Neurotic

I’m an incredibly neurotic individual. Always have been.

As a result I’ve spent a lot of my life being incredibly sad, as persistent self-doubt slowly constricted the enjoyment out of everyday life. I’ve preoccupied myself with what other people think of me, and the baseline assumption has always been a fairly negative one. As a result I’ve found that I have tended to lose concentration very rapidly, losing interest in things and generally becoming less and less motivated to get stuff done. There have been huge numbers of things that I wish I had done, but never did, simply because of what others might think. I’ve always enjoyed weird things like circus tricks and magic, but never really pushed myself to get good or show anyone because it was just too scary to put myself up for scrutiny by those around me. I once rode my unicycle to lectures, and found the whole experience was ruined by the embarrassment and fear that I’d made someone, somewhere, think I was an idiot for doing so. (It was awesome fun though…)

Over the recent years I’ve gradually come to the realisation that what makes me happy, and I mean genuinely content with myself and my life, has very little to do with other people. Even less to do do with what they’re thinking. To this end, I decided to write down a list of the common characteristics of things that I would say actually make me happy:

  • To learn new information
  • To master new skills and perfect old ones
  • To make other people feel better
  • Exercise
  • To create something meaningful

That was it. My whole life, everything I’ve ever wanted and am ever going to need is in those five bullet points. I call them my big five. Imaginative I know…

I wanted to be a doctor because I believed it would cover the first three of these, and it so far it certainly has. The wealth of continually growing knowledge in medicine would ensure I never ran out of things to learn, and the practical procedures are always great fun to practice. Hopefully I’m making people feel better along the way, too…

However what I found was no matter how hard I tried my neurotic brain got rather proficient at throwing a negative spin on each of these characteristics, and pretty quickly they morphed into a rather acrid, menacing set of doubts:

  • I’ll never learn all the necessary information
  • There will always be someone better than me
  • I can’t help everyone, and at some point I’m sure to screw up and make it worse

This threw me into a tailspin, and I lost considerable faith in what I was doing. Something needed to change if was to remain motivated to tackle such a demanding career, and maintain a healthy and happy lifestyle.

So I started to break things down to the level of the big five.

Is this going to teach me anything?

Is it making me better at something?

Is it helping other people?

Is it exercise?

Is it creative?

I focused entirely on these five. I tried to only do things that fulfill at least one of them, and when I was doing something that did, I didn’t question it. Of course my neuroticisms would seep through the cracks of optimism, trickling thoughts of doubt tugging away at my motivational drive, but I forced myself to say ‘yes, this is a good thing that I’m doing, and I’m going to keep going‘. The result?

I got happy.

Not laugh out loud happy. Not even smiling happy. Just ‘content’. It was huge – everything felt warmer and all the colours had a brighter hue. People seemed friendlier while day-to-day jobs seemed more enjoyable. My concentration began to climb, to the point where I could sit comfortably for up to an hour and a half, gently plodding away through some work, and actually enjoy it. I found my working memory steadily improving as it was no longer clogged with negative assumptions like some old oil filter, and my interest in both my work and the people I interacted with was on the rise too.

I decided to use this improvement in my outlook to try and describe what I had been through in the hope that maybe someone else feeling the same thing might read it and find the same results that I did. Below are a number of things that I found made significant improvements to my own wellbeing and helped me to start doing what I wanted without the crushing worry that was holding me back in previous years.

Just start writing

Simple but helps me a lot, especially when feeling pressured to add something to this blog.

It’s very easy to improve a piece of writing that’s sat in front of you, however it is much harder to concoct something great from scratch, so just start writing! Don’t worry about how to structure your ideas, just type everything that pops into your head.

Soon enough there will be something in front of you that you can set about improving and restructuring. It might not be great, but it’s a huge leap in the right direction.

It’s ok to fail

‘If you fail you don’t get what you want’ 

This concept is drilled into every student, for every exam, forever. It makes sense that if you don’t pass the exam or test, or project, then you don’t get to enjoy the reward of the prize it so ominously guards; that admission to the medical school of your dreams, progression to the next academic year, driving a car.

So it came as a bit of a surprise when I realised that just occasionally, failure will get you exactly what you’re looking for… 

I’ll elaborate. Medicine being the beautiful all-encompassing lifestyle that it is, requires not only a certain knowledge base, but also demands proficiency in a variety of practical tasks. Taking blood, suturing wounds and siting cannulas,  to name just three, all require practice, and there is nothing that can replace good old fashioned repetition when it comes to encoding that muscle memory that makes the consultant look so good. 

Along the way, you’re not expected to get it right every time, clearly. As a beginner you are expected to make mistakes, and I knew this as much as the next person, however I was still overwhelmed with anger and frustration every time I didn’t succeed. 

