Night shift and possible perforation

Hi,

A week in the acute medical unit this week, in the hospital that I will be working at next year. This week, and the next 6 or so, are part of the last section of my course as a medical student, aimed at teaching me to carry out the job of a junior doctor next year. Fortunately I have been placed on the acute medical unit, where patients tend to be quite sick, decisions are made daily as there is a high patient turn over (people only usually stay for a day or two) and lots of bloods, cannulas and so on need to be done. This is perfect for me, as I want as much experience as possible in doing these sort of things, as well as ordering scans, making general requests and general dogs-body work around the hospital. I certainly don't have any glamorous expectations of what next year will involve!

My 'non-glamorous' expectations were proved right on Friday when I did my first proper night shift. Previously I had only stayed in the hospital til about 10/11PM, but this week I came in at 9PM and stayed until morning. This night shift was actually a lot of fun, and I got to clerk in several patients who had come into the hospital at night, and carry out lots of procedures including the ever glamorous 'PR' exam. 

Glamorous medicine... Who said being a doctor isn't an attractive profession? Between these and being vomited on there is so much to choose from...

On the night shift I was admitting patients, taking their history, examining them and then planning initial management and investigations. The registrar was a really nice cardiologist, who talked at length about how upset he was about the events in Woolwich (him being a Muslim  and how it was creating so many more problems... Anyway, this blog isn't meant to be a political statement. The problem with this registrar was that he had decided that, as I had passed finals, I was just an 'unemployed doctor' rather than the medical student I still introduce myself as (until August). This meant that, after clerking a patient who had presented with upper tummy pain, and bloody vomit (haematemesis) - I had taken bloods, ordered an erect chest X-ray (to check for perforation) and all those sort of things, he was asking me to look the results and write down what they said, and plan management. This was pretty scary. He was quite stable, so if he hadn't had a perforation into his abdomen from his stomach he could be left  until morning, whereas if he had, he needed much more urgent assessment. In order to be able to tell this, an erect chest x-ray is done, as it will show air under the left diaphragm, showing air has escaped the stomach and is now outside within the abdomen (where it shouldn't normally be). 

See the arrow on the left of the picture (right side of the patient). This points to air which is under the diaphragm, therefore not in the lungs but in the abdomen, which suggests a problem such as perforation. There is air on the other side (the left of the patient) but this is probably just in the stomach and does not suggest a perforation.

Anyway, this is quite an easy diagnosis to make (as they go) as it is either there or not. But it was a very scary idea putting my pen to paper and saying it was there or not, and having his management depend on what I thought. If I was wrong, he could go all night without the proper treatment and be very sick, dangerously ill, by the morning. The 'lovely' registrar was refusing to help me decide what it was until I had sorted out my own plan, as 'I had to work out how to do it at some point'. Good to have practice in this sort of thing, but not now! Anyway, I thought he was fine, had an 'upper GI bleed' and hadn't perforated, and he agreed, so it all worked out in the end.

The rest of the night shift was pretty hectic, clerking in a man with blood clots in his lungs (pulmonary embolism), someone who was a chronic alcohol abuser who couldn't even tell me why he was in hospital, and a patient who was very depressed and was trying to persuade me to kill him. I have a lot of time as a medical student when things are busy, which was really useful for the latter patient. This is all ignoring everything else that happened this week. Needless to say, things are busy, and I am really loving it!

Drugs smuggler

Hi,

Back working on the wards, sadly. We are meant to be preparing for next year when we work as doctors by getting used to the F1 job, but it also seems like a cheeky way to get people to work in areas of the hospital for free! Either way, I have had a pretty good week, so I don't have anything to complain about. I had some lectures and courses at the start of the week, getting my ILS certificate, then spent some time in the emergency department (where I think I may want to work later in life) and in anaesthetics.

The time in the emergency department was fun, and I spent most of it clerking in patients, which  involves taking a structured history and examination, and planning what initially needs to be done for them. I have forgotten a remarkable amount already since my exams, it is very embarrassing! The most interesting cases I saw were someone who had come in with a police escort after eating a lot of heroin to try and smuggle it into the country (but it had ended up in his bloodstream instead) and a Lady (as in Lords and Ladies) who used to be famous for her organised charity work, but had succumbed to advanced Alzheimer's disease (very sad). I hate diseases like dementia. As well as making you ill, the take away who you are/were, making it really difficult for the family as well. Who knows what will happen in my (and your) lifetime to change how these diseases effect us, perhaps removing them all together. Well, we can hope!

