Faking death

Hi,

Another slightly late post, but hey, I am kinda busy... :) This was my last week on my elderly/stroke medicine ward, before changing rotation. We have some fun with an alcoholic who wants us to provide him with special brew in A&E, a 'cardiac arrest' which turns out to be a patient who is holding her breath (...seriously), along with the slightly less serious but much more taxing challenge of how to give a drug called movicol to a patient who is only allowed to drink thickened liquids.

To start with, though, has anyone else read the House Of God? This is a somewhat cynical take on hospital life in the 70s, based around a intern's first year working in the hospital, often described as the 'Catch 22' of medical books. Well, I would definitely recommend it, very funny. I mention this because the 4 weeks I have spent on this stroke unit seem to be getting closer and closer to the world painted by the book. In the book, medicine is not about treating people and getting them better, so they can leave, it is much more about 'Turfing' them to another speciality or a nursing home (as chronically sick people rarely get 'better'). Working in stroke medicine, a lot of the patients on the ward are not expected to make a full recovery so a lot of the work the doctors do seems to be based around trying to get them into nursing homes or other less acute hospitals for rehabilitation. Unfortunately these homes and hospitals don't really want more patients to try and look for, being busy enough already, and try and avoid taking the patients, making it difficult to get rid of them. You can try and transfer more annoying and long term patients to other wards if you find other problems with them. For example, the lovely "BUGGER" lady who is still around is getting a little bit on everyone's nerves. If she were to catch a severe pneumonia from the hospital, then the ward staff would be able to transfer her to the respiratory ward. Fortunately it has not yet come to the tips offered by the 'House Of God' which include putting a patient's bed up very high, so when they fall off they break a hip and you can 'Turf' them to orthopaedics...

For anyone who has read the book.

Moving onto what I got up to this week, the introduction is a good summary of the bast parts. A man was admitted to A&E for a possible stroke, which was why I went down with the registrar to see if he could be thrombolysed. He had a severe weakness all down one side of his body, and could barely walk. After examining him, it was decided that he needed an urgent CT scan. The man was not happy about this, and told us he couldn't wait in the hospital as he really needed some beer. We could obviously not prescribe beer for him (though perhaps we should be able to...) so he started trying to hobble out of the hospital with his one good side. We stopped him, and put him back to bed while he muttered about his special brew, and went off to sort out an urgent CT scan for him. By the time we got back to his bed, he had disappeared and run away from the hospital under the guise of going to the toilet. If we could prescribe alcohol we could stop addicts from running away, and actually give them the care they need. Not sure it would work well in practice though, as I can imagine a lot of patients (and doctors) might take advantage of this... Interestingly enough, you can prescribe alcohol to patients (or children) who drink antifreeze, as it is an antidote... Perhaps useful knowledge to store for an excuse...

While we were in A&E, there was a cardiac arrest call, which involved all the acute teams bleeps screeching at them, and lots of rushing to the bedside of the patient to SAVE A LIFE! I went too, to see what was happening, and was greeted by a rather embarrassed looking junior doctor and a red faced patient. It turned out that the patient had  (for some reason) decided to hold her breath to see what happened, and the doctor had panicked and decided that she had died... You would think that these sort of things only happened in scrubs...

I did spend some time on my ward this week as well, spending a lot of it with the nurses to try and get some of my clinical skills signed off. Carrying out procedures went fine. The main problem was when we were trying to give movicol to a stroke patient. Movicol is a treatment for constipation, and works by keeping water in the poo in the bowel, making it runnier and easier to pass. Stroke patients who have problems swallowing cannot drink watery things, as there is a risk that the water can get into the lungs and cause an aspiration pneumonia, so there are thickeners that can be put in water, tea, and all other food stuffs to make them thicker and easier to swallow. Movicol comes in a sachet, and is meant to be mixed with water before drinking. It turns out that this osmotic effect of movicol cancels out the thickener effect in the water, and heaping thickener into a glass of water makes no difference as it stays watery, meaning the patient cannot take the drug. Feeling cunning, I suggested that we mixed it into the patients porridge, meaning he could eat it this way. Unfortunately the movicol turned the porridge into water as well. After many failed experiments with different food stuffs, my answer was to ask the doctor to prescribe a different laxative. Who knew that the nurses job could be so scientific!

Mad house

Hi,

The elderly medicine/stroke rotation madness continues as more crazy-seeming people are bought in. As I spend more time on the ward, I get more useful and thus actually get less of the things 'I' want done, done; and I get to enjoy free drug company lunches three days of the 5 weekdays!

So drug company lunches... Often meetings in the hospital are sponsored by a drugs company, who put up a little billboard outside the room where something to do with the hospital is being discussed. This may be a teaching session for junior doctors, or a management meeting. In response for putting this board up, and perhaps giving a little talk about their drug as people leave, they put on sandwiches for everyone who turns up (or in one case this week, a yummy hot meal). This is fantastic for Mr 6th-year-medical-student over here, living on the bread line (well, not quite), and doctors love them as well. Who doesn't like free food! I am not too sure how ethical they are, though. Drugs companies shouldn't be trying to 'curry' favour [see what I did there] from doctors with gifts of food, which mean the doctors spend the NHS money on more expensive/different drugs. All choices should be made using evidence as to which are the best to use! I would have thought that these boards and minute-or-two speeches wouldn't make much difference, but if they didn't, then why would drug companies pay the money for the lunches. They must do. I guess drugs companies will argue that they are just using these sessions for 'education', and informing doctors of the most up-to-date and effective drugs (as well as the most expensive, I would imagine). Oh well, definitely not something for me to wonder about too much. As a student the free lunch is something to look forward to!

Perhaps not quite this bad, but I am always sceptical with companies wanting to turn a profit getting involved in the NHS and healthcare

As I said before, it seems that the more I learn about the job of a junior doctor, the more useful I become and the less I get what I need to do. As a medical student what I really need to be doing is seeing as many patients as possible, getting used to signs and symptoms, and performing procedures such as putting in a cannula or taking blood. I have sign offs for these sort of things, which I have to have finished before I can graduate. Unfortunately, these are not the sort of things that the ward really needs doing, as the nurses can do most of the practical tasks. Instead, what really does need to be done is an absurd amount of paperwork for bloods, investigations  discharges, basically anything you can think of. I am spending most of my time being helpful, which is much appreciated, by helping fill all this in. Unfortunately its not too useful for my 'education' - though it does give me a good taster of what work is like as a Junior Doctor (a bit boring :P). Next week I am going to try and be a little more selfish and do what I want need to do. If anyone has time to do these things with me!

