Medicine "oop North"

[M Clayton]

Tomorrow we're going to cripple a patient.

Possibly.

We've a lady who recently had spinal surgery on the ward. She's got a whacking great lump of titanium in her lumbar spine and came to us having had a big GI bleed. She'd dropped her haemoglobin so fast that she collapsed at home and did herself some real damage. For reasons that I hope are clear, we were primarily concerned with correcting the bleed during the early stages of the admissions and, as such, the minor nuances of subtle neurology were largely ignored.

We're now 10 days post event and this lady is, by and large, doing very well. The physiotherapists have been doing their brutal (but very beneficial) thing and, at day 8, just happened to notice that she had a bit of leg weakness and a variable failure of the knee. This isn't unusual in people that have been bed bound for a while and none of us were at all concerned. However, in the spirit of passing on knowledge, I decided to demonstrate a full neurological examination to a couple of our med students. She's a lovely patient and was only too keen to allow the students to witness the examination.

Cranial Nerves were normal. Excellent. So far so good.

Upper limbs weren't. Ah. This was unexpected. I briefly toyed with the idea that I'd simply screwed up the tests because I had an audience but it was really very difficult to ignore the brisk reflexes and extensor weakness and the parasthesia in the hands.

The lower limbs continued the trend of odd neurology.

Bugger. In my heart, I knew that the only possible unifying explanation could be a cord lesion in the c spine region but I still hoped it'd be a peripheral problem. Much discussion with the consultant ensued and we decided that an MRI was the way forward. Cue a trip to the other end of the hospital and an ultimately fruitless hunt for a radiology consultant.

I had lunch. And then I bumped into a radiologist on my way back to the ward.

Apparently, titanium isn't the wonder metal I'd been led to believe. It can move in the early days post surgery when you stick the patient into the MRI tube. This was not encouraging news and led us all to think twice. Who, after all, wants to be responsible for paralysing a patient? Certainly not me and, by the way she pushed me towards nerve conduction studies, certainly not the radiologist.

I organised urgent nerve conduction studies. I wanted the neurologist to tell me I was an idiot who can't perform basic neuro examination. Instead, he told me that I'd underestimated the severity of the signs. Urgent MRI is the only test that will show, one way or other, what this is.

I've made the referral once again. The radiologists have had a pow wow with my consultant and the spinal surgeons. We're going to do it tomorrow. The touch paper's been lit. Let's hope that there are no fireworks....

[M Clayton]

Good news and bad news and then some more bad.

First, the good.

We didn't paralyse our lady despite having to take the nerve wracking step of shoving her into a giant magnet with lumps of unstable metal mere millimetres from her spinal cord. Every single doctor in the hospital added their two-penneth-worth and, as I said last time, I organised the scan. The patient was scared and who could blame her? We'd been telling her for a couple of days that she had to choose between losing her ability to walk or losing her ability to use her arms and walk. Not much of a choice really, eh? There was continued discussion for much of Thursday morning, with relatives being brought along for moral support. Once the final yes had been given, things moved extremely quickly. The porter from MRI arrived at just gone 3 o'clock (a whole hour earlier than planned) and she was back on the ward, seemingly no worse for wear, by 4.

The moment of truth came when I repeated my examination. Nothing new on the upper limbs. Good. Then the lower limbs - pretty normal tone, slightly reduced power on the left and brisk reflexes but, importantly, no new neurology to indicate a movement of the plates. We'd dodged a bullet and everyone was clearly very, very relieved. The next stage of the game involved the wait for the MRI result...

Piccie Time! - Spot the abnormality.

Once again, things had moved much faster than usual. Within twenty minutes of the patient's return, I was bleeped by an unfamiliar extension. The phone was answered by the consultant in MRI who explained that she had a preliminary report for me - this isn't a good sign. If you're phoned by the imaging department within half an hour of an image being taken, there's usually something wrong that you need to do something about (the last time they phoned me was for a woman that had a massive PE despite warfarin therapy) and, in honesty, I'm no neurosurgeon so I didn't fancy having to do something acutely. First, the scan showed lots of chronic degenerative changes throughout the spinal column - no surprises there. More worryingly, there was significant cord impingement at the C4-5 level - literally, the cord is being crushed by an outgrowth of bone and this lady's symptoms are only going to get worse unless something is done. Cue one urgent referral to the neurosurgeons at Leeds who, it seems, are monumentally uninterested in this 82 year old with "a bit of hand weakness"... Watch this space.

