This is part two of my guide to making the most of a cardiac critical care rotation as a medical student. To navigate through this series you can use the linked table of contents.

In this week's post, I am going to focus on what to do once you have actually started on the critical care area (CCA) at the Royal Papworth Hospital (RPH). Oftentimes, medical students feel lost or left out and don't really know where to start and miss out on really interesting opportunities as a result, so the purpose of this post is to help reduce that and get you up to speed as soon as possible.

A suggested daily routine

The best time to get on the wards will be for the morning handover from the night team. At Papworth this is at 7 am. This is where the night team provides an update on the patients under your team's care (there are two teams at Papworth CCA, North and South teams). To make yourself useful to the team consider coming 10 minutes early and printing out the handover sheets which contain a summary of patient information - ask one of the junior doctors how to do this. The printer code can be found by asking staff on the ward.

After handover you should have identified a few patients you find interesting. Ask the team if you could have one or two patients to review and present to the consultant on the ward round which starts at 9am. I suggest observing a couple of ward rounds before reviewing patients on your own so that you know how to do this, although I will share what worked for me below.

The ward round finishes at some point before lunch but generates 'jobs' that need doing by the junior doctors. To be helpful to them you can offer to do some of these jobs e.g. calling another department for a consult, collecting equipment for procedures, or chasing up and finding out results from pending investigations. If there are no jobs you can help with, shadow one of the senior clinical fellows (who are senior registrar-level doctors) as they respond to calls, see any urgent patients or perform procedures.

Procedures - the old adage of "see one do one teach one" is somewhat applicable in CCA. As you shadow the clinical fellows and build your working relationships with them you will have seen many procedures been done, such as central venous lines, arterial lines and tracheostomies. Of these, I think central lines and arterial lines are appropriate for you to attempt. Ask the clinical fellows if they  can teach you to do one. Under supervision you can then attempt to do some, after first observing and assisting a few.

There may be times on the ward when it's a bit quiet and nothing seems to be going on. The first instict of a student may be to leave at this point to go do book work but I strongly advise against. The reason for this is that cool opportunities often come unannounced and you may miss valuable experience. Instead, I just took my laptop in and used it in the doctors' office during quiet periods to work on studying, doing passmedicine questions or work on various research projects. Stay on until the evening handover to the night team at 7pm and present your patients to them.

Finally, there are many other things you can see or do whilst on CCA. There are various weekly MDTs where the consultants discuss complex patients with input from other teams e.g. microbiology, Addenbrooke's general surgery. Additionally, go have a look at an ECMO circuit and ask either one of the clinical fellows or ECMO nurses to teach you how it works. You should also ask about any drug infusions you see, and at some point ask about how a ventilator works and learn its various settings. Learn how to operate an ultrasound probe and what a FICE (focused intensive care echocardiography) entails.

How to prepare for a ward round

It may seem daunting at first but all the consultants in Papworth CCA are super nice and if you say you are a student and want to present a patient to them they will be very receptive. Nevertheless, it pays to be prepared and so I will provide you with a structure you can use.

To begin with, after handover and identifying 'your' patients, log in to the CCA electronic medical record (get a username and password for this on your first day!). It is laid out in a somewhat sensible way but best ask a senior for guidance on how to use it. My order of reviewing a CCA patient (both EMR and/or physical examination) uses a modifed "A to E" approach:

How to present a patient on a ward round

So you've done the hard work of preparing for the ward round - it is absolutely key to be well prepared and know your patient inside-out before presenting to a senior colleague. The actual act of presenting may seem daunting but you get better with it the more you do it. Somethig which worked for me was to use a SBAR approach.

