Emergency

Hi,

Very exciting and eventful week this week. Lots going on each day, and I feel as though I am 'properly' back into the rotations. Most exciting event this week was getting to scrub in and assist in an emergency ruptured Abdominal Aortic Aneurysm (AAA), which can be beautifully compared to having hours of chat with a particular very sad patient, when I was just meant to be clerking them in. All of this is set on the background of the absolutely abysmal bedside manner the surgeons tend to display, making this one very interesting week!

On with business anyway. Monday was the day, as I mentioned before, that I had been offered the chance to assist during an emergency surgery list. These lists usually involve a lot of diagnostic laparotomies, emergency appendectomies and the such. I was looking forward to this, as after our session on Friday, I was confident suturing and such, so happy I could assist and be helpful. Unfortunately, when myself and my partner got there, there were already 2 medical students in the theatre, meaning we would just crowd the place, or sit at the back and watch. Not much fun. They got their first, they go in - fair enough - so we were planning on going off to a surgical clinic or something, and phoning around using the theatre reception phones to try and find somewhere to go. One of the theatre nurses was helping us for a while, disappeared for a few minutes, then came back just as we were about to leave with the news that a suspected ruptured AAA was on the way in an ambulance, and they were just preparing a theatre to use. Did we want to join in?

Hell yes we did!

Just a side note to explain what this AAA is, for anyone who doesn't know. The Aorta is the main artery in the body. It starts from the heart and travels down to the legs, where it splits in two (one to supply each leg, of course). On its course, it supplies pretty much every organ in the body apart from the lungs, and as such, it is a pretty important vessel. An aneurysm is where it swells up to larger than it should be, due to general rubbish being deposited on the walls (or "A load of shit", as the surgeons call it). This rubbish causes the vessel to get bigger, as it still needs to get the blood through. Picture on the left below (a), seeing the big bulge on the normal aorta!

This aneurysm builds up over years, and is often asymptomatic (people do not know they have one) which is often not too much of a problem. However, in this case the aneurysm had build up and the wall had become weakened, meaning it had torn. This is, as you can imagine, very bad. Suddenly all of this blood which was flowing nicely to your body starts pouring out of the aorta and into the spaces in your body. The AAA is in your abdomen (its in the name) so this blood comes pouring out into this area. This causes plenty of pain, and a massive drop in blood pressure (its not in your vessels any more, its in your belly!). This is bad, and has a mortality (chance of dying) of over 80%. The good news for this patient was that if he got into hospital, the mortality is reduced to 40% - still pretty high though.

We wait around for what seems like ages for the patient to come in and have an emergency CT scan. This is because if the aneurysm is above the level of the renal arteries (the little things which look like arms on the diagram above) the operation is far far harder, and he would usually just be given palliative care because he wouldn't survive the operation. Fortunately, this patient had a suitably placed aneurysm, so was taken through to the theatre. No history had come with the patient other than he had been found collapsed. Does he take any drugs? Does he have any medical conditions? Who knows!

 In theatre, I didn't really know what to do with myself, there were people rushing everywhere, and still no sign of any surgeons. It was the anaesthetist's job first. They had to get some blood to cross match in order to get enough to replace the blood he lost (bags and bags went in through the operation), and they had to put in some cannulas in order to be able to give this blood and monitor his blood pressure properly. Once all this was done, they could give him the general anaesthetic and let the surgeons start the operation. This proved to be a lot harder than I had thought - I saw consultant anaesthetists trying again and again to put a cannula into the patient in the arms, but failing because he had lost so much blood they couldn't get into a vein. Next they tried the arteries. Again, failing on the arms, they had to move up and insert a line into the neck. The more central the vessels, the more likely they are to have blood in them - and the body prioritises the brain over everything, so it will get the best blood flow. All the time this was going on, I had been instructed to talk to the patient, keep him from flinching away from the pain of the repeated needles he was being jabbed with, and keep the anaesthetist informed about his concious level. If he stopped talking, then things were getting worse. He was absolutely out of it - no recordable blood pressure, in hypovolemic shock and in agony, He didn't want to talk, and when I tried to engage him he would mutter something about his walking stick, or about a budgie. All this time, I was aware that, if he died before waking - I would have been the last one to talk to him. What do you say? I didn't know.

