Early mornings

Hi,


It seems the higher up the medical school-ladder you move, the further away you need to travel for your placements. While this seemed fair in previous years (letting those who know the least stay close to home and all that) I am starting to change my mind. It is so tiring! For example, this rotation has 8.30 starts at a distant district hospital. The buses here run one an hour, getting in at 45 minutes past the hour. This means I have to arrive at 7.45 in order to be on time. Seeing as the journey on the bus is an hour, and getting myself to the bus takes time, I am getting up before 6AM. Ungodly... This would be (just about) acceptable if it was worth it, but it seems as though these sessions keep starting 20-30 minutes late, meaning I could have gotten up an hour later if I had known. Getting up at 5.45 is a lot earlier than getting up at 6.45! Anyway, rant over...


Because of these stupid early morning starts, impending exams-and-presentations-of-doom and the fact I am currently trying to move out of my house while still in this extended term-time, I am not being too successful with this blog, for which I apologise. Clinics have been very interesting however. Rheumatology seems a very complicated subject, that collects lots of the parts of medicine that other specialities seem to 'mysticize' or don't really understand, including the House favourite Lupus, and the poorly understood disease fibromyalgia. All of these confusing connective tissues disorders, along with the multitude of types of arthritis, which all seem to cross and overlap with one another is very confusing for a poor little medical student! Fortunately, it was highlighted to us how out of our depth we were in this field in one clinic, the favourite quote I take away with me being "Don't feel for heat with your knuckles, you're not a gypo"...


Other than our somewhat outspoken un-PC consultant (or perhaps because of it) this clinic was very interesting. We saw a boy who had had severe burns to his face, which he had received plastic surgery for, but had (somehow, inexplicably) lead to him developing some kind of juvenile arthritis. There was an elderly gentleman with psoriatic arthritis who had been referred by his GP for better treatment as he was still in pain. For some reason the GP had prescribed him diamorphine (Heroin) to help with his pain. This is normally reserved for the worst kind of pain, as people are dying. I am sure he was really enjoying its pain-killing properties! There was a 40 year old woman who had been put on a biologic anti-TNF agent to help treat her rheumatoid arthritis. This had changed her life, allowing her to dress herself, change her grand kids nappies and hold a pen. The side effect was she was losing all of her hair, including her eyelashes. Despite this, she was adamant that she didn't want to stop taking this wonder-drug (which costs about £20,000 a year). I was really moved by this, an attractive 40 year old is willing to lose all her hair in order to get rid of this disease - I suppose this really highlights how debilitating these diseases can be. She was willing to give her 'right arm' to return to normal, and saw having to wear a hat as a small price to pay. These sort of patients, whose lives are turned around by successful treatment, are what really makes clinics and being a doctor. If I have a few people, every once in a while, who I can feel that I help half as much as this lady, all these early mornings will be worth it.

Its not laughter, its not paracetamol, its not even talking and understanding. Some doctor  decided that the best medicine to cheer up his unhappy patients would be heroin... Brilliant!




Now you will have to excuse me - I have to go to bed, in order to be up before 6 again...

Vioxx and deductions

Hi,


I started my last rotation last week, meaning that in 6 weeks time I will have finished my forth year of medical school! This rotation is focused around rheumatology and orthopaedic surgery, meaning joints and bones. This is the last major speciality that I don't have any real clinical experience of, so in a way it is nice to be rounding off that basic medical knowledge of knowing a little bit about something from each speciality. Seeing as my final year is just repeats of rotations I have done already, but with more expected from me, it means I can no longer use the excuse that 'I haven't studied that yet' when my family or friends ask me difficult medical questions!


I spent some time in a physiotherapy clinic as part of this rotation, and I was very impressed! The person I was working with only looked a few years older than me, but she had an amazing well of knowledge on muscular conditions, their causes and good ways to treat them with exercise regimes. A totally different ball game to the things we are taught in med-school (basically just the anatomy). They actually get to heal people with their hands, all her patients seemed so happy with her and by moving their limbs around she healed them - I have decided that physiotherapists are the medical equivalent of Jesus, and any patient I see with any joint or muscle problem for the rest of my career would definitely benefit from a referral to a physio!


