This week I spent a day on SAU - the Surgical Admissions Unit which meant starting the day at 8am with the morning handover and ward round, and staying until the evening handover at 8pm. The aim of these 'surgical on call' days is to get an idea of what happens when patients are first admitted and assessed, and how the unit is run - similar to the 'AMU week' I had when I was on my medicine rotation (which you can read about here). I also went to a hepatobiliary (HPB) clinic (this area of medicine is mostly about the liver, gallbladder, and pancreas) and a very rapid urology theatre list. Oh, and I passed my last two MACCS (mandatory assessments of core clinical skills)!
One of the major things I learnt this week was that communication is integral to practising medicine. First example: the first patient at the HPB clinic had learning difficulties, which meant they didn't have capacity. In medicine, every time we want to do something regarding the patient, we need their consent - including simple things like taking a history or drawing some blood for tests (depending on what we want to do, it can be written or verbal). In order to get consent we have to be sure that the patients are able to understand what we've told them and are able to make a decision based on that information - they need to have capacity. I won't go into all the ethical details (it could end up being a looooong post) but in short, this patient didn't have capacity because she wasn't able to take in the information given to her and wasn't able to make decisions about her health. So what happens when a patient doesn't have capacity? Usually someone else (e.g. a relative or a carer) takes the reigns and makes decisions for them. But it's not that simple. In order to protect the patient, there are rules/guidelines that need to be stuck to: for example everything needs to be in the patient's best interests, and needs to be minimally invasive/harmful. Coming back to the patient in the clinic, they were accompanied by their carer, and the hospital provided a disability liaison who was there to make sure that their needs were met and that everything was ethical.
You'll be pleased to know that it was all done by the book and all parties were satisfied. I also noticed that the consultant, though they mainly talked to the carer to make sure that they, as the decision-maker, knew what was going on, they also tried to talk directly to the patient as well to include them which I though was nice. Although this particular patient didn't really seem to understand anything that was going on, it was reassuring to think that the doctor was still trying to involve the patient, especially since there will be other patients who lack capacity but may still be aware of what is going on and will greatly appreciate being spoken to directly. The same thing applies to children.
Example #2: I spent a lot of time on my SAU day taking histories from patients. This is were listening to the patient is very important in order to pick up all the little clues pointing towards what's wrong. It's said that the diagnosis comes from the history and examination of the patient, and that tests are just to confirm the diagnosis, or to chose between 2 or 3 options. Now that I've actually learnt about some medical conditions and have got more comfortable with taking histories, I've found that my guesses at what the patient has are getting more and more accurate. Communication is also important when presenting the history to a senior - the aim is to quickly and concisely tell them what you've found and what you think in order to allow them to get up to speed and efficiently help the patient. On ward rounds, the junior doctors give the consultant or registrar a summary about the patient's history and their care so far so that when they go see the patient they don't have to ask all the same questions and get straight to point: working out what's going on and how to help them.
The morning and evening handover is another similar example of how critical communication is. During these sessions, the team that has been caring for the patients on the ward all sit down together with the team that are going to be taking over from them for the next shift. They tell the newcomers about the patients, their diagnoses, and the plan for their treatment including tests they need or wards they need to be transferred to. They also include any information about incoming patients (e.g. from A&E), and tell them things they need to monitor e.g. some patients may need repeated blood tests, or some patients may be particular poorly and need a close eye on them. All this means that, despite only turning up on the ward 30 minutes ago, the new team know who they're working with for that shift, and what patients they have - pretty important information if you ask me.
A final example of beneficial communication again stems from my experience on SAU. A young patient was admitted and needed a cannula and some bloods drawn. This involves sticking a needle into their arm in order to slide a little hollow plastic tube into a vein. This allows drugs e.g. pain medication to be quickly administered. So it's undoubtedly beneficial to the patient. Unfortunately it can also pretty uncomfortable and can be a bit painful too. The patient was already pretty anxious and in pain so they obviously weren't feeling to great at the prospect of having the cannula stuck in. I initially went in with the doctor with the hope of getting to try putting the cannula in myself, but once in the room we both agreed it'd be best for the doctor to do it themselves. So instead I was going to watch and see how they used a special connector to draw some blood at the same time. But that plan changed when I saw that the patient was getting a bit distressed about the whole thing. "How old are you?" I asked quickly, trying to distract them. Fortunately for me, there were school-age which meant I could ask lots of questions about school and their favourite subject, and what they wanted to do in life, and it meant I could ramble. It didn't stop them noticing when the needle actually went in but it did seem to help them relax a little throughout the whole thing. It may seem a little lame to some, but to me I felt like I had actually done something to help. I may not have stuck in a cannula or made an important diagnosis, but I felt I had made a slight difference in their care. It also made me once again realise the importance of remembering that a patient is a person not an illness, and that sometimes talking to them can also help.
So that's what I learnt this week! I hope you all have a great week, and good luck to all the people who are blasting their way through exams!
