Skill development

A couple of years ago, I was really worried by the whole ‘qualified and competent’ principle in the law that governs medical actions. Here, the law is that certain professions are allowed to do certain procedures (venipuncture, physical exam etc), but only if you are both ‘qualified’ (either a doctor/nurse/midwife/dentist or under supervision of one) and ‘competent’ (having had the correct training). The second part underlines your own responsibility in this, if you do a procedure that you are allowed to do but haven’t been trained in, you can’t hide behind your qualifications if something goes wrong. I certainly didn’t want to do things I was not allowed to, being quite scared of the disciplinary process that was drilled into us during lectures.

Now it’s quite amusing to read about my somewhat naive concerns. In medicine, there’s a lot of see one, do one, teach one going on. Atul Gawande writes about it in his book Complications and it is true: sometimes, patients serve as guinea pigs for medical students to learn procedures. I’ve contributed to it myself during my final internship by asking the medical students on their internal medicine rotation to draw blood for me on my patients. I remember how important it was for me to get lots of opportunities to draw blood in order to build a routine – and now I was passing on that privilege, knowing that sometimes, patients would have to be stuck twice (or more) to obtain a blood sample.

Actually, venepuncture is taught quite well in medical school – first on a plastic arm, then on a fellow student, then during one afternoon at the outpatient lab where patients are asked if they will allow the medical student to draw blood. So before I unleash a student on a patient, they will have done the procedure 5-6 times at least. For starting IV lines – another common medical student task – they were less well prepared, having done it once or twice or maybe thrice if a kind resident let them during the junior clerkships. However, most hospitals offer a kind of crash course, in which you get to place IV lines in the OR, so again, by the time you enter the ward, you’ll be somewhat familiar with the procedure.

However, a very important procedure, obtaining an arterial blood gas sample, isn’t taught in medical school at all. I was shown once how to do it during my week-long rotation on the Pulmonology ward. When the next ABG had to be drawn, the resident asked me to list the supplies, the steps and how I would explain it to the patient – then she sent on my way – give it a try, if it isn’t succesful, come and get me. Are you sure? I have never done this before. Yes, I’m sure you’ll do fine!

I went to the patient, explained the procedure, conveniently leaving out the fact that this would be the first time ever that I did it. Fortunately, I got my sample in one try. The week after, I coached another medical student through the steps, even though I’d done it only twice by then.

Did I throw away my principles? I could have refused and demanded more training. And still I trusted in my own ability and obeyed the order  given to me. Well, that’s not completely true. I trusted in my resident’s assessment of me. I knew the theory, I just had to gain the hands-on-skills. The point is, like Gawande also argues in his book, there is only one way to learn a procedure: by doing it. Until you actually try it, you can’t learn. Of course I always got help if necessary. Really. I’ve asked an attending to repeat my blood pressure measurements on a patient (the most basic of basic tasks) because I wasn’t sure of my readings. I felt really embarrassed but I knew I couldn’t stand the feeling of maybe having made a mistake.

Eventually, I also realized that someone needs to do the job. As a medical student, it’s easy to get your supervisor. I often went to get them when I couldn’t feel a vein, then I didn’t even try. As the supervisor, you need to call anesthesia to place an IV line, so you better try it at least a couple of times before you start the process of enticing them to come to the ward. So I’ve slowly grown used to starting a procedure even when not completely sure because if you won’t do it, eventually, it will be very difficult to get someone who will.

I haven’t touched much on the most important perspective: the patient’s view of all of this. I’ll come to that in later blog posts, but a vital aspect of medicine still is knowing your limits. I still hold myself to a ‘two tries’ limit – if I can’t place an iv/draw blood/ do an ABG in two tries, I’ll get help. But I will allow myself the space of thes two tries. Gradually, I noticed that I was now able to place IVs in more difficult to see veins – apparently, by taking the time and trying, I slowly built my skills repertoire.

