Basic clinical skills

I was partnered with James as we practiced through skills discussed earlier in the hour.

Like myself, James wishes to become an ER doctor and has a solid background in biomedical science as his undergrad, however, lacked clinical experience and application. This was the complete opposite to myself so we made a good team (I think).

So for the next twenty minutes, we practiced on each other:
* Taking a pulse on the radius, followed by brachical, carotid, popliteal (difficult!), medial malleolus (even more so) and dorsalis pedis pulses (very difficult for me to find on James, but he could find mine pretty easily).

* Using a handheld doppler device to listen for the pulses at the various sites respectively.
* Taking a respiratory rate.
* Taking a tympanic temperature.
* Taking an axillary temperature.

James was a great sport and was very fit (judging by his resting heart rate of 56!).

Whilst these were relatively easy skills from my paramedic days, I was still happy to refine rarely used ones like medial malleolus pulse, dorsalis pedis pulse and the use of a handheld doppler device.

Initiating the Consultation

"Ms Maringich?" I asked.

"Ms MarDENgich" she replied.

I blushed.

"Oh, sorry. My name is Andy, I'm a first year medical student. Your usual GP is currently busy with another patient and has asked me to take gather some information from you before he attends to you. Is that alright?"


"Sure"


I pointed towards a chair in the "consultation room".

She enter and sat down as I took a chair opposite her.

"So, what brings you into the clinic today?" I asked.

"Well... I've got this headache..." she started. "for a couple of days..."

She paused.

I tried to fill the void.

"Ah, you've got headaches for a few days. Anything else?"


"And I've been having some nausea."


Again, she paused, appearing shy.

"Okay, you've got some nausea and headaches for a few days. Anything else?"


She looked away, eyes cast down towards her left.

"Oh, this is a little embarrassing." I tensed. "I've been having some... err, constipation for a few days as well."


I let out a mental sigh of relief. Thank goodness it wasn't some women's business!

"That's okay. So you've got some constipation and nausea. Have I missed anything?"


"Yes, and the headaches too."


I apologised and resummarised her chief complaints.

"So, for today, we'll have a talk about your constipation, your nausea and your headaches. I'll then have to ask you a series of questions about your condition, then possibly conduct a brief physical examination before presenting this to the GP. Is that okay with you?" I asked, awkwardly, especially being a male and implying I was to physically examine a female.

She nodded.

I nodded, breathed a sigh of relief and  looked across to my right.

Two other medical students observing this interaction gave a quick clap and a supportive smile.

Feedback was given by the "patient" (a fellow medical student, whom was actually a guy playing the part of the female patient) and the two observers.

Some points I need to work on:
* I need to stop my hands from rolling over each other as it could be implied I was hurrying the patient up, which I unconsciously did when summarising the points.
* Make an effort to engage the patient in friendly conversation, finding out more about her and her life / family situation prior to the "formal" interview, especially with an indigenous patient.
* Think about what I should say beforehand, especially when negotiating the agenda.

However, feedback was positive in my body language, in making clear what was to happen, and in identifying myself as a medical student.

Slowly slowly :)

Competing priorities

I could see her mouth move on the video screen, the cursor moving across the projected screen.

She was pointing at some pink and blue bits on the computer screen.

Old memories surfaced on haematoxylin and eosin stains.

Way back in undergrad days, we used microscopes to peer into H&E stained cells.

But there were no microscopes present, no physical slides and no lab coats.

Instead, a giant H&E stained picture projected itself onto the screen of the lecture theatre.

However, on my computer screen in front of me sat the latest breaking news on federal politics.

It seemed so much more interesting than being taught histology by video conferencing.

Why Doctors Die Differently

Came across this really interesting article. Do have a read:

A Doctor on How Physicians Face the End of Life

Loss

Word spread like wildfire amongst our PBL groups.

Bill had decided to leave the course.

We hadn't seen him at dissection earlier which surprised us.

I respect his decision, I hope it was an informed decision.

I'll miss Bill, he was a really nice bloke.

Introduction to Dissection

Bright shiny stainless steel stacked against the side of the trolley.

We line up in a row, taking one from the stack before obtaining the shiny instruments right next to it.

Scalpel.

Forceps.

Long Probe.

Paper Towel.

We file past this trolley to the next.

On top lay fifteen hearts all neatly resting on another stainless steel tray.

One by one, we filed past, grabbed one and plopped them on our once-spotless tray.

It was still soft.

And moist.

Under the gaze of the anatomy lecturer, we explored structures of the heart, noting the auricles, seeing the differing wall sizes of the ventricles, probing the strong chordae tendineae and admiring the seemingly fragile semilunar valves.

Didn't realise I would enjoy it as much. Definitely tied the past theory lessons. 

What a brilliant session.

Mantoux

"Next" called a voice from next door.

I got up and walked into a 1960s styled room, equipped with a faux-wooden lino bench and cupboards that had seen better days. On a black very old and chunky seat sat a middle aged female nurse.

"Name?" she called without looking up.

"Andy..." I replied.

"And you're a... ?"

"Medical student".

"Ah" non discreetly.

She continued, blase. "Bring out your arm and let's have a look."

I revealed the red mark on my anterior arm where a few days previously another nurse had poked me with the Mantoux test.

