Professionalism

It’s a funny word.

A word that is completely drilled into us over and over at medical school. Even before we get here we are told that from now on we must behave in a professional manner, not do anything that could compromise our fitness to practice and stay on the straight and narrow.

Yet there isn’t actually an accepted definition.

It’s a very difficult word to define because it means different things to different people and relies heavily on context.

I generally judge professionalism by looking back on things that I or others have done and to think if there was a way to do that that would have respected the dignity of the patient more, that would have been less painful for the patient or that would have been easier on my colleagues?

But still it’s hard to know if I’m hitting at the right ball park. For example last week when I was on my HCA shift – this is a thing that the medical school are making us do at the weekends now, it’s an annoying amount of time to lose from studying and other stuff that I want to be doing but I think I’m learning, though how relevant that learning is, is another matter.
So anyway, I was on my HCA shift on an elderly care ward. I love this ward because although a lot of the patients are confused there are patients with some wonderful stories who’ve been in hospital for a while and want nothing better than to sit there and recount all their travels to you – it’s lovely. I was in a bay this time with a few distressed and sometimes aggressive patients I had been warned.

I had another HCA and a staff nurse working with me. One of the patients was on a mattress on the floor as they had no more low profile beds and he was a falls risk. He was due to be moved but I also questioned that – is it better for him to be on the floor, what about infection risk? Or do we risk putting him in a normal bed and him falling? What’s the right thing to do here? In light of the following events I’m glad he was in a mattress on the floor but I remember questioning it at the time. We got on with the morning work and at one stage I was in the bay alone. This man had been distressed all morning and tossing and turning trying to get up and out of bed despite being unable to stand. I turned my back for a minute and heard him cry out. I spun round and he was half way across the bay on his front with blood all down the front of his hospital gown. Turns out he had pulled his catheter out and was running away in the only way he knew how because he was disorientated and felt like he wasn’t safe. I yelled for help and got down beside him to reassure him and calm him down. I took his hand, looked him in the face and spoke to him calmly and he did begin to calm down. However then the nurse and HCA arrived and he riled up again.
Both this nurse and HCA were incredibly professional all morning, maintaining brilliant dignity when bed bathing patients and talking to them well but I think the nurse at this stage was frustrated with this patient. He had been distressed all morning and we had kept going back to calm him down. He had already pulled out cannulae and catheters before all of which had to be replaced and by this point I think the nurse was done being calm with him. THe nurse didn’t snap but was quite short with the patient and was just generally portraying a frustrated exterior – now this meant that calming the patient down took a lot longer because he picked up on the frustration and amplified it in himself.

Was the nurse being un-professional to outwardly direct his frustrations at the patient?

I don’t know, I know it didn’t sit right with me and I preferred to personally take the calm exterior approach however frustrated I was internally. But I can understand the reason for his frustration. The patient eventually calmed down, the catheter was re-fitted and he was calm for the rest of my shift even as he was hoisted and moved to a low profile bed. So the nurse getting frustrated had no repercussions – so was it unprofessional?

I can’t give you the answer and I don’t think most people can either, its more down to personal opinion. Professionalism is subjective and the most important opinion on whether or not you are being professional is that surely of your patients and your colleagues. If they perceive to be professional then you are, aren’t you? Even if not so much in your personal life?

Well that’s another debate right there. I’ll leave you with this thought:

‘Medicine is, in essence, a moral enterprise, and its professional associations should
therefore be built on ethically sound foundations. At the very least, when physicians
form associations, such occasions should promote the interests of those they serve.
This, sadly, has not always been the case, when economic, commercial, and political
agendas so often take precedence over ethical obligations. The history of professional
medical associations reflects a constant tension between self-interest and ethical ideals
that has never been resolved’

Thank you.

Neuroanatomy: #1 Extraocular muscles!

Any medical students reading this probably just let out an audible groan. Let me take a moment to join you… *groans*.

Neuroanatomy is, at the present moment, running my life. Thankfully I do have an interest in it and I do want to learn but even then spending hours upon hours in the anatomy lab gets a little tiresome.

SO!

With that in mind I have decided to share and share alike my resources for neuroanatomy for any medical students dropping by who this might be relevant to. Sharing is caring people, and it might save us all a little time in the lab.

Without further ado I present to you, a brief overview of the extraocular muscles. This might be a bit of a strange topic to launch straight into but it is one that I am confident with and so wanted to share.

