Sunday, 30 September 2012

Johnny Depp?


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


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


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...

Sunday, 9 September 2012



This has been a crazily hectic week, with my ward seeming more like the set of a sitcom than a hospital. We have had a psychotic patient setting off fire alarms, angry grannies stealing other's zimmer frames and pushing the users to the ground, the 85 year old man who starts each day with 40 press-ups (even after his stroke) and many more. As if this cast wasn't enough to fill up my week, I have also had a busy week for learning, certifying my first death after one of our patients died, learning about the complexities of the social service and trying to get patients out of hospital, and even impressing a VIP with my diagnostic skills!

OK, so quite a good spread of things to talk about, but I will try and keep things short and sweet. Looking back on some of my blog posts, they do tend to ramble a bit, and have some 'flight-of-ideas' elements. Don't section me yet!

The ward I am on has a lovely community feel to it. Because many of the patients are there for a month or two, they get to know one another, and each others families really well. This makes the morning ward rounds, and the jobs afterwards really nice to do, as they will be chatting away with one another, and able to tell you how the patients who are unwell have been doing overnight. 'Jobs' involve all the things that need to be done each day for each patient. These actions are usually decided by the consultant who leads the ward round, and then left to the junior doctors (and medical student!) to sort out over the day, so the results can be presented to the consultant the next day. These can range from taking and monitoring blood results, to organising complex scans and calling nursing homes and relatives to get the patient out of hospital. 

When a new patient comes along, they seem to bring their own personality into this ward environment (assuming they are concious), adding to the friendly atmosphere. The elderly man who does his push-ups at 6.30 every morning who I mentioned before is one example of this, as is the older women who goes around stealing other people's walking apparatus as they are using it. My favourite is the anxious man who has an old tracheotomy which is still healing, and an ulcer just below. For some reason, he has been given 'larvae therapy' (maggots) to help clean this ulcer out, but he is petrified that these maggots will climb down his tracheotomy hole and into his lungs. He seems to be living in constant fear of his lungs filling with maggots (it really doesn't sound nice!). Some patients are more adorable than others, but each brings their own personality to the ward, and adding to that 'zany' sitcom feel. 

Unfortunately there was some trouble with the patient who last week was involved in the shouting match with the grieving relatives while he was having hallucinations. We were having some trouble discharging him, as his wife and family had turned off their phones so we couldn't get hold of them. When we finally did, they admitted that they didn't want him at home, so were trying to keep him in hospital for as long as possible. Before we managed to get him discharged, he managed to set off the fire alarms in this wing of the hospital and escape in the following commotion. Early this week we finally discharged him, only for his family to bring him into A&E a couple of days later as he was 'insufferable'. I am not sure that this is a medical condition, but despite this he headed right for our ward, saying we were friendly, and kept trying to get in to get into one of our beds. He had clearly forgotten me getting him in trouble with the grieving family, and he tried getting into the ward for most of a day before he left. We haven't seen him yet. I hope the family get the help they need, but trying to stick him in hospital really isn't the right thing to do!

A number of the patient's in the ward are nigh on un-dischargeable at the moment, because of their GP situation. Both of these patients had a stroke some time ago, and are now medically pretty well. They both need some rehabilitation to help them learn to cope at home, but there is no reason for them to be in an expensive hospital bed. Sadly, we cannot get rid of them. One of them moved here from Poland 15 years ago, and despite being a GP resident still hasn't signed up for a GP. The other one was recently kicked out of his house by his "scumbag ex-wife" and is now living in a shed behind a pub. His GP is now in a different county to his address. It seems that both of these people will not be accepted into some sort of rehabilitation programme by the community because of these reasons. The man without a GP cannot really leave hospital until he has this rehabilitation, but cannot have this rehabilitation until he has a GP, it seems a little catch 22. The other man will not be accepted by either counties community workers, one because his home address isn't there, the other because his GP isn't there. It seems that a lot of these complaints are delaying tactics, used to delay the need to take patients on. It seems pretty silly to me, as a hospital bed is much more expensive than having someone cared for in the community, but everything seems to be political...

