Calamity week

Hi,


But of a calamity week this week (especially Monday) coupled with moving rotation, and house, has ended up with a very rushed weekend! 

It is sad to change rotation again, and I have been feeling nostalgic towards the end of the week. Not for any real reason, as I have only been here for 2 months, and on this rotation for 4 weeks, but just because I am a bit of nostalgic person I think... The start was a lot rockier, however, and I managed to mess up quite a few things in the hospital.

You know how you can sometimes have 'one of those' days, where nothing seems to go right? I was having one this Monday, after staying up too late doing my essay on Sunday. Usually in life, this can mean dribbling soup over your shirt, or 'loosing' you glasses on the top of your head (I've been there...) but in the hospital there is so much more to get wrong. 

Forgotten where your glasses are? Worst that can happen is you look a bit silly...

I started off by taking an ABG down to A&E (I had not done it, was merely being the courier) and somehow breaking the ABG machine. IT ran out of paper, then started refusing to accept a new role. You can still get it to display results on its little monitor, but no more print outs to take back to the ward. Not sure what to do, I told one of the nurses, who seemed equally confused, and left quickly... 

Deciding to stay away from machines, I went around the ward to talk to a few patients. One of them has a syringe driver slowly infusing GTN into their system to stop them from having a heart attack. It is bleeping in an annoying fashion, something they do when they think the line is blocked (usually means the patient has done something 'foolish' like bending their arm). You can usually just silence them and all is fine. This is clearly upsetting the patient and the rest of the ward, so I try and silence it but somehow press the wrong buttons and stop the infusion all together. GTN works to expand the vessels in the body, stopping them from getting blocked and keeping the heart supplied with a good flow of oxygen. Now I have stopped it. I tell the patient what I have done, and get a nurse right away to correct my mistake. The right things to do, but I shouldn't have ruined it in the first place!

I go for lunch. I need some coffee and time to wake up. I come back from lunch, and am asked by  doctor if I can do some blood cultures for them. This is a skill I need to sign off, so I agree, despite my dopey behaviour. I am really careful with the patient, and get the bloods without hurting the patient (any more than usual) - then stick myself with the needle... ouch! Needlesticks in hospitals are a lot more hassle than the pain, as this is a potential way to catch diseases (such as hepatitis B/C and HIV) so I have to spend the rest of the day in occupational health taking with them, having my bloods tested, and having the patient's bloods tested for these viruses. Pretty scary, though I was pretty sure she didn't have anything like this. After this, I decide to go home and stay home 'til tomorrow, incase I made something go really wrong.

I was wearing gloves at the time, which is meant to decrease risk of transmission as the glove removes some of the patient's blood. It didn't look like this, though - this doesn't seem to have hurt the person at all (and there was more blood...!)

Despite my murderous rampage on Monday, the ward staff are really nice to me  for the rest of the week (or perhaps this is because of my rampage, and they hope to stop it from happening again). The end of the week is sad, and I say goodbye to all of my favourite patients. My favourites are two men at the end of the ward who constantly perv over the nurses and crack jokes to each other. They have both smoked far too much, and are quite ill, though still jolly. During my goodbyes, one of them tells me that he is "A bachelor  Not a GAY bachelor  oh no. A Fun bachelor..." which explains his nefarious plans towards the nurses. The other one spends some time cracking kilt jokes with me, before asking me if I wanted to be recommended by him to join the masons. He divulges that a few of the doctors he has met are masons (secret signals  and all) but won't tell me which ones. He tells me he is highly ranked, but I decline politely. I have more than enough 'communication skills' to learn for medical school, let along learning a load of new secret ones!

Where to go!

Hi,


So, another busy week, though its all the things out of the hospital that are keeping me busy now! At the moment all of the final year medical students are filling in their 'FPAS' applications to decide where they want to be placed, hospital wise, next year on qualifying. There is also another essay due, but I think people want to hear about that about as much as I want to do it, so I won't say any more about that!

The foundation application process is all pretty scary, to be honest with you. It is all about applying to work. as a doctor... I definitely do not feel ready at all, I don't seem to know anything and I have been enjoying my irresponsible student bubble for the last... 6 years and I am not sure how ready I am to be the professional knowing-everything person. I suppose you cannot stop the march of life, but I am enjoying myself right now. Obviously it is not that I don't want to be a doctor, after working for 6 years for this, I definitely do! It is just more that I don't feel ready in the slightest for all the responsibility. Its probably just some wobbles, I hope it will pass!

For finding out which foundation schools to apply to, there are a couple of useful sites to use: thequackguide and quackguide - both made by the same group, one just new (and not fully working yet). These are really useful in summarising all the statistics on competition rate, how big they are and people have written their views on each one (though as they are all positive this doesn't help too much). This brings me to the next scary thing about this application - deciding where to go. You apply to regions, and get them based on your ranking, which is based on how good you are in your year, other academic things, and a very unacademic test called the SJT. The London ones tend to be most competitive. Once you get into your region you are re-ranked and choose jobs, with those highest ranked getting the jobs first on their list. Do you apply to a competitive region and perhaps have less choice over job? Or do you apply to a less competitive region, have first pick of jobs, then end up living in hull? Not too sure, but whichever region you work in, people tend to stay in. I am just a bit worried about choosing where to spend a lot of my life already - everything seems to happen so fast and I don't want to grow up yet - perhaps I need a few peter-pan years of life!

A vaguely related, though fantastic, flow chart to help medical students choose their careers

Then again, perhaps I am just being lazy. After all - I am writing this instead of doing my essay for tomorrow, which says a lot... Perhaps if I don't hand in my essay I can have another year of medical school! Or maybe not the best idea...

So, getting back to my week, its been quite exciting, though shadowed a little by those two previous things. Most weeks are pretty similar, we are expected to spend the days on the ward apart from when we have lectures from the F1s, which serves as our 'peer teaching'. These lectures are actually really useful as, as I have said before, F1s have a good idea on what we want (passing exams [though I am not too sure this is what I want at the moment!]) so the lectures are usually aimed at the right sort of level. When on the ward I spend a lot of time following around the F1/SHO/reg/consultant like a puppy and doing the rubbish tasks for them like paperwork, bloods, cannulas and so on. The bonus of being on a respiratory rotation is that we do loads of ABGs, and I am getting quite good at them now! I did go to an MDT (Multidisciplinary team) meeting, where a variety of healthcare professionals talked about patients with lung cancer, but it was really sad so I don't think I will go again! 

A patient on the ward did have a respiratory arrest this week, which was exciting, seeing all the emergency protocols, and it was good because she was sorted out (had a chat with her the next day). I think emergency medicine could be the career for me - just so exciting! I also bought in my radio for a patient who is mostly blind and has pancytopenia, meaning he has to be kept in an isolation room to stop him getting an infection. He was touched, and it made my day, though it had gone missing by the end of the week! I hope someone hasn't moved it to a different ward (or stolen it!). Its those little things that make it feel like I can actually make a difference  despite being a pretty useless member of the team as a medical student!

Anyway, I procrastinate enough - off to essay!

Bursting bladders

Hi,


A very busy week this week, and another short post. It seems the busier I am, the shorter the post as there is then more to do at the weekend. This week I see some strange things on call, I practice (and mess up) some procedures and I have a fantastic teaching success. 

While on call with my F1, I am asked to carry out a lumbar puncture by one of the doctors, as it will be a good 'learning experience' for me. I decline the offer, I don't think it is a good idea at all to have me sticking needles into people's spinal canals. I do watch it though, and the man it is being performed on has a snake tattooed up his back, the exact point where the needle needs to be put corresponding with the eye. It was strange, watching this needle be pushed into this tattoo's eye, as it looked on fearfully, and ended up with the snake 'crying' blood after the procedure. Very creepy... The on call was also full of other 'fun' experiences, such the man who was in urinary retention with a three way catheter in situ. Usually these catheters can be 'flushed'  to unblock them, but this catheter had been flushed multiple times by the nursing staff with nothing coming out, filling his bladder up ever more with the fluid.  His was well over a 1 1/2 litres on an ultrasound scan - a lot more than normal!!I wonder if its possible to burst from a huge bladder? [according to the guardian and BMJ, perhaps it is: Article here)

A strange, unrelated, bladder related advert

I have also been having a busy time on the ward, practising a lot of the minor procedures I will need to do as an F1. I have been doing a lot of ABGs, and inserting a lot of cannulas, and am now getting pretty good at putting cannulas in (I was pretty terrible last week) I managed to get an ABG on a woman with Parkinson's disease this week, which was a real challenge as her wrist was shaking all over the place. It wasn't all success, though, as later that day I tried inserting a cannula into a woman who had an INR of 8 (a measurement of blood clotting, and normally 1) which ended up with her bleeding all over her pillow and the bed. I did manage to get the cannula in, but had to ask the ward staff to change all the bed clothes as they were soaked. Very embarrassing, though fortunately she was very understanding and kind about it. When taking some of my blood results to the lab to be analysed, I have to wait outside in the public blood-testing area for my results. While waiting there, I decided to be a helpful little medical-student and asked a man, about my age, if I could help him - he looked a little lost... I got the po-faced reply "I am here to give a sperm sample, I'm not sure if I want your help"... Awkward times! I had to go and hide around the corner until he left...

