Exams

Hi,

Time for a quick update as to how things are going. I worked hard for my exams, and let me tell you, revising is nowhere near as fun as bouncing around the hospital. More tiring though. The problem with revision is that during those weeks when you are preparing for your exam, you have no time for yourself. Whenever you do anything fun, it feels as though you should be working, and you are procrastinating. You end up feeling guilty for enjoying yourself. Anyway, enough of that - exams seemed to go well, though I was least sure about the OSCE, which was the last exam, and least prepared for. Let me tell you about two of the stations, for lack of anything else to write about. Who wants to hear about written exams!

The OSCE station I had most problems with was that of a woman who had started bleeding vaginally early during her pregnancy. After asking about dates, pain and amount of blood I wasn't really sure where to go. I cannot really reassure her, as it sounded like an ectopic pregnancy, which would mean it wouldn't be viable. Not point telling someone "it's all going to be fine, don't worry' when its likely the baby cannot survive. I couldn't really tell her that either, as it would have to be diagnosed by blood tests and ultrasound scans. I told her about these, but I really don't think I covered enough in that OSCE to cover the 15-20 marking points. The other OSCE stations (20-30 of them) went with varying degrees of success, but there is one I was very pleased about.

The station I was most proud of came close to the end. This exam lasts for hours, and by the end you are starting to get pretty tired. This was a station where you needed to do a cardiac examination, which involves feeling pulses, looking for signs of cardiac disease in areas from the nails to the eyes, and the obvious listening to the heart. In a 3rd year OSCE there are a few likely problems, such as heart failure or valvular disease, which is probably going to be either aortic stenosis or mitral regurgitation. These are the two easiest-to-hear murmurs, created by problems with the valves in the heart, and among the most common, meaning it is easy to get patients for us to examine. The trick is distinguishing between the two, as they both cause a murmur in the same space of the "lub-dub" of the heart beat, as the heart contracts and with the pulse, they just sound a little different.

[If you are interested Here is Aortic Stenosis and Here is Mitral Regurgitation]


As well as the slight difference in the sound, there are a few other methods of distinguishing between the two. Aortic stenosis partially blocks the flow of blood from the right side of the heart, to the body. Mitral regurgitation causes back flow, so the right heart doesn't just pump blood forward, out of the aorta, but also backwards into the atrium, making it less efficient. Talking to friends in the days before the exam (a good way to revise) we talked about the difference that can be felt at the radial pulse. In particular that aortic stenosis causes a 'slow rising' pulse because of the hindrance the valve causes to the blood leaving the heart. I had never felt one of these before, but in the OSCE, I was sure that there was something odd with the pulse. I went out on a limb and said that the pulse felt like it was slow rising, because it did feel flatter and more delayed, as friends who had felt such a pulse had described it. This was confirmed when I came to listen to the heart with the stethoscope, and heard the ejection systolic murmur, radiating to the carotids. It felt great, having diagnosed someone with my first laying on of hands, and using a sign that I had never even felt before.

Enough self-indulgence. Waiting around and working over summer, exam results came quickly and it turned out I had done more than OK. With grade boundaries up near 90% for an A I had still managed to mission through with some great marks. I won't go into specifics, but I am more than pleased! The OSCE was fine as well, fortunately, though unfortunately we don't get a breakdown of that as it is merely pass/fail. I would like to have known how I did on that ?ectopic question!

The best part about passing all those exams is that I am now off to another university to do research for a year. Something that interests me, and a year where I will have free weekends again! I had to revise a lot of cellular level science for these end of year exams, so hopefully I will know some of it when I get there. I find out about halls on the second week of September, and with term later in September, and no guarantee I will get a halls place this could get quite interesting. I may be sleeping on some friend's sofas for a month or so...

I will keep you posted as to how it goes, but I have a feeling it won't be as exciting to write about as the last clinical year.

Goodbye

Hi,

I am afraid that this will be my last 'proper' and weekly post for the next year. I will still attempt to post every so often to let you know how things are going, but it won't be as interesting, so I will not keep boring you. I am entering exam phase of this year, meaning there will be no more clinical contact this year. Next year I am intercalating at a london university for a year, to study something sciency. While I am looking forward to this, I do not think it will be diverse or interesting to you as readers to put up weekly posts about. I might pop back in once in a while to let you know how things are going, or how planning my elective (month or 2 spent abroad practising medicine - aiming for sub-Saharan Africa) is progressing. Anyway, not to much happened this week...

This is because, as I said before, it is revision time now. I did some revision (I really do not enjoy this, but it has to be done, and it would be terrible to fail now, so I have to) I took a basic exam and saw a few patients.

