Do No Harm (Hopefully)

29. UK. Finally a doctor after some delay. Terrified. Tired. But hopeful. This is a side blog, please don't be offended if you don't see me following you/liking your posts. I probably do, just ninja-like. Some tangerines were harmed in the making of this blog. For science, of course.

[do-no-harm-hopefully]

Guess who's still alive and thriving?

So I'm aware that I've been... exceptionally bad at updating this. Last proper life update in April 2023. But I figured it's about time for a correction.

Short version: did some failing, got some meds, did some succeeding for once, started a new job in a different region, and now kicking ass and taking names as the ward monkey doctor I was supposed to be. And got engaged in the middle of it all.

Long version? Below the cut.

Finished out the rest of my clinical placements. They went swell, especially O&G, which I'm now more convinced than ever I want to pursue. Sure, gynae is my main lean and accidentally ending up as first assistant on a nine-hour op was awesome for a med student, I still loved the obs clinics and CS theatre. When you even like the parts you don't want, it's a win.

Went through the Oriel allocation system for Foundation Programmes, and ended up with my 11th choice. Ouch.

...and then didn't pass written exams. Or resits. Again. And this time, subject to dismissal from the medicine course. Unless...

...there's a reason for a pattern of failing writtens and passing clinicals every time. Guess who after much wrangling, ended up with an ADHD diagnosis, medication for it, and a successful appeal to a second repeat year?

Final year take 2 actually felt so much smoother in many ways. Clinically, familiar enough with the settings to know where to get the most useful experiences. Educationally, coping much better with ADHD-sensitive exam strategies from the personal tutor and reasonable adjustment. Socially, I was moved between different streams rather than slotted into one, which made it easier to make connections and friends.

Decided that I didn't want to have a girlfriend anymore, so I made her my fiancée instead. Not really medical, but too important to miss!

Did final year written exams again... and actually passed this time.

Got allocated through the next Oriel cycle, and after strategically choosing a different but still acceptable deanery, got into the first choice. Not a genuine first choice, but good compromise.

Assistantship (pre-employment apprenticeship) with breast surgery and respiratory went by like a breeze, and extremely glad at the building confidence. Can't lie, having a consultant ask you if you can cover a bay today under indirect supervision 'cos of short-staffing, and feeling confident enough to say "sure, no problem" is wild.

Finally graduated and left the place I've felt trapped by for over half a decade, and was even able to admit I'd miss a few things, like some of the people, the flat I'd lived in, and even the hospital.

Moved to the deanery and took up a new post - as a doctor, at last!

And here I am, starting out in general surgery (don't get too excited, FY1s barely leave the wards and their discharge letters!). Very fond of my fellow FY1s, we're a very tight-knit group looking out for each other, and ended up very lucky with some very supportive SHOs and registrars.

(Shout out also to our very lovely PTs, dietitians, at least some of the nurses, and especially the ward pharmacist, who our whole office adores.)

Have been coping well with the actual work in general surgery. Have had a few rough experiences (like a very traumatic first time on-call), but overall managing well and growing in confidence (helping my much-younger colleagues as the oldest of the group definitely helps building that).

Gaining skills with US-guided cannulation*, doing my own solo reviews/mini-ward rounds, managing a few medical emergencies, churning out discharge letters and death certificates**, getting past my own anxieties to hand out opioids like candy to patients who actually need it. Even ended up mentoring a few medical students of my own, and giving a few departmental teaching sessions coming up!

So yeah. I'm doing okay, I think. 🥲

*I mean... I suck at it, but I usually end up giving up on the US part and cannulating the patient who's "impossible without ultrasound" without ultrasound. Turns out, I can succeed more often than many of my colleagues have tried and still feel unconfident!

**Don't @ me, all but one were expected and palliated, and none died because of my (in)actions, long may that last!

[byjove]

just saw a death certificate from rural 1938 where the attending physician put “DON’T KNOW. NO DIAGNOSIS.” as the cause of death. bruh.

[doctorofwhut]

Wait, are we allowed to do that?

[do-no-harm-hopefully]

I actually once jokingly asked the bereavement office if I could put something like this on a provisional certificate that I knew damn well would be rejected and go to coroners anyway. (Had to put it through anyway, local process.)

