We Must Continue

Next week is my last as a medical student in the hospital. When I return in January, I will do so as an intern. How time flies right by. It will be an opportunity to make new friends and work alongside colleagues. Once again, we will all be going from the most senior people in the chain to the weakest link in the chain. Although we keep getting assured by senior staff that interns are the backbone of any medical or surgical team, I can't help but feel the role will not be as fulfilling as one would expect after finishing years of study. I also feel that although the role may not be "the weakest link" (if there is such a thing), I may not perform adequately to meet expectations. 

Why am I not excited? Why don't I feel all nostalgic while some of my friends have been counting increments of how much of a fraction of a doctor we all have been up until this point? Why can I not smile about it?

I look beyond internship and notice the people around. I've said how much in love I've been with general surgery, but now I have my doubts. Does that cripple me? No. It's reassuring and somewhat refreshing to know I don't have to pressure myself to do what it is I've loved in the past based on but a few months of time in the operating theatres. But then again, I haven't stepped foot as an assistant in an operating theatre for quite some time now. 

Maybe it's delayed gratification. The people around me seem to be doing so well. I've got dreams like everyone else; but unlike some people, they seem to remain as dreams. 

I bought myself a car less than two weeks ago: my gift to myself for all the years of 2-3 jobs and university studies. I was so excited and so happy but now, I feel like I don't deserve it. What have I done? Should I have saved the money for a house or a share portfolio? Perhaps a holiday? It's the largest loan I've taken out for myself and it'll take me at least 3-4 years to pay it off. It also puts even more pressure on me doing extra hours next year.

Somehow I've set myself up to work like a dog, more so than I've ever done. My weekend job's boss contacted me to work 7 days a week before the Christmas break, which I agreed to and they have also asked me to stay on as a relief on-call person should the need arise for support on the weekends, so long as it does not conflict with my responsibilities as an intern next year. So the potential of two jobs will still be on the debating table. Not to mention the lecturing will continue and I have no idea how medical administration will react to all these "extra-commitments". At the same time, will I be able to cope? 

Then there's that problem about whether the masters of surgery coursework is a good idea. I want to do it so I have something under my belt other than a medical degree, which these days is inadequate on its own in a worthy application for specialist training. 

There's so much stress and I'm not sure what I should be feeling. My girlfriend and I have organised an overseas trip for 12 days during the new year period and I'll be back a week before I start work. I'm stressed about whether I'll have my life organised in a week. I'm worried about the trip; whether it will go smoothly or not. I'm afraid of flying. 

Maybe I'm just having a bad run. I feel sick and I can't sleep. I just need to breathe and focus on one problem at a time. 

One at a time. 

"You should make an appointment"

Medical students tend to have overwhelming schedules... so we think, until we meet the medical registrar on the evening shift. Finding the right balance is the most difficult part of my daily life, where like most people I want to fit in activities for study, work and leisure. Having the nagging thought of reminders constantly indicates that I don't seem to get the balance right and I seldom go to bed in the evening without the feeling of satisfaction.

Two weeks ago my colleague and I bumped into each other and he suggested we have coffee "some time." Both of us frantically looked at our schedules to see if we could squeeze in a quick espresso, but we quickly realised how unlikely it was to actually sit down and enjoy each other's company for 30 minutes. In the end, we ended up committing to a time, then postponing, then cancelling and the whole attempt ended up being a complete failure. We had a good laugh about it!

What keeps clinical medical students so busy? Putting personal and social commitments aside (unless you're a cohort's social representative), the clinical hours (rounds, clinics, theatres, wards), tutorial preparation, self-directed learning and extra-curricular research... all of which is quite different than examination preparation and thus requires a different approach to study (depending on the exam). Add on top that you are relatively poor (compared to other graduates our age), doubtful of your career path and constantly telling people who comfort you that you can't see them - you've got a pretty decent mixture of stress, low emotional state and a lack of motivation. This is obviously not a picture of all medical students.

Clinical responsibilities of medical staff are not confined to the walls of their respective wards. They extend into the emergency department, colleagues requiring expert consultation, outpatient clinics and meetings with other healthcare professionals.

