 What is up guys? Karma Medic here and welcome back to another dose. In today's video I'm going to be talking about my last medical placement of my first year ever as a doctor which was in renal medicine and then renal transplant surgery. So by this point I had already done four months in geriatrics, four months in vascular surgery and now my last placement was split up into two two-month blocks which is quite rare for the foundation program but I'm happy that I got it because it effectively meant that I got two placements in one. So as you might imagine I'm going to split this video largely into two sections, one for renal medicine and one for renal transplant surgery. So for those of you who don't know, renal medicine means medicine of the kidneys and if you are a medical specialist in the kidneys then you are called a nephrologist which is named after the nephron, the single basic unit of the kidney which I'm sure you've probably studied at some point in biology class, I'll know later on years in university etc. Now my renal medicine placement was quite similar in big picture terms to my geriatrics placement which I have a whole video about that you can watch up over here so I'll go into a lot more detail about the renal transplant side of things but let's start off by talking about the team. So renal medicine was actually a huge team, we had two wards on the same floor next to each other that both had renal patients on them, one of the wards had a special bay for patients needing dialysis and the other one of the wards had special side rooms for patients who had received or were going to receive kidney transplants. Each of the wards had about 30 patients on them and then there were anywhere between 10 to 20 outliers in the rest of the hospital and so the number of staff needed to cover all those patients was quite large. We had a team for ward A, we had a team for ward B, we had a team for the medical outliers and we had a special team just for taking admissions for kidney patients coming in from A and E as well as the renal transplant surgery team. Each one of these teams having one consultant, one registrar and then several juniors. So when we'd have our handovers in the morning or our board rounds in the middle of the day we were typically about 15 doctors in the room on top of other staff like physiotherapists, occupational therapists etc. So what does renal medicine do? Renal medicine looks after patients who are having problems with their kidneys as you might expect. Largely speaking problems with the kidneys can be broken down into pre-renal, intra-renal and post-renal. So pre-renal meaning something before you reach the kidney that has affected the kidneys. This is typically something like hypovolemia or low blood pressure which means that you don't get enough blood perfusing the kidneys and it can cause injury. Intra-renal means that there's something in the actual kidney causing a problem. A lot of this can be reactions to drugs like interstitial nephritis, more auto immune diseases that can deposit all kinds of different things in the kidney causing problems. And then post-renal we would normally be talking about obstruction. So maybe you have a kidney stone that is preventing urine from properly leaving the ureters or you have a problem in the bladder that is causing back up or back flow of urine to go up the ureters to the kidneys causing hydronephrosis, anything like that. And then of course kidney problems can also largely be split into acute kidney injury or chronic kidney disease. As you might expect one of them has occurred in a relatively short period of time and the other one has been going on for longer. So let's talk about dialysis. Dialysis is something that I would see very very regularly on this placement every single day but it's something that I was very rarely involved in or made any decisions about. Dialysis is the process of filtering someone's blood outside of the body. So effectively doing the job off the kidneys in a patient where the kidneys are not working or not doing a good enough job of filtering the blood we do it using a machine outside of the body called a dialysis machine. In very broad terms you either do this using hemodialysis which is a machine that has a special membrane which can filter the blood outside of the body or you do peritoneal dialysis which is where you use a membrane inside the abdomen of the patient to act as that filter to help filter the blood. It also requires a machine to get the fluids pumping so that you can have that exchange of metabolites, toxins etc. Dialysis was pretty much completely managed by the consultants and the specialist dialysis nurses. Dialysis is an incredibly complicated topic an incredibly complicated process one that I certainly am not competent enough or don't know enough about to manage acutely and actively for a patient that's in front of me. What I can make decisions about is this patient needs dialysis they need off loading or they need filtering of their blood but I can't actually fiddle around and tinker with the machine in order to get it done. The reason for this is that it is so incredibly complicated there's all kinds of filtering speeds filtering pressures different dialysate or fluids that you can use depending on how much or how quickly you want to filter someone it's an entire topic that people study entire masters degrees for and they are the people who help take care of the dialysis but this is a good example of how much of a patient's management on these renal placements was completely out of my scope of practice and was left to the more senior members of the team like consultants or members of the team who had specifically studied and worked in this field and this brings me nicely on to my next