Halves

Hi,

A very busy week, leading to me not actually having time to write up this blog properly this Sunday, so very sorry for that. I hope this will do, I had a very busy weekend! I saw some very interesting neurological medical cases this week, which I want to mainly concentrate on, and went on a very polarised ward round around a cardiac unit, where half of the patients seemed to be chatty and fine, and the other half slipping down towards death... Odd having them all right next to one another.

This week seemed to be a week of neurological halves. As I am sure I have said before, neurology is a very interesting speciality, and can have some very unusual clinical presentations. I think I mentioned "The Man Who Mistook His Wife for a Hat" by Sacks before as a good example of some unusual clinical presentations. This week I met two patients who had 'split' neurological signs cutting the presentations in halves across the body because of the neurological pathology.


The first patient I saw was a woman who had suffered a stroke in her past, which had affected part of the thalamus. Most strokes lead to numbness, weakness or odd tingling sensations (paraesthesia) in the affected areas of the body. This stroke, due to its thalamic involvement, had instead lead to sensations of pain in one of the patient's arms and a burning sensation across one side of her back all of the time. This pain made the use of this one hand and arm almost impossible, because on contact with objects, the pain would make her draw her hand away sharply because it felt as though her fingers were being stabbed or burnt. She gave examples of being unable to open a can, or peel a banana because the pain made such operations impossible. The other hand was fine, but many tasks require two hands to carry out. On this background diagnosis of central post stroke pain, the patient had developed trigeminal neuralgia. This disease causes notoriously painful symptoms, and has been classed as among the more painful medical conditions. It involves the trigeminal nerve, one of the cranial nerves which supplies sensory nerve endings to the face. The disorder causes the face to become hyper-sensitised, with the slightest touch on the affected side causing excruciating pain. This can be as little as hair brushing against the face, and obviously has major impacts on the patients life and nutrition. The poor patient described curling up on the floor because of the pain she was in and crying whenever the face was touched, but the tears tracking down the side of her face made the pain worse. Fortunately, this had just been treated when we saw her, and it was no longer causing this pain. The diagnosis had taken some time, because the dentist had been telling her that she needed root canals, because of this pain, and she had been making repeated trips to the dentist to have a succession of teeth ''sorted out''. If anyone is interested, how to recognise trigeminal neuralgia over a dental problem is that the trigeminal neuralgia will cause the pain when the skin of the face is touched, whereas dental problems will be much less exacerbated by skin contact. This patient seemed to have been split in half by her symptoms, one side of her functioning normally and the other a well of pain.


The second patient I saw was 'split' horizontally rather than vertically. It was just one pathology which had caused this second patients split, he had a benign tumour growing around his cervical spine roots. This tumour had affected the nerve roots C4, C5. C6 leaving the spine to supply the arms, and the compression it caused had affected the movement and sensation in the legs. The interesting thing about this patient was that 'upper' motor signs are very different from 'lower' motor signs, and this patient displayed both at once. Upper motor neurone signs are usually seen in limbs where there is a problem with the central nervous system, whereas lower motor neuron signs are usually seen where there is a problem between the central nervous system and the affecting muscle / sensory nerves. Both have different clinical signs. Upper motor neurone problems cause 'brisk' (very responsive) reflexes and increased muscle tone due to the fact that they have damaged the signals from the brain which calm the muscle response. This means that the muscle is always a little contracted (hence the increased tone) and when a reflex is tested (for instance the knee jerk reflex) it is much more responsive than normal because the brain and spine are not damping it down as they normally would. This does make it very easy to find the sites to hit with the tendon hammer, however, as instead of the normal twitch of the muscle they give a good kick out. Lower motor signs give opposite signs, with decreased reflexes, tone and strength, because they muscles are getting less innervation from the supplying nerves. It is hard to explain so you will have to take my word for it!

Either way, he was a very interesting patient to examine because of all of these signs, and because of the complexity of a full neurological examination I took well over an hour with the procedure. He seemed to appreciate having someone to talk to and explain things to, so I didn't exactly rush things, but all of the effort that went into plotting the affected dermatomes by working out the affected muscle groups and sensory areas (see picture below) was unfortunately wasted in the presentation to the registrar. Normally pretty simple, just regurgitating facts and findings, I managed to get myself in a right tangle involving all of these 'Upper motor signs in the lower limbs' and 'Lower motor signs in the upper limbs' and the corresponding levels of increased and decreased tone/strength/reflexes/sensation. pretty embarrassing as it made it look as though I had no idea what I was talking about. While I rarely fully understand a neurological picture (I think it is one of the hardest specialities, but that's a personal opinion) I at least understood the simple basis which I have (poorly) tried explaining here. Oh well, I suppose I will be off of this rotation in a few weeks, and off to surgery, so I will not be around the reg who seems to think I am easily confused. I am obviously digressing, its not just medicine I find hard, just simple conversation now! I would love to blame being on call for hours, or dehydration, or any other external factors but I think I was just having 'one of those' moments.