But how are our lives any different from any other person in the world? We all have families, friends and responsibilities. We are looking after the sick, who are in fact being denied to carry out and complete their daily tasks, whatever they may be. Imagine being in a state where you are unable to be productive at your normal pace, where your inertia gets completely knocked off its chair.

It's a quiet Sunday at work. I received a phone call in the morning from a 48-year-old lady telling me she needed a CT scan of her abdomen because of "abnormal ultrasound results". She lives a fair way from here, but she was up here last month for work and was directed to the medical centre by a nurse, who thought she was quite unwell.

She wanted to arrange a CT scan in this area, but I arranged for her to have the scan closer to home by faxing the referral over to another department and setting up an appointment. The receptionist at the medical centre who was keeping the referral happily handed it over, saying "she looked very unwell."

Medical receptionists aren't trained medical staff and therefore could not reliably pick up subtle clinical signs, but when they say "this person is really sick," - it's a suggestion that the abnormalities are so obvious, that they're screaming at the trained clinician.

I dug up the ultrasound report:

History of jaundice, acute upper abdominal pain and ascites noted. 


There is diffuse fatty liver infiltration with no focal masses. There is no intra- or extra-hepatic biliary duct dilatation. There are multiple prominent veins in the epigastric region. The gall bladder was not seen. 


Further evaluation with a CT scan of the abdomen and pelvis is suggested to identify the cause of the patient's prominent epigastric veins.


When I called the patient back to emphasise the importance of getting the scan and following up with her doctor, she replied "I know I'm unwell and I can feel it in my heart that things aren't good. But I'm working almost 15 hours a day and I've got to look after my children. It can't be good that I've got bruises everywhere and that I occasionally bleed from my nose and ears."

I almost fell off my chair. This poor lady with fixed professional commitments was working ridiculous hours, almost every day of the week and also looking after her children. I presume she is a single mother as there was no suggestion she had a partner. She had convincing features of liver failure.

It feels very satisfying for a medical student to recognise patterns of illness and to confidently make a diagnosis. This was one situation where I was devastated to recognise what was going on.

We all carry on with life, all our commitments and may never consider how brilliant our functional capacity is. It's also quite interesting to know we usually feel no signs of good health compared to poor health, where it is reflected through symptoms and signs. We are working machines everyday, like clockwork. We work for our future and the future of our children; for financial commitment, to live comfortably and sometimes, to provide for those who were not so fortunate.

So I'm sitting in silence, wondering whether she'll make it to her appointment tomorrow.

The most I could do was as much as the GP could do: tell her this is one of the things you definitely want to follow up... and fast.

ChAos

Medical School always emphasised the correct order of clinical assessment. I'm sure many colleagues would remember a few times during our endeavours of being prompted to assess in the proper order.

One must always begin with the presenting complaint, then take a history of the presenting complaint. Soon after the presenting complaint, one must pay attention to the patient's past medical history, medications and allergies. One should always ask for the patient's family history to determine if there are underlying genetic diseases. Never forget to ask about smoking and alcohol consumption. Also, have an appreciation of the patient's baseline function, their finances and also what they do for a living to understand the impact their illness may have on their lives. The physical examination of relevant organ systems is then performed guided by the history. Based on the findings and provisional hypotheses, one would order investigations that will allow for appropriate management and definitive, evidence-based care. 


In the Emergency Department however, things are quite different. Patients are not often in a position to answer dozens of questions related to their illness. Therefore, the order of the Physician's assessment is distorted. The "shoot first, ask questions later" approach is the mainstay of Emergency Department care, where clinicians are often providing management for patients and occasionally squeezing in a question or two in the process.

On our first day in ED, the six of us sat down with the staff specialist and he asked us a question: A 68-year-old lady comes with chest pain. What are you going to do?


Medical students above all else are taught to be safe clinicians. "If you don't know what the fuck is going on, start with the basics. That might stall you long enough to get to the right answer, or in fact, you may have actually answered the question." We answered the staff specialist's question in the traditional Physician's model.

"We should assess her general appearance."
"I would like to know more about the chest pain."
"Has this ever happened before or is this the first time she's had this pain?"
"I think we should examine her cardiovascular system."

The staff specialist listened patiently until all our eyes were fixed on him for the correct answer, even though one could argue that all of our responses were correct.

