<<silently>>\n<<set $next_plot_link = "disp operation plot link">>\n<<endsilently>>You think you should find something else to do now. The junior doctor is busy doing paperwork and though it's important, you're not going to learn much from it. You head back towards your normal ward.\n\n<<display "disp choose side quest">>
By now it's almost 2pm. You planned to watch an operation in the afternoon, so you [[head to theatre|Watching an operation to remove a tumour]].
"I'm not sure what you could do to improve. Maybe you just need a little more practice?" You say in a non-committal way.\n\n"Think about what was missed and I'll come back to you in a minute" Dr Meera replies. She isn't going to let you get away without spotting something wrong.\n\nWhile Dr Meera says what she thinks you think through the steps of the exam. You've been trying to memorise them for the past week, and manage to recall the student was supposed to feel the lymph nodes in the neck. You tell him once Dr Meera is finished.\n\n<<display "disp exam plot end">>
"I'm a little worried that some of the staff were finding it difficult to hear you in there - one of the nurses asked me what to label the specimen pot as after you said it. Maybe you could tell the registrar what the labels are, and then he can tell the nurse separately?"\n\nThe surgeon nods. "Yes, I have done that in the past and it's worked rather well... perhaps I should go back to that."\n\nAs the conversation ends, you're pleased that there's now a strategy to improve things in theatre.\n\n<<display "disp operation plot end">>
You hang up, and then worry your friend will figure out that you're slightly annoyed. As you head back to the wards for the evening shift, you try to put the whole thing out of your mind.\n\n<<display "disp coffee plot end">>
"Why did you look at the patient's abdomen instead of his face?"\n\n"I know it said in the book to look at their face, but was trying so hard to make sure I felt the right places I kinda forgot it."\n\n<<display "disp exam plot end">>
You're on the bus, on your way home. Finally, you have a few minutes to reflect on what's happened to you today. The question is, what did you learn?\n\nYou learnt the people who are best at pointing out errors are the ones that help you to [[learn from them|http://www.errordiary.org/?page_id=7392]], instead of just feeling bad about them.\n\nYou learnt a little tact can help people learn instead of becoming defensive.\n\nYou learnt that people appreciate good [[strategies|http://www.errordiary.org/?page_id=7403]] for avoiding future errors. Asking them why they made an error can also help them avoid them in the future.\n\nYou learnt that sometimes errors are not individual problems but [[problems with the systems in a hospital|http://www.errordiary.org/?page_id=7379]].\n\nThe end.\n\n<a onclick="location.reload()" class="internalLink">Restart?</a>
<<silently>>\n<<set $next_plot_link = "disp exam plot link">>\n<<endsilently>><<display "disp next plot link">>
You decide to ask the junior doctors whether you can help out with their jobs for today.\n\n“Actually, yes - I’ve got a drug chart here that needs re-writing. Could you do that for me?”\n\nYou get to work and complete the new chart, although you find it difficult to read the spidery hand that wrote the old one - the writing’s practically illegible in several places. When you’ve finished, you read over the chart with the junior doctor to make sure all the drug names and doses are correct. Towards the end, the junior doctor notices an error - you’ve written up 20 units of insulin, not 10.\n\n“I think you might have written this slightly incorrectly - I’m pretty sure Mr. Smith’s on 10 units. Don’t worry about it - it’s really difficult and Mr. Patel’s writing is hard to read at the best of times! Just change that for me.”\n\nYou correct the value and you both read through the rest of the chart. When you get to the end the junior doctor smiles.\n\n“Perfect. Well done! Thanks very much for doing that.”\n\nYou both have a look through the list for more jobs that you can do, and you feel pleased that the junior doctor is happy to have you around.\n\n<<display "disp next plot link">>
You feel really bad for the junior doctor - that's not an easy situation to find oneself in.\n\n"A couple of questions back there looked quite difficult - I thought you coped with it really well. Do you think the patient was offended at all?"\n\nThe junior doctor looked thoughtful.\n\n"To be honest, I was more focused on getting everything I needed from the patient - I didn't think about that much at all really! I'm not sure whether the patient was offended, but if I think he's upset later I might go over and apologise."\n\nYou feel pleased that you managed to raise the issue without causing hurt or upset to your colleague.\n\n<<display "disp admission plot end">>
"It's fine - maybe set a reminder on your phone next time or something?"\n\n"Yeah, good idea - I'll definitely try and remember that for next time."\n\n"Cool - see you later!"\n\nYou hang up and feel good - hopefully the next time you guys arrange to meet up, neither of you will forget!\n\n<<display "disp coffee plot end">>
