Post Mortems and maggots

Hi,



The most exciting thing that I did this week was visiting a mortuary and observing a number of post mortems. This was quite a graphic experience, and explanations are also graphic, so only read if you are happy with this! Post mortems are carried out on people who have either a suspicious cause of death where someone may be to blame (for example, after a surgery or in a possible murder case) or with an unknown cause of death, such as someone who is found dead at home, having not seen a doctor for some time. The post-mortems I saw varied from someone who has been dead for weeks and has started decomposing (maggots and all) to a patient who died on the operating table and still had all the tubes and devices stuck into his body. Later on in the week, I go on my GP placement again, and see a variety of family-planning-based procedures (my GP's speciality), and chat for an hour and a half with a really nice gent who has prostate cancer.


The mortuary visit happened on Monday, so there were a number of bodies needing a post mortem that had been 'stored up' over the weekend, as post mortems here are not carried out on Saturday or Sunday. The location was an innocent-enough looking building, but once I had gone inside, 'scrubbed up' into my blue scrubs and stepped into the room, it all became very strange. There were four tables with dead people lying on them, completely naked, and the walls and floor looked like a tiled public toilet (as I soon found, to make it easy to have all the blood and mess washed off). I was working with a pathologist, who explained what was going to happen but, to be honest, I wasn't really listening too much. I was overcome by the thick smell in the place, which pervaded wherever you were in the room. This was coming from all of the bodies to a degree, but mainly the partly decomposed body in one corner.

The patients are all identified by a tag, as in the movies, so you know that you are cutting up the right one!

The doctor who was carrying out the post mortems left to read up the case files for the patients we would be dissecting today. Only they are not called patients today, something I found very hard to get used to. They are simply just called 'dead' now, which makes sense seeing as they are no longer being treated. So while she was reading up the case notes for the dead, the mortuary technicians (who are people with nurse training) started to prepare the bodies. The one body which had died on the operating table was left, as it needed to be examined with all the medical devices in situ, but the other bodies were 'opened up' by the mortuary  technicians   for the doctor to examine.


This rather gruesome process involved the head being cut open across the back of the scalp from ear to ear, and the scalp being pealed forwards off of the skull, so ot flapped over the face. This meant that the skull underneath could be cut open with an angle grinder, and the brain removed and put into a bag. The skull was then put back on, leaving the head empty and scalp was re-attached and sewn back, so from the front (if using an open coffin) the person would still appear normal, though their brain had been removed. The chest is then opened up from the top to bottom with one long cut, and all of the organs removed, from the tongue down and put into the bag with the brain. The chest will be closed up at the end with all of the organs (including the brain) packed into it. While in a higgledy piggledy way, this means they look normal, again, so they can have an open coffin.


After these have been removed, the technicians job is done, and the pathologist can take over. The organs are cut apart one by one looking for any abnormalities or injuries which may have occurred to them, leading to the death of the person. The body is examined for any signs or injuries, and the organs are weighed. You can tell a lot of an organ is massively over or underweight, for example, a heart in heart failure could be very heavy compared to a normal heart. This was a great learning chance for me, as previously I have only worked on dissecting bodies in the dissection lab, which have been preserved with formaldehyde to last for a year, and hence have unusual textures and colours. These were (mostly) pretty fresh! I got the chance to help out by cutting some of the organs into slices and helping search for the expected problems with them that would have caused death. Cutting into the bowel and stomach was the worst part. These start decomposing first, because of the acidic conditions and all of the bacteria in them, and still have the remains of the patients last meal in them which need to be drained, along with a lot of gas. Needless to say, the smell, which still hadn't died away like most smells do, was still here in force.


There were a number of patients on who the post mortems were carried out on. There was a gentleman who had died in his sleep, and been found dead by his wife. Because of his history of  heart disease and a triple bypass 10 years ago, it was presumed he had had a heart attack while asleep, and that was the organ that the search was focussed on, though all of the other organs needed to be checked (what if he had had a massive stroke, or had a cancer that hadn't been diagnosed...) This man was difficult, because the previous chest surgery meant that he had lots of adhesions and metal clips in his chest to navigate through, though the heart arteries (even the new ones) were very clogged up, suggesting a cause of death.


It worth saying that, even at this point, this is still really strange for me. I am in a room cutting into organs on a table next to a body which has had all the organs removed and has a big gaping hole in its chest and abdomen. The tongue downwards has been removed to bring the windpipe out, and there is just a huge hole there. Other than this, with the scalp back on (this is for the best, the scalps-peeled-over-face look is really creepy) the person looks as though they are asleep. None of the strange colour or texture of the skin as with dissection, and while you are at this table, there are a number of other naked, opened bodies around the room. It almost feels like a horror film scene. And the smell, pervasive to start with, gets quickly worse after the bowels and bladders are cut into.


I see other patients dissected, including the patient who died during surgery to the heart, who still has all of the tubes and medical devices in situ. The worst patient (no, 'dead', sorry) who I see is a patient who had psychiatric conditions, and just liked to live by himself in what was described as a 'filthy flat' by those who picked him up after he had been certified as dead. After not seeing him for a few weeks his neighbours called the police, who visited and then found him to be dead. He was decomposing, meaning there was little point in taking him to the hospital. The position of the body and state of the flat suggested a fall and a death, but this needed to be confirmed by the post mortem. The less said about this man the better really, as writing about him makes me feel a little queasy. The organs were black and mushy because of the decay, there were maggots all over the place which were eating the flesh, and the smell was awful. I couldn't deal with it and had to stand a few paces back for the second half when the stomach and bowels were opened up. Poor chap.


