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Internal Optimist

Discussion in 'Weblogs' started by InternalOptimist, Jan 19, 2010.

  1. InternalOptimist

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    Change to surgery

    Hi,


    I change rotation this week, and location. I am now back living in my 'own' rented house with my flat mates, rather than the hospital accommodation I have been in for the last 8 weeks, and commuting an hour or so drive to another District General Hospital (DGH) every day. Living back with my friends is lovely, though there are bad aspects too. An hours commute rather than 2 minute walk means really early mornings, and the fact I am now living with my friends, and back in a city where I know lots of people, means that I am not spending much more time socially, and a lot less time doing any work. In summary, the move is good for me, though not good for my work or sleep.

    The new rotation I am on is surgery. This week our team was on take, meaning all surgical patients who came into the hospital (a surprisingly large number) came in under our team, meaning we needed to sort them out and either treat them, or somehow palm them off on a different speciality. Palming people off can be easy (if they have a fracture, orthopaedics love it) but is usually very complex, as many people get stuck in hospital for social or 'unknown' reasons, meaning they cannot be transferred to another ward. While being on take was really interesting for me, and meant I got to do a lot of history taking and so on, it also means I have spent no time in theatre yet, and actually still don't know what speciality within surgery I am placed on.




    I was told I was being placed in breast surgery, but one of the junior doctors tells me that that the consultant I have attached myself to is an 'upper GI' surgeon. He spends all his time working away from the ward, and I have seen him for 2-3 minutes this whole week, so I have no idea. It is possible that I have spent a week with the wrong team, but its all learning I suppose!

    It was a good week as well. Clerking patients in when they first get to hospital is something that I really enjoy doing. It needs a lot of brain power to work out which questions to ask to exclude the serious causes / cover the common possibilities, then use your information to decide which causes are most likely, and then order investigations (such as blood tests and X-rays) to prove or disprove your 'differential diagnoses', while excluding serious problems (like heart attacks). I really enjoy having to think like this, and it is much better practice for my finals than doing paperwork. I think working in A&E or an acute speciality where this is the norm would be something I would really enjoy.

    This week I got to go through this routine with a number of different people, being the first person to see them, taking a history and examination, deciding what bloods to investigate, inserting a cannula to take the bloods and give fluids, taking them to the ward and deciding on the initial management. It was often hours and hours between when I saw them and the first time a doctor saw them, so making the right decisions is very important (or at least not missing something really serious such as a heart attack, or ischemic bowel!) Pretty stressful, but so rewarding.

    One of these patients was in acute retention, meaning he hadn't urinated in 4 days. I requested an ultrasound bladder scan to see how much urine he had, and decided that he needed to be catheterised relatively soon, as he had a good few litres in there (as would you if you didn't go to the toilet for 4 days!). I took bloods (looking at kidney function, as this pressure may be damaging them) and decided to call the urology specialist in the hospital to help insert a catheter to relieve the pressure in the bladder. He had had previous surgery to the prostate, and had a stricture - normally catheterising himself but finding it impossible to insert over the last 4 days (hence the massive bladder). I thought that, if he cannot do it, despite having 5 years experience, there is no chance I will be able to! The urologist clearly didn't think so and SHOUTED down the phone at me for a good five minutes about how useless I was, how I was worthless and how dare I waste her time... Completely unnecessary, and time which could have been used catheterising my patient. Instead I had to ask my senior to do it for me, who was just a general surgeon. This went badly, and ended up with continuous bleeding from the penis, and a needle having to be pushed through the abdomen straight into the bladder to relieve the pressure (called a suprapubic catheterisation). It would be a good case for a 'told you so' to the urologist, if I wasn't so scared of her... Fortunately the patient was OK, and was very understanding and lovely about the whole thing. It always seems to be the lovely patients who end up with the raw deal... Since admission I have been to visit him every day, and he always gives me some grapes to eat (reason enough to visit!) and he is recovering well, with surgery planned for the Monday!

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Change to surgery ]
     
  2. InternalOptimist

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    There is no such thing as a free lunch

    Hi,

    Another week in my surgical placement, and I finally learn that I am on an 'upper GI' surgery placement. Still not 100% sure this is the team I am meant to be with, but they are really friendly so I think I will stay here. Should be a pretty similar experience to wherever else I end up put, as long as the signature at the end counts towards passing this year!

    Its a very busy week, I tend to need to get in at 8, and leave between 6 and 7.30, and with 30 mins- 1 hour travel time each way, I can end up away from home about 13 1/2 hours a day. Doing this five days a week means I am effectively working 60-67 hours a week. For free. Rubbish! Leads to me feeling pretty tired when I get home, so I eat dinner and don't want to work, not good for the revision I am meant to be doing.

    I spend much of my time in the wards, this is our 'post-take' week, meaning the floods of patients we admitted last week, we are now trying to get rid of, treat, or ignore. I can be very helpful as a lot of this involves no skill, but just chasing up results and updating lists. I do spend some time in surgery, scrubbing up and 'assisting' in a number of hernia repairs. While 'Assisting' sounds really important, it (as expected) just involves holding a retractor or pushing bowel around every so often. I don't think surgery is the career for me...



    Its all the same thing...


    In more positive news, the lovely man who I clerked last week, who ended up being rejected by the urology registrar for catheterisation and bled out of his penis for hours as a result and needed a suprapubic catheter is doing very well. I have been visiting him every day, and not entirely because I am very guilty about the mess the hospital has got him into. He is really nice and a fun chat for five minutes when I am waiting around. He told me that once he is out of the hospital he wants to buy be a few pints, a really nice offer, but I am not sure if I can be encouraging alcohol consumption (or even socialising with patients) so I politely decline. This is the great aspect of the job. Cutting people up and sticking your hands in their wounds in boring and nasty, its the personal aspect I love.

    Being a surgeon is not all cutting, though. I am invited to a posh (and more importantly free) dinner part way through this week to 'discuss a certain surgical technique'. This fully funded sojourn (by an unknown, shady organisation that wasn't mentioned) involved a fifteen minute talk on this surgical technique at a hotel (surprisingly interesting), which was followed by an hours talk by an Olympic medallist (I have no idea why), about their experience of the olympic games. Very interesting. There was then a three course free meal with wine. Very classy! It did lead to me getting home at 11 this day, though, making it feel as though I spend my life in the hospital, but it doesn't seem as though other specialities have quite as many 'Jollies' as the surgeons. They always seem to be having important 'talks' which happen to be in posh hotels, or the Bahamas. Perhaps it is to make up for the fact that their job involves cutting up bowels, sticking their hands in poo, and never getting thanked as their patients are always asleep...

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: There is no such thing as a free lunch ]
     
  3. InternalOptimist

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    'Killing' a patient
    Hi,


    It's my last week on surgery, and I am now half way through the
    rotations this year until my finals! A scary thought, as I certainly
    don't feel as though I am anywhere near being ready for those exams -
    but still not scary enough to start revising hard, sadly... As well as
    the general surgery shenanigans I have been getting up to in the
    previous weeks, this week I get to spend a day on the 'simulator', an
    advanced electronic dummy that simulates medical problems and lets you
    practice your diagnosis and treatment skills. This is something that
    was mentioned to us at the university open day about 6 years ago, and
    something I have been looking forward to since then!

