Monday, 26 November 2012

Hallucinating snakes


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


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


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


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...