The one sandwich to rule them all

Hi,

I finished up my first rotation as a junior today and thought I should give a bit of an update. The last few weeks have been a bit hectic, as I have had to cover for the breast F1 (who almost forgot to take his annual leave, and took it all at the end) while my SHO was on nights and then recovery. Busy times! Either way, it has been quite an interesting few weeks, where I managed to bleep myself, I got confused over someone as they had changed out of fancy dress, I have some success at the 'sandwich war' and end up making one of my patients cry...

Before that, I would like to comment on the current 'Movember' crop which is going on in my hospital. A number of the juniors have gone for a certain look, which one of my (85) year old patients commented on, asking me why there were so many people "dressed as 70's porn stars" in the hospital... The same lady came in on 31/10 (Halloween) from a nursing home with her carer from the nursing home and her sister, both dressed as witches. I thought it was a bit strange at the time, trying to take blood from this poor old lady as two witches watched on and cackled, but forgot it until a few days ago when two people were trying to talk to me about this patient. I was pretty elusive (patient confidentiality and all) until they asked why I didn't want to talk to them now, as I was much more forthcoming when she was admitted. It was the same two people, but they just looked very different without all of their witch garb on! 

When you are in the hospital, you carry a little black box of evil, which bleeps at you telling you who wants to talk to you (a pager). When you get a bleep, you get a 5 number code to dial, which then lets you call someone at their extension and learn what 'lovely' job they want you to stay extra late to do. Since I started I have wondered how long it will be until I end up receiving a bleep, going to a phone to answer it, but then calling the phone I have just called off (if you follow me - they bleeped me from the phone I answered from). This seemed very unlikely, as you would be in the vicinity, but I am just such an interesting person I like to wonder about fascinating things such as this. Well, this week this happened, I was around the corner, was bleeped then the nurse was rushed off to do something else and I called myself (engaged of course). There is no real reason for me to write it here, so I won't say any more, but it was one of my 'hospital wonderings' at the start...

In pre-op assessment (The last one I did this rotation, and possibly the last one I will ever do, depending on rotations next year and my chosen speciality) I was assessing women coming in for breast surgery. This is almost entirely people with breast cancer who are having the tumour removed, or the entire breast removed, called a mastectomy. One of the women was 70 years old or so, in a wheelchair and from Moldova. She looked like a 'Babushka', and spoke only Moldovan. I tried to use the telephone translation service, but they told me that she was speaking gibberish to them, so I asked her grandson, who was about my age, if he could translate. He readily agreed, but then told me that she was mad and he wouldn't translate what I was saying to her as she wouldn't understand. What then followed was a very difficult pre-op assessment clinic where I tried to get history from the grandson, and examine this lady, while she shouted garbled Moldovan at me and kept flopping her breast out of her top to wave at me (I guess to show me where the cancer was). The only key information I could get from her grandson was that he told me that she "Had experienced clinical death when having eye surgery in the USSR". When I asked what he meant what he meant by clinical death he told me "it means she died, where did you do your training", and refused to say any more. Such a difficult conversation - I am glad I am rotation onto respiratory medicine now, so won't have to try and communicate with them on the ward!

 A little like this, but a little more smiley

Now for the headline piece. The sandwich wars. I big it up because it is a big deal to me, though probably of little to no interest to anyone outside of my hospital. There is a very fought over sandwich in the league of friends shop that everyone in the hospital wants. I normally pack my own lunch, but when I forget/am too sleepy/forget to buy bread, this is the sandwich that I want. There is only one a day, it gets put out at a random time before lunch, and it seems the whole hospital wants it for their own. It doesn't sound anything special, but it tastes like heaven. And I managed to get it! As you join the queue with it, people you have never met before plead to exchange it, it gives you such a sense of power. If I set up a shop selling these sandwiches in the hospital I wonder if I would be rich, but I think the scarcity is what attracts people the most. Like diamonds. If anyone was wondering, the delicious fellow is below:

Never has one sandwich had so much power over so many

Sadly it has been my last day on vascular surgery today. I am in the same hospital for the year (so I can continue fighting for the important things in life like the above) but I am moving onto respiratory medicine from tomorrow for 4 months. I am really going to miss all of my crazy patients. When I was going around to see them and say goodbye this evening one of them, a lady who used to belong to the TA and drive Bedford Mk. 4 Tonne Trucks was crying and had tears pouring down her face when I said goodbye. She is normally very stoic and even though we had to remove one of her legs due to a nasty bone infection, and operate on the foot of the other, I have never seen her upset before. It has been a very touching final day, with the nurses saying lovely things about me, and I hope that my new ward is as nice to me as this one has been!

Poo volcanos, crazy patients and narrow misses

Hi,


Another long delay between posts, following another long period spent in the hospital. The times where I do a week, a weekend and then another week in the hospital mean I am working 12 days in a row, and I get really tired! This leads to me almost making mistakes - not dangerous patient care mistakes but awkward never-return-to-the-hospital mistakes. One of two of which I will cover below. This has been the weekend following one of those sets, and I have really enjoyed being able to have massive lie ins and do very little. I will post some bullet points below from things which have happened during the last couple of weeks, hopefully making it easier for me to write than having continuous prose. The most 'exciting' of which is my own lovely poo volcano which I will finish with. Make sure you are not eating.

