Merry Christmas

Hi,


My last week before Christmas holidays, so a merry Christmas and a Happy New Year you all (or a 'Happy Holidays', depending on which you prefer). The last term has been 16 weeks long, which seems like it has been quite long, given all the essays and the SJT that have had to slot into it as well, so I am looking forward to a nice relaxing Christmas holiday, though revision will have to start soon for finals. Finals are still a long way off, around late March, early April (I think, though I am not definite), but I am not sure my usual revision method will work out too well (cram fervently a week or two before) due to the large volume of facts that I should know but I don't. 

As for this week, it was my last week of my obstetrics and gynaecology rotation. We only have two weeks of this speciality in 5th year, as we have some experience during our 3rd year, and this is meant to just be a refresher. I have been trying to make the most of it, as I cannot remember a lot of my third year as it was so long ago! 

The best part of this week was finally getting a chance to practice my suturing skills on a real live patient. Those who read this relatively regularly will remember that I had lots of practice last week in tying knots (though I did spend most of my post last week complaining about the SJT... sorry about that...) This week I got to practice them for real in theatre, closing up holes in the abdomens of all patients who needed a laparoscopy. These holes only need a couple of stitches  as they are pretty small (large enough to put a small camera down for the keyhole surgery) but its still good 'real life' practice for me. The gynaecological consultant is fantastic in trying to get me as involved as possible, and the team are great fun as well. I can see the appeal of being a surgeon. You do your work in the theatre, which you hopefully enjoy, then you get to go to the staff room and relax for half an hour or more while the patient is taken away, the new one is prepared and sorted out by the anaesthetist, and then you come back and operate again. Quite a relaxed job! 

I do have a scare in one of the theatres, though. I am late to one of the later operations, as I am answering a bleep for one of the registrars, which means I don't know why the patient is having this operation. I am asked to hold something for one of the more junior doctors, as he has to leave, and warned to be careful in case I damage the uterus. Not too sure how careful I need to be, I try and treat it like paper until he returns. Later on, they are talking about a ruptured uterus, and passing dye in through the cervix to watch it leak out into the abdomen. I am petrified that I have made a hole in this poor ladies uterus, but it turns out that she was being operated on for a suspected hole in the uterus, after having a hysteroscopy in Yemen (for some reason?!). I am very glad that this wasn't me, but I suppose this highlights the dangers of surgery and how you have to be careful with everything you do. It also highlights the dangers of having invasive tests done in an underdeveloped country.

While I had good experiences in theatre, I struggled to get much obstetrics experience at all. There are a lot of midwifery students at this hospital and, rightly so, they take precedence over me in getting involved in normal births. Because there were so many students, every time I went to the delivery suite, all women who were giving birth were already partnered with a midwifery student, and those who were due to come in had already had students assigned to them. I spent some time with the obstetrics doctor, though the doctors only tend to get involved when there are problems with labour, rather than in normal deliveries. I did leave my bleep number with the midwives, as they told me they would bleep me as soon as there was someone going into labour who didn't have a midwifery student assigned. I didn't get bleeped though. It is a shame, I agree that you don't really want more than one student in the room when there is a woman giving birth, and the midwifery students need a lot more experience in this than medical students do, but it would be nice to have just a little experience of normal births. I hope I don't run into someone in labour on a plane or something similar, or if I do, I hope there is a midwife present!

Anyway, have a lovely Christmas period, I am off now 'til Janurary, and I will keep you posted after that.

The SJT

Hi,


Despite my new start on an obstetrics and gynaecology rotation this week, the most 'important' thing that happened was sitting the 'Situational Judgement Test' (SJT) - if you want to have a bash at it yourself click here for the official practice site. The SJT is a test which gives you multiple choice options for 'situations' you may find yourself in as a foundation doctor, meaning it is not really knowledge based. This is the first year it has been used properly, so we will see what happens, and it is a test that every final year medical student in the UK now has to sit. It is important, as the results are used to allocate where you work on graduating, and which jobs you get. Do well and you could be doing paediatric surgery in GOSH (if you want...), do badly and you could end up in the Shetney Islands working with incontinent sheep... Well, perhaps not, but you get the idea.

The main problem with this test is that, amongst my year at least, it is perceived as much more of a luck-based-exercise rather than something that requires any skill. One of my friends was telling me that during the pilot phase, two groups were set the SJT, one who had been coached to do well, and the other one hadn't. No difference was seen between the two groups, suggesting that you couldn't practice for it. I don't really like this, as surely you should be able to practice for pretty much anything, from hard maths to soft 'communication skills' - they should all be something that you can practice and get better at. If practising the SJT questions doesn't make any statistical difference, then to me this suggests that the test is far more luck based than anything. After all, you could coach me for a year, but I wouldn't be able to get a (fair) dice to roll any more sixes than you could... 

As you can imagine, the feeling that where we will have to work in future, and the jobs that we can get is being decided by fortune has lead to plenty of outraged Facebook statuses and the like, but sadly there is little that can be done. Despite this feeling that it was luck-based, everyone (myself included) practiced as much as possible for it in the hope to get better scores. It would be stupid not to. I got a couple of books out of the library and have signed up to Pastest for exam revision (generally seen to be one of the better online question banks) as they also have SJT practice questions available.