The first and foremost step in the assessment of any patient with chest pain is an ECG.

In this patient's presentation, which is a common one, the first and foremost knee-jerk response is an investigation rather than a history or physical examination. If one peers into the literature behind this, it's definitely the most appropriate thing to do. It's just so different not practicing the Physician's methodology of taking a history and performing an examination.

The sole purpose of any Emergency Department is to ensure patients are not critically ill, and if they are: resuscitate them. If they are not, either discharge them with GP follow-up or request intervention from the relevant specialist teams. 


Mr. CE is an 82-year-old man who presented to the ED with the complaint: "my heart is missing a beat." At that point, I was attached to the hip of Jackie, an experienced ED resident, and we were seeing patients together. She pulled out his ECG and gave it to me. What do you think?

As I tried to make sense of Mr. CE's myocardial electrical activity, I didn't think his presenting complaint was very critical (in terms of life-threatening causes).

"It looks normal, but I would definitely get a pair of experienced eyes to make sure."

Ok. Well, here's his ECG from 2010 when he presented with a similar concern.


I had a look at the previous ECG and it didn't seem all that different.

Yes, he's had multiple presentations to our department with similar complaints. Although it's less likely to be critical, we should still see him to ensure everything's all right.


The nurse brought the patient into one of the Acute Care observation rooms for patients who are relatively well (i.e. alert and oriented as opposed to moribund).

Immediately, Mr. CE's eyes lit up when we walked into the room and introduced ourselves. He was telling us about why he came in, but often deviated to talk about his past days as an automotive engineer and spoke about his ex-wife's bipolar disorder. The missing beats usually occurred in the morning during breakfast, when he also noticed his temperature rise but not enough to cause a fever. He denied chest pain and any other significant cardiac symptoms. So in the eyes of Jackie, Mr. CE was good to go. The only problem was actually getting out of the conversation, as Mr. CE was so keen to talk to us about whatever he could. At one point I thought he might have been delirious, perhaps even have some flight of ideas (i.e. jumping from one topic to another with no rational transition).

Given that Jackie is a resident, she had to check with the staff specialist, who thought everything was fine but wanted to see Mr. CE herself. So I tagged along and we listened patiently to Mr. CE propel the conversation and the staff specialist was doing whatever she could not to offend him, as she had other patients who required more immediate attention. I think that is one of the rarest qualities of a good doctor: seeming as though they have all the time in the world to listen to a patient's story.

Mr. E, we're confident that this issue is not life-threatening and would be better looked after by your GP. However, I would like to have a look at your urine to ensure there is no underlying infection.


She was worried about an underlying urinary tract infection, which could be making Mr. CE delirious.

Jackie was writing up some notes. She looked up to see whether the staff specialist's impression had changed from her case presentation.

I think the diagnosis is loneliness. 


There it was. It made perfect sense. The poor man had multiple presentations to ED throughout the last couple of years and looking through the previous admission notes, it was clear that he was as talkative as he was on the day we saw him. He wanted affection, attention and respect; the basic things everybody should have in their lives on a daily basis.

In my mind, that's how pathetic our society has become. Neighbours don't look out for one another let alone know each other's names. There's a very high incidence of divorce and separation, suggesting that even the deepest connections between people may be flawed and or we lack the language, effort or love to talk them through. Let's not forget about the horrendous stories of people being found dead in their apartments not because they were visited frequently, but from the odour their remains had left to the other tenants going about their business. Even then, it's about "make the smell go away" rather than the "there's something seriously wrong."

All three of us just stood there in silence, remembering that an important but tragic differential to any non life-threatening presentation may just in fact be a lack of human physical contact, just to start all over again with another person willing to listen.

The saddest part about all this was we couldn't give him the attention he craves. In the principles and practices of emergency medicine, Mr. CE is ready for discharge, never mind his solitude.

In the ED, things are done out of order such that the most common life-threatening diseases are identified as soon as humanly possible.

Unfortunately, it's a unique environment where the patient's needs may not necessarily be addressed and the care maybe misinterpreted as distant, objective medical practice... and the catch is: it's not a misinterpretation.

It's exactly that.