So, back onto the patients who have been admitted this week. Due (in part) to me being super productive [obviously other people are involved, such as physiotherapists, and speech therapists and so on] lots of people got discharged this week, meaning lots of new patients have been admitted to fill their places. Some of these were new admissions needing beds, and others were patients that other wards didn't really want, so somehow managed to get them transferred to one of our empty beds. A very sneaky practice indeed! We have a couple of lovely patients on the ward who don't believe me that they are in hospital. One things he is in an aeroplane, and insists that he is flying whenever you talk with him. These conversations are fantastic, and he really sticks to his guns. I asked him if he drove, and he told me that he didn't need to, as he had an aeroplane. The other is a lady who thinks she is on holiday rather than in a hospital. I haven't tried to correct her, as I think she is pretty lucky to think she is on holiday, She is loving it, and all of the free food that gets bought to her! Unfortunately these 'funny' pathologies are a result of a stroke and parts of the brain dying. Hopefully they will begin to gain more function, though I am not sure how realistic this is. People cannot be sent home on their own if they cannot look after themselves, so if they don't improve they will have to go to a nursing/residential home, or have a large care package for the home.

Other patients include a Spanish lady who has forgotten most of her Spanish and can only speak in English (very interesting) and a man whose symptoms of a stroke were the world 'melting' around him, like a nightmare world. He can still talk, understand, and make sense of things, but still has the sense that everything around him (and everyone) is 'melting'. Very disconcerting. 

Would your world meting around you give you a nostalgia trip?

The final patient who we got from another ward is a lovely little old lady who sits cutely in her chair at the end of the ward, and yells BUGGER at anyone who walks past. I have no idea what she has got, as I can barely have a conversation with her. A colourful character none the less though. Perhaps she has dementia and severe disinhibition? Very similar to one of the patients one of my friends saw in the acute medical unit this week. She had gone in to take an ABG and he told her that he had better get it first time, or he would spank her 'as he loved spanking little girls'...
We were not sure if he was ill or just a bit of a pervert...

Sitcom?

Hi,

This has been a crazily hectic week, with my ward seeming more like the set of a sitcom than a hospital. We have had a psychotic patient setting off fire alarms, angry grannies stealing other's zimmer frames and pushing the users to the ground, the 85 year old man who starts each day with 40 press-ups (even after his stroke) and many more. As if this cast wasn't enough to fill up my week, I have also had a busy week for learning, certifying my first death after one of our patients died, learning about the complexities of the social service and trying to get patients out of hospital, and even impressing a VIP with my diagnostic skills!

OK, so quite a good spread of things to talk about, but I will try and keep things short and sweet. Looking back on some of my blog posts, they do tend to ramble a bit, and have some 'flight-of-ideas' elements. Don't section me yet!

The ward I am on has a lovely community feel to it. Because many of the patients are there for a month or two, they get to know one another, and each others families really well. This makes the morning ward rounds, and the jobs afterwards really nice to do, as they will be chatting away with one another, and able to tell you how the patients who are unwell have been doing overnight. 'Jobs' involve all the things that need to be done each day for each patient. These actions are usually decided by the consultant who leads the ward round, and then left to the junior doctors (and medical student!) to sort out over the day, so the results can be presented to the consultant the next day. These can range from taking and monitoring blood results, to organising complex scans and calling nursing homes and relatives to get the patient out of hospital. 

When a new patient comes along, they seem to bring their own personality into this ward environment (assuming they are concious), adding to the friendly atmosphere. The elderly man who does his push-ups at 6.30 every morning who I mentioned before is one example of this, as is the older women who goes around stealing other people's walking apparatus as they are using it. My favourite is the anxious man who has an old tracheotomy which is still healing, and an ulcer just below. For some reason, he has been given 'larvae therapy' (maggots) to help clean this ulcer out, but he is petrified that these maggots will climb down his tracheotomy hole and into his lungs. He seems to be living in constant fear of his lungs filling with maggots (it really doesn't sound nice!). Some patients are more adorable than others, but each brings their own personality to the ward, and adding to that 'zany' sitcom feel. 

Unfortunately there was some trouble with the patient who last week was involved in the shouting match with the grieving relatives while he was having hallucinations. We were having some trouble discharging him, as his wife and family had turned off their phones so we couldn't get hold of them. When we finally did, they admitted that they didn't want him at home, so were trying to keep him in hospital for as long as possible. Before we managed to get him discharged, he managed to set off the fire alarms in this wing of the hospital and escape in the following commotion. Early this week we finally discharged him, only for his family to bring him into A&E a couple of days later as he was 'insufferable'. I am not sure that this is a medical condition, but despite this he headed right for our ward, saying we were friendly, and kept trying to get in to get into one of our beds. He had clearly forgotten me getting him in trouble with the grieving family, and he tried getting into the ward for most of a day before he left. We haven't seen him yet. I hope the family get the help they need, but trying to stick him in hospital really isn't the right thing to do!

A number of the patient's in the ward are nigh on un-dischargeable at the moment, because of their GP situation. Both of these patients had a stroke some time ago, and are now medically pretty well. They both need some rehabilitation to help them learn to cope at home, but there is no reason for them to be in an expensive hospital bed. Sadly, we cannot get rid of them. One of them moved here from Poland 15 years ago, and despite being a GP resident still hasn't signed up for a GP. The other one was recently kicked out of his house by his "scumbag ex-wife" and is now living in a shed behind a pub. His GP is now in a different county to his address. It seems that both of these people will not be accepted into some sort of rehabilitation programme by the community because of these reasons. The man without a GP cannot really leave hospital until he has this rehabilitation, but cannot have this rehabilitation until he has a GP, it seems a little catch 22. The other man will not be accepted by either counties community workers, one because his home address isn't there, the other because his GP isn't there. It seems that a lot of these complaints are delaying tactics, used to delay the need to take patients on. It seems pretty silly to me, as a hospital bed is much more expensive than having someone cared for in the community, but everything seems to be political...