The exam I took went really well - I presented a relativity complicated case and then got asked a range of questions not at all related to the case. This was a bit out of the ordinary, but as luck would have it they were questions which I know the answers to, so I wasn't going to complain. I tend to find in a day that when you are being questioned, you either find yourself not knowing a single thing, or you are miraculously only asked things you recently learnt. I am sure that things are not always this polarised, but it often seems like it!Anyway - to cut my bragging spell to a close (yes, I am bragging, think of it as a way of making me feel more confident about the actually important exams coming up) I got given straight As and asked about my future plans as a Dr. "I'm not really sure - I like most of it" [apart from UROLOGY]- "Perhaps something quite acute, acute medicine or A&E, both of which are broad specialities?" - I was then told in no uncertain terms that these will be too easy for me and I should be aiming to become a professor of medicine. Great to hear from a respected consultant, but if only it was all 'easy'. That would make things a lot simpler. Anyway - being a professor could well be very administrative and boring, I would rather "exciting", and "patient contact" (and surely treating complex cases is harder than doing research or teaching people?).

Patients wise, the pickings were sparse this week, so I will bring up a case from months ago. This case was a paediatric case that I got involved in mainly by accident, but interesting none the less. It was a young boy who presented to the hospital just eating lots and lots of toilet roll. What an odd symptom. Lots of wondering about psychosocial causes of this strange behaviour, and what toxic effects might having a roll of Andrex floating down your colon have on the child. To cut to the chase, this patient was suffering from pica due to an underling iron deficiency. Pica is a disorder where a person develops an appetite for items which are usually non-nutritious, such as coins and the like. This child had decided to start feasting on toilet paper. With the iron deficiency corrected, he did manage to stop eating so much paper, but he does have a munch every now and again - though this is thought to be psychological more than biological in cause. We should be glad that he was caught early before he developed into a modern day Monsieur Mangetout.

Anyway, I go on, and mainly for the reason that I have little else to talk about. What a disappointing fizzle to end the blog on. Exams come and get in the way, I will keep in touch and definitely start it all up again once I am back in 4th year. Thank you for reading, and don't go anywhere - though a year is indeed some time to wait. Just follow with some of those buttons in the top right and then you will know when the irregular posts come through,

Throughout third year I have learnt far more than in the first two years combined, I have realised that I REALLY want to be a doctor, and most importantly, I now feel that I have mastered the skill of drawing the curtains around the bed whilst the consultant talks to the patient. While the typical lackey role in the ward round, I feel I have practised this enough to close curtains at 5th year level. And I am prepared to stand by that.

Over the next year, I hope to get some work published, make more friends and plan an awesome holiday and elective, ending up somewhere far from civilisation.

Over the next month I plan to pass my exams.After that I think I deserve a nice break.

Thank you, and I hope to talk soon.

Birthday

Hi,

Time in the hospital dying down now as exams draw nearer, which is a shame, but I still have some adventures to pass on. OK, perhaps that is a little too extreme a way of putting it, but I enjoy it! The highlight of this week was the surgical take, which I felt culminated my 3rd year of medicine where I got to manage a patient pretty much on my own from admission in A&E to the night, where I left. Some ward rounds fill the spaces, one where I get a cross 'telling off' from a consultant because my shirt wasn't ironed properly. And, of course, revision lectures where we are reminded about all the fantastic exams which are just on the horizon.

Surgical take, for us, is a long affair - we are meant to arrive around 8 in the morning and stay 'til at least 10 though as it (usually) gets busy around this sort of time, staying for longer is pretty useful. We have the option to stay overnight if we so wish, so we can get the 'real doctor' experience of almost getting to sleep and having your bleep go off countless times. Anyway, I have already discussed the take day before, in a previous post, so I will concentrate on my favourite parts of this one.

I admitted a boy with the SHO I was helping at the time, who had been referred from the GP with possible appendicitis. The main problems with this were that

1) It probably wasn't appendicitis
2) It was his 18th birthday today

Now 1 on its own isn't really a problem, keep them in hospital until you are sure of the diagnosis, and then either treat or send home. 2 on its own shouldn't really be too much of a problem - Patients are in hospital, so really should either be treated or sent home - not much you can do about it. Having both 1 and 2, though, means that if it isn't appendicitis then you have just deprived this boy of his 18th birthday for little reason. A decision as soon as possible is best. Appendicitis (usually) presents with pain in the lower right of the abdomen and a variety of other signs such as raised white cells in the blood, raised CRP (another protein in the blood), and rebound tenderness, rigidity and guarding signs on examination of the abdomen. The boy had pain in the correct location, but not the other abdominal signs. He had a raised CRP but normal white cell count. Does this indicate a threatening appendicitis, or does it indicate a different diagnosis (such as mesenteric adenitis) which he could just be sent home with to enjoy his 18th birthday. Complicating factors such as the fact that he was vomiting last night, and in a lot more pain before he came to hospital confuse things more (has it already ruptured?) To cut this long story short, the SHO I was with didn't want to send him home because of the danger. The SHO's senior, the surgical registrar, thought we could and so the patient got sent home under the proviso that he returned should anything get worse again. He didn't come back that night, so I hope it was all OK. The one bog social blunder I made was when I was taking his history and asked him whether he used any illicit drugs in front of his mum. "Not really" - the mum pipes in straight away "What do you mean not really, of course you don't, just say no". Oops - I didn't press that question. Not all that important really! I should probably think before just running though those check-lists stored away in that little brain!

