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Internal Optimist

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

  1. InternalOptimist

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    Spot diagnosis

    Hi,

    A week in the emergency department for me, where I get to assess and treat lots of patients, see a large overdose, and make a 'spot diagnosis' on a receptionist who is quizzing me on her disease.

    One of the best bits about A&E is patients are meant to be in and out in under 4 hours, meaning that you can see, examine, investigate and treat a lot of patients in each day. I am greeting better at writing management plans that are actually accurate now; something I found difficult. I find diagnosing patients and writing management plans very rewarding (if you get it right). For example, last week a 40 year old lady came into the A&E department who thought she had a pneumothorax. This is a problem where air gets outside of the actual lungs, but is trapped inside the thorax which surrounds them. This can deflate the lungs and make you breathless. I have put a picture of a chest X-ray below:



    This is a chest X ray showing a fully inflated left lung (right of the picture) and a partially deflated right lung. You can see the loss of the normal lung markings, showing that it is just air and not lung across most of the right side. This is a large pneumothorax.

    The 40 year old lady was scared that this had recurred, as she had chest pain and felt breathless. As the first person to see her, I started off with observations to make sure she was stable, took a history and did an examination. A pneumothorax will have reduced air sounds over it if listened to with a stethoscope, as there is no lung there. From the history and examination (which showed she was tender over a few ribs too) I guessed that this was 'musculoskeletal pain' - i.e. she had pulled some muscle in her chest, rather than a pneumothorax. To make sure, I ordered a chest X-ray, which I then had to interpret. I thought she was fine, so went to talk to one of the doctors in the emergency department. He listened to the history, had a look at the chest X-ray and just agreed with me, and told me that I should discharge her. Very rewarding to have your opinions 'validated' by someone- hopefully something I can get right more and more often as time goes on!

    Other patients who I saw this week included someone who had taken nearly 200 tablets of a mixed variety, mostly diazepam, and had come in after being found unconscious on a park bench (he was quite sick, and my job involved the exciting task of looking through all the empty pill packets, working out what he had taken, how much, and finding out how dangerous each one was on toxbase). Another patient was a 98 year old gentleman who had severe dementia, and had been bought in by the nursing home as he had become 'increasingly confused'. This is called delerium, and there are hundreds of causes for it. As the patient couldn't say anything to me, it was very difficult to work out what it was that was causing it, and I had to order loads of investigations. I don't feel I really got to the bottom of it, as everything I did was negative, but my senior decided that it was probably a pneumonia and discharged on amoxicillin. Not too sure how happy I was with that, as I couldn't see any signs on the chest X-ray, and there was no suggestion of infection from the blood markers, but I couldn't really argue...

    Early in one of the mornings, when things tend to be a bit quieter, I was chatting with a receptionist, who asked me if I could diagnose her condition. I asked her for some clues, so she told me to treat her as if she had been bought into A&E unconscious on a stretcher with a low blood pressure, but no other obvious problems. She had a good tan going, so I ventured that "perhaps, because you have this bronze looking skin, you have Addison's disease?". I was right, and she was really impressed. It is mainly because 'hyperpigmented skin' is a typical multiple choice question option for Addison's - and I have just done finals. I felt very smart for the rest of the day, after she had heaped congratulations on me, but also a little smarmy. It is good to get things right, especially for the patients, but if you show off about them you just look like a nob! Fortunately this blog is anonymous, so I can get away with showing off a little bit ;)

    [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: Spot diagnosis ]
     
  2. InternalOptimist

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    Ambulances

    Hi,

    An interesting week in A&E, the most exciting part being a few days with the ambulance service with the paramedics.

    A&E had some interesting cases, some sad cases and some relatively dull cases. The interesting included someone whose pacemaker was giving the wrong signals, a road traffic accident where a cyclist had been hit by a car, who had then run off (leading to us trying to balance the clinical needs of the patient with the police wanting to question them ASAP to catch the car driver), and someone who had dislocated their shoulder (which I got to put back in, something I hadn't done before). Several of the sad cases involved people coming into A&E and dying of problems like cardiac arrests, and one was a patient who liked to 'fake' seizures to get her into hospital. There are always lots of less interesting cases, and people who come into A&E who should have gone to their GP instead, but I am still really enjoying this placement.

    The most exciting part of the week, as I said before, was a few days on am ambulance with a paramedic and a technician. Driving around on blue lights and everyone getting out of your way is very exciting! The saddest case that we saw was a man who had started feeling really breathless and confused while in a supermarket, and the cashier had called 999. He has a strange heart rhythm, which we initially thought was SVT, but was actually fast AF. He was very worried about his car parking ticket running out as we took him on blue lights to the hospital, and I spent the time reassuring him. We arrived, and 10 minutes later he arrested and, despite 40 minutes of resuscitation being attempted, he died. Despite him appearing relatively well in the ambulance, where his main worry was his car, he just died - and we still have no idea why. He didn't seem to have any signs of a heart attack, so we were wondering if it could be a PE. I found it quite upsetting, and I don't think that feeling a bit travel sick from bouncing around in the back of the ambulance at high speed with no windows helped things. We saw a number of other patients including a man who had been found in a very 'compromising' position, who tried to tell us that he had been attacked in his home, though it looked as though the problem had been caused by some kind of strange sex game.