Once the patient was anaesthetised, I was given another astonishingly important job. Hold his arm. Wonderful - this operating table only comes with one arm rest now (who knows where the other is) so you need to hold his arm out, full of lines now, whilst holding up the "blood brain barrier" (the shield that separates the the anaesthetists at the head end from the blood and sterile conditions down the other end) and making sure I didn't touch anyone who was scrubbed up. Arms can get pretty heavy after a while, but that's just me being weak. Better that holding up a leg. Finally someone got an arm board from another theatre, and I could set the arm down. At this time, they were just putting in the graft to make the aorta a closed tube again, rather than a torn hose. Similar to the diagram above (c) this is just a section of tube that is put inside the aorta to let the blood flow through that instead, and stitched on at either end. The surgery isn't done like it is in (c) though,  that is a non-emergency aneurysm repair (EVAR) This surgery involved putting a couple of beefy clamps on the aorta either end of the aneurysm and cutting it open to scoop out all that rubbish inside, and put this tube in. obviously whilst doing this you have to avoid all the blood that is already around the aorta from where it is been bleeding from the tear. When I say avoid it, I mean just stick a suction nozzle in it and try and suck it all out of your way so you can get to the aorta.

Once I had put down this arm, I got to scrub in. Excellent - seeing as they had done the hardest part, putting the graft in, the consultant didn't need another highly experienced assistant any more. He could get away with anyone. I went and scrubbed up (basically just washing your hands for ages, and then dressing in a certain way so what you put on is still sterile) and got to get my hands (or should I say gloves) dirty. We just tried to stop any visible vessels bleeding (the incision and surgery is done in a real hurry in order to get to the rupture, that these cannot be sealed as they are cut through) and put the gut back into the body in pretty much the correct order. At the start, all of the gut had been heaved out of the cavity and just put in a plastic bag to keep it wet and warm 'til now. You would then sew the patient up, but there was a substantial delay to this because he wouldn't stop bleeding. This was due to an effect known as consumptive coagulopathy, where the body had used up all of its clotting proteins in trying to stop the ruptured AAA bleeding into the abdomen. Now that that had stopped, the body could no longer clot the blood, and every single capillary that had been cut through was leaking watery red blood. Normally the clotting would shut them off in an instant, but without these fancy factors, the patient would just keep bleeding. Fortunately, the anaesthetists are equipped to deal with this, and after several bags of platelets didn't slow him down, they gave some fancy proteins and drugs which did. About time as well, all this lack of clotting had not just affected the incision in the abdomen. All of the previous attempts at inserting a line in his arms to his neck had started bleeding, and his lips had swollen and bled over his mouth and face, from the pressure that was exerted during intubation. Quite a lot of blood, everywhere. The abdomen was closed and we were free to go off home.

How long did this operation last do you think? About 5 1/2 hours would be a pretty accurate answer. That's a long time with your arms inside someone's belly, but its major surgery. Most patients survive the surgery if they get to hospital, it is the days/weeks later in ITU that pose a problem. It is a lot for your body to recover from. Hoping that the patient would be fine (obviously, no point in wanting anything but that, is there) I went home for a nice shower. You will be pleased to know that he is still alive in ITU!

That is how I can see the appeal in surgery. That was very exciting, and exactly the sort of environment that I would enjoy working in later. I would love to do something that acute and that exciting, where people come in with such extreme problems, and you have to do that work to save them. Awesome.

