Graduation

Hi,

Firstly, thank you very much for all of the lovely messages on my previous posts - it is nice to feel appreciated. I will keep writing while being a junior doctor, but may take a different format. This weekly format was quite clunky, as some weeks I had loads to say, and some weeks I didn't have very much - perhaps I will change to a 'regular blog' instead, meaning I can update on days when exciting things happen, with shorter posts which are easier to fit into (what is going to be) my busy working life!

I have now graduated, and am due to start work next week. A very scary thought indeed! Graduation was lovely, we had the normal ceremony in the morning, where we came up on stage one by one to be presented with a certificate as part of the main university ceremony, and then in the afternoon we had our own medical students ceremony where we said the (revised) Hippocratic oath (old one not really fit for modern medicine/surgery) and we had our own prizes, speakers and so on. The main event in the morning was a lot more interesting than the one at the university I intercalated at two years ago; it was a lot more relaxed, a lot more fun and a lot less pompous. The event in the afternoon was very informal as well, and much more personalised as it was just for my year. All in all a really enjoyable day, and having this certificate in my hand, and being Dr Internal Optimist is just crazy. When people ask me what I do, I still say that I have just graduated and try and steer the conversation away from that topic. I feel a bit uncomfortable about it, almost as though it isn't right - something that I hope will pass.

Current impression I am likely to make as I start my vascular rotation next week

And it is important that that feeling passes - 'Black Wednesday' is next Wednesday - I start work in less than a week, and have shadowing before that. I am going to have to introduce myself to all of 'my' patients! I have decided on a compromise, which makes it seem less strange. I am going to indroduce myself as "Internal Optimist, one of the doctors looking after your care" rather than "Dr Internal Optimist" as it seems less... strange to me. I don't know why it is - I suppose I have always held those who teach us in quite high regard (yeah, I am a bit of a goody-two-shoes ... or sometimes at least). Having looked up to some very inspirational doctors during my 6 years at medical school, it is very strange having crossed that student-brain-barrier and having entered a position where I could well be the 'inspirational' doctor that medical students see. Sadly it is much more likely that I am the poorly-organised-and-rushing-around-doctor who medical students will not get much help from, but I will try my best.

Anyway, I am looking forward to everything ahead, and while it feels very strange, I think that is a good thing. I will keep posting and keep you all updated. Thank you for being so lovely to me throughout my time posting as a student - writing a blog is good I think. It encourages reflection (and god knows we are told to do enough of that at medical school) and is cathartic to talk about what happened, and look back on how things made me feel. I just wish I had the time (and knowledge) to organise all my old posts in some way to make them more easily findable, and separate them from the 'Dr posts' that will come.

If anyone has any good ideas for a blog title change, please let me know!

Final week as a medical student

Hi,

I would like to apologise for this post being really late, I wrote it over a week ago, then pressed save rather than publish, and went on holiday. The holiday was lovely, but I realise that I need to actually press the right button!

Despite having found out I had passed my finals almost 2 months ago, I have been working as a medical student in the hospital, getting ready for the job of 'doctor' come August. The idea still makes me feel excited and/or scared. However, the gruelling life of a medical student has come to an end for me. This was the last week I am going to spend in hospital as a medical student, and was topped off with my graduation ball. This week I introduced myself as a medical student for the very last time, I did my last referral as a medical student (where, ironically, I got a grumpy doctor who refused to talk to medical students as it was 'inappropriate') and signed myself off as "Internal Optimist, Medical Student" at the bottom of the notes for the last ever time. It is so exciting to think that, after a months holiday, I will be writing "Dr Internal Optimist, GMC *******" at the bottom of the notes instead. 6 years of hard work, not including all of the school work and preparation before university, have gone into this end point. 

But I am not really sure how to feel.

The ending has been a bit spread out; I was really happy to finish my finals, and overjoyed to have passed them, but then I have been working as a medical student for the last 1-2 months. I haven't really had any real 'you are finished forever' moment, which is arguably a good thing. I am so glad after each 'hurdle' that I manage to make it over, I am not sure I would be able to handle all of it at once. Although I will never be introducing myself as a medical student again, I still have one 'hurdle' left - graduation. After graduation, when I have that certificate in my hand, I will feel as though it is well and truly over. It will probably be quite an emotional day, not just for me, but for most of my year.

So I am slightly confused about how to feel at the moment. I am very relieved that I have made it despite friends who were just as able as me dropping out of the course throughout the last 6 years. I am really happy to have made my main 'life goal' over the last 7 years or so. Most of the last 7 years have been aimed at getting into and passing this course, then getting a good set of rotations afterwards, all of which I have managed to achieve. 

But I still feel a bit uneasy. Perhaps it is a sense of 'what now' - having such a long term goal fulfilled leaves me wondering what I should be aiming at now. Perhaps it is the fear of working as a doctor next year; a job where patients put a huge amount of trust in you, and where a simple mistake can have disastrous consequences.