I have a couple of fantastic 'on-calls' this week, which I spend shadowing the junior doctors. learning about their job (which I will have to do next year!) and helping out where I can. I start of learning that chlorpromazine is a fantastic cure for hiccups, but from then on, things seem to get more cynical. The junior doctors are discussing their pay and the hours that they have to work, and things do seem somewhat unfair. They are upset that they have to work a lot longer than their contracted hours to give the care that patients need, but are only paid for the basic hours. Both of the juniors I am spending the evening with are seriously considering changing careers away from medicine. Its a big shame, as they are both lovely people. I am not really sure what needs to be done to keep people happier in the cash-strapped NHS, but I suppose that is why I am not going into politics! 

Towards the end of the on-call, the junior doctor is bleeped to certify a patient dead. As this is something I haven't really encountered before, she gets me to go into the room and do all the relevant examinations to show that they are dead (things like testing the reflex of their pupils, and listening for their heart for one minute). Certainly a good learning point, but very strange, as you need to be in this room for a good 5 minutes to perform all these tests. The both of us in a side room with a corpse was a little creepy, but I can imagine that when on your own, at 2AM, having to walk into rooms with dead people in them, look into their eyes and sit with them listening for sounds of life for minutes could be very strange.  Definitely not something I am looking forward to!

Hopefully not, but you do hear of it happening...

To finish on a more positive note that that morbid image, I can tell you about my great success of this week. I was at an event put on by a group who gave me some funding for my medical elective this weekend, and there were quite a few important rich people there. I was circulating around and chatting away, answering all the usual 'medical student' questions, when one man asked me if I could diagnose a condition that he had. Its pretty common for people to ask me if I can diagnose things, and its even more common for me to have no idea what the answer is, but I said I would give it a go. He told me how he had tooth pain and went to the dentist, who diagnosed him and took out a molar. The pain continued, so he went to the dentist, who took out another tooth. I interrupted him here, and told him that it sounded a little like trigeminal neuralgia. He was incredibly impressed, telling me that he had 4 teeth removed before he was referred to a neurologist, who then managed to make this same diagnosis. I didn't tell him that this was a pretty 'barn door' presentation that we are taught about in medical school - with people sometimes coming to the doctor having had all of their teeth removed, to find out what is causing the pain. Perhaps I should have asked this rich gentleman for a job, given the moaning of the junior doctors I have spent this week with, or even better, charged him £100s for a 'consultation fee'! 

The trigeminal nerve causes trigeminal neuralgia, meant to be one of the most painful things a human can experience! 

The final lap

Hi,

I am back, for my final year, and for some more posts. In the olympic spirit, this is now the final lap of my Farah race, certainly not a Bolt sprint! I had a nice summer holiday away from Uni, and I hope you lot did too! I will try to be a little bit better at posting this year, it seems I will be sepnding a lot more time in the hospital (more like my third year) and a lot less time on coursework. This can only be a good thing, as I really do enjoy going into the hospital (and I hate coursework with a passion!). All my exams from last year were passed, which is nice, and all that stands in the way of me and my Dr-ness is this year. Lets go!

For the next 8 weeks I am on a rotation in a small hospital, far far away. It is so far far away from my ‘home’ hospital that we are given accommodation, which is pretty funky. I currently sleep in an NHS bed, with hospital sheets and an NHS towel. Its as though you get to bring the hospital home with you (!) The hospital itself is very long, thin, and short. It seems to have been decided that building along is a lot more fun than building up, which means it is about ½ a mile long (I have been told this figure by many doctors since starting) which means you have huge long corridors ahead of you whenever you change departments, and it takes ages going places. I think tower-like hospitals seem a lot more efficient. Anyway, this long, yet small, hospital is my home for the next 8 weeks, where I am doing an elderly medicine and a general medicine rotation.

I am starting on an elderly medicine rotation, and am definitely thrown in at the deep end. My department deals predominantly with strokes, and employs a lot fewer doctors than it should, so it is always very busy. Despite this shortage of doctors (or perhaps because of it) there has been between 1 and 3 of the four doctors on the ward each day. I have been very busy trying to help out on the ward, and have ended up in the ward for over 12 hours most days. I suppose its preparing me to sell my social life for the junior doctor years!

The two doctors who I spent most of my time with are very good though. One F1, one CT1 (three years after graduating), they let me get very involved and over this week I go on call, where I see lots of problems and realise that being ‘on call’ seems to mean answering your bleep constantly and never having any time to see the mounting patient list, I get to look after patients in A&E when the come in, and I manage to get into a shouting match with a psychotic patient and a grieving family. At the moment, it seems that the smaller the hospital, the more you get to do and the more involved you get to be!

So, moving onto what I got up to this week, I spent most of my time following around the F1 or the CT1 and doing the jobs that they don’t really want to do, or don’t have time for. This does involve a phenomenal amount of paperwork, from blood requests to ‘TTOs’ (papers which let a patient be discharged from hospital) I definitely don’t look forward the paper-work-swamp that is a junior doctor’s life.

While I was helping my team out in A&E, I was asked to call a patient’s daughter to find out what had happened to him. He was pretty confused, and all the paramedics had been told was that he had had a fall at home. Falls in older people is pretty common, and comes with a barrage of tests such as 24 hour ECGs and head CTs to find the cause, and to make sure there is no injury. While he was being put through these, I called the daughter and found out that he hadn’t actually fallen, but had just felt unsteady and sat down. He was slightly demented, so we couldn’t get a good history from him, but this had been mistaken for new confusion, which had sparked the worry that he had hit his head, which was why the head CT was needed. Just a simple call could have saved all of these pointless investigations. I would love to say that I helped out by making that call, but it was too late, and he had already had many of the investigations anyway. Perhaps if I see someone like that again, I will make sure to get a proper history first!

I spent an evening-night on call with an F1, which involves holding a bleeper and covering all the wards in the hospital, meaning if they have any problems which need a doctor, they can bleep you and you are expected to go there and help them out. We were contacted about a whole range of things in the night, from patients falling over going to the toilet, to weird fits and strange ECGs; from massive prescribing errors made by the junior doctor normally on the ward (80mg Clexane twice a day in a little old lady, leading to an INR of over 5 as ‘DVT prophylaxis’) to disturbed levels of potassium in the blood. It seemed that half the patients in the hospital seemed to have suddenly developed problems with their potassium levels! The problem was that with all of these problems coming in thick and fast from the length of this ½ mile long hospital, there was no real time to go and see the patients, so this list got longer and longer and longer!