• S: situation. An introduction to your patient and the most pressing concern. E.g. "Mrs X is a 67 year old lady 4 days postop after an AVR and grafts (aortic valve replacement and coronary artery bypass grafting). She's had increased oxygen requirements overnight and is currently febrile."
• B: background. Some relevant information. E.g. "The surgery was uneventful. She has type II diabetes currently on an insulin sliding scale, peripheral vascular disease. A chest X-ray performed earlier this morning showed consolidation in the right lower zone and air bronchograms. Morning bloods show a spike in CRP. Her noradrenaline requirement has also been rising and urine output is low. On auscultation she had reduced breath sounds on the right." The consultant may ask you for more information at this point but should have all this information because you did a thorough pre-round before the ward round!
• A: assessment. Your impression of what is going on. E.g. "Based on the clinical picture and investigations I think she is currently septic secondary to a chest infection."
• R: recommendation. What plan you have made to sort out the current issue. "I would reccomend escalating antibiotics,  taking blood cultures and providing a bolus of IV fluids."

It may seem a bit weird coming up with a recommendation at first, because you may be thinking "I'm just a medical student what do I know?". However, this is a great way of developing your clinical skills and acumen and there is so much you can learn from a consultant's feedback from your presentation.

Finally, to cap it off my single most important piece of advice on getting as much as you can out of a rotation in critical care is to get "stuck in". Make yourself part of the team, go for full immersion and try to shadow the junior doctors in their duties as much as you can. One of the best ways to grow in your professional development is to start thinking like the doctors you will become in due course.

Next week, I will discuss some of the ways in which we monitor the vital signs of critical care patients. This will make for some interesting applied physiology and understanding principles of monitoring will help you diagnose and manage patients much better.

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Cover image credits: Olga Kononenko on Unsplash

Cover image credits: Royal Papworth Hospital Media Team

How this guide will work

I realised that this guide will probably be too much to digest in one sitting so I will be releasing it in manageable parts as I write them, aiming for a frequency of one section per week. The sections are putatively as follows (although this may change as I progress through writing them):

Contents

1. Introduction (this post!)
2. How to make the most of a CCU placement: practical tips and suggested daily routine
3. What gets measured gets managed: monitoring a critically ill patient
4. The pharmacological arsenal: important drugs and what they do
5. Cardiac failure: supporting a failing heart
6. Respiratory failure: ensuring gas exchange with impaired lungs

Introduction

In August 2020 I had the chance to spend some time in the cardiac critical care area (CCA) at the Royal Papworth Hospital in Cambridge. Although supposed to be a four week placement, being in the middle of the Covid-19 pandemic meant that due to measures reducing footfall in the hospital, this was shortened to two weeks. Nevertheless I managed to get so much out of this placement, saw some incredible applied physiology and picked up useful clinical skills. I therefore have worked on this document with the aim of 1) educating the reader on what critical care involves and 2) providing tips for medical students on how to make the most of a placement in critical care medicine (CCM) and 3) get just as much out of their placement as I did during mine.

Why critical care?

Why did I choose cardiac critical care? I'm close to graduating from medical school (just a few months more to go at the time of writing) which means I have been working hard towards securing a training job in the speciality of my choice: cardiothoracic surgery. Although specialty applications are not for two more years, it is wise to start working early on strengthening your portfolio because it is a notoriously competitive specialty. In addition, most cardiac surgeons play an active role in the postoperative care of their patients (who all spend at least one day in the CCA) and therefore spending time embedded in CCA is a great way to learn how to manage some of the most complex and critically unwell patients in the entire hospital, and learn how to manage postoperative complications.

What is critical care and what does it involve?

I would define critical care as the care of patients who need close monitoring and support for organ systems that are incapable of functioning without being supported by some external means. Some of these means are summarised in the table below. Organ support may also include various pharmacological agents which can act to augment and/or protect organ systems. These will be discussed in more detail in subsequent sections.

Table 1: Organ support systems

What kind of conditions do we manage in cardiac critical care?

