Do You Feel Ready?

What kind of question is that?

If you’ve ever sat an exam at any point in your life, you’ll have had to answer this question. It’s a universal attempt to make conversation with someone who can’t think about anything but their imminent nightmare. And it’s usually said with a half-joking, half-grimacing smile, because everybody already knows the answer: no, absolutely bloody not.

But instead of being honest, the reply is always a strained and panicked laugh followed by that classic line, “Ready as I’ll ever be!”

After that, the conversation stalls uncomfortably. Because you’re not ready, you never can feel ready. And instead of alleviating your anxiety, your friend has just drawn your attention back to the wild sense of helplessness. And you can tell that they don’t know why they asked.

And yet we all continue to do it. I move about the university before exam week alternating between lying about my preparedness and asking colleagues about theirs, perpetuating this blatantly transparent veneer of professionalism and calm. It’s a strange, frantic, surreal period of time where everybody does their utmost to appear as if they’re holding it together, even though we’re all very well aware that the world is falling apart.

Now that we’re in third year, the professional exam routine is quite familiar to us. We’re well-practised in finding our way to new exam venues, knowing what to bring with us, reading the seating plan, filling in the forms, and identifying notoriously stressy classmates to stay away from. We know how to pep-talk ourselves and how many minutes before the exam is optimal to wee. We know the rules of the exam hall and the format of the questions, and how to budget our time. It’s still utterly terrifying, but at least its vaguely familiar.

In early December, however, we encountered the most terrifying thing any sentient animal can ever experience: change.

This was the first OSCE we’d ever sat. An Objective Structured Clinical Examination is an assessment format used by all branches of health sciences to test their students on skills not adequately demonstrated on paper. They often take the form of simulated clinical scenarios where the examiner watches the student carrying out tasks, and assesses their competence.

We’d been provided with a list of skills that might be tested in this OSCE, which included open or closed gloving, scrubbing for theatre, sterile gowning, surgical knot tying, suturing, and knowledge of surgical instrumentation.

And so the night before the OSCE, Rowena and I turned the flat kitchen into a surgical theatre… of sorts. For the entire evening we repeatedly squeezed into rubber gloves, stitched oranges back together, scrubbed at the sink, and tied knots. Our bewildered flatmates kept coming across us walking about with our dressing gowns on back to front, gloved hands aloft to maintain their imaginary sterility.

Whoever suggested that oranges are an accurate replacement for mammalian skin was clearly high as a kite. The first problem we encountered was that any pressure applied to the orange sent it rolling away across the table. I haven’t spent decades of my life in a surgical theatre, but in my short time I’ve yet to see a surgeon chasing their patient around the table quite in the same way I did.

Not only that, but orange skin isn’t a resilient material, either. Every time I’d go to tie a suture off, the material cheese-wired through the skin and the entire thread came out. The only way around this was to create great big loose sutures that wouldn’t have a hope in hell of keeping a wound together in a real animal. But it was still good practice, I’m sure. One thing’s for certain… it was hysterically funny.

Gloving in particular was very frustrating. You might recall from this previous blog post that from the start, gloving has had one up on me. In our surgical kitchen, I repeated the process time after time until I couldn’t get it wrong. That is, until I started missing the thumb capture again and the whole thing descended into rubbery stretching and squeaking with no real progress into the finger holes. At least my gloves stayed intact. Rowena managed to tear her pair at one point with an impressively loud snap. Unlike me, she’d acquired a spare pair… which she also snapped. In summary, everything was boding well for the next day’s exam.

I turned up outside my allocated room at my allocated time with my small allocated group. This was a holding room, where we would put scrub tops on and read about the simulated scenario before they moved us through to the exam room.

I gave the scenario a once-over. Then a twice-over. And then a third time. And a fourth. For some reason I felt like I needed to memorise it, or that the more times I read it the more clues I could get about how not to bugger the whole thing up. In summary, a dog has turned up at the clinic with a small laceration. You should assume the animal has been anaesthetised, and that the  area has been clipped and surgically prepared. You should imagine that you have performed scrubbing, and behave as if you hands are aseptic. On the first station, you will perform the open gloving technique. On the second station, you will place a single interrupted suture in the laceration.

Pull some gloves on, put a stitch in. That sounds very manageable.

Finally, reading time was up and we were instructed to follow an invigilator through to the Clinical Skills Lab. On the way, I noticed people tucking their scrub tops into their trousers. What the f-

Well I ain’t taking any chances, so I tucked mine into my high-waisted jeans, and continued down the corridor like I’d strolled out of the wrong decade.

The outer edges of lab were divided up into cubicles by the rolling screens you see in hospitals and airports. They took my name and sent me to the one in the far left corner. We’d been told to wait for the buzzer before we entered the cubicle. I stood outside my cubicle and saw the scenario Blu-Tacked to a screen panel, and began to read it again just in case. But the buzzer went off, and I made a startled scurry into the cubicle.

The examiner looked up and said, “No, don’t come in yet, that’s the start of your reading time!”

