The end of oncology

Hi,


This week is my last week on oncology, before I change rotation to neurology. I spend some time in a clinic for people with lymphoma, which seems to be much more complex to run than the other clinics I have been in this month,  and see some really lovely patients. Later in the week, I am back on my GP placement, where reading between the lines of how a patient is feeling about her possibly having an STI makes me feel like House.


Most clinics in the hospital are run like a GP surgery: you go into a room, chat with the doctor who has your notes, and then go home. Not so the lymphoma clinic! Here there are a multitude of different doctors all in one busy room, and each patient file is bought in, and the patient is first discussed. One doctor then goes off and takes the patient to a room to chat with them, and then comes back and talks to whoever is in the room about them. Another doctor of a different speciality may then go and talk with the patient as well, until the group has made a decision about what the best course for the patient is. It seems like the decision is made by committee, rather than just one person. I think the reason for this is that the lymphoma sufferers are both haematology patients (a cancer of the blood) and oncology patients (doctors who deal with cancers), so the professional input from both specialities is useful. This made the clinic a lot more confusing, making it seem almost archaic in the confusion that occurred, though I hope that from the patient's perspective it seemed to be running smoothly!


While at the clinic, I see a man from the Seychelles who has moved to this country. He has HIV and lymphoma, and while the consultant is running an errand outside, he tells me about how much better the care is in this country than where he used to live. He is currently looking fora  job in the country, but cannot get one as he is still having his immigration status checked; I think he is currently applying for asylum. I think it is fantastic that we can still offer this man healthcare and look after him as a country, but I know many people see this as him abusing the system, having never worked here and still being treated for two expensive diseases. I don't really want to get down to the debate, but he clearly wanted to work and give back to the country, and was ever so grateful for the help he was getting. I do doubt that he will ever be able to nearly pay for the expensive treatment he is given with the taxes on whichever meagre job he manges to get. Other than the much better healthcare in this country and other political reasons, he seems slightly confused as to why he is here as well, upset with the stormy rainy weather beating away outside, a far cry from the weather he grew up with I am sure! I am talking to him about his problems with relationships, and his uncertainty as to when to tell people he wants to date/who he is dating that he is HIV positive, when the consultant comes back in and the topic is changed. back to the immediate medical. As a medical student I often find myself talking to patients more about their worries and concerns than medical conditions, but this is no bad thing. Most doctors are far too busy to find the time to do this, and I don't actually know anything, so wouldn't be more useful doing something else. Its a win-win situation! 


Other people I saw at the clinic were not as chatty, but just as interesting. A number of them seemed a lot more concerned about other problems they were having other than the lymphoma, and kept trying to change the topic of the discussion onto these. For example, one man was very upset that his mouth seemed to produce a lot of saliva, and it was slightly unusual. The consultant told him that this was unlikely to be due to the lymphoma that he had, but the man kept coming back to it. Perhaps that because lymphoma is such called, rather than "cancer" it seems a lot less scary to patients, and so they do not worry about it as much? I am not sure if this is a very good reason to explain it, as I am sure they have been told what lymphoma is, and that it is a form of blood cancer.