The other interesting patient on take was mainly interesting because

1) She was a consultant psychiatrist
2) I got to manage her from admission

She came in, and told us that she thought she had renal colic. Psychiatrists study a very different field to most medical doctors, seeing very different patients and signs, so this should really be treated like any patient presenting, as the psychiatrist may not be able to reach an accurate diagnosis on her own. Initially the story checked out, pain down one side, radiating to the back, typically 'loin to groin'. She was spiking a very high temperature, which is unusual in renal colic, and having 'rigors' (shivering with the temperature). A&E was exceptionally busy, and the surgical team were rushed off their feet dealing with the surgical admissions, so I was asked to just go and clerk her - I did so, taking history and examination, and then spent some time hunting down the surgical SHO. In this time I had a bit of an adventure, trying to fix a broken 'pod' machine that is meant to transport blood samples directly from A&E to the pathology labs to be analysed, and talking with an elderly lady, admitted and in a ward, about her suspicions of her husband cheating on her. All well and good, but I still couldn't find this SHO. Finally, once I came across her, she was dealing with someone who had been hit off of their bike by an opening car door in front of them and had ruptured their spleen. Needless to say, this took priority over my patient, so after telling her that the patient thought she had renal colic, the SHO asked me what bloods I thought she needed. I rattled off a few that came to mind as important, the normal stuff really, FBC, LFT, CRP, U+E, coagulation screen and so on. "That sounds great, do them please" and the SHO flits off like a bird. OK - I can take blood, I can fill out forms, I can get blood to pathology (by walking now, I didn't have much success with the pod launcher)- I can do this - easy! Taking blood was a nice easy step (the consultant told me she didn't mind if I messed it up a few times, she was terrible at it when she was training. I am glad I got it first try though - I don't want to find myself on a placement with a doctor I had annoyed by piercing the arms of a number of times) I added in getting an MSU (always important in renal based pathologies) as well, and the patient was kind enough to try and squeeze some urine out. With the help of a very friendly nurse I worked out the different way A&E order bloods (why do there have to be so many interdepartmental differences in a hospital) and sorted them out.Said friendly nurse also showed me where the machines are which read these dipsticks. Where would medical students or doctors new to a hospital be without such friendly people! Thank you. Anyway, the MSU showed blood in urine (definitely a urinary tract pathology somewhere then) and some white blood cells. Whilst waiting for the bloods I couldn't really talk to this patient as she was very spaced out on the opioid analgesics she had been given. I busied myself elsewhere (as I said, very busy that day) and, well, to cut a long story short, the patient had a kidney infection rather than renal colic. Some antibiotics and so on, and she will be fine. She was lovely, very nice and complimentary to me, but you never know where you are with psychiatrists - is she complimenting me to make me feel good about myself? Who knows! I am sure they are not all sneaky, but I have met a few sneaky ones, and always find myself on my guard around them... Perhaps this suggests something less healthy about me! Anyway - picture of urinary tract below, anywhere can have stones or an infection. This shows up in the urine (as it goes past the stone / infection) or often blood. A CT scan can usually complete the diagnosis.

I come to the end of this week, as I really do have more productive things to be doing than writing here. As I said before, I got a consultant very worked up as my shirt wasn't ironed properly, but that doesn't matter too much. He is well known for having a bad temper and getting very upset with people easily. I thought he was fine, though, he just evidently didn't suffer fools gladly. Perhaps a good things when it comes to giving patients the best possible care. Revision lectures have just served to remind me of how close exams are getting. A simple one on Tuesday then launching into them 'properly' after that. I cannot wait for summer. A nice week, this week, though. It really showed that I have (hopefully) been learning this week. Perhaps I will know enough to actually become a doctor at the end of all of this. If I revise for my exams, that is.

Mortality

Hi,

Whenever you are talking medical procedures with other medical students or doctors "morbidity and mortality" is  often bought up. This is referring to the risk of adverse effects or death. This can be referring to the end results of a disease, or the risks of a medical procedure. "This procedure is associated with a high risk of morbidity and mortality" would suggest that the procedure is risky, because it is likely to cause damage (e.g. paralysing the person) or kill them. These terms are bandied around throughout the medical education, and I hadn't really given much thought as to what they mean. Events this week have put a new light on things.