I had no idea what she was talking about, but hurriedly reversed out of my cubicle again, and spotted others trying to reverse the same mistake as me. A big countdown clock on the wall was reaching 10 seconds – presumably what was left of my reading time. It hit 0 and the buzzer sounded again so I, more cautiously, re-entered the cubicle.

The examiner opened the sterile glove packet and offered it to me, “Whenever you’re ready.”

I reached out to take the wrapped-up gloves from inside, and was met quite suddenly by a wave of apprehension. It was critical that I did this whole thing without breaking asepsis. It sounds so simple, but it’s so damn easy to touch something to something else and not even know you’ve done it. My solution was to go steady and watch all parts of my hands, body, the gloves, packet, and the table to ensure nothing got contaminated. But because I’m not a chameleon and can only look in one direction at a time, I just ended up moving in slow motion, like some ridiculous spoof of Casualty.

After laying the packet on the table and folding it back under itself with the utmost care, I reached across and pinched the inside of the first cuff. The tension was unbearable. This is where it usually goes completely pear-shaped. I cannot afford to miss the thumb capture, because then I can’t go back.

To my absolute amazement I caught the cuff, and used it to put on the other glove. My performance was rounded off with a satisfying snap of rubber against skin.

I could feel the moronic smile on my face as I looked up at the examiner and said, “They’re on!”

She smiled condescendingly, “They’re on!”

“Ha. They’re on!” I repeated myself in disbelief.

“Yes, they’re on,” she got caught in the conversational loop, “You can go and wait at the next station now.”

I left the cubicle with my gloved hands clasped in front of my chest – a position that prevents contamination. As I waited outside the next cubicle, reading the scenario yet again, I began to doubt my gloving. Maybe I broke asepsis and didn’t notice. That would be an automatic fail because not only would I have screwed up, but I didn’t show any ability to realise that I’d screwed up. Crap.

The buzzer went off and my rumination was interrupted. I strode into the cubicle with my hands clasped in an exaggerated position to show my next examiner that I could stay sterile. I steeled myself for the next task.

“No, not yet. Please wait outside.” he didn’t even look up.

For God’s sake, why did I do that again?

On the second buzzer, I repeated my grandiose entrance. The examiner was waiting with a clipboard and a bland expression. Nice.

“Please place a single interrupted suture using the appropriate instrumentation.” he instructed.

The table was covered by a large green surgical drape. In the window in the middle was a lacerated synthetic skin pad. To my right, suture material and surgical instruments were lined up.

From the selection, I identified a pair of Mayo Hegar needle holders and a pair of rat-toothed forceps. I took care to arrange my fingers around the instruments in the correct grip, and used the needle holders to extract the curved needle and its thread from the packet.

Rechecking my hand grip and adjusting the holders so that they gripped precisely two-thirds of the way down the needle body, I picked up the far edge of the wound with my forceps. I chose what I thought was an appropriate distance from the wound margin to puncture the skin with the needle, and pushed it halfway through. Then I went to release the holders so that I could re-grasp the needle on the other side and pull it all the way through.

The holders wouldn’t let go.

Damn it. The right-handed needle holders require some strange manipulation to unlock them when used in the left hand, and I couldn’t quite do it. And with the examiner breathing down my neck, all my hands wanted to do was tremor. Mentally effing and blinding about my cack-handedness, I did eventually unlock them, and pulled the needle through. I repeated the process on the near wound margin.

Next I went to form the first knot, and debated extensively about what the right amount of tension would be for this suture. After meticulously adjusting the tension of the first knot, I quite honestly just threw the last three on, because God knows I just wanted to get it done.

Once tied off, I had to reach my left hand over the top of my right to get some Iris scissors from the instrument line to my right, and immediately regretted it. My arms aren’t sterile. What if my glove touched my arm and I didn’t realise?

I was so preoccupied with this potential hazard that as my hand came back into position, the curved needle I had put down on the drape snagged my glove, and I had a moment of poorly-suppressed panic as I rushed to unhook myself. For reasons I will never understand, I didn’t flag it to the examiner as a potential break in asepsis. Idiot.

I estimated the right length at which to cut off the excess suture and went to cut. But the bloody scissors wouldn’t cut, would they? I sweated a bit and then tried again with a bit more gusto, before realising I was using the wrong hand. I gave the examiner a quick embarrassed smile before swapping the suture and scissors between my hands, and this time the cut was clean.

Replacing the scissors and suture on the table, I stepped back and looked at my examiner. His face was expressionless, “Thank you, you may go now.”

I did, very quickly. In hindsight both of those were straightforward tasks – other skills could have been far harder. But in the moment you don’t half overthink it.

The following week was lecture-free, and our cue for the final push in revision for exam week. It’s consistently a terrible week, with all sense of time and proportion lost in the innumerable pages of stuff to learn. As a collective whole, the cohort becomes an exhausted and stress-wired bunch with as single-minded goal – just pass the damn exams.

