The lady in bed 9

Standard

Medical simulation… There is a lot of money being spent on it. It does have some benefits. But it seems very clear to me that the benefits are now being exceeded by the desire to simply sell a new toy to make money for dubious benefit. Although it might not be a bad idea to put one or 2 in a prison recreation yard.

This fine piece of “simulation technology” has just demonstrated that beyond doubt…

http://dangerousminds.net/comments/meet_patrick_the_robotic_proctology_simulation_ass

But as I was making fun of this on Facebook this morning, one of my friends and medical colleague was kind enough to post this:

http://www.pennstatehershey.org/web/educationalaffairs/home/aboutus/services/standardizedpatient

It sort of made me feel bad for all the people working in strip clubs…They really should look into this form of employment. Not only is it less stigmatic, they could put on their resume they were employed by a medical university…Probably doesn’t pay as well though…

But aside from my off color jokes, it is certainly superior to a plastic ass connected to a tv screen and a laptop.

I eagerly look forward to the setups they market for gynecology and urology… I also wonder if there are any hidden “Easter eggs” programmed in? I can just imagine the response to the voice recognition of “My Patrick, your hips are very firm today.”

I will admit when I was in medical school we did have a couple of hours with some plastic strap on breast designed to teach breast examination techniques and findings. While it was certainly entertaining, the educational quality was dubious at best. There are even some pictures of our “educational” experience that I am sure patients would rather not see.

Not to sound like too old of a guy, but there is no substitute for actual experience no matter what your simulator sales rep or the person getting paid to run your sim center says. I think this clip sums it up well…

https://www.youtube.com/watch?v=MR0yVEqJEYw

Of course when I saw this simulator this morning on several pages, I made several of the comments you see here. But I was also reminded of an experience I had when working at one of my favorite jobs. It is also one of the stories I can actually tell at parties without making people think I am psychotic or throw up.

I worked the weekend night shift at the time, 12 hours from 1900 to 0700, Friday, Saturday, and Sunday, every week. For those of you who never worked night shift, we are a different breed. Political correctness and proper decorum are relevant. We are self-reliant and generally goal oriented. (With one of the goals being to make sure we do not burn down the building before all of the “normal” people get back to work in the morning. As such we are also a very tight group. In fact, no matter where you go in the world, night-shifters see eye to eye and even share the same jokes and virtues.

I was at work one summer night, I don’t remember the exact day, but I would bet it was sometime in July, for reasons that will become evident. Trauma season was in full swing. Motorcycle accidents, shootings, beatings, rock concerts, you name it, a majority of the shift was spent in the trauma bays. “Lunch” was usually a piece or two of cold pizza left in the box because nobody else wanted to be the person who took the last one.

As I was returning from a trauma patient to the main part of the emergency department to see what backlog of non-trauma tasks I could help with, I walked past room 9. The door was closed and the curtain was drawn. I was tired and I heard a lady scream. I paused for a moment, attempted to rationalize to myself that I was not assigned to room 9, and that one of my colleagues was probably in the room or knew more about it than I did. I then heard the scream again. Whether it was the desire to provide aid and comfort to a person in need, a duty to help all patients in the department, perhaps lend a hand to a comrade in arms, or just morbid curiosity, I could not say. But ignoring my experienced skill of walking with my head down and moving with a purpose, pretending not to see or hear that which did not immediately concern me, I opened the door and peered behind the curtain. My eyes were met by a middle-aged lady laying in the bed wearing only a hospital gown, her legs spread wide apart, and her looking at me like I was the only one in the world who could save her now. Standing next to her was a person wearing the sky blue surgical scrubs from surgery or that we in the ED would frequently “borrow” from surgery. This person was wearing a surgical mask with a face shield and had an open Foley catheter kit on a tray and the actual catheter in his hand.

I did not recognize this person at all, which is highly disconcerting given that our colleagues at work are also our friends outside of work. We go to breakfast together after work, we went drinking together, went to parties and events at each other’s houses, and there were more than a few couples formed. In my all business like, goal oriented tone, I simply asked “who are you?”