    Regarding the things I have been up to in surgery, I have kept on
    doing ward rounds and ward jobs most mornings with the junior doctor,
    who is really lovely. I also helped run a pre-op clinic where patients
    were seen before their operation to check on their health, take blood
    tests and so on. A very formulaic clinic where the same sort of
    questions were asked to each patient, so I could be very useful here.
    I also spend most afternoons in theatre, to make up for all the time I
    have been missing over the last few weeks. Going to the theatre should
    involve some acting talent or a lovely musical, but sadly in these
    cases it involved cutting out gall bladders and a complicated
    operation for pancreatitis where the necrotic 'rotten' pancreas was
    removed by punching a hole all the way the stomach from the front,
    using keyhole surgery, and draining out all the pus and dead tissue.
    Watching the difference between the consultant and the registrar
    operating was very interesting, as the difference in experience does
    show. Both clearly perform safe and effective surgeries, only the
    consultant does so much more quickly, and the movements he makes seem
    a lot more confident and meaningful. It is almost beautiful to watch,
    but I still don't want to be a surgeon and have to do that every day!

    Onto the simulation training. As I said before, this was something I
    have been looking forward to for ages. Imagine getting your 'own'
    patient to try and diagnose and treat - its like being a real doctor
    but with none of the responsibility if things go wrong. The mechanical
    patient had a rising chest, pulses, heart sounds and opening moving
    eyes, as well as veins which can be cannulated and lots more, meaning
    loads of different diseases can be simulated, diagnosed and treated.

    The way our session worked was there were four of us, and we were put
    into two pairs. The idea was that one person would 'lead' a case,
    while their partner assisted by doing things they asked them to do,
    such as prescribing drugs and carrying out procedures such as taking
    blood. In each scenario there was a trained nurse who would assist in
    doing things a nurse would do, such as giving oxygen and administering
    drugs prescribed. While all this was going on, the other two sat in a
    different room, hidden by a one/two way mirror (why are these words
    the same thing!), and watched what was going on to give feedback at
    the end. The case I got was severe abdominal pain after binge drinking
    in Ibiza, which I diagnosed as acute pancreatitis, (fortunate as I had
    written an essay on this a week ago), initially giving fluids and
    oxygen, then calling for a senior opinion. I did forget to do an ABG,
    but other than that it all went very smoothly, though the 10-15
    minutes the case took flew by in a whirl of activity. The excitement of
    it, and how you get immersed in treating this very sick patient felt
    quite real, and it makes me want to do acute medicine even more!

    The case that I was there to assist my partner for did not go so
    smoothly... This was a patient who had a severe respiratory infection
    on top of a history of heavy smoking. She ordered all the correct
    investigations and initial stabilisation of the patient was successful.
    By this point we had both noticed that the patient was allergic to
    penicillin, she by the wrist band on the patient and myself by
    flicking through the 'admission notes'. Despite this, when working out
    the CURB-65 score (a score used to see how severe pneumonia is), she
    used the result to prescribe co-amoxiclav, which was an appropriate
    antibiotic to give the patient. Other than the fact that they were
    allergic to penicillin. Despite the fact that I knew about this
    allergy, and had in fact only just written down on the drug chart that
    the patient was allergic to penicillin, I went on and wrote up the
    co-amoxiclav to be given, pretty much with the same pen stroke. Well,
    the less said about this the better, but I can definitely say that
    after making such a horrible mistake, that will stay in both of our
    memories and we are very unlikely to make such a mistake again!
    Despite having found out all the evidence (and knowing that we
    shouldn't give co-amoxiclav, which all med students know is penicillin
    based) we didn't link the two and gave it anyway. We were very lucky
    it was only a dummy - but it does show how easy it is to make mistakes
    in medicine, and the dire consequences that can come about if mistakes
    are made...

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: 'Killing' a patient ]
     
  4. InternalOptimist

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    Hallucinating snakes

    Hi,


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

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

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

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

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

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

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Hallucinating snakes ]
     
  5. InternalOptimist

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    Illness

    Hi,


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

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


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


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


    Blown pupil seen here in the patient's left eye

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

    "Is the patient on hyoscine for the chemotherapy?"

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

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

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

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

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

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

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Illness ]
     
  6. InternalOptimist

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    The SJT

    Hi,


    Despite my new start on an obstetrics and gynaecology rotation this week, the most 'important' thing that happened was sitting the 'Situational Judgement Test' (SJT) - if you want to have a bash at it yourself click here for the official practice site. The SJT is a test which gives you multiple choice options for 'situations' you may find yourself in as a foundation doctor, meaning it is not really knowledge based. This is the first year it has been used properly, so we will see what happens. It is important, though, as the results are used to allocate where you work on graduating, and which jobs you get. Do well and you could be doing paediatric surgery in GOSH (if you want...), do badly and you could end up in the Shetney Islands working with incontinent sheep... Well, perhaps not, but you get the idea.

    The main problem with this test is that, amongst my year at least, it is perceived as much more of a luck-based-exercise rather than something that requires any skill. One of my friends was telling me that during the pilot phase, two groups were set the SJT, one who had been coached to do well, and the other one hadn't. No difference was seen between the two groups, suggesting that you couldn't practice for it. I don't really like this, as surely you should be able to practice for pretty much anything, from hard maths to soft 'communication skills' - they should all be something that you can practice and get better at. If practising the SJT questions doesn't make any statistical difference, then to me this suggests that the test is far more luck based than anything. After all, you could coach me for a year, but I wouldn't be able to get a (fair) dice to roll any more sixes than you could...

    As you can imagine, the feeling that where we will have to work in future, and the jobs that we can get is being decided by fortune has lead to plenty of outraged Facebook statuses and the like, but sadly there is little that can be done. Despite this feeling that it was luck-based, everyone (myself included) practiced as much as possible for it in the hope to get better scores. It would be stupid not to. I got a couple of books out of the library and have signed up to Pastest for exam revision (generally seen to be one of the better online question banks) as they also have SJT practice questions available.

    The problem was, the books all contradicted each other. I looked at three in the end, 250 SJTs, the Oxford Assess one and a Third one. Of the three, I preferred the Oxford Assess one, though in some way or other they all contradicted one another at certain points. If they cannot agree on answers to questions, then how are we meant to be able to guess ourselves! Often picking the best one or two answers is pretty easy, but it is when ranking the 'inappropriate' ones that things get difficult. If the answers are all wrong, it is hard to decide which are more and less wrong. For example, in Pastest, there is a question about walking in on your registrar watching pornography in the mess, and you have to chose what to do about it. Pastest have decided that calling the police 'ranks higher' than doing nothing at all. I disagreed with this, as what interest would the police have in something which is not a criminal matter? Sure, it is very unprofessional, but I don't think the police would come and perform an arrest (though if it involved children I am sure it would be a very different story). I filled in a box at the bottom of the pastest page, saying I disagreed, and I got a very snotty email back from them telling me I was being foolish, and linking me to this article (which tells us the police did not bring charges anyway). I was impressed that they replied, and backed up their argument with a newspaper story, though. Despite this, the next day I was doing questions from the 250 SJTs book, and the exact same question came up, very almost word for word. the 250 SJT book had different answers, and told me that the police definitely wouldn't be called, as they were not breaking the law, and the police wouldn't be able to do anything. Crazy.