In my GP placement later on in the week, I am now talking to the patients a lot more. Not taking their histories on my own yet, but now it is more of a 'shared' history taking with the GP, which is good as it gives me lots of practice. I see about ten patients in my time there (in the time she would have seen about 30), with a range of different conditions, from the smoker with the chronic cough with a little blood after smoking 50 pack years of cigarettes (pack years are a calculation of how many years you have smoked the equivalent of a pack of 20 cigarettes a day) to the 20something year old with vaginal discharge. The man with a chronic cough got referred to have a chest X-ray, in case of lung cancer, hopefully to be negative. With the 20something year old, we took vaginal swabs and urine to send off to the hospital, in order to screen her for STIs. In itself, this is pretty standard practice and doesn't seem worth remarking on. What was interesting was her reaction to the concept that she might have an STI. We had taken a sexual history, in which she told us that she had a partner but had not slept with anyone else for the last three years. Here, I was thinking 'poor girl, perhaps her partner has been cheating on her', the most sensible assumption to make if it turned out that she had an STI. When it was mentioned, though, her reaction made me think differently. Instead of the expected reaction of suspicion towards her partner that I would have expected, she did seem upset, but said she was afraid her boyfriend would blame her if it was found they had an STI. I asked if there was any reason for her to feel this way, but she said there was no reason at all. From this, perhaps she knows she has done something naughty and she hasn't told us, and doesn't want him to find out about it. You would have thought that if she hadn't done anything, then she would be suspicious of what he may have been up to. This is all an assumption, as perhaps the reaction could be persuaded by other reasons, such as her being afraid of him being angry with her whether she knows its her fault or not, and perhaps being violent, but it didn't sound like this at all. Whatever the real reason, it highlights that listening to patients is very important. Not just for the diagnosis, but to try and work out the juicy gossip about their personal lives!

Is your gran a drugs smuggler?

Hi,


This week I sit in on a lung cancer clinic where I met a wonderful pair of drugs smuggling 70 year olds, who talked all about the fun times they are having despite one of them having terminal lung cancer. Later on in the week, we spend time talking to patients who have come in for chemotherapy; the patient who my partner and I are 'assigned' to talk to is a local celebrity from his art, though the side effects from the chemotherapy are ruining his career.


Through all these clinics I have been sitting in on, I am becoming aware of how important research seems in cancer medicine. There are special research nurses here, whose job it is to run all of the drugs trials that are occurring. A large number of patients seem to be on some trial or another, which can be very confusing, as the doctor who is treating them is also not sure which medication the patient is on, or even if the patient is on any medication at all, or just a placebo. Trials can only be carried out if one option is not known to be better than the other. For example, if a drug is known to treat cancer, then trials will usually be done on top of these 'gold standard' treatments, the intention being that the patient will still get the best treatment even if the trial drug turns out to be rubbish. This is clearly the most ethical way forward, but having the patients on a number of drugs can make it very confusing for the doctors to work out which of the drugs is creating the side effects that may stop the patient from taking their medication. I suppose research into treatments against cancer is a very hot topic, with cancer often in the headlines of popular newspapers, so it is only to be expected that the oncology department is so focussed on research.

Does anyone else remember super-gran? Perhaps she was just on crack...

One of the patients who was on such a clinical trial was a 75 year old lady with incurable lung cancer. In addition to the treatment she would normally receive for this disease, she was also being given a drug being trialled. In this case, as with most clinical cases, the patient was a lot more interesting than the medication she was on. She was quite a loud and jokey person, and had come in with her friend who was equally boisterous. This gives the consultation a very different atmosphere to the one I had been getting used to. Normally they are very quiet, mature consultations, as you would imagine when people dying and the "C-word" is being discussed (cancer). Here, the atmosphere was completely different (with a different C-word being used regularly) and laughs all around. This patient and the friend she had bought along to keep her company at the consultation were outrageous! After the standard questions had been asked by the doctor, and he was writing up in the notes, we started hearing some of her stories. It turns out that for the last month she had been on holiday with her friend in spain "getting pissed and stoned". She told us that she was scared about how easy it would be to get drugs in Spain at her age, so smuggled out a "load of pills and weed". After her amazing month, a lot of which she cannot remember, she had realised how easy it was for her to get drugs in Spain, so smuggled back a selection for "personal use" on her way back. She refused to tell us her trade secrets, how she evaded customs, but did offer to sell us some of her stash, at what she claimed were very good rates.I told her, in a jokey way, that she was being a bad influence on us poor young ones, but she just shrugged it off and winked, poked at me and told me that she was sure that we had done these sort of things before.