The ward round I found myself on was, as I said before, very polarized. While only a small ward, there seemed to be either very well patients there, who were waiting for discharge or being observed, of very ill patients who were deteriorating daily and had DNR forms filled out beside their beds. One of the most interesting cases on this ward round was one of the seemingly well patients, who was chatty, lively and much younger than the others on the ward. Aged in her early 30s or late 20s this patient had been admitted by ambulance after her heart stopped in the community. She had had a 'down time' of around 50 minutes, meaning that it was about 50 minutes before they could restart her heart, which involved her receiving about 5 shocks and almost constant CPR. At least she was with people who knew how to perform CPR when she first arrested. The mystery with this patient was why her heart had stopped in the first place. She was fine now, and all of the tests at the time (such as toxicology screens and the like) had come back negative. Her heart appeared normal under all of the investigations that have been carried out, so what made it stop? Is it going to stop again? What if she is asleep when it stops, so no-one realises until she is hours dead? Nothing in the history gave any suggestion as to why her heart had stopped, so she was being kept at the hospital in the hope that something 'odd' would happen to her while she was being monitored. Stressing the heart with chemicals and exercise didn't help. It is these sort of mysteries which make medicine interesting, like detective work. The consultant said that the odds are that the patient may be fitted with a pacemaker to shock the heart back into rhythm should it stop again. I hope they get a diagnosis for the reason though, I am a curious person, and I don't believe that things happen for no reason!

This will have to do as an updated blog, and thanks for bearing with me. I would promise something better next week, but I always seem to be busy with something.

Clinics

Hi,

Firstly, happy Easter weekend to all those out there, and I hope you are enjoying whatever holiday you get (if any). This week was pretty 'run of the mill', but I realise that a run of the mill week working in hospitals is still a lot more varied than in many other career locations. What a wonderful profession to go into - where each week is full of variety and interesting little things. Diseases are very varied, and people even more so - so whether you are spending your time chatting away with a 25 year old constant re-offender admitted from prison, or a tottering 90 year old lady who wants to talk about her cats by name as though they are people, its always interesting to go in every day. I suppose I look forward to it in a sick sort of way (whether that cancels out the early early starts we need sometimes is another matter) but its much more fun than the lectures from the past 2 years!

Some good news for you all. I am currently applying to intercalate at a few external universities and have got offered a place at one of them, and had two interviews at another two, awaiting results. That's not really good news for you, it is more my good news to tell you I suppose, but what can we do. I am pleased anyway - definitely intercalating externally on a nice looking course, but my first choice is one of the institutions I had an interview at. Just a waiting game now.

Down to business - I could ramble on all day otherwise. We are assigned our set rotations (as I said before, I am on a gastroenterology rotation) but if we just stuck to these we wouldn't learn nearly enough, as we would miss out on other rotations such as 'endocrinology' or 'renal' based rotations. I have been chopping and changing quite a lot recently, there is only so much you can learn about livers. Correction. I am sure there is an absurd amount you can learn about livers, enough to fill lifetimes of work with hepatic wonderfulness, but there is only so much I want to learn about livers at this current point in my training. I would rather focus on the common sorts of things like asthma, diabetes or heart attacks that the gastroenterology rotation doesn't give that much exposure to. As of such, I have had a very chop-and-changed week floating around different departments in the hospital and trying out different things. One of the best of these trials this week was a morning in an endocrinology clinic, so I will stick to that. No need to waste too much of your day with this post!

In the clinic I spent time in, we were being taught by an amazing consultant. All doctors seem to have very different attitudes towards teaching and the formality/informality of the teaching position. Obviously, doctors who want to teach are worth being with a lot more than doctors who do not want to engage with the students at all, and want you to sit in the corner, out of sight and out of mind. Both 'formal' and 'informal' teaching styles teach plenty, and its always worth being with a doctor who wants to teach, but in my opinion the informal doctors are a lot more fun, and enjoying yourself surely helps learning! Back on track (again) this clinic was headed by a very knowledgeable, interested in teaching, informal consultant. Not that all consultants aren't knowledgeable, but the other two are not prerequisites of the job. As well as learning about all of the conditions we encountered (a wide variety, from hypothyroidism to suspected Turner's syndrome to the rare pheochromocytoma) we also got a good general education. Sorry, to clarify, when I am referring to we here, I am referring to myself and the other medical student I found waiting in the general department, so we paired up. Most doctors only want a maximum of two medical students in their clinics, which is fair enough, as otherwise it makes quite a crowded room. Two medical students seems to give a better experience as well, as  perhaps the doctor puts more effort into teaching if there are two of you (and you both benefit as you are there) - and any hard questions you can hope that the partner knows the answers if you do not!