Despite all of this, I had a great experience in the mortuary, and learnt a lot about different stages of the body after death and lots about organs and how they look and feel when 'natural' (but not from the decomposed person, obviously!) I was told about other students who have thrown up in the post-mortem room, and run out, but this is no surprise after what I saw and smelt! I also heard about some of the more interesting people who have been seen there. The man who died of a perforated peptic ulcer (=hole in stomach) and had his body cavities full of sweetcorn from his last meal, seemingly in places it definitely shouldn't be. There was also the person whose stomach and bowel were full of metal objects, from car keys to cuff links, which they had eaten for some bizarre reason (though perhaps it was because of pica)

A mirena coil, the gynaecologists favourite contraceptive.

As well as this main experience in the mortuary, I did other things in the week (obviously), the main one being the time I spent with the GP on my placement. My GP has a gynae specialism, and so carries out some minor family planning procedures in the surgeries. Today I saw a mirena coil removed from a 30 year old woman so she could have children, and a contraceptive implant removed from a 14 year old girl's arm who was having irregular periods with it and didn't like it. Interestingly, she had come to the GP surgery with her grand mother, as she felt she could share this sort of information a lot more easily with her than with her mum, who she didn't feel happy discussing this with. This is not something that seems rare, from what I have seen, and I wonder if people feel it easier to discuss sex with their less immediate relatives, as they feel they will be treated as less of a child by them as they haven't grown up with them, I don't know... Perhaps this would be an interesting sociological study, as it seems to happen much more commonly than I would have thought.

Ward work and Hitler

Hi,

A relatively calm week, compared to the busy time I had last week with all those early mornings, which is a nice break. I still spend some time on the wards, after I enjoyed it so much last week, as other than a Parkinson's disease clinic I have no time tabled clinical sessions, just lectures. I am not sure about the timetable for this rotation; it seems to vary massively between weeks, sometimes meaning you have plenty of early mornings (last week), other times (like this week) with a few lectures dotted around and little else. I have a presentation to do next week, and other out-of-uni commitments, so it is quite nice for me to have some control over my week and when I can go in and when I don't.

In general, neurology is a very 'post-graduate' type of subject. A lot of the things we are learning or seeing we will not be expected to do (or even necessarily know) as junior doctors, and wouldn't be expected to be doing unless we were specialising in neurology after completing our degree, and working as a doctor. While a lot of neurology is very interesting, with the strange symptoms and signs people can have (the brain is pretty damn complicated), it is also very complex. It does often feel as though a lot of the things we are learning we will never have to apply at all. Will I ever have to interpret an EEG to diagnose absence seizures? I very much doubt it, unless I am a neurologist, and in which case, I will need to be taught again as I will have forgotten by then. I suppose you do learn a lot of things you may never need to know again in medical school - though it is a lot more pronounced in the first few years with all of the microbiology that you learn!


I had a great day on the wards on Tuesday, where I just spent the day with the neurosurgery ward team helping with their ward work. The patient I saw last week who had the cranioplasty (skull reconstruction) is doing very well, and I am told that he could well improve faster now this construction has given his brain more space. I spend a full day examining people before operations, helping out with notes and clerking and other day to day activities. The neurosurgery ward is run by more junior doctors most of the time, as the more experienced registrars and consultants spend their days in surgery instead. I really enjoy working on the wards, which is a fantastic sign, as after I graduate, this is where I will be working for a few years at the very least!


The single timetabled slot I had this week was a Parkinson's clinic, where I was with a specialist nurse seeing patients with Parkinson's disease. I had come across specialist nurses before (for example a heart failure specialist nurse) and had been very impressed with them. This time was no different at all, and he clearly knew exactly what he was talking about. By managing a case load of patients, it means they get better treatment than if the GP was managing their Parkinson's (much more experience), and possibly better treatment than a neurologist because of the specialist knowledge of the nurse, though this is debatable. It is certainly cheaper for the NHS, though, which I am sure factors into it. As well as talking to and examining some lovely people with Parkinson's, I got a good amount of teaching. A lot of it was the pretty standard stuff about the difference between Idiopathic Parkinson's and Vascular Parkinson's, which is fantastic for me to learn, but some of the things I learnt were not entirely medical, but none the less interesting.


For one, I was told about 'Parkinson's trait' where people show traits in life which may make them more likely to get Parkinson's. The nurse was saying that many of the people who come in with Parkinson's have been very obsessive people, who have then developed Parkinson's disease. By obsessive, he means people who tend to focus on one aspect of life obsessively, such as model making or train spotting, and focus on this to the exclusion of other things. While (obviously) most 'obsessive' people do not develop Parkinson's later in life, it is very interesting to see that many of the people who do develop it have this 'personality type'. The nurse said that many of the patients who he sees have had mathsy / physicist / engineer type jobs, where its quite possible that being obsessive about small things can be beneficial. I don't know if it is some kind of genetic defect, predisposing people to Parkinson's later in life and making them obsessive early in life, or if it is the act of thinking about a few things obsessively (or gambling obsessively) which over stimulates neurones and can lead to Parkinson's, but it is a very interesting theory.

