Hi,
Lots done - A ward round covering every single surgical patient in the entire hospital, telling a patient on said ward round that they likely have cancer; clerking in abdominal pains, one of which included an argument between mother and daughter based around sexual activity (catholic mother) and then an argument around smoking, the situation resolved by getting the mother to leave briefly. Ward rounds not enough, I also saw surgeries including a scrotal exploration (looked as nasty as it sounds); an orthopaedic trauma surgery on a fractured hip and a surgery where someone had swallowed a biro and it had perforated their small intestine. On top of these surgeries I also clerked in a patient with a large gluteal abscess, performed a very bad attempt at taking blood and was part of the admittance procedure for a patient who had been bitten by an adder. All this with a twist at the end - could it be any better!
Starting with the ward round. It was long, I was on it for hours and it continued for hours after I had left. It took place at the weekend, meaning that there was just this one consultant surgeon to cover the hospitals surgical patients, meaning he wanted to see all of them. This is a very large hospital, and as such this as a mammoth task, especially given he was not the consultant for many of the patients. Despite this, the ward round was well organised and slick, with perfect interaction from the nurses. Often I do not see nurses on the ward rounds, but having them there was very helpful, as they tend to know the patients the best, and have an experienced and valuable viewpoint. They are also the people who dish out much of the care, so knowing what should be medically done for the patient is very important.
On this ward round, one of the patients was suffering from obstructed bowels, meaning she hadn't passed any motions in some time, and had a distended abnormally enlarged belly. After examination, the consultant decided that the cause must be a caecal tumour (how he knew this is impressive, just based on a mass in the lower right quadrant), and ordered a CT scan to confirm this. Despite the fact that this was a busy ward round, and there was no confirmation of the diagnosis, the consultant then proceeded to tell the patient that they probably had cancer of the colon, which was causing their symptoms, and that they had two choices - they could try operations on it to fix it, or 'just leave it be'. The patient was a very lively 90+ lady, whose son had also died of colorectal cancer. She was asking whether this meant that she would just be left to kick the bucket, and the consultant had to admit it depended very much on the imaging results. The lady was obviously somewhat upset, and we moved on to see another patient. All of this without a definite diagnosis - no imaging results, no blood tumour markers, just obstruction and a mass in the abdomen. I thought at the time that that was a risky thing to say. Why blurt it out in the middle of a busy ward round, when you cannot offer her any care or support, and it is not a definite diagnosis. Why not wait for it to be confirmed and let the normal consultant or registrar give the bad news when more time is available. I suppose I am not in a position to question a highly qualified consultant, perhaps he was trying to make his colleague's lives more easy.
Whilst clerking in patients whilst on surgical take, I saw a variety of cases, mostly to do with abdomens. There are plenty of things which can go wrong with your abdomen, most of them can be dealt with surgically, so surgeons tend to deal with abdomen pain in the hospital. One of said people I was clerking in was a 17 year old girl, who was presenting with recent onset right iliac fossa pain. This is a typical presentation of appendicitis, but can also be mixed up with other diseases as well, such as pregnancy and other problems with your 'woman's bits'. After the history and examination, we had to perform some tests to try and help us determine the cause. If it was something critical such as acute appendicitis, this would mean that the patient would need an operation fast. If it wasn't then it was a lovely sunny weekend, and I am sure the patient didn't want to be wasting her time in the hospital. A urine test is used to look for UTIs and pregnancy, along with bloods to look at markers of appendicitis. When the urine test was mentioned to the girl, the mum chimed in with "that's not necessary, we are Catholics, no sex before marriage and all that". I am sure I do not need to explain to you that many children do not follow parent's wishes, and this was not a good reason to exclude pregnancy or an ectopic from the differentials list. It was attempted to explain to the mum that this was a routine investigation, and everyone of childbearing capability (pretty much 12 upwards) who presented like this had this, but the mum was insistent. Finally a result was reached when the daughter told her mum to back off and "let them do their job". Fortunately the test came back without pregnancy markers, or that could have been an awkward conversation. A similar problem occurred between these two later in the consultation when the daughter was asked if she smoked, and replied no. The mum chimed in this time, telling us that the daughter did smoke, but didn't want the mum to know. Awkward silence followed by half-hearted attempts of the daughter to deny this. This family needed to communicate with one another more! The mum was persuaded to leave the room for a bit for a drink, and then the daughter was asked the more intimate questions about sexual contact and so on in confidentiality (to exclude STIs). The results were, surprise surprise, confidential.