I spent some time on the ward as well, trying to help out the smooth running by talking with patients and family. It feels as though I would be a lot more use if I could, I don’t know, help a patient wash or go to the toilet, but I am not trained so cannot do that. I am stuck as a pretty useless medical student trying to help out however I can. One patient did present who I could distract at the end of this week, and this is what happened.

The patient was having alcohol withdrawal-based hallucinations on the ward, and behaving psychotically, interfering with the other patients, trying to take out their drips and so on. I decided that this was something that the medical student could have a go at helping at, and persuaded her to come to the ‘day room’ with me to watch a little TV. Here I should explain that the day room is a room off the ward with some comfy sofas (and a TV) where relatives can go to get away from the ward and have some time alone. Given the fact that this is an elderly/ stroke ward, there are a lot of sad looking relatives around, and I wasn’t surprised to see three people sitting in there in silence. I politely asked if we could sit down and turn the TV on, to which they answered “Suppose so”. Not the most positive of replies, but it certainly wasn’t a rejection, so I went ahead and turned the TV on as the hallucinating/crazy patient sat down. Almost straight away, the three people who were there before started shouting at the hallucinating patient and me, complaining about how insensitive we were, how their father had just died and they wanted some quiet time, and how we were ruining it. This was clearly not enough, so to add to the problem, the hallucinating patient started shrieking about how he was not right, and needed to be reset and wanted to be normal. I managed to get him out of the door as he was warbling “Reset me! Reset me! Reset me!” which put us right back into the middle of the ward where we were getting some very disapproving looks. An older nurse sharply told him to “put a sock in it” which lead to him standing stock still, refusing to move or interact, in the middle of the ward for the next hour or two. I went back to apologise to the family (their father had died 5 minutes ago, and I wasn’t aware that this had happened, though I knew that we had a couple of patients on the Liverpool Care Pathway), and while I made my apology grovelling and pitiful, it does feel a little unfair that they told me that they were happy with the TV going on before changing their minds. It would have been easy for them to say they wanted a little quiet, but I guess that when people are grieving they can behave a little less normally, and we should be as understanding as possible. Finally the hallucinating patient ‘unfroze’ and started causing problems again trying to help the other patients go to the toilet, for some reason, but in the end there was no damage from my little fiasco…

Sorry for the wall of text and no pictures, but my NHS accomodation doesn't have internet at the moment, so struggling!

Toxic

Hi,


I play nurse, get chatted up by an 84 year old, talk with an overdose patient and have an elderly lady drink a bottle of alcohol gel this week!


A busy week, and my last week on the elderly rotation, a real shame I think. I have enjoyed spending time with the old patients, with all their oddnesses, quirks and wonderful stories, but I am moving off to psych next week, where I am sure I will see many more oddnesses. Anyway - I saw many patients who should be on my next rotation this week so perhaps I am well prepared.

Towards the start of the week I was on a ward round with a consultant and another medical student when we came to a ward with a patient who had fallen out of bed and onto the floor. He was an elderly gent, and could not get up. We helped him into a sitting position and called the nurses to hoist his sizeable mass back into the bed. He was very confused and kept trying to crawl out of bed. There were only 2 nurses on shift to cover the entire ward (15-20 beds) and one of these was a ward sister, who was meant to be filling in paperwork and ensuring the smooth running of the ward from an office. The other nurses were on their lunch break. Seeing as this gent needed constant watching this meant that the ward sister had to stand by his bed for the next 45 minutes keeping him from getting out again, and she wasn't able to get any work done. At the end of my ward round I went over to this bed and offered to give her some time to do her paperwork. I was done for the day anyway, and would only be relaxing at home. This gent turned out to be a real handful, unfortunately. He was exceedingly confused and tried to get out of his bed every minute or so. He ignored me if I asked him to stay there, and if I gently guided him back down the the mattress he would scratch and hit at me. This man had caught MRSA and was producing a lot of sputum which he managed to throw at, and smear all over me. Not nice. In conjunction to hitting me, scratching me and covering me in super-bug ridden bodily secretions this man managed to wet the bed 3 times whilst I was there, needing many bed changes. This wasn't such a problem, and seeing as he had been given a diuretic earlier it could be expected, it was just a shame he wouldn't give any warning. To top it all off, the poor man really didn't seem to enjoy wearing clothes and kept taking off his clothing and giving it to me. Throwing off his covers to reveal his naked glory to the whole ward, and complaining whenever the curtains were closed, it was a fight to maintain his dignity, let alone keep myself safe. Unfortunately I got left looking after this man for 3 hours until I managed to get relief, a little more time in hell than the 20 minutes I was promised. The main thing I learnt from this exercise is that nurses have a VERY hard job. I don't envy them at all. Patients can be hard work.

A lovely patient I got the chance to talk to was full of interesting stories from her older life. So many of the patients have a wealth of life experiences you just never seem to come across as a doctor, with the brief medical questions you ask. Ignoring all of these wonderful stories, this patient had gotten into a fight with her husband before coming into hospital and had managed to press the panic button on her personal alarm and ask for the police. The police had come around to her house and taken her late 80s husband to jail, and bought this lady into hospital to make sure that she was well. Being a lot better off than many of the patients on the ward, she seemed to be very bored a lot of the time as she was relatively well (some pneumonia signs were being checked out) but with no-one to talk to. After talking with her for some time she started asking me somewhat personal questions, such as 'Do you have a girlfriend' and 'How well do you get along'. This was followed after a while with a discussion as to whether I thought she was too old for me. After telling her that I was not free and at more than 4 times my age, perhaps she was a little too old, though no less lovely than anyone else I had met, she started to try and set me up with her granddaughter who was 'naturally blond' and about my age. What was I meant to say? Patients can be inappropriate.


