Monday, 17 December 2012

Merry Christmas


Hi,



My last week before Christmas holidays, so a merry Christmas and a Happy New Year you all (or a 'Happy Holidays', depending on which you prefer). The last term has been 16 weeks long, which seems like it has been quite long, given all the essays and the SJT that have had to slot into it as well, so I am looking forward to a nice relaxing Christmas holiday, though revision will have to start soon for finals. Finals are still a long way off, around late March, early April (I think, though I am not definite), but I am not sure my usual revision method will work out too well (cram fervently a week or two before) due to the large volume of facts that I should know but I don't. 

As for this week, it was my last week of my obstetrics and gynaecology rotation. We only have two weeks of this speciality in 5th year, as we have some experience during our 3rd year, and this is meant to just be a refresher. I have been trying to make the most of it, as I cannot remember a lot of my third year as it was so long ago! 

The best part of this week was finally getting a chance to practice my suturing skills on a real live patient. Those who read this relatively regularly will remember that I had lots of practice last week in tying knots (though I did spend most of my post last week complaining about the SJT... sorry about that...) This week I got to practice them for real in theatre, closing up holes in the abdomens of all patients who needed a laparoscopy. These holes only need a couple of stitches  as they are pretty small (large enough to put a small camera down for the keyhole surgery) but its still good 'real life' practice for me. The gynaecological consultant is fantastic in trying to get me as involved as possible, and the team are great fun as well. I can see the appeal of being a surgeon. You do your work in the theatre, which you hopefully enjoy, then you get to go to the staff room and relax for half an hour or more while the patient is taken away, the new one is prepared and sorted out by the anaesthetist, and then you come back and operate again. Quite a relaxed job! 



I do have a scare in one of the theatres, though. I am late to one of the later operations, as I am answering a bleep for one of the registrars, which means I don't know why the patient is having this operation. I am asked to hold something for one of the more junior doctors, as he has to leave, and warned to be careful in case I damage the uterus. Not too sure how careful I need to be, I try and treat it like paper until he returns. Later on, they are talking about a ruptured uterus, and passing dye in through the cervix to watch it leak out into the abdomen. I am petrified that I have made a hole in this poor ladies uterus, but it turns out that she was being operated on for a suspected hole in the uterus, after having a hysteroscopy in Yemen (for some reason?!). I am very glad that this wasn't me, but I suppose this highlights the dangers of surgery and how you have to be careful with everything you do. It also highlights the dangers of having invasive tests done in an underdeveloped country.

While I had good experiences in theatre, I struggled to get much obstetrics experience at all. There are a lot of midwifery students at this hospital and, rightly so, they take precedence over me in getting involved in normal births. Because there were so many students, every time I went to the delivery suite, all women who were giving birth were already partnered with a midwifery student, and those who were due to come in had already had students assigned to them. I spent some time with the obstetrics doctor, though the doctors only tend to get involved when there are problems with labour, rather than in normal deliveries. I did leave my bleep number with the midwives, as they told me they would bleep me as soon as there was someone going into labour who didn't have a midwifery student assigned. I didn't get bleeped though. It is a shame, I agree that you don't really want more than one student in the room when there is a woman giving birth, and the midwifery students need a lot more experience in this than medical students do, but it would be nice to have just a little experience of normal births. I hope I don't run into someone in labour on a plane or something similar, or if I do, I hope there is a midwife present!

Anyway, have a lovely Christmas period, I am off now 'til Janurary, and I will keep you posted after that.

Monday, 10 December 2012

The SJT


Hi,



Despite my new start on an obstetrics and gynaecology rotation this week, the most 'important' thing that happened was sitting the 'Situational Judgement Test' (SJT) - if you want to have a bash at it yourself click here for the official practice site. The SJT is a test which gives you multiple choice options for 'situations' you may find yourself in as a foundation doctor, meaning it is not really knowledge based. This is the first year it has been used properly, so we will see what happens, and it is a test that every final year medical student in the UK now has to sit. It is important, as the results are used to allocate where you work on graduating, and which jobs you get. Do well and you could be doing paediatric surgery in GOSH (if you want...), do badly and you could end up in the Shetney Islands working with incontinent sheep... Well, perhaps not, but you get the idea.

The main problem with this test is that, amongst my year at least, it is perceived as much more of a luck-based-exercise rather than something that requires any skill. One of my friends was telling me that during the pilot phase, two groups were set the SJT, one who had been coached to do well, and the other one hadn't. No difference was seen between the two groups, suggesting that you couldn't practice for it. I don't really like this, as surely you should be able to practice for pretty much anything, from hard maths to soft 'communication skills' - they should all be something that you can practice and get better at. If practising the SJT questions doesn't make any statistical difference, then to me this suggests that the test is far more luck based than anything. After all, you could coach me for a year, but I wouldn't be able to get a (fair) dice to roll any more sixes than you could... 

As you can imagine, the feeling that where we will have to work in future, and the jobs that we can get is being decided by fortune has lead to plenty of outraged Facebook statuses and the like, but sadly there is little that can be done. Despite this feeling that it was luck-based, everyone (myself included) practiced as much as possible for it in the hope to get better scores. It would be stupid not to. I got a couple of books out of the library and have signed up to Pastest for exam revision (generally seen to be one of the better online question banks) as they also have SJT practice questions available.

The problem was, the books all contradicted each other. I looked at three in the end, 250 SJTs, the Oxford Assess one and a Third one. Of the three, I preferred the Oxford Assess one, though in some way or other they all contradicted one another at certain points. If they cannot agree on answers to questions, then how are we meant to be able to guess ourselves! Often picking the best one or two answers is pretty easy, but it is when ranking the 'inappropriate' ones that things get difficult. If the answers are all wrong, it is hard to decide which are more and less wrong. For example, in Pastest, there is a question about walking in on your registrar watching pornography in the mess, and you have to chose what to do about it. Pastest have decided that calling the police 'ranks higher' than doing nothing at all. I disagreed with this, as what interest would the police have in something which is not a criminal matter? Sure, it is very unprofessional, but I don't think the police would come and perform an arrest (though if it involved children I am sure it would be a very different story). I filled in a box at the bottom of the pastest page, saying I disagreed, and I got a very snotty email back from them telling me I was being foolish, and linking me to this article (which tells us the police did not bring charges anyway). I was impressed that they replied, and backed up their argument with a newspaper story, though. Despite this, the next day I was doing questions from the 250 SJTs book, and the exact same question came up, very almost word for word. the 250 SJT book had different answers, and told me that the police definitely wouldn't be called, as they were not breaking the law, and the police wouldn't be able to do anything. Crazy.

