Finishing Obs and Gynae

My final week in Essex was a short one.  We had the bank holiday on Monday, I went in late on Tuesday and left on Thursday.  I got my logbook (the bane of our lives) “finished” the week before, so all I had to do was a short piece of work commenting on the management of one case according to the literature and I could get signed off.  The rest of the time was for me to do whatever I wanted, and I’m pleased to say I did actually go in.

On Wednesday I got up early for an infertility clinic.  Quite boring, it was a series of couples coming in having failed to make a baby after a year or so of trying.  A few blood tests and fallopian tube check for the woman, a sperm count for the man, and they usually left with a 3 month appointment which would probably end in the woman being told to lose weight again or attempting to get funding for IVF.

For couples who have tried everything properly (weight, diet, enough sex etc.), and have never had a child and can’t conceive, I can understand the value of such a clinic.  But what I couldn’t understand was the obese couples coming in for their 3rd child, complaining that they’ve “tried everything”, and tying up resources.  Call me heartless, but I can’t square it in my mind.

After that clinic thankfully finished I watched a Hycosy procedure to check the patency of a woman’s fallopian tubes.  I didn’t feel particularly welcome by the all-female staff, but the patient didn’t seem to mind.  You’d think I’d get used to the archaic attitudes of some staff members by now, but it just smacks of discrimination to me.  Patients, who are vulnerable, can say no because I’m a man, yes.  Female staff members who disagree with men having anything to do with “women’s bits” cannot.

Later that night I joined the ST7 for her on-call shift in the hopes of maybe scrubbing one last time and seeing some cool stuff.  I was in luck – the umbilical cord had snapped for a Thai lady and she was bleeding steadily.  The midwife hadn’t been able to pull the placenta out and it wasn’t expelling itself, so she was given some syntocinon and the doctor called.  The reg literally just donned a glove and slid her hand up the woman’s vagina.  Her whole hand.  She managed to grab the remainder of the cord and out came a torn placenta and a shitload of blood.  The woman was screaming to high heaven, having only entonox as her analgesia.  Her husband was going quite pale and the baby had been left on the trolley.  I guided the guy to the baby and told him to take his shirt off and hold the screaming baby to his skin.  The midwives loved that.

An hour later and I was scrubbed, only me assisting the registrar repair a really long and 2nd degree tear for a hugely obese woman with the longest pubic hair I’ve ever seen (it was actually braided).  It’s the first time in surgery where I’ve actually felt like I was doing some of the surgery; I was holding back the relevant bits and swabbing as necessary while the surgeon sewed up.  I actually knew what was going on, all of it.  I got alot of teaching and felt great after (thought my back and knees didn’t); she seemed to appreciate the help given that she was the only doctor around and would have struggled without an assistant.

On Thursday I was told the consultant would sign us off.  Sign off means you can go home.  I was told he would be operating so I sought out his patients and took histories.  I followed the first lady to the anesthetics room and chatted to the anaesthetist about helping out.  I did her cannula and watched her drift off to oblivion.  I love that.  The other medical students turned up too but I was the one with the history, which went down well with our consultant.  The woman was having a laparotomy for adhesions and endometriosis.  Turns out she didn’t have endometriosis but her right fallopian tube was stuck to the sides so he took it out.  She was fine after.

The consultant took us to the tea room after and signed us off while simulataneously quizzing us on Obs and Gynae and singing our praises.  When asked what could be improved I told him honestly about the midwives in the first two weeks.  He assured me that things did get better and that he felt exactly the same way when he was in my position and that the situation with medical students and other staff members did annoy him.  Strangely that made me feel alot better.

Surgery; not for everyone, but fantastic with the right people.

Orthopaedic surgery

Last week I scrubbed in for surgery with the orthopaedic consultant and his registrars.  It was the first time I’d scrubbed in a long time, and I had a hard time getting into my gown and gloves.  Still, I remained sterile the whole time so it was merely embarrassing.  X-Rays were being done throughout all the procedures, so I had to wear a heavy lead gown and thyroid shield under my scrubs too.  By the end of the morning my back and knees felt ready to snap and I could see myself on the operating table.