You see a great wealth of things in hospital, and there is a large range of patients and doctors. This week we spent some time trying to communicate with a deaf patient and take a history from her using a large black marker pen and sheets of paper, so she could see what we were writing with her visual impairment. These sort of consultations take a lot more than 5 minutes.
There was a doctor this week who seemed obsessed with Sherlock Holmes (or House). Starting off by trying to deduce things about the surnames of the medical students, he got us following him around trying to diagnose patients without even talking to them. "Medicine is all about deduction". Interesting exercise, and a good doctor, though perhaps a little obsessive.
I saw a very anxious patient throughout this week. Every time I saw her she was sobbing and terrified that she was going to die. She kept telling us that bad things always happen to her, and she was afraid this was the end. She has had a lymphoma for some time but seemed to be otherwise medically (relatively) healthy. Despite this her attitude seemed to be having a negative effect on her health and she seemed to be deteriorating a lot faster than she was before. Emotions and feelings can be very important to the patient, all part of the 'placebo' effect.
A patient with Korsakoff's syndrome livened up the week. You get Korsakoff's when you are a chronic alcoholic and you quickly withdraw from your normal dose of booze, like the patient last week with the delirium tremens. This patient had started to suffer from Anterograde amnesia since admission to the hospital, meaning that he had had problems constructing memories since admission. Every day he would tell us that he was worse than when he came in, despite a marked improvement in his symptoms throughout the week. He just could not remember how he felt a week ago. An ex-CID policeman, he comes from a job with a known tendency for alcohol abuse. Once his wife had died, he ended up spending most of his time at home drinking. So many sad stories in elderly care. Patients can be upsetting.


When doing a general medical on call (not really part of the elderly rotation, but I was offered by a doctor to join them, and it sounded fun, so why not) I came across a lady who had overdosed on a drug called Clenbuterol (I thought it was called clenbutamol for a while. Drug names can be confusing!). A β_{2 agonist, this drug is very similar to Salbutamol, which asthmatics take in their inhalers. Usually used as a bronchodilator in horses by vets, this pill has become a popular drug for weight loss to buy on the internet. Overdosing on this drug had given this lady a marked tremor, but did not seem to be too dangerous with the amount she had taken. Talking with her about the overdose (she is young, in her early 20s) she tells us that she regretted it immediately after taking the drugs, so phoned someone to take her into hospital. Not having written a note, and not having planned it very well, this counts as a low risk attempt. These things have to be classified, and though it sounds harsh, this can be seen as more of a 'cry for help' rather than a definite suicide attempt. This is good for us, as it means we can get her a psych referral and help before she feels even worse and tries to do it again, perhaps with more conviction. The really dangerous overdoses are those who plan things out, write a goodbye note, don't tell anyone that they have overdosed, try and hide what they have done, or lock themselves in a room and do not regret trying to kill themselves. These people need very supportive care and a careful eye. Not that this patient didn't need support, but we could let her go back home without worrying too much about her. Patients can be suicidal.}

Final patient for this week, and final patient for my elderly rotation blog. This lady came in with pneumonia and, from her demeanour, seemed to be one of the classic 'bag ladies' who seem to wander the streets with no home and a supermarket trolley full of odds, ends and low quality alcohol. Not that anyone had any proof of this, and the patient was very confused and could not really tell us whether she owned a supermarket trolley, or fed pigeons in her spare time. Left on the ward in her bed, we came back to find an empty bottle of alcohol gel in her bed, and the patient sleeping soundly. We couldn't get out of her if she had drank this bottle, but we were sure not to put another at the foot of her bed in case it 'disappeared' like the last. After X-raying her chest, it seemed that her lungs had gotten a lot worse. Was the pneumonia not reacting to the antibiotics or had the lady inhaled half of the alcohol gel, which was now sitting in her lungs? A toxicology report of alcohol gel seemed to be pretty safe, apart from the high levels of alcohol! Some patients will do anything to try and get a fix. When I left the ward on friday the consultant was discussing with the X-ray team whether they would be able to do an X-ray of a bottle of alcohol gel to assess how radio-opaque it was. Patients can be sneaky.

Anyway, transferring over to a much slower psych rotation next week. It should be very interesting, what with all the amazing psychiatric disorders there can be, from the 'bog standard' schizophrenia to the weird and wonderful disorders such as Capgras delusion. I think I am going to miss the hustle and bustle of the hospital environment, though, with the fast bleeps going off calling doctors to nearby cardiac arrests and the urgency things can happen with. I think psych is a much slower, more laid back speciality because of the time it can take some of the drugs to work. Perhaps I will be proved wrong!

Alcohol

Hi,

Alcohol abuse, confused patients, growing up, shocking patients and a rectal exam this week!

'How much do you normally drink in a week.' 'How many cigarettes do you normally smoke in a day.' The questions we have to ask patients to assess how much they are harming their bodies. And these things do hurt people. Patients coughing up blood and in pain from lung cancer, or patients with the apparent cognitive function of a 4 year old from decades of heavy drinking. I'm not saying I don't have my vices, but the harm people can inflict on themselves with these everyday substances is shocking. I saw an elderly man throughout this week who has destroyed most of his brain with alcohol. He never knows where he is and is always wandering off around the ward to go to 'an anniversary' or 'a christening' or some other event he seems to have imagined. He doesn't seem to have any friends or family, and often behaves in an obnoxious and rude way (perhaps explaining the lack of friends). He falls over, hurts himself and stays in hospital longer. We cannot let him go home because he will just get lost or fall again, the reason he came in in the first place. All of this has been caused by his personal choice to drink.
Another patient I saw towards the end of this week was suffering from severe alcohol withdrawal, and had delirium tremens. This involves severe confusion and agitation, and can often be coupled with uncontrollable tremors in the arms and legs. Patients can sometimes get psychiatric symptoms such as paranoia or hallucinations. This patient was getting hallucinations of insects crawling over the table and bed, and flying in front of him. You could watch him propped up in his chair trying to pick insects out of the bare air with his fingers all day. Alcohol withdrawal is more common in elderly admissions into hospital than you might think, some older people consume a lot of alcohol. Stopping alcohol suddenly can send you into withdrawal. It is depressing trying to talk to someone who has been destroying themselves this way, finding they don't remember if they have any sons or daughters, or what their favourite food is. Patients can be self destructive.

Anyway, sorry to the morbid start, not a great cheery start to an 'optimistic' blog. How about a happier patient next? I was talking with a 90something year old lady about why she was in hospital. She had come in with confusion and a fall, two of the most common reasons for an elderly patient to be admitted to hospital. She was flat out denying that she was confused on admission, but had scored 2/10 on the AMT. The AMT is a scoring system where 10 simple questions are asked (such as the year, or to identify a pen) and the patient is scored. Most people would easily get 10, but it is used to quickly assess the patients confusion or cognitive impairment. At the time of the conversation I had with her, the patient was sharp, aware and easily scoring 10/10 on the test. How can you convince someone they were confused if they cannot remember? I couldn't work it out, and the lady was getting paranoid as to her 'real' reason to be in hospital so I changed topic onto general chat. I don't want her thinking we are 'conspiring against her' to keep her in hospital, I am sure the hospital would rather have the bed... It turned out that while she came into hospital without her hearing aids, her gardener picked them up from her house and bought them into hospital for her. What an amazing gentleman. Very kind of him, (he was 70something) looking out for his clients. It is simple things like that that make you see through some of the murk that is often portrayed as human nature and let you see that so many people do care, its just often done on a close and personal level, so you don't get to see it much of the time. This lady did say one off-the-wall thing though. She told me that her 'son had died, but he was an awkward child so it was for the best really'. Never expected to hear that from a mother talking about their own child! The patient was being completely serious as well. Patients can be shocking!