The general education we were gaining from this clinic was pretty broad. We were asked questions such as what country 'Chisinau' was the capital of (Moldova, if anyone was wondering). It seems that medical students are expected to have a broad knowledge base. Personally I don't think I have heard of Moldova outside of the Eurovision song contest, but perhaps I am the exception. When the consultant told this specific patient (who was from Moldova) about his questioning, she did ask if we had got the question right. A neat turn of phrase got us out of trouble with her by giving the impression we had, getting the response "Well, they are medical students, they should be smart".

1) It was a lie. I had no idea about this capital. Moldova? They made the 'Numa Numa' song with the strange lyrics, right?

2) Bit of a wake up call really. The public perception of medical students seems to be split into two camps from what I have found. We are either seen as a smart group of hard working genii in the making, or seen as a group of 'work hard, play harder' people who work a bit but go out on some heavy nights out as well. The further you get in your medical education the more people are going to expect you to know about medicine and different things in general. I used to be able to fob off friends and relatives in the first 2 years. "Oh, you say you have a tear to your anterior cruciate ligament? Sorry, I haven't done arms and legs yet, if it was a problem with your heart, I might have an idea". No such joy any more. It is always nice if people ask you something though, even if you don't have an answer (or have to make one up). Makes you feel respected and trusted.

As well as asking us (and teaching us) about a wide range of different topics, while patients were not in the room I add, the consultant also told us an alarming amount about his personal take on life. Again, this was most definitely when patients were not in the room, while he was jokingly friendly and beautifully informal whilst we were in the room, all professionalism and seriousness when patients were there. As it should be. I would like to be like that. Anyway, we learnt that our consultant has a real hatred for monkeys, and one of the worst things he could imagine would be having sex with one of these said creatures, how this came out I am not sure, but I wonder how patients would react should they find out. The consultant also finds 'muscular women a real turn off'. Again, how this came out is beyond me, but yet more information I didn't want to know. Muscular women (and I think he means really muscular here) came above, but only slightly, monkeys on the sliding sex scale. Not sure how comfortable my female partner was during this conversation, but all carried out in the consultants crisp Irish accent, it was a joy to listen to. One of the biggest turn off's about muscular females is, we heard, that if you came home and the dishes were not done, you couldn't ask her to do them because you have been at work all day, you would just get punched in the face. While this sort of conversation is most definitely inappropriate, I think it is this sort of things which keeps some people going in the very PC and polite world we have to live in now. A joke to the wrong person can wind up very badly, so venting away and acting the fool (even if you are a 50odd year old respectable consultant) around people when you can is necessary for a normal life! The consultant did get one of one of the patient's kids to have a chat down the Dictaphone whilst dictating a letter for his secretary to type up. I would love to have a secretary to do work for me! One reason to aspire to be a consultant I suppose.

I digress from what should be the focus of this blog. The patients. But I have talked for some time already, and have many things to do (as usual). In the clinic all of the patients we saw had some form of endocrine problem. The most common by far was hypothyroidism (people with diabetes go to a specialist clinic, as this is the most common endocrine disorder in the population) but this seems like a relatively dull disease to manage, with follow ups basically consisting on checking that the patient is fine. The more exciting conditions we got to see I mentioned before, because they are exciting! There was a patient with a suspected pheochromocytoma, a type of tumour growing in the adrenal glands, releasing adrenaline when it shouldn't be.  This is a rare diagnosis, though, and will need further testing, but it is one of those 'exciting' conditions to come across... perhaps.

Another patient we met that day was a woman who, back in the UnPC days of yore, may have been described as a FLK (funny looking kid). While she had come in for a completely unrelated diagnosis, she was very short and just generally a little abnormal looking. It sounds offensive, saying something like that, but I think being on the outlook for such things is an important part of medicine. After she had gone, the doctor decided that it was possible she had Turners Mosaic, (Turners being where instead of having XX chromosomes, females only have one X) - Turners mosaic females have some cells with XX and some with only one X (XO) due to a defect when they were in the embryonic stage. This means that she would still have gone through normal development (such as starting having periods) which someone who had Turners would not have. It can only be confirmed by genetic testing, though, and does the doctor want to say to her, next time she is in for a check up "Hey, you look a bit odd, perhaps you have a genetic defect, can I test for it please?"

That might be taken as a little offensive.

Happy Easter once again.

Radiotherapy

Hi,

Bit of a mix up this week, and I get to see a variety of different people. unfortunately I have been ill for the latter part of this week so missed out on going in during this time. You can't go into hospital and spread an infection to all the people who are already sick! Despite this I spend some time with a lovely lady who is currently undergoing chemotherapy for a cancer on her face, I sit in on a clinic run by a specialist heart failure nurse, who is Very good, and I clerk in a patient who has vomiting and pain on a background diagnosis if gastritis, but seems to just want morphine and gets very upset when he is denied it. A morphine seeker with a true medical condition?