A video, watch until about 10 seconds in to see Hitler's Parkinsonian-like tremor in one hand behind his back, perhaps explaining why he usually had this hand behind his back or in a pocket.

The other thing I learnt, which I didn't know but probably should have, was that it is assumed that Hitler was developing Parkinson's towards the end of the war. The video above is 'real' footage of Hitler, and you can see up to about ten seconds in that he has a tremor, like that seen in Parkinson's, in his left hand which he keeps behind his back. Supposedly most of the footage showing these tremors was destroyed by the Germans, but some film (such as this Russian film) remains. Back then he would have been treated with anticholinergics. The nurse was telling me (and I don't know how much truth there is in this) that because of Hitler's Parkinson's disease, and the neurological problems it caused (thus ruining his leadership of the German army and nation) this was a reason that the Allies didn't attempt to assassinate him towards the end of the war, and possibly a reason why the Germans made an attempt on his life. Very interesting stuff, but probably more for historians than medical students! 

Half a head

Hi,


A very productive week this week, spending my time on a neurosurgery placement. I got to see a number of surgeries, which were the highlight of the week really, and spent the rest of the time on the wards and in clinics. A much busier week than many of my previous weeks, which was something I really enjoyed. It reminded me a lot of my third year, with all of the contact time with the patients and doctors, and helping out on the ward, the way I am sure I learn best. The surgeries I saw varied from operations to the spine, to operations on the brain and skull, and lasted for hours and hours each. I was a little disappointed that they were not more complicated, though. I was expecting 'Neurosurgery' to be very complex (everyone assumes it is) but really it just seemed very similar to the rest of the surgeries I have seen. Perhaps rocket science is equally as over-rated.

Before I get into my post, though, I would like to thank the people who run medical-artist.com who, in compiling a list of who they think the top medical student blogs are this year, were kind enough to put mine at the top. I am touched that they thought it was that worthwhile-a-read, and its always good to know what you are writing is appreciated. 


Getting back to my week, saying all I did about neurosurgery not being as complicated as I expected, it doesn't mean that I didn't enjoy the operations, or the time I spent in the theatre. I spent half a day in theatre on Monday and a whole day on Wednesday. When I say I spent a whole day, this means the surgical list running from 9AM to 7PM. While the surgeons may be seen as the 'jocks' of the medical world, they sure do seem to work hard! I was with another medical student for both of these sessions, and we were not allowed to 'scrub in' as we have done for other operations previously, letting us hold things for the surgeon and generally help out. This is probably due to the increased risk of infection, and the fact that most of the operations are done down a sort of microscope, meaning the surgeon could look at the minute anatomy more easily down the eye pieces, but there is no room for medial-student-help. The operations were shown up on a screen, making it easy to see what the surgeon could see, but also giving you the feeling that you could just be watching something similar on youtube at home...


Despite all of the time I spent in surgery, I only saw three and a half operations, as they tend to take a long time. On Monday, there was one operation all day for one complicated case, a patient with a meningioma (a type of brain tumour), which was in the posterior fossa of the brain where the cerebellum sits. A complicated operation where part of the skull needs to be removed, and the tumour searched for in the brain meant that this would take a whole day. Unfortunately I was only scheduled in for the afternoon, having lectures in the morning that I couldn't miss. This did mean that I missed the portion of skull being removed, which could have been interesting, but I did get to see the removal of the tumour and everything being put back on again. Seeing the surgeon search for the cranial nerves so they didn't get accidentally cut reminded me why my anatomy was so important, and I regret the fact that I have forgotten so much of the anatomy I had to learn in my first and second years! Interestingly, if the skull cannot be put back immediately (for example, because they think that there will be inflammation in the brain, which will cause it to swell and they don't want it to swell up inside the closed skull causing injury) the part of the skull cannot be kept and given back to the patient at a later date as it used to be. Because bone is a structural material, they used to be able to remove it, sterilise it and give it back at a later date. Laws relating to the use of human tissues mean that this is no longer possible, and instead the skull always needs to be kept with the patient. This means the portion of the skull is kept inside the abdomen along side your guts, where the patient carries it inside them until it needs to be put back (when the inflammation has gone down). The skull can shrink slightly because of the body's macrophages (immune cells) having a little munch on the edges, meaning if it is left in there for some time it can become too small for the original gap, but this is a very interesting concept! 


As I said before, my part in the neurosurgery involves standing by the edge and watching what happens. On Monday this involved standing up from 12 'il 6.30 straight, which seemed like a long time, but on Wednesday I was standing from 9 'til 7, though I did get small breaks as they switched the patients around. Working for this long means you have to be tough to be a surgeon, but at least they and the anaesthetist get to sit down as they work. I feel sorry for people like the scrub nurse who have to stand for the whole day! On Wednesday the three operations I saw were the changing around of a spinal cord stimulator, the removal of a pituitary tumour via a transsphenoidal route (via the nose) and the replacement of most of someone's skull which had been removed in a traumatic accident. A long day, which I shared with my fellow medical student and an osteopath who was a friend of the surgeon and had come to watch and learn.