This week was exceedingly busy. Over the weekend around 60 elderly patients came into the hospital. Seeing as my consultant's firm was 'on take' this meant that they clerked and initially managed all of these patients. This is just how the hospital works, but it meant that on Monday, if it has been a busy weekend like this one, the morning post take ward round can go from 8.00AM (in the morning) to around 9.00PM (at night) or later - that is one long 'morning' ward round! Especially hard on the junior doctors who will then have to go and do all the 'jobs' from the ward round such as organising scans and tests. A very variable-time job depending on who turns up at the door! Patients can be numerous.

As all this happens, I am feeling more and more 'adult'. Only 20, as I went straight to medical school after doing my A levels. Working in the hospital I often get called 'Dr' or 'Sir' by the patients which is very strange, seeing as many of them are more than 4 times my age. Despite telling some patients I am not a doctor they still insist on calling me such. It feels kind of wrong, like I am lying to them.
When it was snowy I was walking back past a school on my way back from the hospital and some kids were the other side of the wall throwing snowballs at the people on the pavement who passed. I crossed over to the other side of the road to avoid them, while muttering away in my head about 'stupid brats'. WHEN DID THIS HAPPEN? I used to be the sort of person who would chuckle away and throw some snowballs back at them, after all - I would have been doing the same when I was at school! I don't want to grow up too fast. I am happy being mature when I need to be, and hopelessly immature when I want as well. It is a lot more fun. I will make sure to fight this unwanted extra-matureness and keep it under wraps for another good few years.

There are certain tests (like the AMT I mentioned before) which we do to measure the patients 'cognitive function'. This is very important in elderly medicine as its important to make sure patients can care for themselves when they are discharged, and it is useful to keep a track of how confused or demented they are. I was talking with a patient and aiming towards doing this test on her after having a chat. The patient kept telling me that she 'was not daft' and 'still had all those brains there'  which seemed about right, and while she was a little hazy when referring to things, she seemed capable of holding a sensible conversation. Once we started on the test (30 simple questions) things changed dramatically. She thought it was the year 2030, she thought she was over 150 years old and had a great array or other misguided perceptions. My favourite part of the conversation was when she identified a pen as 'a stethoscope' and when asked 'what is this, the thing you sleep on' when gesturing towards the bed, she told me firmly that it was East Sussex sitting in her hospital room. Sometimes the confused patients have become very used to living when confused, working ways to get about daily conversations and procedures, and this can easily 'trick' people into thinking they are normal. It always feels silly asking them these test questions as they are so simplistic, and many patients find them patronising. Patients can be crazy.

To end this week I did my first rectal examination on a patient on Friday. I was not expecting this - I was on a ward round with an SHO and another medical student. Because this ward round was lead by an SHO and not a consultant, this meant that we got a lot more opportunity to get involved in what was going on. The SHO had to take the histories and do the basic examinations, but could not write while doing that, so we scribed. If the SHO wanted to write we got the chance of taking the histories or doing the examinations. The last patient of the day had been suffering from rectal bleeding after admission to hospital and we did not know the cause. The SHO asked if we had done a rectal examination before, to which I replied no. "Then this is your big chance, go and get some gloves". I suppose we all need to learn sometime but this was a bit of a shock! I had only practiced once before on a plastic model with an interchangeable prostate some time last year. I suppose an anus is an anus, it cannot be that complicated. Anyway I will not go into details, no-one needs to hear that, but there was a pea sized haemorrhoid on the posterior wall which I found, which I was quite pleased about. The patient did not appreciate the examination, and disturbed the rest of the ward with his unappreciative vocal sounds,  but afterwards thanked me and it was all OK. I don't think all that many people would appreciate such an examination. Patients can be practice.

Strokes

Hi,
I saw a lot of strokes this week, as I am sure you can guess by the title. In fact this was a week of the rotation where I was meant to be on a 'stroke' rotation. Strokes can be very sad: Sometimes patients seem to make a complete or very good recovery, walking out of the hospital days later and other patients are confined to a mental prison. Either trapped in their paralysed bodies or stuck with a brain that will not do what they want it to do. Strokes cause a variety of problems that I'm sure you know of from the FAST campaigns currently on.

Part of stroke that these campaigns don't mention is the dysphasic effects it can cause. I find myself talking to patients who cannot understand what I am saying (receptive dysphasia) but have little problem speaking themselves or patients who can understand what I am saying to them but cannot get words out in the order they want, or use the correct words (expressive dysphasia). Some patients have what is called anomic dysphasia where they can have problems naming everyday objects. This latter dysphasia is common in many types of stroke, but can just occur on its own. This can be strange, talking to a patient relativity normally and then when you ask them to name something (such as a pen or a watch) they cannot. Sometimes they know what to do with the object, they just do not know the name. One elderly lady thought a comb was a phone and tried speaking into it. If it wasn't so terribly sad then this would be almost funny. All of these different effects a stroke has on the body can tell the doctor what is wrong with the patient, showing what area of the brain has been affected. Many of the mental disturbances remind me of "The Man Who Mistook His Wife For a Hat" - psychiatry is exceptionally interesting. Patients can seem crazy.



Anyway, I like writing about the patients I have met this week (maintaining privacy and retaining identifiable facts etc. of course), and as I have received no complaints that is what I will do!
I missed seeing a thrombolysis this week, unfortunately, due to a couple of very eager students rushing off when we were told only 2 of our group could go and watch. I suppose this means I should be a little more in-your-face and just go rather than asking people what they want to do. It was an emergency I suppose, having to run down to A&E, so no time for a nice chat. This is the sort of area of medicine that I find exciting, I should be getting stuck in there, not hanging back being polite! Either way, the half of the group that went didn't get to see it anyway as the patient did not fit the scoring system needed. Patients can be disappointingly well.