I began to dread performing these procedures as each occasion was another opportunity to fail, and fall back into that well of pathetic despair – it was so much easier to let someone else do it… 

Then, one day, having summoned the courage to attempt siting a cannula, I failed again. That familiar thick cloud of self-loathing and anger began to crawl up my spine as I begrudgingly asked my senior to take over. He smiled,  “Sure.” 

He promptly then took three attempts himself before calling the anaesthetist to come and help. “Shit veins”, he chirped, before heading off to do something else. 

I was amazed. There wasn’t a shred of disappointment or frustration as he wandered away, the fact that he hadn’t succeeded clearly wasn’t a problem. The anaesthetist took three attempts herself before that tiny plastic tube yielded any blood, and she explained to me how best to hold down the skin so as to keep the vein from wriggling away as you dive for it. She then smiled and said “well done for having a go!” and disappeared. 

For the first time I had failed and simultaneously realised it’s totally okay. That’s the whole point of having a team, so that one person can help another out when they’re having trouble. Since then, I’ve never been scared to have a go, knowing that there’s a troop of like-minded, supportive team members behind me. 

So what did I gain? I now know the best way to hold the skin to stop the vein wriggling away. I was only shown once, but I can picture exactly in my head how the consultant did it – why? Because I was so frustrated, so emotionally invested in the situation that it was burned into my memory forever. It’s the same every time I get something wrong – I always remember perfectly what the doctor correcting me says, because of that pure emotional attention that you only pay when you’re upset. 

So from now on, I relish the opportunity to have a go, and to fail, because I know I’m going to learn something, and remember it forever. 

How to examine the shoulder

This post is an outline of the examination of the shoulder that is required for the rheumatology and orthopaedics part of the medical school course. Different sites and schools include different things so I’ve tried to make this one as comprehensive as possible by compiling my favourite things from a few sources, and hope it’s of some use.

OSCEs are interesting beasts. They’re designed to measure one’s clinical prowess, although end up being a very artificial process that requires specific attention to learn, rather than just clinical experience. As a result, examinations in particular end up becoming a rehearsed routine that can be rattled off under intense pressure, without much actual thought as to what one is looking for in the first place. What I’ve tried to do here is write the ‘script’ but also give an idea of what to be thinking along the way, to help answer examiner questions and also to help be an actual doctor (which I’m hoping is the ultimate goal). Of course everyone will have their own style, and this is simply my own, but hopefully it might provide a useful framework for you to base your own technique upon.

I like to talk to the patient, as this is what I do in a clinical setting, especially as patients sometimes ask what I’m testing. This also looks better than trying to narrate what you’re doing to the examiner. I also find it much easier to demonstrate movements rather than trying to describe them, and it helps build rapport between you and the patient if they’re playing a game of copying you #psychologywin.

The Dance

BEFORE ENTERING – what age is the patient, are they male or female, what’s their occupation, are they right or left handed, what side is the problem on?

Introduction

*Student enters cubicle, washes hands and smiles*

“Good morning, my name is Will Sloper, I’m one of the fourth year medical students, I’ve been asked to do a quick examination of your shoulder, would that be alright?”

*Patient says yes*

“Thank you, may I ask your name? And how old are you if you don’t mind me asking”

(exposure – please could I ask you to remove your shirt?/put the cat down?)

*Student washes hands and asks patient to stand*

“Before I begin, are you in any pain at the moment?”

*Patient says no/a little/yes my shoulder hurts*

“Great/Okay well I’ll be quick and do my best not to cause you any (more) pain. Is there anywhere that’s really sore to touch?”

*patient points at specific point*

“Alright, I’ll avoid that finger/bruise/bleeding open fracture as much as I can”

“Are you right or left handed?”

*Patient responds (unless they don’t have any hands in which case poor choice of question)*

LOOK


“Do you have anything with you such as a sling or any medications?”

*Student looks around – trying not to appear suspicious of patients*

“Firstly I’ll have a look from the front…”

*Student looks intently at sternum, clavicle and then shoulders*

“…the sides…”

*it may be easier to ask the patient to rotate, rather than try to climb around them*

“…and the back.”

*Student stares blindly at shoulder blades contemplating exactly what it is they’re doing with their life*

“Lovely, please could you turn to face me again?”

*smiles*

FEEL

Now if it’s alright I’ll have a quick feel of your shoulders”

*Student feels temperature with back of hands.

“Ok, now please let me know if any of these parts are tender, I don’t want to cause you any pain.”