The problem was, the books all contradicted each other. I looked at three in the end, 250 SJTs, the Oxford Assess one and a Third one. Of the three, I preferred the Oxford Assess one, though in some way or other they all contradicted one another at certain points. If they cannot agree on answers to questions, then how are we meant to be able to guess ourselves! Often picking the best one or two answers is pretty easy, but it is when ranking the 'inappropriate' ones that things get difficult. If the answers are all wrong, it is hard to decide which are more and less wrong. For example, in Pastest, there is a question about walking in on your registrar watching pornography in the mess, and you have to chose what to do about it. Pastest have decided that calling the police 'ranks higher' than doing nothing at all. I disagreed with this, as what interest would the police have in something which is not a criminal matter? Sure, it is very unprofessional, but I don't think the police would come and perform an arrest (though if it involved children I am sure it would be a very different story). I filled in a box at the bottom of the pastest page, saying I disagreed, and I got a very snotty email back from them telling me I was being foolish, and linking me to this article (which tells us the police did not bring charges anyway). I was impressed that they replied, and backed up their argument with a newspaper story, though. Despite this, the next day I was doing questions from the 250 SJTs book, and the exact same question came up, very almost word for word. the 250 SJT book had different answers, and told me that the police definitely wouldn't be called, as they were not breaking the law, and the police wouldn't be able to do anything. Crazy.

Anyway, the test went OK, though it is very hard to tell how well something that seems to have very little basis on fact went. I am not sure if the practice I did before helped, but at least if I do poorly and do end up working somewhere I don't want, I will not feel that it is through lack of trying. This whole section has turned into a bit of a rant about this test, so I am sorry about that!

In other news, this week I also spent time in gynaecology clinics, antenatal clinics and practising suturing with a very friendly consultant who will hopefully let me practice on real patients next week. The gynaecology team is lovely and very inclusive, so hopefully I will have a lot more to talk about next week when I am not raging about this test...

I will keep you updated on how my application goes, though I will not find out until February. 

Illness

Hi,


A late post, yet again, but I have been ill so perhaps that goes some way towards an excuse... This was my second (and last) week of paediatrics, so I spent time on the wards and ended up catching an infection from one of the ill little kids... The main thing of interest that happened this week (apart from the really important medical student getting ill) was a fantastic piece of clinical detective work which came from one of the doctors on the ward; something House MD would have been proud of.

Me being ill isn't really blog-worthy, so I will brush over it. There are a lot of sick children in paediatrics, especially babies with bronchiolitis around this time of year. I think one infected me with a virus (perhaps RSV, who knows) and I had to take the last day and half off last week with general coryzal symptoms, generalised myalgia and headache... Or man-flu... whichever you think fits best. I am feeling a lot better now, though.

It is a terrible disease... Honest...

Back on track, I spent most of the week when I was in hospital in a variety of different ward rounds and clinics with the nasty children which then went to make me ill. The best part was during a handover, when all of the patients are discussed between the day and night team, to make sure everyone knows what is happening with each patient at that moment in time. One of the patients, lets call him Billy, had been in the ward for the last few weeks, and was receiving chemotherapy for a rare type of cancer that had started in his tummy, but spread out across his body. The subsequent scans had suggested that this treatment was being very effective in controlling the cancer, and it was all shrinking, but overnight the night team had noticed that one of his pupils had become fixed and dilated (a blown pupil).

Blown pupil seen here in the patient's left eye

This raised a lot of worries, most importantly the worry that the cancer had spread to the brain, and was growing there, affecting the nerves coming out of the brain by pressing on them and creating this symptom. The night team had arranged a whole host of brain scans and investigations to be carried out this day to find out what was happening. One of the paediatric consultants, who always dresses pretty shambolically and behaves a little like a crazed professor started asking the night team questions

"Is the patient on hyoscine for the chemotherapy?"

Yes he is, they answered, he has a patch on at the moment

"Where is this patch, is it on his neck perchance?"

Why yes, its on the left of his neck, a bit above the clavicle"

"Well that is the answer, then. Hyoscine is an antimuscarinic, and the drug is passing through the skin into the blood vessels which then feed into the eye, dilating the pupil. Change the position of the patch."

And hey-presto, the patch position was changed to the other side of the neck, and the eye slowly went back to normal. A lot of stress for Billy and his parents avoided, and a lot of expensive (and radiation-filled) scans avoided. A simple diagnosis made without any fancy hospital tests, just a brain. That is the way medicine should be done!

To wrap up, the boy who was hallucinating snakes was discharged this week, with no medical cause found for these sightings. This is good, as it means he hadn't accidentally eaten some illegal/legal drugs, and he didn't have a brain tumour, but it did leave a question mark over the diagnosis. The children's psychiatric team were involved, who decided he seemed he may be slightly on the autistic spectrum (and wanted to follow him up), but they were not sure where these hallucinations came from either. The final decision was it must have been a nightmare which had started this off, and the psychological trauma which this nightmare (i suppose about snakes) had caused had lead to these hallucinations. This has been documented before. Not a perfect answer like I was hoping for, but it is the best we could get... A little like the finale of lost.