A lovely patient was admitted to our ward this week, a man who was described by his son as 'normally really grumpy and cantankerous' but over the last few months had become increasingly more jovial and 'giggly'. He wasn't admitted to the ward for this, but for breathing difficulties. While it sounds lovely, someone enjoying their old age, this change of mood set alarm bells ringing in the consultant's head, and a CT scan of their brain showed a large number of brain metastases from a tumour elsewhere in the body. Getting cancer is a terrible thing, though if it makes you cheery and less bothered about it, I suppose it could be worse. It brings to mind the stories about people who almost die from drowning, who say in the last moments you lose all the worry and panic about it, and just relax and accept it. (for you medicine lovers out there, this is probably due to the hypoxia in the brain shutting down the areas which deal with this fear).

To finish of this week, I was at a bedside teaching session which was being run by one of the junior doctors. Here, they take a group of 2 or 3 students around 'interesting' patients in the hospital, where we perform an examination similar to how we would in our final exams, and present the findings. The idea is to improve our examination techniques, and to practice recognising common conditions. I was told to do a cardiovascular examination on my patient this week, the most important part being listening to the heart. I floundered a little, confused over why I couldn't really hear anything, but then remembered about the medical school myths of patients who have their hearts on the wrong sides of their bodies being bought in to flummox medical students in exams. I listened to the other side, and lo-and-behold, there was a nice beating heart sound! I didn't say anything, but let the other 2 in the group have a listen and went back to present it to the doctor. I presented it as a case of dextrocardia with a heart murmur  and was correct! Definitely a good feel-good factor to boost confidence! Hopefully that one won't mess with me if it comes up in the exams!
*geek out*

The heart in its normal postiion, and switched around in the inherited condition known as dextrocardia. I was so pleased I spotted this!

Johnny Depp?

Hi,


My first week on the new rotation, and I am now on a respiratory medicine firm. It was sad saying goodbye to my old rotation, and I made them a cake as a thank you for putting up with me for the last month. The new set of doctor's whose task it is to look after me seem nice, so hopefully this month will be just as good. I tend to spend most of my time with the junior doctors helping out on the ward, and don't come into too much contact with the consultants who tend to run things from their offices or do clinics, apart from a few days a week when they lead ward rounds. This is very different from previous years where we tend to be attached to consultants in hospitals and clinics. Perhaps this is intended to teach us the knowledge in the earlier years (consultants know a lot) then teach us how to work as junior doctors now. In my opinion, the younger doctors are much better teachers. They have a good idea about what we need to know to pass exams (what we are interested in now) and the correct level to teach things at. The junior doctors will teach about how to recognise pneumonia or a pneumothorax on a chest X-ray, while consultants tend to tell us about things such as CT guided biopsies and other procedures we wouldn't be doing unless we were a consultant. I am sure these things are a lot more interesting, but just much less relevant to us.

And medical students...

Anyway, complaining over, its been a busy week. The most interesting parts were a crazy on call night in the hospital with a 'celebrity appearance', and a number of controversial decisions based around the Liverpool care pathway.

The Liverpool care pathway (LCP) is a way of treating patients in the last days of their life. The decision to put someone on the LCP is not taken lightly, and only made when it seems that they are going to die in the next day or two. It is often used in the very end stage of chronic diseases such as cancer. One of the patients on the ward was very ill, and the decision was made by one of the registrars to put him on  the LCP. The man couldn't communicate, seemed to be mostly asleep all of the time, and could barely breath. The LCP involves 'supportive' care, meaning that they are given drugs to try and make them more comfortable, rather than treatments aimed at 'curing' them (as by this point a cure is impossible). it also means that the family expect the death, and can visit the patient at any time, rather than just in visiting hours. The next day, the patient seemed to have perked up a little and seemed a bit more restless. This day the consultant was doing his ward round and decided that it was inappropriate for the patient to be on the LCP as he seemed to well. I am told that sometimes patients can seem to perk up a little once put on the LCP, as stopping the regular medications and trying to treat their symptoms only can help. Either way, the consultant spent some time berating the registrar for putting the patient on the LCP, talking about how inappropriate it was, and finally making her cry. Certainly not appropriate behaviour, especially as he hadn't seen the patient the day before. The consultant then went and told the family that the LCP was being stopped, and the patient could be back on normal treatment. The next day, after the patient had been put back on his regular medications, he died. The family were clearly upset about this, and the death now looks unexpected as the patient wasn't on the LCP, meaning it should be looked into further. Despite all of this fallout, the consultant isn't anywhere to be seen, running clinics this day instead, and leaving the less senior staff to sort out the ward. Now, I don't mean to be consultant bashing at all, as they do fantastic work, but this is pretty poor practice.

On more positive note, the on call I did this week was crazy. There was loads going on, including a child who had a cardiac arrest from an asthma attack (but it all turned out well, with her being successfully resuscitated). The most exciting part was when the rumour circulated the doctors that Johnny Depp had been admitted into one of the wards. Excited, and dreaming of some sort of romantic encounter, the junior doctor I was attached to hurried to the ward with me in tow. This rumour had obviously spread quickly, as there seemed to be most of the hospital's night staff hurrying to the same place. On arriving, we found a plump middle aged man, inexplicably dressed as a pirate and confused about all the attention he was getting. A wicked rumour!

Hearts

Hi,

As far as interesting cases go, this week was dominated by meeting a man who had two functioning hearts. As well as meeting this very interesting case, I also got on with the normal life of a 3rd year medical student. I met someone who is a very famous musician, in a clinic for people suffering from syncope (faints) and I managed to get dragged into a cubicle half way through another medical student examining a patient, and thoroughly embarrassed on my lack of knowledge. I have also been enjoying the political atmosphere. I love a good debate, and it is always interesting seeing people who you know, but not enough to have had such discussions with before, reveal their political colours (such as all of your classmates). Its great seeing how peoples political views match up to what you might suspect of them. Do those who tend to wear Ralph Lauren polo shirts or YSL cuff links tend towards conservative? Its interesting to sit in a common room and listen to people discuss various aspects, and reactions to other's political views.
"Urgh, I cannot believe you are conservative, I always thought you were a nice person"
 or "Liberal Democrat? What are you doing in medschool, I thought there was an entrance requirement?"
Not always meant in jest, these 'debates' can get pretty ugly, but its a good opportunity to learn more about your friends and classmates.

I will go straight onto this patient who had two hearts, as I never knew this was possible until this week. This was not some form of congenital abnormality, meaning he was born with two hearts, rather he received a heart transplant about 20 years ago, but the old heart was not removed. The new heart was stuck into his chest on the right hand side, next to the old heart, and connected up so they could both function at once, giving him extra pumping volume. This kind of operation, known as a heterotopic heart transplant is rarely performed nowadays, with the main reasons for doing it being if the original heart is suspected to recover (foolish to remove a hear that will improve, just give it some time without the person dying); if the transplanted heart is too small to work properly in the transplantee (i.e. a small woman's heart transplanted into a large man); or if the transplantee's body is suffering from pulmonary hypertension, meaning the heart needs extra force to pump against the increased pressure. This sort of problem is usually surmounted by a heart and lungs transplant now, however, as this gets around the increased pressure int he lungs by giving a new set of lungs as well! I had a very informative talk with this interesting patient about how his life had been going and the problems he had had, but unfortunately I never got to examine him. Seeing him in a clinic, where he had come for a general check up, I felt it would be rude to ask him if I could auscultate or feel his chest to see what having two hearts sounded like. I think this was probably the right decision, as I am sure he gets a lot of attention from medics and students alike wherever he goes, but I regret it at the moment - I hope I see someone else with such a transplant to see! A very "Dr Who" like situation. The two hearts had a pace maker attached to both of them a little after inserting them to make sure that they beat at different times, to stop a large increase of pressure from a combined beat.
Next time I see a really interesting patient I will make sure that I say something and get a chance to examine!

