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Hello World, I've been to London's Air Ambulance for a bit...

Hi. Or rather, #HelloMyNameIs Adam. I like trauma, emergency medicine, PHEC, #FOAMed, twitter and scuba diving (but only when there's sunshine involved afterwards). I also like teaching and education, and I'm one of the final year medical students here in Edinburgh. But for 2 months I wasn't. I was one of the London's Air Ambulance elective students down in Whitechapel at the Royal London Hospital. So as an opening gambit, and by some way of an introduction I thought you might want to hear about that. After all, they're much more interesting than I am, and I can't host you for your elective… I managed to swindle my way into a 2 month elective with LAA just before Christmas 2014 and in a word it was pretty great. For those of you thinking of doing it, just go, now, and apply. Then you can come back and read the rest of my ramblings. For the rest of you, here’s what happened. LAA electives are a bit different, unsurprisingly. To cover its 1800-odd missions a year, LAA runs both their trauma service in two flavours: a helicopter (G-EHMS, aka “Mike Sierra” or MEDIC 1) by day and a car (DA “Delta Alpha” 77 or MEDIC 1 NIGHT) by night, (because apparently, whilst sporting and enjoyable for the pilots, landing in metropolitan areas in the dark is too risky, especially with comparatively empty roads). Alongside the trauma service, there is also a Physician Response Unit (PRU) which responds locally to cardiac arrests to provide quality CPR (along with some advanced post-arrest care like cooling and delivery to a cath lab), but for the most part does jobs for the London Ambulance Service which have been deemed probably not to require hospital, but might benefit from a doctor. There’s a 5 year waiting list for day-time flying shifts, and not much less for the rest of their work, so you’re not going to spend 4, 6 or 8 weeks in a helicopter flying round London taking names and saving lives, in fact the helicopter schedule is totally off-limits to students. Instead you’ll start off scheduled for a couple of night shifts each month and there will be opportunities to see a lot of London Ambulance Service, from the “control” at the Emergency Operations Centre (EOC), to time spent with road crews, and, off the back of some of the folk you’ll meet, a route in to observing with some more specialist units too. (More on that in the future if I run out of other ideas!) As well as the “live” experience there are 5 very experienced senior registrars from a variety of backgrounds as well as the 4 full-time LAA consultants, and opportunities to learn both practical skills and theoretical knowledge from them abound. As it turned out, the PRU was probably my favourite part of the elective. You can read about all the trauma that LAA goes to elsewhere, its splashed all over their shiny new website for a start, and many things have been written about their work (I might even write some more later on!) and there’s even a (not great) telly program on Channel 5. But the PRU is just really cool. I hate that word but it is. It fits into a strange, but now expanding niche in emergency care. That is, it serves to lighten the load both on the ambulance service and on the Emergency Departments of London by going out to people who have called 999 and asked for an ambulance but might in fact be better managed in the community. The work is incredibly varied, you can see older folk with a nasty UTI who couldn’t get to see their GP, you can go to a school and glue the head of a kid who’s taken a nasty fall in the playground, or you can end up in some sheltered housing talking to a lady who’s having the roughest of times and trying to deal with borderline personality disorder to boot. The PRU is crewed about half the time by a small group of GPs and EM docs who have been doing it for a while, usually about once a week or so, and quite often in their own time (in between the rota is made up with the LAA docs who usually work the trauma service). They’re kept firmly in line by an experienced LAS paramedic who is seconded over to run this unit, 9-5, 5 days a week, usually for about a year. As a team, they have perfected their ability to assess a patient using the minimal resources available to them, and as we are so often reminded, quite rightly, it turns out to be all in the history. Some interventions are available to them that aren’t available to paramedics, prescribing antibiotics or other drugs to leave with the patient, bypassing the ED for referral straight to specialists, and doing urine dipsticks being the most used among them; but mostly it is the team’s experience and advanced clinical judgement which makes this unit tick, and empowers them to safely leave so many of their patients at home, with care delivered, advice given, and a plan arranged should anything deteriorate. This wasn’t my first rodeo, I’ve been lucky enough to spend some time with the Scottish Ambulance Service up here in Edinburgh, and have spent more than my fair share of time in our Emergency Department, but it was still impressive to see how these guys dealt with the delicate balance of who to leave at home and who might need a further investigation in hospital. Firstly, this is something that anyone who aspires to work in an emergency department should aspire to be comfortable to do. There are going to be a huge number of people who don’t need to be admitted coming through it every day, wherever it is. The faster and more confidently you can identify their problems, treat them, and crucially, reassure them with appropriate advice, good follow up and a safety net, the better experience they will have. Of course much of this comes with experience and training, but tagging along with teams like this is a fine way to start getting some. Secondly, and this is a bit of a stab in the dark, but I think this idea really might take off. The media is almost swamped with stories of A&E departments being overwhelmed, ambulance services are operating at or near capacity, and we’re struggling to work out how we get the public to access the right care provider for their problem at that time. So maybe this is a solution. Maybe doctors, have a new role to play in assessing people earlier rather than people going through so many steps down a potentially unsuitable line of care. We’re starting to see consultants running triage at A&Es, we’re starting to see doctors out in cars like this. Get in on the ground floor guys and girls, I think we’re going to start being “first on scene” a little more often than we might be used to, even if you never leave the hospital.  
Adam Collins
almost 6 years ago
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Grand Round: Dos and Don’ts