*Student palpates touches both sternoclavicular joints, clavicles, acromioclavicular joints, coracoid processes, greater tuberosities, joint lines, deltoid bulk and insertions, acromion processes, scapular spines, supraspinatus, infraspinatus, borders of the scapulae, and paraspinal muscles*


Now I’ll have a quick feel for the tendons in your shoulder”

*Student passively flexes patient’s arm and feels along biceps for the tendons. Then extends the shoulder (pushes elbow back) to tilt the head of humerus forward, and palpate for the supraspinatus tendon*

“Thank you, have you noticed any tingling or numbness around your shoulder?”

*no/yes/just on the tip of the shoulder/where this knife has been inserted*

“Could you please close your eyes and say yes if you can feel me touch your shoulder?”

*Student lightly touches regimental patch and skin over trapezius*

*yes*

“Thank you”

*smiles – customer service-style, not Willem Dafoe*


MOVE

“Now I’d like to test some movements if that’s alright”

*Patient nods*

“Please could you copy what I do with both hands?”

*Student puts both hands behind head, then behind back*

*Patient copies*

*While patient’s hands are behind back, student places hands on patient’s*

“Now push my hands away” (subscapularis power)

*Patient pushes hands away. Student hovers one hand in front of patient in case they push themselves forwards*


Great, now if you copy me, and I’ll help you at the end of each movement”

*Student then abducts arms above head, patient copies, meanwhile student places hand on patient’s scapula to assess rotation*

*adducts them across the chest*

*flexes forward to 170 degrees*

*extends to 40 degrees*

*Patient copies, and student adds passive movement at the end of each one*

“Any discomfort?”

*Patient says ‘no/yes/screams’*



“Thank you, now hold your hands out like you’re holding a dinner tray

*Student externally and internally rotates arms and patient copies*

*Student applies passive force at the end of each. At the point of maximum external rotation, ask patient to hold their hands there, and let go – see if arm drifts back to centre (Lag sign)*



Specific muscle tests

(Subscapularis has already been tested earlier with hands behind the back, to make it more convenient for the patient)


“Now could you do the same, but push against me?”

*Patient externally rotates against resistance*


And now place your arms by your sides

*Student holds patient’s arms by their sides*

“Push out against me?”

“Thank you, now could you do this?”

*Student holds arms flexed to 90 degrees and slightly abducted so that supraspinatus is aligned with the humerus, with thumbs towards the ceiling*

*Patient copies*

“Now resist me”

*Student pushes down*

And now the same with thumbs down?”

*Same again*


“Thank you”

Impingement tests


“I’m now going to lift your arm up, please hold it there”

*Student passively abducts patient’s arm to maximum abduction and lets go*

“Now could you slowly lower it down to your side, and let me know whether there is any pain”


Now let me take your arm, and let it go all floppy, letting me take all the weight”

*Student flexes shoulder to 90 degrees, elbow to 90 degrees, and then internally rotates the shoulder*

Any pain?”

*no*

*Student repeats motion at varying degrees of abduction, watching patient’s face each time”


Ok, thank you, let your arm go loose again”

*Student stabilises scapula with one hand, and uses the other to internally rotate the patient’s arm and passively flexes it*

Any pain?”

*Patient says ‘no’*


“Finally, please could you do this for me?”

*Student places own hand on contralateral shoulder, with elbow moving across midline*

*Patient copies*

Are you able to get the elbow all the way across?”

*Student looks, showing that she is checking whether elbow has crossed midline*


“And just to finish off, I’ll take your arm, let it go nice and loose, and let me know if this is uncomfortable”

*Student takes patient’s arm, moves it into the ‘POLICE – HANDS UP!’ position (correct anatomical name) and gently externally rotates*

“Does that feel wobbly or unstable?”

*Patient says ‘no’/shoulder dislocates*

Conclusion


“Well thank you very much, I’ve finished my examination, do you have any questions for me?”

*Patient says no*


“Thanks again”

*Student smiles, washes hands and turns to examiner*



Presentation

“I performed an examination of the shoulder on Mrs Bananas who reported tenderness in her….. and upon inspection, noted the presence of a longitudinal scar/slight bruise over the clavicle. The rest of the examination was normal, with good movement and function of all muscles”

(Obviously this bit is going to vary hugely – practice making up a bunch of different presentations and you might find that in the exam, you can adapt one you’ve already made to fit your current patient)

“To complete my examination, I would like to:

  • take a full history
  • do a regional musculoskeletal exam of the elbow and spine
  • do a neurological and peripheral vascular exam of the upper limbs

If asked what management you would do, you can’t really go wrong with:

In accordance with local trust guidelines, this condition can be managed:

  • Conservatively
    • physiotherapy
    • modification of daily activities
  • Medically
    • nsaids
    • steroid injections
  • Surgically
    • manipulation under anaesthesia (adhesive capusilitis)
    • surgical stabilisation (dislocation)
    • arthroscopy (impingement)

I would also want to ensure I am aware of the patient’s desires and concerns, what activities they would like to be able to do, and what their outlook on the issue is like.

