Toxic

Hi,


I play nurse, get chatted up by an 84 year old, talk with an overdose patient and have an elderly lady drink a bottle of alcohol gel this week!


A busy week, and my last week on the elderly rotation, a real shame I think. I have enjoyed spending time with the old patients, with all their oddnesses, quirks and wonderful stories, but I am moving off to psych next week, where I am sure I will see many more oddnesses. Anyway - I saw many patients who should be on my next rotation this week so perhaps I am well prepared.

Towards the start of the week I was on a ward round with a consultant and another medical student when we came to a ward with a patient who had fallen out of bed and onto the floor. He was an elderly gent, and could not get up. We helped him into a sitting position and called the nurses to hoist his sizeable mass back into the bed. He was very confused and kept trying to crawl out of bed. There were only 2 nurses on shift to cover the entire ward (15-20 beds) and one of these was a ward sister, who was meant to be filling in paperwork and ensuring the smooth running of the ward from an office. The other nurses were on their lunch break. Seeing as this gent needed constant watching this meant that the ward sister had to stand by his bed for the next 45 minutes keeping him from getting out again, and she wasn't able to get any work done. At the end of my ward round I went over to this bed and offered to give her some time to do her paperwork. I was done for the day anyway, and would only be relaxing at home. This gent turned out to be a real handful, unfortunately. He was exceedingly confused and tried to get out of his bed every minute or so. He ignored me if I asked him to stay there, and if I gently guided him back down the the mattress he would scratch and hit at me. This man had caught MRSA and was producing a lot of sputum which he managed to throw at, and smear all over me. Not nice. In conjunction to hitting me, scratching me and covering me in super-bug ridden bodily secretions this man managed to wet the bed 3 times whilst I was there, needing many bed changes. This wasn't such a problem, and seeing as he had been given a diuretic earlier it could be expected, it was just a shame he wouldn't give any warning. To top it all off, the poor man really didn't seem to enjoy wearing clothes and kept taking off his clothing and giving it to me. Throwing off his covers to reveal his naked glory to the whole ward, and complaining whenever the curtains were closed, it was a fight to maintain his dignity, let alone keep myself safe. Unfortunately I got left looking after this man for 3 hours until I managed to get relief, a little more time in hell than the 20 minutes I was promised. The main thing I learnt from this exercise is that nurses have a VERY hard job. I don't envy them at all. Patients can be hard work.

A lovely patient I got the chance to talk to was full of interesting stories from her older life. So many of the patients have a wealth of life experiences you just never seem to come across as a doctor, with the brief medical questions you ask. Ignoring all of these wonderful stories, this patient had gotten into a fight with her husband before coming into hospital and had managed to press the panic button on her personal alarm and ask for the police. The police had come around to her house and taken her late 80s husband to jail, and bought this lady into hospital to make sure that she was well. Being a lot better off than many of the patients on the ward, she seemed to be very bored a lot of the time as she was relatively well (some pneumonia signs were being checked out) but with no-one to talk to. After talking with her for some time she started asking me somewhat personal questions, such as 'Do you have a girlfriend' and 'How well do you get along'. This was followed after a while with a discussion as to whether I thought she was too old for me. After telling her that I was not free and at more than 4 times my age, perhaps she was a little too old, though no less lovely than anyone else I had met, she started to try and set me up with her granddaughter who was 'naturally blond' and about my age. What was I meant to say? Patients can be inappropriate.