Despite the legend of a gran, the consultation wasn't all fun and games. She really wanted to stop all of her chemotherapy and enjoy her last few months of life, because of all the side effects she was getting from it. She was getting things like tingling legs and mouth ulcers, things that other patients who we have seen would love to have over the side effects that they put up with, but each person has their own tolerances as to what they would put up with, and these need to be respected by the doctors. I suppose she had decided that she was happy to die, and just wanted to enjoy her last months doing what she wanted, without strange feelings or pains. This was a difficult decision with the doctor, but she was convinced to wait until the next consultation before stopping everything, and was just taken off of the trial medication in case it was causing these effects. It is likely to be the standard chemotherapy causing these, as these are well documented side effects, but this is a chance to see what happens. She was so much fun, I wish her all the best. She did talk about her children and grand-children who she thinks have no idea about her life style. I doubt this is true, but if it is, perhaps someone out there has this rocking gran without even knowing it!

Steve Jobs avoided surgery for his pancreatic cancer for some time, instead choosing to try out alternative treatments

Later in the week, when we are talking with patients who have come in to receive chemotherapy, we meet a local celebrated artist at the centre. He is very demanding that the drugs don't affect his art, but because of the peripheral neuropathies that keep being induced, the time has come for him to choose between continuing treatment or his art, a very hard choice for him. Without the treatment, he will die from his cancer; while with treatment he will probably still die of the cancer, but a lot more slowly and more comfortably. He has already spent all of his savings on avastin, an anti-cancer drug that isn't funded by the NHS (questions about efficacy) as it is possible it could help him. This is understandable from a medical students perspective, but he also spends his money on a lot of alternative treatments. As well as having mistletoe injections twice weekly, he also has tried many other treatments including homoeopathy and talking with a psychic. These are much harder to understand from the scientific background we are taught in, but doesn't mean that they are not popular. Even the great Steve Jobs tried many alternative treatments for his pancreatic cancer, including acupuncture and a psychic, before deciding to consent to surgery. These were decisions that may have let the cancer spread and eventually killing him. Fortunately this patients seems to have a very sensible approach of using the two in tandem, and I am definitely not one to argue with him. If it brings comfort and the thought that something may be helping him, then it would be unfair to try and take away this from him, even if it is just the power of the placebo. He is currently funding his alternative therapy and travel to the cancer clinic by selling his paintings to the cancer centre, which is kind enough to buy them from him so he can continue his treatment. Everyone wins, as they look fantastic on the walls.

My breasts are examined

Hi,


This is a slightly misleading title, as I don't actually have breasts, but this week I do get to don a pair of fake-boobs and have my other class mates examine me. This is good practice for a beast cancer clinic I sit in on later in the week. I have a number of lectures this, and every week, a lot more than in my third year, which is a shame but it is nice to be spoon-fed information again. I am also assessed on my elective this week, by having to present a poster based around my experience there. All in all, quite a quiet week.


In our teaching sessions, we are often taught how to do an examination or procedure then expected to practice it, such as abdominal examinations or auscultating the heart with a stethoscope. This session was a about breast examinations, and as they had decided that letting us practice on the female members of our class was not the best idea (probably a good idea, as it could get awkward), so had a pair of fake breasts for someone to put on, and let people examine them. These breasts had a range of strange lumps in them that the people examining could try and find. When the seminar leader asked if anyone wanted to be the person wearing them, and be examined, no-one volunteered. Secretly I really wanted to, but I thought it would look strange if I jumped up straight away shouting "Me! Me!", and was relieved with the couple of seconds of silence that followed the question meaning I could volunteer while looking as though I was doing it to save anyone else from having to do it. I do not secretly want to have breasts (but if it was a secret, would I tell you?) but I love wearing fancy dress to parties, and being examined by 20 people is a great way to learn the examination yourself. Win win! The only awkward part came when it was an ex-girlfriend's turn, and she was clearly not impressed that she she had to examine my breasts. Awkwardness aside, a great learning experience, though I am definitely not confident that I could spot small lumps at all.


