Procrastination

Hi,


Still on ophthalmology, and seeing some interesting cases, but a lot of my time is really taken up with essays and other boring stuff. Apart from these essays, ophthalmology (perhaps if I write it enough times I will learn to spell it properly) seems to be dominated by a few, common conditions. It seems the same with most specialities: endocrinologists see a lot of diabetes; A&E doctors see a lot of alcohol based problems; and ophthalmologists see a lot of glaucoma and squint patients. The glaucoma patients tend to be older while the squint patients tend to be children who need to have their squint corrected before their brain 'turns off' one eye to stop the double-images that squint produces, losing them vision in that one eye (amblyopia).

Squint is called strabismus, and the clever brain turns one eye off to get rid of the double image it creates. This means that if it doesn't get treated quickly (for instance by patching the healthy eye to force the 'lazy' eye to work properly) the eye may not work properly, something that will stick with you for the rest of your life and is untreatable as it is a neurological condition

Firstly, though, I would like to apologise for my poor time keeping with uploading these posts. I was initially trying to do it every Sunday, which then became Mondays as my Mondays became busy, and today it appears it is Tuesday. This is partly because I am busy with other work, partly because I am not sure what to write about and (largely) partly because I am a chronic procrastinator and seem to be very efficient at putting things off... I do have a number of essays and the such due in which I do keep trying to do, but somehow keep avoiding actually doing, and this committed procrastination is very time consuming. As this year is a lot more laid back than my 3rd year, or intercalated year, I am also enjoying having a social life before it disappears up the chimney with my final year and final exams next year.


Enough excuses, though. This week I spent time in surgery, outpatients clinics and eye accident emergency. The theatre session was very similar to last week, seeing cataract replacements and retinal detachments repaired. While very same-y surgery, the nurses and doctors were really lovely to us medical students, and made the experience really enjoyable. Just having friendly staff who are nice to us (not as common as you might think, we are the bottom of the hospital hierarchy and do just get in everyone's way) and interested in teaching make such a big difference to whatever placement you are on.


The outpatients and accident and emergency are surprisingly similar. The outpatients runs like any other hospital outpatients service, arranging follow up appointments for patients with chronic diseases such as glaucoma or taking referrals from GPs who want a specialist opinion. Here there are a lot of squints and glaucoma patients. Both diseases that can be easily controlled and treated, so quite a positive speciality in that respect. The eye emergency department is very similar to the outpatients, carried out in a similar location and just not needing appointments, people turn up when they have problems with their eyes and are seen as soon as possible. Here, patients with foreign objects stuck in their eyes, rapid changes in vision and so on are seen and examined. I was really surprised by the number of patients who seemed to get metal shards embedded into their eye ball, and needed to have them removed. I suppose metal is sharp and sticks into skin easily, and if you have burrs on your hands and wipe your eyes they may get stuck in. The problem with metal in the eye is it can create a 'rust ring' around the shard, meaning that the patient has to come back for a follow up, strangely also carried out in the emergency department making it almost like a clinic.

A picture from a journal of a rust ring, left after the metal object has been removed

Eye surgery

Hi,


New rotation and a new start this week. Finally leaving dermatology and its sparse timetables behind (though I am not going to lie, I am going to miss all those gaps) and moving onto ophthalmology; medicine of the eyes. Looking at the timetable on Monday, I could see that it was going to be a lot more hands on than dermatology, with clinics and tutorials in the mornings and afternoons of all days! Its going to be like my third year again, I hope I am not too old for all that work...


My favourite part of this week was getting involved in some eye surgery. When I say 'getting involved' I really mean watching some... It is very intricate surgery, and I think that letting a medical student try and assist would be a terrible idea. I saw several cataract removals, and a few retinas be reattached. Cataracts are where the lens becomes fogged in the eye, so you cannot see very well - the surgery involves removing the lens and replacing it with a plastic one, which is clear. Seeing as cataracts are one of the most common surgeries done by the NHS, and the most common cause of reversible blindness in the UK, this is quite an important operation. It is done by making a cut in the eye in the white of the eye, and working through this cut to 'suck out' the old lens after mincing it up, and then a new one is injected in through the same hole. This way there is minimal cuts made in the eye, and only the front of the eye is affected. It takes 15-30 minutes, which I thought was pretty impressive for surgery which involves sticking things in the eye. I was afraid it would deflate, a bit like a tire with a puncture when the holes were made. I am very glad it didn't!


