Radiotherapy

Hi,

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

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


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

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

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

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

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

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

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

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

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

Overdose

Hi,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Have a lovely week.

Confidence

Hi,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Gastroenterology

Hi,

Ok, so my first week on my medicine rotation, which is based around the GI system (top to bottom, including associated organs such as liver, pancreas etc.) and I get back to the 'proper' hands on medicine. Nurses, endoscopies, cardiac perfusion scans, X-ray meetings, hepatitis, a patient who has severe intestinal bleeding, seemingly from switching to a purely raw food diet (not healthy), 'on take' and  ERCPs topped off with an upsetting surprise finding that a patient only had around 3 months to live because of a tumour found instead of gallstones. While sad in places, this is more like it. Much more proactive and time is spend 'doing things' instead of sitting around waiting for the next patient.

Lets get started on my week. To start off our medicine experience we were meant to be with the nurses for a little to 'warm up' at the start the rotation. With shifts starting at 7AM this was no mean feat, I was not used to getting up early after psych where the ward rounds started much later to give the patients time to 'get going'. While far too early for me (most definitely not a morning person) it was nice to fraternise with the nurses for a bit. Helping them give medication to the patients and get them out of bed led to just chatting with the patients as the nurses got on with their general day to day activities. What a lovely way to start the week! I got to hear some wonderful stories from someone who grew up in Australia on a station (a ranch) and how his life led him to the UK. While this was strictly not a nursing activity, I persuaded myself it was for the good of the patients, to prevent boredom, so continued at my leisure. I think the nurses were happy to have me out of their hair anyway. While the nurses there were more than lovely, there is sometimes a bit of disagreeability between the doctor and nursing professions. Some doctors seem to have a very patronising attitude towards nurses, and see their role as menial, and the nurses obviously do not appreciate this. Some nurses see doctors as stuck up, too big for their boots (which some are, in my opinion)  and overpaid. Usually these feelings seem well under the surface though, and don't seem to affect patient care, though we have overheard one nurse telling patients that they would be 'stupid to consent to having a medical student sit in' as it was a waste of their time and we were only nosy. If we qualified as doctors without seeing any patients we would be a danger to society! We have to start somewhere.

Some time spent in the hepatitis clinic with a doctor was a real eye opener. In the morning, despite having solid appointments from 8.30 'til 12 there was only one patient before 10.30. An elderly gentleman who had contracted hepatitis from a blood transfusion some time ago, but had only found out recently. The clinic was for follow up for those who had just been diagnosed with hepatitis to see if they wanted treatment, or if their body was clearing the infection (there is a chance the body can clear the infection, depending on the strain). The only people attending the clinic were people who had the B or C strain as the other strains (A,E,G) do not lead to permanent infection. Many of those in the community who are catching hepatitis are IV drug users and in the morning they need to pick up their methadone, so will not turn up for appointments. Perhaps a different plan needs to be made for when to carry out the clinic. After 10.30 plenty of patients were showing up. Many of them apparently homeless from their unwashed state and ruined clothing, but polite and kind none the less. Drug users get a bad press, which is perhaps fair enough as it is a large cause of crime, but I think judging people in this situation is exceptionally unfair. Many of them have had horrific childhoods including problems such as abuse, and how can you look down on someone for turning to drugs in that situation when you have not been in it yourself. One of the most interesting patients who turned up to the clinic had turned up with his wife, but on reading the covering letter with which he was referred (before the consultation, to find out a little before it started) we found out that the patient had not told his wife how he had caught hepatitis C. The truth was that he had relapsed into using heroin after about 10 years abstinence due to stresses at work, and had been using since. He had told his wife that he had caught it while nursing his father, who was currently suffering from end stage liver cirrhosis due to too much alcohol. At least the patient got the right organ to lie about. In this clinic it is very important to know exactly when the patient caught the virus, as there is a chance of them self clearing it in the first 6 months, but after that if it still remains it will be permanent so treatment should be considered. Treatment is 1/2 a year or a year worth of daily pills and weekly injections to stand some chance of cure, depending on the type of Hep C the patient has. It's got terribly side effects and has been likened to chemotherapy. Putting someone who is unstable, without a home or support, on this medication is not a good idea, so treatment is planned to be when the patient is in the best environment, which is not always easy. Anyway, the patient managed to help us send the wife out of the room under a pretence, so we could ask the questions we wanted. Why he bought his wife along in the first place is what surprises me!