- My consultant was called a 'nasty, spiteful little man' (he is very short) by one of my patients, who is now refusing to see him and has told me that if I bring him to see her again she will write to the board of governors of the hospital as a complaint. As my registrar hasn't been around much lately and my SHO has been on nights, as a result she has been receiving 'F1 lead care'... He is a very straight talking typical surgeon, but I think that her reaction is a little extreme. How am I meant to know if her wound looks as though it needs the types of dressings used changed, or further debridement? It is worth mentioning that on a ward round with my registrar (who is bald) the same patient told me that I had to be nicer to her, or all my hair would fall out and I would end up 'like baldy over there' - cue awkward silence while nurse is in uncontrolled giggles! 

- Talking to the family of one patient who I thought were really racist as they were talking about how 'The Blacks' did things very differently, and how it wasn't really what we were used to in this country. I was on the verge of rebuking them for being so racist and telling them that the nursing staff were all very well trained, and cared a great deal, regardless of the colour of their skin, before I realised that their surname was Black and they were talking about members of their own family. Disaster narrowly averted!

- I influence decision making for one of the first times since I started here. F1 is mostly about chatting with patients, filling in forms and running around the hospital after seniors; you rarely get to decide anything more important than whether to treat a UTI with trimethoprim or nutrofuratoin. This time I was sitting in the 'diabetic foot MDT' where vascular surgeons, orthopedic surgeons, microbiologists and other specialities meet to decide what to do with - you guessed it- patients with diabetic feet who are in the hospital. Usually this involves deciding whether to operate on different people in the hospital, or which antibiotics to use to treat a case of osteomyelitis. This time they were discussing a patient who had a fixed flexion deformity of his knee, meaning it was stuck bent; this meant that his bent leg was developing a pressure ulcer and an infection due to always being pressed into the bed. There is very little point me coming to these meetings, as I have very little to add as an F1, but I have to anyway. This time the surgeons were deciding to perform a below knee amputation on this man for this ulcer and infection, but I chimed in and pointed out that he would still have this flexion deformity in his knee, and it might press the surgical wound onto the bed. "Good point IO, lets do an above knee amputation instead" and he went on to have the operation, and is doing well. I contributed something!

- One of my patients keeps trying to persuade me to get ant farms. He is sure that they will be much better than all the 'boring, plain pictures' that hospitals have on the wards. After all, "they change all the time, and you can bank on the glass if you are bored". I tried pointing out that the ants would, undoubtedly, end up getting out amd "into your food, in your bed, in your stump wound", but he is sure that no-one would mind, as they are only common British ants, found all over the country (though I hastened to point out, not in hospitals!). I would like to point out here, that according to the all-knowing wikipedia "Often, containing ants inside a formicarium can be a challenge."  I don't think I will be suggesting the idea to the chief exec any time soon!

- As for the poo volcano, one of the patients in the hospital over the weekend had a blocked colostomy, where she had a large fecolith (stone made out of really hard poo) at the entrance blocking any poo from coming out. This patient had been admitted under the GI surgeons, and they had been performing enemas on her stoma twice a day to try and soften up this rock of poo, which was bigger than the entrance to the stoma, and was blocking it. Sadly, over the weekend, this job fell to the on call F1 (me) as they had gone home, and the nurses were not permitted to do it due to the danger of perforating the thin stoma tissue. I had never done an enema before, let alone some dangerous-type of one where there was a risk of perforating the bowel and letting poo inside the abdomen! Regardless, I had to do this over the weekend, and the experience was awful. The patient was lovely, but I am sure you can imagine what the experience was like. I was warned that this was quite a messy task so covered the patient and the bed with opened out adult disposable nappies. Usually there are a special sort of incontinence pad which are very absorbent and are used for messy tasks like this, but the ward seemed to have run out of them, so nappies seemed like the next best thing. I had to work this thin tube (usually used to catheterise patients) down into the stoma with my fingers (and hand) very carefully, trying to get it past the large rock of poo which was about the size of a kiwi fruit. This took some time, and was quite messy work, but nothing like what was about to come. After I had finished forcing my fist into this poor person's stoma to get the catheter around this solid lump of poo, I had to squeeze two 500ml bottles of fluid down the tube, one was an oil used to loosen up the mass, the other a phosphate solution to help make the bowel more mobile and expel this rock. I am not sure if it was this phosphate solution or the fact that I had just squeezed a litre of fluid into this ladies already-overfilled bowel, but as I was squeezing the fluid down into this stoma, the liquid poo that was stored behind the fecolith was blossoming out. As she was lying down it was going everywhere. Fortunately I had covered the patient and bed in these nappies, but it was running all over the place, finding gaps in the nappies and dripping off the bed onto the floor. I cleaned up after this as best I could, but it felt as though that smell followed me around for the rest of the day. Why do some people think medicine is a sexy profession? Don't get me wrong, stomas are not bad in themselves (the daily heil even states that they can be sexy), i was just not at all prepared for this process, having never even done a 'normal' enema before, after a long week running around.

Picture of a stoma from the internet

- The rest of last week was mostly taken up with the emotional version of the poo volcano above. A consultant from another hospital had transferred a patient to ours for a pre-operation work up for a relatively major operation (no beds at his hospital, supposedly . Only this patient was 102, and after she was admitted he refused to talk to me, and relayed to me through his secretary that the patient was now our responsibility as they were in our hospital. He told me that he had OK'd this with one of my consultants, who was out of the country for a month, so that didn't really help. The family were (rightfully) distressed and angry about this, and the patient stayed in hospital for a week before I could get another vascular consultant to see her and decide what to do with her. He decided that the first consultant had been out of line, trying to get her out of his care, and wanted to send her home. Trying to tell this to her family, however, was not easy at all. Her grand-daughter really wanted her to have the operation. I couldn't tell if she secretly wanted something bad to happen, as the consultant had been very clear about the risks of this major operation, but it was a very uphill battle trying to get them out of hospital. I think that because of the very strong beliefs of this family (who were rightfully distressed by this poor treatment), this could be why the original consultant tried to get them into another hospital - so he didn't have to deal with them anymore. Either way; its not fair on the people whose hospital he sent them to, as they then have to deal with explaining that this isn't the correct procedure for her, and definitely not right for the patient and family, who are sent out of their area and into hospital for a week for no good reason at all.