    Anyway, the test went OK, though it is very hard to tell how well something that seems to have very little basis on fact went. I am not sure if the practice I did before helped, but at least if I do poorly and do end up working somewhere I don't want, I will not feel that it is through lack of trying. This whole section has turned into a bit of a rant about this test, so I am sorry about that!

    In other news, this week I also spent time in gynaecology clinics, antenatal clinics and practising suturing with a very friendly consultant who will hopefully let me practice on real patients next week. The gynaecology team is lovely and very inclusive, so hopefully I will have a lot more to talk about next week when I am not raging about this test...

    I will keep you updated on how my application goes, though I will not find out until February.

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: The SJT ]
     
  7. InternalOptimist

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    Merry Christmas

    Hi,


    My last week before Christmas holidays, so a merry Christmas and a Happy New Year you all (or a 'Happy Holidays', depending on which you prefer). The last term has been 16 weeks long, which seems like it has been quite long, given all the essays and the SJT that have had to slot into it as well, so I am looking forward to a nice relaxing Christmas holiday, though revision will have to start soon for finals. Finals are still a long way off, around late March, early April (I think, though I am not definite), but I am not sure my usual revision method will work out too well (cram fervently a week or two before) due to the large volume of facts that I should know but I don't.

    As for this week, it was my last week of my obstetrics and gynaecology rotation. We only have two weeks of this speciality in 5th year, as we have some experience during our 3rd year, and this is meant to just be a refresher. I have been trying to make the most of it, as I cannot remember a lot of my third year as it was so long ago!

    The best part of this week was finally getting a chance to practice my suturing skills on a real live patient. Those who read this relatively regularly will remember that I had lots of practice last week in tying knots (though I did spend most of my post last week complaining about the SJT... sorry about that...) This week I got to practice them for real in theatre, closing up holes in the abdomens of all patients who needed a laparoscopy. These holes only need a couple of stitches as they are pretty small (large enough to put a small camera down for the keyhole surgery) but its still good 'real life' practice for me. The gynaecological consultant is fantastic in trying to get me as involved as possible, and the team are great fun as well. I can see the appeal of being a surgeon. You do your work in the theatre, which you hopefully enjoy, then you get to go to the staff room and relax for half an hour or more while the patient is taken away, the new one is prepared and sorted out by the anaesthetist, and then you come back and operate again. Quite a relaxed job!


    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Merry Christmas ]
     
  8. InternalOptimist

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    Drugs

    Hi,


    I'm back, after a nice relaxing Christmas, and ready for my last set of rotations as a medical student - an exciting (and very scary) thought! I am starting back on a 4 week psychiatry rotation, something that I haven't done since my 3rd year (3 years ago!). It looks to be a really interesting selection of things planned for me, mostly based in the community, but with some short stints in psychiatric hospitals. This week, I have to brave all of the introductory lectures, have a very interesting session in a 'Substance Misuse' clinic, have a few psychiatric clinics, and have to section a patient and admit them to a secure psychiatric hospital.

    The introductory lectures were more interesting than normal, as the people running them had thought up engaging games to help 'teach' us about teamwork and so on. My favourite part of this was a game where they created four groups: one made of consultants, one mixed consultants and students, one of random students, and the final one of students who had chosen to work together. They had to each look at a complex picture and talk amongst each other to recreate it as perfectly as possible. The idea was to show how people take leadership roles, how teamwork is important and so on. This was all well and good, but the fun came from comparing the sketches done by the three teams with students in with the one which came from the consultant group. I am not sure if they were meant to do very well, as they are all used to working in teams, but their picture looked as though it had been drawn by a child who couldn't be bothered to play. Despite it being a grid-based-robot-like figure, they had just scrawled a shape onto it. Perhaps their brains are attuned to recognising difficult diagnoses, to the extend that their art skills have regressed to pre-primary levels.


    Most people's pictures looked a bit like this



    The consultant's image looked more like this


    Well, I digress away from my clinical experiences. The best part of this week was attending a 'substance misuse' centre, where people who are addicted to various substances come to receive safe doses to help them stabilise their lives. This may mean giving them methadone every day (pending an alcohol breath test), or may mean giving them other medications shuch as benzodiazepines to keep their addiction in check. The thought behind providing these medications is that many of these people who are addicted to drugs spend much of the day trying to beg/steal money for those drugs, then trying to find a dealer, meat the dealer, take the drugs, and then starting the cycle all over again. As the people take the drugs as a coping mechanism for problems they have had in life, supplying the drugs in a safe environment means that they have a lot more time in their day to do things like train for a job, or look for housing. Once these problems such as education and housing are more stable, the person is less likely to need to rely on the drugs, and then you can look at getting the person off of them. Just trying to take away drugs doesn't work, as it is removing their coping mechanism, which they need for their difficult lives. Talking to patients, I heard some very upsetting stories about abusive childhoods, about losing loved ones and friends, and one person had his girlfriend stolen by a pimp who wanted her to be his prostitute, and was then kidnapped by this pimp, who tried to get money for more drugs by holding him ransom for over a month. I have had such a 'soft' and easy life, I cannot begin to imagine what some of these people have to go though. Its impossible to judge people for using coping mechanisms such as drugs and alcohol when you have no idea about the torment they have to go through in their lives.

    As well as this enlightening trip to the substance misuse clinic, I spent some time in psychiatric outpatient clinics where I talked to a number of patients with different psychiatric complaints, such as schizophrenia and bipolar disorder. The most interesting part of the week came when my consultant and I were called to come straight to the hospital to assess someone who had been admitted through A&E who seemed very manic. This was a 40 year old Irish lady who had come across to Britain to look for some records. It was very hard to find out anything more on top of that, as she spoke very fast (pressured speech), and was very hard to follow (flight of ideas). As well as this, she was very dis-inhibited and tactile, and was trying to stroke me and kiss my hand while I talked to her. By calling around her current GP practice, we found she had a diagnosis of bipolar disorder (though she denied this) and usually took medication for it. She could have left the pills in Ireland, though I think she stopped taking them while over there, leading to her spontaneous trip to Britain. She was clearly very unwell (though I am sure some of the 'pressured speech' just came from her being Irish), and so was sectioned under Section 2 of the Mental Health Act to be assessed and hopefully taken back to Ireland as soon as possible for proper treatment. A very interesting experience for me, though she seemed so lovely and caring - I felt very guilty being part of the team who was keeping her in hospital when she just wanted to 'go outside and do roly-polys down the hills'.

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Drugs ]
     
  9. InternalOptimist

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    Mocks
    Hi,


    A new week in psychiatry, though ruined a little towards the end by the ubiquitous snow which meant I ended up having to cycle through a blizzard! This week started with a mock test (to prepare us for finals), and had a selection of clinical placements and lectures through the rest. Sadly, one of the clinical placements I was most looking forward to, a placement based around people with HIV who had psychiatric problems, was cancelled. I thought it would be very interesting, as some psychiatric problems lead to people having much higher risks of contracting HIV (such as hypersexuality in mania), while addictive problems such as intravenous drug use, which are also covered under the psychiatric remit, can also lead to higher rates of HIV. As well as psychiatric reasons for contracting HIV, HIV infection can itself lead to psychiatric problems, such as anxiety and depression (from having the illness) and HIV dementia. The breadth of possible cases here could have been very interesting, but I suppose I will never know.