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” The words of Sir William Osler, the acclaimed father of modern medicine, are still no less profound. They hark from an age when medicine still retained a sense of ceremony: an amphitheatre filled to the rafters, the clinicians poised in their white coats and ties, all eyes convergent on their quarry or rather the patient seated before them. Any memory of such scenes live out a vestigial existence in black&white photos or histrionic depictions recalling the rise of modern medicine. To think this is how the tradition of grand rounds proceeded in the not so distant past. Today grand rounds have a more tuitional flavour to them. The Socratic dialogue which reportedly took place has been superseded by the much less appetising PowerPoint presentation. It’s a weekly event marked in the calendar. For the ever-busy junior doctor it at least offers the prospect of a free lunch. I gest, they serve a social as well as an educational function. On the other hand medical student grand rounds are purely a learning exercise. They are most importantly not a race to find and present the most ‘interesting’ case in the trust because this is usually interpretted as a vanishingly rare condition, which even your ejudicating consultant has never encountered in a lifetime of experience. It falls short of the primary aim: to learn about the patients who you will be seeing as a junior doctor and as the addage goes - common things are common. What will make your grand round interesting, is not the patient you choose but how you choose to present that patient. Unfortunately, as fair a point Sir Osler makes, the old practice of patient participation in grand rounds has long since faded. You will have to call upon your thespian talents to retell the story to your fellow students. Of course not everyone’s a natural showman, however fortune favours the prepared and in my experience there are only a handful of things to worry about. Structure. This is the back bone of your presentation. Obviously a solid introductory line about the patient with all the salient points goes without saying, it’s no different to presenting to the consultant on ward rounds or in the clinic. Always set the scene. If you clerked your patient on a hectic night oncall down in majors, then say so. It makes the case less one dimensional. The history is your chance to show off - to consider the presenting complaint expressed in the patient’s own words and to form a working differential, which you can encourage your colleagues to reel off at the outset. The quality of the history should guide your audience to the right diagnosis. Equip them with all the information they need, so not just the positive findings. Showing that you have ruled out important red flag symptoms or signs will illustrate good detective work on your part. However you wish to order the relevant past medical/family history, medications, social impact etc is up to you. It’s a subjective thing, you just have to play the game and cater to the consultant’s likes. You can only gage these after a few cases so do the honourable thing and let your colleagues present first. Performance. Never read your slides in front of an audience. Their attention will rapidly wane (especially if they’re postprandial). The slides are an aide-memoire and to treat them as a script is to admit your presence adds nothing more to your presentation. Communicating with the audience requires you to present uncluttered slides, expanding on short headings and obliging your colleagues to listen for the little nuggets of clinical knowledge you have so generously lain in store. Insight. When the consultant asks you the significance of an investigation, always know on what grounds it was ordered and the limitations of the results. The astute student will be aware of its diagnostic or prognostic potential.The same may be said of imaging. Perusing the radiologists report and using it to guide the audience through (anoynmised) CXRs, CTs, US etc is a feather in your cap. Literature reviews of your choosing constitute a mandatory part of the presentation. They are demonstrative of not only your wider reading but your initiative to find the relevant evidence base e.g. the research underlying the management plan of a condition or perhaps its future treatments. Timing. Waffling is only detrimental to the performance. Rehearsing the presentation with a firm mate is a sure way to keep to time constraints. Memorability, for the right reasons, relies on a concise and interactive presentation. A splash of imagination will not go unnoticed. The consultant marking you has seen it all before; surprising titbits of knowledge or amusing quirks in your presentation will hopefully appeal to their curious and humorous side. If anything it might break the tedium grand rounds are renown for. Oratory is a universal skill and is responsible for so much (undue) anxiety. The more timid can take comfort grand rounds aren’t quite the grand occasions they used to be. Illustrator Edward Wong This blog post is a reproduction of an article published in the Medical Student Newspaper, December 2013 issue.  
James Wong
almost 6 years ago
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"So are you enjoying it?"