I was wandering around in the A&E looking for some ambulance crew who didn't look too busy. I had heard that it was possible to go out in an ambulance for a day or two if you asked the right people, and this sounds really exciting, so I was trying to get a phone number off of someone who looked like they knew what they were doing. Whilst looking, I was suddenly approached by a small, hyperactive doctor who grabbed me by an arm, muttering something about an interesting case, and dragged me behind some curtains into a cubical where one of the other medical students was examining a patient. I was a bit lost and flustered, wondering what was going on, and then I was asked a series of rapid questions by the doctor about the patient, their condition, differentials, examination techniques and the such. This was a respiratory problem, and as of yet, i unfortunately do not know all that much respiratory medicine. Especially of this level, as I found out later that this patient had often been hired with his chronic condition for MRCP exams (very high level exams for 'proper' doctors). The other medical student there was on a respiratory rotation, compared to my gastro/cardiac experience thus far, and managed to get the majority of the questions right, whereas I fumbled almost all of them. It was pretty embarrassing, seeming so stupid in front of one of my fellow medical students, while he seemed to know so much more. It was especially unnerving to keep having to say "I don't know" to this excited doctor, who obviously loved teaching, who was pacing around telling me I would never pass my MRCP examination if I gave stupid answers like that! All in all a pretty embarrassing situation, but embarrassing enough to kick me into revision action. I will have to make sure I know more about the lungs then - I think I know plenty about guts and livers by now!

To finish off, I saw someone very famous this week in a syncope clinic. They had been fainting at inopportune times, and were afraid of it happening to them on stage. Another great thing about medicine. Everyone needs medical help, rich or poor, young or old (though mostly the old). Despite all of the lack of knowledge and embarrassment that seems to occur around me, this is a wonderful profession to get into - and I look forward to the day when I actually know something!

Halves

Hi,

A very busy week, leading to me not actually having time to write up this blog properly this Sunday, so very sorry for that. I hope this will do, I had a very busy weekend! I saw some very interesting neurological medical cases this week, which I want to mainly concentrate on, and went on a very polarised ward round around a cardiac unit, where half of the patients seemed to be chatty and fine, and the other half slipping down towards death... Odd having them all right next to one another.

This week seemed to be a week of neurological halves. As I am sure I have said before, neurology is a very interesting speciality, and can have some very unusual clinical presentations. I think I mentioned "The Man Who Mistook His Wife for a Hat" by Sacks before as a good example of some unusual clinical presentations. This week I met two patients who had 'split' neurological signs cutting the presentations in halves across the body because of the neurological pathology.


The first patient I saw was a woman who had suffered a stroke in her past, which had affected part of the thalamus. Most strokes lead to numbness, weakness or odd tingling sensations (paraesthesia) in the affected areas of the body. This stroke, due to its thalamic involvement, had instead lead to sensations of pain in one of the patient's arms and a burning sensation across one side of her back all of the time. This pain made the use of this one hand and arm almost impossible, because on contact with objects, the pain would make her draw her hand away sharply because it felt as though her fingers were being stabbed or burnt. She gave examples of being unable to open a can, or peel a banana because the pain made such operations impossible. The other hand was fine, but many tasks require two hands to carry out. On this background diagnosis of central post stroke pain, the patient had developed trigeminal neuralgia. This disease causes notoriously painful symptoms, and has been classed as among the more painful medical conditions. It involves the trigeminal nerve, one of the cranial nerves which supplies sensory nerve endings to the face. The disorder causes the face to become hyper-sensitised, with the slightest touch on the affected side causing excruciating pain. This can be as little as hair brushing against the face, and obviously has major impacts on the patients life and nutrition. The poor patient described curling up on the floor because of the pain she was in and crying whenever the face was touched, but the tears tracking down the side of her face made the pain worse. Fortunately, this had just been treated when we saw her, and it was no longer causing this pain. The diagnosis had taken some time, because the dentist had been telling her that she needed root canals, because of this pain, and she had been making repeated trips to the dentist to have a succession of teeth ''sorted out''. If anyone is interested, how to recognise trigeminal neuralgia over a dental problem is that the trigeminal neuralgia will cause the pain when the skin of the face is touched, whereas dental problems will be much less exacerbated by skin contact. This patient seemed to have been split in half by her symptoms, one side of her functioning normally and the other a well of pain.


The second patient I saw was 'split' horizontally rather than vertically. It was just one pathology which had caused this second patients split, he had a benign tumour growing around his cervical spine roots. This tumour had affected the nerve roots C4, C5. C6 leaving the spine to supply the arms, and the compression it caused had affected the movement and sensation in the legs. The interesting thing about this patient was that 'upper' motor signs are very different from 'lower' motor signs, and this patient displayed both at once. Upper motor neurone signs are usually seen in limbs where there is a problem with the central nervous system, whereas lower motor neuron signs are usually seen where there is a problem between the central nervous system and the affecting muscle / sensory nerves. Both have different clinical signs. Upper motor neurone problems cause 'brisk' (very responsive) reflexes and increased muscle tone due to the fact that they have damaged the signals from the brain which calm the muscle response. This means that the muscle is always a little contracted (hence the increased tone) and when a reflex is tested (for instance the knee jerk reflex) it is much more responsive than normal because the brain and spine are not damping it down as they normally would. This does make it very easy to find the sites to hit with the tendon hammer, however, as instead of the normal twitch of the muscle they give a good kick out. Lower motor signs give opposite signs, with decreased reflexes, tone and strength, because they muscles are getting less innervation from the supplying nerves. It is hard to explain so you will have to take my word for it!

Either way, he was a very interesting patient to examine because of all of these signs, and because of the complexity of a full neurological examination I took well over an hour with the procedure. He seemed to appreciate having someone to talk to and explain things to, so I didn't exactly rush things, but all of the effort that went into plotting the affected dermatomes by working out the affected muscle groups and sensory areas (see picture below) was unfortunately wasted in the presentation to the registrar. Normally pretty simple, just regurgitating facts and findings, I managed to get myself in a right tangle involving all of these 'Upper motor signs in the lower limbs' and 'Lower motor signs in the upper limbs' and the corresponding levels of increased and decreased tone/strength/reflexes/sensation. pretty embarrassing as it made it look as though I had no idea what I was talking about. While I rarely fully understand a neurological picture (I think it is one of the hardest specialities, but that's a personal opinion) I at least understood the simple basis which I have (poorly) tried explaining here. Oh well, I suppose I will be off of this rotation in a few weeks, and off to surgery, so I will not be around the reg who seems to think I am easily confused. I am obviously digressing, its not just medicine I find hard, just simple conversation now! I would love to blame being on call for hours, or dehydration, or any other external factors but I think I was just having 'one of those' moments.

The ward round I found myself on was, as I said before, very polarized. While only a small ward, there seemed to be either very well patients there, who were waiting for discharge or being observed, of very ill patients who were deteriorating daily and had DNR forms filled out beside their beds. One of the most interesting cases on this ward round was one of the seemingly well patients, who was chatty, lively and much younger than the others on the ward. Aged in her early 30s or late 20s this patient had been admitted by ambulance after her heart stopped in the community. She had had a 'down time' of around 50 minutes, meaning that it was about 50 minutes before they could restart her heart, which involved her receiving about 5 shocks and almost constant CPR. At least she was with people who knew how to perform CPR when she first arrested. The mystery with this patient was why her heart had stopped in the first place. She was fine now, and all of the tests at the time (such as toxicology screens and the like) had come back negative. Her heart appeared normal under all of the investigations that have been carried out, so what made it stop? Is it going to stop again? What if she is asleep when it stops, so no-one realises until she is hours dead? Nothing in the history gave any suggestion as to why her heart had stopped, so she was being kept at the hospital in the hope that something 'odd' would happen to her while she was being monitored. Stressing the heart with chemicals and exercise didn't help. It is these sort of mysteries which make medicine interesting, like detective work. The consultant said that the odds are that the patient may be fitted with a pacemaker to shock the heart back into rhythm should it stop again. I hope they get a diagnosis for the reason though, I am a curious person, and I don't believe that things happen for no reason!

This will have to do as an updated blog, and thanks for bearing with me. I would promise something better next week, but I always seem to be busy with something.

Clinics

Hi,

Firstly, happy Easter weekend to all those out there, and I hope you are enjoying whatever holiday you get (if any). This week was pretty 'run of the mill', but I realise that a run of the mill week working in hospitals is still a lot more varied than in many other career locations. What a wonderful profession to go into - where each week is full of variety and interesting little things. Diseases are very varied, and people even more so - so whether you are spending your time chatting away with a 25 year old constant re-offender admitted from prison, or a tottering 90 year old lady who wants to talk about her cats by name as though they are people, its always interesting to go in every day. I suppose I look forward to it in a sick sort of way (whether that cancels out the early early starts we need sometimes is another matter) but its much more fun than the lectures from the past 2 years!