"Emm" as she used a pen to draw on the skin, determining the size of the lump.

Once the border was clearly defined, she used a ruler and measured the size.

14mm.

She looked up.

"You know what this means?" she looked up past her half glasses.

I nodded.

She pulled out a card the size of a credit card, jotted a few details down such as my name, date of birth, today's date and size and handed it to me.

"Ring that number and make an appointment for a chest X-Ray, then we'll arrange for a doctor to see you."

And with that, the consultation was over.

Next step: Chest X-ray in 3 weeks.

Projectile vomit, lecture style

Our first real medical sciences lecture (apart from the introduction yesterday).

Topic: Cardiovascular system.

Thoughts? Projectile vomit.

The lecturer was great, he was obviously very well experienced as a clinician. However, his presentation style was a little weak, but in his defence, he didn't make the powerpoint presentation.

So unfortunately, he basically read off the powerpoint presentation at the speed of knots. By the end of the half an hour (the lecture was supposed to take 50 minutes), the entire class looked like stunned mullets.

Two hours of reading and researching in the library resulted in a bit more of an understanding as I grappled with Starling's Law of the Heart, Frank-Starling Curve, End Diastole Volume, End Systole Volume, Stroke Volume and Cardiac Work.

Better hit the books again!

First real day

Now that orientations are all over (thankfully), we got down to the nitty gritty class work. I've been anticipating this for a while now and it was, well, rather boring.

We had another welcome by the Dean, followed by introductory sessions on the medical sciences classes. Next we had some surveys to fill in (naturally) including one which was on our personality types.

Another free lunch (yay!) following by another jab, this time specifically Mantoux testing and obtaining a hospital pass.

However, I did learn about the Calgary-Cambridge medical interviewing method which we're expected to master in the next few weeks. Also learnt a bit about basic observation taking (in theory only).

The day past by relatively quickly and like orientation week, I didn't have enough lunch resulting in a rather grumbly stomach.

Not a bad first real day.

An unexpected delivery

Our local hospital, usually, can avoid ramping but unfortunately today there was a massive influx of patients which resulted in all five operational ambulances being ramped.

So, today, I was fortunate and obtained an overtime shift as the ramp team which involved taking over a crew’s patient and babysitting them until a bed is available within the main department.

This was expected to last five hours. In the end our team was there for over twelve.

At 5am, we were looking after a patient whom was hypotensive. As there were no beds available, we had to look after him in the corridor and attempt to increase his blood pressure through intravenous fluid replacement.

Next  to us was a minor treatment room where low acuity patients were brought in by the triage nurse.

In came a female patient complaining of abdominal pain and a friend whom had driven her to hospital. The nurse on duty asked here the usual questions – how long had it been there for, any diarrhoea / nausea / vomiting, any allergies, had she eaten anything unusual.

As a doctor did not normally staff this area, the nurse had to go back to the main department down the hall to obtain a doctor’s order for some medication.

At this time, the patient decided she needed to use the toilet which was diagonally opposite where we were caring for our patient, supported by her friend.

“Help me…” came from the toilet 30 seconds later.
“Help me… Help me! SOMEBODY HELP ME!!!” she yelled

The patient’s friend and I looked at each other.

From the toilet emitted a buzzing noise and an orange light flashed about door. She had pressed the emergency assistance button.

The friend rushed to the door and as I was the closest person around (and was opposite the toilet), went to assist and tried to open the door.

The patient had locked the door so it took some forceful statements from her friend to get her to unlock the door.

Click.

The friend swung open the door and let out a scream.

We were greeted with a bloodied floor and blood in the toilet. The patient was half bent over and a baby crowning.

Without thinking, I rushed in and supported the baby as it delivered the rest of the way. Grabbing the shoulders and the legs, the baby turned out to be a full sized baby boy and before long, he started crying.

“Oh my God, Oh my God” she kept saying over and over again.

The toilet was stained red with blood and amniotic fluid.

A nurse had arrived by now and poked her head through. It must have been an odd scene; a woman bent over, arse in the air, paramedic at the back end next to a bloodied floor and toilet holding a very slippery baby boy.

“Delivery pack!” she shouted and disappeared.

I tried to gain rapport with the patient.

“What’s your name? I’m Andy”

“I’m Emma. Oh my God. I didn’t realise I was pregnant!”

Right.

She continued.

“I’ve missed three periods but I didn’t even know.”

Another head appeared inside the door, this time, thankfully being the senior registrar. She was really quick and rapidly applied two arterial clamps to the umbilical cord and with a pair of scissors (after some tugging) managed to cut the cord.

A nurse handed over a warmed blanket and after wrapping firmly the baby boy in the blanket, quickly gave the new bundle of life away to another nurse.

I poked my head through the doorway and was surprised at the large group of doctors, nurses and orderlies now surrounding the toilet. They even had the foresight to roll the humidicrib over with which the baby boy was now in.

“A towel or a sheet please… for mum” I asked to no one in particular.

A towel appeared from nowhere and after wrapping mum, supported her as she walked outside into an awaiting wheelchair where she disappeared upstairs for her placental birth.

In spite of the blood on my shirt and with very bloodied gloves, I had a massive grin on my face. What an expected delivery and the first one in a hospital setting (in a roundabout way).