The spinal chord stimulator replacement surgery was pretty simple and only took a few hours. Because there was already one in place, this was more about replacement of the unit which had run out of batteries for a new one. This machine is inside the body, and has a small battery with wires in the spine. The patient is given a remote with which they can control how much voltage is put into their spine. Rather than being the terrifyingly painful experience I would imagine it to be, supposedly it is a great pain killer for chronic pain, working by blocking the pain signals going up the spinal chord. 


After this surgery was the surgery for a woman who had been diagnosed with a pituitary tumour. The pituitary gland is a small gland in the brain which controls most of the bodies hormones. Tumours here are usually benign, but they can cause the secretion of many hormones, or interfere with vision as the nerves from the eyes run next to the pituitary gland, and if it gets enlarged it can interfere with these. This surgery is done via the nose, using a similar method to that the Egyptians used to remove the brains from the skull before mummifying their ancestors. This is because the pituitary gland is right behind the nose, and going in this way means you do not need to go through brain, though it does mean that the entire operation is done while looking down one of the nostril! Impressive that this can be done, but it did involve watching a screen for ages as the surgeon fiddled around in the nose. A little more interesting than my experiences of TURPs previously, but only just.

Transsphenoidal surgery route - pretty clever huh! An approach favoured by Harvey Cushing, whose name has become associated with a number of medical syndromes and diseases

The best surgery of the day, and the reason I stayed 'til the end with only a cheese and pickle sandwich keeping me going was the man who had had a serious head injury in April and was having his skull reconstructed. Back in April, he had been hit in the head by a large part of a car while at work, which was travelling at about 70 miles an hour. This had crushed half of his skull, and on admission to hospital he was not expected to survive. Fortunately, with some dramatic surgery, he had recovered and had been living in a rehabilitation home until now. His skull had not been put back on at the time, hough, because of all the inflammation, and because of the large loss of one of his cerebral hemispheres (half of his brain) his head was a very strange shape, missing about a quarter of the top part of his head. It had skin over it, which was growing hair, but he looked distincly different, and wanted to go back to looking more normal, which was the purpose of the operation. A metal plate had been constructed to fit the shape of the skull, and this was going to be screwed in.


I saw him the day before when I was on the ward, to clerk him before the surgery, and was surprised with how well he seemed. Obviously, for someone who was missing half of their brain, he was not perfectly healthy, but other than slow slurred speech, and slight confusion when I asked him to carry out slightly more complex tasks. On physical examination, his body was neurologically normal other than brisk (increased) reflexes across the body. Amazing the sort of injuries the brain can deal with and bounce back - a very plastic organ! Either way, I build up a good rapport with him on this day, and I felt that he really appreciated my presence in the operating theatre before his anaesthetic (he was understandably nervous). As someone who had been a helicopter pilot on the army about a decade ago, this injury had clearly changed his life hugely, but he seemed so determined to do as well as he could. It really puts my problems in perspective! Either way, the surgery went well, the highlight being when the surgeon noticed the surgery lights shining on the plate he was about to insert cast lots of glittery reflections around the walls. He ordered the main lights to be turned off and created a disco... This may seem a little insensitive, but a nice break after hours of painstaking dissection around the edges of the remaining skull. The fact that I really enjoyed talking to the patient about his story (and the theatre-disco) and didn't really care so much about the surgery reiterates to me that I don't think surgery is the sort of speciality for me. It is clever and technical, but so is being a car mechanic.

Almost Automatonophobia

Hi,

Back on the weekly posts now, and it feels good. This week there is a ward round in the stroke rehabilitation ward, where patients are looked after post-stroke and health care professionals do their best to help them improve their function. The real fun comes from my GP day, where I see a number of strange cases, the strangest of all was a 18 year old lady who was applying to be a nurse, but who had what she said was a crippling fear of CPR dummies which would stop her from realising her dream.


The ward round around the rehabilitation ward for stroke victims was an experience. Many of the patients were really quite ill, with serious problems meaning they couldn't function normally. They may have physical problems, such as the inability to walk or feed themselves (whether through problems with arms or inability to chew and swallow) and may have cognitive problems, such as the inability to form words or recognise objects. All of these are equally debilitating, but the people with cognitive impairments seem a lot more interesting from a medical perspective. It is very easy to understand why someone may have problems moving a limb, but a lot harder to understand why a person may no longer be able to recognise and name objects such as a pen. The consultant on this ward round was fantastic, taking plenty of time for each patient and talking slowly and clearly to make sure they understood perfectly, crouched down on her knees to get to eye level with them. Some patients stay in this ward for months and months as they slowly improve, to try and get them functioning as well as possible, but she would still take a decent amount of time to ask them how they were and see how things were going. While the area of medicine doesn't appeal to me all that much, if I am going to be a doctor, I would definitely like to be a doctor like her!


Medical school lectures and seminars are not usually the most interesting of times. Don't get me too wrong, you learn a lot and the subject matter can be fascinating, but there are not usually a lot of laughs bouncing around. This changed in a seminar this week on prescribing, though. We were being taught about how to prescribe, and were looking at the BNF (effectively the bible of drugs), going through drugs that are given for infections in different systems of the body. The atmosphere among the ten or so students there was very strange. Not really sure how to explain in, but just one of those strange buzzing sort of atmospheres that seem to be waiting for something to happen, almost like that  before a storm... The GP tutor said 


"This section of the BNF can be used to help you see which drugs to use for infections to different areas of the body. For example, for skin"... 