    SVT: regular, fast






    AF can be fast and look similar to SVT, but will be irregular rather than regular in rhythm





    While on call with the ambulance guys, I also went into a school full of primary school children and spent some time showing them around the ambulance with the paramedic, letting them turn on the lights and sirens etc. We were still 'on call' whilst doing that, but didn't have any interruptions. I think the point of it was to try and make sure kids are not scared of ambulances if they need to come into hospital, and think they look 'cool' instead! After some of the sadder patients before the school, I didn't really feel in the mood to be very cheerful and upbeat (which you need when talking to children), but it was a nice distraction.

    Seeing a few days in the life of a paramedic was interesting though, as despite there being some interesting things, there is also a lot of calls that they attend that they certainly shouldn't need to; a lot of people misusing the 999 number.

    Quite an emotional week, but busy and interesting. My last week next week, then graduation, a little holiday and I start working as a doctor!

    [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: Ambulances ]
     
  3. InternalOptimist

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    Final week as a medical student

    Hi,

    I would like to apologise for this post being really late, I wrote it over a week ago, then pressed save rather than publish, and went on holiday. The holiday was lovely, but I realise that I need to actually press the right button!

    Despite having found out I had passed my finals almost 2 months ago, I have been working as a medical student in the hospital, getting ready for the job of 'doctor' come August. The idea still makes me feel excited and/or scared. However, the gruelling life of a medical student has come to an end for me. This was the last week I am going to spend in hospital as a medical student, and was topped off with my graduation ball. This week I introduced myself as a medical student for the very last time, I did my last referral as a medical student (where, ironically, I got a grumpy doctor who refused to talk to medical students as it was 'inappropriate') and signed myself off as "Internal Optimist, Medical Student" at the bottom of the notes for the last ever time. It is so exciting to think that, after a months holiday, I will be writing "Dr Internal Optimist, GMC *******" at the bottom of the notes instead. 6 years of hard work, not including all of the school work and preparation before university, have gone into this end point.

    But I am not really sure how to feel.

    The ending has been a bit spread out; I was really happy to finish my finals, and overjoyed to have passed them, but then I have been working as a medical student for the last 1-2 months. I haven't really had any real 'you are finished forever' moment, which is arguably a good thing. I am so glad after each 'hurdle' that I manage to make it over, I am not sure I would be able to handle all of it at once. Although I will never be introducing myself as a medical student again, I still have one 'hurdle' left - graduation. After graduation, when I have that certificate in my hand, I will feel as though it is well and truly over. It will probably be quite an emotional day, not just for me, but for most of my year.

    So I am slightly confused about how to feel at the moment. I am very relieved that I have made it despite friends who were just as able as me dropping out of the course throughout the last 6 years. I am really happy to have made my main 'life goal' over the last 7 years or so. Most of the last 7 years have been aimed at getting into and passing this course, then getting a good set of rotations afterwards, all of which I have managed to achieve.

    But I still feel a bit uneasy. Perhaps it is a sense of 'what now' - having such a long term goal fulfilled leaves me wondering what I should be aiming at now. Perhaps it is the fear of working as a doctor next year; a job where patients put a huge amount of trust in you, and where a simple mistake can have disastrous consequences.

    Don't get me wrong though, I really am happy to finish this course and graduate, it is just there is a slight grey lining to my radiant silver cloud. After graduation, I think the only way that I am going to feel more relaxed about this is by starting work in August, and proving to myself that I can do this job. After all, I have spent 6 years preparing for it, I should be ready by now!

    [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: Final week as a medical student ]
     
  4. InternalOptimist

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    Graduation

    Hi,

    Firstly, thank you very much for all of the lovely messages on my previous posts - it is nice to feel appreciated. I will keep writing while being a junior doctor, but may take a different format. This weekly format was quite clunky, as some weeks I had loads to say, and some weeks I didn't have very much - perhaps I will change to a 'regular blog' instead, meaning I can update on days when exciting things happen, with shorter posts which are easier to fit into (what is going to be) my busy working life!

    I have now graduated, and am due to start work next week. A very scary thought indeed! Graduation was lovely, we had the normal ceremony in the morning, where we came up on stage one by one to be presented with a certificate as part of the main university ceremony, and then in the afternoon we had our own medical students ceremony where we said the (revised) Hippocratic oath (old one not really fit for modern medicine/surgery) and we had our own prizes, speakers and so on. The main event in the morning was a lot more interesting than the one at the university I intercalated at two years ago; it was a lot more relaxed, a lot more fun and a lot less pompous. The event in the afternoon was very informal as well, and much more personalised as it was just for my year. All in all a really enjoyable day, and having this certificate in my hand, and being Dr Internal Optimist is just crazy. When people ask me what I do, I still say that I have just graduated and try and steer the conversation away from that topic. I feel a bit uncomfortable about it, almost as though it isn't right - something that I hope will pass.




    Current impression I am likely to make as I start my vascular rotation next week

    And it is important that that feeling passes - 'Black Wednesday' is next Wednesday - I start work in less than a week, and have shadowing before that. I am going to have to introduce myself to all of 'my' patients! I have decided on a compromise, which makes it seem less strange. I am going to indroduce myself as "Internal Optimist, one of the doctors looking after your care" rather than "Dr Internal Optimist" as it seems less... strange to me. I don't know why it is - I suppose I have always held those who teach us in quite high regard (yeah, I am a bit of a goody-two-shoes ... or sometimes at least). Having looked up to some very inspirational doctors during my 6 years at medical school, it is very strange having crossed that student-brain-barrier and having entered a position where I could well be the 'inspirational' doctor that medical students see. Sadly it is much more likely that I am the poorly-organised-and-rushing-around-doctor who medical students will not get much help from, but I will try my best.

