PBL - A Problem Best Left

She stands in the shower, the warm water dripping down her face. At least now, nobody can see that she's crying. She gets out of the shower, shivers as her feet hit the cold tiles. She wraps herself in her towel and sits on the edge of the bath. As she looks down at her scarred legs she feels that deep lonely ache in the pit of her stomach. She hastily pulls on her clothes and leaves the bathroom. She scrabbles around for her books and pens and throws them in a bag. She turns on her hairdryer to drown out the noise of the students talking noisily and happily in the street. She picks up her bag, pulls on her boots and walks out of the door. Today is just going to be the same. She gets to her seminar group 5 minutes early. She gets out her notes and takes her seat, saying nothing but a polite hello. There's no point saying anything else any more. She feels unappreciated and disliked by the group. As the discussion begins, she is frequently talked over and ignored, and even put down by other members of the group. This isn't what this should be like. This should be enjoyable, and sociable, but instead, she gives in and sits in silence. She sits, and just hopes that soon it will end. She leaves, only to go to her lecture, and sit and cry silent tears, hoping that nobody can see.

This is my attempt at trying to express what PBL days are like for me this year. It's a constant struggled with my group and I dread the days. My tutor has been fantastic, and a great help and support, but I just don't feel valued, and I don't feel like my presence is even noticed. I guess, this is just the way it's going to be.

I Have Returned!!!

Normal service has once again resumed. I'm still not well but am managing to make it in to a good few lectures, and am just about keeping on top of my work - I even have 2 patient case studies written up already!! Unheard of for me! We've now started respiratory medicine, which I'm not particularly enjoying. Sputum is really quite disgusting, but the acute management side of this unit I'm really enjoying. I like knowing how to manage things like pneumothorax and stuff that I would come across pre-hospital. Chest infections with lots of thick green gunk, not so much.

Anyway, thank you to all my guest bloggers - you gave me a lot of really interesting stuff to read and a good break from the blog. If your post hasn't appeared, it's because I'm saving it for a future date.

Also, the boy (Simon) is now back on Twitter as @NorfolkDocToBe which is great, cos I can now talk to him more, even if it's mostly to take the mick out of him!

I'm going to aim to write at least one post a week from now on, but knowing me I'll probably start blogging instead of working so posts will probably be much more frequent than that!

If you have a request for something you want me to write about, or a question that you want to ask me (nice ones please! - if I get any more offensive or rude comments or emails, I will start moderating comments and blocking people. Sad to say it, but it has been happening.) feel free to email me with your requests and questions, or if you just want to chat to me, feel free to email.

Guest Post - I Can Still Hear the Crying

Still have a lot on my plate at the moment, so this is here courtesy of Will (@bungeechump on Twitter). Having not long seen my first in hospital death, this was something that was something that I could really relate to. It's a well written piece and something that I wanted to share.

As graduation races towards me, the knowledge that I will be a "real doctor" in a few short months has made me pause for reflection on my time in medical school. Death is something that medical students are expected to deal with easily. Often this isn't the case. They say you never forget your first cardiac arrest as a medical student, but in practice I found this not to be true – I will never forget my second.

The first cardiac arrest I participated in was fairly uneventful and as morbid as it sounds, unremarkable. An eighty-two year old gentleman who has suffered an out of hospital unwitnessed VF cardiac arrest. He was not a well man to start with, his swollen legs indicative of heart failure and the mere fact that he was over eighty put him at a disadvantage. I stood in the resuscitation bay with one of the SHOs and the registrar. The ambulance was about five minutes out. I noticed the two doctors were wearing gloves and had donned aprons so I followed suit. I knew that statistically the chances of surviving to discharge following an unwitnessed out of hospital cardiac arrest were less than five percent, so I wasn’t expecting miracles. I wasn’t sure what to expect.

A slam on the double doors and in rolls the patient, the paramedics pushing and a nurse pumping on his chest as they wheeled him into the bay. He was already intubated and had good IV access, so that was one less concern. I took over the chest compressions. The sensation of ribs cracking beneath your hands and vibrating up into your shoulders is horrible. It sounds like somebody breaking a large wooden branch in the next room. After each crack, the chest becomes easier to compress until eventually it is soft like an old chain link fence.