The week included me in theatre again, following a patient through who had colorectal cancer. Cancer of the large bowel is a common cancer, and there are a variety of techniques for treating these. This patient had a low level cancer, in the actual rectum, and as such needed a procedure that would remove this cancer without leaving any parts behind. This procedure is called an AP resection (Abdominoperineal resection), in which the anus is cut around, and the colon is cut half way along, and the colon is pulled out of the hole where their anus was like a long sausage. Sounds exciting, if not a little disgusting.

The patient was a drinker, knocking back most of a bottle of spirits a day until his diagnosis of cancer 6 months ago. Since then he had gone tee-total, but his liver had still suffered the damage, and his skin showed the characteristic jaundiced colour that would be expected. With the liver damage he had suffered, the patient had been advised by the doctors that surgery was not the best course of action - other cancer treatments had been tried such as radiotherapy, but the cancer remained. The patient didn't want to die of cancer, so had opted to go for the surgery. It was discussed with the doctors and the surgery was planned to go ahead.

The surgery was planned to be carried out laparoscopically (keyhole) - meaning the colon would be cut and freed up using keyhole surgery, and then the external anal sphincter would be cut around and the colon pulled out. Minimal trauma, minimal blood loss and a faster recovery. This surgery took over 6 hours because of the slow painstaking way the surgeon had to progress through the cutting of the colon. The liver makes many of the proteins in the blood which help it clot (it is like the factory of the body) so that this alcoholic liver damage meant that the blood found it much harder to clot. Because of this, every cut which was made had to be quickly sealed.

Part way through the operation the surgeon decided that he needed to see an inpatient (as in someone who is currently residing within the hospital) as a matter of urgency, and left the patient lying there, keyhole surgery tools inside, under anaesthetic for about 15 minutes whilst he saw this patient and returned. The anaesthetist and scrub nurses said they had never seen something like this before - I was pretty shocked as well - seemed somewhat unprofessional.

The surgery was taking some time, so myself and the colleagues went to a clinic, and one of the nurses in theatre promised to phone me once the operation was reaching a move exciting bit. There is only so much you can watch of the colon being slowly worked away from the abdominal wall before you start getting bored. We were called back after a while to see the conclusion of the operation.

Unfortunately, during the keyhole surgery part of the operation, a major artery was caught by one of the instruments and the patient's abdomen started filling up with blood. The emergency demanded that the patient was opened up 'properly' for the bleeding to be stopped, which it was, and the operation finished using this cut in the belly. The colon was removed through the hole where the anus used to be, very odd, and us medical  students then got to examine the colon, find the cancer, look at the different regions, see the descenting turn to sigmoid, the sigmoid to rectum. The patient had lost 10L of blood (replaced by anaesthetist, obviously) We then went home.

The next day we found out that the patient had died an hour or so after the surgery had finished due to excessive bleeding which couldn't be stopped and metabolic acidosis. That seemingly healthy patient who had been chatting away in the anaesthetic room before being put under had just not woken up. The patient who would have probably had another year or two without the operation. The patient who, had the operation gone perfectly, still probably wouldn't have had any longer than he would have had with the cancer due to the decompensated liver disease. Why was he operated on? I suppose it's patient choice, and he was well aware of the risks. Could the operation have been done any better? There were some obvious lackings within the operation - such as the consultant leaving part way through, and the artery which was clipped, but both of these are not enough to have caused him to die. What will the coroner record? Alcohol related death, due to the liver dysfunction causing the unstoppable bleeding? Surgeon related death, as the cuts the surgeon made ultimately killed him? Or death by misadventure, he chose to have the operation, and signed the consent form which told him there was a high risk of mortality? How does the surgeon feel, does he feel he killed this man, or does he just feel it is part of the job? I am not sure I could deal with such pressures after such a thing happened.

As I was meant to be presenting on a teaching ward round the following day, I presented the patient who had died. I took the group to the mortuary and presented the patients history, his reasoning for the surgery, the surgery and the aftermath. The patient was shrouded in blankets covered in blood, he had kept bleeding long after death was recorded. I thought it would be a learning experience, 'high risk of mortality' is not just something you say. It means something. There are always these risks, and nothing this serious should be undertaken without careful thought on all sides. The student who was with me in the operating theatre was on this ward round as well, and unfortunately ended up very upset and had to leave. Feeling pretty guilty about this, perhaps I shouldn't have taken everyone to the mortuary. I know many medical students haven't been down there and I thought it would be a good learning experience. I suppose seeing the person you last saw chatting away avidly lying there cold and still isn't great.

On a more positive note, I learned a lot from this whole experience, the consultant seemed to really like the 'twist' I put on presenting a patient (though morbid, educational) and apart from this an otherwise cheery week.

Sorry this post has been written in haste, I am off to see Bon Jovi tonight. It is sobering how such calamities can happen, people can lose their lives and their loved ones and our lives just go on like normal. I suppose it is necessary to create at least some degree of distance from such problems, otherwise you will never be able to last in a profession like this.