So that's the good and then the bad. That leaves more bad news to come.

I've had another needlestick. Although, to refer to it as a mere needlestick doesn't do justice to the brutality with which my SHO skewered me. Oh yes, I was assaulted by my own SHO! Clearly, he was hugely jealous of my awesome lumbar puncture technique and sought revenge in the most base way possible - physical violence.

Ok, so I'm being melodramatic. Allow me to backtrack a little if I may...

Mr O is a chap in his 90s with what seems to be an acute confusional state. He got better when we treated his UTI and depressive illness. We were going to send him home. Then he got suddenly worse. He looked a bit like he'd had a stroke with expressive dysphagia, neologisms and perseveration of speech. His CT head showed the usual small vessel ischaemia and involution that we're used to seeing in the scans of old folk. His metabolic and septic screens were negative. Our consultant decided that there could be two causes for this sudden decline - ongoing status without visible seizure activty or a viral encaphalitis. So, we booked an EEG and decided to stick a spinal needle into his back and do an LP to check for evidence of infection. I volunteered to do the LP and the SHO offered to observe me so that he could fill in one of those ridiculous portfolio forms for me.

It all went swimmingly. Honestly, the easiest LP I've ever done (not that I've done all that many) - nice wide space and very still patient. Looking at the quality of the CSF demonstrated that I'd managed to get away with a pretty low trauma tap as well so I was pretty pleased with myself. All good so far. I cleared away all my mess and had the sharps quarantined in the little plastic tray that comes in the kit - on reflection, I should have brought the sharps bin with me to the bedside but hindsight is a wonderful thing. Back to the Treatment Room of Doom (eager readers will remember that that's where I got my first needlestick) and all was going well. I'd taken charge of the sharps and had indicated as such to the SHO but he decided he'd be helpful and scooped up the spinal needle. Can you see where this is headed?

"SHO*", called the nurse from across the room. "Phone for you"

He swung round to answer and, in doing so, stabbed the spinal needle into the top of my right index finger. It was pretty deep - not quite enough to stand up of its own accord, but getting there! And bloody hell, it hurt. Once again, I followed the needlestick injury protocol and got on the blower to occy health. 25 minutes of embarrassing interogation later and I was told to get another of my blood samples off to them for testing and, ideally, try to consent the donor for HIV testing... fat chance of that! Acute confusional states are not known to be particularly useful when informed consent is being sought.

I only hope this chap doesn't turn out to have something nasty like CJD...

*Not his real name

[M Clayton]

Eventful week so far.

Ongoing death, war, pestilence and famine with a smattering of surprise tumours (Surprise! You're riddled with metastatic carcinoma!) thrown in for good measure make my life a truly rosy barrel of infinite laughter. But I could cope with all the shit were it not for you guys. Well, I say "you guys" - what I mean is all the people out there who are neither ward staff nor the patient. Collectively, these people are The Relatives and they make work a thousand times more difficult.

Broadly speaking, there are 4 kinds of Relative.

First, we have Mr and Mrs Informed and Involved. They are typically the middles aged nephew and niece or grandson and granddaughter of the doddery old lady in bed 10 and they're usually frightfully well to do and not keen to make a fuss. Except, that's all they actually do. Every single time they visit they want to speak to the doctor "if it's not too much trouble" and have an in depth discussion of everything from the choice of fluid (why does the current bag have only 20mmol of KCL in it? Yesterday you said that the salt levels were low and my calculations have determined that there needs to be 40 mmol in this bag....). They're outwardly very nice and friendly but they have the potential to turn into Relative type number 2...

Mr and Mrs Everything is Wrong may appear to be nothing more harmful than Informed and Involved at first glance but to treat them as such invites disaster. As their name suggests, nothing about your management of their relative will be right. The speed at which investigations or procedures are organised will never be fast enough. Their relative will be "distressed and in pain" despite being sound asleep. They are the only patient under your care and attempts to remind them that there are 29 other quite sick people on the ward will be met with cries of "but mum's very sick you know".