    The mock clinical examination we had at the start of this week was sold to us a good chance to practice some of our history taking and examination, to help us start to prepare for finals in a few months (Finals in only a few months... Oh god...) but I thought it was more of a chance for them to scare us witless into revising really hard, so they don't have to explain why so many people have failed. It consisted of a range of stations, and the feedback I got from them seemed to conflict. The consultant running the chest pain history station told me that, while I got in all of the relevant questions [things like shortness of breath, and family history of cardiac disease] (one of the few to do so!) -I was too abrupt, and needed to be more personal towards the patient. The next consultant, in a station where the patient was suffering from weight loss, told me that I was too 'chummy' with the patient and I needed to me more formal and direct. While this does show that I need to change the style I use for examinations (and towards patients) it also shows me how objective some of these exams are - as I was being the 'same' (as far as I could tell) for each of these. I suppose some consultants prefer a much more friendly approach, while others may want you to be more efficient. I am sure that, whatever they prefer, they won't fail you on what they think of your style. At least I hope so!

    Other than in the exams, I also saw some patients this week in a visit to the secure ward in the regional psychiatric hospital. I have been here before, during my third year psychiatric placement, though I can hardly remember that far back! I number of keypad and camera-operator opened doors let you in in an airlock type fashion into a rather nice ward. It is a far cry from the images of asylums in film!


    Nothing like this at all.

    In there I have some interesting talks with patients, whose circumstances were quite unique, so I will not go into them too much in the interests of confidentiality. There was an undercover policeman who had become so guilty at his work he had become a serious suicide risk and had to be supervised 24 hours a day, and an immigrant from the eastern block who had been in this country for years before trying crack cocaine, becoming psychotically confused and throwing bread all over a M&S supermarket, after becoming convinced that the people were seagulls. Once admitted to hospital, this man had become involved in a number of fights with other residents of the psychiatric hospital, though when talking to him myself, I thought he seemed very measured and in control, and he seemed to have great 'insight' meaning that he now understood that he was ill, that the hallucinations were not real, and that he needed to take these medications. The synopsis? Don't try crack!

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Mocks ]
     
  10. InternalOptimist

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    What is PC for midget?

    Hi,


    A pretty snowy week, as I am sure everyone else noticed, but it sadly messed up my week of rotations. I usually cycle to the close events, so I made some clinical placements (where I managed to accidentally insult a 'little person' - read on...). I did miss the placement I was most looking forward to this week, though, which was a 'forensic psychiatry' placement. It was run at a secure psychiatric hospital for criminals with psychiatric conditions. Sadly, it is a long way away from my medical school and house, and I couldn't drive there because of the snow. I was really looking forward to this placement, as I had been there one before in my third year. It was set in the grounds of an old asylum (very creepy and deserted looking) and the patients had been very interesting, so it would have been very interesting, and I could have got some cool looking pictures!

    As I am in a bit of a rush (work, play, constantly late submitting my blog) I will just briefly talk about things. As usual! The 'little person' incident was the most embarrassing, and hence probably the most worthwhile talking about. I was helping out in a scheme for adults with learning difficulties, mental health issues, and such like, where they met several times a week to do things like art and cookery courses. This isn't very medical, but I was working with a social worker and it was a lot of fun, making paintings and collages and so on. I was working with a small group of people, making a collage to take back to my flat, while chatting to them about their problems. Very informal, but I think the main reason for this scheme is social. I was talking to a person with abnormal growth, meaning he was less than 4 foot high; he was telling me how he got a lot of insults because of his height, and I was asking him what the correct term was for a shorter person. [He told me he calls other shorter people midgets, but didn't think that was PC for me to use, so I should say 'little person' (which I think sounds a little bad), or shorter person. Anyway, during my talk he was telling me how he was very good at collages, and showed me a very large, A1 sized one that he had been doing over some weeks. He was telling me how the difficulty was in the size, and keeping it homogeneous, and I (for some reason) just blurted out "well, they do say bigger is better"... We had quite a good relationship by that point (before, not after) and I was not even thinking about his size when I said it, just about the mural... Needless to say it didn't go down all that well (though we did patch things up by the end). Very awkward. I won't be making that mistake again.

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: What is PC for midget? ]
     
  11. InternalOptimist

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    Soup kitchen
    Hi,


    This week was my final week on this psychiatry rotation, and looking at it in the 'bigger picture', perhaps my last ever psych rotation. This goes for all of the specialities I have done this year, as unless I choose to take a rotation in one of these specialities when I am a junior doctor (fingers crossed) or choose to specialise in that speciality, I will not do that speciality ever again! This is an extra-big deal for specialities like obstetrics, and psych, where most of the 'acute' conditions are dealt with by specialists. Not such a shame for obstetrics (I have seen things...), but I have really enjoyed psychiatry, and while I don't think its the speciality for me, its a shame to say goodbye.

    This week, the main parts were spending a session in a soup kitchen (but not that one) for homeless people, and another 'simulator session' with a robotic mannequin. The 'simulator session' was a repeat of one which I had earlier this year, where a mechanical patient had a disease and you had to try and manage it appropriately The patient was programmed to respond appropriately to certain interventions, meaning this is a good way for us to practice treating someone without risking killing the poor patient. Last time, we almost did this, by forgetting about an allergy to penicillin. This time, I like to think I have learnt a little, as this didn't happen. It is still a very exciting simulation, as you get caught up in the experience, giving orders to your other fellow 'doctor' and the nurse who is there to help you look after the patient. We had problems such as lots of blood coming out of the rectum, perforated bowels, asthma attacks and so on. Very exciting!

    However, I am meant to be on a psych placement. Sometimes it doesn't really feel like that, as there is so much else planned into the weeks I end up everywhere. Even the psychiatric placements are not always very psychiatric, as you may be able to see from some of my previous weeks. This week, the best placement was at a soup kitchen. It was run by a charity (a church) for anyone, and gave out free breakfasts and lunches. It seemed that this service was heavily used by homeless people, but if I had known about this a few years ago, I could have got some good meals when my budget became a problem! About 50 people were fed breakfast, and then hung around 'til lunch, and I am told that this is a quiet day! There is clearly a great demand for this service, and between breakfast and lunch there was a jumble sale of warm clothing for the homeless people. Not everyone there was homeless, some people had houses sorted out, or hostels, but were still without money for food. There was no need for the people using the service to pay, but many contributed a small amount (50p or so) just to try and help out. I was there to help serve out the food and generally much in with the volunteers who ran the place, and they were all a lot of fun! The person who cooked all the meals was a chef who worked the evening/night shift at one of the restaurants, but came here each morning to cook lunch from food scavenged from supermarkets at its sell by date. He explained that the evening job was for his rent and food, whereas this morning volunteering was for 'him', and let him feel he was doing something useful. These sort of unsung heroes lurk everywhere!