There was a second of silence as she caught her breath, then the guy next to me let out a snort of laughter, which he was clearly trying to contain and 'whispered' to me "Forskin!". This was definitely not a whisper, and the whole room was giggling away for a good minute. Fortunately the GP tutor saw the funny side as well. Its a little scary how many similarities there are to primary school with us fourth year medical students...

My day at the GPs surgery this week involved a huge variety of patients, some of who were really interesting! Being a GP has never been an appealing idea to me, as it seems as though it may become a bit boring, but these days in GP surgeries definitely make it seem like quite an appealing job! One of the patients who I saw today was a definite hypochondriac, who came to see the GP almost weekly, and had used her own money to pay for many investigations that she didn't need, such as a full body MRI scan. She had had a small lump on the inside of her cheek, which while it wasn't visible, and didn't irritate her in any way, she had wanted it removed. Most people she had talked to had said it didn't really need doing, so she had gone  privately. Unfortunately the private doctor who she saw used the equipment in the operation incorrectly, and turned up the diathermy too high. This ended up with her having a large hole in her cheek. A young shopkeeper, she was very unhappy with this result from what was an unnecessary operation, and now had serious health worries. Its important to remember that all operations carry a degree of risk!

This is a child, and a different hole, but you get the idea...

The GP was very busy due to a number of complex patients she needed to see, and I ended up seeing a couple of patients on my own, with the intention of reporting them back to her and making her talks with them shorter. This would hopefully help the waiting times, and give me practice as well. This was, unfortunately, when the most complicated patient turned up, when I was left alone. This wasn't the typical 'complex' patient, with lots of medical problems - just someone that we had definitely not been taught about in medical school. This was an 18 year old, who wanted to be a nurse, but said she had a crippling phobia of CPR dummies. She was afraid that this phobia would hinder her in her training, and wanted it to be cured. How do you approach a patient like that? I have heard of a fear of puppets (Automatonophobia) but never this, though I assume it is similar. It was clearly worrying her, so I tried to be as serious as possible while I got the GP involved, to help me out. In the end it was decided that perhaps she could try CBT to help her out. The GP first suggested 'flooding' by putting her in a room full of the dummies and locking the door. Fortunately she was joking, I don't think that dying from a dummy-induced-heart-attack would look very good. Once home, the internet tells me that she isn't alone, I mean look at the first poster on this facebook page! Some of the things that GPs see and hear about can be really sad, but others can be fantastic!

Hoarder

Hi,


I have finally caught up with myself, and this is last weeks blog. This means that, finally, from this Sunday onwards I can be posting that previous weeks bloggings. This will make it a lot easier for me, as I won't feel as though I am constantly trying to write my blog, and a lot easier for anyone who wants to follow me, as instead of having new posts constantly popping up, there will just be one a week to read, hopefully of a higher quality as it won't be so rushed...


I am getting into the neurology rotation properly now, though as this is the week before Christmas there is a short holiday in the middle of the rotation to break it up and let us have a Christmas. A little bit of a shame to have the rotation interrupted half way through, but if the alternative is missing Christmas, I know which I would prefer...


Despite having plenty of lectures this week, which while interesting are no-where near fun enough to write about here, I do manage to spend some time on the wards. One of the patients who I talk to is a lady who was admitted with intercranial hypertension, due to  blood clots in her brain. Here the pressure inside her skull increases due to the increased amount of cerebrospinal fluid (CSF) in the skull. This has been caused by some blood clots which have formed in her brain to block the normal circulation of the CSF. As it cannot drain properly, the pressure keeps building up, and she needs to have it drained every couple of days by having a needle put into her spine to let some of it out. This is because of something called the Monro-Kellie hypothesis, which means that the skull, a fixed volume, can only hold a certain capacity. The main things in the skull are brain, blood and CSF. In this case the CSF is increased, so the amount of blood in the vessels in the skull can decrease to a point, meaning that there are few symptoms for a while. Once this reaches a level where the blood can no longer decrease, however, the brain starts to become squished, due to the increased pressure and causes symptoms such as headaches and much worse. This works the other way around as well, for bleeds in the skull causing increased amounts of blood, and the CSF can decrease. I feel really sorry for this lady, as having to have the fluid drained every three days means she cannot go home to her family, and means she has to wait here until after Christmas, when the current plan is for a neurosurgeon to put a shunt into the brain, so the CSF can drain automatically down a tube in the neck into the abdomen, where if can be reabsorbed harmlessly. 


The other interesting patient I saw this week was interesting in a much more social way than medical. This was a 50 year old lady, who had been admitted for new onset seizures, to be monitored in the hospital to see if they could get an EEG recording whilst she had a seizure to see if they could diagnose epilepsy. While talking to her, she seemed relatively normal, chatty and friendly, and she clearly took care of her appearance, and was well made up despite being in hospital with leads attached to her head. While this in itself was unremarkable, what the doctor told us about her later was much more interesting. Supposedly, since she had come to hospital, her children had gone to her house for the first time in years to get some of her things to bring to the hospital. They had found her living in absolute squalor, with excrement all over the floor and piles and piles of hoarded items creating a maze throughout the house. They had no idea that she lived like this, as she always seemed so normal on the outside. Unsure what to do, they had called the GP, who had visited and been equally as horrified. The woman still doesn't know that the doctors and children know about this secret - as the children don't really know what to do. This is probably more of a job for social services if this lady seems not to be coping, or perhaps for the psychiatric doctors. She seems so... normal in other respects - personable, well dressed and holding down a decent job. It is a privilege as a doctor to be able to see under people's outer 'skin' and get to know them better. I hope she gets the help she needs.