Over the next week, more things happened, nothing as exciting as Monday, though. On one of the days, I was clerking in a woman who had been admitted from a clinic because of limb ischemia. One of her legs had developed a problem in the artery, and it wasn't getting the blood it needed any more. A simple operation sticking a balloon down the artery and expanding it again, would put her back to normal, otherwise the leg would die and start rotting. Not really a competition. This lady was very unhappy to be in hospital, though, and I started talking about some of her worries whilst examining her. She had lost a number of family members in hospital, including children, one an adolescent. I was just chit chatting with her, really, until I came to feeling her pulse. You should feel both sides, looking for any delay, and as I was feeling on the other arm, it felt all bumpy under my fingers, I turned over her hand, to see what it was, and saw dozens of white scars across her wrist. I didn't change the topic of conversation, I didn't even let on I had noticed, continuing the examination - and I think she bought it, being distracted at the time talking about her pets at the home she lived in by herself. My attitude towards her changed completely, though. I felt I was no longer just clerking in someone who didn't want to be in hospital. I felt I was looking after someone who had been more upset that I could imagine at times in her life. I felt sorry for her. I wanted to help her. But I didn't want to act strangely suddenly. I decided that the best way to do this would be to just talk to her about her worries, her troubles, her past and what she saw in her future. I was there 'til around 8 in the evening (though I hadn't gotten there to clerk her early by any means) and then I visited her the next day, and the day afterwards. There was always a medical reason to lead the visit with. I could be checking on her blood results in order to build a case to present, I could be interested in what the results of the scan were, but I would just end up talking with her. It is sad that, when I am a doctor (sooner rather than later, please), I will not be able to justify doing anything like that. At the moment, it is my time, to spend how I want to learn. If I am being paid to be in the hospital, I will have mounds of work to do, and won't be able to talk to any patients like that. A real shame.

As the week went on, I decided that perhaps I don't want to be a surgeon. Monday was really exciting, but most of their time is spent doing mundane operations again and again. This isn't the main reason, though. Surgeons really do not have any bedside manner at all. Spending time with consultants and registrars in clinics, they would just wander into an examination room, instruct a patient to take off whatever item of clothing was required, wander back in a few minutes later and tell the patient what they were going to do. Then leave.

Surgeon - "I am going to scan your leg"
Patient - "Err, ok - what does that involve?"
"Sit on the couch please" (bear in mind, patient has already taken off trousers from previous 'visit')
"Mmm... ok"
*Surgeon uses duplex scan (ultrasound like device) to assess arterial insufficiency in leg*
Surgeon - "Thank you"- and leaves room
Surgeon - returns 5 minutes later, patient still sitting on couch without trousers on - "You can leave now, we have patient's waiting you know. Your AT has a triphasic response by the way"
Patient - "Psyphasic?"
Surgeon - "We will send you a letter about it in the post, don't worry"

This wasn't just one patient. It happened again and again. Don't get me wrong, surgeons are great fun to hang around, and can be really nice to the patients. It just seems that some of them (don't let me generalise here) don't realise that you should try all the time.

In case you are wondering, a triphasic vascular response is a good thing, and indicates normality. Hopefully the patient will be pleased to find that out!

Have a good week, next week I am doing urology - perhaps not going to be as exciting as this week, but perhaps that is a good thing - I have far too much work I need to be doing!

Surgery

Hi,

I'm back after a nice holiday, and back on the working train. As the first week of a rotation, it wasn't typical, and we started off the week with 'introduction' lectures. These involved learning the history about the area we practice medicine in, the history of surgery, and the history of medicine within the area we practice medicine in. If this wasn't going to be too much fun for our poor bored minds after the holidays, we also managed to get a lecture from an NHS manager on the management of the NHS, the structure of the NHS system, and what managers do. Unfortunately this only served to reinforce the feeling that if anything in the NHS needs to get cut back, this would be a good place to start.

Anyway, moving on from the tedium of the first few days, which did serve to remind me how much more I enjoy the clinical years compared to the first 2 years of lectures, we spent some time with surgeons doing everything they do apart from going into theatre. A bit of a shame we haven't had the opportunity to slip into theatre yet in the first week, but next week... Anyway - I can see why surgery might appeal to people, you seem to do everything an physician does, as well as operate. You see patients with symptoms to plan investigations to diagnose. You prescribe drugs, you run clinics (though they seem to be the bane of the surgeon) AND you operate in your spare time. Despite all of this 'work' surgery seems a lot more relaxed than the other departments I have done rotations in so far. We were taken to the common room a couple of times, and had tea and coffee, watched the election on the TV, and had the opportunity to play some pool or table football. It seems that medics seem to have a lot more work to do compared to surgeons, who can wait around much more waiting for surgery to start, and so on.