    Anyway, I am looking forward to everything ahead, and while it feels very strange, I think that is a good thing. I will keep posting and keep you all updated. Thank you for being so lovely to me throughout my time posting as a student - writing a blog is good I think. It encourages reflection (and god knows we are told to do enough of that at medical school) and is cathartic to talk about what happened, and look back on how things made me feel. I just wish I had the time (and knowledge) to organise all my old posts in some way to make them more easily findable, and separate them from the 'Dr posts' that will come.


    [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: Graduation ]
     
  5. InternalOptimist

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    Finally, a change to the blog, Medical student to doctor!!! Follows:

    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!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Trepidation ]
     
  6. InternalOptimist

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    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.

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Long weeks ]
     
  7. InternalOptimist

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    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...

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Corridor collapse ]
     
  8. InternalOptimist

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    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 be 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!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: The people you work with... ]
     
  9. InternalOptimist

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    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!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Poo volcanos, crazy patients and narrow misses ]
     
  10. spsir

    spsir New Member

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    This is fiction ? Or your personal experience ?
    Medical students life is strange
     
  11. InternalOptimist

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    Hi Spsir - its all personal experience (for better or worse)

    New post below:

    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!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: http://internal-optimist.blogspot.co.uk/2013/11/the-one-sandwich-to-rule-them-all.html ]
     
  12. InternalOptimist

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    Hi,


    Firstly I would like to apologise for taking so long to update my blog, and explain why this has been. One of my colleagues at work approached me a little after the last post and asked if I had a blog online. I asked her why she thought this (obviously not wanting to admit this as its confidential etc etc) and she mentioned finding the blog online while searching for F2 application information, finding it interesting reading a few posts and from them feeling that 'it sounded a bit like you'. On reading further she found more information about what I had been up to in my F1 life (such as laser tag) and linked it to me, she didn't recognise any patients, though, despite being on surgery with me. This worried me, as while I anonymise all patients I mention in the blog, changing and mixing facts about them, I don't really want this blog to be linked to me personally. This isn't because I say anything in it that I feel is inappropriate in the blog, but I feel that being able to link it to me makes it more likely I will censor the emotions and opinions I want to write about. A recent news article over a hospital worker who was disciplined over making inappropriate comments on twitter (anonymously) also scares me. This operating department practitioner said some pretty silly things (such as planning on using a patient's body hair to make him sideburns like Bradley Wiggins) and rude things about the executive board. I don't think I have said anything this serious, but this man was trawled through the media, and investigated by a professional body and cautioned. I don't want this to happen to me.

    I have had a good think, and a chat to a some friends/family about what they think I should do. I think I will carry on posting but I will try and say a lot less, just little bits about what I have been up to and some funny stores. Hopefully by keeping things brief (and professional) I remove even more patient identifiable data, and minimise the information that people could use to identify me.

    Over the last months so much has happened. Most importantly (to me) my favourite patient sadly died. This was someone who had been in the hospital for well over 100 days from when I was doing surgery. I have talked about them previously in the blog, and while on nights last week I was called to an arrest in the surgical ward. On arrival it was this patient who had arrested (completely unexpectedly) and we did all we could but couldn't restart the heart. I was really affected by this happening at 4AM, while I was trying to look after another patient on a different ward who was getting sicker and sicker (and subsequently died), and I had to go and sit down, have a little cry, and wonder if this was really the right job for me. Having had some time to reflect, this is the right job for me, but I am going have to get better at coping with things like this happening. I have been very lucky so far that not many of my patients have died, but things can only get worse...

    And for some quick bullet points to get across some of the more eye-catching things that have happened since I last posted

    - Homeless heroin user on the ward, complaining about the service that we could offer them. They are telling us on the ward round that 'they pay taxes too, and should get more methadone'. My consultant replies curtly 'there is no VAT on Smack' and walks off. Ballsy and it took some time trying to persuade the patient to stay in hospital afterwards, but very brave!

    - On call repeated bleeps from 'outside lines' (often the consultant calling from home to make sure you are doing OK) actually turning out to be recruitment agencies trying to get me to join up. Lying through switchboard to get to medical people working then trying to sell. Not the best time guys!

    - 30 year old obese man came to hospital with breathing problems, got stuck in his car in the car park and had a cardiac arrest: the paramedics had to dismantle the car to get him into the hospital. Fortunately he survived. It was thought he arrested because the getting trapped inhibited his already problematic breathing by putting pressure on his chest, leading to a respiratory arrest.

    - A man I was clerking telling me he had a 'cauliflower heart'. Very confusing until I realised he meant he had had a Coronary Artery Bypass Graft (CABG or cabbage in medical slang)

    - Behind curtains seeing one patient while another talks on their phone, unaware we are next door "get some of those chocolates for the doctors when you come in, they have been lovely.... No not those ones, they are too dear, get the 2 for £5 ones, then we can keep one" Then looking sheepish as we come to see them next on the ward round

    - A patient telling me 'that was a really good session' after I performed a digital rectal examination on him. Needless to say I didn't go back and see him again, and left it to my colleagues instead!