Some good news for you all. I am currently applying to intercalate at a few external universities and have got offered a place at one of them, and had two interviews at another two, awaiting results. That's not really good news for you, it is more my good news to tell you I suppose, but what can we do. I am pleased anyway - definitely intercalating externally on a nice looking course, but my first choice is one of the institutions I had an interview at. Just a waiting game now.

Down to business - I could ramble on all day otherwise. We are assigned our set rotations (as I said before, I am on a gastroenterology rotation) but if we just stuck to these we wouldn't learn nearly enough, as we would miss out on other rotations such as 'endocrinology' or 'renal' based rotations. I have been chopping and changing quite a lot recently, there is only so much you can learn about livers. Correction. I am sure there is an absurd amount you can learn about livers, enough to fill lifetimes of work with hepatic wonderfulness, but there is only so much I want to learn about livers at this current point in my training. I would rather focus on the common sorts of things like asthma, diabetes or heart attacks that the gastroenterology rotation doesn't give that much exposure to. As of such, I have had a very chop-and-changed week floating around different departments in the hospital and trying out different things. One of the best of these trials this week was a morning in an endocrinology clinic, so I will stick to that. No need to waste too much of your day with this post!

In the clinic I spent time in, we were being taught by an amazing consultant. All doctors seem to have very different attitudes towards teaching and the formality/informality of the teaching position. Obviously, doctors who want to teach are worth being with a lot more than doctors who do not want to engage with the students at all, and want you to sit in the corner, out of sight and out of mind. Both 'formal' and 'informal' teaching styles teach plenty, and its always worth being with a doctor who wants to teach, but in my opinion the informal doctors are a lot more fun, and enjoying yourself surely helps learning! Back on track (again) this clinic was headed by a very knowledgeable, interested in teaching, informal consultant. Not that all consultants aren't knowledgeable, but the other two are not prerequisites of the job. As well as learning about all of the conditions we encountered (a wide variety, from hypothyroidism to suspected Turner's syndrome to the rare pheochromocytoma) we also got a good general education. Sorry, to clarify, when I am referring to we here, I am referring to myself and the other medical student I found waiting in the general department, so we paired up. Most doctors only want a maximum of two medical students in their clinics, which is fair enough, as otherwise it makes quite a crowded room. Two medical students seems to give a better experience as well, as  perhaps the doctor puts more effort into teaching if there are two of you (and you both benefit as you are there) - and any hard questions you can hope that the partner knows the answers if you do not!

The general education we were gaining from this clinic was pretty broad. We were asked questions such as what country 'Chisinau' was the capital of (Moldova, if anyone was wondering). It seems that medical students are expected to have a broad knowledge base. Personally I don't think I have heard of Moldova outside of the Eurovision song contest, but perhaps I am the exception. When the consultant told this specific patient (who was from Moldova) about his questioning, she did ask if we had got the question right. A neat turn of phrase got us out of trouble with her by giving the impression we had, getting the response "Well, they are medical students, they should be smart".

1) It was a lie. I had no idea about this capital. Moldova? They made the 'Numa Numa' song with the strange lyrics, right?

2) Bit of a wake up call really. The public perception of medical students seems to be split into two camps from what I have found. We are either seen as a smart group of hard working genii in the making, or seen as a group of 'work hard, play harder' people who work a bit but go out on some heavy nights out as well. The further you get in your medical education the more people are going to expect you to know about medicine and different things in general. I used to be able to fob off friends and relatives in the first 2 years. "Oh, you say you have a tear to your anterior cruciate ligament? Sorry, I haven't done arms and legs yet, if it was a problem with your heart, I might have an idea". No such joy any more. It is always nice if people ask you something though, even if you don't have an answer (or have to make one up). Makes you feel respected and trusted.

As well as asking us (and teaching us) about a wide range of different topics, while patients were not in the room I add, the consultant also told us an alarming amount about his personal take on life. Again, this was most definitely when patients were not in the room, while he was jokingly friendly and beautifully informal whilst we were in the room, all professionalism and seriousness when patients were there. As it should be. I would like to be like that. Anyway, we learnt that our consultant has a real hatred for monkeys, and one of the worst things he could imagine would be having sex with one of these said creatures, how this came out I am not sure, but I wonder how patients would react should they find out. The consultant also finds 'muscular women a real turn off'. Again, how this came out is beyond me, but yet more information I didn't want to know. Muscular women (and I think he means really muscular here) came above, but only slightly, monkeys on the sliding sex scale. Not sure how comfortable my female partner was during this conversation, but all carried out in the consultants crisp Irish accent, it was a joy to listen to. One of the biggest turn off's about muscular females is, we heard, that if you came home and the dishes were not done, you couldn't ask her to do them because you have been at work all day, you would just get punched in the face. While this sort of conversation is most definitely inappropriate, I think it is this sort of things which keeps some people going in the very PC and polite world we have to live in now. A joke to the wrong person can wind up very badly, so venting away and acting the fool (even if you are a 50odd year old respectable consultant) around people when you can is necessary for a normal life! The consultant did get one of one of the patient's kids to have a chat down the Dictaphone whilst dictating a letter for his secretary to type up. I would love to have a secretary to do work for me! One reason to aspire to be a consultant I suppose.

I digress from what should be the focus of this blog. The patients. But I have talked for some time already, and have many things to do (as usual). In the clinic all of the patients we saw had some form of endocrine problem. The most common by far was hypothyroidism (people with diabetes go to a specialist clinic, as this is the most common endocrine disorder in the population) but this seems like a relatively dull disease to manage, with follow ups basically consisting on checking that the patient is fine. The more exciting conditions we got to see I mentioned before, because they are exciting! There was a patient with a suspected pheochromocytoma, a type of tumour growing in the adrenal glands, releasing adrenaline when it shouldn't be.  This is a rare diagnosis, though, and will need further testing, but it is one of those 'exciting' conditions to come across... perhaps.

Another patient we met that day was a woman who, back in the UnPC days of yore, may have been described as a FLK (funny looking kid). While she had come in for a completely unrelated diagnosis, she was very short and just generally a little abnormal looking. It sounds offensive, saying something like that, but I think being on the outlook for such things is an important part of medicine. After she had gone, the doctor decided that it was possible she had Turners Mosaic, (Turners being where instead of having XX chromosomes, females only have one X) - Turners mosaic females have some cells with XX and some with only one X (XO) due to a defect when they were in the embryonic stage. This means that she would still have gone through normal development (such as starting having periods) which someone who had Turners would not have. It can only be confirmed by genetic testing, though, and does the doctor want to say to her, next time she is in for a check up "Hey, you look a bit odd, perhaps you have a genetic defect, can I test for it please?"

That might be taken as a little offensive.

Happy Easter once again.

Radiotherapy

Hi,

Bit of a mix up this week, and I get to see a variety of different people. unfortunately I have been ill for the latter part of this week so missed out on going in during this time. You can't go into hospital and spread an infection to all the people who are already sick! Despite this I spend some time with a lovely lady who is currently undergoing chemotherapy for a cancer on her face, I sit in on a clinic run by a specialist heart failure nurse, who is Very good, and I clerk in a patient who has vomiting and pain on a background diagnosis if gastritis, but seems to just want morphine and gets very upset when he is denied it. A morphine seeker with a true medical condition?

I have spent some time this week seeing a patient who is having radiotherapy. Seeing as she has to come into hospital every week day to have a dose, I get a lot of chances to follow her up if I want to. She is a wonderfully optimistic individual, with a very positive outlook on life. She has a chronically ill son who she has to spend all of her time at home caring for, meaning she never really gets to go out of the house apart from these radiotherapy visits. These cause a lot of problems for her family and friends as they need to cover the care she usually provides whilst she is out of the house. The cancer was originally on her face, and she is receiving radiotherapy following surgery to reduce the risk of recurrence. This has left her with some scarring to the face, but she sees this in an optimistic light as well - telling me that it doesn't matter to her much at all, as she barely leaves the house any more. Seeing such a positive patient is really inspiring. Getting drawn such a poor hand and ending up with cancer whilst having to act as a full time carer must be very stressful for her, but she is still all smiles and laughter when I talk to her (she is in her mid 80s) and very positive about her health, her treatment and her life. Perhaps she is the real optimist? I hope she can keep such a positive demeanour as the radiotherapy progresses. Radiotherapy tends to get worse suddenly around the 3rd week, as it has a cumulative effect on the tissues. A bit like getting sunburnt on sunburn from the previous day. Then again. Then again. Then again. It takes a few weeks for the dose to start having bad effects, but then it gets worse til the end of the 6 week cycle. As of yet, she doesn't seem to be having any ill effects, no burn marks on her face, no hair loss and no pain or nausea, and I hope it stays like this, but I have a strong feeling it will not. I will keep you posted as to whether she manages to keep such an optimistic attitude as the treatment progresses.