They laughed for a good 15 seconds, stopped cold to give me a chillingly stern look, and then skipped an answer altogether and just said “Anyway.”

[do-no-harm-hopefully]

So uh, I've been... quiet. And there's a lot to catch up on, what with the whole repeating-a-year-again business and a new diagnosis that's helped me get through yet another repeat - not even to mention outside-medicine things on the side, like getting engaged.

And hopefully I'll have time and headspace to come back for a fuller update. But the key important update I have to get out now:

Today was my last clinical day at the hospital I've been studying at for the past six years.

And at last, I've stopped bothering to correct people when they call me Doctor Hopefully.

Because I am already in all but name. And in a few weeks, I will be in name too.

[do-no-harm-hopefully]

So it’s been a hot few minutes months since I posted and now a double update on my recent chaos-filled escapades is probably in order (since I’ve done 2x placements without update, including my beloved O&G). But since I am shattered today from a ludicrously long op, until then I wanted to highlight the pure gold that is Geeky Medics’ Theatre Etiquette:

(There is a fourth historical reason, which is fear of static discharge igniting oxygen or other explosive/volatile substances in use. These substances have largely been phased out of theatre use as well as additional anti-static precautions in flooring design, but still relevant in less updated settings.)

(Seeing consultants scrubbing with plain rings on while having vivid memories of other students being yelled at for wearing them on the bare-below-elbows wards definitely messed with my head a bit.)

(In my particular hospital this is also a typical calling card of the anaesthetist, who is most likely to be drifting between theatre areas. They do look super cool though. Then again, anaesthetists usually do anyway.)

(I have never in my life heard anyone ever offer “a hug”, only ever a huddle, presumably to avoid precisely this confusion.)

(On the topic of surgical lights: also be wary of banging your head on them if you’re shorter than the surgeon. I’ve forced the replacement of more than a few sterile handle covers by bumping them!) 

(Guilty as charged, but untrue in my case: not to brag too much, but I’ve been one of the more popular singers.)

[do-no-harm-hopefully]

Everyday I feel guilty that I may have not done enough for my patients. As a newly minted doctor, I still wonder whether I should be given this responsibility to practice medicine but then a patient tells me I was the only doctor who tried to explain their condition to them, the doctor they enjoyed talking to, the doctor they can trust, the doctor they're thankful they got and I think maybe I am meant to be one? Maybe this is what I'm supposed to do after all?

Anyway, hang in there! It never gets easier, you just get better is what I always tell myself.

Awww, that's such a fantastic experience! Every now and then we need little reassurances and reminders that we're in the right place and doing the right thing, so I'm glad you got it when you needed it. :)

[do-no-harm-hopefully]

Where art thou? No updates

Oh hi, thank you for asking! Really wasn't sure anyone read deep enough into my About page to reach the "remind me to get my rear in gear" part!

I am alive! And quite well actually! Just been very, very busy recently, long overdue for an update but one had to come sooner or later. Been on my GP placement for a good few weeks, and sad to be nearing the end of it, been such an amazing experience compared to previous blocks.

Definitely a jump in the deep end (from day 1 it was "here's a room for you, here's your patient list, good luck!"). But it's been incredible how obvious to me the growth and jump in my confidence, independence and familiarity have been. Like, the imposter syndrome has been inverted: hard to feel like I don't belong when I'm giving medical advice which is as good if not better than the practice GPs (no judgment to them, everyone has knowledge gaps, and I have my little niches of expertise).

A whole range of meaningful patient interactions some wholesome and sweet (the wonderful compliment mentioned in my last post for example), some considerably more difficult and emotionally-charged, but tbh I've gotten so many learning points from all of them that I couldn't begin to explain. And the practice itself was very sweet too, great relationship with all the GPs, nurses, receptionists and admins, definitely made it easy to become part of the whole team.

Sadly enough I'll be leaving soon like I said, but next I'm rotating onto my longtime love (obstetrics & gynaecology), so hopefully more good things in the future?

[do-no-harm-hopefully]

“Thank you, Dr Hopefully, for being so thorough.”

“Well, not quite a doctor yet, but you’re--”

“Then hurry up, we need more good ones.”