The defibrillator was attached. A familiar broad complex, irregular waveform tachycardia emerged – ventricular fibrillation. Stand clear, oxygen away, shocking! The man’s entire body tenses up, his arms come up in the air – but then instantly flop back down as the electricity subsides. Continue chest compressions. This cycle continued for about ten minutes with adrenaline injections interspersed. The man’s Grandson arrived and said an emotional goodbye and we stopped resuscitation. I calmly left the room and went back to trying to insert a cannula into a little old ladies forearm.

I was remarkably unbothered by what had just happened. I was suddenly dubious of what they say about your first arrest and how it always sticks in your mind. That was until my second arrest, several days later.

The man had walked into the department. He was a hospital porter and felt unwell and so had wandered down to A&E. He was in his mid-fourties. He looked awful and was complaining of a several day history of headache, breathlessness and general malaise. It was quickly decided that this guy was far too sick to just be sat in majors, and he was transferred to resus.

His level of consciousness was falling and he became unresponsive. His respiratory rate shot up and he was gasping for air. This patient was very unwell, and the anaesthetist was paged so we could get a definitive airway. All of a sudden, he doesn’t have a pulse. Chest compressions begin, and the anaesthetist is here – but the intubation is proving difficult. His oxygen saturations are falling and all the machines are beeping. Finally the tube is in, and compressions can resume.

His chest was very hairy - far too hairy to get a good contact for the defibrillator pads. One of the nurses scurried off to find a razor while somebody else had the bright idea to try and wax his chest with one of the sticky defib pads. This didn’t work. The razor turned up and the pads were on with good contact. The heart trace showed sinus rhythm. Oh shit. Pulseless electrical activity – a bad thing to have if there is no obvious reversible cause, because it is an unshockable rhythm and you just have to keep pushing adrenaline and hoping for the best.

Time flashes by and we still don’t know what has caused the arrest. The most likely culprit was a massive heart attack, or a pulmonary embolus. However we can’t give clot busting drugs because of his history of a headache – if he has a subarachnoid haemorrhage the thrombolytics will turn his brain to mush, but his pupils can’t be assessed because he has had so much adrenaline and atropine so it’s impossible to rule anything out and therefore impossible to really treat anything. Vigorous CPR was attempted to try and bust up a clot mechanically if one was present (cue more ribs cracking, and my arms aching the next day).

This all happened at the weekend, so none of his relatives were in work and they all turned up rapidly until there was a gang of about eight of them in the resuscitation bay within twenty minutes. His wife and sister are holding his hand, sobbing into each other’s embrace, calling out to him and asking him to wake up. His son turns up and stands next to his head, intubated with eyes wide open and staring, flopping around lifelessly as we jump up and down on his chest, telling him to pull through so they can go to the match next week together. His elderly Father stands at the foot of the bed. He fights back the tears, occasionally slapping his son of the legs and telling him to ‘pull through’ and stop messing around.

A pause in the CPR and suddenly a familiar rhythm emerges on the screen. Pulseless ventricular tachycardia. One of the nurses pulls the family off him, and a shock is given. His wife nearly falls to the floor watching her husband convulse off the bed as 120J of electricity pass through his lifeless body. They huddle back round him. I am taking turns doing the chest compressions with one of the nurses, in short cycles so we don’t get tired and therefore not push hard enough. The A&E consultant is talking quietly to the anaesthetist at the head of the bed. CPR has been on-going for 45 minutes and there was been no real improvement. A pause in chest compressions to check the monitor reveals a very irregular agonal rhythm.

The consultant turns to the family and introduces himself. He tells them what we are all doing to try and save their beloved. He tells them we have done all we can but he’s not showing any sign of improvement. He tells them he doesn’t expect the patient to recover. His wife pleads with him, please, just keep going for a little bit longer, he’ll pull through - I know he will.

We all know he won’t pull through. We all know that he has been receiving CPR for so long that all the centres of his brain that make him the person his relatives know and love, are dead. Even if he did get back to sinus rhythm, he would be a vegetable and would end up in intensive care (also known as the cabbage patch) for several years, just waiting for the pneumonia that will kill him.

The consultant looks round at all of us involved in the resuscitation attempt. Then he turns back to the family. I’m sorry, there’s nothing more we can do, we have to stop. The monitors are turned off, the oxygen is disconnected and chest compressions cease. We all take a step back, the sound of multiple pairs of gloves snapping off spells defeat.