As well as spending time with the physio this week, I spent time in a nurse lead clinic for those on biological therapeutic agents for inflammatory joint conditions. This was much more medical, and much more related to those years of lectures I have been through. Very complex though; I think rheumatology is going to take some time to get my head around. The biologic agents these patients are on are basically antibodies which have been made in a lab, which are injected to reduce the levels of inflammation (and thus help their inflamed joints). They all have names ending in __mab such as infliximab. These are very expensive, costing about £20,000 a year per patient, but they really do seem to help. I bet the patients are happy that they don't have to try and foot their own bills! In this clinic I met a person who had suffered a number of heart attacks some years ago, as he had been put on the drug Vioxx. As can be seen by the link, this drug was pulled off the market after it was found that the drugs company who had tested it had withheld information showing that it increased the risk of problems such as heart attack. After all, if you have spent millions developing a new drug, no-one will take it if it might kill them, so that isn't the sort of information you want available to the general public! I remember it being mentioned in a lecture in my first (or second) year, how it was found by using the 'track back changes' function on word when looking at the research they had submitted; meaning that it was previously included but was purposefully removed. Ruthless...  The first time that I had met someone affected by this, and he was remarkably un-bothered by it all. I would probably still be trying to sue them!


I also noticed that (of the admittedly rather small sample size) more than 50% of the patients with Rheumatoid Arthritis (RA) we saw were keen ornithologists, often going on field trips to see birds. RA is believed to have appeared as a disease in the last few hundred years, as while there is evidence of skeletons being affected by different arthritis-related-illnesses, there is no evidence of skeletons with RA before this time. People have guessed that this may be a new environmental substance, or viral infection, that is leading to this 'new' seeming (and certainly not uncommon) disease. Using my expert medical-student knowledge, and this huge sample size of 5 patients, perhaps birds may hold the answer, perhaps they somehow lead to us developing RA, through some kind of parasite or virus they can pass on. If this turns out to be the case, you know where you read it first!

If my brilliant scientific deduction is to be proved correct, we will have to be the ones to do something about it. Birds are inherently lazy...

Follow up

Hi,


Relatively relaxed week this week. I spend some more time in HIV clinics, follow up the rabies-bitten patient who I spoke to last week, and present a case based around Fordyce's spots for my end of rotation assessment. 


In the HIV clinic I am with a different consultant to the one I was placed with last week, and this one is also gay. Somewhat more flamboyant than the person I was with last week, his entire patient list seems to consist of middle aged HIV positive gay men who have a crush on him. When I say it seems to consist of, I mean that every single patient who we saw together was a middle aged, gay, HIV positive man. HIV positive people have several outpatients appointments each year, to make sure that they are still doing well with their disease and drugs (it is very important that they take the drugs every day to stop resistance occurring), which means that the patients get to know the specialists very well. Patients switch between consultants to find one that they like; for example all of the HIV+ afro-Caribbean people are managed by a large, jolly Jamaican woman. Obviously all of these middle aged HIV positive gay men like flirting with this flamboyant consultant, who is very informal with his patients. I can tell why they like him though, he is very complimentary towards them, almost towards being inappropriate, though they clearly love it, and love him for it. The patients range hugely (though always keep within the male, gay, middle-aged category). There are high powered bankers, through to homeless down and outs. All are treated with the same glamorous, dazzling fashion. It looked great fun to be a patient of his, and I know that if I had HIV I would want to come to him (though I don't quite fit into the necessary bracket...)


The rabies-man (hopefully a name that will prove to be incorrect) has refused any medical treatment for his bites. He has decided that chromotherapy is all he needs to balance his bodies energies and push the rabies virus out. I really hope that the dog didn't have rabies, as this is one person I don't want the medical profession to be saying 'told you so' to. Perhaps the worry should be if he doesn't get rabies, and spreads the word that colour-therapy can cure rabies, meaning many other people might be exposed...

