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.

Clinics

Hi,

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

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

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

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

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

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

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

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

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

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

That might be taken as a little offensive.

Happy Easter once again.