God's balls

Hi,

Wow, it has been a long time since I last posted. This job is quite busy, but isn't busy enough to give me an excuse. I suppose I have just been distracted by other things going on in life.

I am on paediatric surgery at the moment, which is a big change to anything I have done before. I was pretty scared when I came into this rotation as I didn't have any paediatric experience previously, and it has taken me a little time to get my head around things. On surgery I am the only F2/SHO and there is usually a registrar and consultant on at the same time. As with most surgical specialities, they spend much of their time in theatre so I am left on the ward trying to work out what to do with my patients. Fortunately at the start of the rotation the general paeds team, who share the paediatric hospital with us, were very helpful. Sadly in the last month or so, due to politics which is well above my paygrade, they have been distancing themselves from my team so I have had to make do much of the time, but fortunately are still around in case one of my patients is genuinely ill. I am getting to spend some time in theatre as well, though, which is quite interesting, but I don't think surgery is the profession for me. The initial cutting is exciting but then all the searching around and stitching up layers is not!

The reason for coming to post today was an absurd situation I found myself in, and I felt I should share it. A 9 year old patient had come in yesterday with an acutely painful testicle. We were worried that this was testicular torsion - a surgical emergency which results from, surprisingly, your testicles getting in a twist. His mother was not keen on him having the surgery and it took about an hour and a half to persuade her that this was necessary. The surgery was performed overnight and found a torted hydatid - a little extra bit on the testicle which is the remains of the female reproductive organs (from when the boy was a foetus). This has no known function and is not important, and doesn't need surgery if it is diagnosed before the operation. The problem is, having a twisted testicle is an emergency and you don't want to faff about trying to work out which one it is with ultrasounds and the like if you are unsure - leaving the testicle twisted for too long will result in it dying permanently. In fact there is a surgical 'saying' - ""Testicular pain - don't engage brain"

The next day, the child was well and happy to go home, but the mum was not happy. I had been left to review this child, as the consultant and registrar had gone to theatre for a different case. The mum was upset that we had operated on the child and found nothing wrong, and upset that we had removed the dead hydatid of Morgagni which had been causing the pain. The reasons for this were that she knew that there was no problem with her child's testicle (hence why she was initially refusing the operation) because she was very religious, and she knew that God wouldn't want to harm her baby; she was upset that we had carried out the operation as she felt that God had been testing her faith and she had failed, showing she didn't trust in him to provide for her; and she was upset that we had removed the dead twisted tissue (why did God put it there if it has no use).

A picture found from the internet of an ultrasound of someone's testicle with the face of the Egyptian god of male virility in it

First, I was glad that the consultant was not around, as I would probably not hear the last of  him being compared to God in 'providing' for this woman. I wasn't too sure how to address her concerns though. I tried to explain that bad things did happen to kids (a point helped by being in the middle of a ward full of sick and disabled children); I tried to point out that perhaps the presence of the hospital was a way for God to provide for this woman in her time of need; and tried to convince her that we had no known function for this tissue, and its removal shouldn't affect her son in any way. She was not amused by my attempts at explaining things and kept trying to drag me into a theological argument. All of this was watched by the husband who was clearly on 'my' or the medical establishments side with regards to the need for the operation, but not keen on speaking up. I feel a lot of the passionate arguments the mum was giving were more for his benefit than mine. I am not a religious person by any means and was trying to keep things civil, but it took me an hour and a half to escape.

An hour and a half!

I was called back twice for questions about wound management by the nurses, which just turned out to be more theological arguments over why God wouldn't want to hurt this boy, and how he must have a special plan for the hydatid of Morgagni, if only we would wait and see. I felt that these recalls were likely due to the husband arguing things with the wife, so she would bring me back and argue them with me. Not ideal given we have about 20 other patients in the hospital at the moment to look after. The third time the nurses called me telling me she just had a couple more questions before she left, I asked them to tell her that I would happily come down if she promised not to talk about God anymore, and if she had any more questions of this nature then perhaps she should take them up with the hospital chaplaincy service. Unsurprisingly, she changed her mind and decided that she didn't need to speak to me any more. I will have to go back tomorrow and ask the nurse if they had to call the chaplain as an emergency to explain the reasoning behind an omnipresent, omnipotent, omniscient, benevolent God.