Other than working in A&E, I also spent some time in anaesthetics this week, and observed the anaesthetics for several different types of surgery. I saw breast surgery including removal of tumours, and someone having a breast reduction on one side to balance their breasts which were asymmetrical. This was all pretty 'normal' and I got to practice putting in certain airways and inserting cannulas. The most interesting case here was a patient who had received a blue dye during surgery to locate the lymph nodes draining from a breast cancer so these could be removed as well. This dye had spread throughout her body and she looked very blue and cyanosed, looking very ill despite being well. A good thing to remember in case it leads to panic on the wards when you think someone is becoming very ill, whereas their 'smurf-y' appearance (technical words...) should only last about 24 hours before fading away.

The other procedures I saw in anaesthetics were based around operations on the throat and airway (trachea). These are complex, as the airway needs to be used to breath for the patient, while it is being operated on. Some of the operations involved using a high pressure of gas, like a tyre pump, to inflate the lungs by blowing it down at high pressure from above the level of the operation. Exciting! One of the others was very interesting as it involved an operation to fix the vocal chords in a certain position and the patient had to be asleep for the operation (from outside the neck inwards) but woken up at intervals to check his voice. Very complicated for the anaesthetist, who had to control the level of conciousness with drugs into the blood stream (as couldn't use the airway to get any drugs in), and didn't want the patient to wake up at the wrong time. Something called a BIS monitor is used in this case to tell how 'awake' or asleep the patient is. This gives a score of 1-100 based on how 'awake' you are, and is shown on the image below. I tried it out and it told me I was unconscious. It had been a long day, but I think it was because it wasn't attached properly. Either that or all those finals exams have broken my brain! 

A BIS monitor showing 97 (awake and alert)

PASSED!

I passed!

Woooo!

Fantastic news! Since the news I have been so happy; it comes in waves, where I seem to forget for a bit, then the thought comes back that I will be a doctor from this August and I am really happy again. I am still finding it difficult to believe, that I am finally going to become a doctor, but it is all very exciting. Over the weeks before results I have wanted nothing more than to pass, and to have that worry lifted is so relieving. I would hate to be resitting the exams I just did again, or having to do that year again!

Anyway, now I have to go back into the hospital for a bit, then have a summer holiday, then get to work, as Dr Internal Optimist. Amazing!

So amazing, I am really looking forward to working in August (combined with a high degree of trepidation/fear!) If you can have a job that you look forward to going to, then I am not sure you can ask for much more. I hope that I still feel this way after working as an F1 for a few weeks!

Either way, there is not much more to say. I passed my exams, I get to be a doctor, I got my first choice of hospitals for first and second year, and I am more than happy. It certainly pays to be an optimist!

I will keep my blog title as 'medical student' for the moment, as I am still going to be working in the hospital for a bit, and can keep you updated about that, and then can update it come my graduation ceremony (when I post as an actual paid doctor)

Thanks so much to all of you for your words of encouragement and luck - they clearly worked out!

I passed guys!

So happy :)

Waiting game

Hi,

So my exams are finished, I got into the F1 and F2 placements I wanted in my top choices of hospital and I am sitting around waiting for my exam results. I think the exams went OK, there were some hard questions and some easy questions, but the most important question is whether there were enough easy questions / I did well enough in the hard questions / I messed up too many of the easy questions. I just want to know if I have managed to pass and can be Dr Internal Optimist!

There is nothing I want more at the moment than to be able to change the title of this blog to '

A WEEKLY BLOG FROM A UK JUNIOR DOCTOR

but before that happens I have to have passed my exams! Lots of nervous energy at the moment as I try and waste away the days before results day. It seems so unreal that I am (hopefully) almost at the end of the journey. I have wanted to be a doctor since I was in 6th form - around 16 years old - so this is about 8 years worth of ambition  and work. All of my A levels, exams and so on just lead up to this point, so very nervous indeed!

Either way, I will continue trying to use up the huge 'hole' left in my life where revision used to be by enjoying myself (so many hours in the day!) and I will keep you posted.

Wish me luck!