At least at RPH, the vast majority of patients in the CCA are post-cardiac surgery patients. These patients require support of their cardiovsacular system, the most common problem being hypotension. What causes this hypotension? The causes of hypotension can be briefly summarised as falling into one of three categories: 1) factors before the heart (preload), 2) factors within the heart and 3) factors after the heart. These are summarised in Table 2.

Table 2: causes of hypotension post cardiac surgery

Other conditions commonly requiring intensive care support are pulmonary oedema, respiratory distress syndrome, severe systemic infections and acute kidney injury necessitating renal replacement therapy.

So, if this stuff interests you, keep an eye out on this page and follow my socials (see links at the top of the page). Next week: practical tips for how you, a student, can make the most of a critical care placement.

Over the past few years I’ve been approached a few times by prospective/current medical students asking me what books to read before applying to medical school/starting medicine/during medical education. So, I thought to put together a list of some of my favourite non-academic books relating to medicine along with a brief review of each. Note, however, that before my own admissions interview I had only read two books on this list: “Better” and “Do No Harm”. The rest of the books are those which I picked up later but nevertheless enjoyed and took away lessons from. By no means is this a definitive list. It’s not going to cover every aspect of a medical education/career. Nor is it an all-encompassing guide on How To Be The Best Doctor. This merely represents which parts of my “want to read” Goodreads library I have managed to get through – a list which sadly continues to grow at a snail’s pace… so many books, so little time.

Anything Atul Gawande has written

Atul Gawande – Better

Atul Gawande – The Checklist Manifesto

Atul Gawande's books make for very good medical reading material. He is a general surgeon, public health advocate, one of minds behind the WHO safe surgery checklist and one of the most skilled medical authors I’ve read. These books in particular I really like and they still influence my clinical practice and approach to life. “Better” deals with how clinicians (surgeons in particular) can improve their outcomes and draws insight from various different contexts ranging from warzones to hyper-specialist surgical centres with miraculous complication/survival rates. “The Checklist Manifesto” details how the aforementioned WHO surgical checklist was developed, and how Dr Gawande applied transferable principles from many fields including the aviation and finance into clinical practice.

Henry Marsh - Do No Harm

This is a great book to read as it’s from the perspective of a senior British neurosurgeon who was just about to retire when he wrote it. It has a lot of poignant reflections and lays bare some of the frustrations which form part of working in medicine. Here’s a quote which I really like, mostly because I spent the vast majority of my first year of clinical medicine self-diagnosed with one or another dreadful malady:

“Most medical students go through a brief period when they develop all manner of imaginary illnesses – I myself had leukaemia for at least four days – until they learn, as a matter of self-preservation, that illnesses happen to patients, not to doctors“

Samuel Shem - The House of God

By far one of the funniest books I’ve ever read, this is a hilariously cynical and raunchy satire based on the author’s own experiences as an intern at Harvard medical school, more than a few decades ago. If you read this, and still want to do medicine after reading it, you’ll be in good stead for the rest of your career – it really covers the good, bad and ugly of it all. Keep in mind though that this book represents an entirely different era of medicine and an antiquated way of doing things. A lot of this book might be considered crude, cruel and distasteful. Medicine nowadays has changed for the better, and now is much more wholesome, less cruel, and generally fairer on patients, families and healthcare workers.

To get a feel for what kind of a book this is, here are the author’s thirteen “laws of the House of God” *:

1. GOMERS** don’t die.
2. GOMERS go to ground.
3. At a cardiac arrest, the first procedure is to take your own pulse.
4. The patient is the one with the disease***
5. Placement comes first.
6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
7. Age + BUN = Lasix dose.
8. They can always hurt you more.
9. The only good admission is a dead admission.
10. If you don’t take a temperature, you can’t find a fever.
11. Show me a [medical student] who only triples my work and I will kiss his feet.
12. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
13. The delivery of good medical care is to do as much nothing as possible

*  note that I personally do not endorse or agree with many of these laws – I just have a thing for gallows humour as a coping mechanism in dealing with life