"When did the pain start Mr Smith?" "Ah so do you enjoy it?" 'It' of course refers to your five year medical degree. Patients can be nice can't they. Often it seems that all patients want to talk about is you. I thought the public didn't like students, aren't students lazy drunks who wake up at midday, squander their government hand-outs on designer clothes, and whose prevailing role in society was to keep the nation's budget baked bean industry in the black? Apparently the same isn't thought of medical students, well maybe it is, but god patients are polite. The thing is I have found these questions difficult; it is surprising how they can catch you off guard. Asking if I am enjoying 'it' after I have woken up at dawn, sat on a bus for 40 minutes, and hunted down a clinician who had no idea I was meant to be there, could lead on to a very awkward consultation. But of course it doesn't "yes it is really good thank you". "Do you take any medications, either from your GP or over the counter?" "Are you training to be a GP then?" Medicine is a fascinating topic and indeed career, which surely human nature makes us all interested in. As individuals lucky enough to be studying it, maybe we forget how intriguing the medical profession is? This paired with patients sat in a small formal environment with someone they don’t know could bring out the polite ‘Michael Parkinson’ in anybody. Isn't this just good manners, taking an interest. Well yes. Just because I can be faintly aloof doesn't mean the rest of the world has to me. But perhaps there is a little more to it, we ask difficult personal questions, sometimes without even knowing it, we all know when taking a sexual history to expect the consultation to be awkward or embarrassing, but people can be apprehensive talking about anything, be it their cardiovascular disease, medications, even their date of birth. We often then go on to an examination: inspecting from the end of the bed, exposing a patient, palpating. Given a bit context you can see why a patient may want to shift the attention back to someone like us for a bit, and come on, the medical student is fair game, the best target, asking the consultant whether they enjoys their job, rather you than me. If we can oblige, and make a patient feel a bit more at ease we should, and it certainly won't be doing our student patient relationship any harm. Hopefully next time my answers will be a bit more forthcoming. "Any change in your bowels, blood in any motions?" "How many years do you have left?" It is a good thing we are all polite.  
Joe de Silva
almost 6 years ago
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Clinics - Making the most of it