The people you work with...

Hi,

I have been thinking a lot about how the people you work with influence how much you enjoy your job. I work with some real characters, for better and worse, and I think that the people who you work with are the main factor which affects whether you enjoy going into work in the morning.

For example, there is the nurse in the pre-op assessment unit who calls me 'Mr Vascularity". I am pretty sure that this isn't something to be proud of, but it always makes me feel noticed (and certainly puts a smile on my patient's faces). It is nice to feel as though you are not just another person wandering around the hospital, but people notice and remember you, and enjoy chatting with you. Especially friendly motherly nurses who help look out for me!

My consultant is pretty much the opposite. He is the 'typical' surgical consultant, very blunt and brief with patients, and difficult to approach. My favourite quote from him this week (and keep in mind I only see him once a week, for his weekly ward round, the rest of the time he spends in theatre, clinic or in other hospitals) was while he was on the phone to a member of office staff. I think someone had had to move his list around to a different theatre which he was less happy with, and this poor office worker had to tell him. I caught the consultant telling the person that.

"I am going to show you what happens when a consultant throws his considerable weight around"

Needless to say, I don't get on very well with my consultant, but fortunately rarely see him. As long as I have my pockets full of gloves and pairs of scissors for him to look at the post-surgical wounds of the patients on the ward, he seems to tolerate me...

So moving onto the other most important group of people I work with. Seniors are obviously important, as are nurses and other clinical staff. The third group is my peers; other junior doctors. On the whole, the juniors at this hospital have all been so supportive of one another. It quickly became apparent who was quite highly strung and got stressed about most things, and who was lazy and would try and avoid as much work as possible, but on the whole I have been very lucky with this bunch of people. The surgical jobs come in waves, with certain firms being much  busier than other firms at any one point. People from the less busy firms seem very happy to come and help those who are much busier. I have been helping others for a few weeks but have been very busy recently, and very glad of the help coming my way when it seems like I will have to stay past 8PM to get things done. One of the other F1s even bought me a pack of Maltesers as I looked tired out from all the running around hospital. How lovely; it is those little things that make the day easier! 

Corridor collapse

Hi,

Again, I start with an apology for the time since the last post - I will try and remedy this by posting little and often in future. The past few weeks have been very busy - the senior house officer (an F2) in my vascular surgery rotation was off, leaving me to deal with basically everything, and then the breast surgery F1 was off, meaning we had to cross cover breast surgery as there are no other juniors on that rotation, leading to another week of heavy work. All in all, I think that next week, now that everyone is back, things will be a lot easier!

Things have been getting easier as the weeks go by and I get used to things a bit more. I have been working as an F1 for about a month now, and I am getting much more used to not only how the job works but (supposedly more importantly) how my consultants like things done. I can have lists prepared at the correct moment, make sure that surgical lists are in the order that each consultant prefers and try not to get in anyone's way so they trip over me...

A couple of exciting/stressful (they often seem to be both...) things happened to me this week. One of my patients became very sick whilst I was trying to run my pre-op assessment clinic. I was meant to be spending all afternoon assessing a stream of patients to try and tell if they were well enough for surgery or not, but had the surgical 'advanced care' unit calling me telling me one of my patients had a heard rate of 30 beats per minute (very low) and a very low blood pressure. My registrar had gone home for a half day off, and my vascular SHO (year on from me) was stuck looking after a breast based MDT which is a big meeting, so I couldn't contact him. The decision to go to the patient and see what I could do was clearly more sensible than staying in clinic, but once I went to the sick patient, people started queueing up in clinic waiting to see me. I ended up being with the sick patient for about 1 1/2 hours so built up a number of patients waiting for me (who were very understanding, the worst being someone grumbling about the car parking fee after waiting so long). The patient had fluid in his lungs (pulmonary oedema) which meant that giving lots of fluids to try and bring up the blood pressure wasn't such an easy choice to make. In the end I gave him 250ml of fluid over 30 minutes to see the effect on his blood pressure/heart rate/urine output (urine output was basically 0 for the last 6 hours), asked for a bladder scan in case his catheter had become obstructed leading to the poor output, and called the critical care outreach team to help me. Sadly, they took some time arriving (hence why I had to stay there for so long) and my interventions didn't do very much. In the end, when they did arrive, the ended up giving atropine and glycopyrrolate (drugs I wouldn't have dared to give on my own). He ended up going to HDU (a ward which is one step down from ITU) but from there improved and seems well now.

The cause of this profound bradycardia (slow heart rate) isn't really known. At first, the critical care team though that, as this sick patient had been on digoxin then received a spinal anaesthetic, it could be these two interacting to block the sympathetic nervous system and slow the heart. I thought it could be digoxin toxicity. We took the blood to test for dogoxin levels, but the lab only does these once a week (strange and unhelpful).