Anyway, the test went OK, though it is very hard to tell how well something that seems to have very little basis on fact went. I am not sure if the practice I did before helped, but at least if I do poorly and do end up working somewhere I don't want, I will not feel that it is through lack of trying. This whole section has turned into a bit of a rant about this test, so I am sorry about that!

In other news, this week I also spent time in gynaecology clinics, antenatal clinics and practising suturing with a very friendly consultant who will hopefully let me practice on real patients next week. The gynaecology team is lovely and very inclusive, so hopefully I will have a lot more to talk about next week when I am not raging about this test...

I will keep you updated on how my application goes, though I will not find out until February. 

Tuesday, 4 December 2012

Illness


Hi,



A late post, yet again, but I have been ill so perhaps that goes some way towards an excuse... This was my second (and last) week of paediatrics, so I spent time on the wards and ended up catching an infection from one of the ill little kids... The main thing of interest that happened this week (apart from the really important medical student getting ill) was a fantastic piece of clinical detective work which came from one of the doctors on the ward; something House MD would have been proud of.

Me being ill isn't really blog-worthy, so I will brush over it. There are a lot of sick children in paediatrics, especially babies with bronchiolitis around this time of year. I think one infected me with a virus (perhaps RSV, who knows) and I had to take the last day and half off last week with general coryzal symptoms, generalised myalgia and headache... Or man-flu... whichever you think fits best. I am feeling a lot better now, though.


It is a terrible disease... Honest...


Back on track, I spent most of the week when I was in hospital in a variety of different ward rounds and clinics with the nasty children which then went to make me ill. The best part was during a handover, when all of the patients are discussed between the day and night team, to make sure everyone knows what is happening with each patient at that moment in time. One of the patients, lets call him Billy, had been in the ward for the last few weeks, and was receiving chemotherapy for a rare type of cancer that had started in his tummy, but spread out across his body. The subsequent scans had suggested that this treatment was being very effective in controlling the cancer, and it was all shrinking, but overnight the night team had noticed that one of his pupils had become fixed and dilated (a blown pupil).


Blown pupil seen here in the patient's left eye

This raised a lot of worries, most importantly the worry that the cancer had spread to the brain, and was growing there, affecting the nerves coming out of the brain by pressing on them and creating this symptom. The night team had arranged a whole host of brain scans and investigations to be carried out this day to find out what was happening. One of the paediatric consultants, who always dresses pretty shambolically and behaves a little like a crazed professor started asking the night team questions

"Is the patient on hyoscine for the chemotherapy?"

Yes he is, they answered, he has a patch on at the moment

"Where is this patch, is it on his neck perchance?"

Why yes, its on the left of his neck, a bit above the clavicle"

"Well that is the answer, then. Hyoscine is an antimuscarinic, and the drug is passing through the skin into the blood vessels which then feed into the eye, dilating the pupil. Change the position of the patch."

And hey-presto, the patch position was changed to the other side of the neck, and the eye slowly went back to normal. A lot of stress for Billy and his parents avoided, and a lot of expensive (and radiation-filled) scans avoided. A simple diagnosis made without any fancy hospital tests, just a brain. That is the way medicine should be done!

To wrap up, the boy who was hallucinating snakes was discharged this week, with no medical cause found for these sightings. This is good, as it means he hadn't accidentally eaten some illegal/legal drugs, and he didn't have a brain tumour, but it did leave a question mark over the diagnosis. The children's psychiatric team were involved, who decided he seemed he may be slightly on the autistic spectrum (and wanted to follow him up), but they were not sure where these hallucinations came from either. The final decision was it must have been a nightmare which had started this off, and the psychological trauma which this nightmare (i suppose about snakes) had caused had lead to these hallucinations. This has been documented before. Not a perfect answer like I was hoping for, but it is the best we could get... A little like the finale of lost.


Monday, 26 November 2012

Hallucinating snakes


Hi,



A change of rotation again today, and onto paediatrics. The best part of this is the fact that I only need to be in at 9AM every day, meaning I get at least an hour of lie in extra compared to the last four months. Obviously this is not the only positive part of the change, and there are a lot of other lovely things around this change. Changing team is a shame, as the F1 I was with was lovely, though this hospital's paediatricians are also very nice. There are no F1s (first year junior doctors) on this hospital's paediatric wards, so this week I spend all of my time spread between a couple of different consultants and the doctors on their teams. Following consultants around is a little different to what I have been doing before, where I have been following around the most junior members of the medical team. This means I get less hands-on experience of what to do next year, but it does lead to a lot more teaching opportunities! 

The team I am with for the next two weeks (yes, that is all my rotation is, a measly two weeks) is really lovely, and I quickly felt settled in and at home. I suppose you would expect paediatricians to be caring, lovely people, if they wanted to look after children, but by the same logic you would hope that all doctors would be very helpful, as they have all chosen a caring profession! The consultants seem very keen on teaching, and the more junior members (who are all still a good few years post-graduation) are very happy to let us get involved, clerking children in when they are admitted to the hospital and doing as much as possible on the ward.

Each day starts with a morning meeting, which is why it cannot start earlier than 9. All of the patients who are in the hospital are discussed between the doctors, and treatment plans decided for each one. There are two main sections to the paediatric work, one dealing with the babies, I.e. those who have just been born or those who were born pre-term, and the other dealing with babies, children and adolescents with any problems that come after birth.

I split my time between the two sections this week, spending some time with the newborn babies doing baby checks. A great chance for me to practice this, which would make a good examination come finals, though it does open you up to be showered in wee by little baby boys... Less said about that the better. 