I have spent some time this week seeing a patient who is having radiotherapy. Seeing as she has to come into hospital every week day to have a dose, I get a lot of chances to follow her up if I want to. She is a wonderfully optimistic individual, with a very positive outlook on life. She has a chronically ill son who she has to spend all of her time at home caring for, meaning she never really gets to go out of the house apart from these radiotherapy visits. These cause a lot of problems for her family and friends as they need to cover the care she usually provides whilst she is out of the house. The cancer was originally on her face, and she is receiving radiotherapy following surgery to reduce the risk of recurrence. This has left her with some scarring to the face, but she sees this in an optimistic light as well - telling me that it doesn't matter to her much at all, as she barely leaves the house any more. Seeing such a positive patient is really inspiring. Getting drawn such a poor hand and ending up with cancer whilst having to act as a full time carer must be very stressful for her, but she is still all smiles and laughter when I talk to her (she is in her mid 80s) and very positive about her health, her treatment and her life. Perhaps she is the real optimist? I hope she can keep such a positive demeanour as the radiotherapy progresses. Radiotherapy tends to get worse suddenly around the 3rd week, as it has a cumulative effect on the tissues. A bit like getting sunburnt on sunburn from the previous day. Then again. Then again. Then again. It takes a few weeks for the dose to start having bad effects, but then it gets worse til the end of the 6 week cycle. As of yet, she doesn't seem to be having any ill effects, no burn marks on her face, no hair loss and no pain or nausea, and I hope it stays like this, but I have a strong feeling it will not. I will keep you posted as to whether she manages to keep such an optimistic attitude as the treatment progresses.


I had the privilege of spending an afternoon with a heat failure specialist nurse. Specialist nurses have, surprise surprise, specialist knowledge about one specific area of medicine, and so tend to be able to run very good clinics for people who have been diagnosed with this condition. You can have nurses specialising in problems from heart failure, as seen here, to Parkinson's disease. While nurses lack the depth of knowledge in other subjects that doctors gain in their training, knowledge of other unrelated diseases is unimportant in this situation. Because of this concentration of knowledge these nurses often know a lot about their chosen speciality, and we had some of the patients who came into the clinic commenting that the nurse know a lot more about their condition than their consultant cardiologist. One of the patients we saw was a 40 year old ex English Premiership football player, who had started suffering from heart failure a few years ago following a heart attack.

Heart failure is where the heart cannot pump sufficient amounts of blood around the body, as it is not working efficiently enough. The three top causes of heart failure are

1) Heart attack. By damaging the heart muscle, the heart becomes less effective and so pumps less effectively

2) High blood pressure. The high blood pressure enlarges the heart, as it has to work harder to pump the blood, getting bigger (in a bad way, exercise makes it bigger in a good way). The enlarged heart has much less space in it, so pumps a lot less blood with each beat

3) Valvular disease. Diseases effecting the valves in the heart can cause heart failure, as with dysfunctional valves (not closing properly, or not opening fully) the heart is less efficient at pumping blood and can become enlarged again

Heart failure is a 'viscous circle' as the body's response to the lower blood pressure is to increase the amount of fluid circulating. This is because the body is acting as though it has lost a lot of blood (a common cause of low blood pressure in cave-man times) and so is trying to increase that fluid again. This just leads to the heart having even more problems pumping too much fluid, and so getting worse. It also causes some of the 'typical' signs of heart failure, such as pitting ankle oedema, where the ankles swell up with fluid because of this increase.

Back to the patient, he used to be a very fit athlete, but due to circumstance had ended up in this position. A lovely man, he spent the time we were examining him telling us stories of the 'old days' when he used to play football, telling us about his young 'bit of stuff' he had at home, and how embarrassing it was that he couldn't even walk up his garden path any more without becoming acutely breathless. Heart failure has a terrible prognosis, worse than lung cancer, with little to do to 'cure' it other than by a heart transplant. it was a shame to see this lovely gent walk out of the clinic knowing that he might not have that much longer to live.