Later on this week, a person collapsed in front of me while I was hurrying through one of the corridors to request an MRA scan for one of our in patients. I was in a real rush as it was almost 5, and I needed to catch the radiologist before he left the hospital (and my consultant had specifically said it needed to be requested today, so it could be done early tomorrow so she could then leave for dialysis). Obviously, I had to stop and try and help out. This lady was in her 80s, and wasn't a patient at the hospital, but was just visiting a friend. She had started walking down the corridor but had found herself very short of breath. I asked a few library staff who were walking down the corridor to get me a wheelchair, and call the medical emergency team while I took her pulse and tried to talk to her. Being in a corridor was very awkward as people were all walking by next to us and staring. Taking the pulse was much less invasive than trying to listen to her heart in this situation, so that was all I could do, and she was very tachycardic (fast heart rate) with a heart rate near 150. She was also very breathless and seemed hot and sweaty. Added onto the fact that she had had a lot of heart problems in the past, I was very worried! By the time the medical emergency team arrived, she seemed a lot better, her heart rate was more normal, and she wasn't breathless or sweaty anymore. They seemed a bit confused as to why I had got them to run all the way out here to this corridor! In the end, they said that she should probably go to A&E to get checked out, so I wheeled her there in the wheelchair. I wish I knew what had happened after that, but sadly I had lots more to do that day and ended up staying quite late in the hospital, so I didn't get to follow up what had happened. I did feel a bit of a wally after calling the medical emergency team, but I know that it was the right thing to do after she had presented in such an alarming way...

Long weeks

Hi,

So I have been working as a 'Junior Doctor' for about 2 1/2 weeks now, and it has been really busy. For the last 2 weeks I have been in the hospital every day, as I was on call over the weekend. All of these long days, added to the fact that I have only just got internet in my new house have lead to this relative silence on the blogging front, but hopefully this won't be too common (though I have no idea how things will go for the rest of the year busy-ness-wise!)

I am on a vascular surgery rotation for the next four months, and on normal week days my job isn't too hard. I have to stay relatively late sometimes (I am meant to work 7.30/8 til 5, but sometimes need to stay til 8 or 9) but during the day the things that need to be done are not too challenging. Most of the other surgical teams at the hospital consist of an F1 doctor (or several if busy teams), an SHO or two (a doctor who has a year or a few worth of experience), a registrar or two (a relatively experienced surgeon) and a number of consultants (who are the most experienced surgeons and run the theatres and patients in the hospital). Sadly, my team is much smaller, as I am currently at a smaller district general hospital, and most of the vascular surgery is done at the nearby(ish) large teaching hospital. There is myself and an SHO who is a year ahead of me in terms of exprerience (he has done an F1 job already), but other than that we have very little. There is no assigned registrar for vascular surgery (we have to steal another
teams one if we have problems) and the vascular surgery consultants work most of the time at the large teaching hospital, meaning we see one of them once a week for a ward round. All of last week my SHO was on nights, meaning I was left alone to try and organise the ward patients.

While this is a little scary, it isn't as bad as it sounds. Most of my patients are relatively well, and are in the hospital for rehabilitation. This is because most of the seriously ill patients are sent to the teaching hospital for their surgeries (cases like major amputations and ruptured AAA), while my hospital does small, more simple procedures like removing varicose veins, and accepts patients once they are medically well from the large teaching hospital for rehabilitation. This means that I don't usually need to worry about really sick people, and instead need to fuss over blood sugar control in diabetics, and warfarin doses controlling INR. Good practice to start off my F1 job, as it lets me get used to how all these things work, but not too exciting as what I really enjoy is the challenge of diagnosing and treating sick patients. When something does go wrong, though, I am left floundering a little - as there is no-one around to help (for example when I was asked to come and remove a stuck PICC line as an 'expert' [turned out it just fell out])

Despite this, my patients (and I do love saying 'my patients' now, still feels unreal) do tend to stay in the hospital for some time while we treat infections or help them get used to walking again, so I have plenty of time to build up relationships with them. This is something that I have been doing well at, and have had lots of lovely things said to me about my bedside manner by patients and nurses. Always nice to have compliments when you are having to stay 3 or 4 hours past your normal home time to clerk in a patient who was meant to arrive in the morning, but came into the hospital in the evening and needs to be seen.

My on call weekend was very different to my normal day job. Here, there are two F1 doctors (myself and another), who work under an SHO and a registrar to try and run the hospital over the weekend. This is crazy busy, as people get sick at the sme rate, but instead of the normal teams which is probably about 30-40 surgical doctors during the week, there are about 4 of you. The registrar has to spend most of their time in the operating theatre doing procedures, and the jobs come thick and fast. Prioritising is very important, but some wards seem to want to badger you for relatively unimportant jobs while you have more going on. Through a large chunk of Sunday I had to go to theatre to assist the surgeon by providing another pair of hands to hold some of the instruments, meaning the ward jobs built up even further. All you could do was try your best to do the most important jobs, it seems like a very silly system.

After on call and this double week I was feeling very tyre'd...

All in all, I have been happy this week go go back to a more normal job with patients I know, but I am really looking forward to the coming weekend and having some time off! Very thankful that I am not in for the bank holiday Monday though - that is going to be hectic!

Trepidation

Hi,

Here I am, sitting at home, getting ready for an early nights sleep, but anxious about tomorrow. I have completed a few shadowing days working with the F1 who currently does the job that I will be doing from tomorrow onwards as Dr Internal Optimist.

The shadowing days have been a mixed bag. There were a few boring days of lectures, then a big night out with the other incoming F1s on Friday to 'get to know' each other. A good start! This week we have had a couple of days on the ward, following the current doctor doing our jobs - mine was very good - very well organised and had loads of time for the patients. I have to remind myself that he has a years worth of experience on me, and is effectively now an 'SHO'. I hope that I am not expected to be quite as efficient when I start, but I will definitely try!

