Celebrity STI

Hi,


Back into the normal run of medical school, and enjoying the fact that I am relatively free from work a the moment, while the weather is also lovely. Usually it seems that the amount of sunshine is directly proportional to the amount of work I have to do, and thus the amount of time I have to spend inside on a computer. Not any more! I can enjoy a cycle to and from the hospital to learn there, and enjoy my time away as my own time... At least until the exam and presentation in a little over a month. Still, they can wait!


This week I spent some time in infectious disease outpatient appointments, and infectious disease ward rounds, and some more time in the sexual health centre, where a somewhat familiar face made a visit.


Clearly, because of confidentiality, I am not going to say anything about the B-list celebrity who was coming in for a sexual health screen, but it is interesting to note that these poor people have to live their whole lives in the public eye, with all these people they have never met knowing about intimate details from their lives. I am sure some use these details for their own publicity, carefully cultivating certain images, but its sad to know that others just want to get on with things and not have rumours fly around about them. Anyway, celebrity or no - everyone should have regular sexual health check ups! Apart from this unexpected visit, the sexual health clinic was pretty similar to previous times I have been there. I would talk to the patient on my own, present them to a doctor or nurse, who would then come in and do an examination with me. There were a large number of teenage boys who had come in with lumps on their penises which had been there for some time. All of these were diagnosed as Fordyce's spots, a harmless feature which just occurs on some penises. Strange that so many came in in one day for these lumps. Perhaps it was sex-ed week at school... Doctors often comment that patients seem to come in clusters of disease, where you won't see something for some time, then a number of that particular condition will come in in one day. I suppose its like buses...

Sexual health clinics are slowly losing the stigma that people have attached to them... Come one come all, they have free sweets!

Other than the time in the sexual health clinic, which I am still really enjoying, I got to join some outpatient sessions and ward rounds with the infectious disease doctors. As I did an intercalated year based around infectious disease last year, I was hoping that my amazing knowledge of all things infectious and puss-filled would come in useful, but it has turned out that I actually know basically nothing about clinical infectious disease. Who could have guessed that having to learn each of the proteins that make up HIV and how they are put together would not have any real-world use. (I use real-world here to mean clinical doctor. I am sure most of the things I learn have little use outside of medicine...) 


Despite my astounding lack of knowledge (as in, I know the same for infectious disease as I did for the other specialities) I really got into the infectious disease clinics. Most specialities have 'bread and butter' cases which make up most of their work load, e.g. endocrinologists see a LOT of patients with diabetes and thyroid disease. This has always put me off of specialities, as I can imagine that the lack of variety would lead to it getting boring (for me, at least). Not so with infectious disease, it seems. The clinic consisted of a huge range of diseases from serious cellulitis, to endocarditis, osteomyelitis and HIV. From just one clinic this was a good range of disease, and there was a lot of detective work to be done as well. Many patients are referred to the infectious disease team with problems like PUO - a long standing fever, or generalised lymphadenopathy. The diagnosis is often not easy to find, as many of the tests are nowhere near 100% accurate at picking up the disease (such as TB) so clinical judgement is important.


One of my favourite things about the infectious disease clinics was all of the patients who have caught weird and wonderful infections while abroad. Obviously the problem-solving and diagnostic side of things is very interesting for these people, as they can be rare diseases, but hearing about their travelling stories (one was distributing free text books through Sub-saharan African slums) is fascinating. Made me want to go back on my elective (until we looked at the lump under the next patients skin, caused by botfly larvae growing under there before becoming flys...)


All in all a great week, and perhaps I will become an infectious disease doctor... Despite the fact that I saw some pretty nasty infections in the sexual health clinic this week, the worst things in medicine (in my opinion) are still those chronic ulcers in the vascular wards, with that necrotic smell from the dying tissue that fills the ward...

General Practice and my own list

Hi,


Busy week this week finishing off my big project, which is now happily handed in. As long as I have passed it I am good and happy. Medical school sometimes seems like a series of hurdles you just need to jump over to get to the end and graduate. One more hurdle passed (hopefully)... Because of this project, I didn't get up to too much this week either, taking the opportunities to stay at home and try and work (but mostly procrastinate) when possible. I did spend a bit of time in the hospital though, and more importantly, spent my last day with the GP I had been placed with. I got to run my own consultation list, which was pretty scary at first. As I got into it, it became easier though stranger, as I think the GP put some of her craziest patients on the list for me to talk to!