    My posts may take more of a vibe like the above in future (though more frequent, and less long). let me know what you think (if anyone is actually left reading this after this hiatus!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Confidentiality ]
     
  13. InternalOptimist

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    Nights

    Hi,

    Just completed a set of nights, and I am still unsure as to whether I enjoy them. The positives are that there seems to be a good team attitude of 'we are all in it together' from the other doctors and nurses during the night, and you get to see quite a few ill patients, which means trying to work out what is wrong with them and hopefully putting things right. This is a lot more active for the brain than my daily job, where the consultant does most of the thinking and decisions, while I spend time following orders and filling in paperwork. Sadly there are negatives as well: I get really tired, and then after the nights I cannot sleep properly for the next week or so as my body clock has flipped; there are very few seniors in the hospital to help support with the above decision making, so if several people get sick you are going to have to be confident in your initial management as it may be an hour or two until someone more senior can come and review the patient; there is also the flood of menial jobs from the wards which have been forgotten by day teams (like writing up regular medications) - sadly all of this cumulates in very large sentences...

    While I was on call over the week, there were quite a few sick people on the wards, sadly 2 of these people died. It was difficult to try and manage multiple ill patients as it involved heading between different wards to try and manage each patient while trying to answer the random bleeps that kept coming though (such as one patient who kept having 4-8 second pauses on his heart tracing without any symptoms. Very scary!)


    [PIC]
    Parts of the ECG for the asymptomatic patient with the pauses. In the end the cardiologists put a pacemaker in, but scary stuff (for me, he didn't seem to notice) overnight!

    The craziest part of the night was when I arrived on the gastroenterology ward to write up a new drug chart, as the old one had somehow been lost when transferring the patient from another ward. While sitting at the table trying to work out which drugs the day team had put the patient on during their stay, and which had been stopped (harder than it should be!) I noticed one of the patients had a defibrillator attached to them. In my experience defibs are only usually attached when someone is having some form of cardiac arrest (or you are worried that they are) so seeing a patient lying still in bed hooked up to one of these really confused (and scared) me... I jogged over to the patient, and saw they were breathing (good start) and looked asleep (to be expected as it was 5AM) so I asked the nurse why they had the defibrillator on them. Supposedly the day team had wanted cardiac monitoring for the patient, but the cardiac monitor that the ITU sent up didn't work - so they had just hooked up a defibrillator to use the tracing that it produces instead. I was confused (and a little concerned - what if someone changed the settings and accidentally shocked the patient). On the plus side, at least if the patient started getting more ill there would be no delay in initiating monitoring and treatment during resuscitation...

    [PIC]
    Like this, but the defib was manual so showed the heart tracing from between the pads

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Nights ]
     
  14. InternalOptimist

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    Deaths, difficult families and the worst day yet
    Hi,

    The last week was a terrible week. Very busy and a lot of difficult conversations with families when I didn't feel I had the time to give them the attention they wanted. My new rotation is gastrointestinal medicine, and it is very busy. The last week seemed to have someone dying every day. Many of these people were people with end stage cancer or other serious conditions, but this didn't make it any easier for me at all. The last 8 months or so I have been very fortunate and only had a couple of patients die - now it is terrible.

    My week started off on call, where among others I clerked in a lovely gent who was in his 60s and had the same birthday as me. He had a pneumonia (I am still pleased with myself when I get a diagnosis, even one as barn door as this - makes me feel like a 'proper' doctor rather than a glorified PA) and his oxygen saturations (the measure of the amount of oxygen your blood is holding) were about 80% instead of the normal 95-100%. Other than this, he seemed pretty well. With pneumonia it is common to use something called the CURB-65 score to estimate how severe it is, and plan your treatment. This man scored 0, but I started him on the treatment plan for 'high risk' pneumonia (normally a score of 3 or more) because of his poor oxygen levels (not included in the CURB-65 score). A CURB-65 score of 0 suggests that this patient should have a 0.6% chance of dying from the pneumonia, but sadly 2 days later he had passed away. After having a good time joking with him about sharing a birthday, I was quite upset by this - especially as it had been so unexpected. I am pleased I had started treating him with intravenous antibiotics (as high risk) rather than oral antibiotics (as you normally would for a CURB 0 patient) as otherwise I would have felt as though I hadn't treated him properly, but I still felt upset over this. 0.6% still gives you that slim chance that someone may die...

    Sadly the week got worse from there, cumulating in Friday which was the worst day I have had since I started work last August. It started off like a normal busy day, our ward works with 2 consultants who take it in turns to accept all new patients, and Friday is our day, so there was quite a lot to do. Part way through the ward round (up on the 2nd from top floor of the hospital) we get a bleep from the surgical ward (ground floor) saying one of our medical outliers has some chest pain. This happens a lot (invariably nothing) so I ask for an ECG and break off from the ward round to go down and check it out, expecting to be able to go back and join in a few minutes. I arrived on the ward, to be shown an ECG with good going ST elevation.


    ST elevation in an ECG from wikipedia

    I was panicked - what to do? ABC! MONA?! or should I be preparing him for PCI? I started treatment and then bleeped the cardiology registrar. No answer - I bleeped the other 3. No answers, so I dragged my registrar down away from the ward round to come and help me out. Fortunately it all went well, we continued ACS treatment (so many TLAs!) and the ECG changes went away, the patient didn't need PCI today (and he is still doing well)

    Sadly, because my registrar and I were pulled away from the ward round (which the consultant completed on his own, as he needed to run a clinic in the afternoon) we were not too sure about the jobs that needed to be done. The SHO is in nights, and the registrar had to go to the consultants clinic in the afternoon, leaving me to work out what needed doing.