** google it if you want to know what this means

*** I literally had this written down in ink on one of my ward notebooks when I was going through some health anxieties of my own

Thomas Morris - The Matter of the Heart: A history of the Heart in Eleven Operations

In case it wasn’t apparent that I have a fascination with everything cardiovascular (I just think that the physiology is the most elegant of all systems in the body) this was the first book I read in 2020. It describes how heart surgery has changed over the the years to be what it is today. The history of cardiac operations is one dominated by a thin line between bravery and foolhardiness, with macabre animal sacrifice and both miracle cures and unmitigated disasters in human patients. Nevertheless, cardiac surgery has developed to what it is today due to some of the finest scientific minds of the time solving seemingly impossible problems. Up until relatively recently, the heart was regarding as a uniquely mysterious and fragile organ, with surgeons not even daring to touch it. Slowly but surely however, advances in techniques and technology such as cardiopulmomary bypass, immunosupression and deep hypothermic circulatory arrest have enabled open heart surgery and even heart transplantation to be carried out with excellent outcomes in hundreds, if not thousands, of centres worldwide. Thomas Morris takes you through this history in an excellently written highlight reel of eleven important operations that changed the field of cardiac surgery.

Featured image by Debby Hudson on Unsplash 

“But did you think about how the patient would have felt during all this?” asked my consultant at our end of placement meeting.

Easter vacation and an untimely end to fifth year clinical attachments (thanks, Covid-19!) have given me plenty of time to reflect on something which I’ve perhaps not paid enough attention to in the past. As medical students, we are privileged to be involved in seeing some incredible things on the wards; things that laypeople can’t even dream of. However, how often do we consider the patient’s point of view? This was what my consultant raised at our end of placement meeting after my obstetrics and gynaecology placement.

I had just submitted a reflective piece on a clinical case I had encountered. My reflections revolved around an obstetric emergency: a prolonged labour, fetal distress on the monitors, and then a burst of activity as a senior obstetrician was called in followed by an emergency excursion to the operating theatre. My takeaway from this experience, at the time, was on such matters as team-working, the excitement of obstetrics and the importance of good clinical judgement under pressure. Hadn’t I forgotten something, though? Although the consultant was pleased that I had a productive time with the obstetrics team, she asked me one simple question: “did you consider how the patient felt during all this?” – I hadn’t. In fact, I don’t think I had paid much attention to this side of things, ever.

Which is why I am writing this piece. We wax eloquent on empathy in our personal statements and during interviews but do we really take the time to empathise with our patients? Sure, clinical attachments are invaluable experiences for us medical students but how often do we stop to think about what the patient might be feeling at the time? While for us an “exciting” case is a learning opportunity, there is a vulnerable, probably scared and worried patient in the middle of it all; while I was seeing some incredible emergency obstetrics, there was a distressed patient who in was in pain, worried and frightened for the safety of herself and her unborn child.

Studies have shown that most PALS (patients’ advice and liaison service) complaints are due to issues with “non-technical skills”. I think that being aware of, and bridging this dichotomy of experience is something that will help us be better doctors, and patients will experience better subjective and clinical outcomes.

A few weeks later I was called in for an organ retrieval – where a team goes to another hospital to retrieve the organs from a brain-dead donor in order to use them as transplant grafts. As there was only one other surgeon I was fortunate enough to assist during the retrieval, and even got to perform my first sternotomy (where we open the chest by sawing through the breastbone). This time, before losing myself to the excitement of it all, I took a minute to solemnly reflect on the fact that the donor laying in front of us was a person, had a family, and had a lifetime of memories and experiences. And I slept much better that night.

