Alcohol abuse, confused patients, growing up, shocking patients and a rectal exam this week!
'How much do you normally drink in a week.' 'How many cigarettes do you normally smoke in a day.' The questions we have to ask patients to assess how much they are harming their bodies. And these things do hurt people. Patients coughing up blood and in pain from lung cancer, or patients with the apparent cognitive function of a 4 year old from decades of heavy drinking. I'm not saying I don't have my vices, but the harm people can inflict on themselves with these everyday substances is shocking. I saw an elderly man throughout this week who has destroyed most of his brain with alcohol. He never knows where he is and is always wandering off around the ward to go to 'an anniversary' or 'a christening' or some other event he seems to have imagined. He doesn't seem to have any friends or family, and often behaves in an obnoxious and rude way (perhaps explaining the lack of friends). He falls over, hurts himself and stays in hospital longer. We cannot let him go home because he will just get lost or fall again, the reason he came in in the first place. All of this has been caused by his personal choice to drink.
Another patient I saw towards the end of this week was suffering from severe alcohol withdrawal, and had delirium tremens. This involves severe confusion and agitation, and can often be coupled with uncontrollable tremors in the arms and legs. Patients can sometimes get psychiatric symptoms such as paranoia or hallucinations. This patient was getting hallucinations of insects crawling over the table and bed, and flying in front of him. You could watch him propped up in his chair trying to pick insects out of the bare air with his fingers all day. Alcohol withdrawal is more common in elderly admissions into hospital than you might think, some older people consume a lot of alcohol. Stopping alcohol suddenly can send you into withdrawal. It is depressing trying to talk to someone who has been destroying themselves this way, finding they don't remember if they have any sons or daughters, or what their favourite food is. Patients can be self destructive.
Anyway, sorry to the morbid start, not a great cheery start to an 'optimistic' blog. How about a happier patient next? I was talking with a 90something year old lady about why she was in hospital. She had come in with confusion and a fall, two of the most common reasons for an elderly patient to be admitted to hospital. She was flat out denying that she was confused on admission, but had scored 2/10 on the AMT. The AMT is a scoring system where 10 simple questions are asked (such as the year, or to identify a pen) and the patient is scored. Most people would easily get 10, but it is used to quickly assess the patients confusion or cognitive impairment. At the time of the conversation I had with her, the patient was sharp, aware and easily scoring 10/10 on the test. How can you convince someone they were confused if they cannot remember? I couldn't work it out, and the lady was getting paranoid as to her 'real' reason to be in hospital so I changed topic onto general chat. I don't want her thinking we are 'conspiring against her' to keep her in hospital, I am sure the hospital would rather have the bed... It turned out that while she came into hospital without her hearing aids, her gardener picked them up from her house and bought them into hospital for her. What an amazing gentleman. Very kind of him, (he was 70something) looking out for his clients. It is simple things like that that make you see through some of the murk that is often portrayed as human nature and let you see that so many people do care, its just often done on a close and personal level, so you don't get to see it much of the time. This lady did say one off-the-wall thing though. She told me that her 'son had died, but he was an awkward child so it was for the best really'. Never expected to hear that from a mother talking about their own child! The patient was being completely serious as well. Patients can be shocking!
This week was exceedingly busy. Over the weekend around 60 elderly patients came into the hospital. Seeing as my consultant's firm was 'on take' this meant that they clerked and initially managed all of these patients. This is just how the hospital works, but it meant that on Monday, if it has been a busy weekend like this one, the morning post take ward round can go from 8.00AM (in the morning) to around 9.00PM (at night) or later - that is one long 'morning' ward round! Especially hard on the junior doctors who will then have to go and do all the 'jobs' from the ward round such as organising scans and tests. A very variable-time job depending on who turns up at the door! Patients can be numerous.
As all this happens, I am feeling more and more 'adult'. Only 20, as I went straight to medical school after doing my A levels. Working in the hospital I often get called 'Dr' or 'Sir' by the patients which is very strange, seeing as many of them are more than 4 times my age. Despite telling some patients I am not a doctor they still insist on calling me such. It feels kind of wrong, like I am lying to them.
When it was snowy I was walking back past a school on my way back from the hospital and some kids were the other side of the wall throwing snowballs at the people on the pavement who passed. I crossed over to the other side of the road to avoid them, while muttering away in my head about 'stupid brats'. WHEN DID THIS HAPPEN? I used to be the sort of person who would chuckle away and throw some snowballs back at them, after all - I would have been doing the same when I was at school! I don't want to grow up too fast. I am happy being mature when I need to be, and hopelessly immature when I want as well. It is a lot more fun. I will make sure to fight this unwanted extra-matureness and keep it under wraps for another good few years.
There are certain tests (like the AMT I mentioned before) which we do to measure the patients 'cognitive function'. This is very important in elderly medicine as its important to make sure patients can care for themselves when they are discharged, and it is useful to keep a track of how confused or demented they are. I was talking with a patient and aiming towards doing this test on her after having a chat. The patient kept telling me that she 'was not daft' and 'still had all those brains there' which seemed about right, and while she was a little hazy when referring to things, she seemed capable of holding a sensible conversation. Once we started on the test (30 simple questions) things changed dramatically. She thought it was the year 2030, she thought she was over 150 years old and had a great array or other misguided perceptions. My favourite part of the conversation was when she identified a pen as 'a stethoscope' and when asked 'what is this, the thing you sleep on' when gesturing towards the bed, she told me firmly that it was East Sussex sitting in her hospital room. Sometimes the confused patients have become very used to living when confused, working ways to get about daily conversations and procedures, and this can easily 'trick' people into thinking they are normal. It always feels silly asking them these test questions as they are so simplistic, and many patients find them patronising. Patients can be crazy.
To end this week I did my first rectal examination on a patient on Friday. I was not expecting this - I was on a ward round with an SHO and another medical student. Because this ward round was lead by an SHO and not a consultant, this meant that we got a lot more opportunity to get involved in what was going on. The SHO had to take the histories and do the basic examinations, but could not write while doing that, so we scribed. If the SHO wanted to write we got the chance of taking the histories or doing the examinations. The last patient of the day had been suffering from rectal bleeding after admission to hospital and we did not know the cause. The SHO asked if we had done a rectal examination before, to which I replied no. "Then this is your big chance, go and get some gloves". I suppose we all need to learn sometime but this was a bit of a shock! I had only practiced once before on a plastic model with an interchangeable prostate some time last year. I suppose an anus is an anus, it cannot be that complicated. Anyway I will not go into details, no-one needs to hear that, but there was a pea sized haemorrhoid on the posterior wall which I found, which I was quite pleased about. The patient did not appreciate the examination, and disturbed the rest of the ward with his unappreciative vocal sounds, but afterwards thanked me and it was all OK. I don't think all that many people would appreciate such an examination. Patients can be practice.