Hard Mattress

After a somewhat lengthy orthopedic surgery where I had been holding a foot / leg up off the table, Dr. Boots handed over the suture material and told me to get to work.

Me:

Umm...should I come around to the other side of the table?

Dr. Boots:

No, sweetheart just get to work, this man's got a bloody tourniquet on! We don't have time for dancing around. Put in some mattress sutures. 

(Some of you might scoff at the fact that I haven't mastered the mattress suture. As a potentially aspiring surgeon I maybe should be able to do them in my sleep, however, I spent most of my time in general surgery trying to perfect my sub-cue stitches and hand-tying. Bad medical student, BAD!)

And now I have.

And they were a thing of beauty. All two of them. Damn you arthroscopy and your tiny wounds!

Dr. Boots:

There, that wasn't so bad now. No need for all the shivering and shaking. You know my 17 year old daughter can do mattress sutures, no problem. She taught herself.

(Surgical Drape) Curtain Falls. 

[For the record...my hands were shaking because my forearm muscles were maxed out from assisting...I swear! I should also add, Dr. Boots is amazing and kind of like the slightly-unimpressed-but-fantastic-teacher orthopedic-surgeon-father I never had. Above example illustrates the way we communicate. Me, hopeless rube in ortho...him ortho king. Get it?]

Palm Reading

I love looking at people’s hands.

My fascination with hands started when I learned how to I.V cannulate.  I found myself subconsciously evaluating the potential ease or difficulty an I.V start would be, even absentmindedly tapping along the length of a vein (usually creeping out the boyfriend or family member).

Now that I’ve been learning so much about how many clues the hands and nails can reveal regarding systemic pathology, I’m becoming borderline obsessive about looking at the hands of people around me…hoping to see some obscure clue to illness.

Last night I came across a quote in my favorite textbook, “Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery” which I thought encapsulated my rekindled curiosity,

“Regarding the hands, ‘one does not need the mysteries of palmistry to read in them something of the past, a great deal of the present, and even a little of the future. In them is written the record of age and sex; of occupation and habits; of skill or ineptitude; of hard work or indolence’ (Cutler)."

Clinical Exam Follies and Triumphs

This week I had the opportunity to invigilate a licensing exam for doctors here in Ireland. Though no one actually said anything to us about confidentiality I am very certain that I am not able to blab about any sort of details. However, I will say that it was a fantastic learning experience to see how different people perform under pressure, how examiners basically set out to shred you to pieces, and how little things can really affect one's rapport with the examiners.

One thing I will take with me for when it come to be my turn on the sharp end of the short-case examination:  if you are told "examine body part [x]" then EXAMINE BODY PART X!!!!!

I was stunned to see people being told specifically to examine one organ or anatomical location to find them faffing around with other systems, only to the irritation of the examiners. The examiners would sometimes have to repeat themselves several times, "stop, examine x!"

There was one candidate who was my hero. She (somehow) remained calm, did very methodical and well organized physical exams, could rattle off differential diagnosis like a champ, answered all the examiners questions clearly and precisely, and was really personable to the patients. I was mentally cheering her on the whole time and wishing I was her. I also felt devastated for the people who started floundering, crashing and burning, knowing all too well the negative spiral of

stressed

mind blank

higher stress

flustered

adrenaline injection

mind completely barren of thought

fear of failure

despair

quavering voice

certainty of failure 

despair

despair

despair.

It was somewhat reassuring (or depressing, not actually sure which) to see that even people who have been doctors for years still get stressed and fumble during clinical exams, it is not just we doclings. 

Fin

Well my first official hospital rotation has come to a close.

Today was my last day on the surgical team and I found myself staring off into space more than once, feeling genuinely sad. It seems like the last 9 weeks screamed by at break-neck-running-behind-my-consultant-speed. The thought of starting on a new team is a little daunting. I feel as though I just figured out my true place with this team, and that I was starting to habituate to their rhythm.

The apple crumble made big waves, the pan licked clean before the end of 1st tea break. The nurses and porters seemed genuinely shocked that I baked for them and many approached me to say thanks, or "fair play to you" which is the Irish equivalent to something like, "well done" . The porters also pretended to have food poisoning all afternoon (yes, pretended) and one proposed marriage.

When the last stitch was thrown in the belly I didn't know if I should shake M.C's hand in a formal manner, or make some cheeky comment (more my style)...so I just had my chlorhexidine shower (as per MRSA case protocol) and went to the gym.

I was happy to hear nothing but silence when I arrived home. The alarm people had to come and tear everything apart because the thing was completely haywire. I think I am going to start calling the alarm system, Hal, from now on. I was able to un-tape my memory foam pillow and yoga blanket from the wall (dampers) and make dinner without earplugs in, which was a pleasure.

Tomorrow I am going to attempt to review some medicine-y things. Like the heart. And probably the lungs. Look up Na+ levels and try to remember what exactly this condition known as diabetes is, which has come to mean only really really bad leg ulcers in my mind.

And so, I begrudgingly shelved my Surgery at a Glance, Surgical Recall, and my Physical Signs for Clinical Surgery and ordered The Oxford Handbook of Clinical Medicine.