The final patient I will mention this week is someone I clerked in when I was on call. With a substantial past medical history, he had come in with severe pain above his belly button (epigastric) and had been vomiting almost continually for the past day. When I was clerking him he mentioned how morphine had managed to relieve his pain when he was in hospital about a year ago. This started ringing alarm bells, as he had been in hospital numerous times over the last year, and obviously hadn't been given morphine then, or he would mention it. While morphine is a great painkiller, I have heard many patients say they do not like it because of its side effects. But it does kill pain very effectively, so perhaps it was the only drug the patient had found that can touch the pain? While I was there, he wasn't being given the morphine because the doctors didn't think that the patient's signs of pain warranted such a severe drug. He wasn't doubling over or wincing in the pain, just complaining of it whilst sitting there and vomiting. He was very insistent that he wanted the morphine, threatening negligence claims against the hospital should he not get it, which I think was putting the doctors off of giving him the drug. Another problem, should he get the drug because he is complaining of pain and feels it would help him? Even if he is is displaying addicted behaviour towards the drug, withdrawing is painful and should the doctors be helping him with this pain? There was no question that he was ill, with the quantity he was vomiting and the previous medical history. I don't know what happened, because of the weekend, but I do know that he was not being given morphine when I left the take, so he hadn't been given it for the first few hours of admission.

Time limitations mean a shorter, blunter, less flowery blog I am afraid. Have a great Easter, for those who get a holiday!

Overdose

Hi,

Quite a varied week this week, but I would like to just talk about a couple of the more outstanding patients, as they were the most memorable. Two of these patients were
 1)someone who came in via A&E who had taken just shy of 100 paracetamol tablets the previous day, and
 2) I saw someone who had gotten some complications, possibly related to a nasty and rare form of cancer he had.
I was also disgusted by one of my fellow medical student's viewpoints as to transplantation in 'those who don't deserve it' which made me pretty disappointed in someone whom I had previously thought was a caring and intelligent individual. Not that I want to rant or anything, there are plenty of medical blogs out there that do that sufficiently!

Anyway, when I went onto my on call this week, as soon as I got there I was told by the consultant that they had a patient for me to see, and had just sent another medical student (my partner) over to talk to them. I was told it was an overdose, but that was all. I arrived a tad after my partner had started talking to the patient, and had the embarrassing part of slipping through the privacy curtains and introducing myself whilst trying to look professional (don't think I pulled it off though). We talked to the patient for some time, getting the important information of how many paracetamol he had taken, how long ago it was and whether he had taken any other drugs with these (more drugs, including alcohol, makes for a worse outcome). It turned out that he had taken just under 100 paracetamol the day before, then locked himself into his room and fallen asleep. 14 hours later his mum (he was my age) had realised he had been in his room for some time and had ended up pushing the door down to find him asleep. Having woken him up and fond what he had done, the ambulance was called and bought him to us.

There is a set treatment regime for this common overdose, and associated graphs and literature easily found in the A&E setting. This treatment regime involves giving a drug called N-acetylcysteine (NAC). Paracetamol needs a certain substance in the body to help its normal breakdown. If this substance runs out (I.e. if too much paracetamol is taken) then paracetamol is broken down to a different substance which is TOXIC. The treatment for paracetamol overdose involves putting into the body more of this substance, so it doesn't run out, and all of the paracetamol is broken down normally. The toxic substance it is otherwise broken down to can ruin the liver and kidneys. The problem with this treatment is that it needs to be given relativity soon after the paracetamol overdose as otherwise the paracetamol gets broken down to this toxic metabolite and damages the liver and kidneys.

Because the patient had hidden his overdose, this was the situation we were faced with. It had been too long since he had taken the pills for the treatment to be likely to work, but it is possible is would help, so he was put on the NAC as soon as possible. We talked to him some more about his reasons  for wanting to commit suicide as it seemed like he had really intended to kill himself, locking himself away, not leaving a trail, taking a very large number of tablets (I would have personally got bored half way through taking that many pills and given up). Anyway - I won't talk about his personal situation but being the same age as me he had had a lot of things happen to him in is life that were not fair, and people shouldn't have to go through. Previous suicide attempts seemed to have been brushed off by the healthcare system and he felt ignored and uncared for. As medical students talking to him we were pretty much helpless. What were we meant to say? "Don't worry, its not all that bad. Sorry to hear you want to kill yourself, perhaps you will feel better next week?" We could just offer a kind ear until his sister showed up and we left them in peace for a bit.

As for the treatment of paracetamol overdose, the treatment of the person is decided on the amount of paracetamol in their blood stream. If it is very low then treatment is not carried out, as it is not high enough to be toxic. A graph like the one below is used.

The amount of paracetamol in the blood is measured and plotted against the time since it was taken (the levels go down over time, as the body breaks it down, so the time the pills were taken is very important). In a 'normal' patient, if the point this makes on the graph is above the 'normal treatment line' the patient needs NAC as the paracetamol levels in the blood were too high. This patient had a point much too high in the blood (I.e. around the letter A) so needed the treatment. If the patient has some damage already to their liver, or took the paracetamol with other drugs such as alcohol, then they should be below the 'enhanced risk' line to avoid treatment, other wise they will need the NAC. For instance, if a patient had taken 5 paracetamol and came in with a level around where the letter B is they would not need the NAC, as they are at no risk of organ damage. Anyway, our patient definitely needed treatment, and blood tests showed that the liver was already damaged, and the kidneys were functioning poorly. The patient was not urinating much, and when he did it was brown thick liquid. Not good.

