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Tuesday, December 1, 2015

Making of a Child Psychiatrist (33): Back to the Grind (3)

So there I was, a newly minted 20 year old, in a shirt and tie and new white coat, with a brand new stethoscope poking out of my pocket, a suitable pen, and a notepad, sitting in the medical school lecture theatre at King’s College Hospital.
As I walked past the library where I had been interviewed just over two years before, I smiled a very happy smile. There was a feeling of triumph in all of us, I suspect.
Our small band of 20 students from The Strand had been swelled with a small number of clinical students from Oxford and Cambridge.
Sadly, I do not remember the lectures from that first day, or the rest of the week. I know we had an introduction (from the Dean Dr. Vernon Hall) to the hospital and to the behaviour we were expected to exhibit. We were not yet clinicians or professionals, but it was expected that we would treat any patients we had to interview or examine, as if we were already doctors. There was an inherent threat that if we did not behave as if we were professionals, we would not last long. I do remember some characters – both the urbane scary ones like John Anderson, Professor of Medicine (with whom I was later a House physician), and the slightly mad Dr. Geoffrey Yates-Bell, a much loved Urologist and prostate surgeon, who entered as if on a stage using some instrument of bladder torture as if it were a pair of castanets. He had a reputation as a practical joker who would get students in his operating theatre to peer into a uroscope to view the wonders of the inside of the bladder, while he quietly released fluid from a catheter into their theatre boots.
We were allocated to medical and surgical ‘firms’ under a couple of consultants. On my medical firm I was soon immersed in a very steep learning curve about how to take a comprehensive history from an allocated patient (‘my patient’), and then how to synthesize the knowledge into some sort of report that could be presented at ward rounds. I loved the first bit. People had interesting stories to tell, had lots of time to spend with you in between tests and meals, and were keen to make sure you understood. I spent far more time than necessary listening to personal stories and then had trouble trying to put it all together, and simplify. I was also more than once asked to leave somewhat curtly, because nursing staff had procedures to complete. Sometimes I had to return later to complete an examination.
Of course in those days, nurses held sway. There was a strict hierarchy through to The Matron, known to have dragon blood in her veins, and breath enough fire to terrify any nurse who did not follow procedures, or complete jobs efficiently on time. Infractions of rules were to be punished severely (whatever that actually meant). The nurses lived in awe of charge nurses and the sisters, and all of them lived in awe of Matron. The other side of this process, of course, was that Matron defended her nurses against everyone else. And that meant doctors, and particularly student doctors. So the nurse passed on their anxieties, stuck to their systems and rules, and treated us like dirt. After all we were the lowest of the low; we knew little if anything, never actually did anything useful, often made errors when we tried, and were just in the way.
Ward rounds were a trial. You had to give a succinct story, try to make sense of it, give a reasonable differential diagnosis (as if I knew anything), and then get cut to shreds for the story, or missing bits, or for going on too long. Other medical students would either squirm with you (knowing it was their turn next) or snigger at your stupidity. Then you had to demonstrate how you had examined the patient. For starters, it was often uncomfortable to ask permission of the patient to examine their chest or abdomen or whatever. Many patients had been examined on multiple occasions. There were those who could get frustrated with ineptitude, or would try and guide you, telling how one of the consultants had done the job, or talked about it earlier.
So within weeks, I had become someone who knew how to examine lungs by watching the inflation, listening to the air flow in and out of the chest, then listening through a ‘hand-warmed’ stethoscope (it was after all England in summer), and learning about the different breath sounds. We learned the special skill of percussion listening to the change in the sound produced over the heart (a more solid object than lung tissue), and being able to discern the level of a pleural effusion. Of course, these days you can go on YouTube, and learn through watching, translating what you see to what you can feel or hear. But in 1964 these and other micro-skills were wonders that could not be learned through books, only experience. And once you ‘got it’; it stayed with you for ever.
So we learned skills in examining the heart, first of all feeling and then percussing to find the outline, then listening at the apex and then roughly where you though the valves were. We learned little tricks like sitting the patient upright or slightly forward if they were big-chested to move the heart up against the chest wall.
All of this was based on the skill of looking. “So, Mr. Martin, when you look at this gentleman what can you see from a distance that might lead to a diagnosis?” This was not so that you began to think you could diagnose from the end of the bed, but rather to stop you rushing in and focusing on minutiae. “Now tell me what you can smell?” At first this was such a strange question that it made you giggle; and extract a frown from the consultant… Oh, he was serious. “Well, there is a sort of sweatiness behind the soapiness of the recent bed bath.” That earned me a couple of sniggers from other students, and a turning away by the consultant to others with more sense. There are some classic (if subtle) smells in the more severe cases of renal disease, or liver disease, or the sweetness that sometimes accompanies diabetes – to name a few examples. And gradually we began to ‘get it’. Of course, some consultants were known to tease. I remember one consultant psychiatrist walking onto a ward late in my training and stating: “ There is a person with schizophrenia on this ward. I can smell it…” Of course, he was on a winner, given it was a psychiatric ward, but we were in awe until a registrar later explained that such ideas had been in vogue for a hundred years, but had been disproven.
Of course, alongside this rich experience of bedside learning we had to endure a whole range of learning practical skills. One example was that of taking blood. As the junior boy on the team, with or without competence, you were often dobbed in to take blood from a large number of patients on the ward. If you did not have the skills to begin with, you did after months of this kind of forced practice. But it began innocuously enough. We began on oranges. Seriously. The skin of the orange often has that slight resistance of human skin. If you press too hard to get through the initial resistance, you may go through the vein. So we practiced until we had a delicate but firm touch. Then we practiced on each other. Seriously. Put on the tourniquet and pump it up. Be patient and watch for the swelling veins in the antecubital fossa. Some people have translucent skin and you can see the bluish tinge of the vein; in others, there may be more fat, or just thicker skin, and you have to feel for the vein. Be patient. Be certain. Be confident. Angle the needle and press confidently. Never rush. Well after you have put holes in several colleagues, and they in you, you do have some belief that you may be able to do this. On to real patients – poor things.
In another memorable practical session we were forced to touch the surface of two layers of toilet paper covering a piece of excrement (cold from memory). Nice. Then the fingers were placed into a Petrie dish with a layer of Agar. We were allowed to wash our hands thoroughly with soap cold water, and then had to place the fingers in another Petrie dish. Finally we repeated the process, but used hot water and soap, drying the hands, again putting the fingers into a third Petrie dish. Finally, having repeated the process, we were shown how to do a surgical scrub, drying the hands carefully, and again ‘infecting the Agar’. The dishes were incubated overnight, and the next day we had some surprises. All three of the first experiments proved to grow bacteria – even when we had used hot water. Only the surgical scrub method removed evidence of E. Coli and some other bugs; even then there were some ‘commensals’ that grew overnight (perhaps from us breathing to hard). You never forget such an experience, and the lesson it teaches; if you are going to do surgery of any kind, cleanliness takes thought, and effort, and careful scrubbing if you want to avoid cross infection. Disgusting demonstration (and some people did gag a little), but brilliant; our teachers did not want us to forget. I never did find out who provided the excrement, but I imagine they were amused at what we poor beginners would have to go through.

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