Token of Inspiration

Medical students have often decided their career paths before graduation and some proportion of colleagues had decided well before they started their studies. Some of us are hell-bent on certain specialties, even sub-specialties. Others are trying to find their feet through the chaos of it all. We are all at different stages of the decision-making process and the path before us has as much twists and turns, if not more than the path that lies behind us all.

Sometimes I ask myself what factors allow students to make firm decisions about their future. Perhaps it's the exposure and our experience through the rotations. Maybe it's our academic thirst to understand the underlying principles of diseases affecting certain organs. Could it be for the detrimental effects of specific disease(s) on the population? Or it may even be our passion to help people in the areas we are most comfortable with. Of course, let's not forget about those who want to study diseases that have or are affecting them or their loved ones.

Thinking about it reminds me of the times I started to seriously consider the rough climates and violent seas of the surgical pathway. When did it start? Where did it start? Most importantly, what was the context in which it started?

It definitely started in the operating theatre, which is no surprise I'm sure. I was in my first year and we had just started studying the musculoskeletal system. Our hospital didn't have many rheumatologists at the time, thus the clinical teachings were conducted by the orthopaedic boys and girls (yes, there were girls).

Dr. QD was the orthopaedic surgeon who made us feel he had all the time in the world for our questions. He asked us all to take turns bringing shorts or singlets so the group could examine one student at a time, rather than asking surgical patients to volunteer for strenuous tests on joints. The week we examined the foot and ankle was my turn to be the patient. I sat down in front of the group of 10 students while he explained the importance of watching someone get undressed to understand their global function, restrictions and disabilities. I proceeded to take my shoes and socks off as everyone watched quietly. At that point, we were all just trying to understand what normal was and I definitely was not a good example of that. I hadn't told anyone I had a problem.

The interesting part of examining your colleagues is one can always pick up underlying abnormalities that have gone undetected for many years. The majority of these are "innocent" heart murmurs. But I had something else going on. So I knew full well Dr. QD was studying me as he was studying all of us every week to ensure the findings were in fact normal. I looked up at the group after I rolled my trousers up to my knees and asked "what do you think Dr. D?"

"You've got a lot going on there." My colleagues were confused as they didn't notice much wrong through their untrained, inexperienced eyes. It was also the fact I had mechanisms in place to make the abnormalities as subtle as possible, just like anyone else with health problems.

After my colleagues took turns examining me and asking questions, Dr. QD and I spoke briefly about my "orthopaedic problem". That's when we built some rapport. It's also when he agreed to let me into his operating theatre every Monday morning.

It was my second Monday morning in theatres and I was thrilled to watch the amazing things they do... from the anaesthetics bay. I remember walking in and feeling the stress of the staff: nurses running around getting equipment ready, the anaesthetist sedating the patient and Dr. QD quietly looking at an MRI of the knee. He was alone and studying the images carefully. "Good morning!" - he turned around and the look on his face was almost "thank God you're here."

The registrar's wife was in the middle of giving birth and Dr. QD told him to be by her side. He had no assistant until the other team's registrar was free to assist him... after their morning list, which wasn't helpful. "Could you give me a hand?" he asked me. "Of course," I said but I didn't know how to scrub or what to do. "Follow me, let's get started before the patient is ready."

He patiently taught me his technique and I carefully imitated his motions. We scrubbed together and my anxiety settled with his patience. He showed me the way to wear gloves after putting gowning up. After several failed attempts of putting on gloves with the gown's sleeves, we both realised time was running out. He asked the nurse to open a new pair, which he took and stretched for me. "Here, just slide your hands through" he said. It's the only time in my life a consultant ever held gloves out for me. Not that I'm special, it's just unheard of.

Luckily about half way through a total knee replacement, a junior registrar showed up and took over my position as first assistant. We completed the procedure altogether and it was a team effort. At the end of it, Dr. QD thanked me and I left to attend the late morning's tutorials. It was then I was sure I wanted to do orthopaedic surgery.

Was I? Ever since the end of our musculoskeletal studies, I lost interest in it while my curiosity for general surgery grew. Something changed... but what was it? Eventually, I forgot about orthopaedics until recently.

Paediatrics has been a tough rotation not only because it's difficult but because the dedicated children's hospital I've been allocated is infected with political bullshit. People are anti-social, arrogant and occasionally just rude. After following them around for several hours, they throw you a bone with a short piece of knowledge that you read the day before.