The penultimate subgroup of Relatives are generally younger than average, maybe even the same age as the House Officer. They are a heady mix of type one and two and can be overly familiar. Perhaps they use your first name without having ever met you before. They may talk to you like an old mate but don't be dragged in - they can go either way and you might find out that they're a consultant herbalist who has extensive experience in dealing with dementia using a subtle mix of ginseng and goat's urine. Approach with caution.

The most dangerous Relative of all is what you're likely to become. The medical professional. They will, no doubt, phone from outer Mongolia and demand to know every single parameter and test result. They'll want to know why you don't yet have 17 different opinions and will demand that you phone them every 4 hours with an update. They will be gravely concerned about most aspects of the management and will want to know your name, GMC number and, if possible, your inside leg measurement. If you encounter such a relative, it would be better to deny all knowledge of their particular patient. Perhaps you could claim to be simply passing through the ward or, better yet, speak Polish at them or claim to be a medical student.

Under no circumstances should any Relative be allowed to get hold of your bleep number. If this happens, you may as well leave medicine and become a monk.

In other news, this weekend, I am pretending to be an SHO. Apparently, the consultants believe that I am more than capable of handling the pressure (and it's not that the hospital continues to be too cheap to pay for an external locum....). Let's hope it goes well eh? It can't be too bad - after all, I played at being an SHO at the same time as being 2 different House Officers. Wish me luck.

[M Clayton]

It’s been a little while since I had the time to properly visit the site, let alone sit down and type a blog entry so, as always, please excuse my tardiness and allow me to roll out that time honoured excuse of “I was busy” in order to explain myself.

I’ve moved on from Care of the Elderly and I’m now playing at being a Cardiology House Officer. I may just use this opportunity to reflect (I hate how the powers that be have stolen that word and that I’m now no longer able to use it without thinking about portfolios and MMC) on my experiences...

The biggest surprise in Care of the Elderly was my reaction to it. Much like my intention to hate paediatrics from the word go, I’d gone into being the Geris House Officer with a heavy heart. After all, who really enjoys looking after decrepit old people? By the time I’d finished my 8 weeks, I’d actually grown to love it. As an acute speciality it moves at a much slower pace than its more sexy counterparts - come on, admit it, none of you have ever said “I want to be a geriatrician when I grow up”. Cardiothoracic surgeon maybe but never geriatric consultant – but this adds to the charm in some ways. You actually get to know your patients and believe me when I say that this is rare in the modern health service. Another massive bonus, from the point of view of training (or should that be Continuing Professional Development?) is that the elderly, god bless ‘em, get sick. A lot. And they present with every possible diagnosis imaginable. Sometimes it’s like being a kid in a sweet shop - a toothless, incontinent, deaf, dry skinned and slightly fusty sweetshop but a sweetshop none-the-less. Pick a page from Kumar & Clark or some other learned tome and you’re almost certain to find that Mabel or Roy (old people have such cute names) in bed 27 has or has had something from that page. What’s more, old Mabel will have had it for so long that she can teach you a heck of a lot more in one protracted chat than Messrs Kumar & Clark could in a solid evening of reading. Finally, the people that work in Elderly Care are nice. Everyone, even the consultants and ward sisters. It’s such a massive breath of fresh air.

This is why I like Care of the Elderly.

However, in the event that you’re all swayed and thinking that Geriatrics is the speciality for you; there is a word of warning. People die. I know, I know, shocking stuff. The simple fact is that the majority of these folk are nearing the natural end to their life (Dr P would absolutely love to see that I’ve picked up her phrase) and don’t need very much to help them shuffle off their mortal coil. I was prepared for this to some extent. I’d made some tasteless jokes about Ash Cash and Jack Frost nipping at their toes but, in reality, I was still rather naive. I certainly didn’t ever believe that over the course of a month I’d lose so many patients that I could fill virtually every bed on the ward with a corpse (should I wish to see myself locked up for a clear act of insanity, that is). It got quite demoralising at one stage and the real low was coming in after two consecutive weekends to find that 5 patients had carked it (so that accounts for 10 of the many). Somewhat surprisingly, I personally only pronounced 3 of the patients so I can blame the on-call teams for killing the patients, can I not?