Rude jokes and general 'banter' should probably be kept for class mates, rather than your examiner...

At the end of the modules we have to present patient cases to the rest of the year. I was presenting someone who I saw in a sexual health clinic who came in and told me, and I quote "I've got lumps on me knob". It turned out that these lumps were just a normal physiological phenomenon known as Fordyce's spots, just large sebaceous glands on the shaft of the penis. The consultation was pretty simple, until he started squeezing these spots to show us what would come out of them... Pretty gross... Either way, I somehow accused the consultant I was presenting to of using prostitutes in front of my year - pretty embarrassing result of a 'witty' quip, but hopefully I won't get kicked out for it.

End of sexual health rotation, pretty uneventful week, and I will keep you up to date with how things go next week in my orthopaedics rotation! My final rotation, and the one with my end of year exams in it!

Gay doctors and HIV

Hi,


Sorry for the recurrently late posts. The Diamond Jubilee has meant lots of fun things to distract myself from and make the most of this 4 day weekend, though also meant that I haven't been with a computer to post until today... Despite my poor posting, I do have things to talk about. Last week was pretty interesting, mainly spending time in outpatients, in both an HIV clinic, and a general infectious disease clinic.


I have noticed that a larger proportion of HIV doctors are (outwardly) gay compared to other medical specialities. Perhaps this is linked to the fact that when they were training this disease was ravaging some of those in the gay community, and they were determined they wanted to help stop it. Perhaps it is related to the fact that there are more gay patients in this speciality, which attracts gay doctors. Perhaps it is just a more accepting patient group, and doctors who are HIV specialists feel happier to be open about their sexuality... Whatever the reason, this is a trend I noticed, and when going into the clinic with the HIV consultant I was secretly trying to work out whether he was gay or not. By some coincidence (small world and all that) one of my friends who I knew outside of hospital life walked into the room, and after the exclamations of surprise at meeting each other here, he introduced me to his husband. I knew he was married, just not to who! It definitely solved the question over whether the consultant was gay though!


In the infectious disease clinic, the most interesting case that I saw was a man who had been travelling through Africa and had been bitten by a dog. He had come in with a walking stick, wrapped in a shawl, very 'new age' style, and talked about how he had been travelling by foot through the birthplace of man. This had been about a month ago, and he had been bitten by a dog, who was one of a pack belonging to a witch doctor. The witch doctor had assured him that there was no rabies in his dogs, because of his medicines, and so this man had travelled home without having any preventative treatment. Recently, with all the media coverage of rabies in the UK, this man's friends and family had urged him to get it checked by the doctors. Unable to diagnose rabies, the only thing that could be offered would be to treat him as though he had been infected, to reduce his risk of contracting rabies. He was not keen on this idea, talking about how he never had any vaccines as they harmed your body, and told us that he could probably get a natural cure in crystals. I am unsure as to why he came into the hospital in the first place, if he wasn't going to accept any treatment. To reassure his friends and family, I guess... After a lot of discussion, and calling the HPA, the man was still sure he didn't want the recommended treatment because it was not guaranteed to work. The recommended treatment consists of immunoglobulin and a vaccine as soon after exposure as possible. This lead to a long discussion about medicine, and how very little is guaranteed. He demanded proof that it would help him, which we then emailed to him to read. He decided he may come back in after reading it if he and his 'healer' decided it was 'appropriate'. Its very strange how someone who is so obsessed over proving things work practices types of medicine that many feel do not have any proof. Perhaps he is more used to the 'definites' that some alternative medicine practitioners work with. This homoeopathic diamond will definitely cure your breast cancer... Perhaps that helps the placebo effect...


I hope he does come back in for the treatment, but it seems that he won't. The odds are that he hasn't got rabies, he will chose crystal therapy, and feel that it has protected him. I hope that's the case, as the alternatives are pretty bad. it seems silly, but all these lectures about 'autonomy' are all about letting patients make decisions that we feel are misguided, and I just need to remember that it is his life, and my beliefs. He should be allowed to follow his own beliefs.