After my first 'real' patient for a skin excision...

Today was great as expected. I got to draw up and give a couple more injections, I am getting better at recognizing different sounds in the chest and I did my first 'real' excision.

I am much more confident with anaesthetising with local anaesthetics. Dr F showed me a few cool tricks and helped me redraw the margins for excision (you need to feel the skin - to determine the tension and therefore might avoid making the ellipse so big!). I cut the skin and as I peeled the skin back, dissected the skin from the underlying tissue. As I used 2% xylocaine with 1:80000 adrenaline, there wasn't too much bleeding, but still a fair bit...being quick helps! Using 3/0 monofilament non-absorbable sutures I set to work. I used a vertical mattress suture in the centre to pull the wound together (most of the way), then using the rule of halves, placed the rest of the sutures (simple, interrupted). I must say that human skin is much more resiliant than you would initally think, but much easier to handle than the pork trotters and bellies I have practiced on. Happy I was doing well, Dr F left me to finish up while she saw some patients. I tried my best to place even sutures tension wise (I put a few more in the middle as there was a bit more tension on the skin there). I removed that original holding suture and replaced it with a simple suture, tidied the ends and cleaned the wound site. I placed a few steri strips for extra hold (it was on the proximal anteriolater aspect of the leg) after I swabbed the site with betadine. I am paranoid about wound dehisence or infection, so after I was sure Dr F was satisfied, it was dressed and a water proof covering was added and the patient was instructed to leave them covered for at least two days and that they will need to be removed in two weeks. When tying I used 5 throws (2+1+1+1). I think they normally don't do the last, but as I said, I didn't want dehiscence. My only regret is that I think I may have actually tightened the sutures too much (too much tension) and considering, they will be left in for 2 weeks. I am hoping the tissue doesn't become necrotic, but I am expecting cross-hatch scarring. I hope not, but it probably will happen. I hope I am there in 2 weeks when he comes for the removal of stiches...I will give the verdict then.

Dr F asked me this afternoon if I could remove a small, but troubling lesion on her wrist for her tomorrow. She must have some confidence in me!

A great "hands on" experience

Yesterday I had another full day with the GP I have been with for the last week (my supervising GP is on two weeks holiday). She is fantastic, unlike my official doctor Dr M (M for male, F for female) who has been a GP for 20 or so years, Doctor F is a relatively recent graduate (FRACP for about 5-6yrs). She is very knowledgeable and is very good at mental health, antenatal care and technical procedures, though if doesn't know the answer to a question she looks it up straight away. I really appreciate how she involves me in the consult and asks my opinion. Rather than me just being a spectator, then asked a difficult question in front of the patient to make me look stupid (pimped to boost the doctors ego)

Anyway, yesterday I was giving a bunch of different injections in adults and kids. Apart from putting about half a varicella vaccine intradermally (forming a bleb under the skin) because an untrusting mother (who's baby cries at the doctor just listening to his chest or touching his ears), let her little boy squirm and the sub cut injection almost came out - needle stick city for sure - I did OK. And bless the elderly gent with numerous skin lesion (and multiple past excisions) who offered for me to cut out a rather large SCC from his right leg. He is booked in for Thursday when Dr F can supervise and guide me... awesome! He also had a benign, but large and irritating skin tag on his back which was causing him grief. Dr F explained it was harmless but it could be removed, but unfortunately she was too busy today. She did however say that if he was happy with it, I (Kaydon) could remove it now. He said it would do HIM a favour! So while Dr F was seeing patients, with the assistance of the practice nurse (I suppose it will pass, but at the moment I feel guilty with someone running around and setting things up for me and fetching things when I need them), I anaesthetised the skin and then cut of the tag. The wound was very shallow, so didn't need to suture it and the nurse put a dressing on it. I will review it on Thursday when I take out his SCC.

Afterward as I was about to leave, I popped in to talk to the nurse in the treatment room and there was a patient who had been waiting for a fluvax for 30mins but his doctor still hadn't checked it, so Dr F came and checked it and I quickly gave it to him (as the nurse was busy cleaning). I told him about potential side effect (local and systemic reactions) and he was very grateful that I could help him as he was in a hurry to get home. Wow I was actually useful! What a fantastic day.

My General Practice experiences

This post is actually a completely rewritten post that started along the lines of "So I am now two weeks into my GP rotation..." Well now I am about to start my fifth, I WILL actually complete it.

I have had highs and low with this rotation but overall I have enjoyed it. My psych rotation has come in handy like expected (I am not nearly as anxious about the concept of anxious/depressed patients or the schizophrenics and borderlines which tend to be more prevalent in the community than I once realized) but I sooo glad to be actually physically examining patients again.

So what have I been doing? Off the top of my head

• I have been giving injections - I have immunized a bunch of kids and a few adults,
• Syringed out a few ears and done basic physical exams.
• Frozen a few skin lesions (cryotherapy)
• Examined a few babies (youngest 15 days old) for hip problems etc - narrowly missed being peed on.
• I have observed a few excisions, and I have practiced excising and suturing on a pork belly and hopefully I will get to do one on a real patient soon.
• Learnt about how that sometime treatment require perseverance and ultimately good luck

I enjoy the fact that almost anything can come through the door. It keeps you on your toes. I really like the mix of counselling, reassurance, education, procedures encompassing follow-up, preventative medicine and immediate management.

Psych - A conclusion

I have finished my psychiatry rotation. I received excellent consultant and patient interview marks - though I am unsure about how I fared in the viva or the final exam. All in all it was a fantastic experience and I thought it was well run and gave me a pretty good peak into the world of mental illness. I enjoyed the luxury of being able to hypothesize/formulate how a person got to where they were in life. As I have eluded to previously, I definitely see how the skills I have learned will help me with patients from any background. I would like to do a psych term as a registrar in the future, but I doubt I will have the time...ohh well. Onward with my general Practice rotation..where I actually get to touch patients!