In summary - if you get the chance to do a placement in Elderly Care, don't be upset. Take the chance. It's great!

[M Clayton]

Gah, time is running short and moving at a ridiculous pace.

I’ve already completed my cardiology placement – 3 weeks is hardly time to get used to the consultants, never mind to actually come to terms with a speciality as complex as cardiology. That said, I’ve had a pretty good time of things of late. My firm has been brilliant – the two consultants were great (as long as you did things their way!) and the registrar was hugely supportive. It was actually nice to do a round on my own and feel that I’d be supported if I made a decision on treatment. So, all in all, a pretty bloody good experience.

We’ve had some pretty impressive patients come in on take – it was hard not to collect some weird and wonderful cases when you consider that we were on take 5 times over a 3 week period. There was the 21 year old full thickness Myocardial Infarction in the absence of coronary artery disease, the 48 year old chap with a McDonalds induced cardio-respiratory arrest (don’t ask) and the 82 year old lady that had impressive runs of pulseless VT who refused all investigation and treatment (yet managed to bring herself out of the tachycardia without intervention and survive to discharge!). Probably the most memorable of the patients has little to do with cardiology and arrived during last week’s acute medical take.

A university student arrived by ambulance in the midst of a major tonic-clonic seizure. Accompanying them was a suicide note and 3 empty boxes of Citalopram - clearly a suicide attempt then. More interesting than that was the manner in which the suicide note arrived - the patient had written it in their course notes and flicking backwards through said notes revealed a fortnight in which this person had slowly but unstoppably gone off the rails. It started off with normal, complicated degree level lecture notes and, little by little, odd comments began to appear. 2 days before the suicide attempt, all semblance of normality had vanished and the lecture notes had been replaced by page on page of nonsensical gibbering. Really rather disturbing. Initially though, this patient did rather well. The first set of bloods all came back as normal and the consultant plan was to discharge him that afternoon once his second U&E had come back as also normal.

It didn't. Quelle Surprise

His renal function was just slightly off kilter and something in my head clicked. I arranged a Creatine Kinase because, as we all know, seizures damage muscle and muscle damage can lead to renal impairment.

900 - much higher than normal but not a disaster. Encourage oral fluids. Supplementary IV fluids. It'll be better tomorrow.

15000 - Not so good. Increase the flow of IV fluids. Patient pissed off at the amount of pissing they now have to do.

86000 - very very unusual in a patient without any evidence of muscle damage and almost unheard of in a patient who has had a short duration seizure.

Once we'd reached 86000, I bit the bullet and called the renal guys in to help. The student was thouroughly bemused by the whole situation and couldn't understand why we were quite so interested in the pH of their urine - after all, there was plenty of it to test! Their expert advice was, wait for it... to continue pushing IV fluids til the CK dropped below 6000. I'd expected exciting management such as dialysis - I got 8 litres of Normal Saline per day. Glad to know that 10 years of experience as a qualified doctor imparts such knowledge...

Anyway, long story short, the student got better. Quite quickly in the end. There's a case report in their somewhere...

In other news - now a respiratory house officer. Sputum is still icky.

[M Clayton]

This will be the briefest of brief entries since I'm almost on my way out to work for the night.

On call as locum medical SHO - so far, so good. Admitted a lot of people last night and dealt with a fair to middling number of sick ward patients. Somehow, we all managed to make it through unscathed (even more astonishing when you consider that the medical cover overnight consists of one reg, an elderly care SHO and a medical SHO and that's it).

Must dash - handover awaits!

[M Clayton]

The dust of being the on call medical SHO has settled. My sleep pattern, however, has not.

In general, covering the nights as the SHO was a piece of piss. I may well just have been very lucky but the admissions were steady rather than nightmarish in intensity and the sick patients weren't beyond my level of management. The nurses at night also seem to be a lot more forgiving when you're not able to get straight to the ward to sign for that paracetamol - some of them were even willing to save up the charts and bring them down to AMU for me to sign!

