lesson learnt.

Days later, I am approached by a man who tugs on my arm with eyes shut and mumbles something inaudible whilst wildly gesticulating with a chocolate chip muffin. I ask if he would like it unwrapped, and proceed to do so, only seconds later to observe him waddle off in an ethanolic miasma dropping most of it in a trail behind him. I sigh deeply and set off to find a dustpan and brush before the nurses follow the trail of crumbs to the feet of the perpetrator to this mess – yours truly, the Hippocratic Oaf.

Once a week, we are asked to take a full history and examination from a patient to later present to the consultant in the scheduled teaching session. When a man as jaundiced as possible turned up on the ward one day, I almost jumped at the chance to clerk him. Profound obstructive jaundice - leaving the patient looking vaguely like Hans Mowlem of ‘The Simpsons’ infamy. I continued to take a thorough history and exam, and we talked for a while. I found out about his life, what he used to do, where he lives now, how he felt about being in hospital. Then came my first ever compliment – to be later told ‘he was ever so impressed by your professionalism, especially as you're only a medical student’. This good feeling was of course, fleeting, as only days later I was brashly informed of the awaiting death sentence of a diagnosis when presenting the case to the consultant.

Advised by my consultant to attend his endoscopy clinic, I made my way down one afternoon to observe what I believed would be a few hours of routine gastroscopies and colonoscopies. After about an hour of standing at the back of the room watching the video monitor the atmosphere abruptly changed. A peptic ulcer they had been treating, unexpectedly decided to bleed profusely. A flurry of action and the consultant summons me over to the table to hold down the victims helplessly flailing hands as they attempted to stem the torrential flow. Vomiting over a litre of blood and bringing new personal meaning to the term ‘haematemesis’, I watched with wide eyes as the patient turned from pale to white, all the while acting as a human straightjacket as I pulled down hard on their arms listening to a horrific melody of gag reflex and gastric reflux.

The Oaf has since started to develop a new found appreciation for life and love.

Living the dream

Life inside the hospital is quite unlike anything I’ve ever experienced. The previous two weeks have hammered home the role of a doctor; the complete lack of glamour, the endless rounding, the tireless adjustment of medications, the utter disillusionment of previously held misconceptions, and the repugnant odours that only the new medical students seem to be bothered by. Ironically, it seems our oxygen saturations fluctuate as frequently as some of the patients as we hold our breath from bed to bed.

Being dropped into the proverbial deep-end - after performing venepuncture successfully only once previously on a plastic arm the subsequent times I have taken blood have been alone, unsupervised, on real patients. The problem with a general medical ward is that the patients on said ward tend to be there for a reason. They have a multitude of different complex medical problems, are quite often elderly, and difficult to bleed. I’ll walk through the ward, noting the various cotton-wool pads covering previous puncture sites, large haematomas and prominent cannulas. The doctor will request a number of bloods, and I’ll skulk over to whichever of the condemned to request permission for a futile attempt at drawing blood. Squaring up to the antecubital fossa, a face full of false confidence as I attempt to make small talk. I’ve even developed my own comedic routine, joking that the tourniquet will most likely be around my neck by the end of the procedure; there’s no business, like SHO business.

Unfortunately the Patch Adams approach isn’t always appropriate. One occasion last week saw me failing to bleed a patient whom I knew was to receive a death sentence once their family had arrived. Despite all the communication skills sessions laid on by the medical school, little was actually said. I think we both understood what was about to happen.

Much of this takes place for the purpose of being signed off in our logbooks. We have to reach the quota, no matter how uncomfortable the situation may be. A teaching round given by the lead consultant highlighted yet another important lesson to me, for when performing a respiratory exam I declared the chest sounds to be unremarkable. Of course, I could not actually hear the expiratory wheeze, but for the helpless screams of “nurse.. nurse... NURSE! I’VE WET THE BED!.. NURSE?!!” coming from the next bed. This carried on for nearly half an hour as we listened to the consultant in stony silence, pretending nothing was happening inches away.