    This is when the real trouble started. One of the patients on the wards bloods came back with a high potassium, which means that they need certain intravenous medications (like insulin). I prescribed these medications while talking on the phone to one of the F1s from the acute medical unit. They wanted to transfer a sick patient to the ward from there, but needed a medical handover to do this. He explained that this patient was for palliative treatment due to her breast cancer which had spread extensively throughout her body, and she was too sick to be transferred to a hospice. He said she was already on a syringe driver with medications such as morphine to take away any pain or suffering, and just needed some TLC on the ward. I accepted all this and said I was happy for the transfer to happen.

    As I come off of the phone and hand the prescription chart to the nurse in charge of the ward, one of the other patient's relatives want to speak to me. He has end stage liver disease and is too old for a transplant, he currently has a bacterial infection in his abdomen which we are trying to treat with antibiotics, but not very successfully. It turns out that on the ward round in the morning, the consultant had been exploring the idea of going down a more palliative route with this man and his family. The thought being that the infection was only getting worse, and we couldn't give him a new liver to replace the old one that the alcohol had destroyed. It seemed that the way he had done this was leaving the family and patient (who was not well enough to process information) to think about what route they think would be best, as continuing active medical treatment would involve a central line, a nasogastric tube and more invasive treatment. Having thought about this from the morning, the family felt quite put out by this and felt that they were being asked to make a decision about whether the patient should 'live or die'. We were always taught at medical school that these sort of decisions should be made clinically, then the decision communicated to the family with their agreement - it isn't fair to leave this decision to the family, so I agreed with why they were so upset. I felt this was a decision a little too advanced for me to have to deal with, and went to pull my consultant out of his clinic to talk to the family, which he wasn't too happy with. It is decided that this patient is for full active treatment, and I need to find the 'IV team' who are the team who can insert central lines and suchlike. As it is a Friday, if I do not get these in today then we will have to wait for Monday, which means no antibiotics or fluid over the weekend, as we cannot get any venous access on this patient, which would not be good.

    On getting back to the ward, a nurse told me that no-one had been able to give the treatment to the man with a high potassium, as the man had no cannula in to give intravenous drugs. It is about 5PM now and my official time to end the shift. I went to start setting up the equipment to insert a cannula and my bleep went off. I decide to answer it before putting in the cannula, as leaving it would mean they would keep bleeping me while I was inserting this cannula. It is the radiologist calling through an urgent report on one of my patients scans. This lady has suspected bowel cancer (but not proven), and had been feeling a bit dozzy and faint so we had done a CT scan of the head. This CT scan had shown a very large mass in her brain which was squashing the brain up and starting to lead to coning within the brain (where the swelling squashes the important parts of the brain that control breathing and can lead to death). This needed urgent neurosurgical input, so I prescribed intravenous dexamethasone (a steroid to reduce the inflammation) and called the neurosurgeons to talk through what they wanted me to do. While on the phone to them, the nurse comes to tell me that they still cannot give my treatment for high potassium or the dexamethasone as no-one is trained in cannulation on the ward. I ask if they could call one of the other nurses from another ward to help out (though the neurosurgeon is not happy to be interrupted)! The neurosurgeons want an urgent MRI scan before deciding what to do.

    I go to get the equipment to insert these cannulas when a very angry man storms into the nurses station and starts shouting that he needs to speak to the doctor in charge. I am the only doctor on the ward, so am asked to speak with him. He is visibly distressed and shouting about his mum; the lady with breast cancer who had been transferred to the ward a few hours ago. He is shouting things like 'why are you killing her' and 'What is this sh*thole anyway', and physically threatening staff members. I tell him I will happily talk to him at his mum's bedside, and go to look at the patient's notes to prepare myself for this conversation. By now it is about 7PM and I am left in the ward on my own. It seems that this lady with metastatic breast cancer has been known to the palliative care team for some time, and has accepted her diagnosis and the fact that she is dying. With this knowledge I go to speak to the son, at the patients bedside. Her husband is also there. Her son is very angry, and stands with his face about an inch away from mine and shouts at me.

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Deaths, difficult families and the worst day yet ]
     
  15. InternalOptimist

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    Lord Voldemort

    Hi,

    Firstly I would like to apologise for my last post. I realise that the title of this blog is 'Internal Optimist' and I also realise that the last post was not very optimistic at all! I had had a pretty rubbish week and it was cathartic to come online and moan about it. Thank you for your support though!

    Since then times have been a bit easier - there have been some difficulties - for example the SHO post where I work has been empty because the SHO who is meant to fill it is on maternity leave, and now one of the registrars and one of the consultants from the team has left the hospital to pursue other interests. This has left our team somewhat depleted, and the workload a bit higher than normal. Despite this there are positives (as well as the fact that I am currently on nights for a week so have escaped the increased workload of the day team!) - Anyway this is in danger of becoming another mopey post like the last one, so I will just tell some stories of what I have been up to / some interesting observations.

