Misogyny

Hi,


I am feeling mostly better now, which is great! Wasn't as great towards the start of the week, so I didn't go into the hospital much, but I did go into a teaching session with a consultant and a couple of other medical students, where we practice ENT examinations on each other. I also hear from a friend about some shocking sexism she was exposed to, from a surgeon who is a well known misogynist...


Most of our teaching comes from talking to patients, and trying out examinations or procedures on them. See the BBC 'Junior Doctors - Your Life in Their Hands' to see what I mean (though I don't really think that much of that that programme, many of them just seem so... unlike-able...). Hence why a few weeks ago I was practising ophthalmoscopy on patients under the directions of a consultant. The ENT consultants have decided that, rather than trying out all these ear, nose, throat examinations on patients - it would be a lot better for us to try them on each other, learning how not to hurt people by being hurt / hurting one another. A good idea, and its great to be taught examinations and so on as you do them, rather than read up on them and pretend you know what you are doing (as I have done before for an ABG). 


The problem with being taught on one another is that if there is something... gross.. in the examination it is a lot more personal. When you are with patients it is all par for the course and expected, but with each other it is a little bit stranger. I was doing this with 2 medical students, and the male one (slightly low on tact) was examining the females ears, when he remarked 'wow I can hardly see anything, these are full of earwax'. Clearly something that is very normal, ears produce wax, and some ears produce more than others... Not something you usually want to hear about your class mate though, and the girl was clearly a bit hurt by this. When I was later examining his nose, it had this giant bogie sitting it it , wobbling around - again, normal for a patient, the nose makes these things, but strange to be peering at a class mates! (at least it wasn't as bad as this one!). With my messed up throat after the tonsil operation, we all had something on the examination to see, just strange to see it on a fellow medical students. Perhaps this is why doctors are not meant to treat their friends or family!


Later in the week, on of my female friends was complaining about how she had been treated when she went into surgery (perhaps on a different rotation, perhaps not - who knows!). The consultant is a well known misogynist, and has previously voiced his opinion that he feels that women are wasting their time in medicine, and would be much more suited to being at home and looking after children. This is clearly quite a... contentious... opinion... Anyway, this consultant was asking the medical student questions, some of which she didn't know the answer to. Pretty standard, but this consultant was clearly not impressed. He asked some harder very obscure questions that she clearly wouldn't have a clue about, then told her she was wasting her time at medical school, because she was too stupid, and may as well leave. He then went on to say she would be a rubbish doctor, and he would write to her parents to tell them that they were wasting their money on her course fees... How rude! And misguided! Who pays their course fees up front now (top up fees), and everyone relies on student loan... There was no reason of him to say things like that other than to be rude and offend her. It was probably because she was a girl, as he doesn't speak like this with any males... It is a shame that the world of medicine is such a hierarchical place. I would love to think that if that happened to me, I would stick up for myself, but really it is hard to do. You cannot afford offending some consultant who signs off your clinical books, then acts as an examiner in clinical examinations later in the year. I would also like to think that I would stand up for someone if I was there, but I don't really know what I would do - such a risk, but would you be able to keep quiet?

Recovery

Hi,


A brief post this week, mainly because I haven't been up to too much. This has been my week off for Easter, and I have spent most of it lying on the settee, watching day time TV and films. I was feeling pretty sorry for myself when I wrote the last blog, and up to about a week after the operation date. Now I am feeling better and better, great news! I can eat proper food and talk. I went to a friends birthday party yesterday, thinking I would be sitting in the corner unable to talk with people very much (not really like me at all) but hadn't really any problem. I did talk a bit too much, though, and have to go home a bit after twelve... Today I made a roast dinner with flat mates and ate properly! 


It is only after you have had things taken away that you realise how important they are. Hopefully, (and now this sounds like I am writing a reflective piece of writing for my medical school) I can use this to appreciate how being ill can make some people pretty grumpy and relate to this. I was pretty grumpy last week, apart from when I was taking too much codine and was just a little loopy...


Anyway, summary - I am now well enough to do the essays and work that I have been putting off and excusing 'because I am too ill' which would make me sad, if I wasn't so glad about this new found health!


To wrap up, please find below a picture of my throat 5 days after the operation. The uvula was more swollen before this picture, but I couldn't really open my mouth enough to take a picture of it. The white bits are probably because of the cautery used to seal off the cut burning and killing the flesh at the back of the throat, which is then coming off. The uvula is still pretty big in this picture (compared to my or anyone else's normal size) which I suppose is because of inflammation from the surgery. It was very awkward, as it felt like there was something there that I wanted to swallow all the time, and it diverted any food or drink around it when I tried to swallow all over the painful parts!