The morning list was paediatric cases, which is the first time I’ve ever deal with kids in a clinical setting.  We started by removing K-wires from a 16 year old girls tibia.  Nothing too complicated; just grip them with the pliers and yank them out.  I got to do 3, and have to say I felt a little queasy doing it.  Next up was a boy with some malformation of his left lower leg, the name of which I forget.  The basic idea was that his medial femoral epiphysis (the bit of the bone that does the growing) needed to be held back as he grew to give the lateral side time to ‘catch up’ and correct his valgum deformity (knock-knees).  This was done by screwing an 8 plate, a small plate in the shape of a figure of 8 funnily enough, into the bone above and below the epiphysis so that the bone couldn’t lengthen.

I’ve helpfully drawn a diagram below for your viewing pleasure:

The last case of the day was a boy who’d come in the previous night having been knocked down by a car.  Amazing, his only injury was a transverse compound fracture of his femur.  This would be fixed with elastic wires.  Going into details about this would take too long and probably another diagram (the one above took longer than you think), so it’ll suffice to say that I was allowed to hammer one of the rods into his femur.

The surgeon asked me if I knew what a kitten pawing at a toy looked like.

Adult Psych ward…with the lads

I rang the buzzer to the ward and looked up at a loud thump directly in front of me.  A small asian man had thrown himself at the door but found it locked.  He smiled at me and shouted, “I’ll get you in!”, before running off to the staff office.  A man came back with him and unlocked the door for me, checking who I was.  The asian man stood there looking triumphant.  I felt I better thank him, still a bit stunned.

And so began my day on the male adult psych ward.

I introduced myself to all the staff as patients walked to and from their rooms, making a lot of noise.  Nurses were here and there asking them to be more quiet and calm down while getting on with other jobs.  The majority of the day was spent doing the ward round.  Unlike in other specialties, a psych ward round happens in one room, with the patients coming to you.  This, coupled with tea and biscuits, was really quite a pleasant change.

Of a short list, the first man wandered in and sat down looking at the ground.  I still don’t know what his diagnosis was, but he’d been smuggling cannabis into his room while staying at the ward and didn’t want to engage with the psychiatrist much.  He was one of the easier patients of the morning.

The second man arrived in a flurry of activity outside and a loud argument with the nurse.  It seems he wanted his Dad to come in with him but they were to be seen separately.  Eventually he entered the room, looking at the psychiatrist with particular disdain and emphasising the word doctor.  He seemed to like me.  This chap was currently experiencing mania and was becoming quite disruptive and aggressive because of it.  He hated everything and everyone in the ward and thought he knew best about anything.  It turns out he was also just a bit of a dick, which is something I didn’t realise you can legitimately think about the mentally unwell (my team assured me it was).  His dad came in later and proved that some of his mental problems probably ran in the family.

The next chap was something else.  After a shouting match outside from another patient and some enthusiastic banging on the doors was quelled, a really big man wandered in with help from a male nurse.  He was giggling to himself and trying to touch everything he could reach.  When asked how he was getting on he started repeating short chunks of german and french without looking at anyone, still laughing.  The psychiatrist and nurses tried to get him back on track but this led to a hysterical monologue about the doctor’s beard.  The doctor took this in his stride and returned that the patients’ beard was longer.  He was led out again after being thanked; his drug doses were adjusted.  Apparently he was also manic like the other man, and had been that way for 2 months.  I found out later that he occasionally came out of it and you could hold a decent conversation with him.

A young man entered the room and sat down smiling, looking around at us in a normal manner.  This made a nice change.  He was then asked how his stay on the Psych ICU was – this is where they put patients who are a danger to themselves and others.  Apparently this guy had lost the plot completely a week ago and threatened to kill the psychiatrist.  He was happy enough while he spoke to us then; until he was told that he’d need another week in the unit.