In the past few days, I have been quite effective, spending a lot of time trying to get patients with problems home from hospital, the most difficult one being someone who is a drug user, has no home, no GP, but we need to discharge while keeping his medications going (so he doesn't turn back to heroin again) and keep his wound dressed. Trying to get a hostel or home to take him was difficult, but he couldn't live in hospital for the rest of his life. He is meant to be going home tonight, hopefully when I go in tomorrow for 'Black Wednesday' he will not be there.

I think it is the things like that where you can make a huge difference by pushing a bit and making an effort, rather than just leaving things to sort themselves out over weeks. I hope I can keep up the good work over the next few months.

Wish me luck, I will keep you updated!

Survivor

Hi,

Back on vascular surgery, and back on the interesting cases. Unfortunately, with essays and the like to do (almost finished this essay), it is not possible to put as much time into going on the wards and into theatre as I would like. Still spending some time meeting patients and seeing interesting things, but passing assessments always has to come first.

This week I met up with the patient with cancer I mentioned some time before, I saw a patient presenting with an unusual swelling in her neck, baffling the doctors, and I found myself talking to a patient who had managed to survive a sequence of dangerous conditions.

The patient who had cancer, I mentioned some blogs ago and despite only mentioning her once here I had been following her through her whole treatment, visiting her once a week to see her radiotherapy and see how she was doing. The idea of this was to see how she coped with the increasing side effects radiotherapy causes on your life, and how she coped with the big life change that having to travel in ever single weekday for radiotherapy for 6 weeks could cause to her life. She finished the course a good month or two ago, and I hadn't seen her since, seeing as she has now gone of home. As I mentioned before, she is a wonderfully optimistic lady, who always has a nice thing to say about her position. I had managed to come upon (though somewhat sneaky means) the appointment time and place for her post-treatment appointment with the cancer specialists, so had decided to follow her here. While this sounds like (and definitely felt like) stalking her, I convinced myself that she would appreciate seeing me again, and anyway, its a valuable learning experience, seeing a follow up post-radiotherapy appointment, right? As is, I managed to persuade the nurses and doctors to let me see said appointment, though they were very confused as to why a 3rd year medical student wanted to be part of the morning, and for only one patient (at this medical school, oncology is not a 3rd year rotation). They were running about 2 hours behind, though, so I got plenty of time to sit and talk to this patient about how she had been keeping herself and how she was feeling. I was pleased to hear that she was feeling great, had no real abnormalities from the treatment other than a little hair loss around the site. She had more things going on in her life again, with someone in her family currently dying in hospital, but still maintained the same positive outlook and cheery demeanour that I remembered from before. Quite by accident I managed to get her appointment shifted forward so she was only waiting for about 30 minutes (I think the oncologists wanted to get rid of me). Not that that is right, as it just meant that others had to wait even longer, but it was unintentional, so I will not feel guilty. There are no signs whatsoever that there is any remnant of the cancer, so a cure is expected, though not guaranteed as who knows what remains in the microscopic level. Great news, and she was obviously very happy with this as well. After a touching farewell I left to return to a lecture. So I hope that I would get to see her again? If I am seeing her again, it will mean she is ill, either coming in with recurrence of her cancer or another medical condition. Its sad that you can see people leave and be unsure as to whether you want to see them again or not, but perhaps you can just hope for another setting, such as on a high street. Good luck to her, whenever I finished talking to her I would always leave with a smile, and I hope that other people who spend time with her give her the care that she is due.

I was spending some time in a clinic later on this week, and saw a good variety of patient presenting with problems with arteries and veins. Common things to see in this setting are problems with the venous or arterial circulation to the legs, stable aneurysms, and the like. One patient came in with a strange pulsatile mass in her neck. It pulsed with the heart beat, and overlay the carotid artery in the neck suggesting a carotid aneurysm (pretty rare). The patient had been referred via a duplex scan, which is an ultrasound scan which can create a picture of what is inside your body, and tell you where the blood is moving. The results from this showed a slightly swollen carotid artery, but nowhere near the size of an aneurysm, or the size needed to be clinically visible on the neck, which this lump was. The surgeons had plenty of questions for this lady, but none of her answers managed to give them an answer for this condition. What are they going to do about it? Are they going to prescribe her lots of invasive but clever tests? Will they admit her for careful monitoring and assess her as an in-patient? Nope. "Go home, and come back if you think its getting any bigger". Talking to one of the consultants after she had been discharged, he admits he has no idea what on earth it could be, but 'that's a bit boring anyway' and it didn't look life threatening. Fair enough, its like the GP option of see if it goes away, and come back if its worse, but that sounded like a bit of a cop out from a high level consultant. Where is the sense of curiosity? Do you not worry that it might be more dangerous than you think? I suppose he didn't want to put the patient though unnecessary, painful tests and waste her and his time. I'm only a medical student, I have no idea what's going on.
Clinics aren't all seriousness though. The surgeon had a good flirt off with a 97 year old woman who had come in with claudication. It started off with:

Doctor: "Don't worry, I will see to you right now"
Patient: :Ooh, I look forward to that, when can we get started? Do all these people have to be here"

And ended with information I don't feel happy about putting in a blog with unknown readership. Needless to say there are some very dirty minded older women out there! Its good to see this consultant not taking himself too seriously though. Makes you much more endearing to the patients.