Extraocular muscles:

The extraocular muscles are responsible for the movements of the eyeball. There are 6 (7 if you count the lovely levator palpebrae superioris which moves the eyelid) and they are:

Superior oblique
Inferior oblique
Lateral rectus
Medial rectus
Superior rectus
Inferior rectus
(Levator palpebrae superioris) 

What do they look like I hear you ask. Well let me refer you to the following beautiful diagrams

Now these muscles are very difficult to see in an actual specimen and are much more easily identified on schematics and in plastinated models. Initially it can be difficult to know which is which but once you have identified them the first time it is becomes a lot easier and their names help substantially.

Let’s hear a little bit more about these muscles:

Superior rectus: originates from the common tendinous ring situated deep in the orbital cavity, it attaches to the top of the eyeball.

Inferior rectus: is in the same plane as superior rectus and has the same origin. It attaches to the base of the eyeball and is difficult to see unless superior rectus is dissected away.

Medial rectus: On the medial aspect of the orbit, also originates from the common tendinous ring. It attaches to the medial aspect of the eye ball

Lateral rectus: Same as the medial rectus but on the lateral side

Superior oblique: originates from the common tendinous ring and passes anteriorly on the medial wall of the orbit, it becomes tendinous and it’s tendon passes through a structure known as the trochlea. By passing through the trochlea which acts as a pulley system the tendon turns 90 degrees to insert on the posterior lateral aspect of the eyeball.

Inferior oblique: does NOT originate from the common tendinous ring. It instead originates from the maxillary bone. The muscle belly passes up under the eyeball before becoming a tendon and inserting on the inferior posterior aspect of the eyeball.

We’ll quickly cover the innervation of these muscles and we’ll in a later post/ a revision to this post look at the action of these muscles. The reason I’m delaying this is because the axis of the orbit is different to that of the eye so the action of the muscles, particularly the obliques, may not be as expected and I feel I can best explain this with a video which I need to film.

So!
The innervation of these muscles is very simple. Remember this: Oculomotor (CN 3) does all except LR6 SO4.
LR6 = Lateral rectus is innervated by cranial nerve 6 which is abducens nerve
SO4 = Superior oblique is innervated by cranial nerve 4 which is the trochlear nerve. (Incidentally another way to remember this is that the superior oblique passes through the pully called the trochlea and is innervated by the trochlear nerve)

Thanks for reading, hope you are somewhat enlightened! I promise to cover the action of the muscles soon!

An interesting case…

Fortnightly we at our medical school take the afternoon to go to a local GP surgery and get some teaching from current GP’s and meet a few patients.

We’ve been going for a few weeks now and I must say our GP is a fantastic teacher, one of those highly enthusiastic people who is ready to tell you absolutely everything he knows about a topic.

Back in our first week we were learning initially about general end-of-bed observations and taking an examination of the hands and face. We learnt first and then to practice what we had learnt on a few patients who had some interesting signs.

One of the patients had psoriasis which on examination of her hands was hardly noticeable but then she rolled up her sleeves and we saw that she was covered. From this I learnt not to just take the surface of things, to dig a little deeper and you might uncover something that you’d otherwise have missed. This would obviously have come out in the history but as we just examining the patient today we could have easily missed it.

By far the more interesting case for me, however, was her husband who just came in the capacity of taxi to bring her into the surgery. He had however had a pretty obvious and extremely interesting operation that I had never seen before or knew existed.

Before he even entered the room we could hear him chatting to our GP in a gravelly, very hoarse voice which at first I just thought was his voice until he walked into the room. It was immediately obvious that he was talking through a valve in the middle of his neck which he pressed in order to make sound and let go of to breath. I had truly never seen anything like it.

He told us that he had had a tumour of his true vocal cords and that in order to be cured he had, had to have a total laryngectomy (surgical removal of the larynx (voice box)). This obviously removed his power of speech however surgery can provide a solution to this. He had, had what is known as a tracheo-oesophageal puncture performed and then a prosthetic valve placed in to allow him to regain a form of speech known as oesophageal speech.

Apparently his degree of speech is very good in comparison to the normal outcome for these patients and I must say that apart from the gravelly tone of his voice his speech was entirely normal. He has learnt to use the valve very well.

The principal of the operation, from my understanding, is that a patient who has had a complete laryngectomy needs to breathe permanently through their neck. A hole (fistula) is made between the trachea and the oesophagus and the voice prosthesis is inserted which does not allow food down the trachea but does allow air into the oesophagus.
Air in these patients enters and leaves through the valve in their neck but when the patient occludes the valve and prevents air escape by this pathway air enters the voice prosthesis and enter the oesophagus and escapes through the mouth. As the air passes through the upper tissues of the oesophagus it vibrates replacing the vibrations previously produced by the vocal cords.