The other operation is where the retina, the layer of cells on the back of the eye, starts peeling off the back of the eye (detaching) due to small holes in it letting fluid get behind it. This operation is similar to the cataract one, in that it is done down a microscope-like-machine with tiny instruments, but as the back of the eye needs to be operated on (rather than the lens which in the front). This meant a number of tiny tubes were put into the eye around the iris (coloured bit) and instruments were put down the tubes to seal the retina back onto the eye (keyhole surgery). Again, I did secretly expect the eye to deflate a bit, but I wasn't going to mention this to the ophthalmologist and get laughed at!


One of the patients who was having the operation had a female name, and long hair and jewellery but the notes said male and they did look distinctly male with a touch of shadow under their chin. This lead to a fun talk from the anaesthetist first, while the local anaesthetic was being put in the eye to numb the pain before the operation started. The anaesthetist kept talking herself into corners while chatting to the patient and us, saying things such as "when this young .... .... patient goes into theatre" and so on, with slightly awkward pauses as she was unsure whether to say man or woman... I was always taught you should refer to them by their chosen gender, but when unsure, best to avoid the topic all together! Fortunately I don't think the patient noticed the pauses (its likely they were more worried about the fact someone was going to stick knives and tubes into their eye in the next 30 minutes). As this patient only had a local anaesthetic to the front of their eye, I was curious as to what they had seen during the operation. The patient said that it was like a kaleidoscope of colours throughout the operation, and as they couldn't feel anything, not an unpleasant sensation at all!

Going in for an eye operation? You will get a trippy display to keep you occupied while they do what needs doing!


One of the other patients coming in for surgery had specifically requested to have a general anaesthesia for the eye surgery, as he hated the idea of people touching his eyes, let alone operating on them. After a long discussion the anaesthetist had agreed to it, and after putting him to sleep, the anaesthetist was teaching me and the other medical student there how to manually breath for someone with a bag-valve-mask (in the name, its a bag stuck to a mask with a valve between). It looks very simple - stick the mask over their nose and mouth and squeeze the bag, but it is a lot more complex to actually get the bag to seal over the face while keeping their airway open. The head needs to be tilted backwards, while keeping the seal with one hand, leaving the other hand available to breath. While I was making my poor attempt at this manoeuvre (and failing) the anaesthetist tried to help instruct me and move my hands to the right location. It was hard a manoeuvre in itself, but the fact that while I wasn't doing it, the patient wasn't breathing was pretty frightening... While I am well aware that the anaesthetist could have stepped in any time before it got dangerous, the fact the patient had been lying there for a minute, while the machine bleeped urgently at me really didn't help me try to concentrate on tipping the patient's head back just right.... I did manage to get it in the end, so no deaths to my name yet, fortunately, though after that shocking performance perhaps emergency medicine is not for me!


Despite all this talk about surgery, it was only a small part of my week. I also did clinics where I found out how little I know about eyes and eye disease, and spent some time in a huge warehouse trying to hunt down stored patient notes to help me in a research project that I need to do. This time was not well spent, as I found none of the notes I was looking for at all, but the sheer magnitude of the number of the notes was huge. Just thinking that each of these files was a person, and all of the sheets of paper in them were filled with their suffering was... indescribable. I am not sure I have seen a place which really sums up what a huge amount of work the hospital does in such an effective way before, but it was almost like some kind of cathedral or church to all the suffering from all of these people; waiting to be pulled from the shelves for the next attendance to the hospital... 

Moving on

Hi,


A pretty insignificant week, as dermatology wraps up with a session where each student does a presentation on an interesting case they came across this rotation. I chose the patient I talked about before, who had been working in nuclear weapons testing, and had ended up covered in skin cancers. A simple, informal affair, and I got to hear about some of the other interesting things that my colleges had seen in the wards, including a man who had come in because his dog had kept licking behind his ear, and a melanoma had been diagnosed and (hopefully) successfully removed, thus saving his life. Man's best friend indeed! It is assumed that dogs can smell the different compounds given off my malignant tumours, such as altered MHC groups, and 'investigate' them. Several papers have been written about using dogs to diagnose cancer, but they are not as sensitive as other investigative methods.