Take

Hi,

Lots done - A ward round covering every single surgical patient in the entire hospital, telling a patient on said ward round that they likely have cancer; clerking in abdominal pains, one of which included an argument between mother and daughter based around sexual activity (catholic mother) and then an argument around smoking, the situation resolved by getting the mother to leave briefly. Ward rounds not enough, I also saw surgeries including a scrotal exploration (looked as nasty as it sounds); an orthopaedic trauma surgery on a fractured hip and a surgery where someone had swallowed a biro and it had perforated their small intestine. On top of these surgeries I also clerked in a patient with a large gluteal abscess, performed a very bad attempt at taking blood and was part of the admittance procedure for a patient who had been bitten by an adder. All this with a twist at the end - could it be any better!

Starting with the ward round. It was long, I was on it for hours and it continued for hours after I had left. It took place at the weekend, meaning that there was just this one consultant surgeon to cover the hospitals surgical patients, meaning he wanted to see all of them. This is a very large hospital, and as such this as a mammoth task, especially given he was not the consultant for many of the patients. Despite this, the ward round was well organised and slick, with perfect interaction from the nurses. Often I do not see nurses on the ward rounds, but having them there was very helpful, as they tend to know the patients the best, and have an experienced and valuable viewpoint. They are also the people who dish out much of the care, so knowing what should be medically done for the patient is very important.
On this ward round, one of the patients was suffering from obstructed bowels, meaning she hadn't passed any motions in some time, and had a distended abnormally enlarged belly. After examination, the consultant decided that the cause must be a caecal tumour (how he knew this is impressive, just based on a mass in the lower right quadrant), and ordered a CT scan to confirm this. Despite the fact that this was a busy ward round, and there was no confirmation of the diagnosis, the consultant then proceeded to tell the patient that they probably had cancer of the colon, which was causing their symptoms, and that they had two choices - they could try operations on it to fix it, or 'just leave it be'. The patient was a very lively 90+ lady, whose son had also died of colorectal cancer. She was asking whether this meant that she would just be left to kick the bucket, and the consultant had to admit it depended very much on the imaging results. The lady was obviously somewhat upset, and we moved on to see another patient. All of this without a definite diagnosis - no imaging results, no blood tumour markers, just obstruction and a mass in the abdomen. I thought at the time that that was a risky thing to say. Why blurt it out in the middle of a busy ward round, when you cannot offer her any care or support, and it is not a definite diagnosis. Why not wait for it to be confirmed and let the normal consultant or registrar give the bad news when more time is available. I suppose I am not in a position to question a highly qualified consultant, perhaps he was trying to make his colleague's lives more easy.

Whilst clerking in patients whilst on surgical take, I saw a variety of cases, mostly to do with abdomens. There are plenty of things which can go wrong with your abdomen, most of them can be dealt with surgically, so surgeons tend to deal with abdomen pain in the hospital. One of said people I was clerking in was a 17 year old girl, who was presenting with recent onset right iliac fossa pain. This is a typical presentation of appendicitis, but can also be mixed up with other diseases as well, such as pregnancy and other problems with your 'woman's bits'. After the history and examination, we had to perform some tests to try and help us determine the cause. If it was something critical such as acute appendicitis, this would mean that the patient would need an operation fast. If it wasn't then it was a lovely sunny weekend, and I am sure the patient didn't want to be wasting her time in the hospital. A urine test is used to look for UTIs and pregnancy, along with bloods to look at markers of appendicitis. When the urine test was mentioned to the girl, the mum chimed in with "that's not necessary, we are Catholics, no sex before marriage and all that". I am sure I do not need to explain to you that many children do not follow parent's wishes, and this was not a good reason to exclude pregnancy or an ectopic from the differentials list. It was attempted to explain to the mum that this was a routine investigation, and everyone of childbearing capability (pretty much 12 upwards) who presented like this had this, but the mum was insistent. Finally a result was reached when the daughter told her mum to back off and "let them do their job". Fortunately the test came back without pregnancy markers, or that could have been an awkward conversation. A similar problem occurred between these two later in the consultation when the daughter was asked if she smoked, and replied no. The mum chimed in this time, telling us that the daughter did smoke, but didn't want the mum to know. Awkward silence followed by half-hearted attempts of the daughter to deny this. This family needed to communicate with one another more! The mum was persuaded to leave the room for a bit for a drink, and then the daughter was asked the more intimate questions about sexual contact and so on in confidentiality (to exclude STIs). The results were, surprise surprise, confidential.

