Fading away?

Hi,

Sadly my blog posts are becoming so irregular I doubt people check in to look for them anymore! I am still alive and doing well, finishing my first year of speciality A&E training in a few weeks, but I feel I should explain why I barely post anymore.

There are two main reasons, the first is time - I am very busy with work and all the things I want to do trying to have a life outside of work (which is a constant struggle!). I have also been doing my membership examination which are needed to become an A&E registrar. This comes in three parts, I have passed the first part and am sitting the second in a couple of months! Sadly revision is also time consuming.

The other reason I have been very tardy with updating my blog is over worries as to what it can be used for. I started it as a way to vent my feelings and frustrations, back when I was in 3rd year of medical school, and back then it was weekly. It was initially aimed at showing what medical school was like for prospective medical students, and aimed at keeping up the hopes of 1st and 2nd year medical students, keeping them looking forward to the clinical years (which were much more fun). As I progressed it basically ended up documenting my journey through, which will hopefully be helpful for people to look through if they are interested. However, this documentation also comes with risk. 

I initially started blogging anonymously to avoid breaching patient confidentiality, and to enable me to say what I thought without feeling people were going to judge me for it. However, I am very much aware that being online isn't totally anonymous and it is not too difficult to find out who someone actually is, unless they make a real concerted effort to stop that from happening (which I haven't). There have been a number of cases in the media which have been concerning. For example, a doctors own reflective pieces in their portfolio (which are mandatory to progress to the next year) being used against them in court. It is hugely important for medical professionals (and anyone) to reflect on their mistakes and feelings, but this sets a worrying precedent. Worrying for me as I have definitely talked about (or reflected) on things in this blog which do not make me look good. Another case in the media was that of Christian Solomonides who was taken in front of the GMC and suspended for some of the things he wrote on twitter. He did not use his name on twitter, but was easy to track down (he used his initials...) Much of the stuff he said on there was very offensive, but as someone who also works in A&E I can see why he feels so exacerbated with some of the people who come into hospital. I also feel worried that I have also ranted about staff and patients (though more politely) and question whether this is a GMC-type offence. I guess I also worry that if I share some of my more ridiculous stories this is the sort of thing that this blog has the potential of turning into.

I have thought about trying to tone things down, make things more anonymous or shorter, but I don't really think these things deal with my core concerns about blogging as a junior doctor (especially given the current political climate and press hunger to turn on doctors, some of whom own £500,000 houses, and go skiing for holiday). This is a huge shame, as my last 6 months working on acute medicine have been crazy. There is a mismatched classic 'medical old-school' team with some real 'characters' in it,  and the whole job revolves around a crazy book where all the patients details are stored. Given the old-school nature of the consultants there is no chance of this book being upgraded to something a little more digital. Given the fact that all patient information for the whole medical team is in this one tatty book, with no copies, this book is treated as though it is The One Ring. The bearer is all powerful, with people coming from far and wide to look at their wonderful book, and woe betide you if you accidentally lose it in Mount Doom.

I could talk about some of the ridiculous things which have happened over the last 6 months, but given the above, sadly I do not know if it is wise. I will keep the blog online as hopefully the posts from 3 years of medical school and 3 years of junior doctor-ing to date will be useful, and will keep it periodically updated with my progress if anyone is interested. I will keep my eye on how doctors and blogs/new media is dealt with, and perhaps come back properly if the winds are blowing in the right direction.

12 days of Christmas in the ED

Working in A&E brings plenty of different experiences, here is a selection of true stories from the 12 days run up to Christmas.


On the first day of Christmas, the ED gave to me: a cockroach infestation in resus bay 3

On the second day of Christmas, the ED gave to me: a patient with a baseball bat to the face, and the chance to assist in a lateral canthotomy

On the third day of Christmas, the ED gave to me, a psychotic gentleman after losing a loved one in hospital , the questionable choice to bring the body to A&E due to a flooded morgue to help the patient come to terms, and the dire mistake and consequences of bringing the wrong body up to the ED.

On the fourth day of Christmas, the ED gave to me, many giggling nurses, several confusing PA calls, my name changed on the computer system to 'Bieber', and in inability to change it back until three

On the fifth day of Christmas, the ED gave to me: A patient who had been hit by a bike, a swollen and painful hand, an X-ray showing a dislocated trapezium bone, a referral to a surgeon who wasn't sure what the trapezium bone was, and the feeling that the MRCS must be pretty crappy. 

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I am now, as you can tell, struggling, to keep fitting my recent experiences into this ridiculous format, and will just list the rest. This was a terrible idea to try and do this!
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On the sixth day of Christmas, a patient presented having electrocuted himself with an iron, wearing a T-shirt emblazoned with 'what doesn't kill you makes you stronger'. The irony was lost on him. Perhaps he was going to turn into a superhero, with a super power of resisting the power of resisting literary techniques.