    The last few weeks have been quite emotional. There have been quite a lot of deaths on my ward, which has been quite upsetting. I think this is partially because the gastro ward I now cover has a lot of sick people on it, lots of end stage liver disease and the like, and I also think I have its been very unlucky that recently there have been lots of people who are very sick. One of the most emotional moments with all of this came the day after a patient with decompensated alcoholic liver disease died. He had been in for about a month and I had got to know him and his family very well over this time, as they visited every day. He was requiring regular ascitic drains to keep his abdomen from filling with fluid, and kept fluctuating between being relatively well and acutely sick. Finally, sadly, he died due to 'SBP' - a bacterial infection of the fluid inside his abdomen. The final time I saw him was when he had started spiking temperatures and his markers of infection in his blood were rising. I went to take blood cultures from him and start antibiotic treatment, and explained the situation to him and his wife in a friendly way. We had a few laughs, I went home and when I came back the next day he had died overnight.
    The next day I had to go down to the bereavement office to fill in the death certificate. As I left the office, his family were sitting out there in a group, tearful, waiting for his possessions and the paperwork. His wife, tears streaming down her face, gave me a huge hug and an outpouring of thanks. Thanking me for being so kind, so caring and fun. "he really enjoyed the last month because of you"... It shocked me and I couldn't really think of anything to say other than 'thank you', and 'sorry for your loss', but I spent the rest of the day in a contemplative mood. Death is not something I like at all, but it is something I had been getting more used to, given all the sad things which have been happening in the ward recently. Being exposed to the relatives right afterwards was not something I was used to, and I think it bought home to me a little more that the patient isn't just an isolated person in hospital who you see. They have their entire family, friends, neighbours, children. All of who are heavily affected by the events. It sounds obvious but its not really something that was in my mind before.

    To lighten the mood a little, one of our other patients (a Romanian man) came to our ward telling us that he had serious problems with his liver. The story was that he had developed a yellow tint to his skin but without any other symptoms (painless jaundice makes you worry about pancreatic cancer), and his GP had sent his blood for some tests. 2 weeks later he had called his GP, but been told that it routinely took them up to 4 weeks to get the results and report them to him. Not satisfied with this, he took a plane back to romania, got his blood taken privately in a hospital there, got the results printed, then came back to the UK and came into hospital with the results to get treated. I think it is pretty shocking that our system is less efficient than travelling to a different country (one we tend to see as much less developed than our own) to get the results and bring them back with you! Sadly, on further investigation, he did have a pancreatic tumour. Medicine seems to rarely supply happy endings!

    A few interesting observations from the hospital:

    There seems to be a war of wants between the nurses and doctors, and the bed managers. Bed managers come around every morning telling people to discharge more people, the calls go up that they are not safe to go home, but we need the beds. What are we meant to do? We keep people in hospital until they are safe to go home (doctor/nurse want) but then we have nowhere to put the new patients that come in via A&E (bed manager want). It seems hospitals just don't have enough beds in them. It is a shame that this seems to create opposition between the bed managers and the doctors, rather than letting them work together for an outcome they could both be happy with.

    I am not sure if anyone else has noticed, but medical professionals seem to hate the word 'cancer'. We always seem to take about "Breast C.A." or "Bowel C.A" rather than saying 'cancer' or 'malignancy'. It reminds me of Harry Potter where they characters don't want to mention Lord Voldemort, instead mentioning him as "you-know-who" or "he who shall not be named". I am not sure why people say "C.A." instead of cancer (its the same number of syllables) but I agree with Dumbledore - instead of being scared of the name, taking the power from that name is an important part of the fight!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - Internal Optimist - A Junior Doctor Blog: Lord Voldemort ]
     
  16. InternalOptimist

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    All the small things

    Hi,

    I have just come off of a long days work and thought it was worth sharing an observation based on a couple of patients today.
    I have noticed that it seems to be the small things that make patients happy and thankful, rather than the big things that we think matter the most in the medical profession. Take the two patients below.

    The first patient is a 35 year old woman who has an aggressive, metastatic cancer. She was in under us a month ago and my consultant hinted to her long term partner that perhaps they could consider getting married due to the poor prognosis. She came back to us this week, much sicker and more poorly, sadly having planned her wedding this week, and having to miss it as she is in hospital, sick. We have been trying to get on top of the infection she has, and the cancer, to give her more time, but this is difficult. We are not sure she will be able to make it out of the hospital, and I have started trying to organise a wedding for her inside the hospital. Since this planning started, she has become a different woman; much brighter, much happier and much more healthy. All of the complex medical procedures and drugs we have been using for her haven't really made much of an impression, but this small idea has made her a different person. Every time I see her she thanks me for the idea of the wedding and the plan, but never thanks the consultant for the chemotherapy or for the complex surgical interventions that have been used.

    The second patient is a lady with heart failure and fluid build up on the lungs. We have been taking all this fluid off, and she can now walk properly due to being able to breath, and her legs not being all swollen all the time. This has made a huge difference to her, but today on the ward round, and yesterday on the ward round, she just wanted to say thanks to me for talking to her and listening to her worries. She is worried about her husband, and how he is coping at home without her, she is worried about her sister and her new diagnosis of cancer, and she is worried about her own heart. On Tuesday I had a sit down and chat with her while taking some bloods for 30 minutes or so, and now every time we see her she wants to thank us for being so kind and listening. Not for all the diuretics which have sorted out her lungs, or the ultrasound which diagnosed the problem.

    The problem I find with medicine is that moments like this; where you can sit down for 30 mins to talk to someone about their worries about their family; or where you can try and sort out a wedding in a hospital, are not usually possible in hospital medicine. I spend most of the time chasing my tail around with far too much to do. I like to think that, if we employed a few more people then we would all have more time to do things like this - things we all want to do.