 Surgery-wise I had a great stint getting involved in surgeries. I went to the theatres, but as it was the weekend there were only 3 theatres open - an emergency surgery theatre, an emergency trauma theatre and a private patients theatre. I spent some time in the two emergency theatres (sound a lot more exciting than the routine private patients one - who knows, I might get ambushed by a TURP again...). Here I saw a range of operations, the more interesting I mentioned before. The scrotal exploration was due to a suspected torsion of the testicle. This involves the testicle twisting around, and cutting off the blood supply to itself. If this isn't treated within hours it kills the testicle, which has to be removed. Seeing the first cut was more than enough to make me wince away, and the smell of burning testicle from the cauterizing was one I was more than happy to get away from. In the trauma theatre I spent my first stint of time with a group of orthopaedic surgeons. They were lovely, gave a good teaching experience about hip fractures and I got to see a hip fracture being fixed with a dynamic hip screw method, allowing the bones to compress on one another, helping them heal back in.

The last surgical case I saw was the interesting condition of BIC-ili-perforation. While not an 'actual' medical condition, possibly due to its rarity - this condition would involve the ingestion of a ball point pen (preferably of black variety) and then subsequent perforation of the ilium, leading to the necessary surgical removal of said object and great excitement of the medical student who is floating around at the time, checking out the emergency surgery list for anything exciting or interesting looking. Not too much to say about this operation really, but once the pen was removed and the hole in the bowel stitched up, I left - I have seen plenty of people closed up again, and I wasn't scrubbed in so wasn't assisting. There is always plenty going on to get involved with instead.

In Saturday evening, I was around in A&E hoping to get involved in the busy, manic rush that I assumed a Saturday night would entail. I was very disappointed with the result - one mandibular fracture came in and the person couldn't be operated on because of their intoxicated state, but the place was near deserted. What was happening? I wanted some practice at a variety of procedures, so made myself known to the A&E doctors, offering to do any mundane tasks they needed to do. I got offered a few techniques I didn't know how to do, such as inserting a catheter and a lumber puncture, both of which I politely declined, I was pretty tired by this point and just wanted to practice something simple, not mess up something new. I got offered a simple taking venous blood off of a man who had come in with hypoglycaemia. Excellent - simple, run of the mill job. I got the stuff ready and went to talk with the man, who was a lovely chap. I was getting a load of wonderful stories from him from the time he got shot in NY (he had the scars to prove it) to the time when he played with a well known jazz player. whilst I tried to find some veins. This proved somewhat harder than I was hoping, unfortunately. He had suspicious track marks (read heroin) on both arms, and didn't seem to have any veins available. After discussions with this laid back chappy, he was more than happy for me to try and get blood from whatever I could feel. I tried, a number of times, and managed to get one bottle. I needed 3, though, and  after stabbing him about 5 times with the needle I decided that this wasn't really fair on him and I would go and get an experience member of the A&E staff to sort him out. He was more than happy with what was happening, which was the main reason I had more than two tries.
"Try again man, its not a problem at all, I have had far worse. I've been shot, you know"
After talking to a registrar on take, he told me that they didn't really need bloods from this chap anyway, and I should just send off whatever I managed to get. Hypoglycaemia is pretty simple. Fortunately I had got the more important bottle (always start with most important, in case the vein collapses) - the full blood count, which would show whether it was an infection which lead to his hypo. After sending it off, I started to get a niggling feeling that I managed to to somehow label it wrong, and it would not even get through. Not much that can be done about that now, unfortunately.

That was an unsatisfactory end to a very satisfactory day. Yes that is the 'twist', if you hadn't realised yet. Not exactly a twist, or exciting, but if I am going to write, why not play with words. All mentioned in this whole post was during my Saturday on take. Other things went on this week, but Saturday was great fun. In the hospital from early morning to night time, a long shift by which I seemed to be failing as a medical student, so I escaped back home to bed. I have missed out parts of this in this post, most notably the man who had gotten bitten by an adder and the quest for anti-venom but I run out of time and risk making you bored, so I shall end here. A very busy very satisfactory day on take. I look forward to graduating. Having the variety and excitement of this every day, all day would be more that I can wish for.

I hope you had a good weekend as well.

Survivor

Hi,

Back on vascular surgery, and back on the interesting cases. Unfortunately, with essays and the like to do (almost finished this essay), it is not possible to put as much time into going on the wards and into theatre as I would like. Still spending some time meeting patients and seeing interesting things, but passing assessments always has to come first.

This week I met up with the patient with cancer I mentioned some time before, I saw a patient presenting with an unusual swelling in her neck, baffling the doctors, and I found myself talking to a patient who had managed to survive a sequence of dangerous conditions.