The other section involves ward rounds, diagnosis and treatment, much like any other medical ward, but in children. There is a large range of patients in the ward, from children being treated for cancer, to the omnipresent respiratory tract infection from RSV. This RSV infection seems to lead to most of the admissions, and plenty of sick wheezy babies. There is little that the hospital can do, and it is mostly supportive care while they get better themselves. 

My favourite patient on the ward at the moment is a 12 year old boy who, two days ago, started seeing hallucinations of snakes everywhere. I realise that my title sounds as though there are snakes hallucinating, but this is not the case (and I am not sure how you would be able to tell if it were). It was this boy who just started seeing snakes wherever he looked for no apparent reason. He has been in for a few days, and refuses to wear clothes as he is convinced there are snakes in them. As he is naked all the time, he has to stay in his room, but otherwise seems very lucid and collected. I had easy conversations with him, and we put jigsaws together and so on without any problems. He seems completely well, other than being able to point out these snakes he can see all the time. There always seem to be one or two present in a room at any time. He has had full toxicology screens for any drugs or substances he may have accidentally eaten, but everything is negative. There is no discernible cause for these hallucinations, though they are obviously very upsetting to him. At a loss of what to do, a referral has been made to the child psychiatrists to see what they think. I will keep you updated next week!

Monday, 19 November 2012

'Killing' a patient

Hi,


It's my last week on surgery, and I am now half way through the
rotations this year until my finals! A scary thought, as I certainly
don't feel as though I am anywhere near being ready for those exams -
but still not scary enough to start revising hard, sadly... As well as
the general surgery shenanigans I have been getting up to in the
previous weeks, this week I get to spend a day on the 'simulator', an
advanced electronic dummy that simulates medical problems and lets you
practice your diagnosis and treatment skills. This is something that
was mentioned to us at the university open day about 6 years ago, and
something I have been looking forward to since then!

Regarding the things I have been up to in surgery, I have kept on
doing ward rounds and ward jobs most mornings with the junior doctor,
who is really lovely. I also helped run a pre-op clinic where patients
were seen before their operation to check on their health, take blood
tests and so on. A very formulaic clinic where the same sort of
questions were asked to each patient, so I could be very useful here.
I also spend most afternoons in theatre, to make up for all the time I
have been missing over the last few weeks. Going to the theatre should
involve some acting talent or a lovely musical, but sadly in these
cases it involved cutting out gall bladders and a complicated
operation for pancreatitis where the necrotic 'rotten' pancreas was
removed by punching a hole all the way the stomach from the front,
using keyhole surgery, and draining out all the pus and dead tissue.
Watching the difference between the consultant and the registrar
operating was very interesting, as the difference in experience does
show. Both clearly perform safe and effective surgeries, only the
consultant does so much more quickly, and the movements he makes seem
a lot more confident and meaningful. It is almost beautiful to watch,
but I still don't want to be a surgeon and have to do that every day!

Onto the simulation training. As I said before, this was something I
have been looking forward to for ages. Imagine getting your 'own'
patient to try and diagnose and treat - its like being a real doctor
but with none of the responsibility if things go wrong. The mechanical
patient had a rising chest, pulses, heart sounds and opening moving
eyes, as well as veins which can be cannulated and lots more, meaning
loads of different diseases can be simulated, diagnosed and treated.

The way our session worked was there were four of us, and we were put
into two pairs. The idea was that one person would 'lead' a case,
while their partner assisted by doing things they asked them to do,
such as prescribing drugs and carrying out procedures such as taking
blood. In each scenario there was a trained nurse who would assist in
doing things a nurse would do, such as giving oxygen and administering
drugs prescribed. While all this was going on, the other two sat in a
different room, hidden by a one/two way mirror (why are these words
the same thing!), and watched what was going on to give feedback at
the end. The case I got was severe abdominal pain after binge drinking
in Ibiza, which I diagnosed as acute pancreatitis, (fortunate as I had
written an essay on this a week ago), initially giving fluids and
oxygen, then calling for a senior opinion. I did forget to do an ABG,
but other than that it all went very smoothly, though the 10-15
minutes the case took flew by in a whirl of activity. The excitement of
it, and how you get immersed in treating this very sick patient felt
quite real, and it makes me want to do acute medicine even more!

The case that I was there to assist my partner for did not go so
smoothly... This was a patient who had a severe respiratory infection
on top of a history of heavy smoking. She ordered all the correct
investigations and initial stabilisation of the patient was successful.
By this point we had both noticed that the patient was allergic to
penicillin, she by the wrist band on the patient and myself by
flicking through the 'admission notes'. Despite this, when working out
the CURB-65 score (a score used to see how severe pneumonia is), she
used the result to prescribe co-amoxiclav, which was an appropriate
antibiotic to give the patient. Other than the fact that they were
allergic to penicillin. Despite the fact that I knew about this
allergy, and had in fact only just written down on the drug chart that
the patient was allergic to penicillin, I went on and wrote up the
co-amoxiclav to be given, pretty much with the same pen stroke. Well,
the less said about this the better, but I can definitely say that
after making such a horrible mistake, that will stay in both of our
memories and we are very unlikely to make such a mistake again!
Despite having found out all the evidence (and knowing that we
shouldn't give co-amoxiclav, which all med students know is penicillin
based) we didn't link the two and gave it anyway. We were very lucky
it was only a dummy - but it does show how easy it is to make mistakes
in medicine, and the dire consequences that can come about if mistakes are made...

Monday, 12 November 2012

Brief orthopaedic stint


Hi,


Sorry for the brief late post this week, but things have been very hectic both in the hospital and socially, with no time to spare. I do realise I start most of my posts apologising for being short/rambly/late but that is just the British way - we love to apologise!

A pretty bitsy week this week, as it was a week of (poorly organised) orthopaedics, added to the fact that my car broke down part way through the rotation, leaving me stranded. That is all fixed now (at some expense) which is a blessing as a car really is a must at the moment! This week of orthopaedic surgery consisted of ward rounds, clinics and theatre time, much like my other rotations, only here they call them 'trauma' ward rounds, which makes them sound a lot more exciting. This, however, is a lie, and all they talk about during them is different eponymous operations, and bones. Lots and lots of bones. I noticed an interesting difference between some of the consultants though. One is very keen and does ward rounds himself twice a day, even when in theatre, while another does one a week, leaving the rest to the more junior members of staff. The former consultant tends to have two or three patients under his care at any time, as his are discharged very quickly, the other seems to have a dozen or so at the moment. This highlights the importance of consultant care when you are in hospital, and shows that they should do a lot fo ward rounds, as well as the fantastic work they do in theatre! 