    I am not too sure why I was placed here as part of my medical rotation, as it certainly didn't have much medical stuff in it, but it was very interesting talking to the people turning up. If I had more time, I would like to volunteer somewhere like that, but I just don't have time to spare at the moment... Many of the people didn't really want to talk to me about their own social situation, but were happy to engage in a chat about other things such as the economy, or literature. Many of them were surprisingly well read! One of the people there had studied history with Gordon Brown at university, and created a reading list for me, which he wrote on an A4 sheet of paper. Sadly I lost this cycling home afterwards! Another person was talking to me about the opposite of fragile. I would have said that this was robust, but was quickly told that I was wrong. Fragile things break easily, robust things just last longer before breaking, so this is not the opposite. This man claimed that there was no real word for this, but the best explanation would be 'antifragile', meaning something that becomes stronger when stressed, rather than weaker and breaking. He had a number of good examples of this, but the one that best stuck in my mind was (of course) to do with medicine and science.
    A hypothesis is a fragile thing, and can easily be disproven. A more robust thing would be phenomenology, being the study of phenomenon. Much harder to prove something is wrong, unless you are measuring it correctly, but still not the opposite of fragile. Here, he claimed the opposite was evidence based medicine (something close to my heart). In EBM, the more you stress your hypothesis (lets say that defibrillation can restart the heart, and save a life), the stronger it gets, as it gains more evidence. Antifragile! (This Antifragile book may have been on my 'reading list' - I am so sad I lost that!)

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Soup kitchen ]
     
  12. InternalOptimist

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    Viagra tips

    Hi,

    I am now starting a GP rotation, my last rotation ever as a medical student (I really hope!). I have this GP rotation for one month, then a month of revision lectures, then my finals. A scary thought, though I really do hope that this is my final medical-student rotation (as otherwise I would be re-doing the whole year...) This GP rotation seems good though, with a lot of chance to run my own clinics and talk with patients. This is good, in that it gets me ready for all the patient-contact parts of my finals, but bad in that it takes up a lot of my time, meaning no real time for revision. The GP practice is about 45 minutes drive away from my home, and I am usually in from 9 'til about 5.30. It is like having a full time job, but without getting paid!

    Because I am spending some time in the GP, it means I get to see a lot of patients. In the first few days I spent time with several of the partners who run the practice, watching their consultations, and some sessions with some of the practice nurses. This GP surgery is right in the middle of the country, in a relatively affluent village, and the patients (and doctors) tend to be quite well off. The GP I spend much of my time with this week is very different to doctors I have met before. He is about 50 years old, but very much 'jack the lad', swearing a lot, and bantering a lot with his male patients, while flirting with the elderly females. This goes down surprisingly well, and his patients clearly love him. I am told that he transferred here a couple of years ago from a nearby (but not close) GP surgery, and over 2,000 patients transferred to follow him. This isn't common, and shows that this consultation style clearly works for him. He is still very much a country man, though, and was sad this Wednesday after having to shoot his pet sheep, as it was ill.


    Thinking about it, I wouldn't mind a pet sheep. I wonder what my flat-mates would say...

    The GP surgery runs a cottage hospital, where they have a few beds and an X-ray machine, so they can admit patients who are mildly ill and treat them without needing to send them to a large, acute, impersonal hospital. This cottage hospital is run by GPs and nurses. This seems like a lovely idea, meaning patients get care from their own doctors, in a location which is much warmer and less rushed than an acute hospital, while not having to travel far from their own homes. If there is a medical emergency, however, an ambulance needs to be called to take the patient to a 'real' bigger hospital. I think this is good for the doctors, as well as being good for the patients, as it means that the GPs can still practice a little hospital medicine, and perform minor operations and investigations themselves. After this week of GP, I really don't think I would mind working as a GP at all! Seeing the same patients time and again seems lovely.

    Towards the end of the week, I was allowed to run my own clinics. This meant that I was given a clinic which patient could choose to book into when they were calling up to make an appointment. The plus sides were that this created more slots, meaning more patients could be seen, and I had 30 minute appointments rather than the normal GP 10 minute ones, but the negative was that I need to check each person I see with a real doctor, to double check my diagnosis and management plan, and prescribe any medications (as I certainly cannot prescribe as a medical student!). I saw a good range of different people and conditions, successfully diagnosing and 'treating' some of the simpler ones, such as otitis media, and colds. I learnt a lot as well. I learnt that if a 12 year old doesn't want you to take her blood, there is nothing you can do to get it- and spent a difficult half an hour before we had to send her away to be calmed down by her mum. I also learnt something that some of my readers may find useful. While prescribing Viagra is a private prescription, meaning the patient has to pay the cost price of the drug (about £30 for 4-6 I think), this is the same price for all drug strengths. This means you pay £30 for several 25mg tablets, and £30 for several 100mg tablets. A trick that the GP taught me is you can prescribe the patient the 100mg tablets, and explain that these are far too strong anyway, so they can break them in half and get twice the 'use' out of them. A useful thing to remember if you need to go to the doctor for these sort of problems yourself!



    The GP strongly advises patients not to buy Viagra online, as it usually doesn't do 'the job' as it hasn't got the correct active ingredients in it. Use the dose trick!

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Viagra tips ]
     
  13. InternalOptimist

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    Rewards

    Hi,


    A good week, though busyness has lead to a slightly late posting again. Cannot win them all! I pick up on some 'hints' during one consultation with a woman, organising a follow up consultation to talk about her concerns, which is very rewarding (giving me a taste of being someone's GP), and I pass on some of the Viagra tips I had learnt a few weeks ago. The latter patient is really impressed with my knowledge of how to 'play the game' and tells me I will make a brilliant GP. I have talked about this before; it is funny how just regurgitating information to a patient which you learnt a few days ago can make you seem so smart. I guess that most of medicine is just remembering and regurgitating information (such as how to treat a heart attack / best blood pressure pills to prescribe in a 50 year old diabetic), until you turn onto research, which is far more science than medicine anyway. Still, its nice to be complimented and have someone think you are good and respect you, even if it is not earned!


    The stark reality of me medical knowledge. Fortunately 6 years at medical school has taught me to pretend I know what I am talking about.

    As for this lady who I called back, she first presented on Tuesday with what she thought was a hernia coming through an old C-section scar. She has had a number of hernias in the past in similar locations, which have required surgery, but on examination I couldn't see anything hernia-like at all. I thought this was a little strange, given the fact that she has had hernias before, so should know what they will be like. I chatted a little more with her while I waited for the duty-GP to finish with his patient and come and check mine, (the duty GP always checks the patient I see to make sure that they are not dying or something horrific before I discharge them). She mentioned this being close to the anniversary of her daughter's death, and on further talking to her about it, she seemed very down about this. Wondering whether this might be the 'actual' reason for her coming to the doctor, I asked her if she wanted to come back on Thursday and talk to me a little more about this, and she happily accepted, though seemed guilty that she would be wasting my time.

    Come Thursday, I was hoping that she would book in for the appointment, and she did! I ended up talking with her for an hour; she was severely depressed, scoring 21/27 on the PHQ-9 (a GP style depression screen). She was worried about so much, her home situation, her daughter's anniversary, someone who had abused one of her other children but had now developed MS, meaning she didn't feel able to go to the police about the situation, there was so much bottled up. Giving her a chance to talk about it all openly, and have a cry, really seemed to help. We talked about her coping mechanisms, and how helpful she found the Samaritains, and ended up increasing the dose of her citalopram (an anti-depressant). At the end, she was so grateful and thankful, saying what a difference I had made. It felt really good, the fact that I had spotted that this lady was unhappy, called her back for a chat, and helped ehr out, though perhaps only a minor amount. This must be the appeal of being someone's GP. You know them well, you are there for them when they are upset, and you can bring them back to help them with any other problems they have, rather than just treating the organ you specialise in in hospital medicine. This really is holistic medicine, something my medical school harped on about all the time in lower years, but I actually like it! If being a GP is like this all the time, I really wouldn't mind it at all. Before this rotation, GP was pretty much considered as a no-no for career, but now I thinkl its well worth considering. I wouldn't say that it has captured my heart, but it would be silly to rule it out when I love aspects like this. Perhaps I will try and get a GP rotation in my F2, and give it a real go.