The patient who had cancer, I mentioned some blogs ago and despite only mentioning her once here I had been following her through her whole treatment, visiting her once a week to see her radiotherapy and see how she was doing. The idea of this was to see how she coped with the increasing side effects radiotherapy causes on your life, and how she coped with the big life change that having to travel in ever single weekday for radiotherapy for 6 weeks could cause to her life. She finished the course a good month or two ago, and I hadn't seen her since, seeing as she has now gone of home. As I mentioned before, she is a wonderfully optimistic lady, who always has a nice thing to say about her position. I had managed to come upon (though somewhat sneaky means) the appointment time and place for her post-treatment appointment with the cancer specialists, so had decided to follow her here. While this sounds like (and definitely felt like) stalking her, I convinced myself that she would appreciate seeing me again, and anyway, its a valuable learning experience, seeing a follow up post-radiotherapy appointment, right? As is, I managed to persuade the nurses and doctors to let me see said appointment, though they were very confused as to why a 3rd year medical student wanted to be part of the morning, and for only one patient (at this medical school, oncology is not a 3rd year rotation). They were running about 2 hours behind, though, so I got plenty of time to sit and talk to this patient about how she had been keeping herself and how she was feeling. I was pleased to hear that she was feeling great, had no real abnormalities from the treatment other than a little hair loss around the site. She had more things going on in her life again, with someone in her family currently dying in hospital, but still maintained the same positive outlook and cheery demeanour that I remembered from before. Quite by accident I managed to get her appointment shifted forward so she was only waiting for about 30 minutes (I think the oncologists wanted to get rid of me). Not that that is right, as it just meant that others had to wait even longer, but it was unintentional, so I will not feel guilty. There are no signs whatsoever that there is any remnant of the cancer, so a cure is expected, though not guaranteed as who knows what remains in the microscopic level. Great news, and she was obviously very happy with this as well. After a touching farewell I left to return to a lecture. So I hope that I would get to see her again? If I am seeing her again, it will mean she is ill, either coming in with recurrence of her cancer or another medical condition. Its sad that you can see people leave and be unsure as to whether you want to see them again or not, but perhaps you can just hope for another setting, such as on a high street. Good luck to her, whenever I finished talking to her I would always leave with a smile, and I hope that other people who spend time with her give her the care that she is due.

I was spending some time in a clinic later on this week, and saw a good variety of patient presenting with problems with arteries and veins. Common things to see in this setting are problems with the venous or arterial circulation to the legs, stable aneurysms, and the like. One patient came in with a strange pulsatile mass in her neck. It pulsed with the heart beat, and overlay the carotid artery in the neck suggesting a carotid aneurysm (pretty rare). The patient had been referred via a duplex scan, which is an ultrasound scan which can create a picture of what is inside your body, and tell you where the blood is moving. The results from this showed a slightly swollen carotid artery, but nowhere near the size of an aneurysm, or the size needed to be clinically visible on the neck, which this lump was. The surgeons had plenty of questions for this lady, but none of her answers managed to give them an answer for this condition. What are they going to do about it? Are they going to prescribe her lots of invasive but clever tests? Will they admit her for careful monitoring and assess her as an in-patient? Nope. "Go home, and come back if you think its getting any bigger". Talking to one of the consultants after she had been discharged, he admits he has no idea what on earth it could be, but 'that's a bit boring anyway' and it didn't look life threatening. Fair enough, its like the GP option of see if it goes away, and come back if its worse, but that sounded like a bit of a cop out from a high level consultant. Where is the sense of curiosity? Do you not worry that it might be more dangerous than you think? I suppose he didn't want to put the patient though unnecessary, painful tests and waste her and his time. I'm only a medical student, I have no idea what's going on.
Clinics aren't all seriousness though. The surgeon had a good flirt off with a 97 year old woman who had come in with claudication. It started off with:

Doctor: "Don't worry, I will see to you right now"
Patient: :Ooh, I look forward to that, when can we get started? Do all these people have to be here"

And ended with information I don't feel happy about putting in a blog with unknown readership. Needless to say there are some very dirty minded older women out there! Its good to see this consultant not taking himself too seriously though. Makes you much more endearing to the patients.

Finally, on the wards I was talking to a gentleman who had been in hospital for 3 months or so. This is a long LONG time for an NHS hospital, which turfs people out as soon as possible. And understandably so - with bed prices for a night in hospital estimated at £800-£1000 A NIGHT, it is expensive to keep people in hospital longer than needed. That patient had been kept in for so long because he had had a series of problems befall him. he had come in with a AAA rupture (a different man to the one we saw come in with the same condition a few weeks ago), which has a chance of death or around 80% before you get to hospital. This had been operated on and repaired, the operation carrying about a 40% mortality rate (please note, these are very rough figures). In recovering from this, due to the immobility in the beds, he had developed compartment syndrome in his leg, infected with MRSA after an operation, which then progressed with deterioration in his health leading to multi-organ failure, which can give 80-90% chance of dying, with the number of organs he had involved. In and out of intensive care, this patient was still alive, chatty and happy with pictures of his extended family up around his bedside. All of these chances added together give the patient less than a 1-2% chance of survival. That is exceptionally small, especially given that the these figures account for a person who was healthy before, and didn't suffer from the previous insults to his system. All in all, a very impressive feat, and made you feel all warm and fuzzy inside when you saw all the smiling faces of his family on the walls, looking down at him as though they wanted him back home. He would make a lovely grandad, very cheerful and fun to be around, and I hope that he managed to make it out of hospital without encountering any more problems or infections. Surely he has used up all of his bad luck by now!