For me, learning how to become a doctor was a big lesson in how to deal with uncertainties and my own insecurity. This example of ‘skill development’ is intended to illustrate one aspect of that learning process – and especially how difficult it is to stick to your principles in the daily reality of clinical practice. Some people become a confident doctor-persona overnight, in others it takes a little longer. And, most importantly: doctors aren’t saints. Doctors aren’t perfect and the process of how to learn isn’t perfect either. But we try, we go on, because we have to -personally, I couldn’t imagine doing something else than helping people.

For those who were curious: I finally learned how to do intramuscular injections during the primary care internship in year five. I don’t think that half of the vaccination was supposed to leak out after I’d removed the needle, but the doctor’s assistant who supervised me, pronounced it as a correct vaccination. I did two more injections, now supervised by the doctor herself and that was it.

And then I consolidated these skills by vaccinating a boatload of unsuspecting first year medical students during my social medicine internship. ‘You’ve done this before, haven’t you?’  ‘Yes’. ‘Great! Here are the vials and here are the syringes. I’ll stay for the first few injections to see whether you’ll be alright.’

I remember how a very insecure looking woman vaccinated me during my first year while an elderly man watched – an exact mirror of the situation I was in. Before she actually injected me, she practiced the ‘throwing a dart like movement’ a few times. I remember being a little bit put off but I didn’t dare to comment. In hindsight I think she was also a social medicine intern who hadn’t had much experience with intramuscular injections… 🙂

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Role model

(..) I was wondering  – you’re rather small, well, I’m not very tall either, but I’m always wondering, you’re so young, and the whole mandatory trying to draw attention to yourself thing during the coschappen, I always wonder what makes young people pursue medicine.

HE SAW MY PAIN! He was the first doctor to acknowledge that the coschappen grading process might be very difficult for shy-er people. I didn’t really say anything in his presence, I just observed, but when all the patients had been seen, I was subjected to a crossfire of questions. Where do I see myself in ten years? Why do I study medicine?

I met this very empathic surgeon during my surgery internship. He was the first and only one to ask the questions that actually matter. Of course, during the admissions process you write a little eassy on how you’ve always dreamed on becoming a doctor, but you don’t know anything about the reality of doctoring. Now you are on the brink of becoming one yourself and you find that you had never really put any thought in BEING that doctor and WHY. I just struggled on, trying to stand out in a class full of extraverted peers.

That afternoon I spent doing clinic with this doctor – ‘doing clinic’ entailed sitting on a stool and maybe palpating someone’s abdomen and taking a blood pressure – was an afternoon full of bad news. I never realized that that is a huge part of a surgeon’s day.

One patient stood out in particular, a a cheery fellow in a wheel chair who had been dropped off by a caretaker. He did not know why he was there, he just smiled a lot and said he already felt a lot better now, all the studies and tests had been quite uncomfortable but he was glad it was over.

We’d spent five minutes reviewing the chart before he came in, and this too, would be bad news. Advanced colon cancer, an urgent resection offered the only chance of curation, buteven then the prognosis would be very bad. The surgeon hesitated a little, but then plunged forward and delivered the bad news as sensitive as he could. They say a lot about callous surgeons but this man certainly wasn’t like that. He got up from his comfortable chair when our patient started crying, went over to his side of the table, and crouched next to our patient’s wheelchair. Quietly, he asked, what are you most afraid of right now?  – and took the time to hear our patients fears and worries.

To provide some perspective, the surgeon decided to introduce our patient to a colleague of his, who specialized in the specific operation that our patient would need. We were already behind schedule, but the surgeon didn’t want this man to leave without any notion of what was going to happen next. So we knocked on the door of the other surgeon, asked him to come with us and see the patient.

The contrast between these two men couldn’t have been bigger. This was a typical surgeon, big, muscled, loud. Of course we are going to fix you, sir! he bellowed and continued to spout well intentioned nonsense. You will be out of the hospital in no time, maybe in time to still catch some of the summer! Then he patted our patient on the head and left. Our patient was quite flabbergasted. Am I going to die now? he asked.

After the patient had left, the surgeon asked me what I thought. This had been one of the first bad news conversations I’d ever witnessed, so I was glad to be able  to share some of my emotions – I was very touched by how our patient took the news. I felt very bad for him, how he had come here expecting good news and then being hit with a sledgehammer.