I had the privilege of spending an afternoon with a heat failure specialist nurse. Specialist nurses have, surprise surprise, specialist knowledge about one specific area of medicine, and so tend to be able to run very good clinics for people who have been diagnosed with this condition. You can have nurses specialising in problems from heart failure, as seen here, to Parkinson's disease. While nurses lack the depth of knowledge in other subjects that doctors gain in their training, knowledge of other unrelated diseases is unimportant in this situation. Because of this concentration of knowledge these nurses often know a lot about their chosen speciality, and we had some of the patients who came into the clinic commenting that the nurse know a lot more about their condition than their consultant cardiologist. One of the patients we saw was a 40 year old ex English Premiership football player, who had started suffering from heart failure a few years ago following a heart attack.

Heart failure is where the heart cannot pump sufficient amounts of blood around the body, as it is not working efficiently enough. The three top causes of heart failure are

1) Heart attack. By damaging the heart muscle, the heart becomes less effective and so pumps less effectively

2) High blood pressure. The high blood pressure enlarges the heart, as it has to work harder to pump the blood, getting bigger (in a bad way, exercise makes it bigger in a good way). The enlarged heart has much less space in it, so pumps a lot less blood with each beat

3) Valvular disease. Diseases effecting the valves in the heart can cause heart failure, as with dysfunctional valves (not closing properly, or not opening fully) the heart is less efficient at pumping blood and can become enlarged again

Heart failure is a 'viscous circle' as the body's response to the lower blood pressure is to increase the amount of fluid circulating. This is because the body is acting as though it has lost a lot of blood (a common cause of low blood pressure in cave-man times) and so is trying to increase that fluid again. This just leads to the heart having even more problems pumping too much fluid, and so getting worse. It also causes some of the 'typical' signs of heart failure, such as pitting ankle oedema, where the ankles swell up with fluid because of this increase.

Back to the patient, he used to be a very fit athlete, but due to circumstance had ended up in this position. A lovely man, he spent the time we were examining him telling us stories of the 'old days' when he used to play football, telling us about his young 'bit of stuff' he had at home, and how embarrassing it was that he couldn't even walk up his garden path any more without becoming acutely breathless. Heart failure has a terrible prognosis, worse than lung cancer, with little to do to 'cure' it other than by a heart transplant. it was a shame to see this lovely gent walk out of the clinic knowing that he might not have that much longer to live.

The final patient I will mention this week is someone I clerked in when I was on call. With a substantial past medical history, he had come in with severe pain above his belly button (epigastric) and had been vomiting almost continually for the past day. When I was clerking him he mentioned how morphine had managed to relieve his pain when he was in hospital about a year ago. This started ringing alarm bells, as he had been in hospital numerous times over the last year, and obviously hadn't been given morphine then, or he would mention it. While morphine is a great painkiller, I have heard many patients say they do not like it because of its side effects. But it does kill pain very effectively, so perhaps it was the only drug the patient had found that can touch the pain? While I was there, he wasn't being given the morphine because the doctors didn't think that the patient's signs of pain warranted such a severe drug. He wasn't doubling over or wincing in the pain, just complaining of it whilst sitting there and vomiting. He was very insistent that he wanted the morphine, threatening negligence claims against the hospital should he not get it, which I think was putting the doctors off of giving him the drug. Another problem, should he get the drug because he is complaining of pain and feels it would help him? Even if he is is displaying addicted behaviour towards the drug, withdrawing is painful and should the doctors be helping him with this pain? There was no question that he was ill, with the quantity he was vomiting and the previous medical history. I don't know what happened, because of the weekend, but I do know that he was not being given morphine when I left the take, so he hadn't been given it for the first few hours of admission.

Time limitations mean a shorter, blunter, less flowery blog I am afraid. Have a great Easter, for those who get a holiday!

Overdose

Hi,

Quite a varied week this week, but I would like to just talk about a couple of the more outstanding patients, as they were the most memorable. Two of these patients were
 1)someone who came in via A&E who had taken just shy of 100 paracetamol tablets the previous day, and
 2) I saw someone who had gotten some complications, possibly related to a nasty and rare form of cancer he had.
I was also disgusted by one of my fellow medical student's viewpoints as to transplantation in 'those who don't deserve it' which made me pretty disappointed in someone whom I had previously thought was a caring and intelligent individual. Not that I want to rant or anything, there are plenty of medical blogs out there that do that sufficiently!

Anyway, when I went onto my on call this week, as soon as I got there I was told by the consultant that they had a patient for me to see, and had just sent another medical student (my partner) over to talk to them. I was told it was an overdose, but that was all. I arrived a tad after my partner had started talking to the patient, and had the embarrassing part of slipping through the privacy curtains and introducing myself whilst trying to look professional (don't think I pulled it off though). We talked to the patient for some time, getting the important information of how many paracetamol he had taken, how long ago it was and whether he had taken any other drugs with these (more drugs, including alcohol, makes for a worse outcome). It turned out that he had taken just under 100 paracetamol the day before, then locked himself into his room and fallen asleep. 14 hours later his mum (he was my age) had realised he had been in his room for some time and had ended up pushing the door down to find him asleep. Having woken him up and fond what he had done, the ambulance was called and bought him to us.

There is a set treatment regime for this common overdose, and associated graphs and literature easily found in the A&E setting. This treatment regime involves giving a drug called N-acetylcysteine (NAC). Paracetamol needs a certain substance in the body to help its normal breakdown. If this substance runs out (I.e. if too much paracetamol is taken) then paracetamol is broken down to a different substance which is TOXIC. The treatment for paracetamol overdose involves putting into the body more of this substance, so it doesn't run out, and all of the paracetamol is broken down normally. The toxic substance it is otherwise broken down to can ruin the liver and kidneys. The problem with this treatment is that it needs to be given relativity soon after the paracetamol overdose as otherwise the paracetamol gets broken down to this toxic metabolite and damages the liver and kidneys.

Because the patient had hidden his overdose, this was the situation we were faced with. It had been too long since he had taken the pills for the treatment to be likely to work, but it is possible is would help, so he was put on the NAC as soon as possible. We talked to him some more about his reasons  for wanting to commit suicide as it seemed like he had really intended to kill himself, locking himself away, not leaving a trail, taking a very large number of tablets (I would have personally got bored half way through taking that many pills and given up). Anyway - I won't talk about his personal situation but being the same age as me he had had a lot of things happen to him in is life that were not fair, and people shouldn't have to go through. Previous suicide attempts seemed to have been brushed off by the healthcare system and he felt ignored and uncared for. As medical students talking to him we were pretty much helpless. What were we meant to say? "Don't worry, its not all that bad. Sorry to hear you want to kill yourself, perhaps you will feel better next week?" We could just offer a kind ear until his sister showed up and we left them in peace for a bit.

As for the treatment of paracetamol overdose, the treatment of the person is decided on the amount of paracetamol in their blood stream. If it is very low then treatment is not carried out, as it is not high enough to be toxic. A graph like the one below is used.

The amount of paracetamol in the blood is measured and plotted against the time since it was taken (the levels go down over time, as the body breaks it down, so the time the pills were taken is very important). In a 'normal' patient, if the point this makes on the graph is above the 'normal treatment line' the patient needs NAC as the paracetamol levels in the blood were too high. This patient had a point much too high in the blood (I.e. around the letter A) so needed the treatment. If the patient has some damage already to their liver, or took the paracetamol with other drugs such as alcohol, then they should be below the 'enhanced risk' line to avoid treatment, other wise they will need the NAC. For instance, if a patient had taken 5 paracetamol and came in with a level around where the letter B is they would not need the NAC, as they are at no risk of organ damage. Anyway, our patient definitely needed treatment, and blood tests showed that the liver was already damaged, and the kidneys were functioning poorly. The patient was not urinating much, and when he did it was brown thick liquid. Not good.

To cut the story short, after a day on the treatment, it was decided that this poor bloke needed a liver transplant as the liver was failing. An organ your body cannot do without and, unlike the kidneys with dialysis, there is no artificial support method for a damaged liver. Either he will get a liver transplant in time, or he will die. Pretty shocking news for his family.