[a-cloak-deactivated20241120]

Hyperkalemia intro with mnemonic!

[a-cloak-deactivated20241120]

For Year 2 medical students/ medical professions. Insulin analogs mnemonics.

[a-cloak-deactivated20241120]

Hypoglycemia introduction summary!

[do-no-harm-hopefully]

(In a tutorial looking at radiographs of fractures)

Teaching Fellow: Anyone want to shout out what you see in this radiograph? Other than the interesting artifact ideally?

Me (barely contained laughter): Is this seriously an example of a Throckmorton’s sign?

Teaching Fellow: Is this a what.

(Turns out, yes, they were referring to the penis as the “interesting artifact” but had not heard of Throckmorton’s sign before. Score: Tumblr 01, Teaching Fellow 00)

[do-no-harm-hopefully]

In the search for Medblr's equivalent of vanilla extract, I now present my horror show:

Create a new crystalloid solution for fluid resuscitation.

Water (H₂O)

Sodium Chloride (NaCl)

Calcium Chloride (CaCl₂)

Potassium Chloride (KCl)

Glucose (C₆H₁₂O₆)

Sodium Acetate (CH₃COONa)

Sodium (S)-Lactate (C₃H₆O₃Na)

Sodium Gluconate (C₆H₁₁NaO₇)

Magnesium Chloride (MgCl₂)

Sodium Bicarbonate (NaHCO₃)

Voting ended onFeb 13, 2023

Please note: this is just for fun and is in fact a terrible idea. I will not be making this solution or putting it into patients, and I highly suggest you follow my example.

The only point of this is to create a sequel to Hartmann's solution so abominable that anaesthetists, nephrologists, ED doctors and other clinicians can all unite in their shared hatred of it.

The rules: poll will be open for 1 week, all percentages will be taken as relative amount, in mol or mmol, compared to each other (for context: 1L of normal saline contains 0.154 moles of sodium chloride in 55.5mol water).

[do-no-harm-hopefully]

Okay. You people. Here are the final results:

Let's just take note of why I included max solubility (at 20°C wherever possible): y'all tried to dissolve nearly 12kg of solutes in 108mL of water.

Any one solute would have surpassed saturation in this solution. This "hydration fluid" is literally a pile of salts sitting in a tiny drenching of water. I mean, there's no way in hell you could get this through an IV without clogging it up, but words cannot describe the carnage if you did.

Let's look at fan favourite glucose alone - easily the Medblr equivalent of vanilla extract with 25% vote share - giving us ~4,167g/100mL. Put that into a standard 500mL over 15min bolus for initiating fluid resuscitation, and that means 20,835g of glucose. Let's generously assume we're putting that into a person with a healthy blood volume, 5,700mL, and at the lower tolerable end of fasting blood glucose levels at 700mg/L blood or 3990mg (3.99g) overall.

For context:

Normal Fasting Blood Glucose: 70-99 mg/dL

Prediabetic Fasting Blood Glucose: 100-125 mg/dL

Diabetic Fasting Blood Glucose: 126+ mg/dL

Typical DKA Blood Glucose: 250+ mg/dL

Typical HHS Blood Glucose 600+ mg/dL

Highest Recorded Survivable Blood Glucose: 2,656 mg/dL

Your result has given our fictional patient a blood glucose 126x the highest known survivable level. A hyperosmolar hyperglycaemic state to end all hyperosmolar hyperglycaemic states. Good job Medblr, you've officially created the stuff of nightmares that will finally bring something all the specialists can agree on.

[do-no-harm-hopefully]

In the search for Medblr's equivalent of vanilla extract, I now present my horror show:

Create a new crystalloid solution for fluid resuscitation.

Water (H₂O)

Sodium Chloride (NaCl)

Calcium Chloride (CaCl₂)

Potassium Chloride (KCl)

Glucose (C₆H₁₂O₆)

Sodium Acetate (CH₃COONa)

Sodium (S)-Lactate (C₃H₆O₃Na)

Sodium Gluconate (C₆H₁₁NaO₇)

Magnesium Chloride (MgCl₂)

Sodium Bicarbonate (NaHCO₃)

Voting ended onFeb 13, 2023

Please note: this is just for fun and is in fact a terrible idea. I will not be making this solution or putting it into patients, and I highly suggest you follow my example.