Another wonderful thing about surgery is the fun nature that a lot of surgeons seem to have. The typical opinion across hospitals of surgeons is pretty similar to 'Scrubs', arrogant, less intelligent and jocks. That's the usual response I tend to hear, if I tell people I am starting surgery, or going to have it as my next rotation. For some of the surgeons, this isn't an inaccurate description. There are some particularly scary surgeons who have reputations across the hospital as those not to cross or annoy, and unfortunately I have one of these in about a month. Despite all this negative press that surgeons tend to get, many of them are really fun to be around. Not always taking things too seriously, they are often jokey and interesting to be around. It seems that many surgeons place a lot of value on general knowledge, perhaps hence the history lessons at the start of the rotation, and like you to know a lot of non-medical things (verging into more academic areas such as physics). The sceptic in me says that this could be because they don't need to know as much medicine, instead concentrating on manual skill for operations, but that would just be harsh, right!

Learnt a few important facts this week, though. Certain surgeons lock the doors as they start the lectures, in order to stop people from coming in late. Sounds a good idea really, but will probably mean about half the rotation don't benefit from the lecture. Also learnt that surgeons expect you to learn a LOT of anatomy. I was embarrassed this week because I couldn't name all of the vascular branches from the start of the Aorta to when it passes under the inguinal ligament in the thigh after bifurcating. This includes all the branches in the pelvis, and is quite a lot (supplying all of your body but the legs) -  but have been told I should know them all by Monday. The plan is if I do know them, I can assist in the emergency surgery list on Monday, which would be exciting. I have some work to do!

On that note, I managed to embarrass myself further last week by missing a patients femoral pulse completely.  The lady had arterial insufficiency to her legs, meaning they were ulcerating, getting infected and starting to decay because the cells were dying as they were not getting enough oxygen/nutrients. Peripheral vascular problems are very common it turns out. Myself and another medical student were asked to feel for this lady's femoral pulse, to see if anything could be felt to work out where the blood supply was being occluded.  A little awkward, as this lady was in a hospital gown, so we had to lift it up to around her belly-button in a cubical with about 8 people in, including us. I couldn't feel anything, and neither could my medical-student college. We reported this to the surgeon who duly wrote it down in the notes. About 5 minutes later, as part of the examination of the abdomen, a senior doctor pointed out that there was most definitely a femoral pulse, and guided out hands to it. It was very obvious, and I have no idea how I had missed it. Perhaps on the frail skin of the old lady I had gotten my land marks confused? Perhaps I was just being dense. We were 'firmly advised' to practice feeling our own femoral pulses 'in bed at night' - with a wink, so we didn't miss it again. Not only did I manage to stop here, but I managed to answer the question as to which bone the femoral pulse was felt against as "the Fibia" I was duly ignored by the doctor, but yes, there is no such bone as "the fibia" and yes, the correct answer would be femur, pretty much the best known bone in the human body. I should have known that around GCSE level, let alone now I am a 3rd year medical student. Not good! Needless to say, this was a pretty embarrassing day, but sometimes days just go like that, the brain doesn't seem to engage.

Well, I will wander off now to learn the branches of the aorta and to do an essay, and won't waste my time or yours rambling on any more. Hopefully next week I will have done some exciting things to report back. While exams loom and work presses on, I still want to get the most out of surgery and get stuck in. We did a workshop on Friday where I learnt to suture pretty effectively, so hopefully I can put that into practice!

Holiday

Hi,

Nothing to say this week, so I will not waste your time gabbling on about something you don't want to hear about.

Just to tell you I had a wonderful holiday in Dublin, saw some friends around the country, and am going onto a surgery rotation next, so the next post will hopefully be a better read than this one.

Nice to have a break and get the chance to see some friends and go on holiday though.

Until next Sunday!

Exam

Hi,

Nothing much to say this week, I am afraid - I had an exam today based around the last rotation, and all went fine, and most of this week has been spent preparing for it (or at least tricking myself into believing that that was what I was doing)

I am going to be off for a few days now as well, visiting Dublin and then we have next week off. Joyous days! Good to finally have a brief holiday. Then onto surgery and final exams.

My favourite point this week was in a lecture about type 1 diabetes (you know, the disease where your body destroys the B-islets in the pancreas, so you no longer produce insulin)

Student "I know it seems like a silly question, but is it possible that this disease stems from some form of evolutionary benefit?"

Lecturer "That is a pretty stupid question. No"

Anyway, no clinical work today so no real blog. Im off to have a happy, belated, Easter! Enjoy your week.