Months of hustling away on research projects in my own free time finally bore fruit this term, with several project abstracts getting accepted to conferences across the UK and in Europe. This site of mine has been up for a few years now but I’ve only recently decided to make use of it. Thus, I’ve decided to share these experiences on my site, because in the words of Austin Kleon in his book “Share Your Work“:

“…in this day and age, if your work isn’t online, it doesn’t exist. We all have the opportunity to use our voices, to have our say, but so many of us are wasting it. If you want people to know about what you do and the things you care about, you have to share…”

EU-CardioRNA Working Group Meeting (Maastricht, NL)

This mini conference took place in a very pretty student city in the Netherlands, Maastricht. Got some serious Cambridge vibes, with the bikes, bridges and medieval buildings. This was a rather niche conference but was nevertheless incredibly interesting due to some high quality science being presented.

I learnt that the field of cardiac transcriptomics research is full of promise, with several molecular pathways underlying pathophysiological processes being understood as well as increased focus being placed on the non-coding aspects of our genome.

Cardiologist and research group leader Professor Roger Foo from the National University of Singapore delivered an excellent talk on a novel long intergenic noncoding RNA (lincRNA) called VentHeart (VHRT) which determines ventricular cell fate of cardiac myocytes, and presented some patch clamp data showing how VHRT knockdown alters action potential morphology; this no doubt excited the cardiac electrophysiologist in me. In addition, he’s also a Cambridge alumnus and I had a fantastic time chatting to him about his research and career advice for clinical academia.

Finally, I got to present a poster of the cumulative efforts of my intercalation year research project. This has been published and the papers on Pgc-1b knockout mice can be found here.

All in all, had a wonderful time and it was also the first trip I had taken abroad completely solo without friends and family so was a great experience!

Cambridge Cardiology Conference and CUSCRS-INSPIRE (Cambridge, UK)

Last November I spent four weeks at the Royal Papworth Hospital in Cambridge, attached to the cardiothoracic surgeons and getting to see some incredible surgery. Coming out of this placement I wanted to get involved in some clinical research so began collecting data on outcomes of cardiac surgery in patients with renal transplants, under the supervision of cardiothoracic surgeon Mr Jason Ali. Some of this preliminary data was presented at the two student led conferences mentioned above. This was quite the valuable warm-up experience, since the feedback and suggestions I received from faculty have been instrumental in preparing this project for presentation at the Society of Cardiothoracic Surgeons Annual Meeting later this month. Watch this space for more updates on the project!

Additionally, the Cambridge Cardiology Conference was something I helped organise as co-conference coordinator of CamCardioSoc (along with the ever-talented Jamie Ho – follow her on twitter, she’s an incoming academic foundation doctor in London due to start this August!). It was such a fun day and we had some inspiring talks from leading clinicians and scientists in the field. See more about the conference here.

What’s next?

I had presented at two conferences before this term, but these few weeks of intense activity presenting my work and meeting such a diverse crowd of people has taught me so much and helped build my confidence and presentation skills! I now look forward to two more conferences before taking a break from research meetings to focus on my end of year exams. As mentioned above, SCTS 2020 will be later this month, and so will the European Heart Rhythm Congress in Vienna for which I will be travelling to present some work I did with the cardiac electrophysiologists at the Royal Papworth last year. Thanks for taking the time to read this post if you’ve got this far and I’m more than happy to help you with advice if you want to get involved in research as a medical student 🙂

Ran my first race last weekend! I started running one year ago after realising my cardiovascular fitness was abysmal, getting breathless after climbing a flight of stairs. Since then I’ve been working on incrementally increasing my distances and this weekend I ran my first race, the Muscular Dystrophy UK Cambridge Town and Gown 10K. I’m also very pleased with the time I ran, setting a new 10K personal best of 53m 18s.

Donate to MDUK

Race results – bib number 1009

Had a wonderful time at Heart Rhythm Congress 2019 with my Student Doctor colleague, Roy Zhang, presenting our research to British cardiac electrophysiologists and learning so much about an exciting field! The poster I presented can be found here: HRC 2019 poster.