point one of the biggest differences I found on my renal medicine placement was just how senior led it was and what do I mean by this what I mean is that the consultants lend all of the decision making and all of the treatment decisions that we would do for patients and then it was left to me to organize those treatment decisions or to enact those plans I wouldn't actually make them myself whereas on geriatric medicine or vascular surgery like I've talked about in the previous videos that you can click up over here a lot of the times it was just me seeing the patient having to make decisions about how to treat them and then I could go to my seniors for advice or approval of my treatment and management plans consultants on this placement were so involved in patient care that they wanted to see all of the bloods every single day they wanted to see all of the vitals and observations themselves with their own eyes and they wouldn't even trust us to say hey I think this patient is stable their hopes have been static for the last x number of hours or days or have reviewed their bloods their inflammatory markers are static their kidney function is stable but I think x y and z they would want to do all of that and see all of that for themselves now obviously renal patients are quite complex and they do require a lot of senior led input but the flip side to this is there were times when I was working on this placement thinking to myself what am I actually doing here because when this was going on I would only be responsible for typing down what the consultant was saying or what the consultant was doing and then later on going and doing all the things that they sense organizing their scans getting that treatment started getting their medication they need whatever it is and I felt what am I really doing here as a doctor on my previous placements I would go see the patient I would examine them I would take their history I would holistically try to figure out what is going on and then come up with a treatment and management plan and then act that plan so I felt like I was doing a lot of doctoring whereas on this placement certainly on the renal medicine side I really didn't feel like I was doing a lot of doctoring it was a lot of just doing what my seniors were telling me to do now I'm not saying that I was perfectly capable of managing all of these patients and making these treatment decisions that's definitely not the case but I think there is a happy medium in between you know being extremely senior led and basically having no input or advice or learning about what is going on with the patient and being left to manage the situation completely on my own what I would have really appreciated is if consultants and seniors took a little bit more time to talk to us about what is going on with the patient why they're making the decisions that they make and then next time they can maybe ask us hey what do you think we should do in the situation I could give my answer and then they could tell me why I've given a good management plan or why they think they would do something different and that way I feel like at least I would be learning a lot more about how to treat and manage these patients on renal medicine and you know me I'm not a shy person I was constantly asking lots of questions trying to get myself involved and trying to learn as much as I can but the honest truth is with the number of patients that we were seeing and how much we had to do I could barely keep up with you know typing and documenting everything that was going on and then having to enact all those plans for the rest of the day it was just a constant game of trying to do everything as quickly as possible to finish all the jobs for all of these patients so this placement was also my first time working with PAs or physicians assistants or physicians associates something that I hadn't had on either of my previous placements and geriatrics or vascular surgery now working with PAs was quite interesting typically and traditionally the role of PA or physician's assistant is to help the physician do the jobs that they need to do help them to do the tasks that are maybe more menial or time consuming so that the doctor can focus on doing the doctoring and all the other learning and training opportunities that they need to do instead of having to do lots of different bloods placing cannulas changing catheters ordering scans etc now a lot of the time this was the experience that I had if we had just finished a ward round and there were eight sets of bloods to do which would take me several hours to do by myself I could split those up with one of the physicians assistants or physicians associates and we could say you do half of them I'll do half of them and then I can get on and move on to the other things that I need to do but one of the problems that we ended up having was that PAs or physicians assistants they're not allowed to prescribe medication and they're not allowed to order scans with ionizing radiation so those two tasks would always be left to the junior doctors and what this meant was that when we were splitting up the teams in the morning to go to ward A to ward B to the outliers or down to A and E they would always need to be a junior doctor present somewhere over there so that we could prescribe and what that meant was that oftentimes we were taken to a particular job or role just because we could do those menial boring repetitive tasks that no one else could do because only we could prescribe and so annoyingly in some ways it actually ended up increasing our workload of those smaller more miniscule administrative tasks now there's recently been a lot of talks about PAs creeping into the scope of junior doctors and taking over some of the role