Don't get me wrong though, I really am happy to finish this course and graduate, it is just there is a slight grey lining to my radiant silver cloud. After graduation, I think the only way that I am going to feel more relaxed about this is by starting work in August, and proving to myself that I can do this job. After all, I have spent 6 years preparing for it, I should be ready by now!

Ambulances

Hi,

An interesting week in A&E, the most exciting part being a few days with the ambulance service with the paramedics. 

A&E had some interesting cases, some sad cases and some relatively dull cases. The interesting included someone whose pacemaker was giving the wrong signals, a road traffic accident where a cyclist had been hit by a car, who had then run off (leading to us trying to balance the clinical needs of the patient with the police wanting to question them ASAP to catch the car driver), and someone who had dislocated their shoulder (which I got to put back in, something I hadn't done before). Several of the sad cases involved people coming into A&E and dying of problems like cardiac arrests, and one was a patient who liked to 'fake' seizures to get her into hospital. There are always lots of less interesting cases, and people who come into A&E who should have gone to their GP instead, but I am still really enjoying this placement.

The most exciting part of the week, as I said before, was a few days on am ambulance with a paramedic and a technician. Driving around on blue lights and everyone getting out of your way is very exciting! The saddest case that we saw was a man who had started feeling really breathless and confused while in a supermarket, and the cashier had called 999. He has a strange heart rhythm, which we initially thought was SVT, but was actually fast AF. He was very worried about his car parking ticket running out as we took him on blue lights to the hospital, and I spent the time reassuring him. We arrived, and 10 minutes later he arrested and, despite 40 minutes of resuscitation being attempted, he died. Despite him appearing relatively well in the ambulance, where his main worry was his car, he just died - and we still have no idea why. He didn't seem to have any signs of a heart attack, so we were wondering if it could be a PE. I found it quite upsetting, and I don't think that feeling a bit travel sick from bouncing around in the back of the ambulance at high speed with no windows helped things. We saw a number of other patients including a man who had been found in a very 'compromising' position, who tried to tell us that he had been attacked in his home, though it looked as though the problem had been caused by some kind of strange sex game. 

SVT: regular, fast 






AF can be fast and look similar to SVT, but will be irregular rather than regular in rhythm





While on call with the ambulance guys, I also went into a school full of primary school children and spent some time showing them around the ambulance with the paramedic, letting them turn on the lights and sirens etc. We were still 'on call' whilst doing that, but didn't have any interruptions. I think the point of it was to try and make sure kids are not scared of ambulances if they need to come into hospital, and think they look 'cool' instead! After some of the sadder patients before the school, I didn't really feel in the mood to be very cheerful and upbeat (which you need when talking to children), but it was a nice distraction. 

Seeing a few days in the life of a paramedic was interesting though, as despite there being some interesting things, there is also a lot of calls that they attend that they certainly shouldn't need to; a lot of people misusing the 999 number.

Quite an emotional week, but busy and interesting. My last week next week, then graduation, a little holiday and I start working as a doctor!

Spot diagnosis

Hi,

A week in the emergency department for me, where I get to assess and treat lots of patients, see a large overdose, and make a 'spot diagnosis' on a receptionist who is quizzing me on her disease.

One of the best bits about A&E is patients are meant to be in and out in under 4 hours, meaning that you can see, examine, investigate and treat a lot of patients in each day. I am getting better at writing management plans that are actually accurate now; something I found difficult. I find diagnosing patients and writing management plans very rewarding (if you get it right). For example, last week a 40 year old lady came into the A&E department who thought she had a pneumothorax. This is a problem where air gets outside of the actual lungs, but is trapped inside the thorax which surrounds them. This can deflate the lungs and make you breathless. I have put a picture of a chest X-ray below:

This is a chest X ray showing a fully inflated left lung (right of the picture) and a partially deflated right lung. You can see the loss of the normal lung markings, showing that it is just air and not lung across most of the right side. This is a large pneumothorax.

The 40 year old lady was scared that this had recurred, as she had chest pain and felt breathless. As the first person to see her, I started off with observations to make sure she was stable, took a history and did an examination. A pneumothorax will have reduced air sounds over it if listened to with a stethoscope, as there is no lung there. From the history and examination (which showed she was tender over a few ribs too) I guessed that this was 'musculoskeletal pain' - i.e. she had pulled some muscle in her chest, rather than a pneumothorax. To make sure, I ordered a chest X-ray, which I then had to interpret. I thought she was fine, so went to talk to one of the doctors in the emergency department. He listened to the history, had a look at the chest X-ray and just agreed with me, and told me that I should discharge her. Very rewarding to have your opinions 'validated' by someone- hopefully something I can get right more and more often as time goes on!

