A Fair Rate Of Knots

Cancer is categorically not funny – and yet somehow I found myself two solid hours into a morning of cancer management lectures absolutely riveted, and laughing unashamedly. And it’s all down to the lecturer.

Our head of school is one of only a handful of board-certified companion animal oncologists in Europe. He holds the highest position of authority in the vet school, and has reached an outstanding level of expertise in his field. But when you meet the guy on the stairs, he’s the one to move out the way. He frequently conducts meetings in the open and relaxed atmosphere of the student cafe. He attends all the vet school balls, fundraisers, and Burn’s Night events, always with an outrageously funny speech to give. He knows all the particulars of the vet student experience; all the things that we enjoy, the things we struggle with, and the things that really get on our nerves. He has a straightforward and no-frills attitude to teaching: we get the information that will be useful, the context to help us assimilate it, and he cuts the superfluous and academic detail to make room for a solid understanding that will make us good at what we do. Everybody in the lecture theatre is very well aware of his qualifications and expertise, and yet he never feels the need to remind us of it. In fact, he actively rejects the notion of trying to be clever for the sake of it, and openly admits when something is beyond his scope of skill or understanding. He has nothing to prove.

That seems to be the trend at the moment. In the first year, and much of second year, we were taught by people with a variety of qualifications, who were not necessarily specialists in the field they were teaching. Many of them were outstanding lecturers, and I miss seeing their names on my timetable. But I frequently got tired of those lecturers who used long and complicated ways to communicate relatively simple concepts, who felt the need to be icy and unhelpful to assert their authority, and who included vast quantities of completely useless detail to show off whatever it is they’re researching.

This year, we’ve had far less of that. In the human medical world, there seems to be a pretty tight correlation between level of expertise and level of arseholic behaviour. But in the veterinary world, I’m not seeing that trend. This year’s lecturers are all senior lecturers and specialists in their subjects. We’re taught pathology by pathologists, anaesthesia by anaesthetists, surgery by surgeons, radiology by radiologists. And for the most part they have their feet on the ground, and no superiority complex. They speak to us like colleagues instead of students, and they’re keen to help us retain and understand the material. They’re passionate about what they do, and they’re sensitive to the enormous pressure we’re under. It’s liberating.

I can’t lie, I spend many lectures holding my eyelids open, or giving up and letting the material fly right over my head. There are some God-awful lecturing styles out there. Many lectures are dry and difficult. But many lectures are engaging, funny, and genuinely quite enjoyable. The head of school’s cancer lectures are among those.

And so after a morning learning how to manage cancer patients, and a confusing but strangely enjoyable lecture on neuropathology, I trotted off to the clinical skills lab to attend something titled “Hand & Instrument Ties”.

I got my scrub top on and took a seat with a bit of excitement – this was the first time I would get to use my own suture kit. A woman came in and introduced herself as a surgical resident over at the Hospital for Small Animals and put something down in front of each of us. It looked like something you would use to develop a baby’s motor skills, or to test the IQ of a parrot.

knot-tying

She wasted no time showing us the principle knots that you can achieve with a needle-holding instrument. They were knots we’d all seen surgeons complete a million times during EMS and work experience, but things somehow got drastically more complicated once we were on the other side of the needle.

My first instinct was to pick up the needle holder with my left hand and set off trying to do the knots the opposite way to how she had demonstrated. But the needle holder was a bit awkward, and didn’t want to be held or used the wrong way around. And so I switched it over to the right hand. Now the needle holder was happy, but my hand sort of wasn’t. I debated internally for a bit. The Veterinary Teaching Office refuse to provide left-handed instruments because they believe that left-handed students should learn to do surgery right-handed. Their rationale is that future employers won’t provide left-handed instruments (however I believe this to be generally bollocks). I know many right-handed people who can’t use a spoon properly with their left hand. May I ask how we’re meant to perform surgery with the wrong hand?

My debate was interrupted by the teacher asking if anybody was left-handed. My offending hand raised guiltily – the only one in the class. I was kind of expecting her to tell me I had to do it with the instrument in my right hand, but instead she said, “You learn to do this left-handed, because that’s what works for you. Get yourself a left-handed needle holder and take it with you everywhere. Get the hospitals to sterilise it for you. Do it your way.”