of junior doctors and I have a lot to say about that but I'm going to do it in a different video specifically about this placement I found that PAs were used in the traditionally correct way to help ease the workload of the junior doctors on the team and help free up some of our times that we could do the things that only doctors could do for example if there's an unwell patient who needs assessment and treatment and management that's only something we could do so we would be freed up to go do that and then some of the other tasks could be done by the PAs the PAs that I worked with were all very lovely and I appreciated them very much on this placement I think with the workload that existed it would be very difficult to do if it was only junior doctors around so I definitely had a positive experience there okay finally let's move on from all the boring stuff all the renal medicine and let's talk about renal transplant surgery which was easily the most fun that I had on this placement now being a doctor inherently comes along with a lot of stress we've got a lot of high pressure situations emotional stressors and even serious conversations about life and death happening on a regular basis because of this keeping my mental health in check has been a top priority for me and I've been doing this with better help this next segment is a paid partnership with better help if you don't already know better help is the world's largest therapy service and it's 100% online and their mission is to make therapy accessible with better help you can tap into a network of credentialed and experienced therapists that can help you with a wide range of issues to get started you answer a few questions about your needs and preferences in therapy so that better help can match you with the right therapist from their network then you can talk to your therapist however it is you feel comfortable whether it's via text chat phone or video call you can message your therapist at any time and schedule in live sessions when it's convenient for you and if you feel like your therapist isn't a good fit for any reason you can switch to a new one at no additional cost with better help you get the same professionalism and quality that you would expect from in office therapy but with the therapist that's custom picked for you and with more scheduling flexibility personally doing therapy over the last couple of years has completely changed my life it's taught me to approach life in a more slow and meaningful way and has better equipped me to deal with the emotional stressors that come along with my job of being a doctor i couldn't recommend it more and i think talking to someone is one of the most important things that you can do for yourself click the link in the description down below betterhelp.com slash karma medic to get 10% off your first month and help support the channel back to the video so i was on this placement for two months and for the first month it was me an sho and a registrar and we had literally we had the best time ever the sho i was working with was so positive and fun and always just happy and excited to be there we would always be laughing and bantering having a good time working really hard to get all of our work done so that we could go down to theater and see what was going on in the afternoon i honestly enjoyed that one month probably the most out of all the placements and work that i've done in the nhs so far no matter how difficult the day was how much work we had or how many jobs there were to do we were always in a good mood and we'd always just work hard to get everything done and crack on and the sad thing is this person this shl they left after one month and what that meant was is that for the remaining month instead of there being three of us on the team there was only two of us and one of them was always a registrar who doesn't get involved with doing the small tiny jobs that all the juniors have to do and so my workload literally doubled from my first month to my second month because all the work that that shl was helping me do previously they were now gone and so all that workload came onto me when i was working with that shl our kind of mantra or goal for every day was to do the ward round do all of the jobs and finish all the work that we had as quickly as possible and efficiently as possible and then in the afternoon go down to theater and see all of the other renal transplant surgeons what they were up to sit in on the surgeries with them scrub up and go and observe surgeries and that was honestly so much fun i'll talk about that a little bit more in the video but after that shl left because the workload was so much larger for me as one person i rarely got time to do that pretty much didn't get to do that at all and most of my time was spent doing the jobs from the ward in the afternoon which was kind of frustrating particularly because i want to do and see and observe as much surgery as possible one of the best parts about this surgical placement was how many little procedures there were for us to do on a regular basis pretty much every day we'd often get asked to assess patients for fistula creation which would involve using an ultrasound to assess the different arteries and veins in the arm see if they were big enough to have a fistula created we would often get asked to remove tunneled hemodialysis lines which are lines that sit in the chest and i'll talk about in a little bit and then there were all kinds of opportunities for doing some suturing abscess drainage all kinds of little you know hands-on technical skills that i find the most exciting and are pretty much what i live for when i'm working in the hospital let's talk about some of these in a little bit more detail so th child stands for