"You hurt Mr Arthur, have you been taught how to avoid that?"\n\n"Yea, sorry about that," he says to Mr Arthur, "I know the books say to look at their face while you feel the abdomen."\n\n"By looking at his face I could see Mr Arthur was uncomfortable before you did, so that would be a good thing to practice next time."\n\n<<display "disp exam plot end">>
"Do you think staff were finding it a little hard to hear you in there?"\n\n"No, not at all - why do you ask?"\n\n"Well, one of the nurses asked me what to label the specimen pot as after you said it. Maybe you're speaking a little quietly? I can appreciate it's probably very difficult to concentrate on it in the middle of an operation."\n\n"Well, I'll try and raise my voice for next time, and I'll make sure to ask the nurse if she can hear me."\n\nAs the conversation ends, you're pleased that there's now a strategy to improve things in theatre.\n\n<<display "disp operation plot end">>
Where would you like to go next?\n<<actions "Join the consultant" "Practice taking blood" "Help the junior doctor with her jobs" "Attend the grand round">>
Fortunately, an operation is due to start when you get there and so you scrub in and watch the initial stages of a large abdominal operation to remove a tumour. The surgeon eventually hands a small specimen on a pair of forceps to the attending nurse and mumbles through his mask,\n\n"OK, here's the upper limit of dissection."\n\nThe nurse takes the specimen and looks over at the surgeon, hoping he'll repeat his words. But he's operating furiously and looks like the kind of man not to be disturbed.\n\n"I think it's the upper limit of dissection" you tell her, and the nurse gratefully labels up the specimen pot.\n\nAfter the operation, the surgeon briefly discusses the risks and benefits of the procedure with you. You wonder whether you should bring up the problems with communication that you observed.\n\nWhat do you say?\n\n* [[Don't say anything|Don't say anything about the surgeon's communication]].\n* [[Tell him no-one can hear him when he speaks|Telling the surgeon people can't hear him speak]].\n* [[Tell him you're worried people might not be able to hear him|Telling the surgeon you're worried people can't hear him]].\n* [[Suggest how the surgeon could help the nurse to hear him|Suggesting how the surgeon can help the nurse hear him]].\n* [[Ask the surgeon whether he thought the nurse could hear him|Asking the surgeon whether he thought the nurse could hear him]].\n* [[Comment that it's often difficult to communicate in a theatre environment|Commenting that it's often difficult to communicate in a theatre environment]].
You say nothing, but worry that the surgeon definitely doesn't realise there's a problem, and that the nurses are too afraid to tell him. Hopefully someone will explain the problem to the surgeon at some stage...\n\n<<display "disp operation plot end">>
"You hurt Mr Arthur, though don't feel bad about it because you're still learning, and he looks ok now."\n\nMr Arthur nods.\n\n"Yea, I'll be more careful next time."\n\n<<display "disp exam plot end">>
"I don't think anyone could hear you in there - the staff nurse had to ask me what to write on the specimen pots."\n\n"The nurse should have been paying attention! That was a difficult operation and I don't have time to stand there repeating myself!"\n\nAs your conversation ends, you get the distinct impression that the surgeon doesn't think he's at fault at all.\n\n<<display "disp operation plot end">>
You decide to catch up with the consultant, who is on a ward round. This happens every day, and consists of a group of doctors meeting all of their patients in turn, finding out what has happened to them and deciding what to do next. It seems rather busy today. One of the junior doctors, who looks a little overwhelmed by a huge pile of notes, gives you a folder which you hold onto. The registrar addresses the team.\n\n“Let’s see Mr. Plumber next. Who’s got the notes?”\n\n“I’ve just given them to the medical student.” says the junior doctor, pointing at you.\n\n“Right good - do you want to write?” the consultant asks. You nod and the team move towards Mr. Plumber’s bed.\n\nAs the team talk to and examine the patient, you make notes in the folder you’ve been given, but neglect to check the patient’s name in the folder before you start. The consultant asks to see the drug chart and you hand it to him. He looks at it, shakes his head briefly and gives it back to you. At the end of the consultation, he catches hold of you in the corridor.\n\n“I think you’re writing in the wrong patient’s notes there - not to worry, it happens to the best of us! It’s easy to make a mistake on the ward round when everyone’s so busy, and there’s patient notes lying everywhere which all look the same.”\n\nHe smiles and then moves on - you’re sad about your mistake, but feel like you’ve learned something too.\n\n<<display "disp next plot link">>
You should [[get the bus home|On the bus home]].