The worst off patient I saw this week had a GCS of 4, meaning they are just one step off of being dead. Severe brain injury is usually a score of 8 or below, so this is very bad. It was very sad watching a patient be ventilated, tubes running in from various machines and with no way to talk to them or contact them. You know they are going to die sometime soon. Perhaps it makes it easier to think of them as already dead. I didn't envy the consultant who had to go and talk to the family and tell them that there was nothing that could be done, and we just had to wait and see. Patients can die.

On a more upbeat note, there was an 80-something year old elderly man who I spent some time speaking to who was full of amazing stories. Biking until he got into an accident around 68 where he had a knee replacement due to the damage, the man had been hang-gliding last year in Turkey. When I am older I wish I could be like this! Positive attitude really helps most areas of medicine, and having a positive attitude after a stroke means all that effort can go into rehabilitation and making you better. This man didn't just want to lie there, he wanted to work out how to cope with the new weakness and problems he had, so he could carry on his active life. This man was home before the week was over. I always had a smile on my face after chatting with him! As well as you helping the patients, patients can help you as well.

One of the elderly ladies who had recovered almost fully from a stroke spent some time trying to persuade me to come to her house and take some un-puncturable bike tires that they no longer used. We had started off just having a nice chat because she looked lonely and had been put in a side room. Some patients like side rooms as they are a lot more private and away from the hustle and bustle of the ward, meaning you can get a (comparatively) good nights sleep. This lady was not keen on being in the side ward, as she wanted to see what was going on and talk to people, as she had not been badly affected by the stroke at all. After chatting with her for some time about her life it turned out she had been a keen cyclist up to a few years ago. Very impressive seeing as she had just hit her 90s! I chatted about cycling as well, having a bike myself and all that, and she started offering me these aforementioned tires. Made of squishy but solid rubber these sound great for avoiding punctures, if not a little solid if used on my racing bike. I was unsure what to say. I don't want to go around taking gifts off of poor old ladies, and I dont even know where to begin regarding the ethics of taking backhanders from patients. I just had to keep changing the subject whenever she tried offering them to me - very hard. In retrospect I think the best thing to do would have just to say no, but it seemed rude at the time...  It would have been better if she had stuck with buying chocolate for the nurses. Patients can be over-generous!

There is always the chance to make a difference in hospitals, whatever your role. Even as a lowly medical student, with what seems like next to no knowledge when a consultant starts quizzing you, can help people's days go a little easier. Perhaps being a medical student gives you that perfect bridge between doctors and patients. Doctors and Nurses are very busy, rushed off of their feet and overworked, but that is just the NHS. Medical students are busy, yes, but we can choose what we do with our time, from practising histories and examinations to trying to sneak chocolates from the nurses station.
I felt I had done something useful this week when I talked with a patient who had come in with a possible stroke, but the consultant decided it was more likely to be a seizure. On a busy ward round, all the consultant really had time to say was that it was much more likely to be a seizure than a stroke from the history. We had to organise an MRI to confirm this, and if they were right and it was a fit then the patient would not be able to drive for a year. This is a rule the DVLA imposes. I suppose sense, as having a seizure while behind the wheel of a car could easily cause an accident. The patient had also developed homonymous hemianopsia, a type of partial blindness which may stop her from driving as well. Unfortunately, driving is an integral part of many peoples lives, especially a 40 year old like this patient, with a busy work, social and family life. The patient looked stunned at this news, and all the round could do was move onto the next patient. With somewhere between 10 and 20 patients to see, treat and listen to in a morning, especially with the complex neurological tests that need to be carried out, and the slow slurred speech many patients suffer from, this is a struggle.
Fortunately, I had some time left at the end of the round before I had to go off to another ward. I thought it would be worthwhile going back to this lady and talking with her about what the doctor had said, and see if she had understood it. After chatting for nearly an hour she seemed a lot happier, but still shocked by the news. Much of the conversation was around how she could now cope and the lingering possibility that it could have 'just' been a stroke. I have never seen someone hoping that they had a stroke before! I have seen this state of hopeful denial plenty of times when I was working in obstetrics, where women would hope that all the doctors they had seen were still wrong and their baby would still be fine, despite having been told many times they had misscarried. It is always sad, but I suppose it fits in with the 5 stages of grief. I think its important to be honest in these sort of cases. When there is a possibility that the patient's hopes may be correct I think its best to be honest about the possibilities and keep it realistic. It isn't fair to foster false hope in someone, as while it may make them happier momentarily, someone is going to have to pick up the pieces afterwards. It was a lot easier to talk with her as she was in a side room. Most wards in this hospital are large rooms with 10-20 patients in them, and a curtain doesn't really offer conversational privacy. It is terrible, seeing someone's life turned upside down within a minute like this. The woman was very upset as she had recently started living a lot healthier and stopped smoking, eating bad food, had taken up exercising, the lot. I suppose sometimes life is just not fair. Its never too late to start living healthily though!
In the end when the MRI came back, it turned out that it was indeed a seizure, and she had to be put on sodium valproate to stop another occurring. I suppose sad things like this happen in hospitals all the time. Patients can often need support.

There was another much happier story about another patient I saw across the week. This elderly gentleman (around 80) had been in the ward for some time due to his extreme condition. He had a lot of expressive dysphasic symptoms and could hardly speak. When I started seeing him he could count up to 8 and name 2 colours. Over the week, I saw him starting off very depressed about his condition, and the failure to get his brain to do what he wanted to was clearly annoying him. As the week went on, with some intensive speech and language therapy from a trained specialist, I saw him slowly get better and become more aware of his condition. Stroke patients are often very depressed, but he worked through it and build on his communication. Often very smiley when I saw him he found it a lot easier to give thumbs up and smiles compared to words. When I last saw him at the end of this week he could name all of the normal objects on his bedside table, count up to twenty and attempt a (very basic) conversation. He understood absolutely everything that we said to him, however, as it was only the part of his brain that used words to speak that was damaged. I remember on the last day seeing him, we asked him to show us his teeth, which is part of a neuro exam that checks the facial muscles which let you smile. He must have been asked to do this dozens of times in hospital, as it a bog standard test, but he still lifted a piece of tissue paper in his hand and looked at us quizzically. We asked him again and he just looked at the tissue paper. What was going on? Had he started suffering from receptive dysphasia as well? It look us a little time to realise that the patient had taken out his false teeth and put them in the tissue paper which was in his hand. What an awesome man - joking around despite the severity of his surroundings! Never lose respect for your patients. Patients can be inspiring!