I was pleasantly surprised by her message, and almost taken aback by the assertiveness with which she said it. I responded, “But the VTO won’t let us have-”

“Never mind the VTO. Buy one from another supplier, take it with you on EMS, take it with you to all of your jobs in the future. I have a friend who does this.”

Confident that I should just do this my way, I wrangled the stubborn needle holder and carried on. The hook on the bottom left of the board allowed us to practice knots used in superficial, easily-accessible tissues like closing the skin. On the bottom right, the hook has a guard around it, to simulate tissues deep inside a body cavity, where you have to use a different technique. The two bands across the top allowed us to practice tying the suture material with our hands instead of an instrument. For some reason, I assumed that using your hands wouldn’t be a lot different to using the instrument. I was wrong.

The hand ties were odd and not all that intuitive, even though they produced the same finished knot as the instrument ties. The upside was that the majority of the hand tie manoeuvres are performed with the left hand – I was at an advantage.

The teacher asked us to rotate the board by ninety degrees to simulate the patient being in a different orientation. The change in orientation threw us off completely. We had all just about got used to where our hands were going, and now they had to go in altogether  different directions. My hands were doing some funky Macarena type stuff when the teacher made an offhand comment.

“If ever you’re doubting which direction you’re alternating to, have a look at the knot and see which way it’s wanting to go.”

The second I began doing this, something seemed wrong. On the very first ‘throw’, I was pulling against the natural grain of the knot, and it didn’t sit flat on the rubber bands. I’d noticed this earlier but assumed it was correct, because it was what she taught us. But it was definitely not the way the knot wanted to go.

I tried to bring this up with her, but if you’ve ever been taught a knot, you’ll know it’s awfully difficult to verbally communicate about what your hands are doing, and when you try and watch each other, you don’t know where to put your eyes to understand what’s happening. We entered a circular conversation that wasn’t producing anything useful.

So I tied the first throw the way she’d taught us. Then next to it I tied a similar knot that lay flat.

“Which one should I see when I complete the first throw?” I asked.

“That one.” she pointed firmly to the flat knot.

I pointed to the skew-whiff knot, “But that’s what we get when we do it your way.

I was nervous that this was starting to sound obnoxious. She paused for quite a while.

“Yes, you’re right.” she said, “That’s why I always start with the thumb on the first throw instead of the finger. If you were ligating a blood vessel, that would never be secure. But that’s the way I’ve been told to teach you.”

Aha, now we agree. So her bottom line is what, that this technique doesn’t work but she’s obliged to teach it to us anyway? Something isn’t right.

And so I messed about until I found a way to edit the technique so that the knot lay flat. Although it might not hold water in the exam, I was happy that I would use my technique in my surgical career.

But it later transpired, after talking to people from other classes, that our teacher had in fact ballsed up. She’d managed to create some odd hybrid between the technique she uses hundreds of times a day, and the technique she was taught to teach us. Ace. I have handed the matter over to the surgical teaching team to decide what they’re going to do about the entire class of vet students currently doing it wrong.

Tuesday and Wednesday of that week saw a bunch of lectures on surgical suture materials, neuropathology, and paraneoplastic syndromes in cancer patients… all of which I reluctantly swept under the rug so that I could keep plugging away with the revision for Thursday’s exam.

When the exam came around, we were supposed to be completing it on lab computers under exam conditions. It took the invigilators quite a while to realise that the system wasn’t working, and so we all sat around like nervous lemons while the IT team scurried around trying to fix it. When these incredibly brainy people had declared that they couldn’t get it to work, the invigilators reappeared with paper copies of the entire exam. I don’t know why we didn’t just do that in the first place.

There were 30 multiple-choice questions, covering anaesthesia, pharmacology, diagnostic imaging, clinical oncology, and general pathology. All of the questions fell into two categories in my mind; either I knew the answer immediately (or thought I did), or I had no idea and couldn’t even make an educated guess.

One question in particular gave us the half life, volume of distribution, elimination rate, and desired plasma concentration for a particular drug in a particular animal of a particular species. Then it asked us to calculate the dose to be administered. Fortunately, I remembered the equation for this, even though it unnerved me that I didn’t use all of the values given. Are they distractors? Are they relevant? Is it a trap? Am I just stupid?

I ran the numbers through my calculator. Then I did it again. Then again just in case. 5400mg. I looked at the options… they were all in the region of 20 to 150. Hmm.