One of the patients I was talking to on the ward had been sent back from a rehabilitation hospital with a more acute illness, but was begging to be allowed to stay in our (acute) ward rather than being sent back to rehabilitation. She claimed that the rehabilitation hospital was full of 'demented crazies' and she would go mad if sent back there. Currently not too sure what to do with her, as she cannot sit in her expensive acute hospital bed, stopping someone else from using it who has just broken a bone. Perhaps this case needs a consultant who comes around more than once a week.

That's all folks, next week perhaps I will be less busy... As you may have been able to tell, orthopaedics doesn't really interest me too much, and its harder to write about something you find less interesting!

Monday, 5 November 2012

There is no such thing as a free lunch


Hi,


Another week in my surgical placement, and I finally learn that I am on an 'upper GI' surgery placement. Still not 100% sure this is the team I am meant to be with, but they are really friendly so I think I will stay here. Should be a pretty similar experience to wherever else I end up put, as long as the signature at the end counts towards passing this year!

Its a very busy week, I tend to need to get in at 8, and leave between 6 and 7.30, and with 30 mins- 1 hour travel time each way, I can end up away from home about 13 1/2 hours a day. Doing this five days a week means I am effectively working 60-67 hours a week. For free. Rubbish! Leads to me feeling pretty tired when I get home, so I eat dinner and don't want to work, not good for the revision I am meant to be doing.

I spend much of my time in the wards, this is our 'post-take' week, meaning the floods of patients we admitted last week, we are now trying to get rid of, treat, or ignore. I can be very helpful as a lot of this involves no skill, but just chasing up results and updating lists. I do spend some time in surgery, scrubbing up and 'assisting' in a number of hernia repairs. While 'Assisting' sounds really important, it (as expected) just involves holding a retractor or pushing bowel around every so often. I don't think surgery is the career for me...


Its all the same thing...


In more positive news, the lovely man who I clerked last week, who ended up being rejected by the urology registrar for catheterisation and bled out of his penis for hours as a result and needed a suprapubic catheter is doing very well. I have been visiting him every day, and not entirely because I am very guilty about the mess the hospital has got him into. He is really nice and a fun chat for five minutes when I am waiting around. He told me that once he is out of the hospital he wants to buy be a few pints, a really nice offer, but I am not sure if I can be encouraging alcohol consumption (or even socialising with patients) so I politely decline. This is the great aspect of the job. Cutting people up and sticking your hands in their wounds in boring and nasty, its the personal aspect I love.

Being a surgeon is not all cutting, though. I am invited to a posh (and more importantly free) dinner part way through this week to 'discuss a certain surgical technique'. This fully funded sojourn (by an unknown, shady organisation that wasn't mentioned) involved a fifteen minute talk on this surgical technique at a hotel (surprisingly interesting), which was followed by an hours talk by an Olympic medallist (I have no idea why), about their experience of the olympic games. Very interesting. There was then a three course free meal with wine. Very classy! It did lead to me getting home at 11 this day, though, making it feel as though I spend my life in the hospital, but it doesn't seem as though other specialities have quite as many 'Jollies' as the surgeons. They always seem to be having important 'talks' which happen to be in posh hotels, or the Bahamas. Perhaps it is to make up for the fact that their job involves cutting up bowels, sticking their hands in poo, and never getting thanked as their patients are always asleep...

Monday, 29 October 2012

Change to surgery


Hi,



I change rotation this week, and location. I am now back living in my 'own' rented house with my flat mates, rather than the hospital accommodation I have been in for the last 8 weeks, and commuting an hour or so drive to another District General Hospital (DGH) every day. Living back with my friends is lovely, though there are bad aspects too. An hours commute rather than 2 minute walk means really early mornings, and the fact I am now living with my friends, and back in a city where I know lots of people, means that I am not spending much more time socially, and a lot less time doing any work. In summary, the move is good for me, though not good for my work or sleep. 

The new rotation I am on is surgery. This week our team was on take, meaning all surgical patients who came into the hospital (a surprisingly large number) came in under our team, meaning we needed to sort them out and either treat them, or somehow palm them off on a different speciality. Palming people off can be easy (if they have a fracture, orthopaedics love it) but is usually very complex, as many people get stuck in hospital for social or 'unknown' reasons, meaning they cannot be transferred to another ward. While being on take was really interesting for me, and meant I got to do a lot of history taking and so on, it also means I have spent no time in theatre yet, and actually still don't know what speciality within surgery I am placed on.



I was told I was being placed in breast surgery, but one of the junior doctors tells me that that the consultant I have attached myself to is an 'upper GI' surgeon. He spends all his time working away from the ward, and I have seen him for 2-3 minutes this whole week, so I have no idea. It is possible that I have spent a week with the wrong team, but its all learning I suppose!

It was a good week as well. Clerking patients in when they first get to hospital is something that I really enjoy doing. It needs a lot of brain power to work out which questions to ask to exclude the serious causes / cover the common possibilities, then use your information to decide which causes are most likely, and then order investigations (such as blood tests and X-rays) to prove or disprove your 'differential diagnoses', while excluding serious problems (like heart attacks). I really enjoy having to think like this, and it is much better practice for my finals than doing paperwork. I think working in A&E or an acute speciality where this is the norm would be something I would really enjoy.

This week I got to go through this routine with a number of different people, being the first person to see them, taking a history and examination, deciding what bloods to investigate, inserting a cannula to take the bloods and give fluids, taking them to the ward and deciding on the initial management. It was often hours and hours between when I saw them and the first time a doctor saw them, so making the right decisions is very important (or at least not missing something really serious such as a heart attack, or ischemic bowel!) Pretty stressful, but so rewarding.

