TSP Blog – Page 5 – The Student Physiologist

Have You Ever Tested A Robot? Pt II

I still haven’t.

Bear with me, though, as this is going somewhere, I swear.

After the last session, in which I provided the robot’s voice and controlled its HR and ECG, it dawned on me that as a result, everyone had the opportunity to be filmed performing the test and gain valuable group feedback, except me.

I wasn’t the only one to notice this, as it transpired.

During a subsequent lab session, wherein we practiced manual BP, honed bedside manner, discussed contraindications and compared different methods of BP measurement, it was revealed that the remainder of our ECG feedback period would be completed in the lab. We no longer had immediate access to the simulation mannequin, so thanks to a willing volunteer, another of my colleagues was able to complete the procedure and again receive feedback in a partitioned area of the lab.

Then it was my turn to step up to the plate.

I was the last to ‘go’, as it were. The difference between my assessment and the other’s lies in that everyone else enjoyed an element of seclusion: the curtains around the bed-space being pulled in the first session and the high walls that separated one section of the lab from the other, in the second. The rest of the group stayed outside of these boundaries in everyone else’s case. Not for me, though. I stood away from the couch, preparing to make my entrance to the imaginary treatment room I could see in front of me and just before I could open the invisible door, the consultant physiologist taking the session said “Wait, I’m just going to call everyone else in, if that’s ok?”

“…If that’s ok”, as if I had a choice.

Everyone else filed in. They kept filing in for what felt like an age. My lecturer, the rest of my class and the head of physiology. Then, they all looked at me, waiting.

I’m not sure how I’d have fared if I’d known this was going to be the format for my peer assessment, but I feel no shame in admitting that I don’t remember ever being as scared as I was before I started moving. I didn’t know how to begin, so I just went for it. I walked into the ‘room’ (after, somewhat embarrassingly, opening the invisible door) and performed the test as I would out on placement.

I asked all the required questions and added one or two patient identifiers to account for the fact that I didn’t call my patient from any waiting room and gained a consented, accurate trace.

Not only did I do it all with the eyes of more than a couple of people scrutinising my every move, I did it with a piece of equipment I have never used before and the most tentacle-like cable configuration I’ve ever seen in my life- if you’ve tried to untangle the wires behind your television when you’re moving house, you’ll know what I mean but, trust me, this was worse. In addition, I managed to ignore a completely new experience: the fact that I was so scared that the back of my neck was sweating..!

Fear is natural. It’s normal to be scared of doing something that’s relatively new to you, especially when you know you’ll be watched and judged doing it. Whatever ‘it’ is, it wouldn’t feel like a real achievement if we didn’t feel fear beforehand. I’m glad it was sprung on me, if I’m honest. My final assessments and various practical examinations for the rest of my career will follow this format so it’s good to have a grasp on some of the emotions I’ll be feeling before them. If you’re just beginning the PTP programme, you’ve got things like this to look forward to, so just try to enjoy it. Realise that the fear of these things is normal and, most importantly, the sooner you take a deep breath and swallow the lump in your throat, the sooner they’ll be over!

Thanks!

Light At The End Of The Tunnel

Having being around for a few years now, I’ve read an ECG or two in my time. If you’re still early on the road to becoming a fully-fledged Physiologist though, let me assure you of one thing: IT DOES GET EASIER!

I won’t lie, even with the experience I now have, there are still the occasional strips that leave me scratching my head like a confused monkey but on the whole, a 12-lead doesn’t scare me anymore. One thing that I think many students will find at some point during their learning, is that their more experienced counterparts have somehow forgotten how difficult it is to read an ECG. You might take an ECG for someone to check and receive a reply along the lines of ‘Well, obviously this is…’ Not all that helpful!

Learning to read an ECG is a lot like learning to read a new language. Sure, if you’ve been practicing for a long time, you’re pretty fluent, but it’s important to remember how hard you found it back when it was still just a foreign language to you. Only then can you start to empathise with those who are in that position now. And if you are in that position now, don’t give up!

If I could offer one word of advice to you, the person reading this who is desperately trying to get to grips with ECG, it would be this: get to know what a normal ECG looks like really, really, REALLY well. Then, get to know how that relates to the electrical and mechanical activity of the heart. (I suppose that’s sort of 2 pieces of advice but stick with me here). If you can get all of that into your head, you’re putting yourself the best possible position for progression. If you instantly know what a normal ECG looks like, any abnormality should stand out like a sore thumb. You might not know what the abnormality is, but if you know how the ECG waveforms relate to the mechanical activity of the heart, you can at very least a take good, educated guess on what that abnormality suggests the heart is actually doing. You won’t be an expert, not at first, but you will have the foundations on which you can build and make yourself one.