B was 54mg. Maybe I’m just an order of 2 out. Maybe I’ve dropped a couple of decimal places getting lost between litres, millilitres, micrograms, milligrams, minutes, and hours. Whichever way I worked it, I couldn’t get 54, always 5400. Time’s running out, I had better just go for 54mg.

In the review the following week, it transpired that they had withdrawn that question, because the correct answer wasn’t in the options. The correct answer was 5400mg.

It also transpired that I knew a few more of them than I thought – because I finished with a percentage score in the high eighties. I can’t see that I’ll keep that up for very long.

With the exam behind me, I looked forward to the weekend. Believe it or not, we’re already halfway through the first semester, and that can only mean one thing… the clan are coming North!

That Saturday, we packed in a whole lot of fun. Our visit to the National Museum took in the Nature, Technology, and Scottish history sections. I’m not actually convinced that I’ll have seen every part of that museum by the time I graduate – it’s enormous.

You can take the fam out of Yorkshire, but you can’t take Yorkshire out of the fam, so it was off to Gregg’s for lunch, and a scoot up the Royal Mile to the Museum of Childhood. Apparently grotesquely deformed brachycephalics have always been quite popular…

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After a good few hours ripping the mickey out of my Dad’s age, we popped into a year-round Christmas shop, got absolutely outraged by the price of everything, and promptly left. ‘Tis the season to be extorted. On our way back to the hotel, we took a chance to appreciate how different my city looks with a bit of sunshine from the heights of North Bridge, and popped into a local crafts market.

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I didn’t see much of them on Sunday, but by ‘eck had we done so much the day before that I couldn’t complain. It doesn’t make saying goodbye any easier, though.

But there was no time to dwell, because last week rattled by with many, many, many more lectures on surgical materials, musculoskeletal imaging, airway management, analgesics, fluid therapy, radiotherapy, haemolymphatic pathology, epidemiology, autonomic pharmacology, anaesthetic pharmacology, and a nice juicy pathology practical full of diseased hearts and lungs.

Last Friday, I rounded off the week with a practical on large animal clinical skills. I was again pleasantly surprised by the luxuries bestowed upon third year students – the skills lab by the large animal hospital was actually heated. Given that it’s currently -2 Celsius outside, that was an unexpected and much-appreciated blessing.

I spent the session trotting around the lab from fake horse to fake cow doing rectal exams, drawing blood from tails and necks, pumping oral fluids down throats, drawing up and administering drugs, and all the other things I’m going to immediately forget how to do when a real large animal is put in front of me.

I constantly surprise myself with my own ineptitude. I’ve come to realise that everything that everybody does is harder than it looks. There’s always more to it that you think. I get instructions for a task and it looks relatively straightforward. And then I attempt it, and things go wrong that I could never predict would go wrong. I have a talent for coming up with novel ways of screwing up straightforward tasks. I had literally just responded to a teacher to say that I would do a vaginal exam before a rectal to minimise cross-contamination, and then immediately proceeded to shove my slippery gloved hand right into the simulator’s anus. Excellent work.

Only minutes later, a teacher handed me a horse-measuring stick, which I genuinely do know how to use. But under her watchful eye, I failed to fully extend the stick, failed to get the spirit level level, took my measurement from the top of the indicator instead of the bottom, and then failed to recognise how unlikely it was that this horse was eight feet tall. What are you doing, you clown?

When I look around the room and watch my colleagues, I feel a little less stupid. Everyone makes these mistakes, and we’re often being asked to do very tricky things. But I’m a bit different, because over the last two years I’ve lost any remnant of inhibition and now just launch myself into tasks to make sure I have a go. I’m that person that everybody watches make a complete fool of themselves, before noting what not to do and having their turn. I consider it to be a public service.

That brings us to the weekend. The weekend which I spent chipping away at the sizeable pile of lectures I neglected in order to make room for revision. It’s Tuesday now, and I’m spending my evenings writing up the day’s lectures, and then seeing if I can fit any more extra ones in before bed. Slowly but surely the pile is shrinking. Whether the information is actually seating itself in my head is another matter, but at least I feel better about my situation.

Please do join me again in a couple of weeks. They’re set to be absolutely rammed with lectures and a couple of practicals. But more importantly, there’s Halloween, a charity rugby match, and Bonfire Night. I cannot wait – see you there!

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