Ambulances

Hi,

An interesting week in A&E, the most exciting part being a few days with the ambulance service with the paramedics. 

A&E had some interesting cases, some sad cases and some relatively dull cases. The interesting included someone whose pacemaker was giving the wrong signals, a road traffic accident where a cyclist had been hit by a car, who had then run off (leading to us trying to balance the clinical needs of the patient with the police wanting to question them ASAP to catch the car driver), and someone who had dislocated their shoulder (which I got to put back in, something I hadn't done before). Several of the sad cases involved people coming into A&E and dying of problems like cardiac arrests, and one was a patient who liked to 'fake' seizures to get her into hospital. There are always lots of less interesting cases, and people who come into A&E who should have gone to their GP instead, but I am still really enjoying this placement.

The most exciting part of the week, as I said before, was a few days on am ambulance with a paramedic and a technician. Driving around on blue lights and everyone getting out of your way is very exciting! The saddest case that we saw was a man who had started feeling really breathless and confused while in a supermarket, and the cashier had called 999. He has a strange heart rhythm, which we initially thought was SVT, but was actually fast AF. He was very worried about his car parking ticket running out as we took him on blue lights to the hospital, and I spent the time reassuring him. We arrived, and 10 minutes later he arrested and, despite 40 minutes of resuscitation being attempted, he died. Despite him appearing relatively well in the ambulance, where his main worry was his car, he just died - and we still have no idea why. He didn't seem to have any signs of a heart attack, so we were wondering if it could be a PE. I found it quite upsetting, and I don't think that feeling a bit travel sick from bouncing around in the back of the ambulance at high speed with no windows helped things. We saw a number of other patients including a man who had been found in a very 'compromising' position, who tried to tell us that he had been attacked in his home, though it looked as though the problem had been caused by some kind of strange sex game. 

SVT: regular, fast 






AF can be fast and look similar to SVT, but will be irregular rather than regular in rhythm





While on call with the ambulance guys, I also went into a school full of primary school children and spent some time showing them around the ambulance with the paramedic, letting them turn on the lights and sirens etc. We were still 'on call' whilst doing that, but didn't have any interruptions. I think the point of it was to try and make sure kids are not scared of ambulances if they need to come into hospital, and think they look 'cool' instead! After some of the sadder patients before the school, I didn't really feel in the mood to be very cheerful and upbeat (which you need when talking to children), but it was a nice distraction. 

Seeing a few days in the life of a paramedic was interesting though, as despite there being some interesting things, there is also a lot of calls that they attend that they certainly shouldn't need to; a lot of people misusing the 999 number.

Quite an emotional week, but busy and interesting. My last week next week, then graduation, a little holiday and I start working as a doctor!

Spot diagnosis

Hi,

A week in the emergency department for me, where I get to assess and treat lots of patients, see a large overdose, and make a 'spot diagnosis' on a receptionist who is quizzing me on her disease.

One of the best bits about A&E is patients are meant to be in and out in under 4 hours, meaning that you can see, examine, investigate and treat a lot of patients in each day. I am getting better at writing management plans that are actually accurate now; something I found difficult. I find diagnosing patients and writing management plans very rewarding (if you get it right). For example, last week a 40 year old lady came into the A&E department who thought she had a pneumothorax. This is a problem where air gets outside of the actual lungs, but is trapped inside the thorax which surrounds them. This can deflate the lungs and make you breathless. I have put a picture of a chest X-ray below:

This is a chest X ray showing a fully inflated left lung (right of the picture) and a partially deflated right lung. You can see the loss of the normal lung markings, showing that it is just air and not lung across most of the right side. This is a large pneumothorax.

The 40 year old lady was scared that this had recurred, as she had chest pain and felt breathless. As the first person to see her, I started off with observations to make sure she was stable, took a history and did an examination. A pneumothorax will have reduced air sounds over it if listened to with a stethoscope, as there is no lung there. From the history and examination (which showed she was tender over a few ribs too) I guessed that this was 'musculoskeletal pain' - i.e. she had pulled some muscle in her chest, rather than a pneumothorax. To make sure, I ordered a chest X-ray, which I then had to interpret. I thought she was fine, so went to talk to one of the doctors in the emergency department. He listened to the history, had a look at the chest X-ray and just agreed with me, and told me that I should discharge her. Very rewarding to have your opinions 'validated' by someone- hopefully something I can get right more and more often as time goes on!