One of these patients was in acute retention, meaning he hadn't urinated in 4 days. I requested an ultrasound bladder scan to see how much urine he had, and decided that he needed to be catheterised relatively soon, as he had a good few litres in there (as would you if you didn't go to the toilet for 4 days!). I took bloods (looking at kidney function, as this pressure may be damaging them) and decided to call the urology specialist in the hospital to help insert a catheter to relieve the pressure in the bladder. He had had previous surgery to the prostate, and had a stricture - normally catheterising himself but finding it impossible to insert over the last 4 days (hence the massive bladder). I thought that, if he cannot do it, despite having 5 years experience, there is no chance I will be able to! The urologist clearly didn't think so and SHOUTED down the phone at me for a good five minutes about how useless I was, how I was worthless and how dare I waste her time... Completely unnecessary, and time which could have been used catheterising my patient. Instead I had to ask my senior to do it for me, who was just a general surgeon. This went badly, and ended up with continuous bleeding from the penis, and a needle having to be pushed through the abdomen straight into the bladder to relieve the pressure (called a suprapubic catheterisation). It would be a good case for a 'told you so' to the urologist, if I wasn't so scared of her... Fortunately the patient was OK, and was very understanding and lovely about the whole thing. It always seems to be the lovely patients who end up with the raw deal... Since admission I have been to visit him every day, and he always gives me some grapes to eat (reason enough to visit!) and he is recovering well, with surgery planned for the Monday!

Catheterisation on the left, to get urine out of the bladder, and suprapubic catheterisation on the right, bypassing the penis and just putting a tube right through the belly into the bladder.

Monday, 22 October 2012

Calamity week


Hi,



But of a calamity week this week (especially Monday) coupled with moving rotation, and house, has ended up with a very rushed weekend! 

It is sad to change rotation again, and I have been feeling nostalgic towards the end of the week. Not for any real reason, as I have only been here for 2 months, and on this rotation for 4 weeks, but just because I am a bit of nostalgic person I think... The start was a lot rockier, however, and I managed to mess up quite a few things in the hospital.

You know how you can sometimes have 'one of those' days, where nothing seems to go right? I was having one this Monday, after staying up too late doing my essay on Sunday. Usually in life, this can mean dribbling soup over your shirt, or 'loosing' you glasses on the top of your head (I've been there...) but in the hospital there is so much more to get wrong. 


Forgotten where your glasses are? Worst that can happen is you look a bit silly...

I started off by taking an ABG down to A&E (I had not done it, was merely being the courier) and somehow breaking the ABG machine. IT ran out of paper, then started refusing to accept a new role. You can still get it to display results on its little monitor, but no more print outs to take back to the ward. Not sure what to do, I told one of the nurses, who seemed equally confused, and left quickly... 

Deciding to stay away from machines, I went around the ward to talk to a few patients. One of them has a syringe driver slowly infusing GTN into their system to stop them from having a heart attack. It is bleeping in an annoying fashion, something they do when they think the line is blocked (usually means the patient has done something 'foolish' like bending their arm). You can usually just silence them and all is fine. This is clearly upsetting the patient and the rest of the ward, so I try and silence it but somehow press the wrong buttons and stop the infusion all together. GTN works to expand the vessels in the body, stopping them from getting blocked and keeping the heart supplied with a good flow of oxygen. Now I have stopped it. I tell the patient what I have done, and get a nurse right away to correct my mistake. The right things to do, but I shouldn't have ruined it in the first place!

I go for lunch. I need some coffee and time to wake up. I come back from lunch, and am asked by  doctor if I can do some blood cultures for them. This is a skill I need to sign off, so I agree, despite my dopey behaviour. I am really careful with the patient, and get the bloods without hurting the patient (any more than usual) - then stick myself with the needle... ouch! Needlesticks in hospitals are a lot more hassle than the pain, as this is a potential way to catch diseases (such as hepatitis B/C and HIV) so I have to spend the rest of the day in occupational health taking with them, having my bloods tested, and having the patient's bloods tested for these viruses. Pretty scary, though I was pretty sure she didn't have anything like this. After this, I decide to go home and stay home 'til tomorrow, incase I made something go really wrong.


I was wearing gloves at the time, which is meant to decrease risk of transmission as the glove removes some of the patient's blood. It didn't look like this, though - this doesn't seem to have hurt the person at all (and there was more blood...!)

Despite my murderous rampage on Monday, the ward staff are really nice to me  for the rest of the week (or perhaps this is because of my rampage, and they hope to stop it from happening again). The end of the week is sad, and I say goodbye to all of my favourite patients. My favourites are two men at the end of the ward who constantly perv over the nurses and crack jokes to each other. They have both smoked far too much, and are quite ill, though still jolly. During my goodbyes, one of them tells me that he is "A bachelor  Not a GAY bachelor  oh no. A Fun bachelor..." which explains his nefarious plans towards the nurses. The other one spends some time cracking kilt jokes with me, before asking me if I wanted to be recommended by him to join the masons. He divulges that a few of the doctors he has met are masons (secret signals  and all) but won't tell me which ones. He tells me he is highly ranked, but I decline politely. I have more than enough 'communication skills' to learn for medical school, let along learning a load of new secret ones!

Monday, 15 October 2012

Where to go!


Hi,



So, another busy week, though its all the things out of the hospital that are keeping me busy now! At the moment all of the final year medical students are filling in their 'FPAS' applications to decide where they want to be placed, hospital wise, next year on qualifying. There is also another essay due, but I think people want to hear about that about as much as I want to do it, so I won't say any more about that!

The foundation application process is all pretty scary, to be honest with you. It is all about applying to work. as a doctor... I definitely do not feel ready at all, I don't seem to know anything and I have been enjoying my irresponsible student bubble for the last... 6 years and I am not sure how ready I am to be the professional knowing-everything person. I suppose you cannot stop the march of life, but I am enjoying myself right now. Obviously it is not that I don't want to be a doctor, after working for 6 years for this, I definitely do! It is just more that I don't feel ready in the slightest for all the responsibility. Its probably just some wobbles, I hope it will pass!