It was very sad to leave the GP I have been working with, its very unlikely that I will be with her during my GP rotation next year as the medical school tries to balance out rotations in large and small practices. This means that, as this GP practice is practically a polyclinic, I will probably be in a single room that doubles as the GP's bedroom next year. This is one of the most exciting parts of general practice, it comes in all flavours!


The GP had decided that for this visit, she would give me my own 'list' of patients to see, meaning  people who had called up for appointments had been given the option to see me. I wasn't going to be the only person seeing them, fortunately (unlike when I was in Tanzania), so this wasn't unsafe. It just helped the GP see more patients, and helped me practice running my own surgery, as it were. I was given log in details to the software used to display the appointments, patient notes, 'QOF alerts', and so on. Made me feel pretty important! I got used to the software, pulled up the notes for the first patient, and went out to the waiting room to call her name...


The first patient didn't go as well as I would have hoped, as she seemed convinced that I was a doctor, despite all my protesting against the idea. She opened with the phrase "Its a good thing that they assured me you were a doctor before I saw you walk through that door, as you do look very young"... I don't know who had been assuring the patient that the medical student was definitely a doctor, but it made her (probably) gout presentation a lot more complex than it needed to be!


This was followed by a couple of very straight forward cases where women wanted to delay their periods for a holiday and an anniversary. Not much I could do as a student here as much of these was prescribing, something that I definitely shouldn't be allowed to do yet! This was where the simple cases ended, though, and the rest of the day seemed to be filled with complex psychiatric patients. If I didn't know better, I would have said that the GP found it hard to deal with these patients who there is very little to do for in general practice, so gave them all to me to see instead... If I didn't know better...


I slogged through consultations with a number of people who had been diagnosed with borderline personality disorder (where I think I was demonised a little more than idealised), and as was beginning to give up hope with general practice, when a 10 year old girl came in who had been suffering from mouth ulcers in her cheeks. A nice simple case, or so I thought, but after a minute or two of talking I began to feel a bit uneasy. The girl had come in with her mum, and their relationship just felt a bit wrong. Not really sure what it was, but there seemed to be some tension and... well, I am not really too sure what it was. On talking with the GP afterwards (before deciding on a course of action, of course) she told me that this 10 year old  had been manipulating her mum and dad for the last few years into getting what she wanted after she had been caught stealing sweets from a local shop. It seems that as a GP you get to be part of everyone's life story, and hear about all those things that go on 'behind closed doors'. A great job if you are a bit nosey like me, but as it seems that everyone is crazy beneath the surface I may not be won over by the GP quite yet!

A borderline patient example with Barney - from the site in the top left...

Before leaving, I was discussing my patients with the GP and other practice partners. One of them, most eloquently, said that borderline personality disorder patients are the hardest to deal with in general practice, whether they love you or hate you, as they are very hard to get rid of. This is because you cannot refer them for counselling as you would with many other minor psychiatric problems "as it is like wanking for these patients, they just cannot get enough"... Not the most politically correct way of putting your point across, but I think I see where he is coming from. Perhaps counselling reinforces their behaviours by giving them too much attention. 

The GP who I have been with all of this year said some very nice things about me before I left, about what an amazing doctor I would make when I qualified and how she had every faith in me. Very glowing praise, and I am sure she says it to all medical students who she teaches, but it made me feel good. She has added me on facebook to keep in touch, so I will have to remove all of those embarrassing photos, but it will be good to keep in touch!

Essays

Hi,


Sorry, just a quick post to say that I haven't really got too much to say about last week. I have been spending a lot of time doing a 'research based essay' - basically a medical-school dissertation. Whenever large work assignments come along, the medical students all seem to shut down, cutting out important things to try and work on their work, and I am no exception. The main problem is that while I do cut out lots of fun things to try and work, I manage to distract myself on the most banal things and procrastinate unless there is real time pressure. Because of this, I have still got loads of essay to do in the coming week, as it is due in in a few days, but have missed out on loads of 'extra-curricular activities'...


There is always a strange attitude at the medical school when there is a lot of work, people just seem tired and in a strange mood... Because of this I won't really post much today, as this time would be much better spent on my lovely essay into "Can serum potassium and serum lactate levels predict mortality in patients admitted to the emergency department in cardiac arrest".


Now all I need to do is stop procrastinating by writing this and get back to it!

Sexual health

Hi,


Again, I am sorry for the late post. A stubborn essay and other things in life keep delaying me from posting on the weekend Sunday as previous, and have even delayed me past a bank holiday Monday this time! 