And so it begins

Attention dear readers, I regret to inform you that unfortunately the Oaf has taken a turn for the worse. Acute pharyngitis, submandibular lymphadenopathy, nasal coryza, otitis media, myalgia and conjunctivitis. Yes, vitals remain stable, but I suspect a mild pyrexia and neutrophilia. The diagnosis? Man Flu. To the non-medically trained friends of the Oaf, all this sounded rather alarming for what in layman’s terms they described as ‘a cold, if that, even’. However, I shall remain adamant that the world as we know it has stopped turning and vigils shall be held throughout the land as my health hangs in the balance by a mild viral agent.

In other news, the medical school in its infinite wisdom has issued each student a keypad in order to make the lectures more interactive. Quite why they gave these to us a week before being dispersed to all corners of the country for our 10 week hospital placements remains a mystery. Perhaps feelings of guilt surfaced, for spending a disproportionate sum of the medical schools budget on improving the schools research score and they decided to treat us all? The few final lectures that involved some form of audience participation proved rather futile. The ever technologically-incapacitate lecturers who can barely understand how to load their PowerPoint presentations from their USB sticks to the computer terminal and projector were left utterly perplexed by the new-fangled multiple-choice element. I must add, that at this I did point out that simply raising our hands to answer the questions would be far quicker and cheaper than the new keypads, but was briskly corrected by my friend who kindly pointed out that as medical students we are only able to answer questions in EMQ format from now on.

The other evil necessity provided by the school this week is the logbook; a ring-bound bastard and master to us signature slaves. For the next few years we will be required to get various tutorials, procedures, case histories and case presentations signed off by whichever health professional will lend a scribble in order for us to fulfil the curriculums demands. In fact, having already been a few days on my placement I have found an F1 doctor who has told me that if by the end of the firm I need anything signed off he’ll do it, regardless. Always comforting to know, we’ll see how it goes for now…

Open for business

I’ve been back for over two weeks now. The transition from lackadaisical, tardy, pre-clinical student into someone who appears on a superficial level to resemble a respectable member of society, and in the correct setting, occasionally mistaken for a real doctor has commenced.

The third year kicked off with the usual suspects; paper work, timetables and introductory talks. The hall was packed out with familiar faces, and a number of fresh ones – the Oxbridge transfers, the graduate-entry students, the MaxFax dentists and a few who failed to progress to the fourth year. So with our over-subscribed year swelling to around 300, then commenced the first clinical demonstration. A man wheeled in suffering from an acute exacerbation of his COPD, accompanied by a respiratory consultant demonstrating the art of history taking and examination. As the hour drew on, the patient seemed to deteriorate to the point where he could barely move. I must admit, I have never seen the lecture theatre fall under such stony silence. It was therefore quite a relief to see this decrepit old man leap off the examining table in cabaret fashion, as the consultant lauded over the delight of 300 hysterical students who had come to the realisation that they had been duped.

This preceded a rather stimulating lecture highlighting how little we actually understand in a clinical context, and our complete incapacity to organise hard data into a logical list of medical problems. The upshot of this was in the delivery, from another consultant alumnus with a cutting sense of humour: How do you elicit a shifting dullness? Ask a group of dentists to switch rooms. Yes, it’s not all that bad.

Later during the week I visited the Fresher’s Fayre - the Student Union packed full of exciting stalls, freebies and amateur decor. Upon entering I was given a warm reception from a friend, swiftly handed a leaflet concerning gonorrhoea and thrust a handful of free condoms – it’s always reassuring to know just how your peers may think of you. Following on, I spent a good hour scouting out the few societies I intended to join whilst concurrently conscripted to a host of others I had not, and ended the afternoon skulking around the Anatomy Society’s free buffet table – to which I might add, that the chocolate chip cervix was a particular delight.

So in just a few hurried weeks the Oaf shall be deployed for duty, bare below the elbow, stethoscope concealed in pocket and nervously tagging along on a ward round trying to avoid eye contact with both patients and professionals – much like a raised JVP, to be obliterated under pressure.