    I feel like I have had a really rewarding day because of these things, not because of the ascitic drains I put in today, or the clever diagnosis of rheumatoid lung I (might) have made, and the patients feel the same. It would be nice to have a system which let us do more of these things, but I will certainly do my best to try and do what makes a difference, clinical or not

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: All the small things ]
     
  17. InternalOptimist

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    The good, the bad and the ugly

    Hi,

    I am sorry for not posting in some time. There are a number of reasons for this - first and foremost that sadly I am very busy at the moment. Another reason is that I have been reminded of the GMC guidance for doctors a few times over the last few months (the GMC monitors and regulates doctors working in the UK), and this guidance states that (and I quote) "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name." This guidance can be found here under point 17. The GMC also makes lots of other recommendations such as not revealing any patient identifiable information (I re-iterate that I mix and match, and change patient information so none are identifiable at all).

    This is obviously concerning to me as I have worked hard to be working as a doctor, and I enjoy it a lot, and don't want to lose it because I am breaching this guidance. The option of losing my anonymity as per the guidance seems to be an even worse option, as I feel this could impact on patient confidentiality. If people knew where I was working.studying then does that make it easier to identify people I may have seen?

    Some thoughts for me to ponder on, while I leave you with some thoughts to ponder on. The great Junior Doctor Switcharound has been and gone, and I am now working as an FY2/SHO/TLA in a large teaching hospital. This whole period seems a little Mad Hatter's Tea Party-esque where all junior staff up and leave their jobs on a Tuesday and start work on Wednesday with the evening to move to a different house and then work out what the new job requires them. I am sad to be leaving behind my old hospital, I felt as thought I knew most of the people who worked there and whenever it was a tough on call or night shift there would always be a nurse or two on each ward that I knew who would kindly (or not so much as you will find out!) brew me a tea/feed me cake/tell me interesting stories to keep me going! I have now moved to a much larger hospital, so I am sadly expecting it to be a little less friendly, with less of a community feel, but I am hoping to be proved wrong!




    The real reason for this post, general natter aside, is to say that I think that key hospital events fall into 3 (or sometimes 4) categories. Good, bad, ugly and occasionally miraculous. I will give some examples from my last month as an FY1/HO that may make interesting reading

    Good
    A few weeks before this event, a lady came to our ward who we diagnosed with very advanced breast cancer. My consultant - who is a very straight talking man - advised her and her partner that if they wanted to get married now was the time, as they didn't have much time left to decide. A few weeks later she came back into the hospital getting sicker much more rapidly, but with her wedding planned for a few days time. Sadly she was far too sick and couldn't make the wedding that they had planned. I worked with the hospital chaplain and we organised a wedding in the ward for them. We turned the clinical room into a bridal room for her to prepare, and many of the other patients got involved. A wonderful experience with a bittersweet ending, as she sadly died the next day. Letting the couple share that moment of happiness didn't take any medical skills, but meant the world to them. As Robin Williams' Patch Adams said:

    "You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome."

    Bad
    I was talking to the lovely lady who I mentioned in my previous post with heart failure and she mentioned that she had been getting recurrent abdominal bloating and had lost a bit of weight recently. The consultant had already ordered a CT scan of her chest, and I asked him if it was worthwhile adding a CT of her abdomen to the request to look into this. He said he didn't really think it was, but I did it anyway - and now she has a diagnosis of advanced ovarian cancer. Since I explained this diagnosis to her she seems to have lost a lot of her fight and I had to leave the hospital before she was discharged, though it looked like she was getting worse. The fluid build up in her lungs had been due to the ovarian cancer. I am not sure if she will manage to leave the hospital, and in part I feel like I am deserting her moving hospitals, but I know that is silly.

    Ugly
    During one of my on call shifts over the weekend I had worked from 8AM to 6PM without anything to eat due to the never-ending stream of jobs, and the nurses on my normal ward took pity on me and when I arrived to do the jobs they had asked me to do, they instead took me to a side room and fed me tea and a slice of birthday cake! I was famished so I quickly devoured both, spluttering thanks (along with cake crumbs) to the nurses. After I had wolfed it all down, I asked them where the cake had come from - was it one of their birthdays?
    No. It turned out that it was a cake which had been given to a 94 year old naturist on our ward who was very sick with hospital acquired pneumonia (more likely than pneumonia caught outside of hospital to be caused by unusual weird and wonderful bugs). [On a side note, this 94 year old wandered the corridors every night, naked after taking her clothes off, and pressed herself to the windows of the nursing station to look at the people inside!]

    Not only had the nurses fed me this geriatric-cake, but they had actually seen her blow/slobber our her candles over a few minutes (those lungs weren't too good, due to all the pneumonia). The family had kindly given the nurses half the cake, but the nurses were not too sure how safe this cake was, so had decided to test it on me. These were not even random people I didn't know - they knew me well as I had worked on their ward for a few months. It was all meant to be a joke, but sadly this joke ended up with me eating some super-bacteria-infected-victoria-sponge. Fortunately I didn't get too sick. I felt a little man-flu-ish over the next few days but nothing worse.

    A similar incident happened to me over a previous weekend on call - one of the respiratory specialist nurses I knew well from my previous rotation was doing bank work as a ward nurse, and asked me to come in and see something 'urgently' as she was worried about it. It was a very large boil on a man's back, which I dutifully (with gloves on) began to inspect it. Unfortunately after touching it, it started squeezing large amounts of pus out of it, like toothpaste. This was very unexpected, and of course I had to deal with it professionally. I got some gauze and made sure all the pus came out (once I had started I had to finish) while this nurse and the HCA sat their giggling at me. The man thought it was hilarious as well - he must have been in on it. The persecution I suffer while just trying to carry out my house officer duties like re-writing drug charts!