This week I start my sexual health rotation, and get the chance to get 'stuck in' right away... (sorry)... The best part of this week was spending some time at a sexual health clinic, where I tok histories from patients on my own (after seeing one done) but didn't carry out any examinations. I was very happy with this turn of events, as talking with people was very easy once I had explained that I wouldn't be carrying out the examination afterwards.


I really enjoyed my week, not because of the subject matter, but I think it was because it is so accessible for a medical student. If someone has a sexually transmitted infection, if can only be one of a handful of causes. The most common can be counted on one hand, and even an extended list is very simple compared with, say, a list of possible cardiac problems. As well as a small list of possible causes, a sexual history is very structured, comes written on a proforma that you need to fill in, and is all in all quite simple. You need to ask around their symptoms, their general health and their history of sexual contact (i.e. who did you last have sex with, what type of sex, did you use protection, who was the person before that, etc). The hard part here is asking these questions without embarrassing them, yourself, or seeming as though you are being judgemental. Obviously the medical profession do not judge people at all, but it can be hard to ask about the sex that a patient is having with his girlfriend 20 years younger than him, while cheating on his wife, without the patient thinking you sound judgemental (especially if they feel guilty about it themselves).


I saw some very interesting cases this week. I met actors from the adult film industry attending to have certificates proving they were clean from sexually transmitted infection (and let them continue to act), though these people did not need much of a history as they were attending more for a screen than with symptoms. There was a woman younger than me, who had come in with recurrent genital warts, and seemed very relieved that it wouldn't be me doing the examination (I suppose it is bad enough exposing yourself to someone for an examination, and when you don't feel you 'look right' down there it would be even harder). The most interesting was a middle aged man, who looked a little like Clooney. He insisted that he had been with his wife for 10 years, and she was the only person that he had had sex with in this time, but he just wanted to come in for a sexual health check up. There was clearly something fishy about this, but however tactfully I asked it (the usual way is something like "when was the last time you had sex with someone other than your wife") I couldn't get him to disclose whether he had had sex with someone else. I was sure that he had, but what can you do? He just got the tests, and I hope he is clean, or he will have a problem explaining to his wife how they both have an STI despite the fact he has been faithful. I suppose its possible he feels his wife has been cheating on him, but it isn't really the sort of question that you can ask a stranger (not that many of these questions are things you can ask strangers!) 

For examinations, there is ALWAYS a chaperone present - to protect the doctor as much as the patient!

All in all, the interest here comes from the history, learning about people and trying to read between the lines, rather than the complexities of disease and pathology like other disease specialities. As I said before, I really enjoyed this as a medical student, but I am not sure how much I would enjoy it as a qualified doctor, as I may feel it gets a little same-y. None the less, I did get to try the genital-warts-freeze-spray on my hand (the nurse offered for me to try it, and I didn't want to look like a wuss in front of her [after all, patients get it sprayed on their genitals]) which I didn't think was too bad... Until I was at a social playing laser-tag afterwards - it really burns! Not enjoyable, and I can only imagine what it would be like 'down there'... At least now I can tell patients that it will hurt, and I am sorry, but I have 'tried it out' myself... 


As well as histories and examinations, the sexual health clinic also looks at samples right then and there under a microscope, which can spot diseases such as candida by spotting yeasts. I have a look at some of the slides with one of the nurses who is working on this (everyone here seems very friendly) and its amazing how many bacteria you get in an average vagina. There are hundreds and hundreds of Lactobacillus on each slide that was made up from a swab from a vagina. The 'friendly' bacteria that live down there, stopping nasty infections from getting hold... gross... 

A slide of Lactobacillus (the rod-like-things) - a bacteria found in vaginas... and yoghurt...

To finish things off, one of the nurses told me that women who wash out their vagina with washing products (shower gel etc) are much more prone to infections because of washing away all this Lactobacillus (you should use water)... Telling women this doesn't really get results, though, and people tend to do it. The tactic that is used, she tells me, is telling women that some men who attend the clinic ask why their new girlfriend smells 'so bad' down there, and if there is anything they can do. These men, the nurse tells the over-washing-woman, are suffering because their girlfriends use washing products 'down there' which end up making it 'smell worse'. As no-one wants to be smelly there, this leads to many more women washing themselves properly than just telling them they will get more yeast infections. A wonderful example of people being manipulated for their own good...

Alcoholic nurses?

Hi,


My last week on ENT this week, and another slightly late post. Sorry about this, but I keep getting distracted by other things in my life. Don't feel too taken aback, though, as these distractions are affecting the work I am meant to be doing as well - its nothing personal... This week I spent some time in ENT outpatients with a fantastic consultant, but spent a lot more time trying to help out a friend who has had some form of psychotic breakdown and has now fled the country.