This person then lowered the catheter and his mask, and stated the most obvious fact of the night to me “I don’t work here.” I thought the patient was going to faint, but he continued on…”I am from surgery, I am one of the new residents, and I am not very good at putting in Foley catheters so my attending physician (consultant for the UK folks) told me to come down here and practice.”

My next question to this doctor was “does anyone know you are here?” With a look that seemed like he did not grasp the importance of this question simply said “no, why?” After what I would say was “politely” informing him that he cannot wander around to different departments performing procedures on patients at his leisure, he seemed a bit shocked by my revelation. Being focused on him, with my bullshit tolerance level running low, I can only imagine the look on the face of the patient who was witness to all of this.

Seeing this as just another problem to be fixed this evening, I told him not to touch anything or anyone until I got back. I left the room to find one of the boss-type people to inform them there was a stranger in the department dressed in scrubs, and let them know I would take care of it. The only person I could find was one of the emergency attendings, so I simply informed him there was a surgery resident in the department for procedures and I will take care of it. His response was basically, “do what you need to do.”

I returned to room 9 to find both the patient and the doctor frozen in the exact same positions I had left them in. So I first told him to go ahead and throw out the used catheter still limply dangling from his hand. I went and got a new kit explaining to him that now the old one was contaminated and some time had passed, we would have to start again. He looked extremely upset about what he perceived as the wasted kit. Next I asked him to explain step by step what he was going to do. He expertly talked about how to remove the lid of the kit, maintain sterile technique, scrub the site, etc. feeling comfortable he at least knew what he was talking about, I gave him the ok to begin. He did everything right without coaching under my watchful eye, and was now ready to insert the catheter. Before he did, I asked him to identify the landmarks and tell me exactly where he was going to insert the catheter before he did.

This is where things got complicated…

He described to me what I thought were superfluous landmarks, like labia, because what I was focused on was if he knew which hole was the correct one. He then identified the vagina and the clitoris, and I was just about to give him the go-ahead, but for some reason decided to ask the redundant question “where are you going to put the catheter?”

Thus far having been successful with no guidance or coaching he very confidently used his free hand to point to the hood of the clitoris.

In the split second it took my mind to process this, I immediately knew why I had heard the screaming.

This young surgeon was trying to insert a Foley catheter into the patients clitoris. But in one of those moments where I am tired, hungry, and my BS tolerance has run out, rather than say something educational, constructive, or even helpful, in my deadpan voice and sideways glare, I just blurted out “You don’t spend too much time down there do you?”

To which he bowed his head and shook it, indicating, “no” he did not have a lot of experience with female genitalia. The patient started to laugh uncontrollably. I took this as a good sign. A laughing patient never complains.

I then took the catheter from his hand and told him that he just needed to watch this one. After I had put the catheter in, he stated with amazement “it didn’t even look like there was a hole there!” and again I deadpanned, “that is why the urine stays in.” The look on the patient’s face was relief. The look on his face was awe and admiration.

After this I went on to draw him the anatomy, explain to him the common variances, problems he might encounter in both males and females, as well as what to do when they happened. We made sure with the charge nurse if any patient needed a Foley for the rest of the night, we would be called to do it. By the end of the shift, our young surgery friend could reliably insert Foleys into men or women. I was proud of my student, and everyone else just went about their business as if nothing was out of the ordinary.

Just another day, “living the dream.”

On my way home though, I remember thinking. That guy was a doctor. A surgery resident. He went to medical school, passed human gross anatomy, did years of clinical rotations. Probably used more than a few simulators, including the very same ones I learned my skills on! But in the end, when it was time to perform the skill on a real person, he could talk through every movement of the procedure, but not only could he not do it, he didn’t even understand what he was actually looking at.

But I also realized that the reason was not because of his individual ability. It could have been anyone; it could have been me, learning a procedure for the first time. The problem was not him or his deficiency, the problem was that there is no substitute for experience in medicine.

There are still things that I am not very good at. I need more practice. More experience, on real patients. One thing I have never done, but I am sure will not benefit my career or ability, is get real time feedback on my performance inserting my finger into a rubber asshole. But I bet somebody will spend a lot of money to make sure others get to do it. Oh well, at least they might take away where the hole actually is…

Let’s end this with a song?

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