You look at your watch and realise that if you hurry, you can catch the medical grand round. This is a weekly event where medical staff watch each other present interesting patients and new research. You make it on time and listen to the talks, jotting down important references.\n\nOutside in the corridor, a consultant whom you recognise walks up to you.\n\n“Hi - you’re one of the students I’m tutoring in pathology, aren’t you?”\n\nYou nod with a sinking feeling that you’ve forgotten something.\n\n“Were we supposed to have a lunchtime tutorial today?”\n\nAs you remember, you reply. “Yes we were - I’m really sorry, I just completely forgot about it!”\n\n“That’s fine - why did you forget? Are you on a particularly busy rotation at the moment? I know that you medical students can be really pushed for time during the day.”\n\n“I have been busy, but actually I forgot to put it in my calendar. Could we possibly re-arrange the tutorial? I’ll definitely make sure I attend.”\n\n“Of course we can - just e-mail me.”\n\nThe tutor leaves, and you feel like you’ve been given a reprieve. Next time, you’ll double-check that the tutorial’s in your calendar.\n\n<<display "disp next plot link">>
Dr Meera is teaching the group how examine the abdomen. A gentleman called Mr Arthur volunteered to be examined, so you and Dr Meera are watching another student do this. He's feeling the abdomen -- pressing on Mr Arthur's stomach to feel for abnormalities. As he feels one area it's obvious to you that it's tender, but the student doesn't notice. Mr Arthur's face screws up first, before he makes a noise,\n\n"Oooph" he goes. The student notices then, lets go of the area and apologises before continuing.\n\nAfter the examination Dr Meera thanks Mr Arthur and asks you to tell the student what you think of his examination.\n\nWhat do you say?\n* [[Don't say anything|Don't say anything about the student hurting Mr Arthur]].\n* [[Mention the student hurt Mr Arthur|Mention the student hurt Mr Arthur]].\n* [[Try to encourage the student|Try to encourage the student]].\n* [[Tell the student to look at the patient's face next time|Tell the student to look at the patient's face next time]].\n* [[Ask the student why he didn't look at Mr Arthur's face|Ask the student why he didn't look at Mr Arthur's face]].\n* [[Ask the student what he's been taught about avoiding hurting patients|Ask the student what he's been taught about avoiding hurting patients]].\n\n
You say nothing, although the clerking did make you feel very uncomfortable. You're too nervous to discuss with the situation with the junior doctor, but wonder whether there's a way to bring up the issue without making both of you feel awkward.\n\n<<display "disp admission plot end">>
A tourniquet is an elastic strap that squeezes the arm to make its veins fill up with blood. This makes them easier to find and insert a needle into.\n\n<<back>>
When a patient is admitted to hospital a doctor will do a thorough interview with the patient. This is called clerking. Doctors will enquire about what brought them in and their background health, and then examine relevant parts of the patient's body.\n\n<<back>>
You ask the junior doctor,\n\n"Did you find any of that history difficult? Some of those questions looked quite hard to ask - I guess we're used to seeing people who are married to someone of the opposite gender quite a bit on the take."\n\nThe junior doctor replied.\n\n"Yeah, I guess that was something that made the history a little harder. I wasn't expecting it! I guess it's always good to bear in mind that every patient is different."\n\n"Do you think Mr. Giles was upset at all?"\n\n"I don't think he was that bothered, but I'll go and check on him later, just to give him some reassurance."\n\nYou note that medicine seems like the kind of job where people are often rushed off their feet trying to get things done - perhaps occasionally, it's good to make people think.\n\n<<display "disp admission plot end">>
Medical Student Errors
"You hurt the patient, you should try not to do that next time."\n\n"Yea, sorry." the student says to Mr Arthur\n\n"It's okay, you're still learning," he replies.\n\n<<display "disp exam plot end">>
<<silently>>\n<<set $next_plot_link = "disp admission plot link">>\n<<endsilently>>Dr Meera watches your group examine another patient, then the teaching session ends.\n\n<<display "disp choose side quest">>
You speak up while you're both ordering a chest X-ray.\n\n"Sorry… I think the patient might have been pretty offended back there. People can find it really difficult when others assume they're straight, and I don't think you apologised."\n\nThe junior doctor stops and looks at you.\n\n"I don't think it's a big deal. There's no need to apologise - people should just toughen up. Most people wouldn't think twice about a throwaway comment like that."\n\nAcknowledging there's a clear disconnect between the two of you, you leave the matter there, but all the same you wonder whether there's a way to bring up the issue without making both of you feel awkward.\n\n<<display "disp admission plot end">>