This is what it looks like in the flesh:

Oesophageal speech, I’ve been told, is hard to master especially initially but there are clinics for these patients to go to where they can learn to speak well using these prostheses and the result is truly astonishing.

There are of course implications on this man’s life, he will never be considered in the same way and there will be a prejudice that comes from the sound of his voice. He said himself that children are scared of him now and he does resent that, but for him the ability to still communicate close to how he used to succeeds that and once people get to know him they understand and there is no judgement.

It amazes me everyday the things that modern medicine can achieve and this man and his surgery reminded me why I decided medicine was the career for me in the first place.
Very cool!

Just to show those of you who haven’t seen this – here is a patients story:

https://www.youtube.com/watch?v=SaREnCLP3RM

Why We Shouldn’t Complain about the NHS…

I’ll admit that I’ve done it, and I’m sure we all have at some point. Admittedly when you are sitting in A&E, nursing a concussion only to look at the clock and realise you’ve already been here for 3 hours it is hard to see the rosy side of our healthcare system with it’s long waiting times and ever decreasing availability of services. However we shouldn’t be so fast to complain.

I learnt a couple of days ago that someone I know from America is dying. He has a congenital heart defect and requires a new pacemaker as well as a follow up surgery to try and reduce the defect. Unfortunately he cannot afford either of these things.
And that’s that.
The American healthcare system just watches whilst he dies from something completely preventable.

Now, the American system is fine for those people with insurance and it tries to help those who are the poorest and can’t afford healthcare but it misses a chunk of people in the middle. Unfortunately for my friend no insurance company will cover him with reasonable premiums because he has a congenital disease. So he can’t afford to pay the premiums, and certainly can’t afford to pay upfront for the surgery despite hardly missing a day of work in his life.

His family are very strong and are glad that they’ve had the time that they’ve had. They have accepted that at any day they could wake up and he could not be with them anymore but we have to ask ourselves why they should have to accept this? Both him and his wife work extremely hard, they are pillars of the community and yet because they don’t have the monetary means the healthcare system leaves them by the wayside.

Healthcare is there to alleviate suffering. My friend is suffering because he can’t afford care and his family are suffering with the knowledge that they can’t do anything and will suffer more when he eventually passes away. It’s pretty ironic don’t you think that it is a healthcare system which has caused this suffering?

I had strong and mixed emotions when I heard about this, I was mad that this is happening to such a young man and wonderful family, I was sad for them and then I was extremely grateful. The horrifying truth is that in the UK my friend wouldn’t be dying because we have a healthcare system that is free at the point of access and that does not discriminate based on economic standing.

So yes we may have to wait 4 hours in A&E or 6 weeks for our knee op and that’s annoying, but at least we get care and we don’t have to worry that we can’t afford it.
I have a new found respect for the NHS and the values it upholds and if anyone catches me moaning about it again, feel free to give me a slap!

Throwback Thursday: Throwback to First Year: Sem 1

It’s a lovely morning and I’ve got some great tunes on on 8 tracks (an app which I cannot recommend downloading enough, it is wonderful to search for all kinds of music, especially easy listening music to study to.) and I felt like now was a good time to write about first year.

It will obviously be completely impossible to write about first year as a whole in one blog post so I think for now I’ll just focus on what starting medical school was like and the first semester as a whole.

I distinctly remember our introduction lecture, I’m pretty sure I was slightly hungover and tired from the freshers night I’d been on the previous evening but I was pretty excited. That lecture felt like the start of the medical journey I was embarking on. I met up with some fellow medics who were in the same block in halls as me and we walked up to the hospital together. It was pretty strange because I hadn’t met them before that morning and they are still my closest friends today. The introduction lecture itself was not particularly exciting and was spent mostly with the senior lecturers trying to scare us with attendance/performance statistics. We went for coffee afterwards and lo and behold we were on our way.
There was a lot of admin stuff to get done and I’m pretty sure I obliterated that from my memory for my own sanity though I do remember going to collect our fancy magnetic badges with our names and new ‘medical student’ title on them.