The only point of this is to create a sequel to Hartmann's solution so abominable that anaesthetists, nephrologists, ED doctors and other clinicians can all unite in their shared hatred of it.

The rules: poll will be open for 1 week, all percentages will be taken as relative amount, in mol or mmol, compared to each other (for context: 1L of normal saline contains 0.154 moles of sodium chloride in 55.5mol water).

[do-no-harm-hopefully]

Week 1 in ED done

Oh look, an update from me without any particular purpose, been a while since one of those! I’m pretty shattered and there’ve been a few meh spots throughout the week (mix of hospital time and teaching time), but mostly, and especially my time in ED itself, it’s been a good one. 

Put more cannulas in in one week than I have in all the years prior, played an active role in an arrest team in an ALS setting, so many blood gases I’ve had day-nightmares about the machines demanding 15+min to run a sample, been left unofficially in charge* of management for more than a few patients (*with a supervisor always next cubicle over), briefly followed a patient into interventional radiology for a percutaneous embolisation... and perhaps most delightful of all to me, felt useful in both my knowledge and actions for one of the few times in my medical degree.

Like, I’m fond of obstetrics & gynaecology and am still very strongly leaning towards it, but I gotta say: I like Emergency Department. A lot.

[do-no-harm-hopefully]

Pet peeve: algorithms being appropriated for things they were never validated for

So I had a simulation day recently, which was actually a really useful experience (first time even practicing being the lead on an acute patient’s management), but one of my incidents bugged me. Sim patient comes in with a history of COPD and a very clear ongoing exacerbation.

A to E goes fine and dandy, oxygen titred to hold at around 92% sats for a known retainer, salbutamol back-to-back, ipratropium, steroids as required, bloods incl. cultures taken, regular ABGs and CXR pending because the fictional portable machine is busy. And then I dawdle ‘cos I’m not sure whether to also prescribe Abx for a potential infectious exacerbation via pneumonia. Temperature is normal, not able to bring up any sputum, so fellow med student suggests I look at CURB-65 score. 

Instant regret. He’s already scoring a minimum 2 due to age (83) and resp rate (32), but urea won’t be back for hours bc there’s a delay in labwork which appears in the scenario just as I’d suspect in real life (plus a delay in the CXR and an ambiguity in interpreting it - turns out, the whisps and opacification around the hilum were nothing more than an unusually prominent hilum). I cave and back out on following the CAP algorithm and just left it at my present management while waiting on NIV.

Good news is, the scenario was written as a non-infective exacerbation, but ambiguous enough that I could’ve justified giving Abx anyway until review by a senior; my performance is exactly what would be expected of an FY1. It’s only afterwards in the debrief that I’m reminded of the facepalm point. The main issue is that CURB-65 was never designed for diagnosing pneumonia, despite so many hospital trusts co-opting it for that. It was only ever meant for assessing severity of already confirmed or suspected community-acquired pneumonia to decide when to admit. CURB-65 being used by some trusts as a diagnostic tool, without validation, had thrown a massive wrench into the gears of what should’ve been based on clinical judgment.

And it’s far from the only one. Glasgow Coma Score was only ever intended for traumatic brain injury, and even then its inter-rater validity has been questioned. The WHO pain ladder was only created for cancer pain management, and even though it’s shown usefulness in other contexts its use is still unvalidated and possibly incorrect in most of them.

This, friends, is why we go back and read the original studies. Because just because someone in a position of authority says a certain tool is clinically useful for a given purpose doesn’t mean it is.

[do-no-harm-hopefully]

For the first time in a while, I’ve signed up to do some peer teaching for 1st years over a revision special event, and one of those sessions is a cardiac exam, so I threw this together to help with remembering the examination and signs of stenosis and regurgitation of the aortic and mitral valves. 

I’ve always loved the symmetry of this diagram, and it’s genuinely helped me to easily recall the cardiac cycle stage and manoeuvres needed to identify all of these murmurs.