"I'm actually a little worried that some of the staff were finding it difficult to hear you in there."\n\n"Why do you say that?"\n\n"Well, the nurse had to ask me what to label the specimens… I just wonder whether she can always hear what you want her to label them as before she sends them off."\n\n"Right, OK. Well, I'll ask her and hopefully we can work something out for next time."\n\nYou're pleased that the surgeon seems to have understood you and will hopefully avoid the problem in future.\n\n<<display "disp operation plot end">>
A cannula is a thin plastic tube inserted through the skin into a vein to allow medical staff to give drugs or water through it. They're usually inserted into a vein the back of a patient's hand.\n\n<<back>>
You buy a coffee and sit down, but distracted by your thoughts, you eventually look at your watch and see that a whole hour has passed. At this point, you're pretty sure your friend isn't coming. You shrug it off - something probably came up. You know it's not a big deal - but you give her a quick call anyway.\n\n"Hi!"\n\n"Hey - we were going to get coffee today, remember?"\n\n"Oh! Oh God, I'm so sorry, it totally slipped my mind - just wasn't in my diary. I'm busy right now - can we talk later? I'll make it up to you, I promise!"\n\nWhat do you say?\n\n* [[Nothing, and hang up the call.|Hanging up on your friend]].\n* [[Don't mention her absence.|Not mentioning your friend's absence]].\n* [[Try to take some pressure off your friend.|Trying to take pressure off your friend]]\n* [[Suggest how she could remember next time.|Suggesting how your friend can remember appointments]].\n* [[Ask your friend why she forgot.|Asking your friend why she forgot]].\n* [[Suggest it's easy to forget meetings that haven't been formally arranged.|Suggesting it's easy to forget meetings that haven't been formally arranged]].
"Someone told me to always ask 'who lives with you at home' instead of 'Do you live with your wife'. That way you don't have to worry about accidentally getting someone's gender or relationship wrong."\n\n"Oh! That's probably good practice - I guess I'll bear it in mind."\n\nAs you leave to find more jobs to do, you feel like a mutual understanding has been reached between you.\n\n<<display "disp admission plot end">>
It’s Monday morning and despite sleeping through your alarm, you’ve just about made it into the hospital in time for some [[small group teaching|Examining Mr Arthur's abdomen]].
"You should look at the patient's face next time you feel the abdomen. You spot signs of pain earlier than way."\n\n"Yea, sorry about that, I'll remember to do it next time."\n\n"It's ok, I'm glad you learnt something," the patient replies.\n\n<<display "disp exam plot end">>
"Yeah, no worries - I don't know about you, but I find it really hard to remember stuff when the time/date hasn't been sorted. I guess we didn't really talk about this - that could be why."\n\n"I guess so - we should definitely try to talk more about what we're going to do before it happens. But yeah, I'm sorry about all this - hopefully see you later?"\n\n"Definitely - see you."\n\nYou put the phone down and feel pleased that both of you have agreed on a way forward.\n\n<<display "disp coffee plot end">>
It's the end of the day shift and you've arranged to [[meet a friend in a local cafe|Meeting a friend in a cafe]].
"It seems like it can be really hard to make yourself heard in theatre - everyone has masks and a lot of people seem to be concentrating on other things."\n\n"I guess that's true, but I've never had a problem with it!"\n\n"Well, one of the nurses had to ask me what to label the specimens as today… I just wonder whether she can always hear what you want her to label them as before she sends them off."\n\n"Right... well, perhaps I'll talk to the nurse and we can try to work something out for the future."\n\n<<display "disp operation plot end">>
You're both looking at biochemistry forms when you decide to bring the matter up.\n\n"Just out of interest - why did you ask about his wife back there? Should we be doing that for every patient?"\nThe junior doctor stops and looks guilty.\n\n"Oh - no, I guess it's not the best thing to do. Sorry - I'm not setting a great example. When you're clerking a patient, don't put a gender on their partner unless they tell you."\n\n"No worries, I just thought I'd ask. I guess it's never an easy situation to be in when you have to ask about that part of a persons life!"\n\nThe junior doctor nods and you feel like your message got through.\n\n<<display "disp admission plot end">>
<<silently>>\n<<set $next_plot_link = "disp coffee plot link">>\n<<endsilently>>You only planned to watch one operation, so you leave and try to fit one last thing before you leave.\n\n<<display "disp choose side quest">>