Other patients who I saw this week included someone who had taken nearly 200 tablets of a mixed variety, mostly diazepam, and had come in after being found unconscious on a park bench (he was quite sick, and my job involved the exciting task of looking through all the empty pill packets, working out what he had taken, how much, and finding out how dangerous each one was on toxbase). Another patient was a 98 year old gentleman who had severe dementia, and had been bought in by the nursing home as he had become 'increasingly confused'. This is called delerium, and there are hundreds of causes for it. As the patient couldn't say anything to me, it was very difficult to work out what it was that was causing it, and I had to order loads of investigations. I don't feel I really got to the bottom of it, as everything I did was negative, but my senior decided that it was probably a pneumonia and discharged on amoxicillin. Not too sure how happy I was with that, as I couldn't see any signs on the chest X-ray, and there was no suggestion of infection from the blood markers, but I couldn't really argue...

Early in one of the mornings, when things tend to be a bit quieter, I was chatting with a receptionist, who asked me if I could diagnose her condition. I asked her for some clues, so she told me to treat her as if she had been bought into A&E unconscious on a stretcher with a low blood pressure, but no other obvious problems. She had a good tan going, so I ventured that "perhaps, because you have this bronze looking skin, you have Addison's disease?". I was right, and she was really impressed. It is mainly because 'hyperpigmented skin' is a typical multiple choice question option for Addison's - and I have just done finals. I felt very smart for the rest of the day, after she had heaped congratulations on me, but also a little smarmy. It is good to get things right, especially for the patients, but if you show off about them you just look like a nob! Fortunately this blog is anonymous, so I can get away with showing off a little bit ;)

Referrals

Hi,

First, very sorry for the really late post. Things are getting out hand. I always tried to post on Sundays, but then with busy weekends this started shifting to Monday/Tuesday and now it seems to have shifted all the way to Friday. Hopefully I can catch up. The problem is, things re really busy and, while I enjoy sitting down to write a post, it takes time which I don't really have! Perhaps, come August, I will try and keep it regular but remove the 'weekly' from the title to take away that expectation (which I am struggling to meet!) What do you think?

Anyway, moving on to what I have been up to this week (by which I mean last week), it was a bit more empty than the week before. A bank holiday when I didn't need to go in, and a day of lectures meant I only spent a few days in the hospital. I am still on an acute medicine rotation for this week, before moving onto emergency medicine for the next few weeks. 

The day in the acute medical unit consists of a consultant lead ward round at 8AM, seeing most patients. Patients are normally only admitted to this ward for a day or two, so each patient is an interesting case, needing diagnosis and management plans, which keeps things interesting. There are two consultants who split up and see the patients who have been admitted in the last 24 hours, and a registrar (slightly less experienced) who sees the patients who have been in for over 24 hours, and adjusts their management plans. There are about 30 beds in total. After all patients have been seen by one of these three groups (each consultant has junior doctors with them to help things along) everyone goes into a meeting room, and all patients and plans are discussed. All the plans are put onto a big spreadsheet, which is printed off and pasted on the wall. The rest of the day consists of the consultants going somewhere (still not sure where, perhaps there is a secret bar out back?) while the juniors carry out the 'jobs' on the list. These could be things like taking blood, asking specialists for referrals, or inserting a chest drain. This is the most useful part for me, as I can just grab jobs off of this list and do them, meaning I am helping the team out, while learning myself.

One of the most useful things I was trying to practice this week was referrals to other specialities. This is where a patient needs a more specialist opinion for a complex disease, and you try and persuade a specialist to come and see them. As a regular reader might know, I have had bad experiences in referring to specialists before (like this), so I thought it would be a good idea to get used to how to do it. Different specialists want different information; a cardiologist will want to know about previous heart attacks or angina, and cardiac risk factors (like smoking, family history of heart disease, high cholesterol etc) while an endocrinologist might quiz you on the exact insulin regime the patient has, how closely they stick to it, and their blood glucose highs and lows. Being prepared for what they ask you is very important, as they won't hang around if you need to pop off and ask the patient! This week I referred patients to the dermatologists (one for a very interesting rash that looked vasculitic (is it lupus!?)) and I took a patient over to vascular surgery myself to try and squeeze him into the radiographer's  list of vascular imaging, where they use an ultrasound machine to view the vessels in the legs, and try and work out what the blood flow is like. This sort of negotiation should be really useful come next year when I need to get patients treated and out of hospital as quickly as possible. By taking this patient to the radiographer myself (rather than leaving him to a hospital porter, who may take ages to get there) and negotiating slotting him in between two patients I got him the imaging a day earlier, meaning he could be seen by the vascular surgeons a day earlier, and out of hospital a day earlier (just a bed for a day is about £400 according to the department of health). 

A typical looking vasculitic rash

 As well as trying to do my part to save the NHS money, I also got to participate in draining fluid out of several abdomens due to liver disease. This involved sticking a needle and syringe into the belly to suck out fluid to analyse, and while exciting for me, may not be the sort of thing that people really want to read about!