Attending my first “serious” (i.e. not student-run) conference back in September 2018 was quite an enjoyable experience. I got to meet some interesting people from a wide range of backgrounds, in addition to seeing incredibly cutting-edge research being presented from diverse disciplines.

Finally, I’m very pleased I was able to present the research I conducted during my intercalated degree, picking up a Rob Clarke award (silver) for undergraduate research for it along the way.

The pre-clinical medical sciences course at Cambridge (MVST) is predominantly theoretical and assessment consists of formal written exams at the end of the year. Two key learning skill are 1) understanding concepts and 2) memorising facts. In my experience, different people prefer one way over the other – I never had to rely on rote learning to get through exams until I came to Cambridge. This was disadvantageous during exam term, as the first components of examination (MCQ or SAQ based papers)  rely heavily on fact-based knowledge. These components are critical to passing 2^nd MB and differentiate between students to a greater extent than the essay questions in terms of tripos classification (i.e. there is less spread between students in essay paper marks than in MCQ paper marks).

Thus, despite only counting for 50% of the final tripos class, doing well and scoring more than 90% on 2^nd MB exams is a strong predictor of achieving a high overall class. This post contains some tips and tools I picked up along the way that I found to help with rote learning, that centres around the software Anki.

Anki

Anki is a powerful flashcard software and it’s a free download for Mac, Windows and Android (the iOS app costs money and I don’t recommend downloading it – just use the mobile version of ankiweb.net). Create an account and it syncs your flashcards across your devices too. There are plenty of YouTube tutorials covering the technical aspects of using the software.

Anki uses a technique called ‘spaced repetition’ to help you retain information. Once you’ve finished a set of cards, it flags them for review at a later date. The interval depends on how easy you could recall those cards. For example, if you indicate that a card was easy it is flagged for follow up in 4 days; if you indicate a card was hard it is scheduled for follow up the next day. These intervals can be changed in the settings if you prefer. Spaced repetition has been shown to work in human¹, rat² and pigeon³ models of learning. Although this is anecdotal evidence, Anki definitely helped me in 2^nd year when it came to learning drugs for MODA and the minute details of BOD lectures. I’m convinced Anki pulled my paper 1 grades up from around ~80% in MVST1A to high 90s in MVST1B.

It should be noted that Anki requires you to be consistent – a large backlog of cards is not easy to go through, so make sure you complete whatever cards are marked for review on the day they are meant to be reviewed. There are daily limits that Anki sets which you can change  – I changed mine to 20 new cards per deck per day and unlimited review cards per day. Closer to exams, I reset the review counter and go through the cards as if they are new cards.

Optimising flashcard design

Having a powerful flashcard software is not the end of it. Making good flashcards just as important. My advice for flashcard design:

1. Write the answers in the form of numbered lists
2. Try avoid having more than 6-7 bits of information on each card
3. Write the front of the card as a question
4. Use the image occlusion plugin (it covers parts of images with labels that can be revealed in the answer card) to learn diagrams – very useful in NHB

First, an example of a bad flashcard:

Here is an example of these changes implemented to make a better flashcard:

Image occlusion cards are useful for studying diagrams, like this diagram of the inner ear you will come across in NHB.

Conclusion

Spaced repetition is a useful technique for memorising facts that are vital for a strong performance in end of year exams. Anki is a free flashcard software using this technique with many plugins that can help revise material. The key to making the most out of Anki is to be consistent and do the cards on the day they are flagged for review. Flashcards should also be optimized to make reviewing them less tedious, increasing efficiency.

References

1. Ausubel DP, Youssef M. The Effect of Spaced Repetition on Meaningful Retention. J Gen Psychol. 1965; 73: 147-150.
2. Roberts WA. Spaced Repetition Facilitates Short-Term Retention in Rat. J Comp Physiol Psych. 1974; 86 (1): 164-171.
3. Roberts WA. Short-Term Memory in Pigeon – Effects of Repetition and Spacing. J Exp Psychol. 1972; 94 (1): 74-&.