Illness

Hi,


A late post, yet again, but I have been ill so perhaps that goes some way towards an excuse... This was my second (and last) week of paediatrics, so I spent time on the wards and ended up catching an infection from one of the ill little kids... The main thing of interest that happened this week (apart from the really important medical student getting ill) was a fantastic piece of clinical detective work which came from one of the doctors on the ward; something House MD would have been proud of.

Me being ill isn't really blog-worthy, so I will brush over it. There are a lot of sick children in paediatrics, especially babies with bronchiolitis around this time of year. I think one infected me with a virus (perhaps RSV, who knows) and I had to take the last day and half off last week with general coryzal symptoms, generalised myalgia and headache... Or man-flu... whichever you think fits best. I am feeling a lot better now, though.

It is a terrible disease... Honest...

Back on track, I spent most of the week when I was in hospital in a variety of different ward rounds and clinics with the nasty children which then went to make me ill. The best part was during a handover, when all of the patients are discussed between the day and night team, to make sure everyone knows what is happening with each patient at that moment in time. One of the patients, lets call him Billy, had been in the ward for the last few weeks, and was receiving chemotherapy for a rare type of cancer that had started in his tummy, but spread out across his body. The subsequent scans had suggested that this treatment was being very effective in controlling the cancer, and it was all shrinking, but overnight the night team had noticed that one of his pupils had become fixed and dilated (a blown pupil).

Blown pupil seen here in the patient's left eye

This raised a lot of worries, most importantly the worry that the cancer had spread to the brain, and was growing there, affecting the nerves coming out of the brain by pressing on them and creating this symptom. The night team had arranged a whole host of brain scans and investigations to be carried out this day to find out what was happening. One of the paediatric consultants, who always dresses pretty shambolically and behaves a little like a crazed professor started asking the night team questions

"Is the patient on hyoscine for the chemotherapy?"

Yes he is, they answered, he has a patch on at the moment

"Where is this patch, is it on his neck perchance?"

Why yes, its on the left of his neck, a bit above the clavicle"

"Well that is the answer, then. Hyoscine is an antimuscarinic, and the drug is passing through the skin into the blood vessels which then feed into the eye, dilating the pupil. Change the position of the patch."

And hey-presto, the patch position was changed to the other side of the neck, and the eye slowly went back to normal. A lot of stress for Billy and his parents avoided, and a lot of expensive (and radiation-filled) scans avoided. A simple diagnosis made without any fancy hospital tests, just a brain. That is the way medicine should be done!

To wrap up, the boy who was hallucinating snakes was discharged this week, with no medical cause found for these sightings. This is good, as it means he hadn't accidentally eaten some illegal/legal drugs, and he didn't have a brain tumour, but it did leave a question mark over the diagnosis. The children's psychiatric team were involved, who decided he seemed he may be slightly on the autistic spectrum (and wanted to follow him up), but they were not sure where these hallucinations came from either. The final decision was it must have been a nightmare which had started this off, and the psychological trauma which this nightmare (i suppose about snakes) had caused had lead to these hallucinations. This has been documented before. Not a perfect answer like I was hoping for, but it is the best we could get... A little like the finale of lost.

Hallucinating snakes

Hi,


A change of rotation again today, and onto paediatrics. The best part of this is the fact that I only need to be in at 9AM every day, meaning I get at least an hour of lie in extra compared to the last four months. Obviously this is not the only positive part of the change, and there are a lot of other lovely things around this change. Changing team is a shame, as the F1 I was with was lovely, though this hospital's paediatricians are also very nice. There are no F1s (first year junior doctors) on this hospital's paediatric wards, so this week I spend all of my time spread between a couple of different consultants and the doctors on their teams. Following consultants around is a little different to what I have been doing before, where I have been following around the most junior members of the medical team. This means I get less hands-on experience of what to do next year, but it does lead to a lot more teaching opportunities! 

The team I am with for the next two weeks (yes, that is all my rotation is, a measly two weeks) is really lovely, and I quickly felt settled in and at home. I suppose you would expect paediatricians to be caring, lovely people, if they wanted to look after children, but by the same logic you would hope that all doctors would be very helpful, as they have all chosen a caring profession! The consultants seem very keen on teaching, and the more junior members (who are all still a good few years post-graduation) are very happy to let us get involved, clerking children in when they are admitted to the hospital and doing as much as possible on the ward.