tunneled hemodialysis line and what this is is a line that comes out of the chest here tunnels underneath the skin into one of the major veins and then goes and sits directly in the right atrium of the heart the purpose of this line is to facilitate hemodialysis which is that dialysis with the machine outside of the body that we talked about before in order to filter the blood you need to pass blood very very quickly at high speeds and you can only do that using a thick line you can't use something like a small cannula you need a thick thick line that goes directly into one of the major vessels and then goes into the heart the benefit of having this line in place is that you can have it for a long period of time sometimes up to a year or up to even two years as an outpatient on dialysis you are receiving dialysis two to three times a week and so you need to use this line to pass blood through and filter it at very high speeds with the dialysis machine and you need to do that many times a week for up to a year or two years now the obvious disadvantage of having this line or piece of plastic tunneled underneath your skin exposed to the outside environment and going directly into the heart is that it makes you prone to having an infection or the line becoming infected and when it does become infected the renal transplant surgeons are asked to remove that line so thl line removal is something that we did pretty commonly every thursday or friday patients would be booked into a thl line removal clinic then we would go down to see at least one to two patients a day for the removal in the afternoon but also up on the wards sporadically throughout the week we would get asked to remove lines that were infected this for me was a very cool procedure so as i mentioned the line comes out of the chest over here and is tunneled underneath the skin before entering one of the major veins and going into the heart so once it's entered the skin about two centimeters up underneath the skin there's something called a cuff now what this cuff is is a part of the tube that is made of a special material so then it sticks to the surrounding skin over time and you get a bit of fibrosis there the reason for that is if you were to take this tube and tug on it and pull it out there would be a direct line or opening to a major vessel near the heart which you obviously don't want because it's a major risk for bleeding and so this cuff would hold the line in place it would get literally fused and fibrosis to the skin over there so that it could stay in place and not move but of course when it's time to remove that line you need to free it from that surrounding tissue from the surrounding fibrosis in order to pull it out so what this procedure would involve is anesthetizing the local area and then taking a scalpel and making a small incision above the cuff then using some tools to dissect the skin around that cuff to free the plastic line from the surrounding tissue and once you had done that you'd ask the patient to take a deep breath pull on the line get it out of there and then apply pressure to stop the bleeding from inside now although it sounds very simple and I'm sure it's not that exciting to a lot of people this was the first time that I had taken a scalpel and cut on someone's skin a lot of the previous times I've been involved in surgery you know I would never make the initial incisions into someone's body most of the time what I would be doing is helping the surgeon with different tools once the body was already open and once we were inside the area with that we needed to be more closing up the tissues and the skin at the end of the surgery but actually opening the skin was something I had never done before and this was a particular kind of milestone or exciting moment in time for me I'll never forget that first time that I made the incision in the skin and you know I felt like it was me performing this procedure and me doing this which was really really cool of course I wasn't allowed to do this whole thing by myself I needed appropriate supervision and teaching from my seniors to be able to do this procedure but after a few times of doing it they would let me do the whole thing from start to finish while watching which was extremely extremely exciting and it feels so good to say that I can remove a tunnel hemodiasis line so the other surgery that was very commonly done on this placement was creation of a fistula so fistulas are where you make a connection between a vein and an artery and you put them together the reason for doing this is that you want to arterialize the vein you want to make the properties of the vein similar to that of the artery so that you can pass high volumes of blood at high speeds through the vein for the purposes of dialysis now veins and arteries as you know are going to be very very different both in their elasticity their structural integrity and the volumes of flow of blood that they can withstand but in the process of making a fistula you connect the vein to an artery and then the high pressure and high flow blood from the artery goes into the vein and over a period of several weeks the vein arterializes or becomes more similar to an artery and it becomes capable of withstanding the high pressures and volumes that are required for dialysis so that later in the future you can use a needle to stick into the vein and you can pass that high flow and high volume of blood that we talked about before like when you had a tunneled hemo dialysis line okay construction's gone let's continue so before making a fistula we need to assess if a patient is suitable to have a fistula made and what we do is we use an ultrasound machine to look at the arteries and the veins in the arm to see if they're large enough