Therefore, the most important first step is to learn what is ‘normal’ but I’ll discuss that in detail in a later post.

Are Athletes At Greater Risk Of Pacing In Later Life?

If so, what is the cause?

The Athletic Heart Syndrome isn’t indicative of any pathology in athletes, and although it is theorised that the changes the heart undergoes as a result of training, there exists no evidence of long-term effects. The athletic heart often has a resting rate much slower than that of an individual of a less active nature. This is not uncommon in physical athletes, as it has been reported that Sir Chris Hoy has a resting HR of 30bpm and fellow cyclist Miguel Indurain one of just 28..!

The cause of this is a very active vagal tone, resulting in bradycardia. As I’m certain many of you are aware, this is a condition that would almost certainly (correct me if I’m wrong) require pacemaker intervention in elderly patients, but in the case of athletes, this bradycardia is due to an increased stroke volume which means the required workload of the heart is decreased. All well and good whilst one is in training, but what if this lower HR did not ‘reset’ to within the normal parameters once training had ceased? I don’t think I’m incorrect in assuming that this would lead to the same treatment a non-athlete, former or otherwise, would receive anyway, regardless of any prior level of fitness.

There is in fact a 2007 study by Baldesberger et al, that suggests this is indeed the case.

Published in the European Heart Journal and found in full here: http://eurheartj.oxfordjournals.org/content/29/1/71 it is shown that there is a statistically significant increase of sinus node disease in the tested former cyclists when compared to the control group, in this case golfers.

Interestingly, I have stumbled across a British Heart Foundation- funded study run in part by the University of Manchester, that they feel suggests the increased presence of arrhythmias in athletes is due to molecular changes as oppose to increased activity in the autonomic nervous system.

The study in rodents showed a decrease in HCN4, a protein found in the mammalian SA node. In humans, a mutation in the HCN4 gene is sometimes found in patients exhibiting sick sinus syndrome and in those who display bradycardia, so the teams behind this study believe that if they can replicate the rodent’s results in humans, it will help us understand arrhythmias that endurance athletes often suffer in later life.

The published study can be found here: http://www.nature.com/ncomms/2014/140513/ncomms4775/full/ncomms4775.html

I’ll answer my second question, “if so, what is the cause?” with an obligatory “je ne sais pas”, but it’s clear that we are edging ever- closer to an answer. Of course, whether that answer is due to molecular changes, or nervous ones remains to be seen.

Either way, it is stated by the team at the University of Manchester that although endurance training can have harmful effects on the heart, these effects are more than outweighed by the benefits.

As an added bonus, here is a short video by Sarah Pratt showing some common differences in an athlete’s ECG (in this case the featured athlete is the NHL’s Tobi Rieder *!*) compared with that of the rest of us. Enjoy!

As ever, if I’ve missed anything, or am just plain wrong about any part of this piece, sound off in the comments below and I’ll do my best to rectify this.

Thanks!

Have You Ever Tested A Robot?

I haven’t. That part comes in a few weeks.

I have, however, BEEN the robot in question, as today, I provided the voice and cardiac controls in my university’s simulation suite.
My peers performed ECGs on a rather frightening, dead-eyed humanoid that was, unbeknownst to them and in
conjunction with my voice, being used as a conduit for a scenario pertinent to our learning. That’s me on the right, there, next to my control station (a closer view makes up the header for this post) which allowed me to alter heart rate, breathing rate, create a whole host of arrhythmias and not only see my colleagues, but speak to and hear them as well.

I was a patient named Christopher Smith who had been admitted to A&E. That was all the information that had been supplied, barring my NHS number and date of birth. It was the job of my fellow students to check three patient identifiers, get a brief idea of what was wrong with me and to perform an ECG accordingly, with a brief assessment of the adjustments needed and that of the trace itself.

It was made clear both before and after the session, that it was ok to make mistakes and that this was predominantly what the session was for. It’s extremely unnerving, having a conversation with an expressionless robot that can visibly and audibly breathe, so it was nice to be reassured that the pressure wasn’t as high as it could have been.