For finding out which foundation schools to apply to, there are a couple of useful sites to use: thequackguide and quackguide - both made by the same group, one just new (and not fully working yet). These are really useful in summarising all the statistics on competition rate, how big they are and people have written their views on each one (though as they are all positive this doesn't help too much). This brings me to the next scary thing about this application - deciding where to go. You apply to regions, and get them based on your ranking, which is based on how good you are in your year, other academic things, and a very unacademic test called the SJT. The London ones tend to be most competitive. Once you get into your region you are re-ranked and choose jobs, with those highest ranked getting the jobs first on their list. Do you apply to a competitive region and perhaps have less choice over job? Or do you apply to a less competitive region, have first pick of jobs, then end up living in hull? Not too sure, but whichever region you work in, people tend to stay in. I am just a bit worried about choosing where to spend a lot of my life already - everything seems to happen so fast and I don't want to grow up yet - perhaps I need a few peter-pan years of life!


A vaguely related, though fantastic, flow chart to help medical students choose their careers

Then again, perhaps I am just being lazy. After all - I am writing this instead of doing my essay for tomorrow, which says a lot... Perhaps if I don't hand in my essay I can have another year of medical school! Or maybe not the best idea...

So, getting back to my week, its been quite exciting, though shadowed a little by those two previous things. Most weeks are pretty similar, we are expected to spend the days on the ward apart from when we have lectures from the F1s, which serves as our 'peer teaching'. These lectures are actually really useful as, as I have said before, F1s have a good idea on what we want (passing exams [though I am not too sure this is what I want at the moment!]) so the lectures are usually aimed at the right sort of level. When on the ward I spend a lot of time following around the F1/SHO/reg/consultant like a puppy and doing the rubbish tasks for them like paperwork, bloods, cannulas and so on. The bonus of being on a respiratory rotation is that we do loads of ABGs, and I am getting quite good at them now! I did go to an MDT (Multidisciplinary team) meeting, where a variety of healthcare professionals talked about patients with lung cancer, but it was really sad so I don't think I will go again! 

A patient on the ward did have a respiratory arrest this week, which was exciting, seeing all the emergency protocols, and it was good because she was sorted out (had a chat with her the next day). I think emergency medicine could be the career for me - just so exciting! I also bought in my radio for a patient who is mostly blind and has pancytopenia, meaning he has to be kept in an isolation room to stop him getting an infection. He was touched, and it made my day, though it had gone missing by the end of the week! I hope someone hasn't moved it to a different ward (or stolen it!). Its those little things that make it feel like I can actually make a difference  despite being a pretty useless member of the team as a medical student!

Anyway, I procrastinate enough - off to essay!

Sunday, 7 October 2012

Bursting bladders


Hi,


A very busy week this week, and another short post. It seems the busier I am, the shorter the post as there is then more to do at the weekend. This week I see some strange things on call, I practice (and mess up) some procedures and I have a fantastic teaching success. 

While on call with my F1, I am asked to carry out a lumbar puncture by one of the doctors, as it will be a good 'learning experience' for me. I decline the offer, I don't think it is a good idea at all to have me sticking needles into people's spinal canals. I do watch it though, and the man it is being performed on has a snake tattooed up his back, the exact point where the needle needs to be put corresponding with the eye. It was strange, watching this needle be pushed into this tattoo's eye, as it looked on fearfully, and ended up with the snake 'crying' blood after the procedure. Very creepy... The on call was also full of other 'fun' experiences, such the man who was in urinary retention with a three way catheter in situ. Usually these catheters can be 'flushed'  to unblock them, but this catheter had been flushed multiple times by the nursing staff with nothing coming out, filling his bladder up ever more with the fluid.  His was well over a 1 1/2 litres on an ultrasound scan - a lot more than normal!!I wonder if its possible to burst from a huge bladder? [according to the guardian and BMJ, perhaps it is: Article here)

A strange, unrelated, bladder related advert

I have also been having a busy time on the ward, practising a lot of the minor procedures I will need to do as an F1. I have been doing a lot of ABGs, and inserting a lot of cannulas, and am now getting pretty good at putting cannulas in (I was pretty terrible last week) I managed to get an ABG on a woman with Parkinson's disease this week, which was a real challenge as her wrist was shaking all over the place. It wasn't all success, though, as later that day I tried inserting a cannula into a woman who had an INR of 8 (a measurement of blood clotting, and normally 1) which ended up with her bleeding all over her pillow and the bed. I did manage to get the cannula in, but had to ask the ward staff to change all the bed clothes as they were soaked. Very embarrassing, though fortunately she was very understanding and kind about it. When taking some of my blood results to the lab to be analysed, I have to wait outside in the public blood-testing area for my results. While waiting there, I decided to be a helpful little medical-student and asked a man, about my age, if I could help him - he looked a little lost... I got the po-faced reply "I am here to give a sperm sample, I'm not sure if I want your help"... Awkward times! I had to go and hide around the corner until he left...

A lovely patient was admitted to our ward this week, a man who was described by his son as 'normally really grumpy and cantankerous' but over the last few months had become increasingly more jovial and 'giggly'. He wasn't admitted to the ward for this, but for breathing difficulties. While it sounds lovely, someone enjoying their old age, this change of mood set alarm bells ringing in the consultant's head, and a CT scan of their brain showed a large number of brain metastases from a tumour elsewhere in the body. Getting cancer is a terrible thing, though if it makes you cheery and less bothered about it, I suppose it could be worse. It brings to mind the stories about people who almost die from drowning, who say in the last moments you lose all the worry and panic about it, and just relax and accept it. (for you medicine lovers out there, this is probably due to the hypoxia in the brain shutting down the areas which deal with this fear).

To finish of this week, I was at a bedside teaching session which was being run by one of the junior doctors. Here, they take a group of 2 or 3 students around 'interesting' patients in the hospital, where we perform an examination similar to how we would in our final exams, and present the findings. The idea is to improve our examination techniques, and to practice recognising common conditions. I was told to do a cardiovascular examination on my patient this week, the most important part being listening to the heart. I floundered a little, confused over why I couldn't really hear anything, but then remembered about the medical school myths of patients who have their hearts on the wrong sides of their bodies being bought in to flummox medical students in exams. I listened to the other side, and lo-and-behold, there was a nice beating heart sound! I didn't say anything, but let the other 2 in the group have a listen and went back to present it to the doctor. I presented it as a case of dextrocardia with a heart murmur  and was correct! Definitely a good feel-good factor to boost confidence! Hopefully that one won't mess with me if it comes up in the exams!
*geek out*

The heart in its normal postiion, and switched around in the inherited condition known as dextrocardia. I was so pleased I spotted this!