    Miraculous
    A brief mention at the end for a, miraculous event that happened.

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: The good, the bad and the ugly ]
     
    #137 InternalOptimist, Aug 15, 2014
    Last edited: Aug 15, 2014
  18. InternalOptimist

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    Time out

    Hi,


    I know it has been a very long time since my last post - (months!) but I have been mulling over this GMC situation I mentioned in my last post. I have decided that instead of posting long detailed posts as I have been before I will just post a little story of bit of information that I have been thinking about without background, adding to the anonymous person-and-situation-changing that happens already. I don't want to stop writing things down...

    That being said, finding time for writing things down is tough! When I last posted I had just finished my F1 and was starting a rotation in A&E as an F2. I now just completed the 4 month rotation in A&E and am working as a GP now for the next four months.

    A&E was amazing. The breadth of different conditions, learning different skills, and all the crazy reasons for people coming in was great. I looked forward to going into work each day, and perversely, while all the nights and weekends were a bit rubbish, having time off during the week was really nice. Lots of very sick people, exciting trauma situations, people with odd things in odd places and so on. I am now applying for A&E speciality training and have my interview soon. Hoping that this goes well!

    Despite all of the 4 hour target pressure and the news about A&E being swamped (it is) I think I am finding my new rotation on GP more stressful. In A&E there is great banter with the other staff, always people to ask to help out, and the sense you are all in it together. In GP I am stuck in my own room, trying to see people every 15 minutes who usually have little wrong with them, but occasionally can be very complex. Trying to pick the complex ill patients from the rest is difficult without any investigations, and trying to manage time to see each patient in about 10 mins (leaving time to do paperwork, referrals, etc) is very difficult. The simple patients who have colds and want antibiotics should be able to be seen in 3-4 minutes, but usually take 10-20 due to all the arguing over the fact that they want drugs. They patient who is suicidal and depressed cannot be condensed down to 10 minutes, and makes everything run late. At least in A&E if you need to spend more time with a sick patient or difficult case you can, in GP it is a real struggle. As you get more experienced working as a GP I am sure this gets easier, but is still a crazy idea.

    I think most of the difficulties with being a GP isn't around making complex diagnoses or performing complicated procedures (though there is a lot of scope for these), but it is mainly around communication with patients. I thought I was good at communicating - had dozens of lectures on it at medical school and 'practice' it plenty with friends/at the pub/all the time but this can be a real struggle!

    Either way - I am now applying for A&E, hoping that this crisis in UK hospitals gets better (some good comments on the problems places like this) and now on GP which is much less relaxing than I hoped!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Time out ]
     
  19. InternalOptimist

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    Nuclear war
    Hi,

    Today I saw a lady who had become obsessed with the fear that we might have a nuclear holocaust this year. What do you do with this situation? I tried to explain that it is unlikely, but I couldn't say that it certainly won't happen. What with all these problems in Ukraine and the Middle East, she told me that perhaps I should be more worried and left.

    Perhaps she is right!

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Nuclear war ]
     
  20. InternalOptimist

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    The Great Cholesterol Con?
    Hi,

    Had a recurrent difficult consultation over the last few weeks - a lady had had routine blood tests done as part of her NHS health check which had shown a raised cholesterol. It is generally accepted (and pretty widely known) that high cholesterol levels lead to an increased risk of diseases such as heart attacks. This is based on a wide body of evidence from multiple studies and meta-studies backed up by government organisations such as NICE and mostly by the most important source of all - Wikipedia.

    This lady had read a book called "The Great Cholesterol Con" which suggests that cholesterol is not linked to heart disease at all, and there is nothing to gain from lowering it at all. For this purpose she had started a "sausage diet" where she ate 1-2 sausages every meal, breakfast, lunch and dinner, along with the rest of her food. Predictably her cholesterol was crazy high. I tried to talk her through the evidence behind the ideas of lowering cholesterol, but I hadn't read the book so couldn't do this very effectively. I asked her to come back the next week so I could have some time to do some research. She was a little bit annoyed about this - she felt as a doctor I should know all this already, but agreed to return.

    I read up on the arguments in the cholesterol book, which are based around inconsistencies in the Framingham Heart Study which suggested that as your cholesterol dropped, your risk of heart disease rose. It seemed as though this book was very selective in the data which it displayed to portray its arguments (well summed up by this review of a similar book) and ignored huge swathes of evidence which did indeed suggest high cholesterol levels (rather than just all cholesterol) are bad for you. You obviously need some cholesterol (and some salt, sugar, etc) but having too much can be a problem.

    I collected up all of my research and information and bought it back to the next consultation with this lady. She was having none of it, and told me I had been taking backhanders from the statin producing pharmaceutical companies to peddle their wares. I tried to explain that as the patents on drugs such as Simvastatin had expired there would be no specific drugs company to try and pay me off, but the more I tried to disagree with her the more angry I made her.

    This was a loosing battle - I guess all we can do is display the evidence to the best of our ability and let people make decisions for their own health based on that. It was just upsetting that this wasn't a concious decision to damage her own health (like someone who smokes 40 a day, knowing full well it is bad for them) but a misinformed decision to try and help her own health, possibly guided by someone more interested in book sales than helping people. That said, she is coming back next week for another round of discussion, so wish me luck

    [For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: The Great Cholesterol Con? ]
     

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