Everything going to plan, it would emerge that my chest pain was a result of atrial fibrillation and a heart rate of a mere 32-35bpm. It was also an assessment of how quickly we prioritised the test itself. Due to the presenting chest pains, attaching the limb leads first, so as to gain a visible rhythm strip before a full 12-lead was the correct response, then adjusting the paper speed on the trace itself so as to provide an useable ECG was the next desired step. All the while, I was talking to the student practitioner, asking questions about the test and about the situation in order to see how they reacted and whether they felt comfortable keeping me, as a patient, calm at the same time as carrying out the test with the required level of haste.

These sessions were filmed and then followed a group feedback discussion. The group seemed pleased with the outcome, overall. The comments made were mostly of a positive nature, and the few criticisms there were from myself, my peers and our lecturer, were minor and constructive. This has most certainly been my most enjoyable session to date, and one I did not mind getting up at 4:30am to help set up, so needless to say, I’m very much looking forward to the next one.

I will add that the first half of the session used me as a living mannequin. The reasons that I didn’t comment on this until now are twofold;

It was effectively the same as what I have written about, only without the technology
Seeing my naked torso on film reminded me that I’m still carrying holiday weight. This wouldn’t be a problem, were it not the weight from four holidays.

Thanks!

New Experiences

Hello!

Apologies for the prolonged silence, I grew a year older recently and attended all manner of surprise parties and gift-giving events as a result.

Already this year, myself and my colleagues have been thrust into a couple of new experiences and have a few more to look forward to in the very immediate future.

The first was the start of an inter-professional module, in which Occupational Therapists, Physiotherapists, Nurses, Midwives, Learning Difficulty Specialists and us Physiologists were divided into groups and given a series of tasks to plan with the aim of completing them throughout the year. Presumably, this is to simulate a clinical multi-disciplinary team and to help prepare us for the inescapable fact that setups such as these are going to be present throughout the rest of our careers.

I shan’t lie; I was more than slightly nervous about the whole thing.

I didn’t want to be there and neither did my colleagues, so I felt I was correct in assuming that the rest of the group who were to be allocated with me would also rather be spending their time in other ways.

It turns out, my assumption was correct. This is not to say that we as a group were disinterested once we had arrived at the meeting; quite the opposite, in fact. As it turns out, my group are all a studious bunch and, like myself, have taken the view that whilst it isn’t particularly ideal, the quicker we muck in and do the work, the quicker we can be done with it and get on with our degrees.

This however, was something that I was prepared for (to an extent). What I was not expecting, was my second new experience: to be assigned two first year students to mentor.

I shan’t lie; I’m still more than slightly nervous about the whole thing.

The last time I was in any way responsible for someone’s learning was the last restaurant in which I worked (a two-rosette affair, so as you can imagine, there was not much room for error). The televised “Gordon Ramsay” style of teaching, wherein the senior-most member of staff berates, belittles and rattles off the first 75% of the “Viz Profanisaurus”, is actually not that far from reality (the first time I burned a piece of fish I was subjected to the most obscene eight hours of verbal abuse that I have ever experienced), and although this is not the way I’d ever speak to another human being, I’m very well aware of the fact that I’ve been exposed to this ‘style’, and I’m frightened that I fall into it if I get asked the same question for the fifth time (it works: I have NEVER burned another piece of fish).

In fairness, this is just another challenge I want to overcome, so I can, all joking aside, not wait to help these new students leap the same hurdles that I have already and give them all the preparation they require for the coming months.

Thank you.

Q. What Natural Phenomenon Can Speak In Any Language?

A. An echo.

EDIT 17/9/15:

It has been brought to my attention that I didn’t word some of my last post particularly well. Upon looking this over, this is indeed the case.

It was not my intention to convey that healthcare scientists need not perform ECGs I intended to imply that whilst on my last placement, physiologists did not perform them, it was the responsibility of the A.T.O. hence, this is what led my mentor to say what they did regarding newly qualified and echo. This may not be the case across all trusts.

I neglected to include that due to the advanced nature of the practise of echocardiography, it is not featured in the PTP program. (This is good news for me and anyone else currently studying this degree, as I shudder to think of the extra workload that would be associated with it).

If in future I make an error such as this, let me know and I shall endeavour to rectify it.

Many thanks,

TSP.