Hearts

Hi,

As far as interesting cases go, this week was dominated by meeting a man who had two functioning hearts. As well as meeting this very interesting case, I also got on with the normal life of a 3rd year medical student. I met someone who is a very famous musician, in a clinic for people suffering from syncope (faints) and I managed to get dragged into a cubicle half way through another medical student examining a patient, and thoroughly embarrassed on my lack of knowledge. I have also been enjoying the political atmosphere. I love a good debate, and it is always interesting seeing people who you know, but not enough to have had such discussions with before, reveal their political colours (such as all of your classmates). Its great seeing how peoples political views match up to what you might suspect of them. Do those who tend to wear Ralph Lauren polo shirts or YSL cuff links tend towards conservative? Its interesting to sit in a common room and listen to people discuss various aspects, and reactions to other's political views.
"Urgh, I cannot believe you are conservative, I always thought you were a nice person"
 or "Liberal Democrat? What are you doing in medschool, I thought there was an entrance requirement?"
Not always meant in jest, these 'debates' can get pretty ugly, but its a good opportunity to learn more about your friends and classmates.

I will go straight onto this patient who had two hearts, as I never knew this was possible until this week. This was not some form of congenital abnormality, meaning he was born with two hearts, rather he received a heart transplant about 20 years ago, but the old heart was not removed. The new heart was stuck into his chest on the right hand side, next to the old heart, and connected up so they could both function at once, giving him extra pumping volume. This kind of operation, known as a heterotopic heart transplant is rarely performed nowadays, with the main reasons for doing it being if the original heart is suspected to recover (foolish to remove a hear that will improve, just give it some time without the person dying); if the transplanted heart is too small to work properly in the transplantee (i.e. a small woman's heart transplanted into a large man); or if the transplantee's body is suffering from pulmonary hypertension, meaning the heart needs extra force to pump against the increased pressure. This sort of problem is usually surmounted by a heart and lungs transplant now, however, as this gets around the increased pressure int he lungs by giving a new set of lungs as well! I had a very informative talk with this interesting patient about how his life had been going and the problems he had had, but unfortunately I never got to examine him. Seeing him in a clinic, where he had come for a general check up, I felt it would be rude to ask him if I could auscultate or feel his chest to see what having two hearts sounded like. I think this was probably the right decision, as I am sure he gets a lot of attention from medics and students alike wherever he goes, but I regret it at the moment - I hope I see someone else with such a transplant to see! A very "Dr Who" like situation. The two hearts had a pace maker attached to both of them a little after inserting them to make sure that they beat at different times, to stop a large increase of pressure from a combined beat.
Next time I see a really interesting patient I will make sure that I say something and get a chance to examine!

I was wandering around in the A&E looking for some ambulance crew who didn't look too busy. I had heard that it was possible to go out in an ambulance for a day or two if you asked the right people, and this sounds really exciting, so I was trying to get a phone number off of someone who looked like they knew what they were doing. Whilst looking, I was suddenly approached by a small, hyperactive doctor who grabbed me by an arm, muttering something about an interesting case, and dragged me behind some curtains into a cubical where one of the other medical students was examining a patient. I was a bit lost and flustered, wondering what was going on, and then I was asked a series of rapid questions by the doctor about the patient, their condition, differentials, examination techniques and the such. This was a respiratory problem, and as of yet, i unfortunately do not know all that much respiratory medicine. Especially of this level, as I found out later that this patient had often been hired with his chronic condition for MRCP exams (very high level exams for 'proper' doctors). The other medical student there was on a respiratory rotation, compared to my gastro/cardiac experience thus far, and managed to get the majority of the questions right, whereas I fumbled almost all of them. It was pretty embarrassing, seeming so stupid in front of one of my fellow medical students, while he seemed to know so much more. It was especially unnerving to keep having to say "I don't know" to this excited doctor, who obviously loved teaching, who was pacing around telling me I would never pass my MRCP examination if I gave stupid answers like that! All in all a pretty embarrassing situation, but embarrassing enough to kick me into revision action. I will have to make sure I know more about the lungs then - I think I know plenty about guts and livers by now!

To finish off, I saw someone very famous this week in a syncope clinic. They had been fainting at inopportune times, and were afraid of it happening to them on stage. Another great thing about medicine. Everyone needs medical help, rich or poor, young or old (though mostly the old). Despite all of the lack of knowledge and embarrassment that seems to occur around me, this is a wonderful profession to get into - and I look forward to the day when I actually know something!