The seventh day of Christmas was not a good shift. I was called a 'dirty fingering heterosexual' by a furious patient, a very anxious man presented who thought he had cyanide poisoning from eating a bag of apricot seeds from a health food shop and refused to leave, and a patient snuck into the A&E toilet and cut her wrists, barricading herself inside.

The eighth day of Christmas started of promisingly with the ambulance service bringing in a patient coded as 'shooting/stabbing/penetrating wound', exciting the department to prepare for a trauma call, until it turned out it was a man who had dropped a kitchen knife on his foot.

On the ninth day of Christmas, a patient with dementia was bought in due to pneumonia. We were transferring them from the ambulance trolley onto one of the A&E beds, when the patient started taking a poo. The carer, who had come in from the nursing home, shouted 'catch it' and the nurse managed to grab the stick of stool mid-air out if instinct. With her bare hands. Merry Christmas...

The tenth day of Christmas was more positive, with a patient telling me they had named the pulmonary embolism they had developed after surgery 'Jeremy Hunt' as it was a "potentially fatal clot" and a drag queen attended with mallet finger after getting their fingers stuck together while gluing on their eyelashes.

They eleventh day of Christmas was a day of detective work.  A child presented having eaten berries from the garden of an unknown origin, but the mum had bought in the leaves from the plant (if only I had a botany degree as well, but good ol' google has the answers as always if you look hard enough). There was also the interesting conundrum of a patient presenting in acute alcohol withdrawal which can be very dangerous and even fatal unless the patient continues drinking, but with the added problem that she had been given a bail condition that she couldn't drink any alcohol, due to an assault, and if she did she would go back to prison. 

The twelfth day of Christmas started well, with plenty of gifts to the department of tasty food from the local Jewish ambulance service (Hatzola) and Muslim communities (interestingly we had many more gifts from groups that were not Christian), but then was ruined when I mistook the medical consultant for a patient who had come in with solvent abuse induced hallucinations, and told her that she needed to pull her act together and that we were not going to give her the glue back that we had confiscated... I am going to have to keep my head down until the New Year!

Procedures and nights

Hi,

Sorry for the poor rate of posting - I have been very busy but that is always my excuse. I am now in a training post as an emergency medicine trainee. The hours are pretty rubbish, and I am working every weekend this month, but I love the job. I get to see a complete range of diseases and people every day and get to do a lot of different things.

I am on nights this weekend, but over the last week and this weekend I have seen people ranging from a 45 year old woman with vaginal bleeding 4 weeks following her last period (quickly diagnosed as her next period and discharged) to people in cardiac arrest and with severe burns and explosion injuries following bonfire night mishaps. 

I really like the procedural side of A&E, and the chance to get away from the constant push to see and discharge people before they 'breach' the 4 hour wait and sit in a room for 20 minutes and do some suturing or put a joint or broken bone back in place. Yesterday night (or this morning more accurately) someone came in with eye pain for 3 days following angle grinding some metal without eye protection. I am not an expert with the equipment needed to examine eyes (called the slit lamp, and often seen at opticians) but I could see a small piece of metal just over the iris (similar to the picture below)

Metal piece in eye, picture taken from Opthobook.com

I have not taken things out of the eye before, but remember being taught how to back at medical school. The registrar on had also not done this procedure before and was caught up with a sick person which we couldn't get venous access on, and was trying to gain access with the ultrasound machine. I thought I would have a gentle try and if failed, would have to get the person to come back to see the specialist tomorrow. I bent the end of a needle and managed to use that to get the metal out of the eye. Very rewarding, but nerve-racking, poking the end of a long needle towards someone's eye and repeatedly telling them they have to hold very still!!

I also had a patient last night/this morning who had abdominal pain and a large mass at the lower part which felt like it could be the bladder. I have not had any ultrasound training but am always in awe of the more senior A&E doctors who can rock up with the ultrasound probe and diagnose heart failure, PE, pneumothorax and so on in seconds at the bedside. I thought I would have a go with the ultrasound (no radiation, nothing to loose) to see if I could see if this was the bladder.We normally have a special machine called the bladder scanner to measure for bladder volume but our department's one broke 6 weeks ago and is still apparently being repaired... Positioning the probe over the bottom of the abdomen I could see the large circular bladder, and using the measuring tools on the USS it was massive. We put in a catheter and 1 1/2 litres drained out. Although this is a very simple thing, it was very rewarding to be able to work out how to do something, make a diagnosis and be able to make a clinical difference to that patient.

I also managed to do a special nerve block to the femoral nerve for a lovely 90+ year old lady with a hip fracture last night/this morning as well! 

As you can see I have been doing loads with my shifts, and feel like I am learning lots of new useful skills. Sadly I have one of my professional exams coming up and having sunk over £300 into it I now need to spend much of my free time revising, as it is coming up next month! It seems there is no rest for the wicked.

Finally, I really hope that as junior doctors we do not need to strike, and the BMA and the government manage to re-enter negotiations, but given all of the poisonous rhetoric being put out but Jeremy Hunt, and the hatchet jobs appearing in news papers (most recently today in the Mail on Sunday) I think that it may well come to that. This is a huge shame, but a small price for us as a country and profession to pay for continuing the good work that the NHS can provide and preventing the destruction of the NHS and many doctor's lives.