Lastly a voluntary patients was brought in.  A large man wandered through in a bit of a frenzy.  I don’t know what it was about him but he scared me.  He had a buzz about him, but it was different to the manic patients we’d seen.  He gave a long history of mental illness centered around borderline personality disorder, delusions and pathological jealousy.  He’d served time in jail for following a policeman to his house with a pair of scissors.  Numerous other forensic history markers came out, including injunctions from women he’d stalked.  Perhaps I was right to be scared.

After the ward round I went and met my new consultant, had a bit of teaching, and generally recovered from the mayhem of the male ward.  Phew.

"Heeeerrre's Johnny!"

Interesting patients

More GP today (do you get the impression I rather like this placement?) and I thought I’d share with you a couple of patients who stuck in my mind.

An asian lady peeked round the door hesitantly after being called over the tannoy.  We beckoned her in and she came and sat down, never quite looking at us.  She sat uncomfortably, fiddling with her coat, and I swore she had a look of mild amusement and embarassment on her face.  ”Doctor I’ve still got these terrible pains in my elbows and shoulders these last few months – what can you do about it?”.  The doc whisked up her recent blood tests on the computer screen.

“Your Vitamin D levels are very low – have you been taking the tablets we gave you?”

This turned out to be the source of embarassment.  ”Uh, no doctor I, er, ran out…”

The GP asked why she hadnt returned for the repeat prescription waiting in the reception.  This turned out to be the source of both amusement and embarassment.  ”Er, well I went to the homeopathic doctor and they gave me tablets to take instead…”

The other student and I shared a look and silent giggle, probably unfairly, but the woman knew what she’d done and thought it was amusing too.  As well as embarassing.  The GP, the old pro, took it in his stride as he’d apparently seen it countless times.  A mild telling off and urging to keep taking the “proper” tablets, and she was on her way, assured the pains would go away if she complied.

About mid-way through the morning a large man came bounding through the door about 5 seconds after being called.  He must have moved fast.  ”Hello!  Hello!  How are you?”, he boomed, lunging for us students’ hands for a shake.  ”No need to tell me your names, I’m terrible with them and I won’t be here long enough anyway, oh God its lovely to meet you how are you how are you??”.

Taken aback, but also sharing in his good humour we played along politely.  He seemed to take a particular liking to me, “Ah yes I knew you were a doctor when I saw you outside I did!!  You have the look!  Practicing doctor I assume, yes yes??”

I was wearing my nice shirt and had my NHS lanyard on, but I assured him I was just a student.

He finally sat down and turned his blaring music off.  The GP seemed not to notice any of this while he pulled up the records.  The patient was just here for a review of high cholesterol, and he was calmly told that the levels were ok at the moment.  After laughing away with joy at this he thanked the doctor and us for seeing him.  ”Right then! I’m off to the clozapine clinic…”.

“Oh yes, how is the schizophrenia?”, the GP casually mentioned.

After a further 5 minutes of rocking back and forth and assuring us he was fine and dandy, he rocketted out of the room.  And then came back again to shake us students hands again and wish us luck for the future, again.

“He seems a little high doesn’t he?  Maybe they need to check his meds…”, the GP said off-hand, shaking his head as he called in the next patient.  Us students sat there wide-eyed.

Surgical splatter

Today I made the effort to get in for 8:30am (I know!) to watch some of the neurosurgery I’ve spent the last 2ish weeks harping on about.  I didn’t scrub for anything, though this was hardly surprising.  The other student and I did get some good teaching, however.

The first case was a vetriculoperitoneal shunt placement and 4th ventricle cyst drainage.  It took about an hour and a half.  Essentially the idea is that a thin tube at the base of the brain drains excess CSF away to the peritoneum in the abdomen to be reabsorbed.  It’s about controlling pressure in the fixed-size brain box.  I’m not sure I’ll forget the process of ‘tunnelling’ any time soon; imagine a surgeon pushing with most of his weight on a thick, long metal rod down the patients neck all the way to the abdomen.  Nice.