Surgery-wise I had a great stint getting involved in surgeries. I went to the theatres, but as it was the weekend there were only 3 theatres open - an emergency surgery theatre, an emergency trauma theatre and a private patients theatre. I spent some time in the two emergency theatres (sound a lot more exciting than the routine private patients one - who knows, I might get ambushed by a TURP again...). Here I saw a range of operations, the more interesting I mentioned before. The scrotal exploration was due to a suspected torsion of the testicle. This involves the testicle twisting around, and cutting off the blood supply to itself. If this isn't treated within hours it kills the testicle, which has to be removed. Seeing the first cut was more than enough to make me wince away, and the smell of burning testicle from the cauterizing was one I was more than happy to get away from. In the trauma theatre I spent my first stint of time with a group of orthopaedic surgeons. They were lovely, gave a good teaching experience about hip fractures and I got to see a hip fracture being fixed with a dynamic hip screw method, allowing the bones to compress on one another, helping them heal back in.
The last surgical case I saw was the interesting condition of BIC-ili-perforation. While not an 'actual' medical condition, possibly due to its rarity - this condition would involve the ingestion of a ball point pen (preferably of black variety) and then subsequent perforation of the ilium, leading to the necessary surgical removal of said object and great excitement of the medical student who is floating around at the time, checking out the emergency surgery list for anything exciting or interesting looking. Not too much to say about this operation really, but once the pen was removed and the hole in the bowel stitched up, I left - I have seen plenty of people closed up again, and I wasn't scrubbed in so wasn't assisting. There is always plenty going on to get involved with instead.
In Saturday evening, I was around in A&E hoping to get involved in the busy, manic rush that I assumed a Saturday night would entail. I was very disappointed with the result - one mandibular fracture came in and the person couldn't be operated on because of their intoxicated state, but the place was near deserted. What was happening? I wanted some practice at a variety of procedures, so made myself known to the A&E doctors, offering to do any mundane tasks they needed to do. I got offered a few techniques I didn't know how to do, such as inserting a catheter and a lumber puncture, both of which I politely declined, I was pretty tired by this point and just wanted to practice something simple, not mess up something new. I got offered a simple taking venous blood off of a man who had come in with hypoglycaemia. Excellent - simple, run of the mill job. I got the stuff ready and went to talk with the man, who was a lovely chap. I was getting a load of wonderful stories from him from the time he got shot in NY (he had the scars to prove it) to the time when he played with a well known jazz player. whilst I tried to find some veins. This proved somewhat harder than I was hoping, unfortunately. He had suspicious track marks (read heroin) on both arms, and didn't seem to have any veins available. After discussions with this laid back chappy, he was more than happy for me to try and get blood from whatever I could feel. I tried, a number of times, and managed to get one bottle. I needed 3, though, and after stabbing him about 5 times with the needle I decided that this wasn't really fair on him and I would go and get an experience member of the A&E staff to sort him out. He was more than happy with what was happening, which was the main reason I had more than two tries.
"Try again man, its not a problem at all, I have had far worse. I've been shot, you know"
After talking to a registrar on take, he told me that they didn't really need bloods from this chap anyway, and I should just send off whatever I managed to get. Hypoglycaemia is pretty simple. Fortunately I had got the more important bottle (always start with most important, in case the vein collapses) - the full blood count, which would show whether it was an infection which lead to his hypo. After sending it off, I started to get a niggling feeling that I managed to to somehow label it wrong, and it would not even get through. Not much that can be done about that now, unfortunately.
That was an unsatisfactory end to a very satisfactory day. Yes that is the 'twist', if you hadn't realised yet. Not exactly a twist, or exciting, but if I am going to write, why not play with words. All mentioned in this whole post was during my Saturday on take. Other things went on this week, but Saturday was great fun. In the hospital from early morning to night time, a long shift by which I seemed to be failing as a medical student, so I escaped back home to bed. I have missed out parts of this in this post, most notably the man who had gotten bitten by an adder and the quest for anti-venom but I run out of time and risk making you bored, so I shall end here. A very busy very satisfactory day on take. I look forward to graduating. Having the variety and excitement of this every day, all day would be more that I can wish for.
I hope you had a good weekend as well.