and suitably close to each other or in the right place to be able to make a fistula and I realize this is all a little bit confusing without an explanation so let's zoom in I'm gonna put on this 20k and let me do my best to explain this is a little hard doing on yourself all right I'm a little bit hairy so bear with me I'm not sure how clearly this is gonna come across on camera but we typically make fistulas either down here by the wrist using the radial artery which is here by the thumb which is where you feel to get the radial pulse and you can also use an ABG so you can arterial blood gas over here or we make them up over here using the radial artery which sits just inside of the bicep over here so the radial artery runs over here and right above it we have the catholic vein that is well I can see and feel it here but I'm not sure if it comes up on camera but the catholic vein runs something like this up to that classic Y that you probably know over here and then goes up the bicep and further up the arm so if you're making a fistula down here using the radial artery and the catholic vein they're both very close together and you can simply connect the vein to the artery and you can get a nice fistula coming up over here there's also the bacillic vein which starts somewhere up over here and then runs down under the arm underneath the elbow and up here deep under the bicep so if you're gonna use the bacillic vein and the radial artery you obviously need to transpose it or move it closer to the radial artery to create that fistula up over here we've got the brachial artery which you can feel for the brachial pulse you've probably done this if you're in medical school studying for the cardiac exam so the brachial artery runs over here when we have the bacillic vein like we talked about right over here and then the catholic vein which runs up over here you can use the brachial artery and the catholic vein or the brachial artery and the bacillic vein if you're making a fistula up over here okay so when we're using the ultrasound machine we're assessing the size of these arteries and veins and whether they're big enough or suitable enough to be able to stitch them onto each other to make a fistula now although i was scrubbed into a lot of these fistula creating surgeries i never actually did any these are highly technical where you're taking literally an artery in a vein and you're stitching them onto each other very very technical surgery that uses loops or magnifying kind of lenses or glasses which i obviously can't do so i couldn't do any of it but i observed a lot of them i watched a lot of youtube videos about them so that i could understand what it is that i was seeing and i found it very very interesting so on calls and night shifts on renal medicine were kind of interesting so in renal medicine our on calls and nights would only cover the renal medicine wards so those were the wards a and b that we talked about the renal outliers and the rest of the hospital and then patients coming up from a and e the evenings on call for these shifts weren't too busy i found that a lot of renal medicine patients could become unwell fairly quickly like on vascular surgery but in terms of busyness and hecticness they weren't that bad renal medicine nights on the other hand were particularly busy and particularly stressful the reason is that there were a lot of patients to cover you have about 30 patients on each of wards a and b and then like we said before somewhere between 10 and 20 medical outliers and then the patients coming in from a and e as well and so there were a lot of patients with a lot of things that can go wrong and you were responsible for all of them with of course the help of a registrar on top of that in renal medicine there was this kind of protocol called early morning bloods so for patients that were going to be seen on the early morning ward round and needed decisions made about them at that time early on in the day we would want a set of bloods that had already been taken at like 5am or 6am so that they were back by the time we saw them at about 9 o'clock in the morning now what this meant was if you were on the night shift you had to do early morning bloods for a whole lot of patients and sometimes this would be something like six or seven or eight patients where you had to go take their blood at about five o'clock six o'clock in the morning and renal patients are notoriously difficult to bleed their veins are particularly deep or small or i don't know just flat just they were so difficult to bleed and waking up a patient at five o'clock in the morning to take blood from them is never going to be a fun experience and what this meant was is that you're basically acting like a phlebotomist from about four thirty five o'clock in the morning until i don't know something like seven just taking all of these bloods that need to get done as early morning bloods on the renal transplant side of things when i was on call or working on the weekend i'd be working in oncology or infectious disease similar to how i was when i was on my geriatrics placement now this was great because those two wards typically didn't have a lot of things to do they typically weren't very busy for those shifts and so whenever i finished all of my jobs i would go down to theater on the third floor i would look at the big board that listed all the different surgeries that were going on and see if i recognized anyone's name and if i recognized anyone's name because they were going to be doing a procedure i would text them on my phone and say hey do you mind if i join do you mind if i sit in with you and they would almost always say yes which was incredible because you're operating out of hours and there's pretty usually only