It's my fault - I expected to get a lot more out of it. My first week was orthopaedics and given I had spent my elective mostly in theatre, I thought it would be a good idea to have an understanding of what outpatient medicine was like in the fracture clinic.

The orthopaedic team were welcoming, friendly and we clicked quickly. Next thing I knew, I was assisting in theatre when needed and when they didn't, I was seeing patients in the clinic. At first, it was with the fellow. A few patients later I was seeing patients on my own. I would take the history, present it to the consultant or fellow, show them the follow-up imaging and offer my management plan. They would obviously over-write it with a more precise management plan while giving me constructive feedback. It was an amazing learning experience.

There was an icing on the cake as well. It was Thursday and the rostered consultant showed up to the clinic: it was Dr. QD! We were both very surprised to see each other again. We shook hands and caught up briefly. "Good to see you again mate." I explained I was here for a week during my paediatric term. "Well, we have a busy clinic this morning! So, let's get to it!"

So off I was seeing patients on my own and by the end of a six hour clinic, I had seen 40 patients. The experience was amazing. I decided to stay back and see some patients in emergency with the orthopaedic registrar. Dr. QD was the on call consultant that evening and I had a brief chat to him on the phone.

"You should really consider orthopaedics mate. It's a good career choice and you've made it clear you can tolerate the workload. Thanks for your help today." I was very happy he gave me his opinion and it very much lifted my spirits. There's nothing better to be useful to both patients and doctors as a medical student.

After almost four years of being a medical student and pondering about the influential factors facilitating our career-decisions, I realise now the most important factor is our personal experiences with the teams we are allocated. It's the passion of the team, their dynamics and we hope one day, we return to the very same team and do more than we ever thought we could. At least that's what I want, but teams in hospital change every six months if not more frequently. We all move cities, hospitals and get rostered on different times.

I'll never forget the people who didn't brush you aside as a medical student. They took me in, realised my potential and convinced me that it's possible to do what I'm expected to do in a few short years. Unfortunately it's uncommon; doctors don't teach very much because they are over-worked and pre-occupied with more pressing issues.

Overall, the people that validate you with recognition and the allocation of responsibility are those who we wish to see again and work with in the future. They are the essence of my inspiration.

Who knows? I am actually re-considering orthopaedics as a career choice and the only substance behind that are the brief, direct words of Dr. QD, orthopaedic surgeon.

The Symbol of Orthopaedic Surgery

Chilling One Day; Some Day

I'm in the middle of a bar waiting for my other colleagues to show up so we can get on with our revision of Medicine, Surgery & Paediatrics. After a schooner of light beer, I'm already feeling light-headed and after 2 meals and 2 snacks, I'm feeling hungry again.

The day was filled with lectures, slides and learning objectives. It's much like any other lecture day for medical students. What I find so profound is there are pages and pages, chapters if you like, dedicated to describing single dot points lecturers have summarised onto a single slide of a 67-slide presentation compressed into an hour. This means that one can spend days if not hours going through a single lecture, when in fact there are so many to go through. Plus, there's the self-directed learning, integrated clinical attachments and assignments that are all to be done prior to our examinations.

There's so much to cover already and the work is definitely piling up. I decided to write this entry because I read Sharp Incisions' last entry on the blog. She was a point of hope for me; she solidified my faith that there were medical students out there who will push forward and beyond what's expected of us.

But she threw in the towel for her blog and I'm incredibly happy she has decided to devote time to what means most to her.

Why can't I do that? Why do I stress about things like organising all these extracurricular activities? Stressing about things like attending social events, whether I'll be able to control my diet for the day and how many cups of coffee I've had? Because I do -- even if I am just sitting comfortably somewhere trying to relax, I'll stop what I'm doing to focus on what's stressing me out.

It's all getting overwhelming again. Interestingly, my schedule in the elective term, which demanded more hours, was easier for me to handle. I happily went and did what I was capable of doing competently for 10-18 hours a day... after which I came home satisfied with the difference I made.