Anyway, I spent some time this week in a variety of places in the hospital. With a loose timetable, the plan is that the student will spend some time wandering the hospital picking out things that they want to do. While this can be quite exciting, it can also be a bit of a chore. Being turned away from places and having to compete with fellow students for that space-for-one in the MRI room can be a little time consuming. Anyway, I got some great experience sitting in on some endoscopies. Not doing them, not by far, but watching the procedure and having it explained, so when the time comes I will know what to look for and how to carry out the procedure. I saw a variety of problems with the stomach and duodenum, which was good for learning, from oesophageal varices (often caused by drinking damaging the liver and thus raising blood pressure) to a completely obstructed duodenum meaning a good few litres of  partially digested food had to be sucked out of the oesophagus and stomach to see what the problem was. The procedure is called an OGD (Oesophogastroduodenoscopy) - as in it looks at the oesophagus, stomach and proximal duodenum. Nice and self explanatory. Patients can choose to have sedation (still concious but 'out of it') for the procedure or a numbing throat spray. The nurses were recommending the patients have the throat spray but after seeing both of these in action I would personally go for the sedation every time, you are too 'out of it' to really notice the procedure and are unlikely to remember it in the end. The throat spray doesn't seem to numb too well, though when I tried some myself it seemed to be very effective. I suppose its a little different if you are having a great big tube shoved down your throat.

I also saw cardiac perfusion scans being carried out. Creating an image like the one below, a radioactive isotope is injected into the patient to see the blood flow around the heart, to see if there are any problems. Our patient was, surprise surprise, a smoker. It seems so many of the diseases in medicine can be caused by, or exacerbated by, smoking. In all honesty it is a surprise it is still legal. Some politics going on there perhaps, but the phasing out in public places is definitely a good thing. It has reduced the number of people coming into hospital with respiratory problems and heart attacks significantly. The X-ray meeting I sat in on was interesting to see. The gastro consultants had collected up the most complicated scans from this week (mostly CT and MRI, despite the x-ray meeting name) and were showing them to a consultant radiologist, who was helping interpret them. The hospital is like a spider's web, with all of these different specialities working together. Its impressive that it all works (most of the time).

When on a ward round we came across a patient who was suffering from numerous ulcers in the stomach and duodenum. I don't really have much to say about her, other than the only reason that we could think of for all of these ulcers to be in her digestive tract was her recent change in diet to only eating raw food. The gastro consultant was very scornful towards these 'fad diets' and 'strange ways of eating' but I suppose if you spent all of your days picking up the pieces of those which go wrong then perhaps you have a right to be angry towards those who promote such things.

The 'on take' I did this week was great fun. Patients usually come into the hospital from either A&E or a referral from the GP. Patients in A&E are assessed and those who cannot be dealt with there and then and sent home are sent to be clerked by the on take team. The same goes for patients who are referred by their GP and need to become in-patients. On clerking there are plenty of questions that should be asked, about family, social situation and the like, and it is a good idea for a full examination of the patient so that when they are on the ward the doctors can see changes in condition or signs, and they have a good idea about what is wrong with the patient. When I was on the elderly ward, I remember the first thing you would always look at in a patient's notes was the clerking from their admission. Filling out these forms seemed very important, far too important to leave for a medical student to do! You don't want to miss a sign or a key part of the history, as whatever you clerk them in with, most doctors will take as read and not bother asking these questions again. I clerked in a patient who was experiencing chest pains, with a strong family history of heart attacks with 3 brothers who had died of heart attacks. She had her little girl there with her, about 7 still in her school uniform and very upset. The girl hated hospitals, after her grandad had died in one (again a cardiovascular problem) late last year. I tried to make her feel more comfortable by being friendly and nice, but it wasn't that easy in an acute medical ward, stuck in a tiny room curtained off from the corridor. Hope I managed to get down all the relevant parts of the history in the history. I left the investigations needed and the treatment plan boxes though, no need to stretch those limits on my first week and end up killing someone! A neurological examination on a lady with unexpected occurrences of syncope yielded nothing at all. I don't like not knowing the answers, so I plan to pop back in after the weekend and see if the cause has been found yet with the more specialist investigations. Medicine is detective work, and I love it!