Finally, on the wards I was talking to a gentleman who had been in hospital for 3 months or so. This is a long LONG time for an NHS hospital, which turfs people out as soon as possible. And understandably so - with bed prices for a night in hospital estimated at £800-£1000 A NIGHT, it is expensive to keep people in hospital longer than needed. That patient had been kept in for so long because he had had a series of problems befall him. he had come in with a AAA rupture (a different man to the one we saw come in with the same condition a few weeks ago), which has a chance of death or around 80% before you get to hospital. This had been operated on and repaired, the operation carrying about a 40% mortality rate (please note, these are very rough figures). In recovering from this, due to the immobility in the beds, he had developed compartment syndrome in his leg, infected with MRSA after an operation, which then progressed with deterioration in his health leading to multi-organ failure, which can give 80-90% chance of dying, with the number of organs he had involved. In and out of intensive care, this patient was still alive, chatty and happy with pictures of his extended family up around his bedside. All of these chances added together give the patient less than a 1-2% chance of survival. That is exceptionally small, especially given that the these figures account for a person who was healthy before, and didn't suffer from the previous insults to his system. All in all, a very impressive feat, and made you feel all warm and fuzzy inside when you saw all the smiling faces of his family on the walls, looking down at him as though they wanted him back home. He would make a lovely grandad, very cheerful and fun to be around, and I hope that he managed to make it out of hospital without encountering any more problems or infections. Surely he has used up all of his bad luck by now!

Relativity short blog today, as I spent the weekend at my grandmother's 95th birthday party. Lovely to see family I had never met before, but means this has been knocked out in under an hour... Have a great week!

Emergency

Hi,

Very exciting and eventful week this week. Lots going on each day, and I feel as though I am 'properly' back into the rotations. Most exciting event this week was getting to scrub in and assist in an emergency ruptured Abdominal Aortic Aneurysm (AAA), which can be beautifully compared to having hours of chat with a particular very sad patient, when I was just meant to be clerking them in. All of this is set on the background of the absolutely abysmal bedside manner the surgeons tend to display, making this one very interesting week!

On with business anyway. Monday was the day, as I mentioned before, that I had been offered the chance to assist during an emergency surgery list. These lists usually involve a lot of diagnostic laparotomies, emergency appendectomies and the such. I was looking forward to this, as after our session on Friday, I was confident suturing and such, so happy I could assist and be helpful. Unfortunately, when myself and my partner got there, there were already 2 medical students in the theatre, meaning we would just crowd the place, or sit at the back and watch. Not much fun. They got their first, they go in - fair enough - so we were planning on going off to a surgical clinic or something, and phoning around using the theatre reception phones to try and find somewhere to go. One of the theatre nurses was helping us for a while, disappeared for a few minutes, then came back just as we were about to leave with the news that a suspected ruptured AAA was on the way in an ambulance, and they were just preparing a theatre to use. Did we want to join in?

Hell yes we did!

Just a side note to explain what this AAA is, for anyone who doesn't know. The Aorta is the main artery in the body. It starts from the heart and travels down to the legs, where it splits in two (one to supply each leg, of course). On its course, it supplies pretty much every organ in the body apart from the lungs, and as such, it is a pretty important vessel. An aneurysm is where it swells up to larger than it should be, due to general rubbish being deposited on the walls (or "A load of shit", as the surgeons call it). This rubbish causes the vessel to get bigger, as it still needs to get the blood through. Picture on the left below (a), seeing the big bulge on the normal aorta!

This aneurysm builds up over years, and is often asymptomatic (people do not know they have one) which is often not too much of a problem. However, in this case the aneurysm had build up and the wall had become weakened, meaning it had torn. This is, as you can imagine, very bad. Suddenly all of this blood which was flowing nicely to your body starts pouring out of the aorta and into the spaces in your body. The AAA is in your abdomen (its in the name) so this blood comes pouring out into this area. This causes plenty of pain, and a massive drop in blood pressure (its not in your vessels any more, its in your belly!). This is bad, and has a mortality (chance of dying) of over 80%. The good news for this patient was that if he got into hospital, the mortality is reduced to 40% - still pretty high though.

We wait around for what seems like ages for the patient to come in and have an emergency CT scan. This is because if the aneurysm is above the level of the renal arteries (the little things which look like arms on the diagram above) the operation is far far harder, and he would usually just be given palliative care because he wouldn't survive the operation. Fortunately, this patient had a suitably placed aneurysm, so was taken through to the theatre. No history had come with the patient other than he had been found collapsed. Does he take any drugs? Does he have any medical conditions? Who knows!

 In theatre, I didn't really know what to do with myself, there were people rushing everywhere, and still no sign of any surgeons. It was the anaesthetist's job first. They had to get some blood to cross match in order to get enough to replace the blood he lost (bags and bags went in through the operation), and they had to put in some cannulas in order to be able to give this blood and monitor his blood pressure properly. Once all this was done, they could give him the general anaesthetic and let the surgeons start the operation. This proved to be a lot harder than I had thought - I saw consultant anaesthetists trying again and again to put a cannula into the patient in the arms, but failing because he had lost so much blood they couldn't get into a vein. Next they tried the arteries. Again, failing on the arms, they had to move up and insert a line into the neck. The more central the vessels, the more likely they are to have blood in them - and the body prioritises the brain over everything, so it will get the best blood flow. All the time this was going on, I had been instructed to talk to the patient, keep him from flinching away from the pain of the repeated needles he was being jabbed with, and keep the anaesthetist informed about his concious level. If he stopped talking, then things were getting worse. He was absolutely out of it - no recordable blood pressure, in hypovolemic shock and in agony, He didn't want to talk, and when I tried to engage him he would mutter something about his walking stick, or about a budgie. All this time, I was aware that, if he died before waking - I would have been the last one to talk to him. What do you say? I didn't know.