Relativity short blog today, as I spent the weekend at my grandmother's 95th birthday party. Lovely to see family I had never met before, but means this has been knocked out in under an hour... Have a great week!

TurpTurpTurp

Hi,

A very different week compared to last week's excitement, but at least I now know that I don't want to be a urologist! Seeing as we get to see a bit of everything on the rotation, I suppose a lot of time is spent working out what you don't want to do. If you wanted to do everything, well, you couldn't.

As the first paragraph suggests, this week was spent doing urology surgery. Perhaps it is a little premature for me to say this so prematurely, but if I ended up having to go into urology surgery, I would probably leave medicine and go into something different. Perhaps I could joint he police force, being a detective looks exciting from TV.

Not that my experience this week was a bad one. The teachers had plenty of time for us, and in theatre we were walked through what was going on in a friendly manner. The low point here was that we didn't get to assist or scrub in at all this week, but that's just because of the procedure that was being carried out.

Yes, that's right - a whole week of surgery and I only saw one procedure. No - it wasn't just one chance in the theatre, had plenty of those opportunity - it was just the same procedure again and again. While surgeons in urology do carry out a range of operations, from surgical treatment of bladder cancer to operations on the kidneys, there is one operation they do far more than any other. This is called the TURP, which stands for Transurethral Resection of Prostate. Sounds pretty fancy, doesn't it!

Enlarged prostates are very common (in men, obviously) and cause a range of problems with urination by putting pressure on the urethra. The prostate is basically like a ring doughnut, the middle of which the urethra passes through. As the prostate grows, this puts pressure on the urethra, making it harder to urinate. Prostates can enlarge by themselves, for no obvious reason, or they can be cancerous. Whatever the reason for their enlargement, if the patient wants to be able to go to the toilet normally this is the operation for them.

We saw one on Monday and it looked pretty exciting. A tube is passed up the urethra via the end of the penis, up into the bladder, as though the patient was being catheterised. This tube is larger than a catheter, though, and the doctor passes an instrument similar to an endoscope up through the tube with a camera on it in order to visualise the bladder and urethra. With this camera another instrument can be passed up, which looks like a loop of wire, and used to cut away at the prostate encroaching on the urethra - see below.

Here you can see the insertion of the tube down to the level of the prostate, which can be operated on (see small organ above and below the tip of the tube)

This is the image the surgeon can see. The operation from this point on is carried out by feel and what can be seen in the camera. The wire loop can be seen, and is linked up to a diathermy, using electricity to cut through the prostate and seal the blood vessels after the cut is made.


The tube also has to pump water continuously into the urethra and bladder in order to make the tube as open as possible, to make the operation easy.

Now you can see why it was not possible for us to assist - this is carried out by one surgeon with anaesthetist(s), assistant theatre technicians and nurses there to help with the procedure. It still sounds like a lot, but the operating theatre would have been pretty empty, comparative to normal, if it weren't for all of the medical students standing in the corner peering at the screen.

The surgeon works the loop around the urethra, making the hole bigger by cutting away bits of prostate from the inside. This damages the urethra as well, but like when you graze your knee, the surface will just grow back again, so that is no worry. With bloody water being pumped out of the patient's penis, and the surgeon working away, as I said before, this seems like quite an interesting surgery. But then it just goes on and on. And on. The surgeon is working away, shaving little bits of prostate away for some time, and then another patient comes in, and exactly the same thing is carried out. Starting to get a little boring. Then another. You get the picture.

That was only the first day - the rest of the week consisted of seeing more and more TURPs, there were some performed by LASERS! Again, sounds exciting in principal, but just involves a slightly different instrument being used, a small spark on the screen, and the instrument being moved around for some time within the vision, slowly singeing back the prostate to allow the passage of urine. Not thrilling.

The rest of the week, when we were not in these theatre sessions, involved talking to patients (again, always the positive of the weeks) and being taught by the interested doctors.

Now, I am not saying that this is all urologists do - I am assured there are other operations, but I personally wouldn't want to do more than one or two of these operations a week, it just seems so mundane. It is not even like being a physician and treating pneumonia after pneumonia. At least there patients are able to chat with you, you have plenty of confounding factors to take into account and a thousand and one other interesting sidelines possible. Here a patient comes in, is treated, leaves and repeated. You may as well be assembling things on a factory production line. A very necessary job, and I am glad that someone does it, but not for me, thanks!

With that, I will have to depart. Had a lovely BBQ in the sun today, and got some work done, which is nice - hoping to keep it rolling. Next week will be more interesting, I can smell it!

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!

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.