Monday, 29 October 2012

Change to surgery


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


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!


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


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!