Starting with the ward round. It was long, I was on it for hours and it continued for hours after I had left. It took place at the weekend, meaning that there was just this one consultant surgeon to cover the hospitals surgical patients, meaning he wanted to see all of them. This is a very large hospital, and as such this as a mammoth task, especially given he was not the consultant for many of the patients. Despite this, the ward round was well organised and slick, with perfect interaction from the nurses. Often I do not see nurses on the ward rounds, but having them there was very helpful, as they tend to know the patients the best, and have an experienced and valuable viewpoint. They are also the people who dish out much of the care, so knowing what should be medically done for the patient is very important.
On this ward round, one of the patients was suffering from obstructed bowels, meaning she hadn't passed any motions in some time, and had a distended abnormally enlarged belly. After examination, the consultant decided that the cause must be a caecal tumour (how he knew this is impressive, just based on a mass in the lower right quadrant), and ordered a CT scan to confirm this. Despite the fact that this was a busy ward round, and there was no confirmation of the diagnosis, the consultant then proceeded to tell the patient that they probably had cancer of the colon, which was causing their symptoms, and that they had two choices - they could try operations on it to fix it, or 'just leave it be'. The patient was a very lively 90+ lady, whose son had also died of colorectal cancer. She was asking whether this meant that she would just be left to kick the bucket, and the consultant had to admit it depended very much on the imaging results. The lady was obviously somewhat upset, and we moved on to see another patient. All of this without a definite diagnosis - no imaging results, no blood tumour markers, just obstruction and a mass in the abdomen. I thought at the time that that was a risky thing to say. Why blurt it out in the middle of a busy ward round, when you cannot offer her any care or support, and it is not a definite diagnosis. Why not wait for it to be confirmed and let the normal consultant or registrar give the bad news when more time is available. I suppose I am not in a position to question a highly qualified consultant, perhaps he was trying to make his colleague's lives more easy.
Whilst clerking in patients whilst on surgical take, I saw a variety of cases, mostly to do with abdomens. There are plenty of things which can go wrong with your abdomen, most of them can be dealt with surgically, so surgeons tend to deal with abdomen pain in the hospital. One of said people I was clerking in was a 17 year old girl, who was presenting with recent onset right iliac fossa pain. This is a typical presentation of appendicitis, but can also be mixed up with other diseases as well, such as pregnancy and other problems with your 'woman's bits'. After the history and examination, we had to perform some tests to try and help us determine the cause. If it was something critical such as acute appendicitis, this would mean that the patient would need an operation fast. If it wasn't then it was a lovely sunny weekend, and I am sure the patient didn't want to be wasting her time in the hospital. A urine test is used to look for UTIs and pregnancy, along with bloods to look at markers of appendicitis. When the urine test was mentioned to the girl, the mum chimed in with "that's not necessary, we are Catholics, no sex before marriage and all that". I am sure I do not need to explain to you that many children do not follow parent's wishes, and this was not a good reason to exclude pregnancy or an ectopic from the differentials list. It was attempted to explain to the mum that this was a routine investigation, and everyone of childbearing capability (pretty much 12 upwards) who presented like this had this, but the mum was insistent. Finally a result was reached when the daughter told her mum to back off and "let them do their job". Fortunately the test came back without pregnancy markers, or that could have been an awkward conversation. A similar problem occurred between these two later in the consultation when the daughter was asked if she smoked, and replied no. The mum chimed in this time, telling us that the daughter did smoke, but didn't want the mum to know. Awkward silence followed by half-hearted attempts of the daughter to deny this. This family needed to communicate with one another more! The mum was persuaded to leave the room for a bit for a drink, and then the daughter was asked the more intimate questions about sexual contact and so on in confidentiality (to exclude STIs). The results were, surprise surprise, confidential.
Surgery-wise I had a great stint getting involved in surgeries. I went to the theatres, but as it was the weekend there were only 3 theatres open - an emergency surgery theatre, an emergency trauma theatre and a private patients theatre. I spent some time in the two emergency theatres (sound a lot more exciting than the routine private patients one - who knows, I might get ambushed by a TURP again...). Here I saw a range of operations, the more interesting I mentioned before. The scrotal exploration was due to a suspected torsion of the testicle. This involves the testicle twisting around, and cutting off the blood supply to itself. If this isn't treated within hours it kills the testicle, which has to be removed. Seeing the first cut was more than enough to make me wince away, and the smell of burning testicle from the cauterizing was one I was more than happy to get away from. In the trauma theatre I spent my first stint of time with a group of orthopaedic surgeons. They were lovely, gave a good teaching experience about hip fractures and I got to see a hip fracture being fixed with a dynamic hip screw method, allowing the bones to compress on one another, helping them heal back in.