A couple of days after seeing this patient, myself and the other 5 students on my firm were discussing some of the patients we had seen that week. Most of us had met the same patients, but had all spent varying time with each one, so talking about the patients with each other lets us learn more. I was talking to my colleges about the patient who had come in with a paracetamol overdose, and the fact that he will now need a new liver. One of my colleges, a nice friendly girl, usually with a smile on her face, goes and drops a bombshell of a reply.

"Why give him a new liver? He destroyed his old one. What a waste!"

You are joking, right? All those years of boring ethics lectures and you can pop out a comment like that?

No, she wasn't joking. She genuinely and honestly thought that because this patient had damaged himself and destroyed his own liver he shouldn't be allowed a new liver and should instead be left to die. What about ex-alcoholics who need new livers? What about people involved in car accidents where they were exceeding the speed limit? What about people who decide to smoke and end up with lung cancer? What about people who eat too much, get fat and end up having a heart attack? Nope! They don't deserve our treatment because they did this to themselves! 

Its quite simple. Mental illness is a disease, just like having a broken leg or a stroke. With the right management, care, and support into turning his life around this person will not remain suicidal for the rest of his life. Just because he was ill enough to think that suicide was the only way out of the situation he was in, does that mean you just want to go and kill him for it?

Anyway, I will not rant for too long on this case. It was just amazing to see someone who seemed like a nicely balanced, friendly person with a decent ethical education rain down judgement on someone whose life was so different from hers that she must have no idea of how he felt. How can you look down on someone who decided to take their life after all of these bad things happen if you haven't had them happen to you? How does this medical student know that if half these things had happened to her she wouldn't have gotten upset and tried something similar. And then how would she like to be told, once she was in a better place mentally, that she would be left to die because she had done this to herself. It is beyond belief. Anyway - I really hope that the next few years bring this eduction to those who need it on the course. I hope there are not that many third year medical students and upwards who would think like this.

Anyway, I wasn't that outspokenly offended by her - I showed my distaste (I think I might have used disappointment rather than distaste) in her views, but I have to spend time with her and don't want her to think that I am a massive morally righteous douche-bag so  I kept it calm, but kind of regret that now. 

So as not to end on a negative note I will mention one of the other patients I saw this week. A 35odd year old man presented to the A&E with massive abdominal pain and vomiting. A lot of vomiting. As in he had been vomiting almost continuously since about 8 hours ago that morning and had managed to get through 4 buckets since he had gotten to A&E. He had a complicated history of a rare multifocal cancer (a cancer that appears in multiple places in the body). Like any good medical professionals, when we heard about this we and the F1 had a good old google/Wikipedia search to find out a bit about this. With the amount of odd rare disorders there are out there, doctors cannot know a lot about everything, unfortunately, and while each of them is rare or Very rare, there are a lot of them out there, so you will see some every now and then! Anyway - this was a very complicated case. We were unable to even examine his abdomen because of the amount of pain he was in, doubled over and clutching himself. Was it the cancer causing his vomiting and pain? Was there new obstruction from a growth? Was it the chemo he was on disagreeing with him suddenly (less likely) or was it a completely new diagnosis unrelated to the cancer? I don't know yet either! I hope to find out on Monday though. Anyway, the main reason for bothering to point that out was the complexity that some cases can come in with. I find it hard to imagine being a consultant and having ultimate responsibility over such cases. No-one knows what is causing pain/vomiting/any symptom and the patient is on your ward. If you don't find out, they may die. Scary! All of that trust and the absurd amount of knowledge you must need if you are a speciality consultant! Perhaps I will become a GP after all, so I can just refer on the really complex stuff!

Another busy week, so another poorly put together blog. As the year goes on I am sure they will get worse and worse, but I am afraid you will have to live with it, or give me an extra couple of hours a day! Then I might be able to get the work done I need to as well!

Have a lovely week.

Confidence

Hi,

A very full week, but very little time to write about it, unfortunately. I got more 'on take' experience, spent some time with a very optimistic lady undergoing radiotherapy for a cancer on her face and spent a day with an F1, where I got to do LOTS. Did my first Arterial Blood Gas (ABG). A wonderful week, but I enjoyed it too much, and now have an essay deadline for Monday (tomorrow) so I will try and be concise and brief, so as to finish the essay tonight and get some sleep!

Ok, I had a great time when I was on take again this week. Spending much of the day on take, until about 8PM, it also gave me a good taste of what it is like to work as a doctor (not that I will get that privilege for another good few years!) Anyway, the set up is the same as last week and I was seeing patients who were being admitted from A&E, or who were referred to the hospital from their GP. Their names are written down as they come in from these respective locations on a list, and as medical students we get to clerk them from here. This can take a good hour a patient if done thoroughly, and is like being a 'real' doctor. You start off knowing very little about the patient, just one sentence which has been put down on this list 'confused with abdo pain' or the like, and you have to do a full history and examination from this. Presenting this to the doctor in charge, they then want your differential diagnoses (very important across medicine) and your initial management plan. Very exciting!

Anyway - when I was on take I clerked in several people, including an old lady who had come in after falling on the floor and being there for over 24 hours before being found. Being too weak to lift herself, all she could do was lie there and wait. The history taking was complicated as she had slight alzheimer's and was absolutely starving and really wanted something to eat. I made sure I got her one of those NHS snack packs (like a lunch box, for those who haven't seen them, with sandwiches, biscuits etc. inside) which she wolfed down faster than I thought possible, then promptly fell asleep. On trying to wake her up (slightly afraid something terrible had happened due to the speed at which it happened) I got told to go away as she was sleepy. I wasn't really sure what to do here, she needed to be seen so treatment plans could be made, but if she wasn't going to talk to me there wasn't much I could do. As it was, I came back in 15 minutes and she was awake again (odd lady) and rather sheepishly apologised for being blunt and offered to help me finish off my history. Anyway, to cut a long story short, it seemed she had got a UTI which had caused her to fall (common causes of all evil in old people) which we could easily treat with an antibiotic such as co-amoxiclav. For the rest of the day, whenever I went past her bed I got a lovely smile and wink from her over some plate of food or other. While she had fallen and stayed on the floor for a day, perhaps she hadn't eaten for a week before that! It was either that or she was the 'Big Bad Wolf' who had snuck in in disguise to get some free food!

Another patient I saw on take was a kind Gent who was suffering from photophobia and headache. Typical meningitis alarm bells here. As you may be aware, untreated bacterial meningitis nearly always kills the patient. This is always something to be on the look out for to treat fast! The crucial diagnostic test for meningitis is a lumber puncture, where a needle is pushed into the spinal canal to take a sample of the CSF (the juice the brain is suspended in). The doctor asked me if I would be interested in doing this procedure. I know the drill, push the needle in between L3/L4 (low enough to avoid hitting the spinal chord, which has split into the stringy "cauda equina" by then) until you get some flashback and then take some samples. I was NOT happy to do this. I am usually really up for trying any new procedure I can get my hands on, and as long as you are honest, smiley and seem confident towards the patient they don't seem to mind. But a procedure involving sticking a needle right next to their CNS, with a risk of paralysis is out of my depth. A good thing too, seeing as when I saw it done it took the (highly skilled) registrar a good 15 minutes of 'poking around' (I believe that is the technical term) after putting the needle in before they got the flashback. I contented myself with taking his blood instead, after the procedure when he was complaining of a [more] shattering headache (common side effect, changing the pressure around the brain). He told me his veins tended to flummox medical professionals seeming to disappear and refuse to yield more than a few mm of blood when found. But he had a cannula in, so I reasoned they couldn't be that bad. I managed to get a vein nicely the first time, filling the necessary bottles, which felt good - but then again perhaps the fear from the lumber puncture had dilated his vessels after he had come through A&E and they had had their go. Still made me feel good though, I can still become that doctor figure I want to!
[If anyone was curious, he didn't have meningitis]

Despite all of this, my last day this week was still the best day for me. I ended up spending almost the entire day with an F1 doctor (first year after graduation) doing all of her tasks with her. This was more through choice than anything else, as the timetable is somewhat vague. We developed a quick 'you scratch my back' type relationship over the course of the day. I did a lot of her menial work, like filling out MMSE forms (which any monkey can do, it just involves asking questions clearly and ticking boxes) and filling out reams of figures on slips of paper to plot how patients blood results were changing from yesterday. That latter one seemed pointless, as the computer systems have a mode which can do this, but who am I to question why. Anyway, in return for the running around with X-ray forms and other fun things I got to do I got bought a cup of coffee and, by far best of all, got to do an ABG. I was also asked if I would like to catheterise a male patient but I declined as I had only ever practised on a plastic model and had never seen it done before. I got to do plenty of bloods and other such wonderful things, but lets focus on the highlight of my week.