Commencing the first clinical year is a milestone. Things will now be different as your student career steers straight into the unchartered waters of clinical medicine. New challenges and responsibilities lie ahead and not just in an academic sense. After all this is the awaited moment, the start of the apprenticeship you have so desired and laboured for. It won’t be long before these clinical years like the preclinical years before them, will seem just as distant and insular, so why not make the most of it? The first days hold so much excitation and promise and for many they deliver, however, it would be wise not to be too optimistic. I am afraid your firm head standing abreast the doors in a prophetic splaying of arms is an unlikely sight. In this new clinical environment, it is natural to be a little flummoxed. The quizzical looks of doctors and nurses as you first walk in, a sure sign of your unexpected arrival, is a recurring theme. If the wards are going to be your new hunting ground, proper introductions with the medical team are in order. This might seem like a task of Herculean proportions, particularly in large teaching hospitals. Everyone is busy. Junior doctors scuttling around the ward desks job lists in hand, the registrar probably won’t have noticed you and as luck would have it your consultant firm head is away at a conference. Perseverance during these periods of frustration is a rewarding quality. Winning over the junior doctors with some keenness will help you no end. What I mean to say is that their role in our learning as students extends further than the security of sign-off signatures a week before the end of the rotation. They will give you opportunities. Take them! Although it never feels like it at the time, being a medical student does afford some privileges. The student badge clipped to your new clinic clothes is a license to learn: to embark on undying streaks of false answers, to fail as many skills and clerkings as is required and to do so unabashed. Unfortunately, the junior doctors are not there purely for your benefit, they cannot always spare the time to directly observe a history taking or an examination, instead you must report back. With practice this becomes more of a tick box exercise: gleaning as much information and then reconfiguring it into a structured presentation. However, the performance goes unseen and unheard. I do not need to iterate the inherent dangers of this practice. Possible solutions? Well receiving immediate feedback is more obtainable on GP visits or at outpatient clinics. They provide many opportunities to test your questioning style and bedside manner. Performing under scrutiny recreates OSCE conditions. Due to time pressure and no doubt the diagnostic cogs running overtime, it is fatefully easy to miss emotional cues or derail a conversation in a way which would be deemed insensitive. Often it occurs subconsciously so take full advantage of a GP or a fellow firm mate’s presence when taking a history. Self-directed learning will take on new meaning. The expanse of clinical knowledge has a vertiginous effect. No longer is there a structured timetable of lectures as a guide; for the most part you are alone. Teaching will become a valued commodity, so no matter how sincere the promises, do not rest until the calendars are out and a mutually agreed time is settled. I would not encourage ambuscaded attacks on staff but taking the initiative to arrange dedicated tutorial time with your superiors is best started early. Consigning oneself to the library and ploughing through books might appear the obvious remedy, it has proven effective for the last 2-3 years after all. But unfortunately it can not all be learnt with bookwork. Whether it is taking a psychiatric history, venipuncture or reading a chest X-ray, these are perishable skills and only repeated and refined practice will make them become second nature. Balancing studying with time on the wards is a challenge. Unsurprisingly, after a day spent on your feet, there is wavering incentive to merely open a book. Keeping it varied will prevent staleness taking hold. Attending a different clinic, brushing up on some pathology at a post-mortem or group study sessions adds flavour to the daily routine. During the heated weeks before OSCEs, group study becomes very attractive. While it does cement clinical skills, do not be fooled. Your colleagues tend not to share the same examination findings you would encounter on an oncology ward nor the measured responses of professional patient actors. So ward time is important but little exposure to all this clinical information will be gained by assuming a watchful presence. Attending every ward round, while a laudable achievement, will not secure the knowledge. Senior members of the team operate on another plane. It is a dazzling display of speed whenever a monster list of patients comes gushing out the printer. Before you have even registered each patient’s problem(s), the management plan has been dictated and written down. There is little else to do but feed off scraps of information drawn from the junior doctors on the journey to the next bed. Of course there will be lulls, when the pace falls off and there is ample time to digest a history. Although it is comforting to have the medical notes to check your findings once the round is over, it does diminish any element of mystery. The moment a patient enters the hospital is the best time to cross paths. At this point all the work is before the medical team, your initial guesses might be as good as anyone else’s. Visiting A&E of your own accord or as part of your medical team’s on call rota is well worth the effort. Being handed the initial A&E clerking and gingerly drawing back the curtain incur a chilling sense of responsibility. Embrace it, it will solidify not only clerking skills but also put into practice the explaining of investigations or results as well as treatment options. If you are feeling keen you could present to the consultant on post-take. Experiences like this become etched in your memory because of their proactive approach. You begin to remember conditions associated with patient cases you have seen before rather than their corresponding pages in the Oxford handbook. And there is something about the small thank you by the F1 or perhaps finding your name alongside theirs on the new patient list the following morning, which rekindles your enthusiasm. To be considered part of the medical team is the ideal position and a comforting thought. Good luck. This blog post is a reproduction of an article published in the Medical Student Newspaper, Freshers 2013 issue.  
James Wong
over 5 years ago
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The power of the story: teaching doctors to ‘feel’ patient-centred care

Following the death of her 21-year-old son, Margaret Murphy, external lead of the WHO’s Patients for Patient Safety programme, has been teaching doctors and students how an engaged, knowledgeable patient can be the key resource in his or her own care  
theguardian.com
over 4 years ago
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Second Stage of Labour: Clinical Skills Tutorial for Student Midwives

This tutorial was made to help prepare you for your second stage clinical skills lab  
youtube.com
about 4 years ago
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Course Lectures Online

MacAnatomy is the online portal to the Education Program in Anatomy at McMaster University.  
macanatomy.mcmaster.ca
almost 4 years ago
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Fractures of the humeurs and possible nerve injuries

Presented and edited by Dr. Akram Jaffar, Ph.D. This video and its channel are supported by "Human Anatomy Education" Page on Facebook http://www.facebook.co...  
youtube.com
over 3 years ago
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Pericardium - dissection

This video and its channel are supported by "Human Anatomy Education" page on Facebook http://www.facebook.com/AnatomyEducation After watching this video, it...  
youtube.com
over 3 years ago
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Figure 4-1b, [STEP WISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5–11 YEARS OF AGE]. - Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma - NCBI Bookshelf

National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug.  
ncbi.nlm.nih.gov
over 3 years ago
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What influence the development of student capability that support lifelong, self-directed learning?