I'm back here in Sydney, back in my own role and financial circumstances. In other words, I've come back to real life and it's been an eye-opener how much more difficult life is over here, even if the hours are shorter per week. I'm slowly understanding that the number of hours one works or studies a week doesn't determine how awesome they are; which was obviously quite a weak assumption for me to make previously.

However here I am, trying to figure out how to critically appraise a guideline on Paediatric Anxiety & Depression for tomorrow's presentation while waiting for my colleagues to arrive so I can summarise surgical diseases of the Breast and listen to their summaries. I've hit a brick wall and can't get in touch with colleagues that know how to access the appraisal tool we're expected to use.

Sharp Incisions, I hope you find your feet and please, for the sake of everyone out there, never take off those spectacles. Medicine is not just another job - you reduce morbidity, mortality and make a difference to people. You can give them hope, care and comfort without their financial commitments. Just like all of us, you need some time to yourself, your family and to smile again. I'll miss your entries and your insight.

Like everyone else, I'm in a bit of a rut right now and hopefully when I wake up tomorrow, I'll feel better and won't constantly remind myself of the upcoming exams, assignments, professional and personal commitments. One day, I'll be able to wake up and focus on absolutely nothing but my plate of breakfast in front of me. Until that day, I'm going to push forward - I need to believe that day is going to happen.

I really do.

Input Peripheries

It's been a few weeks since I returned from my Elective term and it feels different being back in Australia. My time overseas was not awful, and the living conditions were far from terrible. However, there are certain comforts one takes for granted and yearns for while overseas; perhaps that's what people mean by the expression "home-sick".

The first week of Paediatrics was packed with lectures and presentations. Chapters and endless pages of literature topic by topic all squeezed into one or two hours at a time. I think it's rather humorous that Clinicians emphasise oh so very much the importance of evidence-based practice and yet, we are still using traditional didactic teaching methods with some additional fancy gadgets compared to a few decades ago... all of which arguably have little evidence in the context of educational efficacy. But hey, that's why we have clinical attachments for the next three weeks - where each week we'll all be in different departments. Just when we get the hang of where to show up at what time, the names of all the staff members and our second chat with the consultant that involved being asked questions we couldn't answer, we will be off to experience the disorientation again in another department. Charming!

But I don't really mind. I just enjoy predicting how miserable I'll be in six weeks from now. So on our first day back, I was curious about how people might have changed after their elective term. How did their experiences affect them? Are they affected at all? I pondered all the way to the wrong train station, then all the way back to another train station and then back on the wrong train again. I showed up at 1045 when we started at 0830. I don't think I've ever been so late in my university years; at least not by mistake.

Morning tea time! Unheard of in my elective hospital and something I welcomed before our next couple of lectures on a Tuesday morning. I was talking to one of my colleagues, who is hell-bent on becoming a surgeon and already in the process of deciding which pathway he should take to become the sub-specialist he would like to become. I admire people who have already understood and appreciated their years ahead, but being so specific? I can't help but feel their insight must be restricted to what they've seen in the context they saw it.

I listened intently to his stories from New York, where he saw dozens of trauma cases, scrubbed into case after case learning techniques and getting down to the fundamental principle of Surgery: to save life in dire need. He was sure he wanted to become a Trauma Surgeon and from his list of credentials plus the scholarship he received to see what he did, I see him on the successful path to doing exactly what he wants to.

He passionately explained "procedures unknown to us in Australia" to save the lives of people who were in horrific accidents, victims of domestic violence and gang warfare. He described the unique procedures to me and yes I agree, they were quite radical and probably not performed in Australia routinely. And only a handful of people could perform them.

But throughout this encounter, he never explained anything about the patients except for their presentation to hospital. Typical surgeon I hear you say, but that's not true. Surgeons must still take an interest in their patients beyond their anatomical planes and site of haemorrhage. Patients are not just a list of potential complications, risk factors and mechanical defects... and to hear my colleague explain these patients and their management depressed me because I'm sure he didn't know a single one of their names.

So some of us are already falling into the trap of adapting personality and behavioural traits that will not make us good doctors. And this fine medical student, a distant colleague of mine, is well on the way of becoming what he always dreamed of... but I'm sure somewhere in those dreams he didn't consider the guilt of not providing reassurance, or empathy.