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Rewards ]
     
  14. InternalOptimist

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    Final week of rotation as a medical student?
    Hi,

    Firstly, sorry for the late post. I have always tried to post Sundays, this has crept to Mondays and Tuesdays, and now suddenly we are on Wednesday night. its not because I don't care, its just that I am a little busy at the moment, and keep managing to do something else instead!

    It has been a long journey, but the last week was (hopefully) my last week of rotation as a medical student. I have a few weeks of revision ahead of me (hence why I am so busy at the moment), and then my final exams. After these (apart from being very relieved that they are over), I will have a little more hospital time, before (hopefully) starting work as a doctor! Crazy, but all very reliant on me passing these exams. I have always been a 'crammer' before, loving to cram up on information the week before a test, but now there seems to be too much information for this, so I am trying to get rolling earlier, so I don't fail.

    Other than revision, there has been this fiasco with the SJT test. I was placed in my first choice of region with a pretty high score, which was nice as it is a relatively competitive region to get into. I was happy for a day or two, before all the offers were withdrawn, and the tests remarked, before the offers are made again come the 8th (Friday). I am not too worried about my mark, as it was well above the borderline, but if I was on the borderline (either of just getting into my choice, or just missing out) I would be stuck to the news on this at the moment. As it is, I am watching it closely, but more out of an attempt at procrastination. Hopefully I will stay where I was last put, though!

    In my last week of medical student rotations, I had some fantastic consultations. I was left morning and afternoon consultation slots most days, meaning I saw about 10-15 people a day on average, a lot less than a real GP, but similar, in that the patients coming in could have had anything wrong with them. I saw some pretty strange situations, such as the middle aged woman who had come in with her children to find out what she could do about her husband's addiction. This wasn't an addiction to gambling, drinking or smoking as you might think, rather an addiction to the Facebook game 'FarmVille', which had taken over his life, causing him to be fired from work. There was also an interesting case of a shrinking lady, who was about 80, but had shrunk down to 4 foot something due to hyperparathyroidism, meaning a hormone which released calcium from her bones was too high, causing her spine to crush down and for her to shrink. Strangely enough, the treatment for this was to put her on an analogue of parathyroid hormone (a drug that does the same as the hormone causing the problem) which was meant to solve the problem. Whether it does this by creating positive feedback, and thus lowering the parathyroid hormone produced, or whether it had some other effect on the bones, making them stronger, I am not sure. I will look it up; I am clearly still a long way away from finals proficiency!


    The highlight of this week, and perhaps the highlight of my medical education to date was a fantastic consultation that I had on Friday, my last day. The patient was a man who hadn't been seen by the GP for many years, but came in with severe depression. He wasn't someone who used doctors much, but had been persuaded to come in by his son. He started the consultation saying he wasn't too sure why he had come in, as he wasn't interested in any of our 'pills or potions'. As I have said before, I have half hour appointments with patients (because I am much less efficient than a real doctor), and this appointment was before my lunch break, so I had even more time. I ended up talking with him about his issues for a good hour and a half, something that a GP wouldn't be able to do at all. Most of the issues were not solvable by me or a doctor at all, issues such as unemployment, problems with the family, and so on. I will not go into any detail because of confidentiality, but I think he ha every right to be depressed. I ran a PHQ-9 questionnaire by him (used to assess severity of depression), and he scored 23/27, putting him as severely depressed. In the end, I explained what we could do to help him, mainly being medication, and talked about the Citizens Advice Bureau, which could help him with more tangible things such as accommodation. Many of his problems were coming from having such low mood and energy that he couldn't face doing anything in life, which means his life got worse, making him more upset. I talked about the benefits of SSRI drugs in this situation, in that they would provide a temporary 'crutch' for his mind (like a plaster cast for a broken bone), picking him back towards normal, meaning he could start sorting out his life, and get on top of these feelings. He was exceptionally grateful for my time and talking to him about it, saying that it had helped a great deal, and was keen on trying the medication as it sounded like the right route to take. This had all gone on without a doctor, so I called in the GP to double check what I thought and to prescribe the medication. The GP was very pleased with how I had done, and happy to prescribe. The patient was very thankful to me, and when I was arranging a follow up appointment in two weeks (as protocol) asked if he could see me, as I had been so helpful. What a reward, having someone want to see you over all of the actual doctors at the surgery. Sadly, as it was my last day, this wasn't possible, but it was so rewarding to have someone want to come back and see me. That must be one of the most rewarding things to have as a general practitioner; to have patients trust you with their health, and want to see you over other medical professionals.

    Anyway, that was a fantastic consultation, and while only possible because of my long consultation times and free lunch break, it felt as though I could really offer something to the patient and the GP surgery in all. My very last patient was relatively simple, and the GP didn't even bother coming into see them when I presented them to her in her room. As they didn't need any drugs prescribed (or so I had decided) she just said that that all sounded fine, and I could sort it out. They were simpler than the gentleman in the previous paragraph, but this felt like a big step as well; I was seeing patients, deciding on a diagnosis and treatment, then initiating it all on my own. I am so excited about later this year when I (hopefully) get to do this myself at hospitals, but very scared about it as well. Such responsibility...

    Anyway, posts may be less frequent and less wordy for the next few weeks, you don't want to hear about my revision after all! But I will try and keep these experiences in sight as I slog to cram my head full of (seemingly inane) medical conditions such as Buerger's disease, or Ehlers–Danlos syndrome. I really want to be a doctor!

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Final week of rotation as a medical student? ]
     
  15. InternalOptimist

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    Ooooh, I'm half way there

    But I am still, living on a prayer!

    Sorry for the cheesy start... I am half way through my final examinations and the 'revision madness', combined with the relatively small revision play list has got to my head. I though I would 'give it a shot' at putting song lyrics as an introduction. Don't worry; it won't happen again ;)

    Anyway, trying to work hard at the moment to finish off the final exams, but I am finding it tough to keep focussed (but not as tough as 'working the diner all day'...) It seems as though I have been working hard for far too long, and the poor brain is getting fatigued! Just need to keep focussed, will all be over by next Wednesday... 'one way or another'...

    Exams so far have gone OK. There have been some hard questions and some difficult moments in clinical examinations, but there have also been stations/questions which I have done really well in. I just hope that the goods outweigh the bads! I have one more knowledge (written) test and one more clinical examination (where you are assessed on taking histories/performing examinations) left, so I am actually over half way there, but then that isn't nearly as catchy as a song...