Reference searching capability contributes to lifelong, self-directed learning competence, and it is influenced by training in reference searching, critical thinking, problem-based learning and English language, as well as formative evaluations.  
Nani Cahyani Sudarsono
about 10 years ago
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Labyrinth and the Liminal Student

Background The transition period from undergraduate training to postgraduate “foundation” practice is brief – often only a matter of a few days - but its impact is profound. What was previously a well supported, structured learning environment is suddenly a strange and potentially frightening place where critical decision-making skills, authority and professionalism seem suddenly more relevant than all of the knowledge amassed in undergraduate training. Foundation doctors indicate that the undergraduate experience does little to prepare them for the shock of actual practice. Summary of work An emerging initiative within the University of Edinburgh’s College of Medicine and Veterinary Medicine is to adopt the easy-to-use authoring tools and principals associated with Game Informed Learning to afford collaborative groups of later year undergraduates and foundation doctors the scope to create learning objects for undergraduates. Conclusions Using in-house developed instruments such as the branching scenario authoring tool “Labyrinth”, these groups draw on their recent experience of this transition period to create learning objects that not only directly address perceived gaps in the range of learning support activities available to undergraduates but also, using the principals of game-informed learning to situate the activities within realistic contexts, and plausible scenarios which offer an indication of what practice will feel like. Take-home message Learning tools to ease the transition between medical student and doctor.  
Jennifer Willder
almost 10 years ago
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Layered Learning

This is a work booklet, which helps students gain or reinforce knowledge of the anatomy of the posterior lower leg. Using multi-sensory and artistic techniques the students are guided through creating their own three-dimensional, layered anatomical paper model. This technique can be applied to any anatomical structure, along with physiological or pathological processes, and transformed into learning work booklets for students.  
Heather Sullivan
over 7 years ago
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Clinical Photos: Mitochondrial inheritance

© 2009 NHS National Genetics Education and Development Centre Genetics and Genomics for Healthcare www.geneticseducation.nhs.uk Clinical photographs - Mitochon…  
Nicole Chalmers
over 5 years ago
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Clinical Photos: X-linked conditions

© 2009 NHS National Genetics Education and Development Centre Genetics and Genomics for Healthcare www.geneticseducation.nhs.uk Clinical photographs of X-linke…  
Nicole Chalmers
over 5 years ago
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Conditions caused by abnormalities in chromosome structure

NHS National Genetics Education and Development Centre Genetics and Genomics for Healthcare  
Mr Malcolm Landon
over 5 years ago
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Proximal Tubule Diuretics for Students

Proximal tubule diuretics e.g. acetazolidamide.  
almostadoctor.com - free medical student revision notes
over 5 years ago
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Chest X-Ray Basics in 5 min

The basics of the chest x-ray in 5 minutes by Dr Kate Henderson, Specialist Trainee in Anaesthesia and Education Fellow at Manchester Royal Infirmary  
YouTube
over 5 years ago
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Who is oPortfolio aimed at?

This is a post about oPortfolio - a project that Meducation and Podmedics are collaborating on. We have a Kickstarter project and would love your support! Students? Junior Doctors? Senior Doctors? Over the last two days we've been asked by lots of people who oPortfolio is for. Some people want it for students, others to replace junior doctor systems, and some for revalidation purposes. The simple answer is that it's for everyone going through their medical careers from student to consultant and on to retirement. Challenges There are two challenges to building a system that's relevant for such a wide variety of people. The first is to make something that has all the features that are needed for all the people. We are strong believers in self-directed learning and want that to be at the core of oPortfolio. We want people to be able to build their own personal portfolios, keeping a log of everything they want to - their own personal space for reflection and learning. oPortfolio should be something that you find useful at all stages, and that's crucial to our vision. The second challenge is working with existing ePortfolio systems, and to have functionality that deaneries and Colleges need to adopt our platform if they want to. Making a system that is incompatible with existing systems, or that involves doctors still having to use other horrible software defies the whole point of what we're doing. If a user's oPortfolio has to be manually copied & pasted into another system, everyone loses out. This, therefore, also has to be a large consideration as we move forwards. At all times, we will have to balance these two challenges up against each other. Conclusion oPortfolio is for everyone. It certainly won't have all the features that everyone needs from day one, but our aim is to build a solid base everyone can use, and then expand it from there. With regards to who we give our initial focus to, it will be the people who support us on Kickstarter. They are showing genuine support for what we're doing, and therefore deserve to be prioritised. That only seems fair. Please support us today. Thank you.  
Jeremy Walker
over 6 years ago