The breast cancer clinic I did the day after this session was very useful in putting these skills to practice. I was with a male consultant, and so he made sure that there was a female nurse in with him every time he examined a patient as a 'chaperone'. With what is seen as an intimate examination, I suppose its sensible not to take risks, and have women claiming that a doctor and a medical student molested them in an examination room. It is a bit of a shame that female doctors are trusted not to molest people, and hence do not need a chaperone, while male doctors do, but unfortunately I suppose that this is based on history, and the fact that most of the doctors who do behave in a sexually inappropriate way are men. Anyway, it turned out that carrying out these examinations on real breasts and feeling real lumps was a lot easier than it was on the foam breasts. While breasts could be examined to exclude breast cancer, many of the women there were because they were being treated, or they had presented to the GP with a lump they had found in their own breast and been referred. This made things very useful, as they could say where the lump was.

The type of examination breasts I wore. Not the most realistic things, but probably a good idea to get used to these, as they will be used in my examinations

All of the lectures that we are having  this year are starting to become a little boring. I thought I had escaped lectures after leaving my 2nd year, then had a year of them in my intercalated degree, now have another year with quite a few in them now. My third year didn't have nearly this many in it. I hope its just the oncology rotation that will be like this, and the other rotations will have a lot less lectures.They are no bad thing, I mean being told the information is better than the third year where you constantly had to seek it out while at the hospital, but I was looking forward to getting back on the wards and practising clinical medicine. I suppose I have the rest of my life to enjoy that, so perhaps I should enjoy the more laid back pace of the lectures while I can. This week we had three, yes three, lectures on how NOT to prescribe chemotherapy. I know this is a serious topic, as poor prescriptions will kill people (it is a toxic drug after all), but we are not expected (or even allowed) to prescribe chemotherapy as a foundation years doctor, and then hopefully we would be taught properly if we became an oncology registrar? Perhaps I am just feeling grumpy as I need to get up for lectures at 9 again.


At the end of this week, I had the assessment for my elective. I had to sum up my 6 amazing weeks onto one A1 sheet of paper. If I was to say my elective was life-changing it wouldn't really be much of an overstatement, but this isn't really the sort of thing you can write on an assessed poster. Working out how to fit all of the experiences down into such a small space was (almost) harder than eating the disgusting sweet-spaghetti (which I made sure not to mention). Despite all the work, the presentation went very differently to how I expected it to. I got one of the academic professors assessing mine (luck of the draw) and instead of asking all around the subject, as I was expecting, I just got asked academic question after academic question. What were the three main forms of malaria after Plasmodium falciparum? (Fortunate I did that immunology degree, really!), If a young patient presented with low heart rate low blood pressure what would the most likely diagnosis be? (No idea with that one, snake bite?) and so on. I do not think I performed very well at all, unfortunately, but what can you do. Still do not have my mark back, but I would hope that I would have been told by now if I had failed. One more assessment out of the way, and one step closer to being a doctor... 

The Hospice

Hi,


This week I spend a few days working in a hospice as part of my oncology rotation, which is a fantastic experience, being completely different to how I expected. I also attend a gynaecological cancer clinic, which is a long drive away, and spend a day in a GP practice where my assigned GP wants me to run the consultations. I am not sure if I am ready for that here at all, despite doing effectively the same thing in Tanzania all on my own...


The visit to the hospice is intended to let us get some experience of... well.. hospices. The medical school is very keen on showing us lots of out-of-hospital medicine, and I agree, I think it is a good idea to see as much of the varied world of medicine as possible. Not just to let us to plan our careers, but to help us understand how each speciality works when we are specialists ourselves. It is unlikely that a surgeon will be visiting hospices to learn about them once working, but could be referring patients to their care.