The back of my throat, 5 days post op. Most notable is the inflamed uvula. Sorry about the pictures if you think they are nasty, but I always find this sort of thing interesting!

My operation

Hi,


This week I got a taste of the patient experience by having my own tonsils taken out. Not to be content with this, fate decided that my rotation (now ENT) would have me observing other people having their tonsils taken out the day before my operation, just to get me in the mood... Since my operation, I haven't really been in a fit state to get back on the wards and have been lazing around home watching day time TV and generally getting bored. I don't know how people do it, there is so little to do at home, but I still feel too out of it to start the essays I need to do...


Before my operation, I spent some time in outpatients seeing patients with problems with their ears, nose or throat (as the ENT moniker would suggest). I can now use an otoscope to look in people's ears to see the eardrum properly, but I don't really know what I am looking for once I can see the ear drum. Perhaps that will come with time... I also spent an afternoon with an audiologist, where patient's ears are tested to see what pitch of sounds, and at what volume, can be heard, plotting diagrams like the one below for each ear. From this you can see things like hearing loss and possible nerve or brain damage. 

An audiogram showing hearing loss into the higher frequencies, the most common type of hearing loss in old age.

One of the audiograms was very unusual, and showed a big dip in the middle frequencies, meaning they needed to be a lot louder for the patient to hear, which then rose back to normal for the higher frequencies. This was mirrored in both air conduction (noise from headphone) and bone conduction (noise vibrated into skull via an alice band) suggesting the origin was not a problem with the outer ear, but instead a problem with the inner ear and nerves. The cause for this could be something like an acoustic neuroma, affecting certain parts of the nerve going away from the ear and thus the hearing signals carried by those nerves. Obviously we didn't tell the patient these suspicions, and instead sent him to the ENT doctor who could carry out investigations such as an MRI scan to see what the cause may be.


The day before my tonsillectomy, I was in the children's hospital watching ENT surgery, which was some tonsillectomies, a few people who needed grommets put into their ears (to stop the build up of fluid behind the ear drum) and one boy who needed the frenulum under his tongue cut, as it was too short, meaning he was 'tongue tied'. Obviously, given the operation I was having the next day, the tonsillectomies took most of my attention. The mouth is held open by a metal gag, and fabric swabs put into the back of the throat to stop blood getting down there. The mucosa that covers the tonsils is cut through with a diathermy, then the tonsils are scooped out, a stitch was put through the area where the tonsil was to stop bleeding, and the area cauterised for the same reason. It didn't look too much fun, but not too brutal either... The surgeon I was with this day was the same one who was down to be operating on me tomorrow, but had given tomorrows list to a different consultant, as he had to be at a meeting. A shame, as I had hoped I could check on his skill!


The day of the operation, I got up early so I could have some breakfast before my scheduled 'fast' time, then went to the hospital. I was in the afternoon list, and was feeling pretty peckish by the time I was meant to go into theatre... All part of the patient experience I suppose! Either way, the surgeon and anaesthetist came to see me before the operation, and both were aware I was a medical student, it must have said so on my notes. This made the explanations pretty simple for the operation. The operation was all fine (I was asleep, I just remember the anaesthetic making me feel very light headed and 'trippy' before I fell asleep) but I was in quite a lot of pain when I woke up. I got some fentanyl, went back to the ward, got some oramorph, and had to wait for 4 hours before I could go home to make sure I wasn't bleeding. My flat-mate was kind enough to drive to the hospital to pick me up to take me home, as I was told I wasn't allowed to use public transport because of the risk of infection. The nurse on the ward was really nice and kind; I think having a nice nurse is much more important than having a nice doctor. You barely see the doctor in your time in hospital, whereas you see the nurse all the time! 


Now I am just sitting around at home, taking my codine, paracetamol, diclofenac and difflam rinse as often as possible, feeling pretty spaced out. Easter holiday next week, so I won't be missing any time on the wards, just time that I should be spending doing my essay. I apologise for the poor quality of this post, but I do feel a little out of it. Perhaps I will have to go back to some daytime TV in a bit, though after what i heard last week, I will be avoiding Jonathan Ross! 