Other than this, I do very little dermatology this week. This has been a very relaxed rotation indeed, and its a shame that stops now, and I am back having to spend WHOLE DAYS in the hospital at any time. My next rotation is ophthalmology and ENT, and as chance would have it, I am having my own tonsils removed in about a month, due to recurrent tonsillitis, which coincides perfectly with my ENT rotation. I don't just get to watch tonsillectomies, or even assist. I actually get to try one out myself. How is that for a learning experience...


Still, it might be a little strange if I have medical students in on the operation, as they would be my friends from the wards. I'm not going to say no, though, that would just be silly after all the patient's operations I have seen myself.

Very little to report from this week I am afraid, though I hope to have a lot more to tell next week!

Translating

Hi,


This week is my penultimate week in dermatology, and I think I am looking forward to the end of this rotation. While its fantastic for spending time relaxing and on other 'extra-curricular' activities, it seems very hands-off which can get boring at times. Despite this 'boring' feeling to the rotation, I still get to spend some time in clinics this week, where I work on translating the complex medical language the consultant uses for the patient, who has no idea what is going on. The lectures continue this week as well, though one in particular is much more exciting as the consultant who is giving it had taken a large amount of tramadol before for pain relief as he had recently had shoulder surgery. He was somewhat 'high' and pretty crazy for the duration of the lecture, making it a lot more fun (though I cannot say I learnt too much from it!)


As I said before, in one of the clinics I was it (remember we are expected to be very hands on in dermatology) the consultant was talking to the patient after I had taken their history, and quizzing me at the same time. Asking me my differential diagnoses (the list of problems it could be) I listed off a number of diseases such as solar keratosis, Bowen's and SCC. The problem the patient had presented with was a red scaly patch on the face. I chose to use phrases like 'SCC' when talking to the consultant as I didn't want to start talking about 'Squamous cell cancer' in front of the patient, which may upset them (the 'C' word) when it may not even be that. The consultant continued talking to me and the patient using the same phrases (Bowen's, SCC and so on), before leaving to prepare the minor procedures room to have a biopsy of the site taken.  I had seen the look of confusion on the patient's face while the consultant was talking, so once he had left, I asked 'did you catch all of that'.


"What the F*** was he talking about" the middle aged woman replied, clearly a little worried about all those three letter abbreviations that were being slung around. Usually the dermatologists are very good at talking in 'normal speak' to the patients, saving their Latin and Greek names for us long suffering medical students. I assume that this had been different as I had started off with the abbreviations and pretentious-sounding-names myself, so perhaps the dermatologist had though I had already explained these to the patient. Fortunately, as a medical student we are in the privileged position of understanding a few of these complex words while still remembering that not everyone does, so I could try and explain what the dermatologist had been saying (or at least the parts that I had understood...). This went pretty well, even though I had to explain around the 'Cancer' issue where one of the main reasons for the biopsy was because we were checking that this was not some kind of skin cancer. Bowen's disease is basically a squamous cell carcinoma 'in situ', meaning it hasn't spread at all, even to different layers of the skin, and so is easily treated. Good practice for me to explain things to patients, but a far cry away from trying to break real 'bad news' to a patient, such a terminal diagnosis. I do wonder what it is like having to do that for the first time, but hopefully I will not have to try that for a long long time!

Dermatology is a collection of fancy Greek and Latin derived words. Take a guess at what a diagnosis of a "melanocytic nevus" on your skin would mean...

Throughout my rotation in the dermatology department, I have met and got on very well with a chap working as a health care assistant in his year after finishing school. Initially he wanted to do medicine, but didn't get the grades, so is working as an HCA for a year before starting a different undergraduate course (neuroscience). His intention is to study medicine after finishing this degree. Seeing as I am leaving the department after next week, I have given him my contact details and told him that if he needs any help in writing personal statements or anything then he should contact me, as I would be happy to help. He was really enthusiastic about medicine, and it seemed a shame that he couldn't study medicine now, needed to spend three years of his life doing a course he wasn't really interested in, and even after that was in no way guaranteed to get in. I suppose I am feeling lucky to be here this week, and perhaps even a little guilty that I could be working harder during this very laid back rotation.