ORIGINAL POST:

Having seen what trust-employed cardiac physiologists are required to do, it seems rather strange to me that echocardiography isn’t really taught in either the PTP or STP programmes. By all accounts, it’s touched upon in the final stretch of the STP pathway, but not in a comprehensive manner. Assistant Technical Officers perform the vast majority of ECGs in my trust, so it isn’t necessary for qualified healthcare scientists to be placed in that area. My mentor told me that her cardiology department needs echocardiographers and that the discipline is underinstructed by the universities. Bear in mind this is only because it isn’t a part of the syllabus as it’s not currently required by the framework of Modernising Scientific Careers.
As a result, the trust I have been stationed in has taken to rounding up the students and providing its own echo tutorials after the working day is finished.
This is a great idea and is beyond the call of duty for the department physiologists, but it doesn’t strike me as something that should fall to the trust to have to subsidise. Echo is an increasingly utilised skill and the one that hospitals need their physiologists to be proficient in. If it isn’t being taught at undergraduate or masters level, then trusts will have to pay for the training and overtime required to bring their staff up to speed with each new generation of practitioners.

Over the summer, my university has purchased an echocardiography unit, so I assume we’ll have a bit of a head start, but surely if the practice of echocardiography is so important in the profession, it’s something that should be mandatory to teach in the academic training. Perhaps this is something that will be factored into the equation as the PTP and STP courses continue to change over time.

The Times They Are A-Changing.

Hello again!

It seems that as soon as I mentioned just how quickly this profession is evolving, something has been raised that enables me to give you an idea of how much.

This blog is called The Student Physiologist. The career’s professionals are known as physiologists or physiological scientists, ergo, myself and my peers are subsequently coined physiology students.

This, however, will soon be a thing of the past, as by the time I qualify, these terms will no longer exist. In their place will be Healthcare Scientist.

It’s difficult to find any sort of identity in such a changing professional environment and this difficulty is bolstered when a physiological scientist tries to explain their role within the NHS. We are among the most patient-facing scientists in the clinical setting, yet we are arguably the least “seen”, in that no matter the description of who you are and what your job is, patients and other staff alike will invariably refer to you as “nurse” or “doctor”. Whilst doctors and consultants are prevalent in this career, it is difficult to convey to patients and staff, the differences between medic and scientist in both the hospital and these roles specifically.

This has highlighted to me, the need for a global identity and perhaps a way for we, as the people with that identity, to forge it for ourselves.

As the evolution moves ever forward, this blog may be named The Healthcare Scientist and I may be signing off with the same name.
We shall see.

Thank you.

An Introduction.

Hello.

I have this last academic year, completed my first full year of Cardiac Physiology.
My course consisted of four modules, each focusing on broad, yet still specific areas of science and scientific practice.

The modules were as follows;

Biomedical Skills.
– Medical physics, algebra, calculus, etc.

Anatomy and Physiology.
– Exactly what it sounds like; anatomical systems, terminology, dissection, prosection, and a hell of a lot of pop quizzes.

Cellular biochemistry and Genetics.
– Microscopy, mrganic chemistry, pharmacology and, shockingly… Genetics.

Physiology and Patient Care.
– The physics, biology and methodology behind various medical tests and how to use and perform them, then interpret the results, patient psychology and care, and the pathology of cardiac and respiratory disease, etc.

I refrained from creating this blog until the start of my second year due to the irrelevant content of the first year as a whole. Whilst the first three modules listed were required by the curriculum, they were far from ‘physiology-centric’ and the final module was little more than a (very good) detailed introduction. This will change, however, from here on out.
I must stress that this is not a slight on the course structure or its content so far, as nearly everything that myself and my colleagues have been taught has been engaging and informative, I simply felt that to document such a broad range of topics on a Cardiac Physiology blog would quickly become something akin to an unwanted university lifestyle diary. I can assure you, that aside from study tips, this shall not be the case.

The next steps of my journey are the ones that will be of greatest interest to fellow students, physiologists and hopefully to the relevant governing bodies.

In the forthcoming posts, I shall document my feelings on the course structure, content, struggles I have encountered and where the career path seems to be going.
I intend to post once a week without fail, but will update with more frequency as points of interest present themselves.

To those just starting their journey, I will post some relevant information regarding the Physiology module from last year, but mainly to assist with what’s to come.

If you know anyone who is currently journeying down this pathway, or is thinking of doing so, point them in this direction. I aim to network, exchange ideas, discuss common issues and everything in between.

Thank you.