To cut the story short, after a day on the treatment, it was decided that this poor bloke needed a liver transplant as the liver was failing. An organ your body cannot do without and, unlike the kidneys with dialysis, there is no artificial support method for a damaged liver. Either he will get a liver transplant in time, or he will die. Pretty shocking news for his family.

A couple of days after seeing this patient, myself and the other 5 students on my firm were discussing some of the patients we had seen that week. Most of us had met the same patients, but had all spent varying time with each one, so talking about the patients with each other lets us learn more. I was talking to my colleges about the patient who had come in with a paracetamol overdose, and the fact that he will now need a new liver. One of my colleges, a nice friendly girl, usually with a smile on her face, goes and drops a bombshell of a reply.

"Why give him a new liver? He destroyed his old one. What a waste!"

You are joking, right? All those years of boring ethics lectures and you can pop out a comment like that?

No, she wasn't joking. She genuinely and honestly thought that because this patient had damaged himself and destroyed his own liver he shouldn't be allowed a new liver and should instead be left to die. What about ex-alcoholics who need new livers? What about people involved in car accidents where they were exceeding the speed limit? What about people who decide to smoke and end up with lung cancer? What about people who eat too much, get fat and end up having a heart attack? Nope! They don't deserve our treatment because they did this to themselves! 

Its quite simple. Mental illness is a disease, just like having a broken leg or a stroke. With the right management, care, and support into turning his life around this person will not remain suicidal for the rest of his life. Just because he was ill enough to think that suicide was the only way out of the situation he was in, does that mean you just want to go and kill him for it?

Anyway, I will not rant for too long on this case. It was just amazing to see someone who seemed like a nicely balanced, friendly person with a decent ethical education rain down judgement on someone whose life was so different from hers that she must have no idea of how he felt. How can you look down on someone who decided to take their life after all of these bad things happen if you haven't had them happen to you? How does this medical student know that if half these things had happened to her she wouldn't have gotten upset and tried something similar. And then how would she like to be told, once she was in a better place mentally, that she would be left to die because she had done this to herself. It is beyond belief. Anyway - I really hope that the next few years bring this eduction to those who need it on the course. I hope there are not that many third year medical students and upwards who would think like this.

Anyway, I wasn't that outspokenly offended by her - I showed my distaste (I think I might have used disappointment rather than distaste) in her views, but I have to spend time with her and don't want her to think that I am a massive morally righteous douche-bag so  I kept it calm, but kind of regret that now. 

So as not to end on a negative note I will mention one of the other patients I saw this week. A 35odd year old man presented to the A&E with massive abdominal pain and vomiting. A lot of vomiting. As in he had been vomiting almost continuously since about 8 hours ago that morning and had managed to get through 4 buckets since he had gotten to A&E. He had a complicated history of a rare multifocal cancer (a cancer that appears in multiple places in the body). Like any good medical professionals, when we heard about this we and the F1 had a good old google/Wikipedia search to find out a bit about this. With the amount of odd rare disorders there are out there, doctors cannot know a lot about everything, unfortunately, and while each of them is rare or Very rare, there are a lot of them out there, so you will see some every now and then! Anyway - this was a very complicated case. We were unable to even examine his abdomen because of the amount of pain he was in, doubled over and clutching himself. Was it the cancer causing his vomiting and pain? Was there new obstruction from a growth? Was it the chemo he was on disagreeing with him suddenly (less likely) or was it a completely new diagnosis unrelated to the cancer? I don't know yet either! I hope to find out on Monday though. Anyway, the main reason for bothering to point that out was the complexity that some cases can come in with. I find it hard to imagine being a consultant and having ultimate responsibility over such cases. No-one knows what is causing pain/vomiting/any symptom and the patient is on your ward. If you don't find out, they may die. Scary! All of that trust and the absurd amount of knowledge you must need if you are a speciality consultant! Perhaps I will become a GP after all, so I can just refer on the really complex stuff!

Another busy week, so another poorly put together blog. As the year goes on I am sure they will get worse and worse, but I am afraid you will have to live with it, or give me an extra couple of hours a day! Then I might be able to get the work done I need to as well!

Have a lovely week.

Confidence

Hi,

A very full week, but very little time to write about it, unfortunately. I got more 'on take' experience, spent some time with a very optimistic lady undergoing radiotherapy for a cancer on her face and spent a day with an F1, where I got to do LOTS. Did my first Arterial Blood Gas (ABG). A wonderful week, but I enjoyed it too much, and now have an essay deadline for Monday (tomorrow) so I will try and be concise and brief, so as to finish the essay tonight and get some sleep!