The hospice was lovely, and very different to what I had expected a hospice to be like. I have no idea why, but I had imagined  a hospice to be a little like an old people's home, with dying people sitting in their rooms, or if they could manage it, in large chairs in a circle, not doing very much. This perception was proven wrong from the moment I stepped into the warm, friendly and very professional reception. No strange and stuffy nursing-home-esque furnishings here. The staff were very friendly and accommodating, and despite the clinical feel to the building (I suppose it plays many roles similar to a hospital) it felt a lot more... fuzzy? We had talks from doctors, nurses, volunteers, carers and patients and talked to a number of patients who had come here. While we were learning about the different pain killing medication that was prescribed, we were asked if anyone wanted to try out one of the sublingual tablets. They said 'morphine' on the packet, but we were assured they were placebos. No-one seemed interested, after his talks on their sometimes nasty flavour, but he then said that they were wild berry flavour. Sounds delicious, right? I thought so, as I volunteered straight away to have one. Having put it in my mouth (don't worry, they did turn out to be placebos) there was just a bit of a bitter taste, and certainly no wild berry flavour... It also lasted for over a minute, rather than the 10 seconds to dissolve that he had taught us. I asked him about the flavour, and just said "yes, well, I lied... Otherwise no-one would have had one!" Are doctors allowed to lie?

Sublingual tablets do a similar job to the "pain killing lollipop" that Jade Goody was often seen sucking, which is meant to provide pain killing medication through the mucosa of the mouth.

I had always assumed that hospices were for people who were dying, so they could spend their final days (should they be too ill to go home) in a nicer environment than a hospital, while still receiving the same standard of care. This is one of the roles for the hospice, but it also fulfils many other roles as well. Many of the patients who I saw were not there 'to die', rather because they were ill, and needed somewhere to be cared for carefully for a month, but not so ill as to need to be in an intensive setting such as a hospital. The hospice is a much nicer environment, so attracts this sort of care. Unfortunately the hospice is also not NHS run, but still free to patients. It has about 20% of its cost paid for by the NHS, with the remaining cost sought through fund raisers and donations. I remember as part of the RAG at my medical school a couple of years ago, dressing up in a giant mascot costume and fund raising for the hospice at a shopping centre with some other students in scrubs. Fantastic fun, until the whole thing became far too hot. While I was at the hospice, they had had to close their activities centre, which was a big sociable room where those staying there could relax, talk, and partake in activities organised for them (yes, I know it sounds a little like a nursing home!) All the patients I talked to were very sad about this, as they enjoyed these sessions, but when the hospice is run as a charity, there is no guaranteed income, meaning that these sort of closures sometimes need to be made in order to keep the more essential services running. Hopefully the NHS hospitals don't see its relative cheapness (as it doesn't use NHS money) as a good excuse to put patients there to save themselves money. Hopefully this wouldn't happen, as those who would make these decisions will be far removed from the money aspects. 


Moral of the story: Charity run hospices are wonderful, donate to your local one!


The gynaecological cancer clinic was, unfortunately, a long way away from the hospitals we normally work at, and my accommodation. Fortunately I have a car, and motored us over there. It seemed a little but pointless to go such a long way for 3 hours worth of consultations, but I suppose to fit us into the timetable they need to branch out. Fortunately it was a very worthwhile clinic, with a very good consultant and registrar running the appointments. Unlike the palliative care clinic, there was a lot less bad news, and a lot more patients who had low grade cancers, with the doctors mostly aiming for a cure for most patients. There were a few patients who were not expected to be cured, and were being treated palliatively with treatments such as radiotherapy, to slow the cancers progression and reduce some of the nasty symptoms they were getting. What impressed me most was the fact that all of these patients were well aware that they had an incurable illness. There didn't seem to be any secrets that the doctors were keeping from the patients, and if the doctor was worried that the patient was not curable, the patient would know as well. I don't know what I was expecting, but such upfront honesty and openness with the patients just felt right.


I also get to do GP placements every few weeks in this year, where I spend a day in a GP's surgery in a sleepy country village. I am fortunate in that this is the same GP surgery I spent some time in in my first year, with the same doctor. She is very friendly, informal, and nice, and I am very pleased to have been placed back with her! The surgery is a large polyclinic, so I hope to get a lot of experience in a lot of different fields. We saw about twenty patients over the course of the day, the appointment times being a lot longer as I was there to take up the time. Normally GPs can see about 30-40 patients in one morning! The doctor wanted me to run the consultations, with her able to step in and ask supplementary questions, but I didn't think this would be a very good idea. I don't remember a lot, and felt I would like to see a few before trying them for myself. She seemed to understand, and I participated by adding in questions when she asked me - a much less worrying start! The patient who stood out most in this day was a large man who looked just like Hagrid from Harry Potter who had broken his leg.