The second case was a large left frontal meningioma.  It was due to be a long operation so I only stayed until the microscope came out for the debulking.  A large ‘bi-coronal’ incision (ear to ear across the top) was made and the scalp retracted anteriorly and posteriorly.  The temporalis was loosened (I think) and then burr holes were drilled.  The sound is something else.  A cutting tip was then used to join the holes in a semi-circular fashion so that a flap of skull could be cracked off.

After the drilling was done the surgeon took an instrument with a hard flat tip at the end and wedged it under the bone.  He lifted it up and we caught a glimpse of brain and dura.  He then slipped, the flap snapped back down and covered me and the other medical student in bits of blood, bone and God knows what else.

“I didn’t mean it.”, chirped the surgeon.

A worried mum

First day of GP today and the 8:30 start wasn’t too painful, thankfully. We’re meant to be doing neurology there, so naturally we sat in on a general clinic dealing with all the coughs and colds.

Despite the sarcasm, I actually had a good day. Me and the other student did preliminary histories for a chest pain and a back pain which went down quite well with the GPs (I thought we were slick as fuck).

Toward the end of the morning clinic (and my blood sugar levels) a Mum brought her 1 year old boy in to see the doctor. He came in spritely enough, looking around interestedly with a snotty nose and sat down as well as a 1 year old can be expected to. My niece would have been pulling the steth from the doctor’s neck.

His mum started to paint a picture of a weeks history of fever and anorexia and him being generally unwell. Apparently he also had a ‘sticky eye’. Having answered no to all the GPs questioning about the salient points, the picture of an over-worried mum began to emerge, even to us lowly, inexperienced 4th years. The doctor examined the boy’s chest, ears, nose and throat and his tummy (the throat exam seemed a bit like hard work and I remember hating it when I was a nipper) and it was all pretty normal. Both eyes were tiptop too. In fact, this kid was just fine (though yes he could have a virus).

But Mum wanted antibiotics. The GP reasoned that he didn’t need them, but this seemed to fall on deaf ears. She kept on, even pleading at one point that she would only give half the dose for a couple of days and then stop if he seemed like he was getting better (!!), which unsurprisingly led to us students suppressing a gasp and leading the doctor to give mum a (probably pointless) education lesson in antibiotic use. Eventually he gave in and gave a script for amoxy out with the advice that she hold off for a week to see if he was getting better.

I imagine this is a common occurrence in general practice. I wonder how i’ll deal with it when and if the time comes?

Breast surgery

With the end of year exams coming up in, oh, 3 weeks or so, the final rotation of the Met3b placement has taken a bit of a back seat to revision and clinical skills.  That said, I have enjoyed it so far.

I sat in with the consultant breast surgeon the other day for a clinic.  Most of the patients were there for general surgery on lumps, bumps, thyroids and other things but a few were breast patients.  An elderly woman arrived with breast cancer which was being treated primarily with Anastrozole.  In to the next room she went for an examination.  Me and another male medical student were kindly invited in to do the examination too.  The surgeon stood there with the patient and asked her to take her top off.

“Oh, if I’d known I was going to have two lovely young men here I could’ve put a song on and everything!”.

The surgeon found this exceptionally funny, and the two of us went very red.  After we were done (told yet again that our breast exam technique was no good and asked what idiot had taught us) we went back to the interview room and waited for the surgeon to come back.

“And that’s what an elderly woman’s breasts feel like, boys.  A young woman’s feel very different, but then I’m sure the two of you already know that full well!”.  Oh lordy…

Quite a kerfuffle

As I stood with one of the nurses and hassled her to sign my little booklet, I spied another nurse filling up a tray with cannula stuff.

“Ooh, don’t suppose I could have a go?”, I ventured.

She was really quite happy to let me do it.  It turned out that the drip was for a African lady who came in with a sickle crisis and had pulmonary hypertension with oedema and as such was struggling to breathe.  I thought this was a golden opportunity to listen to a boggy chest (my own term) so I grabbed the nearest other medical student and off we went.