Time out

Hi, 


I know it has been a very long time since my last post - (months!) but I have been mulling over this GMC situation I mentioned in my last post. I have decided that instead of posting long detailed posts as I have been before I will just post a little story of bit of information that I have been thinking about without background, adding to the anonymous person-and-situation-changing that happens already. I don't want to stop writing things down...

That being said, finding time for writing things down is tough! When I last posted I had just finished my F1 and was starting a rotation in A&E as an F2. I now just completed the 4 month rotation in A&E and am working as a GP now for the next four months. 

A&E was amazing. The breadth of different conditions, learning different skills, and all the crazy reasons for people coming in was great. I looked forward to going into work each day, and perversely, while all the nights and weekends were a bit rubbish, having time off during the week was really nice. Lots of very sick people, exciting trauma situations, people with odd things in odd places and so on. I am now applying for A&E speciality training and have my interview soon. Hoping that this goes well!

Despite all of the 4 hour target pressure and the news about A&E being swamped (it is) I think I am finding my new rotation on GP more stressful. In A&E there is great banter with the other staff, always people to ask to help out, and the sense you are all in it together. In GP I am stuck in my own room, trying to see people every 15 minutes who usually have little wrong with them, but occasionally can be very complex. Trying to pick the complex ill patients from the rest is difficult without any investigations, and trying to manage time to see each patient in about 10 mins (leaving time to do paperwork, referrals, etc) is very difficult. The simple patients who have colds and want antibiotics should be able to be seen in 3-4 minutes, but usually take 10-20 due to all the arguing over the fact that they want drugs. They patient who is suicidal and depressed cannot be condensed down to 10 minutes, and makes everything run late. At least in A&E if you need to spend more time with a sick patient or difficult case you can, in GP it is a real struggle. As you get more experienced working as a GP I am sure this gets easier, but is still a crazy idea.

I think most of the difficulties with being a GP isn't around making complex diagnoses or performing complicated procedures (though there is a lot of scope for these), but it is mainly around communication with patients. I thought I was good at communicating - had dozens of lectures on it at medical school and 'practice' it plenty with friends/at the pub/all the time but this can be a real struggle! 

Either way - I am now applying for A&E, hoping that this crisis in UK hospitals gets better (some good comments on the problems places like this) and now on GP which is much less relaxing than I hoped!

Final week as a medical student

Hi,

I would like to apologise for this post being really late, I wrote it over a week ago, then pressed save rather than publish, and went on holiday. The holiday was lovely, but I realise that I need to actually press the right button!

Despite having found out I had passed my finals almost 2 months ago, I have been working as a medical student in the hospital, getting ready for the job of 'doctor' come August. The idea still makes me feel excited and/or scared. However, the gruelling life of a medical student has come to an end for me. This was the last week I am going to spend in hospital as a medical student, and was topped off with my graduation ball. This week I introduced myself as a medical student for the very last time, I did my last referral as a medical student (where, ironically, I got a grumpy doctor who refused to talk to medical students as it was 'inappropriate') and signed myself off as "Internal Optimist, Medical Student" at the bottom of the notes for the last ever time. It is so exciting to think that, after a months holiday, I will be writing "Dr Internal Optimist, GMC *******" at the bottom of the notes instead. 6 years of hard work, not including all of the school work and preparation before university, have gone into this end point. 

But I am not really sure how to feel.

The ending has been a bit spread out; I was really happy to finish my finals, and overjoyed to have passed them, but then I have been working as a medical student for the last 1-2 months. I haven't really had any real 'you are finished forever' moment, which is arguably a good thing. I am so glad after each 'hurdle' that I manage to make it over, I am not sure I would be able to handle all of it at once. Although I will never be introducing myself as a medical student again, I still have one 'hurdle' left - graduation. After graduation, when I have that certificate in my hand, I will feel as though it is well and truly over. It will probably be quite an emotional day, not just for me, but for most of my year.

So I am slightly confused about how to feel at the moment. I am very relieved that I have made it despite friends who were just as able as me dropping out of the course throughout the last 6 years. I am really happy to have made my main 'life goal' over the last 7 years or so. Most of the last 7 years have been aimed at getting into and passing this course, then getting a good set of rotations afterwards, all of which I have managed to achieve. 

But I still feel a bit uneasy. Perhaps it is a sense of 'what now' - having such a long term goal fulfilled leaves me wondering what I should be aiming at now. Perhaps it is the fear of working as a doctor next year; a job where patients put a huge amount of trust in you, and where a simple mistake can have disastrous consequences.

Don't get me wrong though, I really am happy to finish this course and graduate, it is just there is a slight grey lining to my radiant silver cloud. After graduation, I think the only way that I am going to feel more relaxed about this is by starting work in August, and proving to myself that I can do this job. After all, I have spent 6 years preparing for it, I should be ready by now!

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!

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!