    Most of this month has involved me holing myself up in my room (or my ivory tower if you prefer), avoiding having any fun with my flat mates and working at cramming as many facts into my brain as possible, so I can regurgitate them on demand. Not living with other medical students this year is both a blessing and a curse. It makes it a lot harder to practice clinical examinations and histories, as they don't really want to/know how to pretend to have certain conditions for me to practice on. On the positive side, it leads to a much more relaxed atmosphere as around exam time, if the whole house is medical students worrying about the same exams, it feels much more stressful, and people mentioning some condition you cannot remember off the cuff while cooking dinner (those delta waves in Wolff–Parkinson–White syndrome) leads to more stress when you feel as though you don't know as much as your compatriots. This year I have been pretty removed from all that stress, but conversely I don't know if I am learning enough/too much! My thought process has always been that you don't (usually) regret working too much for an exam, but you are far more likely to wish you had worked harder, so I may as well work hard and hope for the best!

    As for exams, things are going OK. I have had a few mistakes, most embarrassingly being very sure about a diagnosis of squamous cell carcinoma (SCC) in one of my clinical exams, after taking a history from, and examining, a patient with a prosthetic lesion. It had been created by some kind of skin putty moulage technique, and looked (very similar to) the picture below, but with a darker centre. I described it as below, with the central ulceration, and assured the examiner the most likely diagnosis was SCC


    A 'classic' SCC lesion - and I swear the moulage looked just like this!

    At the end I formulated my management plan, referral to dermatologist, etc and then for the further questions I was told that the dermatologist thought it was a melanoma, and I had to talk about the management of that condition instead. Below is a picture of a melanoma:




    Melanoma from good ol' Wikipedia

    They don't really look very similar at all. I am not too sure what they were hoping for with the moulage, but I hope I wasn't penalised. I think that the paint that I identified as the 'central ulcer' was in fact the melanoma, and the raised edge around it must have been some kind of irregular border. Other people seemed to get it right, though, so perhaps it is just me! Perhaps the lesson here is not to be too certain about anything :p

    Hopefully small mistakes like this will not lead to me failing the station, as you can only fail a few stations before failing the exam! I did pretty well across the rest of the examination, so hopefully I will still pass. I finish my exams next Wednesday, AND find out my job allocation for next year on the same day. Hopefully it is going to be a really good day!

    Just need to focus on doing well in the next two exams, so I can pass my exams, and be a (hopefully) brilliant doctor next year!

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Ooooh, I'm half way there ]
     
  16. InternalOptimist

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    Waiting game

    Hi,

    So my exams are finished, I got into the F1 and F2 placements I wanted in my top choices of hospital and I am sitting around waiting for my exam results. I think the exams went OK, there were some hard questions and some easy questions, but the most important question is whether there were enough easy questions / I did well enough in the hard questions / I messed up too many of the easy questions. I just want to know if I have managed to pass and can be Dr Internal Optimist!

    There is nothing I want more at the moment than to be able to change the title of this blog to '
    A WEEKLY BLOG FROM A UK JUNIOR DOCTOR

    but before that happens I have to have passed my exams! Lots of nervous energy at the moment as I try and waste away the days before results day. It seems so unreal that I am (hopefully) almost at the end of the journey. I have wanted to be a doctor since I was in 6th form - around 16 years old - so this is about 8 years worth of ambition and work. All of my A levels, exams and so on just lead up to this point, so very nervous indeed!

    Either way, I will continue trying to use up the huge 'hole' left in my life where revision used to be by enjoying myself (so many hours in the day!) and I will keep you posted.

    Wish me luck!

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: Waiting game ]
     
  17. InternalOptimist

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    PASSED!

    I passed!

    Woooo!

    Fantastic news! Since the news I have been so happy; it comes in waves, where I seem to forget for a bit, then the thought comes back that I will be a doctor from this August and I am really happy again. I am still finding it difficult to believe, that I am finally going to become a doctor, but it is all very exciting. Over the weeks before results I have wanted nothing more than to pass, and to have that worry lifted is so relieving. I would hate to be resitting the exams I just did again, or having to do that year again!

    Anyway, now I have to go back into the hospital for a bit, then have a summer holiday, then get to work, as Dr Internal Optimist. Amazing!

    So amazing, I am really looking forward to working in August (combined with a high degree of trepidation/fear!) If you can have a job that you look forward to going to, then I am not sure you can ask for much more. I hope that I still feel this way after working as an F1 for a few weeks!

    Either way, there is not much more to say. I passed my exams, I get to be a doctor, I got my first choice of hospitals for first and second year, and I am more than happy. It certainly pays to be an optimist!

    I will keep my blog title as 'medical student' for the moment, as I am still going to be working in the hospital for a bit, and can keep you updated about that, and then can update it come my graduation ceremony (when I post as an actual paid doctor)

    Thanks so much to all of you for your words of encouragement and luck - they clearly worked out!

    I passed guys!

    So happy :)

    [For the rest of the post, and the rest of my blog, please go to: A weekly blog from a clinical years UK medical student: PASSED! ]
     
  18. InternalOptimist

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    Drugs smuggler

    Hi,

    Back working on the wards, sadly. We are meant to be preparing for next year when we work as doctors by getting used to the F1 job, but it also seems like a cheeky way to get people to work in areas of the hospital for free! Either way, I have had a pretty good week, so I don't have anything to complain about. I had some lectures and courses at the start of the week, getting my ILS certificate, then spent some time in the emergency department (where I think I may want to work later in life) and in anaesthetics.

    The time in the emergency department was fun, and I spent most of it clerking in patients, which involves taking a structured history and examination, and planning what initially needs to be done for them. I have forgotten a remarkable amount already since my exams, it is very embarrassing! The most interesting cases I saw were someone who had come in with a police escort after eating a lot of heroin to try and smuggle it into the country (but it had ended up in his bloodstream instead) and a Lady (as in Lords and Ladies) who used to be famous for her organised charity work, but had succumbed to advanced Alzheimer's disease (very sad). I hate diseases like dementia. As well as making you ill, the take away who you are/were, making it really difficult for the family as well. Who knows what will happen in my (and your) lifetime to change how these diseases effect us, perhaps removing them all together. Well, we can hope!

    Other than working in A&E, I also spent some time in anaesthetics this week, and observed the anaesthetics for several different types of surgery. I saw breast surgery including removal of tumours, and someone having a breast reduction on one side to balance their breasts which were asymmetrical. This was all pretty 'normal' and I got to practice putting in certain airways and inserting cannulas. The most interesting case here was a patient who had received a blue dye during surgery to locate the lymph nodes draining from a breast cancer so these could be removed as well. This dye had spread throughout her body and she looked very blue and cyanosed, looking very ill despite being well. A good thing to remember in case it leads to panic on the wards when you think someone is becoming very ill, whereas their 'smurf-y' appearance (technical words...) should only last about 24 hours before fading away.

    The other procedures I saw in anaesthetics were based around operations on the throat and airway (trachea). These are complex, as the airway needs to be used to breath for the patient, while it is being operated on. Some of the operations involved using a high pressure of gas, like a tyre pump, to inflate the lungs by blowing it down at high pressure from above the level of the operation. Exciting! One of the others was very interesting as it involved an operation to fix the vocal chords in a certain position and the patient had to be asleep for the operation (from outside the neck inwards) but woken up at intervals to check his voice. Very complicated for the anaesthetist, who had to control the level of conciousness with drugs into the blood stream (as couldn't use the airway to get any drugs in), and didn't want the patient to wake up at the wrong time. Something called a BIS monitor is used in this case to tell how 'awake' or asleep the patient is. This gives a score of 1-100 based on how 'awake' you are, and is shown on the image below. I tried it out and it told me I was unconscious. It had been a long day, but I think it was because it wasn't attached properly. Either that or all those finals exams have broken my brain!