The last surgical case I saw was the interesting condition of BIC-ili-perforation. While not an 'actual' medical condition, possibly due to its rarity - this condition would involve the ingestion of a ball point pen (preferably of black variety) and then subsequent perforation of the ilium, leading to the necessary surgical removal of said object and great excitement of the medical student who is floating around at the time, checking out the emergency surgery list for anything exciting or interesting looking. Not too much to say about this operation really, but once the pen was removed and the hole in the bowel stitched up, I left - I have seen plenty of people closed up again, and I wasn't scrubbed in so wasn't assisting. There is always plenty going on to get involved with instead.
In Saturday evening, I was around in A&E hoping to get involved in the busy, manic rush that I assumed a Saturday night would entail. I was very disappointed with the result - one mandibular fracture came in and the person couldn't be operated on because of their intoxicated state, but the place was near deserted. What was happening? I wanted some practice at a variety of procedures, so made myself known to the A&E doctors, offering to do any mundane tasks they needed to do. I got offered a few techniques I didn't know how to do, such as inserting a catheter and a lumber puncture, both of which I politely declined, I was pretty tired by this point and just wanted to practice something simple, not mess up something new. I got offered a simple taking venous blood off of a man who had come in with hypoglycaemia. Excellent - simple, run of the mill job. I got the stuff ready and went to talk with the man, who was a lovely chap. I was getting a load of wonderful stories from him from the time he got shot in NY (he had the scars to prove it) to the time when he played with a well known jazz player. whilst I tried to find some veins. This proved somewhat harder than I was hoping, unfortunately. He had suspicious track marks (read heroin) on both arms, and didn't seem to have any veins available. After discussions with this laid back chappy, he was more than happy for me to try and get blood from whatever I could feel. I tried, a number of times, and managed to get one bottle. I needed 3, though, and after stabbing him about 5 times with the needle I decided that this wasn't really fair on him and I would go and get an experience member of the A&E staff to sort him out. He was more than happy with what was happening, which was the main reason I had more than two tries.
"Try again man, its not a problem at all, I have had far worse. I've been shot, you know"
After talking to a registrar on take, he told me that they didn't really need bloods from this chap anyway, and I should just send off whatever I managed to get. Hypoglycaemia is pretty simple. Fortunately I had got the more important bottle (always start with most important, in case the vein collapses) - the full blood count, which would show whether it was an infection which lead to his hypo. After sending it off, I started to get a niggling feeling that I managed to to somehow label it wrong, and it would not even get through. Not much that can be done about that now, unfortunately.
That was an unsatisfactory end to a very satisfactory day. Yes that is the 'twist', if you hadn't realised yet. Not exactly a twist, or exciting, but if I am going to write, why not play with words. All mentioned in this whole post was during my Saturday on take. Other things went on this week, but Saturday was great fun. In the hospital from early morning to night time, a long shift by which I seemed to be failing as a medical student, so I escaped back home to bed. I have missed out parts of this in this post, most notably the man who had gotten bitten by an adder and the quest for anti-venom but I run out of time and risk making you bored, so I shall end here. A very busy very satisfactory day on take. I look forward to graduating. Having the variety and excitement of this every day, all day would be more that I can wish for.
I hope you had a good weekend as well.
Your lying, deceiving Mother-daughter pair seem to have materialised from an episode of House!!
ReplyDeleteSounds like a fun week!!
Fantastic blog, its a rare insight to hear about what third year medical students get up. It lovely that you take the time to let the world know.
ReplyDeleteI'm thinking about studying medicine and one of the things I'm a bit scared of is disagreeing with other hospital staff, if I feel like something could have been handled better.
Personally, in situations like the one with the 90+ lady, I'd probably be the same and not say anything although I found it a bit off.
My usual trick is to try to think up a non-threatening, light-hearted way to question what just occured, only to find that the moment has passed!
Here's to being able to say something next time!
Thanks for the positive feedback, always good to hear something nice!
ReplyDeleteIts a good plan taking a light-hearted approach - I like it. That way you can put forward your point of view without seeming confrontational. Next time, huh!
Don't let being scared of confrontations put you off of medicine. I think most jobs will have disagreements within them, unfortunately.