the registrar who's doing the surgery or the operation unless it's something more complicated than the consultant needs to be called in which means as the second person scrumped up or assisting you get to do a lot more you're a lot more involved and my favorite experience for this by far was when i saw one of my registrars from vascular surgery on the board i texted them i said hey can i come and they said yeah sure come and it was something which if you're a surgeon is going to be extremely basic and simple and not fun or interesting at all but for me it was absolutely incredible which was incision and drainage of an obsessive infection in someone's foot this registrar was absolutely lovely they let me do pretty much the whole thing from start to finish under their guidance and assistance and it was you know one of the times where i felt like i'm doing the surgery and i was even put down as the first surgeon on the notes which was really really exciting it was an absolutely great learning and teaching experience of course with the consent of the patient and i'm just really appreciative for those opportunities particularly in f1 and f2 you don't you don't get any surgical theater time allocated to you and so anytime you spend in theater you kind of have to make for yourself or really be keen and push for and do in any spare time that you have and so i did my best to take all of those opportunities and spend as much time as i could in theater because i know i would otherwise never get it and if you're done with all of your jobs and there's nothing left for you to do you might as well be doing something interesting and fun whilst you're in the hospital i didn't really want to sit at my desk and scroll through my phone doing nothing so that was great and if i looked on that board and i didn't recognize anyone's name i would literally just look for a procedure or surgery that i thought was interesting or cool i would go to that theater knock on the door introduce myself to the people operating and say hey you know my name is nasser i'm an f1 on x or y placement would you mind if i observed this surgery and they would always say yes no one ever told me no and through doing that i was able to meet so many different consultants and different surgical specialties and just have long conversations with them about what is your day-to-day life like working as a surgeon in this specialty what's the training like and they would talk to me about the procedures that we were seeing and it was just incredible i found like i was actually getting the teaching that i'm supposed to get but of course this was happening out of hours once i'd already finished all of my other jobs and i was kind of making the time for this it was really great experience it was so much fun to go down there during my own cool shifts and see what was going on in theater and in surgery and i'm very happy that i did okay so final thoughts about renal medicine and renal transplant surgery for renal medicine the first two months of this placement i think this was easily my personally my least favorite or least enjoyable a specialty rotation that i did in my first year as an f1 doctor i found the day-to-day to be pretty boring and extremely focused and lasered in on the numbers and making sure every little number for the patients was being actively managed or treated or modified in some way shape or form it was very very academic for my liking i just think my personal interests in medicine and surgery didn't quite mesh with what was happening on the day-to-day job in the renal medicine wards on top of that it was extremely senior led which made me feel like i wasn't learning and progressing as a doctor and i wasn't having as much autonomy and learning experiences as i wanted and as i had had in my previous specialty rotations renal transplant surgery on the other hand was easily a 10 out of 10 for me i think this is the first 10 out of 10 rating that i've given to one uh one of the rotations that i've been through i thought it was incredible i just loved the team we gone on so well everyone was in a positive mood we were always working efficiently and quickly to get everything done and i got to spend tons of time in theaters whoops learning about and observing so many different procedures getting to do a lot of procedures on the wards like those tunneled line arrivals that we talked about ultrasound scanning lots of stitching drainage of abscesses and making incisions i really really enjoyed it and i had such a good time i felt like i was looked after every day and the seniors would really make a good effort to teach me and talk to me about the things that we were doing and seeing which made me feel like a part of the team and b like i was actually learning and progressing and becoming a more competent doctor yeah i think i can safely say i genuinely enjoyed pretty much every minute of my renal transplant surgery placement even though the workload was extremely high in the second half because i lost that sho who is working with me but overall 10 out of 10 so this rotation actually finished a few months ago now i'm now an f2 doctor working in a different hospital i'm currently working in acute medicine and that is uh that it's it's its own it's its own field i need to make an entire video about that because there's definitely a lot to dive into and talk about so if you enjoy these types of videos please do subscribe to the channel like this video leave a comment let me know what you think and that video will be out soon once i've finished this rotation and have some time to collect my thoughts on it and come tell you what my experience has been like thank you so much for watching i hope you enjoyed this video and i will catch you in the next one peace