Each day starts with a morning meeting, which is why it cannot start earlier than 9. All of the patients who are in the hospital are discussed between the doctors, and treatment plans decided for each one. There are two main sections to the paediatric work, one dealing with the babies, I.e. those who have just been born or those who were born pre-term, and the other dealing with babies, children and adolescents with any problems that come after birth.

I split my time between the two sections this week, spending some time with the newborn babies doing baby checks. A great chance for me to practice this, which would make a good examination come finals, though it does open you up to be showered in wee by little baby boys... Less said about that the better. 

The other section involves ward rounds, diagnosis and treatment, much like any other medical ward, but in children. There is a large range of patients in the ward, from children being treated for cancer, to the omnipresent respiratory tract infection from RSV. This RSV infection seems to lead to most of the admissions, and plenty of sick wheezy babies. There is little that the hospital can do, and it is mostly supportive care while they get better themselves. 

My favourite patient on the ward at the moment is a 12 year old boy who, two days ago, started seeing hallucinations of snakes everywhere. I realise that my title sounds as though there are snakes hallucinating, but this is not the case (and I am not sure how you would be able to tell if it were). It was this boy who just started seeing snakes wherever he looked for no apparent reason. He has been in for a few days, and refuses to wear clothes as he is convinced there are snakes in them. As he is naked all the time, he has to stay in his room, but otherwise seems very lucid and collected. I had easy conversations with him, and we put jigsaws together and so on without any problems. He seems completely well, other than being able to point out these snakes he can see all the time. There always seem to be one or two present in a room at any time. He has had full toxicology screens for any drugs or substances he may have accidentally eaten, but everything is negative. There is no discernible cause for these hallucinations, though they are obviously very upsetting to him. At a loss of what to do, a referral has been made to the child psychiatrists to see what they think. I will keep you updated next week!

Catchup

Hi,

Ok, there is some need for some serious catchup, just for the purpose of continuity, before I promise to start my weekly blogging routine this weekend. Bear with me, so I can get into this.

Over the few months up to Christmas I have been on a reproductive rotation and a paediatric rotation. These were the first full time rotations I have been on in my medical training, and as such it would be best to start from these.

On the Reproductive rotation, I spent time doing Gynaecology and Obstetrics. This is quite a specialised subject, and this can be seen as a good or bad thing for one to start on. For one thing, it means there are (relativity) few complaints that a patient can have, meaning forming diagnoses and knowledge is less of an issue at a medical student level. When there are around 5 common Gynae diagnoses, it means you will know something about each one, and can take a good guess at which a patient is presenting with. There are obviously a lot more, much rarer, conditions, but as a 3rd year medical student these are less important. On a down side, if you are not considering Gynae as a career then perhaps the Gynae rotation is of less interest and use. I suppose its always useful being able to diagnose conditions and be aware of the Gynae differentials.

Anyway - In my time in Gynae I learnt to perform basic examinations, take a smear, take a Gynae centred history, learnt about the common Gynae complaints and got to assist in my first surgeries. The first surgery I assisted in was a hysterectomy for a large fibroid growth. This is basically a benign tumour in the uterus, and the patient was happy for the whole uterus to be removed so that it wouldn't grow back. The patient was friendly, easy to talk to and personable. I scrubbed in and got to assist in the operation, and then even more so when the assisting doctor got bleeped away. While it felt like a lot to me, I suppose I wasn't really doing much: Holding things, cutting thread with scissors, passing things to the surgeon and such. The surgery team works beautifully. Like a well oiled machine. There is often little talk in the theatre (other than occasional banter or music playing in the background) with the assisting doctor or theatre nurses passing things to the surgeon or assisting when they see that they are needed. While surgery does not appeal to me as a career (lacks a large element of the 'puzzle solving') this must be something fantastic to be the centre of. Anyway, the patient got better fast, and I saw her improve quickly in a few visits over the couple of days before she was discharged. Success! At least I didn't kill her.

Well I suppose I cannot talk about loads of cases in this 'summery' but needless to say the Gynae team were really nice and friendly, and provided the patients with first rate care. The only problem I saw was when I went to work with a surgeon, but the surgery list had been cancelled for the day. The patients and surgeon had not been told and all were very annoyed. Unfortunately the operations could not happen as there were not spare theatres, and they could not be carried out in the afternoon as the surgeon had a clinic of about 30 people to see then. The patients had been starved, bought into hospital and worried for no reason and the surgeon had wasted his time. Annoyance at the management came from this - an error in communication was the diagnosis.