"That's OK - how come you forgot? That's not like you at all! Busy day?"\n\n"Oh - yeah, there's been lots going on at work and my mother's been phoning non-stop lately - she's been going crazy about my sister's wedding, you know. It's hard to keep on top of things sometimes!"\n\n"Yeah, I totally understand, no worries."\n\n"It's all my fault - I guess I just need to get more organised when things get busy! But yeah - thanks so much for being so nice. See you later!"\n\nYou hang up the phone, and feel pleased that you helped your friend realise how busy she is. You remember times when you've messed loads of things up because you've been too busy, and reflect that sometimes, a gentle reminder has been exactly what you needed.\n\n<<display "disp coffee plot end">>
"OK - see you later."\n\n"Gosh, I really feel bad - sorry again. See you."\n\nYou hang up the phone, annoyed at your friend's constant apologies. You head back to the wards, determined to keep busy and push the annoyance out of your thoughts over the rest of the day.\n\n<<display "disp coffee plot end">>
You decide to ask one of the nurses whether there are any patients that need blood taken for tests. She doesn't, but one patient does need a [[cannula|What is a cannula?]] to be inserted.\n\n“Mr Johnson’s a new admission, he’s going to need a cannula. Don’t worry about bloods - we’ve already got them.”\n\nYou’ve never actually put in a cannula before, although you’ve practiced quite a bit on dummies. Nervously, you get everything you need, find the patient and begin the procedure. Things go smoothly enough until you’re ready to insert the bung on the cannula. As you pull out the needle, you forget to take off the patient’s [[tourniquet|What is a tourniquet?]] and blood gushes out onto the floor and all over the patient. You apologise profusely, quickly insert the bung and begin the long process of cleaning up all the mess. A nurse notices that you’ve come a little unstuck and helps you get all of the blood off the floor and the patient. As you’re putting everything away, he says,\n\n“Don’t worry about that - I saw you had good cannula technique, it’s just the last part. Before you pull the needle all the way out, just press down on the vein above the cannula - it’ll stop any blood from coming out before you put the bung in.”\n\n“Oh right! That’s really useful, thanks.”\n\nThe next cannula goes in without any mess and you find you’re really grateful for that nurse’s advice.\n\n<<display "disp next plot link">>
You're called over by one of the junior doctors, who looks pleased to give you something to do.\n\n"Why don't you [[go down to Emergency Admissions|Helping new admissions]] and meet patients as they are admitted? Actually, I'll come with you and find you a patient to [[clerk|What is clerking?]]."
Devon Buchanan and Angela Sheard
"Don't worry at all - it's no big deal! Could have happened to anyone. Let's see... Friday lunchtime instead?"\n\n"That'd be great - I'll definitely be there!"\n\n"See you there."\n\n"Bye! Thanks again."\n\nYou put down the phone and head back to hospital feeling satisfied - it always feels nice to put someone else's mind at ease.\n\n<<display "disp coffee plot end">>
As you walk into the admissions unit the junior doctor talks to you.\n\n"Actually, this is your first time here isn't it?"\n\nYou nod.\n\n"OK then, I'll clerk this first patient and you watch, OK?"\n\nThe junior doctor enters the bay.\n\n"Hello Mr. Giles, I'm Dr. Brown and this is one of our medical students. Would it be OK if I asked you some questions?"\n\nThe junior doctor begins taking a history as you find a chair and sit down nearby. After establishing some important information about Mr. Giles' current problem and his overall health, the junior doctor asks about how well he's coping at home.\n\n"Mr. Giles, do you manage alright at home?"\n\nMr. Giles nodded.\n\n"Who lives with you - your wife?"\n\nMr. Giles glances briefly at the tall, silent gentleman standing next to him, and casts his eyes downwards.\n\n"No actually, I'm married to my partner, Tom."\n\nThe junior doctor shrugged and made a note in the clerking form.\n\n"Right, OK."\n\nAs the junior doctor continues to talk to Mr Giles, several aspects of the conversation clearly make Mr. Giles feel rather uncomfortable, like asking about his HIV status. Once the history and examination are complete, the junior doctor leaves to order some investigations, with you trailing behind him. The junior doctor doesn't seem at all fazed by what happened, and you're unsure whether you should say something.\n\nWhat do you say?\n* [[Don't say anything|Don't say anything about the clerking]].\n* [[Comment that the patient may have been offended]].\n* [[Acknowledge the situation was difficult|Acknowledging the situation was difficult]].\n* [[Suggest a different way to ask the question|Suggesting a different way to ask the question]].\n* [[Ask why they asked about the patient's wife|Asking why they asked about the patient's wife]].\n* [[Ask whether they found the clerking difficult|Asking whether they found the clerking difficult]].