Why do the exam?

The main purpose of the shoulder exam is to elicit whether the patient has any:

  • pain/impingement
  • stiffness
  • reduction of function
  • evidence of previous disease/surgery

And as with all musculoskeletal examinations, it’s a good idea to follow a structure of:

  • look
  • listen
  • feel
  • move
  • special tests

And always, always, always…

  • ask about pain
  • compare the two sides
  • watch the patient’s face during movement

The things to look out for in the shoulder exam are as follows:

  • Looking
    • swelling
    • muscle wasting
    • deformity
      • internally rotated at rest suggests posterior dislocation of the shoulder
    • skin changes
      • bruising
      • thinning
      • rashes
    • scars
    • Winging of scapular
      • long thoracic nerve
  • Feeling
    • Temperature
      • inflammation
    • muscle wasting
      • may suggest nervous injury
    • sensation
      • axillary nerve lesion
    • joint palpation
      • warm, rubbery swollen joints are suggestive of active synovitis
    • Bony deformity
      • previous fracture
    • Tendons
      • feel for tendon rupture/sensitivity
  • Moving
    • failure of movement could be:
      • muscular
      • neurological
      • tendinous
      • articular
    • Passive movement:
      • feel for crepitus
      • tells you if problem is muscular or intra-articular
    • Pain on movement suggests impingement or inflammation
    • Muscles to test:
      • Deltoid
        • abduct beyond 15 degrees
      • Rotator cuff
        • subscapularis
          • lift off test
        • supraspinatus
          • empty can test
          • abduction first 15 degrees
        • infraspinatus
          • external rotation
          • Lag sign 
        • teres minor
          • external rotation
          • Lag sign
      • Teres Major
        • internal rotation
  • Special tests
    • Subscapularis
      • lift off test
    • Supraspinatus
      • empty can – impingement if pain
      • Neer’s test
      • Hawkin’s test
      • Scarf test
    • Instability
      • Crank apprehension test

Common pathologies to watch out for:

  • Adhesive capsulitis
    • ‘frozen shoulder
      • loss of external rotation
      • loss of abduction
      • pain on active movement
      • reduced active and passive range of movement
  • Impingement
    • Pain on impingement tests
    • may have reduced abduction
    • Painful arc 60-120 degrees
  • Rotator cuff injury
    • pain on external rotation
    • supraspinatus tests show weakness/pain
    • subscapularis tests may also
  • Instability
    • repeated previous dislocation
    • apprehension test
    • may have deformity
  • Osteoarthritis
    • pain on movement
    • reduced range of movement

Someone Else’s Trousers

I always put my money down someone else’s trousers, so people don’t talk about me.

Want to remember what to include on an anaesthetic pre-operative checklist? Well look no further – now you’ll be even more confused!

  • I
    • Identity
      • name
      • date of birth
      • wristband
  • Always
    • Allergies
      • allergies
      • reactions to medications
  • Put
    • Proposed Procedure
      • what do you understand about the procedure you’re having today?
  • My
    • Medical History
      • do you have any medical problems?
      • have you ever been to hospital before?
      • what’s the background to you having this procedure?
  • Money
    • Metalwork
      • do you have any metalwork in your body?
  • Down
    • Drug History
      • what medications are you on?
      • why are you on drug X?
      • when did you last take your medication?
  • Someone
    • Systems Review
      • CVS
        • pacemaker
        • hypertension
        • stroke
        • chest pain
      • Neuro
        • epilepsy
      • Gastro
        • acid reflux
      • Resp
        • asthma
        • lung disease
      • Endo
        • diabetes
        • thyroid
      • Renal
      • Liver
      • Joints
  • Else’s
    • Exercise Tolerance
      • how far could you walk before you get short of breath?
      • how many stairs could you climb?
  • Trousers
    • Today (current health)
      • how is your health today?
      • coughs or colds?
      • recent fevers?
  • So
    • Social History
      • do you smoke?
        • how much?
      • do you drink?
        • how much?
      • other drugs?
  • People
    • Previous General Anaesthetics
      • have you had a general anaesthetic before?
      • were there any problems?
      • do you suffer from motion sickness?
      • has anyone in your family reacted badly to anaesthetic drugs?
  • Don’t
    • Drink/Eat (last meal)
      • when was the last time you ate and drank?
      • what did you have?
  • Talk
    • Teeth
      • are those your own teeth?
      • do you have any loose teeth, caps or crowns?
  • About
    • Airway Assessment
      • jaw protrusion
        • can you put your bottom teeth in front of your top teeth for me?
      • neck extension
        • could you put your chin on your chest and then look up
        • touch chin to each shoulder
  • Me
    • Mallampati
      • please could you open your mouth as wide as you can?
      • now stick out your tongue?