The time in ENT outpatients was spent mainly with a fantastic friendly consultant. He showed a lot of concern for my ex-tonsils and was very jokey, while staying formal enough for (most) patients, and sharing a lot of knowledge. When I say formal enough for most patients, I mean things went swimmingly with all patients but one, where his joking fell embarrassingly flat. Here he was (for some reason) joking about the nurse who sits in the corner of the consultation room to help with the preparation of equipment, and saying that she needed to drink gin throughout the day in order to put up with him and the other doctors, and if the patient needed, they could borrow some of it. The patient took this a little too literally, and started an outraged monologue about how it was unacceptable for nurses to be drinking on the job, and the state of the NHS. Despite the consultant and nurse's best efforts, the patient wouldn't believe that this was a joke (because it sounded far-fetched that they were back-tracking now...) and was grumpy with the doctor and 'drunkard nurse' for the remainder of the consultation. Perhaps there will be a law suit coming this way!

A scope used to look down patient's noses to their vocal chords - one of the things the 'drunk nurse' had to prepare for the ENT doctor.

Fortunately, the other consultations were conducted in fully professional ways, and no more problems were had. The most interesting of these 'normal' consultations was a man who had come for the results of a biopsy of a lump in his neck. He had come in with another male, who we assumed to be his partner because of how they were acting with one another, and I noticed the consultant carefully avoiding any labels for this other person in the room (it would be embarrassing to wrongly call a brother a partner, and visa versa!) The biopsy had unfortunately shown a lymphoma, and this news had to be broken in a skilful and optimistic way. The two people were evidently very upset by the news, both crying, though the consultant tried to reassure them that it was very treatable. At the end, as they left, the questions they were both asking the nurse were the same things that the doctor had tried to explain. Usually, when bad news is broken to a patient, they don't hear much afterwards due to shock, and the 'you have cancer' bouncing around in their head.


Despite these clinics, by far the most exciting thing that has happened to me this week is that one of my friends has had what seems like a severe psychotic breakdown. His mum called me to let me know that things were not right, she couldn't really get hold of him and asked me to go and check on him. I went over to his house, as I couldn't get him on the phone, where he then proceeded to tell me how everyone was persecuting him. The police had it in for him, had sensors in his rooms in his house to monitor his movement and the phone companies had hacked his mobile to use the camera to watch him (this was why he wouldn't call anyone). The university had hacked his laptop, so he bought a new one, which had then been hacked and they had uploaded documents detailing how to plagiarise work efficiently (he assumes to get him in trouble) which had then mysteriously disappeared. There were people opposite his flat who were recording him all night in his room, which he could tell by the faint glow of what looked like a burglar alarm in their window. He knew there were people watching him as he could hear their voices mocking him, and talking about what he was doing. He hadn't left the house in a week, as he was afraid he would be kidnapped. And there was more.


He was clearly not feeling well, and being a good medical student, I took a full history. Key to note was the fact that he had been taking a lot of Ritalin, which he claimed was for his ADHD, but I think it was to help him do his essays and increasingly heavy work load. He had been taking more and more as his deadlines approached, and was now feeling like this. I thought this was probably related, but he was adamant that he had never had any problems before and needed it to be normal. He wanted to get away from this 'persecution' so I offered to let him stay at mine for a few days to get away from it and think about what he wanted to do. He was going to finish Uni in a month or two, so I didn't want him to do anything rash.


Anyway, he had a lot of stuff and wanted to pack clothes, so I took some of his items back in the bus (this was still too soon after my op to be cycling), did some research online finding out about stimulant psychosis (my best guess for cause) and then drove to his to pick him and his items up. I double parked my car due to no close parking with the hazards on, and spend the next 45 minutes ringing his bell and calling him to no answer. Annoyed with how he would just not open the door now, I tried to go home, but found that my car had now run out of battery. Very embarrassing given its stupid parking location! 


Either way, I sorted that out in the end, and then later that night his mum called again to tell me he had gotten a taxi to a nearby airport, and was taking a plane to get to another country. I don't know how he afforded this, as he had been buying a lot of new things recently (possible mania?) but he is now in a different country and trying to sort things out is ongoing. All of his items are still in the UK, from his mobiles to his clothes and expensive laptops. Crazy trying to deal with the fall out from this, but scary to see how someone who seemed (relatively) normal can flip to being so paranoid and uproot their life like this!