The patient's beard and clothing matched Hagrid's almost perfectly. If he wasn't so serious, I would have thought he was joking around.

This man had had a real alcohol problem, put on a lot of weight, and the drunkenness, coupled with the poor vitamin intake from the lack of food had caused him to fall down the stairs. At the moment he couldn't leave the house because of his obesity and broken leg combination (some carers had come to bring him to the GP surgery), and all of his shopping was being done by a well meaning neighbour. This neighbour was sensible enough not to buy this man any alcohol, and for the last month he had not had anything to drink at all. He confessed that although the first week was very tough, he now felt a lot better because of it. A broken leg turning out to help someone out was quite interesting, though unfortunately he confessed that as soon as he could walk on the leg again, the first thing he would do would be to go down to his local and get himself a "pint or twelve". The GP tried hard to convince him not to start drinking again, but he wanted to. Without the patient making the decision themselves that they want to give up, it is unfortunately just not possible to get them to stop any harmful behaviour, whether it be smoking, drinking, other drugs or just plain over-eating. 

Estimating when someone will die

Hi,


This week I attend what I thought was a breast cancer clinic, which turned out to be a palliative care clinic, and very sad. I also go on a ward round with the haematology team, who see a lot of blood based cancers as part of their work. In my second week back in medical school, and I have quickly gotten used to the differences. I suppose it is all about what you perceive as 'normal'. The time in Tanzania had me seeing that as almost 'the norm', and coming to the UK had me in some kind of culture shock at seeing how different the healthcare is. This sounds a little drama-queen-ish, but to a mild degree, I think it is true. Now I am used to the UK healthcare, I don't spend my time looking at things twice, or being impressed by a consultant going the extra mile. 


The breast-cancer-turned-palliative-care clinic was the highlight (in some respects) of the week for me. I had been expecting a clinic for those with breast cancer, so had read about breast examinations, important points in the history, and other useful information. Any clinic where cancer is dealt with isn't going to be a walk in the park emotionally, but I wasn't expecting anything mind-blowingly upsetting, as breast cancer tends to have relatively good cure rates (better than many cancers). On my arrival, the clinic turned out to be a palliative care clinic that was focussed around lung cancer. This will make it a lot more upsetting, as it means that only patients who are dying will be seen, rather than everyone. Lung cancer also has a much worse prognosis than breast cancer, progressing faster and with much more likelihood of being incurable.


I was sitting in this clinic with one other medical student and the palliative care consultant. She warned us before it started that some of the patient's cases can be very upsetting, but it is good to see these sort of things as a medical student, and important to come to terms that not everyone can be cured by modern medicine, and am important part of medicine is letting people die comfortably. The first patient who we see is a ex-service man who has come in with his wife, with advanced lung cancer. The cancer has spread to a number of sites in his body, such as the liver and the bone, causing a variety of problems and pains which he wants the palliative care consultant to help him with. This involves a discussion about pain killers and other palliative medication, which is relatively emotionless, as it is all factual. The emotional talk comes later, after the man asks how much time the doctor thinks he has left to live. This is a question that doctors do not like to answer, as it is very hard to tell, and whatever answer they give can make huge impressions on the patient's life. It is possible, though, for the doctor to take a wild guess. The general rule for guessing how much time the patient has left is to look at the frequency with which new symptoms are appearing. If new symptoms (from the illness, such as ascites or bone pain) are appearing at a few a month, then the patients life expectancy is likely to be measured in months. A few a week means it is likely to be measured in weeks and if they are appearing daily, then its likely that the patients life expectancy may be measured in days. This can be very inaccurate, and everyone has heard of doctors giving patients weeks to live, who then turn out to live for years. Despite this inaccuracy, it is fair to give a guess (making sure the patient is very aware that it is only a guess) as to how long the doctor feels the patient may have if the patient asks. You cannot exactly say you will not tell them!