No, what do you think?

I wanted to start talking about the patient’s feelings again, but he interrupted me.

Don’t you think that [colleague] was completely inadequate? He’s a surgeon, loud, expressive, while this man needed a calm reassurance.

And then he looked at me and asked me how I was doing, as an introverted person in the middle of a group of extraverts. I’m afraid to say that I lied and said I was doing fine. At the previous clerkship I had shared my feelings with our clinical facilitator and it came back in my grade in a very nasty way, everything I had shared in all honesty, wanting to become a good doctor, was used against me. So naturally, I now knew that I could trust no one and I just smiled and said that I loved medicine and that everything was fine. He didn’t take that for an answer, he asked me why did I go into medicine? Why do I love it so much? At the time, I just tried to give politically correct answers, but now I realize the lesson he was trying to teach m. Don’t try to become someone you aren’t, become a doctor because you want to. Otherwise you won’t make it, otherwise it won’t be worth the constant struggle.

I’ve worked with a lot of doctors throughout the years, but he was the only one who really recognized what I was going through, most likely because he himself was introverted. He didn’t say anything, just looked at me and wished me good luck on my journey of becoming a doctor. Now I see the truth and wisdom in his words and I am grateful for it, that he took the time to talk with me, one of the many, many medical students they see every day.


A glimpse of heaven

We thought he wouldn’t make it to the afternoon when we visited him in the morning. We, a cloud of white coats, gathered around his bed. The attending took his hand and looked him in the eye for a long time. He sighed. There is no way to translate his words into concise English, but he said the equivalent of ‘You’re very ill. We are afraid that you will not live for much longer.’. They shared a moment together, he, the oncologist who helped and guided him the past few years, him, the man whose body was now really failing him. He didn’t say anything but it was clear that he understood.

I had the responsibilty of caring for him during his last hours. Before this internship, I would have never felt up to this, but somehow, pieces just fell into place and I could finally become that doctor I wanted to be, the rock in the storm.

However, he didn’t die that day. And not the day after either. Family members from all over the country visited, said their goodbyes. He was surprisingly lucid, at the beginning we thought that maybe there were some signs of delirium but these receded. I began to feel some hope again, despite the odds. But on one morning, I read in the file that the patient was now barely able to wake up.

Being a ‘sub intern’, my patient load was lighter than that of the residents and I was able to check in on my patient every couple of hours. We never spoke of much, I watched him silently for a while to see if there were any signs of distress and then tried to wake him to ask him if we could do anything to make him more comfortable. This little rather one-sided conversation would last a few minutes and then he would fall asleep again and I could turn my attention to the family members.

There is always a kind of holy atmosphere in the room of a dying person, a silent anticipation of what is going to happen. I can’t describe it in words but it’s a very powerful atmosphere which makes me pause every time. It’s the atmosphere that is created when someones soul is preparing to depart their body. Do I belive in the ‘eternal soul’?  From a theological and scientific viewpoint, I don’t. I can’t. But with this specific patient I experienced something that transcends simple answers.

He had now been dying for almost twelve hours. The family was getting restless, asking me how much time there was left, couldn’t we do something to speed it up (the patient was now entering the phase where the brain sort of disconnects from the body and sometimes forgets to breathe). I answered their questions to the best of my ability – we never know ‘how long it takes’,

Dying is a really strange process. Sometimes, it happens in an instant, but sometimes, it’s a long and drawn out journey – sometimes, it feels almost equal with a birth but then in reverse. ‘Letting go’ takes a lot of energy, it’s certainly not just a passive shutting down of bodily function. So I’m honest with family members and explain to them that ‘the last part of life’ doesn’t just ‘happen’, it is an active process, and as a family, it often helps to talk to the person, to touch them, because hearing is the last thing that stops. And of course, this takes a toll on the family, and it is important to urge them take care of themselves, take breaks, go home to sleep for a while – but we can never ‘predict’ the moment of death. ‘Euthanasia’ is completely out of the question as that has to be requested by the patient themselves. In case of refractory symptoms, we can administer painkillers or other symptom-directed therapy, and in rare cases of terminal anxiety, we can administer a sedative. But usually, when a family asks me to ‘speed things up’, the patient is already oblivious to what is going to, far away on their journey to the next life, and is is their discomfort that prompts the question.