We were taught to carry out intimate examinations by professionals trained to act as patients and teach us to perform them on themselves. An odd experience, but much much better than the fabled olden days of students practising such things on unconsented patients under anaesthesia!

The obstetrics rotation was very hands on. I got to assist in births and saw births from normal deliveries to water births to forceps aided deliveries to a C-section of twins.

I cannot say how amazing seeing a birth was, or how privileged I felt being accepted by all of the mums-to-be. Childbirth can be a scary time, and having them allow me to help out, under experienced supervision of course, was very generous. Fortunately all of the babies I saw were completely 'normal' and while some of the mums had problems with the delivery none of the babies were adversely affected. I saw one mum suffer from a Postpartum haemorrhage (PPH) which is where the uterus does not contract properly after the birth and all of the blood which would normally be supplying the baby (a lot) is not cut off as it should be and so pours out. A very scary time for me (and much more so for the mum and dad) as everyone was running around sorting things out and treating. I didn't know what to do with myself, so hid in a corner and noted down everything that happened for the notes. An important job, honest! Fortunately this, while not common, is a side effect that is well expected and drugs exist to make the uterus contract. Everything turned out fine!

I saw another very touching case, but it was somewhat unique, so I will not put it on here in case it in any way breaks confidentiality. Perhaps I can combine it with another some time later. Who knows.

In the obstetrics rotation, time was also spent in other smaller units, such as the Early Pregnancy Clinic, where women with problems during the pregnancy, such as bleeding, came to have a scan and bloods taken to see if they have miscarried or if their babies are fine. Very sad.

On the paediatric rotation I spent time trailing after doctors in hospitals, sitting in outpatient clinics and I also spent some time in the community, seeing children in nurseries and the such.

When in the hospital much of my time was spent observing. This was a shame, as I enjoy being hands on, but I suppose that children need the highest level of care and don't want to be scared by me. I heard that there was a clown that went around the hospital keeping the children amused. Unfortunatly I never got so see this, but wonder as to how much of a good idea this is - I am sure that if you have coulrophobia and are in a hospital this would be the last thing you would want to see. I did get to take a lot of histories from children in the assessment unit, while the doctors were busy elsewhere and present the patients back to the doctors. Hopefully saving the doctors time and getting the patients treated faster. Hopefully. When I was with a registrar we also got bleeped down to A&E for a child who was having real trouble breathing. Follow the ABC's and the child was put on oxygen. A suspected diagnosis of croup later and some inhaled steroids and the child was playing around on the floor. That's one good thing about children's hospitals, full of bright colours and toys!

Anyway - this sort of quick recovery really pulls me towards wanting to work in A&E. Making that sort of difference so quickly is really appealing, feeling like you are changing peoples lives every day is amazing. Well - keeping my options open but I will keep my eye on emergency medicine!

Time spent in outpatients involved seeing patients either before admission, or who needed to be seen by a specialist and had been referred by another professional, such as a GP. I did least here, mainly watching consultations. With a high volume of patients and little time common it meant there wasn't time for me to take a history and report it to the Dr, but I still got to learn about plenty of things from 'observing'. Saw some sad cases of abuse or suspected abuse, though, which I suppose is just something you have to get used to. Sitting in on clinics from general surgery to a clinic for premature babies who have lung problems due to being on a ventilator for so long gave a good variety and depth to the learning. Paeds is far broader than Gynae- and I think it is breadth that I am looking for in a medical career. Variety is the spice of life, after all! Who knows - early days, and I am not sure I have the patience to deal with children day in day out - too much bribery. I have a lot of respect for the patience needed to be a paediatrician!

In the community we saw children in clinic-like settings and visited nurseries. In the nursery I spent time with children with disabilities such as aspergers. What can I say? My course requires me to go and play games with children as a way to learn. I love my course.

Anyway, This post is very long, and pretty basic missing out a lot of the learning and interesting things that happened over those months, but its only a basic catch up. Sorry for the poor blogging style - it can only get better (though don't expect much any time soon - time limitations)!

I will be back at the weekend to talk about this last week.

Don't forget to smile.