The start of neurology

Hi,


I have finished my oncology rotation now and have moved onto my neurology rotation, where we study everything to do with brains, from the medical to the neurosurgical. I live with someone who studies neuroscience as a PhD, so have high hopes for this rotation. Hopefully whenever I come home confused about something regarding brains, he can help me out. This rotation has a large number of lectures in as well, but unfortunately these are all in a hospital that is an hour away from the main hospital and where I live, so a lot of time is spent this week travelling to and from the lectures and neurological wards. Neurology and neurosurgery is relatively specialist, so it is not carried out in all hospitals, rather in centres of excellence, which in this case happen to be a bit far away...

Brown–Séquard syndrome is due to a partial injury on one half of the spinal chord, giving split symptoms across one half of the body and the other, as some parts of the spine cross over after leaving, while others do not

Despite all of the lectures I am getting, reminding me of all those wonderful and interesting things we were taught about in first and second years such as Brown–Séquard syndrome, I still do get the chance to spend some time on the wards. We were put into pairs and sent to see patients, in order to report back to the doctor and guess at a diagnosis for each patients. My partner and I talked to and examined a really friendly 80 year old woman, who despite being really lovely and wanting to help us out, was very hard to examine as she could barely hear us and seemed to be unnaturally cold, so as soon as we took the blanket off of parts of her body to examine them she would shiver violently, but insist that we carried on. Our examination showed that she had a strange mix of upper and lower motor neuronal signs, suggesting that both her central nervous system (brain and spine) and her lower motor neurones (all the other nerves) were being damaged. This means that whatever disease she has is affecting both the peripheral and central nerves. The most likely disease we thought to be causing these symptoms was a motor neurone disease such as ALS, but as we didn't know what the patient was really diagnosed with, we didn't tell her what we thought in case we were very wrong, and we didn't want to scare her. You distinguish between upper and lower motor neurone disease by testing reflexes, power and looking for signs such as fasciculations. As medical students we are not very used to what 'normal' is, so it can be hard to tell when things are abnormal, especially seeing as each person is going to have different reflexes and strengths, and older people tend to be quite weak. As it was, when we presented to the consultant she agreed that motor neurone disease was the most likely diagnosis, but it was not confirmed yet, and could be a range of other diseases. She then asked us to name some of the other diseases that it could be, which didn't work out very well for us, with our list of two or three. I hope that everyone is wrong, though. Motor neurone disease doesn't have a very good prognosis, and many of the other differentials will lead to a much better life. It always seems to be the lovely patients who have the worst diseases, odd...


Later in the week, I was on the ward and chatting with a patient who had been in the hospital for a month after getting Guillain–Barré syndrome. She was a mother of two, and a great believer in herbal and alternative therapy over conventional western medicine. She explains to me that, because of this, she doesn't really believe in vaccinations at all, and has avoided them since she was 18. Despite this aversion to them, the GP managed to persuade her to have a flu vaccine a month or two ago, because she has severe asthma, and usually gets severe chest infections meaning she tends to end up in hospital over Christmas. Some days after the vaccine, she started getting a tingling in her legs, a little like pins and needles, which started to progress up her body as her legs became weaker and weaker. As this went on over a few weeks, she saw her GP a few times, who first told her that it was nothing, and then told her that it was probably a trapped nerve in the spine and gave her pain killers. Finally, on her fourth visit, the GP sent her to hospital, but by this time she couldn't walk and to get to the GP she had to be carried to the car by her husband. For the past week she had had to be washed and carried about the house by this man, because she was too weak to move. Guillain–Barré syndrome is pretty rare, which makes it hard for the GP to diagnose, but you would have hoped that he would have noticed that this woman should be sent to hospital sooner, given the fact that she was too weak to even have a bath herself. The illness paralyses muscles of the body, and progresses until it paralyses the muscles used for breathing, killing the person. At least it was caught before this happened.


Guillain–Barré syndrome is an autoimmune illness, which can rarely follow certain infections. It is due to the body's immune system getting confused and attacking the peripheral nervous system which supply the muscles, thus paralysing them. It is very very rare to get this after a flu vaccination - one in millions chance, so I feel really sorry for this poor lady who was so opposed to vaccines getting such a terrible side effect when she finally consented to having one. Once in hospital, she could go on ventilation to help her muscles breath for her, and could be given medication to help the body reverse the damage that was being done. It is very slow to get better, but people often do get better, and the day I came to talk to her she had just eaten orange squash and chocolate for the first time since this all happened. Because of the effect on swallowing muscles, and the fear of food or drink going into her lungs by accident, she had been fed by tube for some time. I was curious as to whether she was giving her children vaccines, and she was, seeming to understand the importance of them. This is good news, and not what I expected from your stereotypical unemployed mum from a rough area. Despite her poor background, this illness seemed to have given her a new lease on life. She delighted in telling me how she planned to not smoke once she was out (being confined to bed for a month had forced her to give up) and wanted to start eating more healthily and get a job. The women around the ward had clearly had part in this and were shouting out encouragement from behind the curtains where we were talking. Drawing the curtains may give privacy for an examination, but offers nothing of the sort for talking! It was really lovely to see how something so bad could have such a positive impact on someone, giving them the feeling that their life really was worth something, and making them want to do something with it. I just hope that she can stick to her decisions after leaving hospital!