Getting back to the point, when the patient asked the doctor how long he had left to live, in a tactical and roundabout way, his wife started crying, pulling at him towards the door and telling him he should ask such things. He told the doctor that he really did want to know, and the wife started sobbing hysterically, trying to pull him to leave. I decided that this is when medical students can actually be of some use, and take the crying woman by the arm (kindly, I am not dragging her) and lead her out of the room to the waiting room. I chat with her there for 10 to 15 minutes about what she is worried about (I volunteer for Samaritans in my free time, so have had plenty of training for these sort of talks), until the consultant comes along to find me, telling me that there is actually a quiet room for this exact sort of situation, rather than me taking them to the waiting room where there are other patients. I am a bit embarrassed, but take the wife to the quiet room to keep talking, while the consultant goes to finish her consultation with the patient, after checking that the wife doesn't want to return to the room ("definitely not!"). The wife thanks me profusely before leaving, and I feel as though I have been useful, an unusual feeling as a medical student! After the consultation, the other medical student (who had remained in the room) told me that the man seemed to be taking his coming death a lot better than his wife, and once she had left the room had confessed that his biggest fear was how she would feel when he was gone, or very ill at the end stage of his illness. The consultant estimated him to have some months left, though as I said before, this can be very inaccurate, and the patient seemed to accept this.


We see about ten patients in the morning, and despite the fast throughput, the palliative care consultant seems to give each patient as much time as they want, giving them time to talk about their symptoms and the progression of the disease (the reasons for them coming to the clinic) as well as the much more difficult touchy-feely issues around the fact that they are dying. The patient who made the most impression on me was a lovely mannered kind old man who had a very horse voice when we were talking to him. In the first couple of years of medical school, this is taught as one of the signs of lung cancer, as the cancer is affecting the left recurrent laryngeal nerve. This horse voice had only come on in the last week, and was the reason for his visit. It suggested that his lung cancer was progressing (I.e. it is getting bigger, hence why this nerve is now involved) despite the fact that he was currently on chemotherapy). The conversation was based around the fact that, seeing as this was his third different drugs combination, and they all had not worked, it might be a good idea to stop chemotherapy and come to terms that the cancer was not curable. The man seemed to accept this gracefully, and seemed to have been expecting such a statement from the doctor. I found it a lot harder, however, and found myself feeling really upset that this gentleman could no longer be treated, and the fact the treatment was being stopped seemed as though we were 'giving up' with him, and consigning him to death. I know this is not the case, and the fact he was at the palliative care clinic meant that he wasn't being given up on, but this is something that is very important in modern medicine, as everyone dies, but something I know I will struggle to come to terms with.

As can be seen by this anatomy diagram, the left recurrent laryngeal nerve runs under the arch of the aorta, and hence can be affected by grows in the lung. The right doesn't descend as far, and is not affected.

At the end of the clinic, the consultant took me aside to thank me for dealing with the wife I mentioned in a "professional, yet lovely" way. She said it made it a lot easier for the husband to talk about his illness, without her having to ask the lady to leave. She also told me to try and forget about the emotions I experienced in the clinic, instead taking away the knowledge I gained about the conditions I saw, and the service that is offered. It is always good to feel valued, and I think she must have been able to tell that a few of the patients had left me feeling upset.


