Night shift and possible perforation

Hi,

A week in the acute medical unit this week, in the hospital that I will be working at next year. This week, and the next 6 or so, are part of the last section of my course as a medical student, aimed at teaching me to carry out the job of a junior doctor next year. Fortunately I have been placed on the acute medical unit, where patients tend to be quite sick, decisions are made daily as there is a high patient turn over (people only usually stay for a day or two) and lots of bloods, cannulas and so on need to be done. This is perfect for me, as I want as much experience as possible in doing these sort of things, as well as ordering scans, making general requests and general dogs-body work around the hospital. I certainly don't have any glamorous expectations of what next year will involve!

My 'non-glamorous' expectations were proved right on Friday when I did my first proper night shift. Previously I had only stayed in the hospital til about 10/11PM, but this week I came in at 9PM and stayed until morning. This night shift was actually a lot of fun, and I got to clerk in several patients who had come into the hospital at night, and carry out lots of procedures including the ever glamorous 'PR' exam. 

Glamorous medicine... Who said being a doctor isn't an attractive profession? Between these and being vomited on there is so much to choose from...

On the night shift I was admitting patients, taking their history, examining them and then planning initial management and investigations. The registrar was a really nice cardiologist, who talked at length about how upset he was about the events in Woolwich (him being a Muslim  and how it was creating so many more problems... Anyway, this blog isn't meant to be a political statement. The problem with this registrar was that he had decided that, as I had passed finals, I was just an 'unemployed doctor' rather than the medical student I still introduce myself as (until August). This meant that, after clerking a patient who had presented with upper tummy pain, and bloody vomit (haematemesis) - I had taken bloods, ordered an erect chest X-ray (to check for perforation) and all those sort of things, he was asking me to look the results and write down what they said, and plan management. This was pretty scary. He was quite stable, so if he hadn't had a perforation into his abdomen from his stomach he could be left  until morning, whereas if he had, he needed much more urgent assessment. In order to be able to tell this, an erect chest x-ray is done, as it will show air under the left diaphragm, showing air has escaped the stomach and is now outside within the abdomen (where it shouldn't normally be). 

See the arrow on the left of the picture (right side of the patient). This points to air which is under the diaphragm, therefore not in the lungs but in the abdomen, which suggests a problem such as perforation. There is air on the other side (the left of the patient) but this is probably just in the stomach and does not suggest a perforation.

Anyway, this is quite an easy diagnosis to make (as they go) as it is either there or not. But it was a very scary idea putting my pen to paper and saying it was there or not, and having his management depend on what I thought. If I was wrong, he could go all night without the proper treatment and be very sick, dangerously ill, by the morning. The 'lovely' registrar was refusing to help me decide what it was until I had sorted out my own plan, as 'I had to work out how to do it at some point'. Good to have practice in this sort of thing, but not now! Anyway, I thought he was fine, had an 'upper GI bleed' and hadn't perforated, and he agreed, so it all worked out in the end.

The rest of the night shift was pretty hectic, clerking in a man with blood clots in his lungs (pulmonary embolism), someone who was a chronic alcohol abuser who couldn't even tell me why he was in hospital, and a patient who was very depressed and was trying to persuade me to kill him. I have a lot of time as a medical student when things are busy, which was really useful for the latter patient. This is all ignoring everything else that happened this week. Needless to say, things are busy, and I am really loving it!