The general strategy we were using was to abandon Pathology with its 50 hours of lectures, and focus solely on Clinical Foundation and all its topics. Revision for Rowena and I, and the vast majority of our colleagues, had begun a solid month earlier. This week was the last opportunity to cement that knowledge. But what you find is a heartbreaking realisation that the material you revised so hard four weeks ago has since sieved away in the tide of new information still being taught. Drug tables that I had memorised detail upon detail were suddenly half empty when I tried to visualise them in my mind. I’d see drug names that previously I could have written paragraphs about, which now I couldn’t even identify as a painkiller or a parasite killer. It makes you want to cry.

And you do. There are moments at the 14th consecutive hour of sitting at your desk where you just don’t feel like you can win this one, and you have a really good damn cry. You let it have its five minutes, get it out in really filthy language and an appropriate level of violence, and then sit your ass back down and carry on.

And you keep doing that day in, day out, until the deadline hits and you have to accept that what you already know is all you’re going to walk into the exam with. You’ve done everything you can.

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Monday’s exam was a series of eight questions worth 50% of the final mark. There’s ten marks available for each one, and ten minutes to answer it. I know a lot of people approach these SAQ exams by reading all the questions and starting with the ones they’re most confident about. This is a smart strategy, because you gain the marks quickly on the stuff you know well, and leave the ones you’re less likely to get marks on until the end. But for whatever unknowable and probably ridiculous reason, I don’t like that. I like to start at question one and just complete the paper from front to back. Besides, I’d rather not  know what’s coming.

This paper covered a lot of topics. There were questions about about the safety mechanisms of anaesthetic machines, using Propofol in cats, a comparison of anaesthetic monitoring in dogs and horses, a nice one about drug resistance in bacteria, and a terrible one that listed four drugs found in a parasiticide combination for cats, and asked for details of their mechanisms and pharmacokinetics. I’d only heard of two of them.

Diagnostic imaging had a question about interpreting periosteal reactions on radiographs, surgery asked about the different methods of ligating haemorrhaging blood vessels, and oncology asked about the classes of chemotherapeutic agents and managing their side effects. I walked out without an inkling either way about how it went. But never mind, keep going forwards. The following morning was the Clinical Foundation multiple-choice paper, which meant that we had Tuesday afternoon and Wednesday to revise pathology for every body system, and every species, in time for Thursday and Friday’s exams.

Cramming is not a good idea, but sometimes there’s no choice, and it was everyone’s intention to cram pathology. But with all the good intentions in the world, and all these plans about getting home and starting immediate intensive pathology revision, it’s a bit harder than it sounds. The adrenaline high that propelled you through the day’s exam fizzles out, and the only thing your knackered mind wants to do when you get home is to crash and sleep indefinitely. We knew we had less than 48 hours to revise all the pathology taught across the whole semester, but my God when your mind doesn’t want to engage, it just won’t engage.

The pressure is on, it’s crushing, and its inescapable. We’re racing against the clock. And we’re among the best at turning that pressure into productiveness. But I just spent hours staring at my pathology notes. Willing my mind to process something. But it was like pushing against a brick wall – there was no response at all. Just blankness and silence.

With time running out, no progress being made, and so much at stake, frustration builds quite quickly into anger.

So Rowena and I sat at the kitchen table to revise together, as we had often done for pharmacology. We generated diseases from a list at random, and tried to recall everything we knew about that disease from memory before checking it against our notes. But even with our ‘shortlist’ of the most significant diseases from the course, there were still over 190 of them, a number that felt insurmountable in the time we had left. We spent almost as much time reassuring and supporting one another as we did revising, just to contain the panic.

Pathology had an MCQ on Thursday and an SAQ on Friday. The SAQs were very different to the ones we’d done before. They provided a photo of an organ and asked for a description of its abnormalities, suggestions of possible diagnoses, and a discussion of those diseases. There was canine liver cirrhosis, pituitary adenoma, atrial haemangiosarcoma, splenomegaly, and pyomtera; urolithiasis in a wolf; pyothorax in a cat; Johne’s disease in cattle; and white muscle disease in a pig. I’m not going to lie, of all the exams we sat that week, I rather enjoyed pathology.

And all of a sudden, it was over. For the first time in months, the weight of the course had lifted. No deadlines, no pressure, no work. Just freedom.

That gnawing, buzzing, scratching anxiety and invasive fear of failure was gone. The world went from grey to colourful, and I had literally no idea what to do with myself. Every hour of every day had been spent revising. What now?

Well, that evening Rowena and I tried a Malaysian restaurant just down the road, and then returned to our beloved sofa with a film and a whiskey (or three). How wonderful it was just to do nothing.

I can safely say that after three weeks off over Christmas, I am most certainly no longer doing nothing. The new year has seen the beginning of the ‘real medicine’. We’re covering specialities of medicine faster than I can process them – it’s insane. And I love it.

A couple of weeks ago I received my results for the December exams. To my great surprise I passed the OSCE, received 85% for Clinical Foundation, and 93% for Veterinary Pathology. Believe me when I say I have absolutely no idea how that happened. But it did, and I doubt it will happen again!

I’m now past the halfway mark in vet school, which is an enormous deal in its own right. Next time I get a chance to breathe, I’ll let you know what exactly has been keeping me so busy this January. For now, here’s the token Christmas Market selfie to show you that we do also make time for fun.

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