You see a great wealth of things in hospital, and there is a large range of patients and doctors. This week we spent some time trying to communicate with a deaf patient and take a history from her using a large black marker pen and sheets of paper, so she could see what we were writing with her visual impairment. These sort of consultations take a lot more than 5 minutes.
There was a doctor this week who seemed obsessed with Sherlock Holmes (or House). Starting off by trying to deduce things about the surnames of the medical students, he got us following him around trying to diagnose patients without even talking to them. "Medicine is all about deduction". Interesting exercise, and a good doctor, though perhaps a little obsessive.
I saw a very anxious patient throughout this week. Every time I saw her she was sobbing and terrified that she was going to die. She kept telling us that bad things always happen to her, and she was afraid this was the end. She has had a lymphoma for some time but seemed to be otherwise medically (relatively) healthy. Despite this her attitude seemed to be having a negative effect on her health and she seemed to be deteriorating a lot faster than she was before. Emotions and feelings can be very important to the patient, all part of the 'placebo' effect.
A patient with Korsakoff's syndrome livened up the week. You get Korsakoff's when you are a chronic alcoholic and you quickly withdraw from your normal dose of booze, like the patient last week with the delirium tremens. This patient had started to suffer from Anterograde amnesia since admission to the hospital, meaning that he had had problems constructing memories since admission. Every day he would tell us that he was worse than when he came in, despite a marked improvement in his symptoms throughout the week. He just could not remember how he felt a week ago. An ex-CID policeman, he comes from a job with a known tendency for alcohol abuse. Once his wife had died, he ended up spending most of his time at home drinking. So many sad stories in elderly care. Patients can be upsetting.


When doing a general medical on call (not really part of the elderly rotation, but I was offered by a doctor to join them, and it sounded fun, so why not) I came across a lady who had overdosed on a drug called Clenbuterol (I thought it was called clenbutamol for a while. Drug names can be confusing!). A β_{2 agonist, this drug is very similar to Salbutamol, which asthmatics take in their inhalers. Usually used as a bronchodilator in horses by vets, this pill has become a popular drug for weight loss to buy on the internet. Overdosing on this drug had given this lady a marked tremor, but did not seem to be too dangerous with the amount she had taken. Talking with her about the overdose (she is young, in her early 20s) she tells us that she regretted it immediately after taking the drugs, so phoned someone to take her into hospital. Not having written a note, and not having planned it very well, this counts as a low risk attempt. These things have to be classified, and though it sounds harsh, this can be seen as more of a 'cry for help' rather than a definite suicide attempt. This is good for us, as it means we can get her a psych referral and help before she feels even worse and tries to do it again, perhaps with more conviction. The really dangerous overdoses are those who plan things out, write a goodbye note, don't tell anyone that they have overdosed, try and hide what they have done, or lock themselves in a room and do not regret trying to kill themselves. These people need very supportive care and a careful eye. Not that this patient didn't need support, but we could let her go back home without worrying too much about her. Patients can be suicidal.}

Final patient for this week, and final patient for my elderly rotation blog. This lady came in with pneumonia and, from her demeanour, seemed to be one of the classic 'bag ladies' who seem to wander the streets with no home and a supermarket trolley full of odds, ends and low quality alcohol. Not that anyone had any proof of this, and the patient was very confused and could not really tell us whether she owned a supermarket trolley, or fed pigeons in her spare time. Left on the ward in her bed, we came back to find an empty bottle of alcohol gel in her bed, and the patient sleeping soundly. We couldn't get out of her if she had drank this bottle, but we were sure not to put another at the foot of her bed in case it 'disappeared' like the last. After X-raying her chest, it seemed that her lungs had gotten a lot worse. Was the pneumonia not reacting to the antibiotics or had the lady inhaled half of the alcohol gel, which was now sitting in her lungs? A toxicology report of alcohol gel seemed to be pretty safe, apart from the high levels of alcohol! Some patients will do anything to try and get a fix. When I left the ward on friday the consultant was discussing with the X-ray team whether they would be able to do an X-ray of a bottle of alcohol gel to assess how radio-opaque it was. Patients can be sneaky.

Anyway, transferring over to a much slower psych rotation next week. It should be very interesting, what with all the amazing psychiatric disorders there can be, from the 'bog standard' schizophrenia to the weird and wonderful disorders such as Capgras delusion. I think I am going to miss the hustle and bustle of the hospital environment, though, with the fast bleeps going off calling doctors to nearby cardiac arrests and the urgency things can happen with. I think psych is a much slower, more laid back speciality because of the time it can take some of the drugs to work. Perhaps I will be proved wrong!