Internal Optimist

[InternalOptimist]

Gastroenterology
Hi,

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

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

Some time spent in the hepatitis clinic with a doctor was a real eye opener. In the morning, despite having solid appointments from 8.30 'til 12 there was only one patient before 10.30. An elderly gentleman who had contracted hepatitis from a blood transfusion some time ago, but had only found out recently. The clinic was for follow up for those who had just been diagnosed with hepatitis to see if they wanted treatment, or if their body was clearing the infection (there is a chance the body can clear the infection, depending on the strain). The only people attending the clinic were people who had the B or C strain as the other strains (A,E,G) do not lead to permanent infection. Many of those in the community who are catching hepatitis are IV drug users and in the morning they need to pick up their methadone, so will not turn up for appointments. Perhaps a different plan needs to be made for when to carry out the clinic. After 10.30 plenty of patients were showing up. Many of them apparently homeless from their unwashed state and ruined clothing, but polite and kind none the less. Drug users get a bad press, which is perhaps fair enough as it is a large cause of crime, but I think judging people in this situation is exceptionally unfair. Many of them have had horrific childhoods including problems such as abuse, and how can you look down on someone for turning to drugs in that situation when you have not been in it yourself. One of the most interesting patients who turned up to the clinic had turned up with his wife, but on reading the covering letter with which he was referred (before the consultation, to find out a little before it started) we found out that the patient had not told his wife how he had caught hepatitis C. The truth was that he had relapsed into using heroin after about 10 years abstinence due to stresses at work, and had been using since. He had told his wife that he had caught it while nursing his father, who was currently suffering from end stage liver cirrhosis due to too much alcohol. At least the patient got the right organ to lie about.

[Blog continued at A weekly blog from a 3rd year UK medical student ]

[InternalOptimist]

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

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

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

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

[Sorry, started that post half way through the blog, but as usual - if you want the whole think continued at A weekly blog from a 3rd year UK medical student ]

[InternalOptimist]

Overdose

[copied from half way through]

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


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

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

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

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

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

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

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

[Blog continued at A weekly blog from a 3rd year UK medical student ] if you want to read the full start/end etc!

Have a good week!

[InternalOptimist]

Hi,

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

[Blog continued at A weekly blog from a 3rd year UK medical student ]

[InternalOptimist]

Hi,

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

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

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

[Blog continued at A weekly blog from a 3rd year UK medical student ]

[InternalOptimist]

Hi,

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

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


The first patient I saw was a woman who had suffered a stroke in her past, which had affected part of the thalamus. Most strokes lead to numbness, weakness or odd tingling sensations (paraesthesia) in the affected areas of the body. This stroke, due to its thalamic involvement, had instead lead to sensations of pain in one of the patient's arms and a burning sensation across one side of her back all of the time. This pain made the use of this one hand and arm almost impossible, because on contact with objects, the pain would make her draw her hand away sharply because it felt as though her fingers were being stabbed or burnt. She gave examples of being unable to open a can, or peel a banana because the pain made such operations impossible. The other hand was fine, but many tasks require two hands to carry out. On this background diagnosis of central post stroke pain, the patient had developed trigeminal neuralgia. This disease causes notoriously painful symptoms, and has been classed as among the more painful medical conditions. It involves the trigeminal nerve, one of the cranial nerves which supplies sensory nerve endings to the face. The disorder causes the face to become hyper-sensitised, with the slightest touch on the affected side causing excruciating pain. This can be as little as hair brushing against the face, and obviously has major impacts on the patients life and nutrition. The poor patient described curling up on the floor because of the pain she was in and crying whenever the face was touched, but the tears tracking down the side of her face made the pain worse.

[Blog continued at A weekly blog from a 3rd year UK medical student ]

[InternalOptimist]

Hi,

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





I will go straight onto this patient who had two hearts, as I never knew this was possible until this week. This was not some form of congenital abnormality, meaning he was born with two hearts, rather he received a heart transplant about 20 years ago, but the old heart was not removed. The new heart was stuck into his chest on the right hand side, next to the old heart, and connected up so they could both function at once, giving him extra pumping volume. This kind of operation, known as a heterotopic heart transplant is rarely performed nowadays, with the main reasons for doing it being if the original heart is suspected to recover (foolish to remove a hear that will improve, just give it some time without the person dying)

[ Blog continued at A weekly blog from a 3rd year UK medical student ]

[InternalOptimist]

Hi,

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

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

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

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

On that note, I managed to embarrass myself further last week by missing a patients femoral pulse completely. The lady had arterial insufficiency to her legs, meaning they were ulcerating, getting infected and starting to decay because the cells were dying as they were not getting enough oxygen/nutrients. Peripheral vascular problems are very common it turns out. Myself and another medical student were asked to feel for this lady's femoral pulse, to see if anything could be felt to work out where the blood supply was being occluded. A little awkward, as this lady was in a hospital gown, so we had to lift it up to around her belly-button in a cubical with about 8 people in, including us. I couldn't feel anything, and neither could my medical-student college. We reported this to the surgeon who duly wrote it down in the notes. About 5 minutes later,

[ For the rest, please go to A weekly blog from a 3rd year UK medical student as usual! ]

[InternalOptimist]

Hi,

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

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

Hell yes we did!

[For the rest of the blog, please go to A weekly blog from a 3rd year UK medical student ]

[InternalOptimist]

Hi,

A very different week compared to last week's excitement, but at least I now know that I don't want to be a urologist! Seeing as we get to see a bit of everything on the rotation, I suppose a lot of time is spent working out what you don't want to do. If you wanted to do everything, well, you couldn't.

As the first paragraph suggests, this week was spent doing urology surgery. Perhaps it is a little premature for me to say this so prematurely, but if I ended up having to go into urology surgery, I would probably leave medicine and go into something different. Perhaps I could joint he police force, being a detective looks exciting from TV.

Not that my experience this week was a bad one. The teachers had plenty of time for us, and in theatre we were walked through what was going on in a friendly manner. The low point here was that we didn't get to assist or scrub in at all this week, but that's just because of the procedure that was being carried out.

Yes, that's right - a whole week of surgery and I only saw one procedure. No - it wasn't just one chance in the theatre, had plenty of those opportunity - it was just the same procedure again and again. While surgeons in urology do carry out a range of operations, from surgical treatment of bladder cancer to operations on the kidneys, there is one operation they do far more than any other. This is called the TURP, which stands for Transurethral Resection of Prostate. Sounds pretty fancy, doesn't it!

Enlarged prostates are very common (in men, obviously) and cause a range of problems with urination by putting pressure on the urethra. The prostate is basically like a ring doughnut, the middle of which the urethra passes through. As the prostate grows, this puts pressure on the urethra, making it harder to urinate. Prostates can enlarge by themselves, for no obvious reason, or they can be cancerous. Whatever the reason for their enlargement, if the patient wants to be able to go to the toilet normally this is the operation for them.

We saw one on Monday and it looked pretty exciting. A tube is passed up the urethra via the end of the penis,

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