His family rush towards him and hold him, all of them sobbing. All we can do is stand and watch. I slip out the side of the room and walk back towards the main area of the department. I walk past an angry young woman shouting at one of the nurses about how she’s been waiting for four hours, and I feel angry. If only she had a clue as to why she’d been waiting for so long, I’d bet she’d go and sit down and shut right up.

I can still hear the crying in the background. I sit down in one of the cubicles and gather my thoughts. Now this was an arrest that I will never forget.

Oh Balls...

OSCE went very very badly. I will almost certainly have a resit in the summer. Balls.

Stress City

OSCE tomorrow afternoon. Logbooks not finished. Stressing. The FEAR has well and truly set in. I'm incredibly tired and ill and lonely. The boyfriend is so far away and I just want to crawl in a hole and hide. Would be grateful if you'd send comments willing me on to get this work done. Need all the help and support I can get at the moment.

Guest Post - How To Deal With Meeting A Person With Depression

This guest post was written by madsadgirl originally. It's another fantastic piece of writing, about those like me living with depression. You can read her blog here:

http://madsadgirl.blogspot.com/

How To Deal With Meeting A Person With Depression

It is a sad fact of life but the majority of people in this country feel very uncomfortable about the subject of mental illness. What makes it worse is that a significant proportion of the population are likely to suffer from the most common form of mental illness, depression, at some point in their lives, yet that particular illness still carries a serious stigma with it.

The problem for the sufferer of depression is that it can be a very debilitating illness, but to the majority of non-sufferers that you meet you show no signs of having anything wrong with you. There are no tell-tale spots or rash, you have no stitches, bandages or plaster cast, and you don't require sticks, crutches, or a walking frame to get around. You can be, however, very seriously ill indeed and yet there are no outward signs that would be obvious to those that you meet. So short of carrying a bell or clapper like the lepers of long ago, or wearing a notice around your neck proclaiming "I have depression; treat me carefully" most people would not realise that there is anything wrong with your health.

I don't know how depression manifests itself in other people, I can only describe what I feel, but my depression is not only something that affects the way that I feel about things, it also has some very definite symptoms that I feel physically. When it is at its worst, depression makes me feel as though my head and body are not connected to each other. My body feels numb, like the numbness that you feel in your lip after having an injection at the dentist's, and my head has a woolly feeling with a tendency to feel very light-headed as though I have drunk alcohol on an empty stomach. All of this is combined with an overwhelming desire to cry, though I have no idea what I am crying about, it is just something that I have to do.

So these are the physical symptoms that I feel, which in themselves may not seem like much, but are nonetheless capable of lowering my mental state to a level even lower than it is already. I find it impossible to concentrate; reading becomes something that is unbelievably difficult. I have always loved reading, and half an hour with a good book before I lay down to sleep was the perfect end to the day. Now I find that I have to read the same page repeatedly to stand any chance of understanding what I have read. I have always been shy, but depression makes it incredibly difficult to interact with people that I do not know. Social functions become trials that can cause anxiety to build up days in advance, and small talk something to be avoided because you are likely to become tongue-tied while attempting to have the simplest conversation.

When somebody asks you "How are you?" you answer automatically "Fine" although you aren't really. You answer like this because you know that they really don't want to know that it took a monumental effort to get out of bed, that getting yourself to this stage in the day has been a war against irrational feelings, and that if they ask you anything else you are likely to burst into tears. You hate it when they say "Smile, things could be worse" when you know that there is nothing that could make you feel worse than you do at that particular moment and and smiling is the last thing on your mind because you are finding it almost impossible to just exist. If you were to answer the "How are you?" question truthfully, the questioner would become embarrassed and not know how to further the conversation because they would find it difficult to deal with someone with a mental illness.

Mental illness is something that happens to people. They don't ask for it, and they most certainly would prefer not to have it. Unfortunately, while the medical profession has made incredible advances in the treatment of many of the diseases and injuries that affect us physically, diseases of the brain are not so easy to treat. While we are very similar physically, we are all unique mentally; that is what makes it so difficult to 'cure' mental illnesses.

The next time that you meet someone who suffers from depression, please remember that they are a human being just like you, they don't want to feel the way that they do, and that you can't catch what they have got through contact with them. But most of all, remember that they don't like being stigmatized because they have a mental illness. Remember that; because at some time in the future the person with depression could be you. 

Guest Post - Max and Me

Guest post submitted by Nooreen Akhtar. For sufferers of Depression like myself, this is a fantastic piece of writing explaining exactly what it is like for us on a day to day basis. Well worth reading. The black text is the entirety of the post, exactly as it was sent to me. Thank you for this wonderful submission.