[do-no-harm-hopefully]

Oh hi, it’s been a hot minute since I was last active here. Needless to say it’s been a wild ride and a retrospective is overdue (for context: on this day last year I was diagnosed with Covid, forcing me to quarantine alone in my flat for 10 days just after learning I’d have to repeat 2nd year), but needless to say I’m in a much better place than I was.

But no, this isn’t that retrospective. Not yet. Instead this is a rant about an offhand comment of advice to medical students given by a lecturer I otherwise and quite fond of and am glad is overseeing my first proper placement of 3rd year. The context? Advice on how to make the most of the placement. The controversial comment that set me on edge?:

“You get out of it what you put into it.”

To explain how and why I loathe this statement and this idea, let’s give some story time about my relationship with obstetrics & gynaecology.

My involvement with O&G has grown a lot from a passing interest before starting med school to my default answer of my probable-but-not-confirmed future career path. By beginning of year 2, take 1, I was already deeply invested from all biospychosocial angles, on my way to my first publication in a related research field, and rearing to go get some clinical experience.

Now, the second year curriculum in my course is pretty irregular, and O&G only fitted into a single composite placement of around 8 weeks which it shared with about 7 other specialties which received much more attention. Our scheduled time on labour ward consisted of 1.5 days total.

I on the other hand went 5 times in that 8wk period, in my own spare time while juggling the mess of other specialties I had simultaneously. I was so hyper-aware that there were clinical competencies and presentations for the curriculum I needed to be comfortable with, so desperate to put myself more at ease in a setting that I could very likely end up working in, and so nervous that I needed all the opportunities I could get despite people being nervous about having me observing them looking exactly like my cis male birth gender (and tbh, I doubt that even having a “they/them” pronouns badge would’ve helped there).

And what did I get out of all that, of putting more than twice as much time and energy into it as I was expected to? Other than sitting, waiting and reading the textbook cover to cover, in between acting as an unofficial porter for rooms I wasn’t allowed into: one NIPE and one observed normal vaginal delivery, both on the final day. Because the midwives assumed that the mothers-to-be under their care wouldn’t want someone like me observing them (which would be valid... if they even asked). Because of “shortages” of clinicians to teach me, even though that ward was virtually the only one in the hospital not to have staff missing with Covid, and surprisingly few on their arranged annual leave. Because there were always student midwives and nurses who the ward staff thought needed the experience more than I did. Because the rota meant that every time I went back it was somehow always a different team and no-one ever recognised me as someone who’d been coming back time and time again.

Come year 2, take 2, my very first day on labour ward, I’d accompanied and assisted a mother throughout their normal vaginal delivery, followed them into theatre and scrubbed in to assist in their perineal laceration repair along with two caesarean sections, one of which twins. 

I wasn’t doing anything different - in fact, my confidence had been severely shaken from the previous year. I certainly hadn’t “put in” any more than I had the year before. I just got lucky to have the right kind of patients who are happy to have me there, the right day when I’m not competing with other healthcare profession students, the right registrar who noticed my enthusiasm and kindly took me under her wing to push me into as many opportunities as she could spot.

And this is why “You get out of it what you put into it” sends me into a quiet rage, because it translates to “If you don’t get sufficient learning opportunities, it must be your own fault for not trying hard enough”. Granted, it probably rings true for people who avoid the learning responsibilities that are expected of them, but it sure as hell does not mean enthusiasm and dedication pays off. And nothing hurts more when your enthusiasm and dedication and extra effort to get those learning experiences don’t pay off due to pure circumstance, and the only response you get is that “you must be to blame for that.”

And I think we can be more emotionally and intellectually honest about that. The people who care abut putting in that much of their heart and soul into it deserve more honesty about that. And if I were asked to give my thoughts on this to a bright-eyed and naive young med student as I was when I started, it would be this:

“Sometimes, you will put far more into it than you will receive. Sometimes you will go the extra mile and yet not find it productive for reasons beyond your control, because the system or circumstance fails you. And when it does, it’s okay to be upset and disappointed. It doesn’t mean you didn’t deserve to be here. It doesn’t mean you don’t have what it takes. It doesn’t mean you won’t be able to catch up later. And it doesn’t mean you should stop trying to get the opportunities to grow and improve as a clinician that you’ve fought for and earned.”