 Finally, I spent some time sitting on on some ERCPs. This is both a diagnostic intervention and treatment, and involves putting an endoscope down the throat (like I was seeing earlier in the endoscopy clinic) and pushing a small wire up into the common bile duct from the duodenum. The plan is to find out if there are any gallstones in the duct from the gall bladder. The doctor carrying out the procedure can see down the endoscope, so can see what is ahead, and there is an X-ray machine above the patient so the doctor can see an X-ray of where the wire is (because the endoscope cannot go into the common bile duct). Down the X-ray the image looks just like the image below.

The large black worm like thing from the top right and curling at the bottom is the endoscope that has been passed down from the throat. The vertebrae can be seen behind it. Just above the top of the endoscope you can see where the wire has been passed out, vertically up, and the doctor has injected a contrast which shows up as darker on the X-ray. This contrast travels along the tubes of the bile ducts, and any blockages can be seen as the contrast will not be able to travel past them. In the picture above the contrast has travelled perfectly up into the liver (top left, with many branches where the bile is produced) and along the duct to the pancreas (the duct branching off to the right and upward). This is because the pancreatic duct joins the bile duct just before they empty into the duodenum. A large problem that the doctor carrying out the procedure seemed to have was getting the wire into the bile duct and up to the liver, rather than up to the pancreas. This is important as the wire is passed up the tube, and then a balloon is inflated on the end before it is pulled out. This has the effect of catching any small stones that the thin wire has gone passed and pulling them out into the gut where they can be passed without causing more problems.
Anyway, one of the patients I saw this carried out on had a large area of blocked flow in the common hepatic duct (the straight thick piece of duct moving down and slightly right after the branches join together and before the wiggly line joins from the left (the gall bladder). This was not clearable with the ERCP trawling technique, and this coupled with the history of onset (gradual jaundice coming on over 2 weeks, without pain) meant that it didn't seem to be due to stones in the gall bladder. Due to the position of the obstruction and the relatively slow onset (gall stones cause a sudden blockage and hurt a LOT [women who have had gall stones say that the pain can be worse than their labour pains]) the most likely cause of this is gall bladder cancer. A rare cancer, but most common in women over 70, the patient fitted the bill perfectly. The cancer has to be advanced to be big enough to start obstructing the flow of the bile, and unfortunately this means that the patient has a poor prognosis as it will have started spreading. The consultant said that other patients he has seen with such symptoms and results from the ERCP tend to live for another 3 months or so. 3 months?!?! What a shocking result for a very healthy and chatty lady who was lovely to me when i went to chat with her before the procedure to ask consent. It was not a definite diagnosis, just based on clinical experience, so the patient will need scans to check the mass, and the consultant would then talk with the surgeons to see if they would have any interest in operating on the mass, should it look operable from the scans. Unfortunately the doctor said that surgeons rarely operate on such advanced cancers.
So this lady likely has approximately 3 months left to live, with little chance that there are any possible treatments to cure her. And she doesn't know yet, because this has to be confirmed with scans and talk with the surgeons. I feel bad knowing this sort of information about this lady when she doesn't even know herself, but I suppose it's not fair telling patients these sort of things when you are not sure, as it may well be a mistake and be something easily treatable, and no-one wants the stress of being told they likely have cancer and 3 months left to live, then being told next week that actually its all fine.

I would like to finish with a question for you, if you would care to answer. How would you like me to write this blog? Would it be better if it were a lot more science/medical describing conditions and treatments in more detail so improve knowledge? Would it be better if it concentrated more on how I felt throughout my training / my encounters with patients (however horrific that sounds) - Any feedback would be much appreciated!