Written by a friend.

Max and Me

The radio goes off at 7 am, and when I open my eyes I can tell Max is already awake. As I start to pull myself up the exhaustion hits me, and I wonder how much sleep I managed to get. Max must have kept me up for hours going on and on about money problems, the heavy workload we have at university and life after graduation. I turn off the radio and reach for my glasses when he starts trying to convince me to spend the day in bed, keep the curtains closed, ignore my timetable and stay under my duvet where its warm and safe. It sounds like such a good idea I nearly give in, but I pull on my glasses, climb out of bed and start planning my day. I wonder round the flat gathering my lecture notes and incomplete assignments with Max making annoying comments in the background, which I try to ignore. Once everything seem ready, I head to the bathroom and jump into the shower. The shower feels great, all the smells from fancy shower gels and shampoos calm me down and wash away the exhaustion. It’s nice to be away from Max’s constant complaining, but I can’t spend all day in the bathroom when there’s work to be done. As I walk out feeling refreshed and start planning my outfit for the day, but as I go through my cupboard Max comments about how all my clothes make me look fat and that I should really make more of an effort to lose weight. I try to argue back but there’s no winning this fight and it easier to just let it go even though I wonder if he might be right. Once I’m ready and out the door walking to lectures you would never figure out that Max was with me. It’s a secret that no one can know about, I’m scared they won’t understand or will judge me, and when I’m outside or around other people it’s easier to pretend that Max is not part of my life. The next few hours are spent hanging out with my friends, going to lectures and trying to complete coursework. From time to time Max will secretly start whispering in my ear about how my friends don’t really like and they’d probably be better off without me. It drives me up the wall when he starts while I try to finish my work in the library. He spends the entire time putting me down or convincing me to just go home back to bed. Some days I just plain ignore him, but today I give in and head into town instead. I walk in and out of shops, seeing loads of items I’d love to buy. Max tries to convince me to buy them, telling me that they will cheer me up and make me feel better today, and a lot of the time I give in, because he’s right it does make me feel a lot better. When I get home, I put everything away and start wasting time finding random things to read online. One of my friend’s then sends me a text reminding me that I was supposed to going out for a party. I’ve known about this party for ages and had originally planned to go but Max suggests that it might just be easier to stay at home and watch DVDs, and again I give in and text my friend back with a made up excuse. The evening goes by, a mixture of DVDs, videogames and avoiding coursework that really needs to be done. Before I head to the kitchen to turn the light before bed, Max starts having a massive go at me, and the comments sometimes reduce me to tears. The subject matter varies from friends, family, work, but he tends to always criticise me as a person. Today it was how I’m never going to succeed at my future goals, how I’m kidding myself that I am smart enough to be at university and that the best thing to do would be drop out and leave, and today I believe him. He follows me as I head to the bedroom and as I curl up under the duvet, he lies next to me going on and on. Seems like it’s going to be another long night.

Max is not real, but Max is not imaginary either. Max is a dark shadow that has followed me for a while now. Max is a real disease that affects several million people all across the globe. Max is depression. What I have described is one of my bad days, and I have them a lot. But I am trying to get help so that Max becomes a decent memory rather than that annoying and demeaning voice in my head. If you have the same problem or know someone who does, encourage them to get help, because the good days you start to have make every bad day well worth it.

Don't forget that I'm looking for another guest post for the weekend, so submissions by midnight Thursday please!

An Invitation

As I'm really busy at the moment with possibly life changing decisions to make, revision to do, still feeling ill, and putting up with my family, I'd like to invite somebody else to write a post for me. Would like it to be about an experience as a patient, a medical student during your training or a paramedicine student during your training, or someone in a medical career coming across something particularly interesting.

Submissions to dysdiadochokinesia@hotmail.com by midnight (UK time) tonight preferably for the first post, and midnight Thursday for the second post of the week.

Look forward to reading them!

Thank You

I wanted to say thank you for all your thoughts, comments and prayers, and kind messages that you have sent me. They are all playing a part in my decision making, and I'd be grateful if you'd keep them coming and spread the word for me. I really appreciate your kind words, and they're all helping me on my way to reaching a decision. I think I'm nearly there, but I just need those last few bits of help and reassurance to keep me on the right track for me.


Thank you, all you kind people, and thank you social media.

Faye
xxx