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.