The end of oncology

Hi,


This week is my last week on oncology, before I change rotation to neurology. I spend some time in a clinic for people with lymphoma, which seems to be much more complex to run than the other clinics I have been in this month,  and see some really lovely patients. Later in the week, I am back on my GP placement, where reading between the lines of how a patient is feeling about her possibly having an STI makes me feel like House.


Most clinics in the hospital are run like a GP surgery: you go into a room, chat with the doctor who has your notes, and then go home. Not so the lymphoma clinic! Here there are a multitude of different doctors all in one busy room, and each patient file is bought in, and the patient is first discussed. One doctor then goes off and takes the patient to a room to chat with them, and then comes back and talks to whoever is in the room about them. Another doctor of a different speciality may then go and talk with the patient as well, until the group has made a decision about what the best course for the patient is. It seems like the decision is made by committee, rather than just one person. I think the reason for this is that the lymphoma sufferers are both haematology patients (a cancer of the blood) and oncology patients (doctors who deal with cancers), so the professional input from both specialities is useful. This made the clinic a lot more confusing, making it seem almost archaic in the confusion that occurred, though I hope that from the patient's perspective it seemed to be running smoothly!


While at the clinic, I see a man from the Seychelles who has moved to this country. He has HIV and lymphoma, and while the consultant is running an errand outside, he tells me about how much better the care is in this country than where he used to live. He is currently looking fora  job in the country, but cannot get one as he is still having his immigration status checked; I think he is currently applying for asylum. I think it is fantastic that we can still offer this man healthcare and look after him as a country, but I know many people see this as him abusing the system, having never worked here and still being treated for two expensive diseases. I don't really want to get down to the debate, but he clearly wanted to work and give back to the country, and was ever so grateful for the help he was getting. I do doubt that he will ever be able to nearly pay for the expensive treatment he is given with the taxes on whichever meagre job he manges to get. Other than the much better healthcare in this country and other political reasons, he seems slightly confused as to why he is here as well, upset with the stormy rainy weather beating away outside, a far cry from the weather he grew up with I am sure! I am talking to him about his problems with relationships, and his uncertainty as to when to tell people he wants to date/who he is dating that he is HIV positive, when the consultant comes back in and the topic is changed. back to the immediate medical. As a medical student I often find myself talking to patients more about their worries and concerns than medical conditions, but this is no bad thing. Most doctors are far too busy to find the time to do this, and I don't actually know anything, so wouldn't be more useful doing something else. Its a win-win situation! 


Other people I saw at the clinic were not as chatty, but just as interesting. A number of them seemed a lot more concerned about other problems they were having other than the lymphoma, and kept trying to change the topic of the discussion onto these. For example, one man was very upset that his mouth seemed to produce a lot of saliva, and it was slightly unusual. The consultant told him that this was unlikely to be due to the lymphoma that he had, but the man kept coming back to it. Perhaps that because lymphoma is such called, rather than "cancer" it seems a lot less scary to patients, and so they do not worry about it as much? I am not sure if this is a very good reason to explain it, as I am sure they have been told what lymphoma is, and that it is a form of blood cancer.

In my GP placement later on in the week, I am now talking to the patients a lot more. Not taking their histories on my own yet, but now it is more of a 'shared' history taking with the GP, which is good as it gives me lots of practice. I see about ten patients in my time there (in the time she would have seen about 30), with a range of different conditions, from the smoker with the chronic cough with a little blood after smoking 50 pack years of cigarettes (pack years are a calculation of how many years you have smoked the equivalent of a pack of 20 cigarettes a day) to the 20something year old with vaginal discharge. The man with a chronic cough got referred to have a chest X-ray, in case of lung cancer, hopefully to be negative. With the 20something year old, we took vaginal swabs and urine to send off to the hospital, in order to screen her for STIs. In itself, this is pretty standard practice and doesn't seem worth remarking on. What was interesting was her reaction to the concept that she might have an STI. We had taken a sexual history, in which she told us that she had a partner but had not slept with anyone else for the last three years. Here, I was thinking 'poor girl, perhaps her partner has been cheating on her', the most sensible assumption to make if it turned out that she had an STI. When it was mentioned, though, her reaction made me think differently. Instead of the expected reaction of suspicion towards her partner that I would have expected, she did seem upset, but said she was afraid her boyfriend would blame her if it was found they had an STI. I asked if there was any reason for her to feel this way, but she said there was no reason at all. From this, perhaps she knows she has done something naughty and she hasn't told us, and doesn't want him to find out about it. You would have thought that if she hadn't done anything, then she would be suspicious of what he may have been up to. This is all an assumption, as perhaps the reaction could be persuaded by other reasons, such as her being afraid of him being angry with her whether she knows its her fault or not, and perhaps being violent, but it didn't sound like this at all. Whatever the real reason, it highlights that listening to patients is very important. Not just for the diagnosis, but to try and work out the juicy gossip about their personal lives!