Patients

Hi,


A lot of the time in blogs, I talk about what I did (or didn't do), about what the hospital is like, and what I saw. Basically, a lot about me. Now, while I may enjoy talking about myself, this probably isn't why people read this blog, and it isn't really the most important (or interesting) thing in medicine. What takes this title probably varies between different people, but in my opinion it is the patients. While the diseases they present with can often be the same (with respect to their pathological cause), their stories about their lives, how they cope with their illness and everything else are invariably different and interesting. This week I will talk about some of the patients I saw in my last week on ophthalmology and at the GPs (in an anonymised way, of course, to prevent recognition...) from the morphine-dealing-mum to the side effects of Jonathan Ross


The ophthalmology clinic started with a wonderfully cheery looking Russian lady who had come in with a punctured eye. Worried about the risk of infection, the doctor wanted to find out how this had happened so as to get the best treatment. Despite all of his (and my) best efforts, we just had no idea what this lady was saying. It wasn't because of a language barrier as (I think) she spoke near perfect English. It was more that her accent was so thick it was unintelligible. The consultation meandered on for about five minutes with us absolutely unable to understand her, while she seemed to understand us perfectly. In retrospect, we probably should have communicated by writing things down, but embarrassed to admit that he couldn't understand what she was saying, the doctor just told her that he needed another opinion, sending her to one of the other specialists in the hope they would have more luck... Talk about passing the buck!


The next patient who came in talked English in a perfectly understandable accent, and on examination with the slit lamp, the ophthalmologist diagnosed him with a vitreous haemorrhage (basically a bleed in the eye). The ophthalmologist had left the room to collect a part of the notes, so I was talking to the patient about how this had happened. He works as a painter, and was having a night in, with some pizza and TV. He was watching reruns of 'Friday Night with Jonathan Ross' when he suddenly started getting floaters in his vision, along with loss of vision. My verdict? Jonathan Ross makes your eyes bleed...

A picture of the back of the eye (the retina) after a vitreous haemorrhage 

A later patient, coming back after a year for a follow up appointment, on entering the consulting room proclaimed proudly to the ophthalmologist "you have lost weight". The ophthalmologist, a somewhat business like doctor, just replied that he hadn't and was the same. This lead to minutes of discussion where the patient tried to convince the doctor he was losing weight, while the doctor tried to start the consultation, but kept denying his weight loss. It would have been a lot easier to just accept it and move on! Later in the same consultation, after receiving the iris-widening eye drops that are used to look into the eye more easily, the 30 year old patient asked if he could buy some from the doctor, as it would make him look 'pretty cool' at raves, and could be useful for attracting ladies in coffee shops (after all, everyone knows big wide pupils are attractive). I told him that the drops made the vision blurry, so he may end up chatting up a coffee machine, which earned me a laugh from the patient and a scolding from the ophthalmologist...


There were many other patients worth mentioning, such as the patient who had seen a vitrectomy on youtube (such as the one below) and wanted one for himself, despite having no symptoms, but I could go on all day. A moment of self-indulgence means I want to say that I can now do ophthalmoscopy properly now, after just pretending I could for some time. The ophthalmologist was kind enough to get me to do it on each patient and tell him what I saw. By the end I managed to spot hard exudate in one patent, and microaneurysms in another, diagnosing diabetic background retinopathy in both. A successful clinic!

A vitrectomy, where the jelly inside the eye is removed. Apart form the start, it is surprisingly squeamish-friendly! 


My time with the GP was equally interesting on the patient front. There was the vegetarian (macrocytic) anaemic 90 year old who the GP wanted to give B12 shots to help combat the anaemia, but who was petrified of needles. I recommended Marmite to her, and promised it would be a more pleasurable alternative (somehow she hasn't heard of it...) I just hope she doesn't hate it and wish she had taken the injections! Other patients I saw with the GP included the woman who had broken her arm in the USA and been sent back with some kind of cyborg-like-exoskeleton over it which no-one in the practice seemed to have seen before. The supporting documents she had been given were very sparse, and the DVD she also had wouldn't work on the computers. Very futuristic, but somewhat impractical when no-one knows what to do with it! There was also a mother who had just had a new child at 50 years old, and was struggling to cope with it, after her husband had left her. She admitted that the oramorph (morphine) the GP had given her for unrelated pain had all gone, as she had had a party and shared it with her friends for a 'high', and said she needed more. Not really the responsible behaviour of a new mother, or of a 50 year old lady...


Basically, the patients make medicine. The reason I enjoy clinics so much at the moment is because of the wonderful (and sometimes absurd) things you hear from your patients. Later, as I learn more, I am sure that I will enjoy the process of diagnosis and management of disease as well (not something I can do at the moment), but I hope that I don't lose the enjoyment from hearing about peoples lives. If I can get paid to do this for my whole life, I am going to be a very happy optimist!