Then lectures began. It was an interesting first semester with just a mish mash of information to try and bring us all onto a similar level before we started working on bodily systems. This was fine but it made revision particularly difficult when it came to Christmas because there were very few links between topics like Pathology and Pharmacology at this stage. I spent a lot of the first semester just getting acquainted with the university, the hospital (which I still struggle to find my way around), the city and being heavily involved in the musical theatre society Showstoppers – the only society which really stole my heart and who I intend to commit the majority of my free time to this year!

Then before I could blink we’d finished the first semester and had already broken up for Christmas. In terms of work the first semester was almost entirely lectures and tutorials with some time in the anatomy lab working with cadaver bodies (a very strange and disturbing concept to begin with – though you quickly get used to it) and we did start on some GP attachments once a fortnight which served to remind us why we were here and actually taught us some things which were very relevant to our future practice such as history taking and very basic physical examination. I really enjoyed the GP attachments, they were probably the best part of the year as a whole. It just gave us a chance to meet and chat to real patients about their problems even though we have less of an idea what that means than they do.

We also got to see a birth in first year. I think I was in my second week when I went in to watch one – it was crazy. The experience was amazing though and probably the most memorable clinical experience of medical school so far. I’m not sure what purpose the birth visit was supposed to serve given our complete lack of clinical knowledge at that stage but what I took from it was a reminder why I was at medical school and some valuable teaching from an anaesthetist who was there to supervise the spinal block the patient received and took the time to teach me a little about the relevant anatomy and the procedure itself. I also took away a greater understanding of patient communication and how it makes such an incredible difference to the patient experience. It was made particularly clear from this particular experience because the midwives were so very good at communication and bedside manner whereas the obstetrician who came in when the possibility of a c-section was put on the cards was awful at communicating and this made the patient much more apprehensive about the potential for a c-section and this did not help the situation at all. Overall it was a valuable clinical experience and one I think I will always remember. The miracle of life is not quickly forgotten.

Christmas was pretty much a chocolate fuelled revision holiday. I was so panicky about the January exams because they were in a format which I had never had before. We had two written papers (a multiple choice style and a long answer style) and an anatomy spotter test. For those of you unfamiliar with the concept of anatomy spotters we have a series of stations set up in the lab with a range of questions from pins in cadavers (dead body specimens) to blu tac pointing to structures on an x-ray. There are approximately 60 questions in 30 minutes giving 30 seconds a question before you move on to the next station. It’s a high pressure situation with no time for you really to stop and think, you either know it, or you don’t. Simple. This was the paper that scared me the most for that very reason. I wanted to well as our first year counts towards our final year rankings amongst the year group but at the time of revision  I was really just looking to pass!

Thankfully I didn’t need to panic as much as I did because the papers were all fine and I did much better than I anticipated. Woo! We had a lovely exams blowout by going to watch Frozen (despite the fact we’d all seen it several times before) and going to Sprinkles which is the most amazing ice-cream place in the world. We also went out to the Palace of Dreams – otherwise know as Jesters the official worst night-club in the UK but for that very reason – the best night out you will ever have.
Then we had a couple of days off, now I definitely remember not knowing what to do with myself during these few days. It was nice to not feel guilty about not revising every second of every day but equally I felt pretty without purpose. I didn’t even have any Showstoppers rehearsals to go to because the show I was in in first semester was over and done with before Christmas. Incidentally that was one of the funniest shows I’ve ever been in and I still love the cast to pieces! We had a reunion yesterday and performed one of the songs from the show at this years Bunfight where the societies try and get all the new freshers to sign up, it was so much fun and so nostalgic!

The first semester as a whole was a bit of a blur, what with moving into halls, meeting so many new people, starting a completely new course which was finally exactly what I wanted to do, trying to divide my time between all the new stuff I was trying out – it was just amazing. I don’t think that any semester will ever really match up to that very first one.

Care, Compassion and Commitment…

To me these are the things that make up a good medical student and a good doctor.And of course you need to have a little bit of charisma and personality as I hope to demonstrate with this frankly glorious photo if I do say so myself.
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This is me, little bit exuberant at times but I like to think that I possess the qualities to become a good doctor. My name is Lydia Edge and I’m just starting my second year of medical school in the UK. Having just completed first year and finding that the more I progress through medical school the more I need somewhere to share the experience I’ve decided to start a blog where I can do just that.
Expect to find posts not just about medical school but about university life in general, about my summers and how I’m spending my time away from studying. I’m still learning about myself as well as about medicine so there will be an element of reflection about decisions I’ve made, paths I’ve taken. Let’s see how it goes!

Ask questions, get involved, I would love to hear from all of you!