Sunday, 10 January 2010



Ok, so an attempt at a weekly blog. Good luck.
This first week has only had 2 days worth of clinical experience, what with supplementary lectures, snow, and the such, so don't go expecting too much!

After Christmas I was unsure what to expect in a clinical situation, but it was amazing coming back to the wards. Elderly medicine is completely different to the last rotations (though I am sure there are some who would argue it is very similar to Paeds due to the need for care and so on). The breadth of the material covered and knowledge required is broad again, due to the fact it is treating anyone over a certain age, whatever the condition (basically). Despite this there are still common presentations such as confusion, stroke, falls, heart failure which bring most of the patients into hospital. A little like Paeds in that respect, broad with common illnesses. But with a very different focus. OK, I suppose you might be right if you argued that they were similar. Anyway, I carried out a ward round where I met many patients with a range of illnesses and helped plan treatment or investigations to reach a diagnosis. One particular patient was very upset, telling us that the only thing she had to look forward to was heaven. She was in tears but couldn't be put on anti-depressants because she had very abnormal thyroid test results. It could be that this depression was being caused by the thyroid abnormalities. Even though this is sensible, it was still really sad seeing this poor lady so upset. I spent some time holding her hand and talking, though I am not sure how much went in, while the doctors wrote up the notes. I was writing up notes for many of the patients while a doctor examined them, and carried out some examinations of my own. A great learning experience. I also failed at taking blood for the first time. I have usually been very good at taking blood from patients in the previous rotations, and haven't missed a vein before. This time I had to use a syringe rather than a vacutainer method, as there were no vacutainers on the ward. And I missed the vein. I suppose you have to mess up sometimes, and as long as it doesn't kill someone that's a blessing. Patient was fine about it, he didn't care at all. Lovely man.
I spent some time at the mortuary as the F1 I was with had some death certificates to fill in. I learnt to fill in these forms(though the forms I filled in for her had to be redone, as it turns out I am not allowed to fill them in and her sign them). Learnt to examine a body posthumously for a pacemaker. I'm used to dead bodies now, though, after years of dissection, so no worries then. Still sad, reading through a patients notes working out the causes of death, seeing them decline and die. At least I get a job at the end where I get to fight against death. Not sure its a winning battle.
On another day I got to get stuck in with a consultant ward round. Pretty similar to other ward rounds, but the medical staff who may be grilling you are careful around the consultant who can grill them. I phoned up 'next of kin' to let them know their grandma was in hospital. Introducing yourself and saying you are from a hospital gives people a bit of a scare, but after assuring them I was not telling them that their grandma had died it was a good opportunity to take a social background history. The patient seemed a lot happier having well wishes passed on as well. Many of the patients I saw today were severely confused or suffering from other apparent psychiatric conditions. I spent some time with an elderly lady who was insistent on singing to us, as it was her preferred mode of conversation. She had decided as soon as she had seen me, along with about 5 other medical staff, that she had met me before and trusted me completely as we understood each other. I wasn't really sure what to say about this, but it let me talk with her and help a colleague carry out a MMSE (mini-mental state exam) to assess the function of her brain. Later on with this colleague we were taking the blood from another elderly lady. I was holding her hand and taking her mind off of things on one side, whilst my colleague was trying to find a vein to take blood from. With very few veins we decided to take from the hand, where there were some flimsy surface veins visible. Unfortunately there seemed to be some sort of rupture when taking the blood and the patch of skin over the vein started to swell up as blood seemed to drain into the skin around the vein. We used this as an easy source of blood for the tests (LFT, FBC and so on) which also helped us reduce the swelling. Unsure what to do with this patch of skin, we covered it with cotton wool and left. Checking with the doctor who was in charge of the patient, we are told that this is quite common in elderly patients, so we haven't done anything bad. Fortunate. I am sure that haemorrhaging an elderly lady is impolite in the least.
The only elderly man we saw as a patient this day was an ex-Olympic athlete. Fully cognisant and interactive, he seemed in a much better condition than most of the other patients we had seen today. Unfortunately on reviewing his X-ray it seems that he has got mesothelioma, likely to be from asbestos exposure, and has a very poor prognosis, with most of his right lung function gone. Just because the brain is happy and working, I suppose it doesn't mean that the body has to follow suit. The snow brings in a lot more elderly people, falls and pneumonias and the such. It also stops people from getting home, filing up wards and overflowing into any other available space that can be filled with a bed.
Death has been a large part of this week. Very different to paeds/obs/gynae where death is a rarity and usually avoidable, in elderly medicine death is ever present and ultimately unavoidable. Not that death is ultimately avoidable anywhere, it is just that most of the death is bunched up at the ends of peoples lives, in this speciality. Its not that patients don' get cured and go home. Of course they do, all the time, its just that there is a much higher death rate, and the knowledge that if you try and cure them they may end up back in hospital. Perhaps that gives a very different outlook for doctors who specialise in elderly care. I think it definitely requires a specific type of person.
That will do for this week, not a complete week and not a complete blog, very bitty but that is how my mind works I suppose. This and that.

No comments:

Post a Comment