Other patients who I saw this week included someone who had taken nearly 200 tablets of a mixed variety, mostly diazepam, and had come in after being found unconscious on a park bench (he was quite sick, and my job involved the exciting task of looking through all the empty pill packets, working out what he had taken, how much, and finding out how dangerous each one was on toxbase). Another patient was a 98 year old gentleman who had severe dementia, and had been bought in by the nursing home as he had become 'increasingly confused'. This is called delerium, and there are hundreds of causes for it. As the patient couldn't say anything to me, it was very difficult to work out what it was that was causing it, and I had to order loads of investigations. I don't feel I really got to the bottom of it, as everything I did was negative, but my senior decided that it was probably a pneumonia and discharged on amoxicillin. Not too sure how happy I was with that, as I couldn't see any signs on the chest X-ray, and there was no suggestion of infection from the blood markers, but I couldn't really argue...

Early in one of the mornings, when things tend to be a bit quieter, I was chatting with a receptionist, who asked me if I could diagnose her condition. I asked her for some clues, so she told me to treat her as if she had been bought into A&E unconscious on a stretcher with a low blood pressure, but no other obvious problems. She had a good tan going, so I ventured that "perhaps, because you have this bronze looking skin, you have Addison's disease?". I was right, and she was really impressed. It is mainly because 'hyperpigmented skin' is a typical multiple choice question option for Addison's - and I have just done finals. I felt very smart for the rest of the day, after she had heaped congratulations on me, but also a little smarmy. It is good to get things right, especially for the patients, but if you show off about them you just look like a nob! Fortunately this blog is anonymous, so I can get away with showing off a little bit ;)

Referrals

Hi,

First, very sorry for the really late post. Things are getting out hand. I always tried to post on Sundays, but then with busy weekends this started shifting to Monday/Tuesday and now it seems to have shifted all the way to Friday. Hopefully I can catch up. The problem is, things re really busy and, while I enjoy sitting down to write a post, it takes time which I don't really have! Perhaps, come August, I will try and keep it regular but remove the 'weekly' from the title to take away that expectation (which I am struggling to meet!) What do you think?

Anyway, moving on to what I have been up to this week (by which I mean last week), it was a bit more empty than the week before. A bank holiday when I didn't need to go in, and a day of lectures meant I only spent a few days in the hospital. I am still on an acute medicine rotation for this week, before moving onto emergency medicine for the next few weeks. 

The day in the acute medical unit consists of a consultant lead ward round at 8AM, seeing most patients. Patients are normally only admitted to this ward for a day or two, so each patient is an interesting case, needing diagnosis and management plans, which keeps things interesting. There are two consultants who split up and see the patients who have been admitted in the last 24 hours, and a registrar (slightly less experienced) who sees the patients who have been in for over 24 hours, and adjusts their management plans. There are about 30 beds in total. After all patients have been seen by one of these three groups (each consultant has junior doctors with them to help things along) everyone goes into a meeting room, and all patients and plans are discussed. All the plans are put onto a big spreadsheet, which is printed off and pasted on the wall. The rest of the day consists of the consultants going somewhere (still not sure where, perhaps there is a secret bar out back?) while the juniors carry out the 'jobs' on the list. These could be things like taking blood, asking specialists for referrals, or inserting a chest drain. This is the most useful part for me, as I can just grab jobs off of this list and do them, meaning I am helping the team out, while learning myself.

One of the most useful things I was trying to practice this week was referrals to other specialities. This is where a patient needs a more specialist opinion for a complex disease, and you try and persuade a specialist to come and see them. As a regular reader might know, I have had bad experiences in referring to specialists before (like this), so I thought it would be a good idea to get used to how to do it. Different specialists want different information; a cardiologist will want to know about previous heart attacks or angina, and cardiac risk factors (like smoking, family history of heart disease, high cholesterol etc) while an endocrinologist might quiz you on the exact insulin regime the patient has, how closely they stick to it, and their blood glucose highs and lows. Being prepared for what they ask you is very important, as they won't hang around if you need to pop off and ask the patient! This week I referred patients to the dermatologists (one for a very interesting rash that looked vasculitic (is it lupus!?)) and I took a patient over to vascular surgery myself to try and squeeze him into the radiographer's  list of vascular imaging, where they use an ultrasound machine to view the vessels in the legs, and try and work out what the blood flow is like. This sort of negotiation should be really useful come next year when I need to get patients treated and out of hospital as quickly as possible. By taking this patient to the radiographer myself (rather than leaving him to a hospital porter, who may take ages to get there) and negotiating slotting him in between two patients I got him the imaging a day earlier, meaning he could be seen by the vascular surgeons a day earlier, and out of hospital a day earlier (just a bed for a day is about £400 according to the department of health). 

A typical looking vasculitic rash

 As well as trying to do my part to save the NHS money, I also got to participate in draining fluid out of several abdomens due to liver disease. This involved sticking a needle and syringe into the belly to suck out fluid to analyse, and while exciting for me, may not be the sort of thing that people really want to read about!