An ABG is where a needle is stuck into the wrist at a steep angle to go and pierce the radial artery (the one you can feel with your fingers at your wrist). This is needed to see the levels of oxygen, CO2 and the pH of the blood. You need to get this information from an artery, as you want to know how much oxygen is getting to the tissues, not coming away from it. I have to be honest here, I don't think I have ever seen an ABG carried out in real life, but I have read about them (Wikipedia) and heard about them plenty. I suppose I may have seen one carried out on a programme like scrubs, if that counts. Anyway, when I was asked if I wanted to do one, I wasn't going to say no. They don't seem too hard, just feel for the artery with two fingers and stick the needle between them. After all - I seem to have a knack for finding veins, and you can FEEL arteries! I went and got the necessary hardware as the F1 asked me if I know about these.

"Yes, I have a pretty good idea of what it involves"
There we go. Not a lie at all, and said with a confident smile. Again, you can get so far with confidence.
"Sure, that's fine then, talk me through what you do as you do it then please!"
That's fine with me. I don't want to be left alone to do this at all! Unfortunately, as I come up to see the patient  I suddenly feel really bad. Its one of the several alcoholics we have on the ward (being gastro there is always alcoholic liver disease around) and he has been very out of it for the last couple of days. I am more than happy with explaining myself to a nice patient, trying to win them over and then doing the ABG, but doing it for the first time on someone who is barely concious seems somewhat wrong to me. Yes, he is unlikely to care too much, but what about informed consent? Too late now, I can't really pull out. Better carry it out well!
I prep the area, unsure as to what help these alcohol wipes really have. I am sure I read somewhere they increase the chance in infection by breaking skin layers. Stop. Where did all of this doubt come from!? Before I saw this patient I was calmly confident - now I have noticed it is not someone who would care if I messed up why does it matter more?

"Would you mind if I took some blood from the artery in your wrist, sir? It might be a bit painful I am afraid"
Patient flops his hand forward and upside down, grunts in agreement but doesn't open his eyes. He isn't the sort you could have a conversation with, brain encephalopathic from chronic alcohol use. That seems like as much consent as I am going to get. I start feeling for the pulse. Not as strong as most people's I am sure - but perhaps that means the artery is bigger, and as such has less force on the walls? I don't know, I just want to stay calm and confident. That's the trick.

I talk the F1 what I am doing, angling at about 45 degrees and angling the bevel to catch the flood flow as soon as I hit the artery. The idea with this technique is that once you hit the artery the blood flow has enough force from being in the artery to fill up the needle, pushing the plunger out.
There is nothing else for me to wait for now - hesitation loses that confident air you need to keep. I push the needle in between my two gloved fingers. Not even a twitch from the patient, still sitting there with his eyes closed. I can feel the pulse on both, so the artery is definitely between them as well. But my fingers are big, and gloved, the artery small and hidden below all that flesh, what if I am a few mm to one side? I might miss it, or clip it and damage the wall, leading to lots of bleeding from the wrist. I don't want that! I am sure it is here somewhere, but it seems deeper that I might have thought... Keep the confidence!

Finally (so that's a little under a second in real time) I see a trickle of blood appear in the plastic part of the needle that attaches to the metal needle. Flashback! This is quickly followed by a nice squirt or two of blood squeezing into the syringe and filling it up. I pull it out, making sure to cover immediately with gauze and keep pressure on for a good minute to stop bleeding. Still no reaction from the patient. Where is the applause! Finished. Nice. First time. Relief.

I walk the sample over to the nearest analyser machine. No need to send it off to the lab to be analysed, these machines do it on the spot! The nearest one is over in ITU. I come back with the slip of printed paper. respiratory alkalosis I tell the F1, and walk them through how I came to this conclusion. More learning.

Well, that was exciting for me, though I did feel like am imposter through much of that. I think it must have been mainly due to the fact that the patient was not with it at all, just sitting there glazed, that made me feel bad for sticking a needle into him. I felt like the guy from the movie "Paper Mask" I had been recommended to watch by a member of hospital staff. It all worked out fine for me in the end, but boy am I glad I didn't accept that offer to practice a lumber puncture earlier! I suppose we all have to learn by trying something for the first time, and after that experience I am still up for giving these new things a go (but not all of them. I will steer clear of neurosurgery for a good few weeks, don't worry!)

The F1 has offered to let me practice catheterisation next week if I am around and there is the option for it to be done. Sounds good to me - just keep confident, right! If I can keep this symbiotic relationship with this F1 I can get to do loads of stuff. But we do have these 'log books' we have to collect proof we have done 'useful'  things in, such as consultant ward rounds. The funny thing is, on some of the days this week, which have been unremarkable, I have collected around 5 signatures. This day I collected none. What can you do.

Anyway - this turned out FAR too long, and I am not going to read through it all again - so apologies for any parts which are poorly written / grammatically incorrect. I now need to get onto this essay so I get some sleep before my 8AM ward round tomorrow. Or is it 7.30?

Cheers for sticking with me, I really enjoyed writing this week!

Gastroenterology

Hi,

Ok, so my first week on my medicine rotation, which is based around the GI system (top to bottom, including associated organs such as liver, pancreas etc.) and I get back to the 'proper' hands on medicine. Nurses, endoscopies, cardiac perfusion scans, X-ray meetings, hepatitis, a patient who has severe intestinal bleeding, seemingly from switching to a purely raw food diet (not healthy), 'on take' and  ERCPs topped off with an upsetting surprise finding that a patient only had around 3 months to live because of a tumour found instead of gallstones. While sad in places, this is more like it. Much more proactive and time is spend 'doing things' instead of sitting around waiting for the next patient.

Lets get started on my week. To start off our medicine experience we were meant to be with the nurses for a little to 'warm up' at the start the rotation. With shifts starting at 7AM this was no mean feat, I was not used to getting up early after psych where the ward rounds started much later to give the patients time to 'get going'. While far too early for me (most definitely not a morning person) it was nice to fraternise with the nurses for a bit. Helping them give medication to the patients and get them out of bed led to just chatting with the patients as the nurses got on with their general day to day activities. What a lovely way to start the week! I got to hear some wonderful stories from someone who grew up in Australia on a station (a ranch) and how his life led him to the UK. While this was strictly not a nursing activity, I persuaded myself it was for the good of the patients, to prevent boredom, so continued at my leisure. I think the nurses were happy to have me out of their hair anyway. While the nurses there were more than lovely, there is sometimes a bit of disagreeability between the doctor and nursing professions. Some doctors seem to have a very patronising attitude towards nurses, and see their role as menial, and the nurses obviously do not appreciate this. Some nurses see doctors as stuck up, too big for their boots (which some are, in my opinion)  and overpaid. Usually these feelings seem well under the surface though, and don't seem to affect patient care, though we have overheard one nurse telling patients that they would be 'stupid to consent to having a medical student sit in' as it was a waste of their time and we were only nosy. If we qualified as doctors without seeing any patients we would be a danger to society! We have to start somewhere.

Some time spent in the hepatitis clinic with a doctor was a real eye opener. In the morning, despite having solid appointments from 8.30 'til 12 there was only one patient before 10.30. An elderly gentleman who had contracted hepatitis from a blood transfusion some time ago, but had only found out recently. The clinic was for follow up for those who had just been diagnosed with hepatitis to see if they wanted treatment, or if their body was clearing the infection (there is a chance the body can clear the infection, depending on the strain). The only people attending the clinic were people who had the B or C strain as the other strains (A,E,G) do not lead to permanent infection. Many of those in the community who are catching hepatitis are IV drug users and in the morning they need to pick up their methadone, so will not turn up for appointments. Perhaps a different plan needs to be made for when to carry out the clinic. After 10.30 plenty of patients were showing up. Many of them apparently homeless from their unwashed state and ruined clothing, but polite and kind none the less. Drug users get a bad press, which is perhaps fair enough as it is a large cause of crime, but I think judging people in this situation is exceptionally unfair. Many of them have had horrific childhoods including problems such as abuse, and how can you look down on someone for turning to drugs in that situation when you have not been in it yourself. One of the most interesting patients who turned up to the clinic had turned up with his wife, but on reading the covering letter with which he was referred (before the consultation, to find out a little before it started) we found out that the patient had not told his wife how he had caught hepatitis C. The truth was that he had relapsed into using heroin after about 10 years abstinence due to stresses at work, and had been using since. He had told his wife that he had caught it while nursing his father, who was currently suffering from end stage liver cirrhosis due to too much alcohol. At least the patient got the right organ to lie about. In this clinic it is very important to know exactly when the patient caught the virus, as there is a chance of them self clearing it in the first 6 months, but after that if it still remains it will be permanent so treatment should be considered. Treatment is 1/2 a year or a year worth of daily pills and weekly injections to stand some chance of cure, depending on the type of Hep C the patient has. It's got terribly side effects and has been likened to chemotherapy. Putting someone who is unstable, without a home or support, on this medication is not a good idea, so treatment is planned to be when the patient is in the best environment, which is not always easy. Anyway, the patient managed to help us send the wife out of the room under a pretence, so we could ask the questions we wanted. Why he bought his wife along in the first place is what surprises me!