The lady lay there with the 02 mask on and was clearly a bit distressed.  I did all the intro and asked her if I could quickly listen to her chest before I put the drip in.  Sure enough I heard the fine crackles and even a bit of a wheeze.  Result, onto the needle.

She had a nice straight vein which I could see had been used before.  The nurse assured me this was fine to use so in I went.  And got nothing.  For a good 30 seconds I moved the needle around getting nothing, very aware that the it hurt the poor woman and the other student and nurse were watching me.  As I was about to give up I pushed a bit deeper and felt a little tug before the flashback, the bloody lovely flashback, filled up the needle.

The nurse, student and now visiting CNS all breathed audible sighs of relief (for some reason).

A bit of a commotion ensued as the nurse fumbled with the syringe to draw off some blood and a bloody mess (forgive the pun) developed on the patient’s bed.  She wasn’t best pleased and I apologised unreservedly.

When we were done, the nurse gave me the syringe and paperwork to fill out.  I did so, only to be told that I had done it wrong and that the lab would now not accept the blood bottle.  Balls.  To compound matters the nurse somehow managed to spill the entire (apparently useless) bottle of blood over another nurse which somehow became my fault as my initial error had caused that to happen.

To make things yet still worse, we now needed to retake the blood.  Fook.

Luckily the nurse took pity on me (which I only half needed, remember) and decided to take the blame when explaining to the patient.  Who was actually not that fussed about the whole thing now she could breathe.  Thank God for that.

Yeh, it wasn't this bad...

Interim grading

My current firm is a bit stricter than my previous two.  This is generally a good thing as I personally like a bit of structure, but some of the goals we’re set each week are a little hard to achieve with so many students on one ward.

I’ve been told that it is possible to go to other wards, but I haven’t done this yet for fear of upsetting other students on them.  Or just being told by staff to fuck off.

Anyway, for some reason the clinical teachers decided to give us all a mid-placement grading and general assessment.  This was done individually and consisted of reviewing our clerkings, logbook and general behaviour and attitude.

I was seen by one of the consultant metabolic doctors and his registrar.

“Yes, your clerkings are generally improving and you seem competent.  We’re a little dissapointed that you haven’t gone on-call yet, though.  And we have noticed that you seem to get visibly frustrated with the…less able students you work with.”

A bit stunned at this revelation, and not knowing whether to laugh or protest, I apologised and said I didn’t realise I was doing it.

“Well, the thing is as a doctor you’re going to be surrounded by stupid people so you really need to get used to it.  Or become better at hiding it.”

I laughed a small, polite laugh and thanked them for their time.  When asked if they had been unkind to me I said no and made my way to the door.  When I got outside I started laughing and couldn’t believe what had just happened.  Other students asked me what was wrong and now that I’ve told them, it’s a recurring joke that they all tell me to stop getting so frustrated when someone else is talking.

Language barrier

In the East End of London, there is a dense population of people who basically don’t speak english.

This is fine if, like many of the doctors in the area, you have the relevant bilingual skills. If however you’re like me and only speak English and Bad English (thanks Bruce Willis) then you may sometimes find yourself in unfortunate situations.

A few weeks ago I attended clinic with my sexy consultant surgeon.

“Ash, take this patient and tell me what you find.”, he said while handing me a thin file.

File thickness usually correlates with how straightforward a case is, so I was looking forward to getting to work. A 30 year old man had presented to his GP with pain and a lump in the groin.

My first hurdle was pronouncing the guy’s name to call him into “my office”. It’s important to try to get names right as I know as a patient how irritating it is when medical staff don’t. And never use their first name unless given permission. The current practice of doing so annoys the shit out of me. Maybe I’m just old-fashioned.

So I get this guy to hobble to the desk. He nods as I say hello and get his permission to talk to him before the doctor.

“So what’s brought you in today, Sir?”

The guy clearly must have thought, much like I did, that the consultant wouldn’t have let me see him if we had no hope of communicating. So off he went in elaborate detail (I presume) in Begali describing his hernia.

When he’d finished (it took a while), I could only smile, apologise, and show him back to the waiting room.