Anyway, I could go on about more patients I have seen and more of the stuff I have got up to, but I think this is plenty long enough for now. Saturday was a bit of a shame, as I had a hiccup in planning a medical elective for my 4th year. This elective involves picking any country and practising medicine there for a month or two. The selection is enormous. Do you go to the USA and work with NASA? Do you go to sub-Saharan Africa and work in a 10 bed hospital supplying an area the size of Wales? I chose the latter, and was planning on going to a meeting at the British Library. Unfortunately they did not tell me the time or location until the day of the meeting, about 15 minutes before it started. I didn't stand a chance of getting there in time. Hopefully I can go to another one. The hospital I am thinking of applying for has no running water or electricity, apart from for one hour a day on a generator to do operations. At night you have to help people give birth or care for people by gas lamp. Water is transported around in buckets. I know it doesn't sound like everyone's cup of tea, but this sounds like an amazing chance to make a difference and get some experience in a different setting. I will get some cheap medical text books off of Amazon and Ebay for the hospital, and hopefully build up a rucksack of medications to replenish the low supplies!

Anyway, enjoy your week, and I will be back next week. Remember FAST! If you get to hospital and treatment within 3 hours you are much more likely to get completely better!

Death

Hi,

Ok, so an attempt at a weekly blog. Good luck.

This first week has only had 2 days worth of clinical experience, what with supplementary lectures, snow, and the such, so don't go expecting too much!

After Christmas I was unsure what to expect in a clinical situation, but it was amazing coming back to the wards. Elderly medicine is completely different to the last rotations (though I am sure there are some who would argue it is very similar to Paeds due to the need for care and so on). The breadth of the material covered and knowledge required is broad again, due to the fact it is treating anyone over a certain age, whatever the condition (basically). Despite this there are still common presentations such as confusion, stroke, falls, heart failure which bring most of the patients into hospital. A little like Paeds in that respect, broad with common illnesses. But with a very different focus. OK, I suppose you might be right if you argued that they were similar. Anyway, I carried out a ward round where I met many patients with a range of illnesses and helped plan treatment or investigations to reach a diagnosis. One particular patient was very upset, telling us that the only thing she had to look forward to was heaven. She was in tears but couldn't be put on anti-depressants because she had very abnormal thyroid test results. It could be that this depression was being caused by the thyroid abnormalities. Even though this is sensible, it was still really sad seeing this poor lady so upset. I spent some time holding her hand and talking, though I am not sure how much went in, while the doctors wrote up the notes. I was writing up notes for many of the patients while a doctor examined them, and carried out some examinations of my own. A great learning experience. I also failed at taking blood for the first time. I have usually been very good at taking blood from patients in the previous rotations, and haven't missed a vein before. This time I had to use a syringe rather than a vacutainer method, as there were no vacutainers on the ward. And I missed the vein. I suppose you have to mess up sometimes, and as long as it doesn't kill someone that's a blessing. Patient was fine about it, he didn't care at all. Lovely man.

I spent some time at the mortuary as the F1 I was with had some death certificates to fill in. I learnt to fill in these forms(though the forms I filled in for her had to be redone, as it turns out I am not allowed to fill them in and her sign them). Learnt to examine a body posthumously for a pacemaker. I'm used to dead bodies now, though, after years of dissection, so no worries then. Still sad, reading through a patients notes working out the causes of death, seeing them decline and die. At least I get a job at the end where I get to fight against death. Not sure its a winning battle.
On another day I got to get stuck in with a consultant ward round. Pretty similar to other ward rounds, but the medical staff who may be grilling you are careful around the consultant who can grill them. I phoned up 'next of kin' to let them know their grandma was in hospital. Introducing yourself and saying you are from a hospital gives people a bit of a scare, but after assuring them I was not telling them that their grandma had died it was a good opportunity to take a social background history. The patient seemed a lot happier having well wishes passed on as well. Many of the patients I saw today were severely confused or suffering from other apparent psychiatric conditions. I spent some time with an elderly lady who was insistent on singing to us, as it was her preferred mode of conversation. She had decided as soon as she had seen me, along with about 5 other medical staff, that she had met me before and trusted me completely as we understood each other. I wasn't really sure what to say about this, but it let me talk with her and help a colleague carry out a MMSE (mini-mental state exam) to assess the function of her brain. Later on with this colleague we were taking the blood from another elderly lady. I was holding her hand and taking her mind off of things on one side, whilst my colleague was trying to find a vein to take blood from. With very few veins we decided to take from the hand, where there were some flimsy surface veins visible. Unfortunately there seemed to be some sort of rupture when taking the blood and the patch of skin over the vein started to swell up as blood seemed to drain into the skin around the vein. We used this as an easy source of blood for the tests (LFT, FBC and so on) which also helped us reduce the swelling. Unsure what to do with this patch of skin, we covered it with cotton wool and left. Checking with the doctor who was in charge of the patient, we are told that this is quite common in elderly patients, so we haven't done anything bad. Fortunate. I am sure that haemorrhaging an elderly lady is impolite in the least.
The only elderly man we saw as a patient this day was an ex-Olympic athlete. Fully cognisant and interactive, he seemed in a much better condition than most of the other patients we had seen today. Unfortunately on reviewing his X-ray it seems that he has got mesothelioma, likely to be from asbestos exposure, and has a very poor prognosis, with most of his right lung function gone. Just because the brain is happy and working, I suppose it doesn't mean that the body has to follow suit. The snow brings in a lot more elderly people, falls and pneumonias and the such. It also stops people from getting home, filing up wards and overflowing into any other available space that can be filled with a bed.
Death has been a large part of this week. Very different to paeds/obs/gynae where death is a rarity and usually avoidable, in elderly medicine death is ever present and ultimately unavoidable. Not that death is ultimately avoidable anywhere, it is just that most of the death is bunched up at the ends of peoples lives, in this speciality. Its not that patients don' get cured and go home. Of course they do, all the time, its just that there is a much higher death rate, and the knowledge that if you try and cure them they may end up back in hospital. Perhaps that gives a very different outlook for doctors who specialise in elderly care. I think it definitely requires a specific type of person.
That will do for this week, not a complete week and not a complete blog, very bitty but that is how my mind works I suppose. This and that.