Ok, I had a great time when I was on take again this week. Spending much of the day on take, until about 8PM, it also gave me a good taste of what it is like to work as a doctor (not that I will get that privilege for another good few years!) Anyway, the set up is the same as last week and I was seeing patients who were being admitted from A&E, or who were referred to the hospital from their GP. Their names are written down as they come in from these respective locations on a list, and as medical students we get to clerk them from here. This can take a good hour a patient if done thoroughly, and is like being a 'real' doctor. You start off knowing very little about the patient, just one sentence which has been put down on this list 'confused with abdo pain' or the like, and you have to do a full history and examination from this. Presenting this to the doctor in charge, they then want your differential diagnoses (very important across medicine) and your initial management plan. Very exciting!

Anyway - when I was on take I clerked in several people, including an old lady who had come in after falling on the floor and being there for over 24 hours before being found. Being too weak to lift herself, all she could do was lie there and wait. The history taking was complicated as she had slight alzheimer's and was absolutely starving and really wanted something to eat. I made sure I got her one of those NHS snack packs (like a lunch box, for those who haven't seen them, with sandwiches, biscuits etc. inside) which she wolfed down faster than I thought possible, then promptly fell asleep. On trying to wake her up (slightly afraid something terrible had happened due to the speed at which it happened) I got told to go away as she was sleepy. I wasn't really sure what to do here, she needed to be seen so treatment plans could be made, but if she wasn't going to talk to me there wasn't much I could do. As it was, I came back in 15 minutes and she was awake again (odd lady) and rather sheepishly apologised for being blunt and offered to help me finish off my history. Anyway, to cut a long story short, it seemed she had got a UTI which had caused her to fall (common causes of all evil in old people) which we could easily treat with an antibiotic such as co-amoxiclav. For the rest of the day, whenever I went past her bed I got a lovely smile and wink from her over some plate of food or other. While she had fallen and stayed on the floor for a day, perhaps she hadn't eaten for a week before that! It was either that or she was the 'Big Bad Wolf' who had snuck in in disguise to get some free food!

Another patient I saw on take was a kind Gent who was suffering from photophobia and headache. Typical meningitis alarm bells here. As you may be aware, untreated bacterial meningitis nearly always kills the patient. This is always something to be on the look out for to treat fast! The crucial diagnostic test for meningitis is a lumber puncture, where a needle is pushed into the spinal canal to take a sample of the CSF (the juice the brain is suspended in). The doctor asked me if I would be interested in doing this procedure. I know the drill, push the needle in between L3/L4 (low enough to avoid hitting the spinal chord, which has split into the stringy "cauda equina" by then) until you get some flashback and then take some samples. I was NOT happy to do this. I am usually really up for trying any new procedure I can get my hands on, and as long as you are honest, smiley and seem confident towards the patient they don't seem to mind. But a procedure involving sticking a needle right next to their CNS, with a risk of paralysis is out of my depth. A good thing too, seeing as when I saw it done it took the (highly skilled) registrar a good 15 minutes of 'poking around' (I believe that is the technical term) after putting the needle in before they got the flashback. I contented myself with taking his blood instead, after the procedure when he was complaining of a [more] shattering headache (common side effect, changing the pressure around the brain). He told me his veins tended to flummox medical professionals seeming to disappear and refuse to yield more than a few mm of blood when found. But he had a cannula in, so I reasoned they couldn't be that bad. I managed to get a vein nicely the first time, filling the necessary bottles, which felt good - but then again perhaps the fear from the lumber puncture had dilated his vessels after he had come through A&E and they had had their go. Still made me feel good though, I can still become that doctor figure I want to!
[If anyone was curious, he didn't have meningitis]

Despite all of this, my last day this week was still the best day for me. I ended up spending almost the entire day with an F1 doctor (first year after graduation) doing all of her tasks with her. This was more through choice than anything else, as the timetable is somewhat vague. We developed a quick 'you scratch my back' type relationship over the course of the day. I did a lot of her menial work, like filling out MMSE forms (which any monkey can do, it just involves asking questions clearly and ticking boxes) and filling out reams of figures on slips of paper to plot how patients blood results were changing from yesterday. That latter one seemed pointless, as the computer systems have a mode which can do this, but who am I to question why. Anyway, in return for the running around with X-ray forms and other fun things I got to do I got bought a cup of coffee and, by far best of all, got to do an ABG. I was also asked if I would like to catheterise a male patient but I declined as I had only ever practised on a plastic model and had never seen it done before. I got to do plenty of bloods and other such wonderful things, but lets focus on the highlight of my week.