As usual, I also tried to ‘contact’ the patient. I remember vividly how I was almost afraid to speak to dying patients when I started working on this ward, as if I’d disturb them, but I learned by example of a great oncologist that patients usually really appreciate the care you show them (or they will just continue to sleep). I softly touched his hand and said his name. I did not expect a reaction but I wanted to try anyway.

He opened his eyes. Hi, he said. Hi! I responded enthusiastically, maybe a little inappapropriate for this situation, but I was so surprised that he actually spoke that I said the first thing that came to mind. He returned my gaze and we shared a moment of silence.

It felt like hours. I don’t know what happened, but I was suddenly connected with my patient on a level that I have never experienced before. We saw each other, he saw me and I saw him, and it felt like we belonged, like it was exactly right. There were no barriers, there was no doctor or patient, we just were.

I was suddenly jolted back to the present and I had to struggle to control my emotions. My patient had gone to sleep again, the crackling sounds of his breath filling the room. I didn’t say much but I think everyone present could see how touched I was.

What happened? I don’t know, I think I got a glimpse of heaven. I’ve read a lot about near death experiences and how they can also be felt by observers – this felt like it. The odd thing is that I can hardly put it into words. It was just a moment but it was so much more than that. It was like coming home, arriving after a long journey and seeing that this is your place. Nothing changed during the mere seconds that this lasted, but I felt like I had been somewhere else, in a very bright and light place.

I will always cherish this experience, this gift from my patient. I think it’s the best gift ever. It’s a glimmer of hope in the very dark and bleak reality of the oncology ward.


Oncologyclinic.gif

Somehow, the internships just zap my mental energy, after an entire day in the hospital I don’t feel the wish to struggle on the Händel anymore. I’m still working on the folk pieces, of course, because I’ve scheduled lessons on them, but as it will be a while before the next lesson, all semblance of regular / focused practice has come to a halt… My big harp has gotten quite out of tune after being neglected for a while… I wanted to tune it again but the tuner just broke on me (no idea how! Changing the batteries certainly didn’t help and it were new batteries which worked fine in other appliances).

Today was just like watching a bad .gif over and over. The attending with whom I was working did oncoloy clinic and while all cancer is bad, cancer in the head/neck region is especially bad. It basically eats your face and the only treatment is to remove everything it can get to – so then you will hopefully be cancerfree but also missing half of your lower jaw if you are unlucky. And I thought end stage colon / breast carcinoma was bad, but imagine a tumor sitting near your brainstem and there’s nothing they can do about it so it’s a matter of time before you become basically brain dead…

Fortunately, I didn’t have to say anything so I just sat there on my stool (the doctor gets the real chair) and watched as the attending patiently explained everything to the patients and their families. Halfway someone would inevitably being crying and then everyone except the doctor was crying – and of course, as a med student you should be professional so I was pinching myself discreetly to not to join in. And that over and over, just like a .gif where you already know the ending – they came in not really knowing the diagnosis / implications or perhaps they knew but it didn’t sink in yet  and then the news is broken to them and you almost hear the shattering of their plans and dreams…

But then there is the doctor, who leaves room for a silence, offers a tissue, asks a few questions… And the room is filled with a bit of hope – even while there is no hope, the doctor is there and will stick to their side until the very end.

This is what continues drawing me to medicine, even though I sometimes wonder whether I can be a good doctor as an introvert. Being there with and for someone in the worst parts of their life and hopefully being able to help them through it… And even when they don’t make it, knowing that you were there for them, that you really took the time to listen to them and reassure them, guiding them through the storm…

But I wonder whether I’ll be strong enough to avoid being knocked off my feet.


My life right now

*notices strange red rash/bump on right leg*

OMGWTFBBQ IT’S CELLUTITIS I NEED TO GO TO THE DOCTOR!@#$%!!!!!!!

Wait. I bumped into the table this morning.