The haematology ward round that I participated in later this week was a much more positive affair. There were a lot of patients with blood cancers, and all of the patients we saw had good prognoses, with the doctors aiming to cure all of them. Blood cancers are much easier to treat. Some of the patients were in special side rooms, and we avoided going in with the essential doctor and nurses, as the treatments for these cancers can often leave patients with a very poor immune system, meaning it is important not to expose them to infections. My favourite patient on this ward round (I am not sure if we are allowed favourite patients...) was a lady who, as a side effect of her treatment had had a nasty fall down her stairs, and because of her slatted metal bannisters, had torn off a lot of the skin from both of her arms. She was otherwise pretty well, and charming and chatty, so I went back later to talk with her some more. She had her arms wrapped up in two huge bandages around cotton wool, and I asked her if they were inconvenient. She said that the nurses and doctors had offered to change them to something smaller a number of times, but she preferred them like this. She had always gotten cold arms in the past, but now they were always so toasty warm!

The start of fourth year

Hi,


So here I am, back in in the UK and back in my university hospital. I will continue with the weekly blogs, but have a little bit of a back log now, due to the fact that I was posting all of the elective blogs after my return, through my first 8 weeks of rotations. Despite the fact the blogs will be weekly, I will try and post the next few as quickly as possible to catch up with myself, then get back into the old regime. Daily is far too often for me to write, or for you to bother reading, and was only worthwhile for my elective, when so much was happening at once!


My first rotation on my return is Oncology, which will last for about 6 weeks. I hardly saw any oncology patients on my elective, and seeing as I intercalated in immunology last year, this means that I have about a year and a half since I had really done anything in oncology. In fact, I have a year and a half hiatus where I have done very little clinical work at all, excluding the elective (which was so different it hardly counts). Needless to say, I hardly remember anything and am approaching this week with some trepidation.


Having intercalated, whereas much of my university doesn't, I am in a new year, with some old friends and many new people. I was social secretary in my second year, organising many events for the then freshers, meaning that I know the year below (which is now my year). Despite this, it is still strange being in a rotation with new people, after I have gotten to know my year so well over the last 3 years. This isn't all bad, though, and it is nice to get to know people who I have only ever seen out at bars a little better. I am now officially starting my fourth year, even though this is my fifth year at Uni, given my intercalated degree, which makes for slightly complex explanations when people from outside medicine ask which year I am in!


The Oncology rotation seems to be predominantly seminar/lecture based, which is a real shame. The time table tells me that I spend a lot of time in lectures or with free time rather than on the wards. Despite this, I do have some clinical experience each week. Not as much as in my third year, but hopeful;y enough to let me remember all the things I used to know (all two of them...) My first day on oncology sees me in a specialist oncology ward with no real purpose, other than to talk to and examine a few patients, and report back to the doctors in charge of the ward. This isn't really of too much use to the patients, though with all the time I have I may find out something useful that the doctor's didn't know, but it is very useful to me, as I get to practice all of the skills I don't really have. This is a common way of learning used in hospitals, and patients are normally only too happy to help out "You have got to learn sometime!" 


This whole experience was pretty confusing. Not because of my poor history taking and examination skills, though these were sub-par, as expected. It was because of the massive difference to the environment I was used to in Tanzania. I know it sounds cheesy and strange, but the difference really is scary. I suppose I expected it when I went to Tanzania, I expected it to be poorly supplied and poorly staffed, and so wasn't too surprised. Coming back to the UK, I suppose I expected it to be 'normal' - as it was what I would expect to be used to. Perhaps a combination of the fact all the clinical experience I have had in the last one and a half years has just been the gritty Tanzanian hospital, and the fact that the oncology ward is fantastically staffed and well supplied (cancer is, after all, very popular with the media, and hence seems to collect a lot of funding). To say I was 'overcome' would be a little bit of an overstatement, but I really was shocked at how spacious and clean the ward was, and more than anything, how caring the nurses are. I suppose in Tanzania I was used to the nurses who didn't really do anything, patients never got washed and there were not even any bedsheets to clean. Here the nurses take the time to do everything, feeding patients who cannot feed themselves and taking time out to help explain things to us. Perhaps I am just enjoying being back at the bottom of the medical food chain, where everyone knows a lot more than me, and is happy to explain it to me, compared to my opposite experience in Tanzania, but it is lovely here. I love the NHS.

A new badge for me to wear.