Once the patient was anaesthetised, I was given another astonishingly important job. Hold his arm. Wonderful - this operating table only comes with one arm rest now (who knows where the other is) so you need to hold his arm out, full of lines now, whilst holding up the "blood brain barrier" (the shield that separates the the anaesthetists at the head end from the blood and sterile conditions down the other end) and making sure I didn't touch anyone who was scrubbed up. Arms can get pretty heavy after a while, but that's just me being weak. Better that holding up a leg. Finally someone got an arm board from another theatre, and I could set the arm down. At this time, they were just putting in the graft to make the aorta a closed tube again, rather than a torn hose. Similar to the diagram above (c) this is just a section of tube that is put inside the aorta to let the blood flow through that instead, and stitched on at either end. The surgery isn't done like it is in (c) though,  that is a non-emergency aneurysm repair (EVAR) This surgery involved putting a couple of beefy clamps on the aorta either end of the aneurysm and cutting it open to scoop out all that rubbish inside, and put this tube in. obviously whilst doing this you have to avoid all the blood that is already around the aorta from where it is been bleeding from the tear. When I say avoid it, I mean just stick a suction nozzle in it and try and suck it all out of your way so you can get to the aorta.

Once I had put down this arm, I got to scrub in. Excellent - seeing as they had done the hardest part, putting the graft in, the consultant didn't need another highly experienced assistant any more. He could get away with anyone. I went and scrubbed up (basically just washing your hands for ages, and then dressing in a certain way so what you put on is still sterile) and got to get my hands (or should I say gloves) dirty. We just tried to stop any visible vessels bleeding (the incision and surgery is done in a real hurry in order to get to the rupture, that these cannot be sealed as they are cut through) and put the gut back into the body in pretty much the correct order. At the start, all of the gut had been heaved out of the cavity and just put in a plastic bag to keep it wet and warm 'til now. You would then sew the patient up, but there was a substantial delay to this because he wouldn't stop bleeding. This was due to an effect known as consumptive coagulopathy, where the body had used up all of its clotting proteins in trying to stop the ruptured AAA bleeding into the abdomen. Now that that had stopped, the body could no longer clot the blood, and every single capillary that had been cut through was leaking watery red blood. Normally the clotting would shut them off in an instant, but without these fancy factors, the patient would just keep bleeding. Fortunately, the anaesthetists are equipped to deal with this, and after several bags of platelets didn't slow him down, they gave some fancy proteins and drugs which did. About time as well, all this lack of clotting had not just affected the incision in the abdomen. All of the previous attempts at inserting a line in his arms to his neck had started bleeding, and his lips had swollen and bled over his mouth and face, from the pressure that was exerted during intubation. Quite a lot of blood, everywhere. The abdomen was closed and we were free to go off home.

How long did this operation last do you think? About 5 1/2 hours would be a pretty accurate answer. That's a long time with your arms inside someone's belly, but its major surgery. Most patients survive the surgery if they get to hospital, it is the days/weeks later in ITU that pose a problem. It is a lot for your body to recover from. Hoping that the patient would be fine (obviously, no point in wanting anything but that, is there) I went home for a nice shower. You will be pleased to know that he is still alive in ITU!

That is how I can see the appeal in surgery. That was very exciting, and exactly the sort of environment that I would enjoy working in later. I would love to do something that acute and that exciting, where people come in with such extreme problems, and you have to do that work to save them. Awesome.

Over the next week, more things happened, nothing as exciting as Monday, though. On one of the days, I was clerking in a woman who had been admitted from a clinic because of limb ischemia. One of her legs had developed a problem in the artery, and it wasn't getting the blood it needed any more. A simple operation sticking a balloon down the artery and expanding it again, would put her back to normal, otherwise the leg would die and start rotting. Not really a competition. This lady was very unhappy to be in hospital, though, and I started talking about some of her worries whilst examining her. She had lost a number of family members in hospital, including children, one an adolescent. I was just chit chatting with her, really, until I came to feeling her pulse. You should feel both sides, looking for any delay, and as I was feeling on the other arm, it felt all bumpy under my fingers, I turned over her hand, to see what it was, and saw dozens of white scars across her wrist. I didn't change the topic of conversation, I didn't even let on I had noticed, continuing the examination - and I think she bought it, being distracted at the time talking about her pets at the home she lived in by herself. My attitude towards her changed completely, though. I felt I was no longer just clerking in someone who didn't want to be in hospital. I felt I was looking after someone who had been more upset that I could imagine at times in her life. I felt sorry for her. I wanted to help her. But I didn't want to act strangely suddenly. I decided that the best way to do this would be to just talk to her about her worries, her troubles, her past and what she saw in her future. I was there 'til around 8 in the evening (though I hadn't gotten there to clerk her early by any means) and then I visited her the next day, and the day afterwards. There was always a medical reason to lead the visit with. I could be checking on her blood results in order to build a case to present, I could be interested in what the results of the scan were, but I would just end up talking with her. It is sad that, when I am a doctor (sooner rather than later, please), I will not be able to justify doing anything like that. At the moment, it is my time, to spend how I want to learn. If I am being paid to be in the hospital, I will have mounds of work to do, and won't be able to talk to any patients like that. A real shame.

As the week went on, I decided that perhaps I don't want to be a surgeon. Monday was really exciting, but most of their time is spent doing mundane operations again and again. This isn't the main reason, though. Surgeons really do not have any bedside manner at all. Spending time with consultants and registrars in clinics, they would just wander into an examination room, instruct a patient to take off whatever item of clothing was required, wander back in a few minutes later and tell the patient what they were going to do. Then leave.