Being a doctor in training: freaking out over totally innocent skin lesions…

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How can you be sure you really studied enough for orthopedics? If you can name exactly which muscle is aching after a particularly intense Pencak Silat training.

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When your most profound and touching experience of the day consists of finally understanding the inguinal canal.


Qualified and competent

When I was doing my primary care internship, the H1N1 flu scare was on its peak. Thousands of vaccines had been ordered and the nurse practitioners spent a lot of time vaccinating everyone. It never crossed my mind to offer to help – after all, I’d only done a venapunction on a classmate, definitely not comparable to an intramuscular injection. The very thought of damaging an important nerve due to lack of experience made me shudder – I was content with observing.

My fellow students didn’t have such qualms. They had even been asked to help out, their doctors assuring them that ‘it’s not that difficult, I’ll show you and then you can have a go’ – and I was about the only one who hadn’t done about 30 IM injections.

According to Dutch law, medical actions (injections etc) are restricted to doctors. They can delegate them, however, to other healthcare professionals. So essentially, in order to perform a medical action, you need to be both qualified (either registered as a doctor / obstetrician / dentist OR ordered by one) and competent (having had the proper training).

I know I did the right thing by not asking. My doctor also did the right thing by not asking me. Still, I feel a bit stupid for missing such a great learning opportunity…

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The only thing I’ve done while not being competent, was to prepare an IV bag of amoxicillin during the nursing internship. The nurse that supervised me was a great woman, encouraging me to take more responsibilities because she knew I was capable, I just wasn’t really vocal about it. So, within a few days I progressed from just washing a patient on my own to caring for an entire room (6 patients) on my own. Knowing that I wasn’t allowed to touch the meds, I always let her do the counting/mixing /sorting / administering thing.

And then she cornered me. “Have you ever prepared an IV bag?” I’d observed it quite a few times but I’d never done it. “I think a doctor should be able to do that, you’ll find it a very useful skill. Here, do you want to prepare this bag?”

“I’m sorry, I’m not allowed to.”

“Come on, I’m here to help you and essentially I’m doing it, you are just doing the steps.”

“But…” I was severely tempted and I gave in. She’d be there all the time so what could go wrong?

Nothing went wrong, as could be expected. It was quite fun to do and I felt (yes it’s stupid) somewhat honoured for being coaxed into a restricted medical action. I did break the law, however…

 


When a patient dies

You might wonder why I put ‘Number of ‘my’ patients that died’ in the random facts in my first post. Being part of the end stages of their lives was a very special experience. I’d like to share a few ‘images’. It’s been a year since I’ve seen real patients but somehow, it’s like it happened just a moment ago.

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They’d stuck a white A4 paper on the door. There was one word on it: ‘Belet’. I remember not knowing what it meant, so I opened the door and peered inside. There, was my patient, a very kind old woman, whom I’d cared for in the past few days. She was one of the first patients with which I was allowed to work on my own. I don’t know how I realized that she was dead – I don’t remember going in more than a few steps but the atmosphere of the room had changed, something had left.

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He was producing a very scary noise. It sounded like a lawn mower that wouldn”t start, a low rumble. A year later, I’d learn that patients in the terminal stage of life wouldn’t be bothered by it, but at that moment I was terrified, thinking he was suffocating. He was a very big man, with a friendly face. We never got around to any conversation, however, he barely responded and in the night following the shift I worked, he died.

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Dying can be a very lengthy, exhaustive proces. The first part was rather quick – I’d just helped him eat his dinner and all of a sudden, he slumped. I don’t know all the medical details – after all, it was a nursing internship – but the family was called, the patient moved to a different room and the waiting started. We didn’t expect him to last the night – but he did. Another day passed – no change in his condition. He was lying there very relaxed, eyes closed, barely responsive, but still alive. Eventually, he lasted over 14 days. What I remember most clearly is the family: they were absolutely exhausted, completely drained, both physically and emotionally. I think they were eventually happy that they were able to go home, at last.

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(and now I’m wondering – how will these memories survive – now I clearly remember which details I changed and which I didn’t… but eventually, this blog post will be the only reminder of these patients)