EWTD Compliance

The Oaf has contacts whom have recently embarked on their various careers in medicine. Fresh out of medical school with provisional GMC registration, they have now been in their FY1 jobs for about a month. They are also the first cohort of junior doctors to have to fully adhere to the European Working Time Directive, which came into force as they started. In effect, they are legally bound to work a salaried job of no more than 48 hours per week, although prior to this the EWTD had an enforced 56-hour week. With a little snooping around through Facebook contacts, and spying on their colleagues various status updates, the Oaf has collated a brief snapshot to illustrate the success of the implementation of the EWTD:

Finished early! Only 90 minute’s overtime!

How can 12 hour days be healthy.... :( especially when I’m only being paid for 8 of them... sigh.

Has worked 38 hours in 3 days. Meh.

Is wondering how many people actually manage to adhere to a working time directive?!?

...No chance. Leaving at least an hour late every day, in for our rota'd off days, someone's having a giraffe at my expense!

...My half day finished at 5:30 weds - wonder why our half days can't start in the afternoon rather than at 8am?

...just done a 77 hour week, so not me!!

and of course:

Went from being "in a relationship" to "single"

The overwhelming impression the Oaf gets is that the EWTD is likely to save the government millions of pounds as there is now no obligation to pay their doctors for the extra hours they work, and indeed in doing so would be deemed illegal. Ironically, the various concerns raised over inexperienced doctors and lack of continuity of care with the EWTD may well not be of relevance in future with the number of hours still being worked. But the junior doctors, who are in ever increasing levels of debt, who no longer receive free hospital accommodation and who are short changed in their pay slips have once again be forced into an impossible position. We are truly fortunate to have such a compassionate and dedicated workforce.

New horizons

We finally made it, the bookend of the summer and on the cusp of clinical school. Part of me questions whether I should have done something more productive with my time off. However, after working the entirety of the previous summer holiday answering phones in an NHS call centre until I became so numb and disillusioned in my position as an NHS pawn that I started to question how I’d ever function in a real job, I can confidently say I’m glad I took the time off to do nothing of any real importance. I’m sure that many of my peers will have spent their holiday earning a crust, participating in cutting edge research or perhaps building orphanages in the third world, as seems to be the craze presently.

Monday heralds the beginning of our lives as ‘professionals’, as has been acutely demonstrated by the numerous extensive e-mails concerning dress codes, placements and punctuality. We have slogged through the dry, academic and occasionally irrelevant material in order to arrive at this point. I feel an odd concoction of exhilaration and apprehension at the prospect of not just talking to patients, but having to perform basic exams, venepuncture and cannulation for the first time on the unsuspecting poor souls. Thankfully, there shall be a short respite before being dumped on a ward. An intensive, four-week course designed to get our clinical and communication skills to a level of minimal bare competence. This is likely to prove, for some, to be a long four weeks.

There have been a few incidents in the pre-clinical years that have stuck with me. At times, no matter how clued up you may be, it is easy to be lost for words. A short stint in surgery earlier this year has been burnt into my conscience, the first truly poorly patient I’d ever witnessed – just prior to them being admitted to intensive care. It wasn’t that their GCS was hovering around 8, nor that their blood pH had dropped to levels I thought were clinically impossible. Rather, that with the surgical house officer running around and nurses busy with various tasks; I, standing around looking concerned became the perceived information point for a quite anxious next of kin who had just arrived. At first I didn’t realise who they were, instead assuming they were a member of the hospital staff. Eventually after a few minutes of explaining my role as an uninformed observer the SHO turned up and took over. Yet, during the intervening moments of not really knowing what was going on and several failed attempts to explain that I really couldn’t tell them what was happening, as not only I was unqualified to do so, but because I genuinely did not know have since left an impression. That after all, was my first day in hospital medicine.

So comes the next few years of feigning competence, yet claiming ignorance. A difficult balance to maintain, but the barefaced truth being I am eagerly awaiting the nostalgia to come. I’m the Hippocratic Oaf, and I’m a third year medical student.

Service update

Just a quick update, as some of you may have noticed the address of this site has subtly been changed. For reasons unbeknown to the Oaf, the Google wizards decided to suspend the previous address. It would seem that there are a number of blogs that have suffered the same fate, citing a glitch as the proprietor to this mess.

Nevertheless, the Oaf shall persist. For those of you whom previously subscribed you will most likely need to re-subscribe with this new address, for which I apologise.

Thank you all!

Oaf