Perhaps the whole point of being a Trauma Surgeon is not to interact with people or obtain consent; the law has provided that for you - just ensure the patient is resuscitated so that they can form opinions again. Oh and if their opinions were not what was expected (i.e. instead of "thank you so much, God bless you, I'm alive" one is told "you couldn't spare two minutes to explain what you did; you told me to come back in two weeks to be seen again but I don't know why") - then maybe, just maybe, the principles and philosophies you (medical student) based your career on need revision.

The problem "is" choice.

Welcome to the Operating Theatre

Stepping inside an operating theatre can be daunting for anybody. It is a unique, somewhat uncomfortable environment where people have an unusual sense of humour and a rare degree of multi-tasking competence. The sterile field, everyone dressed in the same scrubs with masks covering their faces makes telling staff apart impossible.

What is the role of the medical student in the operating theatre? The answer varies from useless to critical. If you're in a fully staffed operating theatre (i.e. one surgeon, one registrar, one resident, two nurses, one anaesthesiologist, one anaesthesiology registrar and two technicians), one could argue a medical student is relatively useless and their education comes second to... well everything else. In the far corners of the world (i.e. one surgeon and one nurse; if that), a medical student holds the potential of shifting the potential risks down from patient mortality to morbidity, and receiving a flood of knowledge from the surgeon. That all depends on the experience and competence of the medical student, which goes without saying.

But it's always confusing the first time. The basic assumption of fitting right in with everybody around you, who are dressed the same in every sense can be abandoned. Nurses in particular can easily tell when a rookie enters the theatre and immediately assumes the authoritative role. "Stand at least 50 centimetres away from this table. Don't touch this. Keep your hands between your chest and umbilicus. No no, go and scrub again. Hold this. Shut up." Although this could be interpreted as nurses exercising their right to power before the student graduates, it must not be forgotten that they are also responsible for maintaining infection control in an operating theatre. If you are new to the environment, you may very well be seen as a risk rather than a benefit, especially if you are only there to absorb information.

There is an unspoken language in the operating theatre and a dialect of body language that is foreign to all newcomers. It can be hard to pick, even if your thighs are hard-pressed against the operating table. For instance, there is a very particular way a nurse holds equipment compared to that of a surgeon. Equipment is given in such a way that the surgeon can use the instrument the moment his or her fingers wrap around it. This might seem obvious when written down, but may go unnoticed in the middle of surgery. If the nurse knows the operation well, they will know exactly what instrument to give the moment the surgeon raises their hand. Instruments may also appear to be simple, but often have multiple functions and surgeons almost always have multiple grip techniques.

Among all the operations I've seen and the myriad of interactions between theatre staff I've witnessed and participated in, I ask myself who's role is the most difficult. It is not the surgeon, but actually the assistant across the operating table.

To be a competent assistant, one must have theatre experience but must also know the theory behind the operation. However, due to overwhelming demands and lack of resources, the assistant usually is a junior doctor or a senior medical student. In this situation, it is very uncommon to "know" the operation and even if one knows the theory, they might not understand their role at certain phases of the operation.


How a surgeon communicates with their assistant(s) is very interesting. The surgeon asks for a retractor, receives it and places it in the correct anatomical plane. Then, he or she applies tension in a specific direction such that the relevant tissues are correctly demonstrated. Once this is maneuvre is complete, the surgeon presents the instrument to the assistant and they assume control (and responsibility) of the instrument. This process can take place without a word... The unspoken language of theatre.

Assisting requires patience but also stamina - following an operation carefully whilst holding retractors larger than one's own hands can be very painful and distracting.

Most importantly, the role demands the assistant to assume the surgeon's visual perspective whilst remembering their own. In other words: as an assistant, you must understand what structures the surgeon must see and display these correctly with the accurate application of tension on the instruments (i.e. retractor, suture, clamp etc.), even if the correct position obstructs your own field of view. The assistant's field of view comes second to the surgeons' and unfortunately, the mind constantly prioritises its own view. So you are constantly battling with your own instincts. If you apply too much tension, you damage the superficial tissues and may cause bleeding. Too little tensions results in lack of retraction. And when the medical student assumes the role of the assistant, they must avoid getting yelled at, constantly corrected and answer all questions related to the anatomy correctly - even if the anatomy being asked has nothing to do with the operation.