    A BIS monitor showing 97 (awake and alert)

    [For the rest of the post, and the rest of my blog, with pictures, please go to: A weekly blog from a clinical years UK medical student: Drugs smuggler ]
     
  19. InternalOptimist

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    Night shift and possible perforation

    Hi,

    A week in the acute medical unit this week, in the hospital that I will be working at next year. This week, and the next 6 or so, are part of the last section of my course as a medical student, aimed at teaching me to carry out the job of a junior doctor next year. Fortunately I have been placed on the acute medical unit, where patients tend to be quite sick, decisions are made daily as there is a high patient turn over (people only usually stay for a day or two) and lots of bloods, cannulas and so on need to be done. This is perfect for me, as I want as much experience as possible in doing these sort of things, as well as ordering scans, making general requests and general dogs-body work around the hospital. I certainly don't have any glamorous expectations of what next year will involve!

    My 'non-glamorous' expectations were proved right on Friday when I did my first proper night shift. Previously I had only stayed in the hospital til about 10/11PM, but this week I came in at 9PM and stayed until morning. This night shift was actually a lot of fun, and I got to clerk in several patients who had come into the hospital at night, and carry out lots of procedures including the ever glamorous 'PR' exam.


    Glamorous medicine... Who said being a doctor isn't an attractive profession? Between these and being vomited on there is so much to choose from...



    On the night shift I was admitting patients, taking their history, examining them and then planning initial management and investigations. The registrar was a really nice cardiologist, who talked at length about how upset he was about the events in Woolwich (him being a Muslim and how it was creating so many more problems... Anyway, this blog isn't meant to be a political statement. The problem with this registrar was that he had decided that, as I had passed finals, I was just an 'unemployed doctor' rather than the medical student I still introduce myself as (until August). This meant that, after clerking a patient who had presented with upper tummy pain, and bloody vomit (haematemesis) - I had taken bloods, ordered an erect chest X-ray (to check for perforation) and all those sort of things, he was asking me to look the results and write down what they said, and plan management. This was pretty scary. He was quite stable, so if he hadn't had a perforation into his abdomen from his stomach he could be left until morning, whereas if he had, he needed much more urgent assessment. In order to be able to tell this, an erect chest x-ray is done, as it will show air under the left diaphragm, showing air has escaped the stomach and is now outside within the abdomen (where it shouldn't normally be).


    See the arrow on the left of the picture (right side of the patient). This points to air which is under the diaphragm, therefore not in the lungs but in the abdomen, which suggests a problem such as perforation. There is air on the other side (the left of the patient) but this is probably just in the stomach and does not suggest a perforation.

    Anyway, this is quite an easy diagnosis to make (as they go) as it is either there or not. But it was a very scary idea putting my pen to paper and saying it was there or not, and having his management depend on what I thought. If I was wrong, he could go all night without the proper treatment and be very sick, dangerously ill, by the morning. The 'lovely' registrar was refusing to help me decide what it was until I had sorted out my own plan, as 'I had to work out how to do it at some point'. Good to have practice in this sort of thing, but not now! Anyway, I thought he was fine, had an 'upper GI bleed' and hadn't perforated, and he agreed, so it all worked out in the end.

    The rest of the night shift was pretty hectic, clerking in a man with blood clots in his lungs (pulmonary embolism), someone who was a chronic alcohol abuser who couldn't even tell me why he was in hospital, and a patient who was very depressed and was trying to persuade me to kill him. I have a lot of time as a medical student when things are busy, which was really useful for the latter patient. This is all ignoring everything else that happened this week. Needless to say, things are busy, and I am really loving it!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: A weekly blog from a clinical years UK medical student: Night shift and possible perforation ]
     
  20. InternalOptimist

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    Referrals

    Hi,

    First, very sorry for the really late post. Things are getting out hand. I always tried to post on Sundays, but then with busy weekends this started shifting to Monday/Tuesday and now it seems to have shifted all the way to Friday. Hopefully I can catch up. The problem is, things re really busy and, while I enjoy sitting down to write a post, it takes time which I don't really have! Perhaps, come August, I will try and keep it regular but remove the 'weekly' from the title to take away that expectation (which I am struggling to meet!) What do you think?

    Anyway, moving on to what I have been up to this week (by which I mean last week), it was a bit more empty than the week before. A bank holiday when I didn't need to go in, and a day of lectures meant I only spent a few days in the hospital. I am still on an acute medicine rotation for this week, before moving onto emergency medicine for the next few weeks.

    The day in the acute medical unit consists of a consultant lead ward round at 8AM, seeing most patients. Patients are normally only admitted to this ward for a day or two, so each patient is an interesting case, needing diagnosis and management plans, which keeps things interesting. There are two consultants who split up and see the patients who have been admitted in the last 24 hours, and a registrar (slightly less experienced) who sees the patients who have been in for over 24 hours, and adjusts their management plans. There are about 30 beds in total. After all patients have been seen by one of these three groups (each consultant has junior doctors with them to help things along) everyone goes into a meeting room, and all patients and plans are discussed. All the plans are put onto a big spreadsheet, which is printed off and pasted on the wall. The rest of the day consists of the consultants going somewhere (still not sure where, perhaps there is a secret bar out back?) while the juniors carry out the 'jobs' on the list. These could be things like taking blood, asking specialists for referrals, or inserting a chest drain. This is the most useful part for me, as I can just grab jobs off of this list and do them, meaning I am helping the team out, while learning myself.

    One of the most useful things I was trying to practice this week was referrals to other specialities. This is where a patient needs a more specialist opinion for a complex disease, and you try and persuade a specialist to come and see them. As a regular reader might know, I have had bad experiences in referring to specialists before (like this), so I thought it would be a good idea to get used to how to do it. Different specialists want different information; a cardiologist will want to know about previous heart attacks or angina, and cardiac risk factors (like smoking, family history of heart disease, high cholesterol etc) while an endocrinologist might quiz you on the exact insulin regime the patient has, how closely they stick to it, and their blood glucose highs and lows. Being prepared for what they ask you is very important, as they won't hang around if you need to pop off and ask the patient! This week I referred patients to the dermatologists (one for a very interesting rash that looked vasculitic (is it lupus!?)) and I took a patient over to vascular surgery myself to try and squeeze him into the radiographer's list of vascular imaging, where they use an ultrasound machine to view the vessels in the legs, and try and work out what the blood flow is like. This sort of negotiation should be really useful come next year when I need to get patients treated and out of hospital as quickly as possible. By taking this patient to the radiographer myself (rather than leaving him to a hospital porter, who may take ages to get there) and negotiating slotting him in between two patients I got him the imaging a day earlier, meaning he could be seen by the vascular surgeons a day earlier, and out of hospital a day earlier (just a bed for a day is about £400 according to the department of health).


    A typical looking vasculitic rash

    As well as trying to do my part to save the NHS money, I also got to participate in draining fluid out of several abdomens due to liver disease. This involved sticking a needle and syringe into the belly to suck out fluid to analyse, and while exciting for me, may not be the sort of thing that people really want to read about!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: A weekly blog from a clinical years UK medical student: Referrals ]
     

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