Speaking of clinical surgery...if you haven't watched this TEDtalk by Abraham Verghese, please go make yourself a cup of tea and spend the next 18 minutes watching an extraordinary author and surgeon discuss the lost art of physical assessment. It is another typically awe-inspiring TEDtalk.

It is late so I'll close with a quote by Yeats, cited in Verghese's book, Cutting for Stone, 

The intellect of man is forced to choose

perfection of the life, or of the work, 

And if it take the second must refuse

A heavenly mansion, raging in the dark. 

Clinical Skills?

Today was a review session for clinical skills, where the lab is full of various plastic body parts for students to practice various invasive procedures on.

I was letting Eileen have a go at cannulating my arm (ha! everyone knows that nurses are the worst patients!!) and couldn't help but observe a couple of students practicing IM injections nearby.

Student A was wearing a thick rubber arm cover, student B* was holding the needle.

Student A: Ok, so draw up your fluids and give it a go.

Student B draws up saline for injection, pinches the rubber arm section, and angles the needle almost parallel to the skin, at about 10 degrees.

Student A: Um, are you sure you are doing that right? You are supposed to do it at an angle.

Student B: Well, not a 90 degree angle.

Student A: Yah, but not like that dude.

Student B: I am pinching the skin, this is how you are supposed to do it. (As he injects 3mls into plastic arm, still with needle at approx 10 degrees from skin surface). Whatever, I don't care, I am sure that is right.

5 months people, 5 months until we hit the wards. Good times. Oh medical students, sometimes the perfect combo of arrogance and inexperience!

---

*Student B is one of the top students in our anatomy class.

IV Starts

Today in clinical we are learning the fine art of I.V cannulation. 

This oughtta be interesting. 

Last year I had to just about bite my tongue off when we were taught to aspirate before injecting in IM and SC injections. When I was in nursing school *cough* 11 years ago that had already been turfed thanks to evidence based medicine that demonstrates the only area where this is indicated is in dorsogluteal IM's (even there it is debatable but certainly NOT indicated with SC injections). 

Ok well initially I didn't bite my tongue and said it to another student but the bat-like hearing of our clinical skills prof exposed me and I was told in no uncertain terms I would fail the OCASE if I didn't aspirate. Sigh. I muttered something about doing it for the exam and never again. (BAD medical student!! BAD!!!)

Anyway, I am interested to see how the IV starts are going to be taught. I wonder how many I may have done in my career as a nurse? Hard to calculate but based on rough figures...7 years, 200 shifts per year (with great variation in # of starts per shifts) maybe averaging 6 starts per shift...that comes out to 8400 starts. Okay even if that is a gross over-estimation, I am well past the 5000 mark. Hey! That is kinda cool. I never actually figured that out before. 

Below is a comment that I left on Rob's blog ages ago when he wrote about learning how to start IV's. They are some of the little tips/tricks I've gleaned mostly from other nurses, much more experienced than I. 

--

I love IV starts. These are some of the rituals I go through when I am starting an I.V. 

First off, most people believe that there is a metal needle in their arm. When people are really anxious about it (esp PEDS) I show them how it works with a demo needle that I chuck. It seems to really calm a lot of folks down. I only usually show adults if they are going to have the IV in for a long time, it makes them more relaxed about moving the tethered limb around. 

Some tricks I use for tough starts (I am sure you know these already but in case you don't):

-In the elderly with the feathery skin and veins don’t use a tourniquet as you are more likely to have it roll or blow with the induction. Just anchor the vein above the site with the thumb of free hand and go at a very superficial angle. As soon as you get flashback take the needle out and gently advance the catheter. 

-For tough starts go for the radial vein near the wrist (usually very juicy as not many people use it).

-Warm people up with either warm blankets or (my personal favorite) 100cc saline bags that you put in the microwave for 10-30 sec. This is great with PEDS also, I warm the bags up then kling wrap the bags to their hands and feet–go off and do some other task and when you return–BAM! the veins are waiting for you. (Just make sure you hold the bag on your own skin for about 10 sec to make sure it is only warm not hot. I think that hot wet towels are a bad idea because as soon as you take them off it cools the limb down a lot and if you get caught up doing something else then you have a cold, wet limb to try and salvage a start out of. Dry heat is better.)

-Drop people’s hands so that their arm is hanging below the chair. 

-Don’t slap the veins as sometimes that causes them to flatten out.

-Take your time. 

Really. I spend as much time as I need just chatting with the patient while I palpate around for the best vein. The longer I take to find a good one, the greater the likelihood I’ll find one on the first poke.

-Don’t be afraid of small guage needles on hard starts. No matter what they tell you blood *will* run through a #20, even a #22 in a pinch. Not everyone needs a #16 in the pinky to prove your abilities.

-If you hit a valve going in, you can try to gently push through or just pull back a bit and if the line is good just secure it there. 

-Tape is our friend. Use paper tape on the elderly, especially if you don't feel like tearing their skin off when you d/c the I.V. 

-And finally, feet are sometimes better than you think. Esp in people who’ve had lots of chemo or alternative drugs (ahem) in specific veins.

So there you go blogworld. My free, unsolicited advice on I.V starts. Now I am off to learn how to do it! There may be some major tongue biting today as well, but must go and see what the gold-standard-medical-school-OCASE-way of doing it is. 

I won't mention my aversion to gloving with difficult starts!