I have a couple of fantastic 'on-calls' this week, which I spend shadowing the junior doctors. learning about their job (which I will have to do next year!) and helping out where I can. I start of learning that chlorpromazine is a fantastic cure for hiccups, but from then on, things seem to get more cynical. The junior doctors are discussing their pay and the hours that they have to work, and things do seem somewhat unfair. They are upset that they have to work a lot longer than their contracted hours to give the care that patients need, but are only paid for the basic hours. Both of the juniors I am spending the evening with are seriously considering changing careers away from medicine. Its a big shame, as they are both lovely people. I am not really sure what needs to be done to keep people happier in the cash-strapped NHS, but I suppose that is why I am not going into politics! 

Towards the end of the on-call, the junior doctor is bleeped to certify a patient dead. As this is something I haven't really encountered before, she gets me to go into the room and do all the relevant examinations to show that they are dead (things like testing the reflex of their pupils, and listening for their heart for one minute). Certainly a good learning point, but very strange, as you need to be in this room for a good 5 minutes to perform all these tests. The both of us in a side room with a corpse was a little creepy, but I can imagine that when on your own, at 2AM, having to walk into rooms with dead people in them, look into their eyes and sit with them listening for sounds of life for minutes could be very strange.  Definitely not something I am looking forward to!

Hopefully not, but you do hear of it happening...

To finish on a more positive note that that morbid image, I can tell you about my great success of this week. I was at an event put on by a group who gave me some funding for my medical elective this weekend, and there were quite a few important rich people there. I was circulating around and chatting away, answering all the usual 'medical student' questions, when one man asked me if I could diagnose a condition that he had. Its pretty common for people to ask me if I can diagnose things, and its even more common for me to have no idea what the answer is, but I said I would give it a go. He told me how he had tooth pain and went to the dentist, who diagnosed him and took out a molar. The pain continued, so he went to the dentist, who took out another tooth. I interrupted him here, and told him that it sounded a little like trigeminal neuralgia. He was incredibly impressed, telling me that he had 4 teeth removed before he was referred to a neurologist, who then managed to make this same diagnosis. I didn't tell him that this was a pretty 'barn door' presentation that we are taught about in medical school - with people sometimes coming to the doctor having had all of their teeth removed, to find out what is causing the pain. Perhaps I should have asked this rich gentleman for a job, given the moaning of the junior doctors I have spent this week with, or even better, charged him £100s for a 'consultation fee'! 

The trigeminal nerve causes trigeminal neuralgia, meant to be one of the most painful things a human can experience! 

Monday, 3 September 2012

The final lap


I am back, for my final year, and for some more posts. In the olympic spirit, this is now the final lap of my Farah race, certainly not a Bolt sprint! I had a nice summer holiday away from Uni, and I hope you lot did too! I will try to be a little bit better at posting this year, it seems I will be sepnding a lot more time in the hospital (more like my third year) and a lot less time on coursework. This can only be a good thing, as I really do enjoy going into the hospital (and I hate coursework with a passion!). All my exams from last year were passed, which is nice, and all that stands in the way of me and my Dr-ness is this year. Lets go!

For the next 8 weeks I am on a rotation in a small hospital, far far away. It is so far far away from my ‘home’ hospital that we are given accommodation, which is pretty funky. I currently sleep in an NHS bed, with hospital sheets and an NHS towel. Its as though you get to bring the hospital home with you (!) The hospital itself is very long, thin, and short. It seems to have been decided that building along is a lot more fun than building up, which means it is about ½ a mile long (I have been told this figure by many doctors since starting) which means you have huge long corridors ahead of you whenever you change departments, and it takes ages going places. I think tower-like hospitals seem a lot more efficient. Anyway, this long, yet small, hospital is my home for the next 8 weeks, where I am doing an elderly medicine and a general medicine rotation.

I am starting on an elderly medicine rotation, and am definitely thrown in at the deep end. My department deals predominantly with strokes, and employs a lot fewer doctors than it should, so it is always very busy. Despite this shortage of doctors (or perhaps because of it) there has been between 1 and 3 of the four doctors on the ward each day. I have been very busy trying to help out on the ward, and have ended up in the ward for over 12 hours most days. I suppose its preparing me to sell my social life for the junior doctor years!

The two doctors who I spent most of my time with are very good though. One F1, one CT1 (three years after graduating), they let me get very involved and over this week I go on call, where I see lots of problems and realise that being ‘on call’ seems to mean answering your bleep constantly and never having any time to see the mounting patient list, I get to look after patients in A&E when the come in, and I manage to get into a shouting match with a psychotic patient and a grieving family. At the moment, it seems that the smaller the hospital, the more you get to do and the more involved you get to be!