I could go into massive detail and tell you all about the work I did over the course of 4 nights but it'd be boring. I could bitch about the generally poor quality of A&E referrals ("yes, she has a barn door pneumonia that could be managed in the community but we did a D-Dimer and it's positive so she needs a CTPA" - not at 3 in the morning she doesn't mate!) but there's a post in itself there. I'm so tired that, right now, I haven't the energy to formulate a decent post about anything of that ilk.

What I will say is that I went from nights straight into an on call weekend so, over the course of 7 days, I was at work for a not insignificant 84 hours. On call weekend was followed by a post take "standard day" (which started at half 7!). I hope you can understand why I grew to hate the hospital and all who were found within it.

Off on holiday tomorrow (Australia! woo!) so I shalln't be about for a little while. Be good kids - when I get back, we embark on the next stage of our F1 journey. I hope you can join me for the fun and games of anaesthetics and critical care....

[M Clayton]

I come from a Land Down Under, where beer does blow and men chunder...

Or, more accurately, I now have my resident's visa so, if I chose to, could piss off and live Down Under. I'm not too sure that Colin Hay would have been able to get that to fit the tune although he'd probably give it a good go.

Anyway. Back to reality.

I've started my 3rd and final F1 block now and am looking forward to spending the next 4 months in my pyjamas. Yes, I have embarked on the endlessly entertaining journey through Anaesthetics and Critical Care where I am 100% supernumerary and thus able to play to my heart's content. Superb

A gentle start to things today with a vascular theatre list. I had been a little bit worried because, as you may recall, I used to be the Vascular House Officer and I remember having trouble with cannulating some of these arteriopathic folk. Also, they tended to have smelly ulcers and toes that dropped off if you looked at them the wrong way... My fears were unfounded (for today at least) and we had 3 relatively straightforward cases to be getting on with.

For various political and logistical reasons involving a complete lack of beds, we were late starting the list so everyone was a little bit pissed off when the carotid endarterectomy arrived. The cannula was a doddle but the consultant could not get the art line - in a way it was nice to see that even the experts screw it up sometimes but it did make the delay to the list that little bit more pronounced. No GA for this lady - just shed loads of Bupivicaine into the skin. Unfortunately that meant I had to talk to her for the duration of the op and we had nothing in common (who does have something in common with landed gentry!?) and it was a bit of a struggle. I think she was probably as glad as I was when I was able to tell her that the skin was closed and we were done!

The second case was a bit more hands on. I managed to get another phat cannula in (grey, back of hand - get in!) despite having an audience of thousands and the consultant let me manage the airway during induction. Had a bit of a faff when she started trying to get off the bed when I had the LMA half way in and copious secretions meant I nearly lost my bottle but, in the end, we got her stabilised and into the theatre. She continued to be a bit of a mare and needed a lot of analgesia to keep things comfortable. Things got a little bit more exciting when the consultant left me in charge and went for his lunch but, aside from pissing the surgeon off by failing to get the bed at the perfect height, we both survived.

The final case was a chap I've seen loads of times with his diabetes. We nibbled his final 3 toes off under a spinal block.

Then I went home

[M Clayton]

I'm still having a great time playing at being an anaesthetist - every single consultant I've been in theatre with has been keen to let me get on and play. I've intubated virtually every patient that's needed to be tubed (as well as a couple of patients where and LMA would probably have sufficed) and I've already lost count of the number of LMAs that I've inserted. My cannulation is coming on to the point where I'm almost as cocky as the big boys and try to put greys into the back of hands (frequently a foolhardy proposition!) and I'm getting pretty bloody good at maintaining airways with the one handed anaesthetic grip. All in all, good stuff!

Highlight so far include being "forced" to maintain airways manually for half the patients on a day list because, and I quote directly here, "it's cheaper than using an LMA", sticking an orange cannula into the external jugular vein of a needlephobic intravenous drug user (why are they always the most scared of needles?!) and standing for a 2 hour orthopaedic op holding a dodgy cannula taught since it was the only one we could get in and we really needed the fluid to go in!

Happy Days!

[M Clayton]

I did my first solo spinal anaesthetic today (well, the consultant was present in the room, but didn't help) and it went bloody well. I was even more proud of the fact that the lady had a significant kyphoscoliosis so none of the anatomy was where it should have been.

Good times. Anaesthetics is great