An ABG is where a needle is stuck into the wrist at a steep angle to go and pierce the radial artery (the one you can feel with your fingers at your wrist). This is needed to see the levels of oxygen, CO2 and the pH of the blood. You need to get this information from an artery, as you want to know how much oxygen is getting to the tissues, not coming away from it. I have to be honest here, I don't think I have ever seen an ABG carried out in real life, but I have read about them (Wikipedia) and heard about them plenty. I suppose I may have seen one carried out on a programme like scrubs, if that counts. Anyway, when I was asked if I wanted to do one, I wasn't going to say no. They don't seem too hard, just feel for the artery with two fingers and stick the needle between them. After all - I seem to have a knack for finding veins, and you can FEEL arteries! I went and got the necessary hardware as the F1 asked me if I know about these.

"Yes, I have a pretty good idea of what it involves"
There we go. Not a lie at all, and said with a confident smile. Again, you can get so far with confidence.
"Sure, that's fine then, talk me through what you do as you do it then please!"
That's fine with me. I don't want to be left alone to do this at all! Unfortunately, as I come up to see the patient  I suddenly feel really bad. Its one of the several alcoholics we have on the ward (being gastro there is always alcoholic liver disease around) and he has been very out of it for the last couple of days. I am more than happy with explaining myself to a nice patient, trying to win them over and then doing the ABG, but doing it for the first time on someone who is barely concious seems somewhat wrong to me. Yes, he is unlikely to care too much, but what about informed consent? Too late now, I can't really pull out. Better carry it out well!
I prep the area, unsure as to what help these alcohol wipes really have. I am sure I read somewhere they increase the chance in infection by breaking skin layers. Stop. Where did all of this doubt come from!? Before I saw this patient I was calmly confident - now I have noticed it is not someone who would care if I messed up why does it matter more?

"Would you mind if I took some blood from the artery in your wrist, sir? It might be a bit painful I am afraid"
Patient flops his hand forward and upside down, grunts in agreement but doesn't open his eyes. He isn't the sort you could have a conversation with, brain encephalopathic from chronic alcohol use. That seems like as much consent as I am going to get. I start feeling for the pulse. Not as strong as most people's I am sure - but perhaps that means the artery is bigger, and as such has less force on the walls? I don't know, I just want to stay calm and confident. That's the trick.

I talk the F1 what I am doing, angling at about 45 degrees and angling the bevel to catch the flood flow as soon as I hit the artery. The idea with this technique is that once you hit the artery the blood flow has enough force from being in the artery to fill up the needle, pushing the plunger out.
There is nothing else for me to wait for now - hesitation loses that confident air you need to keep. I push the needle in between my two gloved fingers. Not even a twitch from the patient, still sitting there with his eyes closed. I can feel the pulse on both, so the artery is definitely between them as well. But my fingers are big, and gloved, the artery small and hidden below all that flesh, what if I am a few mm to one side? I might miss it, or clip it and damage the wall, leading to lots of bleeding from the wrist. I don't want that! I am sure it is here somewhere, but it seems deeper that I might have thought... Keep the confidence!

Finally (so that's a little under a second in real time) I see a trickle of blood appear in the plastic part of the needle that attaches to the metal needle. Flashback! This is quickly followed by a nice squirt or two of blood squeezing into the syringe and filling it up. I pull it out, making sure to cover immediately with gauze and keep pressure on for a good minute to stop bleeding. Still no reaction from the patient. Where is the applause! Finished. Nice. First time. Relief.

I walk the sample over to the nearest analyser machine. No need to send it off to the lab to be analysed, these machines do it on the spot! The nearest one is over in ITU. I come back with the slip of printed paper. respiratory alkalosis I tell the F1, and walk them through how I came to this conclusion. More learning.

Well, that was exciting for me, though I did feel like am imposter through much of that. I think it must have been mainly due to the fact that the patient was not with it at all, just sitting there glazed, that made me feel bad for sticking a needle into him. I felt like the guy from the movie "Paper Mask" I had been recommended to watch by a member of hospital staff. It all worked out fine for me in the end, but boy am I glad I didn't accept that offer to practice a lumber puncture earlier! I suppose we all have to learn by trying something for the first time, and after that experience I am still up for giving these new things a go (but not all of them. I will steer clear of neurosurgery for a good few weeks, don't worry!)

The F1 has offered to let me practice catheterisation next week if I am around and there is the option for it to be done. Sounds good to me - just keep confident, right! If I can keep this symbiotic relationship with this F1 I can get to do loads of stuff. But we do have these 'log books' we have to collect proof we have done 'useful'  things in, such as consultant ward rounds. The funny thing is, on some of the days this week, which have been unremarkable, I have collected around 5 signatures. This day I collected none. What can you do.

Anyway - this turned out FAR too long, and I am not going to read through it all again - so apologies for any parts which are poorly written / grammatically incorrect. I now need to get onto this essay so I get some sleep before my 8AM ward round tomorrow. Or is it 7.30?

Cheers for sticking with me, I really enjoyed writing this week!