Surgeon - "I am going to scan your leg"
Patient - "Err, ok - what does that involve?"
"Sit on the couch please" (bear in mind, patient has already taken off trousers from previous 'visit')
"Mmm... ok"
*Surgeon uses duplex scan (ultrasound like device) to assess arterial insufficiency in leg*
Surgeon - "Thank you"- and leaves room
Surgeon - returns 5 minutes later, patient still sitting on couch without trousers on - "You can leave now, we have patient's waiting you know. Your AT has a triphasic response by the way"
Patient - "Psyphasic?"
Surgeon - "We will send you a letter about it in the post, don't worry"

This wasn't just one patient. It happened again and again. Don't get me wrong, surgeons are great fun to hang around, and can be really nice to the patients. It just seems that some of them (don't let me generalise here) don't realise that you should try all the time.

In case you are wondering, a triphasic vascular response is a good thing, and indicates normality. Hopefully the patient will be pleased to find that out!

Have a good week, next week I am doing urology - perhaps not going to be as exciting as this week, but perhaps that is a good thing - I have far too much work I need to be doing!

Surgery

Hi,

I'm back after a nice holiday, and back on the working train. As the first week of a rotation, it wasn't typical, and we started off the week with 'introduction' lectures. These involved learning the history about the area we practice medicine in, the history of surgery, and the history of medicine within the area we practice medicine in. If this wasn't going to be too much fun for our poor bored minds after the holidays, we also managed to get a lecture from an NHS manager on the management of the NHS, the structure of the NHS system, and what managers do. Unfortunately this only served to reinforce the feeling that if anything in the NHS needs to get cut back, this would be a good place to start.

Anyway, moving on from the tedium of the first few days, which did serve to remind me how much more I enjoy the clinical years compared to the first 2 years of lectures, we spent some time with surgeons doing everything they do apart from going into theatre. A bit of a shame we haven't had the opportunity to slip into theatre yet in the first week, but next week... Anyway - I can see why surgery might appeal to people, you seem to do everything an physician does, as well as operate. You see patients with symptoms to plan investigations to diagnose. You prescribe drugs, you run clinics (though they seem to be the bane of the surgeon) AND you operate in your spare time. Despite all of this 'work' surgery seems a lot more relaxed than the other departments I have done rotations in so far. We were taken to the common room a couple of times, and had tea and coffee, watched the election on the TV, and had the opportunity to play some pool or table football. It seems that medics seem to have a lot more work to do compared to surgeons, who can wait around much more waiting for surgery to start, and so on.

Another wonderful thing about surgery is the fun nature that a lot of surgeons seem to have. The typical opinion across hospitals of surgeons is pretty similar to 'Scrubs', arrogant, less intelligent and jocks. That's the usual response I tend to hear, if I tell people I am starting surgery, or going to have it as my next rotation. For some of the surgeons, this isn't an inaccurate description. There are some particularly scary surgeons who have reputations across the hospital as those not to cross or annoy, and unfortunately I have one of these in about a month. Despite all this negative press that surgeons tend to get, many of them are really fun to be around. Not always taking things too seriously, they are often jokey and interesting to be around. It seems that many surgeons place a lot of value on general knowledge, perhaps hence the history lessons at the start of the rotation, and like you to know a lot of non-medical things (verging into more academic areas such as physics). The sceptic in me says that this could be because they don't need to know as much medicine, instead concentrating on manual skill for operations, but that would just be harsh, right!

Learnt a few important facts this week, though. Certain surgeons lock the doors as they start the lectures, in order to stop people from coming in late. Sounds a good idea really, but will probably mean about half the rotation don't benefit from the lecture. Also learnt that surgeons expect you to learn a LOT of anatomy. I was embarrassed this week because I couldn't name all of the vascular branches from the start of the Aorta to when it passes under the inguinal ligament in the thigh after bifurcating. This includes all the branches in the pelvis, and is quite a lot (supplying all of your body but the legs) -  but have been told I should know them all by Monday. The plan is if I do know them, I can assist in the emergency surgery list on Monday, which would be exciting. I have some work to do!

On that note, I managed to embarrass myself further last week by missing a patients femoral pulse completely.  The lady had arterial insufficiency to her legs, meaning they were ulcerating, getting infected and starting to decay because the cells were dying as they were not getting enough oxygen/nutrients. Peripheral vascular problems are very common it turns out. Myself and another medical student were asked to feel for this lady's femoral pulse, to see if anything could be felt to work out where the blood supply was being occluded.  A little awkward, as this lady was in a hospital gown, so we had to lift it up to around her belly-button in a cubical with about 8 people in, including us. I couldn't feel anything, and neither could my medical-student college. We reported this to the surgeon who duly wrote it down in the notes. About 5 minutes later, as part of the examination of the abdomen, a senior doctor pointed out that there was most definitely a femoral pulse, and guided out hands to it. It was very obvious, and I have no idea how I had missed it. Perhaps on the frail skin of the old lady I had gotten my land marks confused? Perhaps I was just being dense. We were 'firmly advised' to practice feeling our own femoral pulses 'in bed at night' - with a wink, so we didn't miss it again. Not only did I manage to stop here, but I managed to answer the question as to which bone the femoral pulse was felt against as "the Fibia" I was duly ignored by the doctor, but yes, there is no such bone as "the fibia" and yes, the correct answer would be femur, pretty much the best known bone in the human body. I should have known that around GCSE level, let alone now I am a 3rd year medical student. Not good! Needless to say, this was a pretty embarrassing day, but sometimes days just go like that, the brain doesn't seem to engage.

Well, I will wander off now to learn the branches of the aorta and to do an essay, and won't waste my time or yours rambling on any more. Hopefully next week I will have done some exciting things to report back. While exams loom and work presses on, I still want to get the most out of surgery and get stuck in. We did a workshop on Friday where I learnt to suture pretty effectively, so hopefully I can put that into practice!