So, moving onto what I got up to this week, I spent most of my time following around the F1 or the CT1 and doing the jobs that they don’t really want to do, or don’t have time for. This does involve a phenomenal amount of paperwork, from blood requests to ‘TTOs’ (papers which let a patient be discharged from hospital) I definitely don’t look forward the paper-work-swamp that is a junior doctor’s life.

While I was helping my team out in A&E, I was asked to call a patient’s daughter to find out what had happened to him. He was pretty confused, and all the paramedics had been told was that he had had a fall at home. Falls in older people is pretty common, and comes with a barrage of tests such as 24 hour ECGs and head CTs to find the cause, and to make sure there is no injury. While he was being put through these, I called the daughter and found out that he hadn’t actually fallen, but had just felt unsteady and sat down. He was slightly demented, so we couldn’t get a good history from him, but this had been mistaken for new confusion, which had sparked the worry that he had hit his head, which was why the head CT was needed. Just a simple call could have saved all of these pointless investigations. I would love to say that I helped out by making that call, but it was too late, and he had already had many of the investigations anyway. Perhaps if I see someone like that again, I will make sure to get a proper history first!

I spent an evening-night on call with an F1, which involves holding a bleeper and covering all the wards in the hospital, meaning if they have any problems which need a doctor, they can bleep you and you are expected to go there and help them out. We were contacted about a whole range of things in the night, from patients falling over going to the toilet, to weird fits and strange ECGs; from massive prescribing errors made by the junior doctor normally on the ward (80mg Clexane twice a day in a little old lady, leading to an INR of over 5 as ‘DVT prophylaxis’) to disturbed levels of potassium in the blood. It seemed that half the patients in the hospital seemed to have suddenly developed problems with their potassium levels! The problem was that with all of these problems coming in thick and fast from the length of this ½ mile long hospital, there was no real time to go and see the patients, so this list got longer and longer and longer!

I spent some time on the ward as well, trying to help out the smooth running by talking with patients and family. It feels as though I would be a lot more use if I could, I don’t know, help a patient wash or go to the toilet, but I am not trained so cannot do that. I am stuck as a pretty useless medical student trying to help out however I can. One patient did present who I could distract at the end of this week, and this is what happened.

The patient was having alcohol withdrawal-based hallucinations on the ward, and behaving psychotically, interfering with the other patients, trying to take out their drips and so on. I decided that this was something that the medical student could have a go at helping at, and persuaded her to come to the ‘day room’ with me to watch a little TV. Here I should explain that the day room is a room off the ward with some comfy sofas (and a TV) where relatives can go to get away from the ward and have some time alone. Given the fact that this is an elderly/ stroke ward, there are a lot of sad looking relatives around, and I wasn’t surprised to see three people sitting in there in silence. I politely asked if we could sit down and turn the TV on, to which they answered “Suppose so”. Not the most positive of replies, but it certainly wasn’t a rejection, so I went ahead and turned the TV on as the hallucinating/crazy patient sat down. Almost straight away, the three people who were there before started shouting at the hallucinating patient and me, complaining about how insensitive we were, how their father had just died and they wanted some quiet time, and how we were ruining it. This was clearly not enough, so to add to the problem, the hallucinating patient started shrieking about how he was not right, and needed to be reset and wanted to be normal. I managed to get him out of the door as he was warbling “Reset me! Reset me! Reset me!” which put us right back into the middle of the ward where we were getting some very disapproving looks. An older nurse sharply told him to “put a sock in it” which lead to him standing stock still, refusing to move or interact, in the middle of the ward for the next hour or two. I went back to apologise to the family (their father had died 5 minutes ago, and I wasn’t aware that this had happened, though I knew that we had a couple of patients on the Liverpool Care Pathway), and while I made my apology grovelling and pitiful, it does feel a little unfair that they told me that they were happy with the TV going on before changing their minds. It would have been easy for them to say they wanted a little quiet, but I guess that when people are grieving they can behave a little less normally, and we should be as understanding as possible. Finally the hallucinating patient ‘unfroze’ and started causing problems again trying to help the other patients go to the toilet, for some reason, but in the end there was no damage from my little fiasco…

Sorry for the wall of text and no pictures, but my NHS accomodation doesn't have internet at the moment, so struggling!