Anyway, I spent some time this week in a variety of places in the hospital. With a loose timetable, the plan is that the student will spend some time wandering the hospital picking out things that they want to do. While this can be quite exciting, it can also be a bit of a chore. Being turned away from places and having to compete with fellow students for that space-for-one in the MRI room can be a little time consuming. Anyway, I got some great experience sitting in on some endoscopies. Not doing them, not by far, but watching the procedure and having it explained, so when the time comes I will know what to look for and how to carry out the procedure. I saw a variety of problems with the stomach and duodenum, which was good for learning, from oesophageal varices (often caused by drinking damaging the liver and thus raising blood pressure) to a completely obstructed duodenum meaning a good few litres of  partially digested food had to be sucked out of the oesophagus and stomach to see what the problem was. The procedure is called an OGD (Oesophogastroduodenoscopy) - as in it looks at the oesophagus, stomach and proximal duodenum. Nice and self explanatory. Patients can choose to have sedation (still concious but 'out of it') for the procedure or a numbing throat spray. The nurses were recommending the patients have the throat spray but after seeing both of these in action I would personally go for the sedation every time, you are too 'out of it' to really notice the procedure and are unlikely to remember it in the end. The throat spray doesn't seem to numb too well, though when I tried some myself it seemed to be very effective. I suppose its a little different if you are having a great big tube shoved down your throat.

I also saw cardiac perfusion scans being carried out. Creating an image like the one below, a radioactive isotope is injected into the patient to see the blood flow around the heart, to see if there are any problems. Our patient was, surprise surprise, a smoker. It seems so many of the diseases in medicine can be caused by, or exacerbated by, smoking. In all honesty it is a surprise it is still legal. Some politics going on there perhaps, but the phasing out in public places is definitely a good thing. It has reduced the number of people coming into hospital with respiratory problems and heart attacks significantly. The X-ray meeting I sat in on was interesting to see. The gastro consultants had collected up the most complicated scans from this week (mostly CT and MRI, despite the x-ray meeting name) and were showing them to a consultant radiologist, who was helping interpret them. The hospital is like a spider's web, with all of these different specialities working together. Its impressive that it all works (most of the time).

When on a ward round we came across a patient who was suffering from numerous ulcers in the stomach and duodenum. I don't really have much to say about her, other than the only reason that we could think of for all of these ulcers to be in her digestive tract was her recent change in diet to only eating raw food. The gastro consultant was very scornful towards these 'fad diets' and 'strange ways of eating' but I suppose if you spent all of your days picking up the pieces of those which go wrong then perhaps you have a right to be angry towards those who promote such things.

The 'on take' I did this week was great fun. Patients usually come into the hospital from either A&E or a referral from the GP. Patients in A&E are assessed and those who cannot be dealt with there and then and sent home are sent to be clerked by the on take team. The same goes for patients who are referred by their GP and need to become in-patients. On clerking there are plenty of questions that should be asked, about family, social situation and the like, and it is a good idea for a full examination of the patient so that when they are on the ward the doctors can see changes in condition or signs, and they have a good idea about what is wrong with the patient. When I was on the elderly ward, I remember the first thing you would always look at in a patient's notes was the clerking from their admission. Filling out these forms seemed very important, far too important to leave for a medical student to do! You don't want to miss a sign or a key part of the history, as whatever you clerk them in with, most doctors will take as read and not bother asking these questions again. I clerked in a patient who was experiencing chest pains, with a strong family history of heart attacks with 3 brothers who had died of heart attacks. She had her little girl there with her, about 7 still in her school uniform and very upset. The girl hated hospitals, after her grandad had died in one (again a cardiovascular problem) late last year. I tried to make her feel more comfortable by being friendly and nice, but it wasn't that easy in an acute medical ward, stuck in a tiny room curtained off from the corridor. Hope I managed to get down all the relevant parts of the history in the history. I left the investigations needed and the treatment plan boxes though, no need to stretch those limits on my first week and end up killing someone! A neurological examination on a lady with unexpected occurrences of syncope yielded nothing at all. I don't like not knowing the answers, so I plan to pop back in after the weekend and see if the cause has been found yet with the more specialist investigations. Medicine is detective work, and I love it!

 Finally, I spent some time sitting on on some ERCPs. This is both a diagnostic intervention and treatment, and involves putting an endoscope down the throat (like I was seeing earlier in the endoscopy clinic) and pushing a small wire up into the common bile duct from the duodenum. The plan is to find out if there are any gallstones in the duct from the gall bladder. The doctor carrying out the procedure can see down the endoscope, so can see what is ahead, and there is an X-ray machine above the patient so the doctor can see an X-ray of where the wire is (because the endoscope cannot go into the common bile duct). Down the X-ray the image looks just like the image below.

The large black worm like thing from the top right and curling at the bottom is the endoscope that has been passed down from the throat. The vertebrae can be seen behind it. Just above the top of the endoscope you can see where the wire has been passed out, vertically up, and the doctor has injected a contrast which shows up as darker on the X-ray. This contrast travels along the tubes of the bile ducts, and any blockages can be seen as the contrast will not be able to travel past them. In the picture above the contrast has travelled perfectly up into the liver (top left, with many branches where the bile is produced) and along the duct to the pancreas (the duct branching off to the right and upward). This is because the pancreatic duct joins the bile duct just before they empty into the duodenum. A large problem that the doctor carrying out the procedure seemed to have was getting the wire into the bile duct and up to the liver, rather than up to the pancreas. This is important as the wire is passed up the tube, and then a balloon is inflated on the end before it is pulled out. This has the effect of catching any small stones that the thin wire has gone passed and pulling them out into the gut where they can be passed without causing more problems.
Anyway, one of the patients I saw this carried out on had a large area of blocked flow in the common hepatic duct (the straight thick piece of duct moving down and slightly right after the branches join together and before the wiggly line joins from the left (the gall bladder). This was not clearable with the ERCP trawling technique, and this coupled with the history of onset (gradual jaundice coming on over 2 weeks, without pain) meant that it didn't seem to be due to stones in the gall bladder. Due to the position of the obstruction and the relatively slow onset (gall stones cause a sudden blockage and hurt a LOT [women who have had gall stones say that the pain can be worse than their labour pains]) the most likely cause of this is gall bladder cancer. A rare cancer, but most common in women over 70, the patient fitted the bill perfectly. The cancer has to be advanced to be big enough to start obstructing the flow of the bile, and unfortunately this means that the patient has a poor prognosis as it will have started spreading. The consultant said that other patients he has seen with such symptoms and results from the ERCP tend to live for another 3 months or so. 3 months?!?! What a shocking result for a very healthy and chatty lady who was lovely to me when i went to chat with her before the procedure to ask consent. It was not a definite diagnosis, just based on clinical experience, so the patient will need scans to check the mass, and the consultant would then talk with the surgeons to see if they would have any interest in operating on the mass, should it look operable from the scans. Unfortunately the doctor said that surgeons rarely operate on such advanced cancers.
So this lady likely has approximately 3 months left to live, with little chance that there are any possible treatments to cure her. And she doesn't know yet, because this has to be confirmed with scans and talk with the surgeons. I feel bad knowing this sort of information about this lady when she doesn't even know herself, but I suppose it's not fair telling patients these sort of things when you are not sure, as it may well be a mistake and be something easily treatable, and no-one wants the stress of being told they likely have cancer and 3 months left to live, then being told next week that actually its all fine.

I would like to finish with a question for you, if you would care to answer. How would you like me to write this blog? Would it be better if it were a lot more science/medical describing conditions and treatments in more detail so improve knowledge? Would it be better if it concentrated more on how I felt throughout my training / my encounters with patients (however horrific that sounds) - Any feedback would be much appreciated!