Sunday, 30 September 2012

Johnny Depp?


Hi,


My first week on the new rotation, and I am now on a respiratory medicine firm. It was sad saying goodbye to my old rotation, and I made them a cake as a thank you for putting up with me for the last month. The new set of doctor's whose task it is to look after me seem nice, so hopefully this month will be just as good. I tend to spend most of my time with the junior doctors helping out on the ward, and don't come into too much contact with the consultants who tend to run things from their offices or do clinics, apart from a few days a week when they lead ward rounds. This is very different from previous years where we tend to be attached to consultants in hospitals and clinics. Perhaps this is intended to teach us the knowledge in the earlier years (consultants know a lot) then teach us how to work as junior doctors now. In my opinion, the younger doctors are much better teachers. They have a good idea about what we need to know to pass exams (what we are interested in now) and the correct level to teach things at. The junior doctors will teach about how to recognise pneumonia or a pneumothorax on a chest X-ray, while consultants tend to tell us about things such as CT guided biopsies and other procedures we wouldn't be doing unless we were a consultant. I am sure these things are a lot more interesting, but just much less relevant to us.

And medical students...

Anyway, complaining over, its been a busy week. The most interesting parts were a crazy on call night in the hospital with a 'celebrity appearance', and a number of controversial decisions based around the Liverpool care pathway.

The Liverpool care pathway (LCP) is a way of treating patients in the last days of their life. The decision to put someone on the LCP is not taken lightly, and only made when it seems that they are going to die in the next day or two. It is often used in the very end stage of chronic diseases such as cancer. One of the patients on the ward was very ill, and the decision was made by one of the registrars to put him on  the LCP. The man couldn't communicate, seemed to be mostly asleep all of the time, and could barely breath. The LCP involves 'supportive' care, meaning that they are given drugs to try and make them more comfortable, rather than treatments aimed at 'curing' them (as by this point a cure is impossible). it also means that the family expect the death, and can visit the patient at any time, rather than just in visiting hours. The next day, the patient seemed to have perked up a little and seemed a bit more restless. This day the consultant was doing his ward round and decided that it was inappropriate for the patient to be on the LCP as he seemed to well. I am told that sometimes patients can seem to perk up a little once put on the LCP, as stopping the regular medications and trying to treat their symptoms only can help. Either way, the consultant spent some time berating the registrar for putting the patient on the LCP, talking about how inappropriate it was, and finally making her cry. Certainly not appropriate behaviour, especially as he hadn't seen the patient the day before. The consultant then went and told the family that the LCP was being stopped, and the patient could be back on normal treatment. The next day, after the patient had been put back on his regular medications, he died. The family were clearly upset about this, and the death now looks unexpected as the patient wasn't on the LCP, meaning it should be looked into further. Despite all of this fallout, the consultant isn't anywhere to be seen, running clinics this day instead, and leaving the less senior staff to sort out the ward. Now, I don't mean to be consultant bashing at all, as they do fantastic work, but this is pretty poor practice.

On more positive note, the on call I did this week was crazy. There was loads going on, including a child who had a cardiac arrest from an asthma attack (but it all turned out well, with her being successfully resuscitated). The most exciting part was when the rumour circulated the doctors that Johnny Depp had been admitted into one of the wards. Excited, and dreaming of some sort of romantic encounter, the junior doctor I was attached to hurried to the ward with me in tow. This rumour had obviously spread quickly, as there seemed to be most of the hospital's night staff hurrying to the same place. On arriving, we found a plump middle aged man, inexplicably dressed as a pirate and confused about all the attention he was getting. A wicked rumour!


Monday, 24 September 2012

Faking death


Hi,

Another slightly late post, but hey, I am kinda busy... :) This was my last week on my elderly/stroke medicine ward, before changing rotation. We have some fun with an alcoholic who wants us to provide him with special brew in A&E, a 'cardiac arrest' which turns out to be a patient who is holding her breath (...seriously), along with the slightly less serious but much more taxing challenge of how to give a drug called movicol to a patient who is only allowed to drink thickened liquids.

To start with, though, has anyone else read the House Of God? This is a somewhat cynical take on hospital life in the 70s, based around a intern's first year working in the hospital, often described as the 'Catch 22' of medical books. Well, I would definitely recommend it, very funny. I mention this because the 4 weeks I have spent on this stroke unit seem to be getting closer and closer to the world painted by the book. In the book, medicine is not about treating people and getting them better, so they can leave, it is much more about 'Turfing' them to another speciality or a nursing home (as chronically sick people rarely get 'better'). Working in stroke medicine, a lot of the patients on the ward are not expected to make a full recovery so a lot of the work the doctors do seems to be based around trying to get them into nursing homes or other less acute hospitals for rehabilitation. Unfortunately these homes and hospitals don't really want more patients to try and look for, being busy enough already, and try and avoid taking the patients, making it difficult to get rid of them. You can try and transfer more annoying and long term patients to other wards if you find other problems with them. For example, the lovely "BUGGER" lady who is still around is getting a little bit on everyone's nerves. If she were to catch a severe pneumonia from the hospital, then the ward staff would be able to transfer her to the respiratory ward. Fortunately it has not yet come to the tips offered by the 'House Of God' which include putting a patient's bed up very high, so when they fall off they break a hip and you can 'Turf' them to orthopaedics...



For anyone who has read the book.

Moving onto what I got up to this week, the introduction is a good summary of the bast parts. A man was admitted to A&E for a possible stroke, which was why I went down with the registrar to see if he could be thrombolysed. He had a severe weakness all down one side of his body, and could barely walk. After examining him, it was decided that he needed an urgent CT scan. The man was not happy about this, and told us he couldn't wait in the hospital as he really needed some beer. We could obviously not prescribe beer for him (though perhaps we should be able to...) so he started trying to hobble out of the hospital with his one good side. We stopped him, and put him back to bed while he muttered about his special brew, and went off to sort out an urgent CT scan for him. By the time we got back to his bed, he had disappeared and run away from the hospital under the guise of going to the toilet. If we could prescribe alcohol we could stop addicts from running away, and actually give them the care they need. Not sure it would work well in practice though, as I can imagine a lot of patients (and doctors) might take advantage of this... Interestingly enough, you can prescribe alcohol to patients (or children) who drink antifreeze, as it is an antidote... Perhaps useful knowledge to store for an excuse...

