Jonny Martin splits his attachment between John Radcliffe Hospital, Oxford, and Craigavon Area Hospital, Portadown, and appreciates their differences It is often said that time is one of the greatest resources a medical student has. Only s/he can spare enough to tease out the finer points of a patient's history. Their neighbour's cat's social activity may not be directly relevant to their renal failure, but it can allow the humble student to set up a rapport with the patient that would put a Macmillan nurse to shame. In the fast paced arena of acute medicine, however, the medical student must learn, perhaps for the first time, to ration what becomes a most precious commodity.

Oxford

In the John Radcliffe Hospital, as a new medical student on the "front door", when you see a patient, time is everything. You have 10 minutes. After this, the curtain is pulled back so a face can peer in to see what rare disease is taking so long to identify. Your fledgling diagnosis directed history and exam skills have been tested to the limit with this sprained knee, and as you attempt some non-specific test you find yourself presenting. Gone are the days of the confident, well drilled medical student slickly delivering the negative findings of his or her exam. Now you need to get to the point. The cubicle is needed, your time is up. The senior house officer repeats the exam to the tune of your potted history, and before you've voiced your dubious exam findings it's a "double tubigrip, ibuprofen, and next patient please." But it has to be. Very few people want to be in an accident and emergency department. Fewer still like being there four hours without being seen. With this in mind, a medical student can feel, maybe not quite a spare part, but more a rate-limiting step in the patient care pipeline. For the first few days at least.

Over the course of my two weeks in the casualty department at the John Radcliffe I learnt fast. Whistlestop fracture clinics, frenetic periods on front door, the odd jog to a crash call, all with a generous smattering of teaching sessions to bind it all together. I enjoyed my time there very much, but equally looked forward to moving from a lightning paced level one trauma centre to the more subdued atmosphere of a District general hospital in my home town.

 

One of Oxford's landmarks, the radcliffe camera was built in the 18th century

Portadown

"See one, do one, teach one." This is a maxim used to describe the pace of skill acquisition in medicine. In my time at Craigavon Area Hospital, I got to teach as I did the first one I'd seen: It was while grinding bone on bone, reducing the first wrist fracture out of cast I'd seen. A student nurse who was masking the patient asked me if we should stop because the patient was moaning so much. I mumbled that the ketamine didn't have to knock you out cold as she wouldn't remember a thing and I continued to yank.

Perhaps not that impressive, but during my attachment in Craigavon I had no shortage of experience. Blood gases, venflons, reductions, suturing, electrocardiograms, plastering, assisting in minor operations, and much more. The team there went out of their way to get me involved.

I was a novelty, being from Oxford, and when you're a novelty, people want to play with you. They want to show you things, help you do things, get you involved. Sure, they regularly have home grown students, but I was their first from Oxford. They missed you when you weren't there. Not a "we missed you" in a "where the hell were you" sense, but in a "we missed out on you" kind of way.

Observations

When I saw my own patients, I began to learn of the hidden agendas they sometimes bring with them. On my general practice attachment, it was brought up by the "there's one more thing, Doctor" line as the patient got up to leave. In accident and emergency, I felt it was when the diagnosis was just about to be made:

• Might it be broken, Doctor? (Can I go on the sick?)
• It isn't broken, is it? (Self employed - no sick pay.)
• Remember, bouncers beat me up. (I'll want you to stand up in court.)
• Might they have to go into care? (Worried daughter.)
• Can they still go into care? (Worried son.)
• Will it be OK by 16 March? (Sportsman's big match.)
• I let her out of my sight for 5 seconds! (Guilty mother.)

I also noticed personality could allude to how seriously to take a particular patient. You just know that your typical shower fearing agricultural type, would only come to casualty if his arm was hanging off, whereas the young, cool Kwik-fit fitter could present with pathology you wouldn't show your own mother. Now obviously these are sweeping generalisations in the extreme, where such superficial assessment could lead to mis-diagnosis if used as a replacement for clinical acumen... but still.

Background

Previously accident and emergency services were offered in about 20 hospitals in Northern Ireland. This was deemed a bit excessive for a country with just 1.5 million inhabitants, so now a "golden six" group of hospitals is emerging, and these are to be the only ones offering a wide range of acute services. Craigavon Area Hospital in Portadown is one of them. Even so, it is no level 1 trauma centre and formal teaching is not to the same level as in Oxford.

I have tended to use Craigavon and Portadown interchangeably so I should explain why. Craigavon was a development conceived in the sixties to join the communities of Portadown and Lurgan, thus creating Northern Ireland's second largest city. They got as far as making a lot of roundabouts on the road connecting Portadown and Lurgan, a hospital, a shopping centre, and a massive residential area. Not forgetting, of course, the obligatory dry ski slope, man made lakes with watersports centre, and golf course. Then, surprisingly, they discovered they were penniless. At about the same time they remembered that people from Portadown didn't like Lurgan folk much, and neither party was warming to the idea they might be co-habiting the same city quite soon. They gave up, wrote the whole thing off as a bad job and called it Craigavon. But don't get me wrong, it's a nice place. My home, thank you very much.

 

Craigavon Area Hospital, Portadown

Oxford on the other hand, you know already: old university, Inspector Morse, and many, many tourists. There are three main hospitals which between them offer a full range of services - the old Radcliffe Infirmary in the city centre, and the Churchill and John Radcliffe hospitals in the outskirts. The only casualty department is situated in the John Radcliffe, but it is home to over half of the dedicated trauma surgeons in the country. It is unique in that the unit is manned 24 hours per day by a resident consultant traumatologist in addition to the casualty medical staff. Consequently, it is an extremely busy department, which, as a level 1 trauma centre can't ever close its doors. Thus at times patients can line the corridors and wait obscene lengths of time to be seen. Craigavon, however, is steady rather than busy, with an average wait well under an hour. This allows a more relaxed atmosphere, resulting in high morale, excellent informal teaching and "a bit of craic" in the department.

The difference between Oxford and Portadown is stark and I believe splitting my attachment between the two has given me a unique opportunity to compare the practice of acute medicine in vastly different settings within the NHS.