Is your gran a drugs smuggler?

Hi,


This week I sit in on a lung cancer clinic where I met a wonderful pair of drugs smuggling 70 year olds, who talked all about the fun times they are having despite one of them having terminal lung cancer. Later on in the week, we spend time talking to patients who have come in for chemotherapy; the patient who my partner and I are 'assigned' to talk to is a local celebrity from his art, though the side effects from the chemotherapy are ruining his career.


Through all these clinics I have been sitting in on, I am becoming aware of how important research seems in cancer medicine. There are special research nurses here, whose job it is to run all of the drugs trials that are occurring. A large number of patients seem to be on some trial or another, which can be very confusing, as the doctor who is treating them is also not sure which medication the patient is on, or even if the patient is on any medication at all, or just a placebo. Trials can only be carried out if one option is not known to be better than the other. For example, if a drug is known to treat cancer, then trials will usually be done on top of these 'gold standard' treatments, the intention being that the patient will still get the best treatment even if the trial drug turns out to be rubbish. This is clearly the most ethical way forward, but having the patients on a number of drugs can make it very confusing for the doctors to work out which of the drugs is creating the side effects that may stop the patient from taking their medication. I suppose research into treatments against cancer is a very hot topic, with cancer often in the headlines of popular newspapers, so it is only to be expected that the oncology department is so focussed on research.

Does anyone else remember super-gran? Perhaps she was just on crack...

One of the patients who was on such a clinical trial was a 75 year old lady with incurable lung cancer. In addition to the treatment she would normally receive for this disease, she was also being given a drug being trialled. In this case, as with most clinical cases, the patient was a lot more interesting than the medication she was on. She was quite a loud and jokey person, and had come in with her friend who was equally boisterous. This gives the consultation a very different atmosphere to the one I had been getting used to. Normally they are very quiet, mature consultations, as you would imagine when people dying and the "C-word" is being discussed (cancer). Here, the atmosphere was completely different (with a different C-word being used regularly) and laughs all around. This patient and the friend she had bought along to keep her company at the consultation were outrageous! After the standard questions had been asked by the doctor, and he was writing up in the notes, we started hearing some of her stories. It turns out that for the last month she had been on holiday with her friend in spain "getting pissed and stoned". She told us that she was scared about how easy it would be to get drugs in Spain at her age, so smuggled out a "load of pills and weed". After her amazing month, a lot of which she cannot remember, she had realised how easy it was for her to get drugs in Spain, so smuggled back a selection for "personal use" on her way back. She refused to tell us her trade secrets, how she evaded customs, but did offer to sell us some of her stash, at what she claimed were very good rates.I told her, in a jokey way, that she was being a bad influence on us poor young ones, but she just shrugged it off and winked, poked at me and told me that she was sure that we had done these sort of things before.


Despite the legend of a gran, the consultation wasn't all fun and games. She really wanted to stop all of her chemotherapy and enjoy her last few months of life, because of all the side effects she was getting from it. She was getting things like tingling legs and mouth ulcers, things that other patients who we have seen would love to have over the side effects that they put up with, but each person has their own tolerances as to what they would put up with, and these need to be respected by the doctors. I suppose she had decided that she was happy to die, and just wanted to enjoy her last months doing what she wanted, without strange feelings or pains. This was a difficult decision with the doctor, but she was convinced to wait until the next consultation before stopping everything, and was just taken off of the trial medication in case it was causing these effects. It is likely to be the standard chemotherapy causing these, as these are well documented side effects, but this is a chance to see what happens. She was so much fun, I wish her all the best. She did talk about her children and grand-children who she thinks have no idea about her life style. I doubt this is true, but if it is, perhaps someone out there has this rocking gran without even knowing it!

Steve Jobs avoided surgery for his pancreatic cancer for some time, instead choosing to try out alternative treatments

Later in the week, when we are talking with patients who have come in to receive chemotherapy, we meet a local celebrated artist at the centre. He is very demanding that the drugs don't affect his art, but because of the peripheral neuropathies that keep being induced, the time has come for him to choose between continuing treatment or his art, a very hard choice for him. Without the treatment, he will die from his cancer; while with treatment he will probably still die of the cancer, but a lot more slowly and more comfortably. He has already spent all of his savings on avastin, an anti-cancer drug that isn't funded by the NHS (questions about efficacy) as it is possible it could help him. This is understandable from a medical students perspective, but he also spends his money on a lot of alternative treatments. As well as having mistletoe injections twice weekly, he also has tried many other treatments including homoeopathy and talking with a psychic. These are much harder to understand from the scientific background we are taught in, but doesn't mean that they are not popular. Even the great Steve Jobs tried many alternative treatments for his pancreatic cancer, including acupuncture and a psychic, before deciding to consent to surgery. These were decisions that may have let the cancer spread and eventually killing him. Fortunately this patients seems to have a very sensible approach of using the two in tandem, and I am definitely not one to argue with him. If it brings comfort and the thought that something may be helping him, then it would be unfair to try and take away this from him, even if it is just the power of the placebo. He is currently funding his alternative therapy and travel to the cancer clinic by selling his paintings to the cancer centre, which is kind enough to buy them from him so he can continue his treatment. Everyone wins, as they look fantastic on the walls.