While we were in A&E, there was a cardiac arrest call, which involved all the acute teams bleeps screeching at them, and lots of rushing to the bedside of the patient to SAVE A LIFE! I went too, to see what was happening, and was greeted by a rather embarrassed looking junior doctor and a red faced patient. It turned out that the patient had  (for some reason) decided to hold her breath to see what happened, and the doctor had panicked and decided that she had died... You would think that these sort of things only happened in scrubs...

I did spend some time on my ward this week as well, spending a lot of it with the nurses to try and get some of my clinical skills signed off. Carrying out procedures went fine. The main problem was when we were trying to give movicol to a stroke patient. Movicol is a treatment for constipation, and works by keeping water in the poo in the bowel, making it runnier and easier to pass. Stroke patients who have problems swallowing cannot drink watery things, as there is a risk that the water can get into the lungs and cause an aspiration pneumonia, so there are thickeners that can be put in water, tea, and all other food stuffs to make them thicker and easier to swallow. Movicol comes in a sachet, and is meant to be mixed with water before drinking. It turns out that this osmotic effect of movicol cancels out the thickener effect in the water, and heaping thickener into a glass of water makes no difference as it stays watery, meaning the patient cannot take the drug. Feeling cunning, I suggested that we mixed it into the patients porridge, meaning he could eat it this way. Unfortunately the movicol turned the porridge into water as well. After many failed experiments with different food stuffs, my answer was to ask the doctor to prescribe a different laxative. Who knew that the nurses job could be so scientific!

Monday, 17 September 2012

Mad house


Hi,

The elderly medicine/stroke rotation madness continues as more crazy-seeming people are bought in. As I spend more time on the ward, I get more useful and thus actually get less of the things 'I' want done, done; and I get to enjoy free drug company lunches three days of the 5 weekdays!

So drug company lunches... Often meetings in the hospital are sponsored by a drugs company, who put up a little billboard outside the room where something to do with the hospital is being discussed. This may be a teaching session for junior doctors, or a management meeting. In response for putting this board up, and perhaps giving a little talk about their drug as people leave, they put on sandwiches for everyone who turns up (or in one case this week, a yummy hot meal). This is fantastic for Mr 6th-year-medical-student over here, living on the bread line (well, not quite), and doctors love them as well. Who doesn't like free food! I am not too sure how ethical they are, though. Drugs companies shouldn't be trying to 'curry' favour [see what I did there] from doctors with gifts of food, which mean the doctors spend the NHS money on more expensive/different drugs. All choices should be made using evidence as to which are the best to use! I would have thought that these boards and minute-or-two speeches wouldn't make much difference, but if they didn't, then why would drug companies pay the money for the lunches. They must do. I guess drugs companies will argue that they are just using these sessions for 'education', and informing doctors of the most up-to-date and effective drugs (as well as the most expensive, I would imagine). Oh well, definitely not something for me to wonder about too much. As a student the free lunch is something to look forward to!


Perhaps not quite this bad, but I am always sceptical with companies wanting to turn a profit getting involved in the NHS and healthcare

As I said before, it seems that the more I learn about the job of a junior doctor, the more useful I become and the less I get what I need to do. As a medical student what I really need to be doing is seeing as many patients as possible, getting used to signs and symptoms, and performing procedures such as putting in a cannula or taking blood. I have sign offs for these sort of things, which I have to have finished before I can graduate. Unfortunately, these are not the sort of things that the ward really needs doing, as the nurses can do most of the practical tasks. Instead, what really does need to be done is an absurd amount of paperwork for bloods, investigations  discharges, basically anything you can think of. I am spending most of my time being helpful, which is much appreciated, by helping fill all this in. Unfortunately its not too useful for my 'education' - though it does give me a good taster of what work is like as a Junior Doctor (a bit boring :P). Next week I am going to try and be a little more selfish and do what I want need to do. If anyone has time to do these things with me!

So, back onto the patients who have been admitted this week. Due (in part) to me being super productive [obviously other people are involved, such as physiotherapists, and speech therapists and so on] lots of people got discharged this week, meaning lots of new patients have been admitted to fill their places. Some of these were new admissions needing beds, and others were patients that other wards didn't really want, so somehow managed to get them transferred to one of our empty beds. A very sneaky practice indeed! We have a couple of lovely patients on the ward who don't believe me that they are in hospital. One things he is in an aeroplane, and insists that he is flying whenever you talk with him. These conversations are fantastic, and he really sticks to his guns. I asked him if he drove, and he told me that he didn't need to, as he had an aeroplane. The other is a lady who thinks she is on holiday rather than in a hospital. I haven't tried to correct her, as I think she is pretty lucky to think she is on holiday, She is loving it, and all of the free food that gets bought to her! Unfortunately these 'funny' pathologies are a result of a stroke and parts of the brain dying. Hopefully they will begin to gain more function, though I am not sure how realistic this is. People cannot be sent home on their own if they cannot look after themselves, so if they don't improve they will have to go to a nursing/residential home, or have a large care package for the home.

Other patients include a Spanish lady who has forgotten most of her Spanish and can only speak in English (very interesting) and a man whose symptoms of a stroke were the world 'melting' around him, like a nightmare world. He can still talk, understand, and make sense of things, but still has the sense that everything around him (and everyone) is 'melting'. Very disconcerting. 

Would your world meting around you give you a nostalgia trip?


The final patient who we got from another ward is a lovely little old lady who sits cutely in her chair at the end of the ward, and yells BUGGER at anyone who walks past. I have no idea what she has got, as I can barely have a conversation with her. A colourful character none the less though. Perhaps she has dementia and severe disinhibition? Very similar to one of the patients one of my friends saw in the acute medical unit this week. She had gone in to take an ABG and he told her that he had better get it first time, or he would spank her 'as he loved spanking little girls'...
We were not sure if he was ill or just a bit of a pervert...



 
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