Another night of Obs

Last week I tried again for another night, hoping to repeat the “sucess” of the previous one.  A 15 year old girl 34 weeks pregnant comes in with severe abdominal pain.  Her blood pressure is up and the midwives are rushing around.  It’s all very dramatic, and I’m told no about 3 times when I ask to get involved.  The doctors come along and I’m allowed straight in.  Sometimes I think other health professionals really do just get in our way on purpose.  It turns out she’s abrupting – the placenta is coming away from the lining of the uterus; she goes down for a crash c-section.  The surgeon opens up and out comes the baby.  It’s pretty small and they point that out to me as a sign of a pre-eclamptic baby.  The placenta comes away and has a huge clot behind it – where it had abrupted.  I see the baby after in the neonatal unit, looking pretty small and pathetic – I get told he has a big head and tiny bottom half because hes been growth restricted in the womb (IUGR) and his head has been spared at the expense of his body.  I go home, asking for a phone call if anything good should happen.  I get called back at 2:30 to a woman who has had 2 kids already – parity 2, they usually move fast.  I go into the birthing room with the midwife and the woman is in a big bath in her bikini, sucking down entonox.  After all the pleasantries I feel her tummy when she’s in pain and feel the contractions.  Quite amazing.  15 minutes later, and after a lot of bloody and pooey water, it’s all over.   My first natural birth – much better than interventional births.  I won’t be doing obstetrics for a career.

Two nights later I go back. I can deal with nights; there are less people, the atmosphere is better and it’s a good alternative to insomnia. After checking the board and sweet-talking a couple of midwives (very important as a male), I introduce myself to a lady who is 8cm dilated and get permission to come back for the birth. If the midwives really like you, they’ll call your mobile when things start moving so you don’t have to hang about pointlessly. On my way out I hear a scream from a side room and knock on the door (as you do).

The midwife comes to door looking fairly nonchalant and I ask if I can see the birth. I go in and catch the woman screaming again, sucking down entonox big time. Her partner is having his hand crushed, looking a bit pale. When she stops I introduce myself, the husband looks quite relieved to have another male around.

As the babies head starts to push out, the woman screams that she’s going to shit herself. This happens sometimes, and the novelty for me has worn off, so I just take off my jacket and put on a pair of gloves, much to the man’s amusement. Eventually a little face pops out and starts to gasp, the midwives tell the baby to shush and wait until she’s all out, and a minute later she is, squalling in that beautiful, relieving way that only fresh neonates do. I join the student midwife in checking the baby and placenta over after we’ve cleared up a bit. I congratulate the new family and leave to recheck the first lady.

She hasn’t done much, but another lady has just become fully dilated so I go there instead. I say lady; she was 17, her skinny partner looks younger than my youngest brother. They’re both quite pleasant, and she’s has an epidural so isn’t in much discomfort. Father Ted comes on the TV and the baby girl is born to the sound of “my little pony”. Excellent.

The girl tore a second degree on the way out so we set her up for examination and stitching. I stand at the end of the bed watching the midwife work and teach. “Don’t make that face, doctor! You’re putting me off!”, the girl shouts at me, laughing. Apparently I was gaping with mouth open.

I returned to the doctors room after that and have some pizza with the on-cal docs. My first lady still hasn’t shifted, and they go off to forceps deliver a really big baby, very worried about a shoulder distocia. I go home and tell the midwife not to call if the lady gets going. That’s the benefit of being a student; you can go home whenever you want and not worry.

Ophthalmology part 2

A chap sat in a cubicle on his own.  I was told this was the station I should sit at so I introduced myself and sat with him.  I decided to try and take a bit of a history, despite this being a probably fruitless cause for reasons explained earlier.  It turned out he’d had trouble reading and seeing details for about 2 years, with lots of “floaters” crowding his vision.  Numerous trips to his GP hadn’t gone anywhere and finally he’d referred himself to Moorfields.  He’d been here since 10am and it was now 4pm.  I felt I built up a good rapport with him (thanks Barts), and we had a laugh and a joke.  I must have done well because he started opening up to me.  He was terrified of going blind and thought that life wasn’t worth living if he ended up that way.  His wife couldn’t deal with the stress and had left him at the hospital on his own earlier on.  He told me he was really depressed about the whole thing, and almost got a bit tearful.

His english wasn’t perfect, but I assured him I could understand him.  But he was very concerned that he couldn’t understand what any of the doctors were saying to him – a mixture of jargon, speed, and, as it turned out, absurdly thick accents themselves.

I asked if I could have a look in his eyes with my direct, and he obliged.  I couldn’t see a thing.  At first I thought he had a high refraction index and I wasn’t using the right lens on the dial, but he didn’t wear glasses.  The disc looked blurred regardless of the dial.  I sat down and shrugged saying I was just a student and couldn’t see anything.

Eventually the doctor came back, or rather the consultant came through with about 8 doctors in tow.  Must be something interesting going on here.  But they didn’t come back to the patient; they squeezed past him without a word and went straight to the computer screen full of angiograms and retinal images.  At one point the consultant examined the patients eyes with a slit lamp – again, without so much as a word.  Lots of talk followed with words that I struggled to keep up with: this guy didn’t have a chance.  The basic story was that he had a lot of cells in his vitreous and they didn’t know why.  Rather than start treatment with steroids empirically, they wanted to sample the vitreous at surgery and get some pathology done – this would also hopefully improve his vision a bit in the meantime.

I looked over at the guy who now was turning grey.  Clearly what he had understood hadn’t reassured him.  I gave him a friendly look and (hopefully) a passifying face.  The consultant went to leave but the other doctor looked at him, “Ok, I’ll tell him”.  And so followed a big stream of basically unintelligible english toward the patient.  I struggled to understand the guy for Gods sake.  The consultant got up and left and I asked the patient, aloud, “Did you understand that?”.

“No.”, he said, dabbing his eyes.

The more junior doctor asked for a second to write up the notes and then he would explain.  The patient looked at me and asked if there was any hope.  I put my hands on my chest and told him I was just the student.  After a while the doctor  turned around and proceeded to explain.  Again with complicated words, a thick accent, and no allowance for comprehension.

This finished the patient off and he started to cry, saying how he had explained everything to me, he didn’t understand, was depressed and worried about going blind.  The doctor just repeated himself and told him not to worry.  Then he told him to wait outside again.  I was not impressed.

All the guy needed was a few minutes for a slower explanation: “we don’t know what’s wrong but we need to sample your eye at surgery to find out.  I can’t say if you’re going to go blind before we have the sample but please don’t worry about this for now.  I can tell you’re upset but we’re going to look after you.”  It wouldn’t have taken much.

I asked the doctor, who now seemed a bit down-trodden, what was wrong with the patient.  He said they didn’t know, but to give him a minute while he arranged to tests and he would explain.  He went off; so did I.  As I got outside I saw the patient sitting there still dabbing his eyes.  He saw me and smiled so I went over to him.  I shook his hand and said I understood how upset he was.  I told him to try not to worry and that they would look after him.  It’s all I could do before I left, depressed and upset myself.

Ophthalmology part 1

I can’t believe I ever wanted to be an optometrist; it really is one of the most boring jobs ever.  And that’s the nice hospital kind where it’s actually about healthcare!  Not the commercial, high street, variety where patients with anything even slightly out of the ordinary are immediately referred to a place like Moorfields on an emergency basis so they can return ASAP to buy that expensive pair of spectacles.  It happens.

Moorfields is very much a centre of excellence, but I couldn’t work there.  It’s an ancient building which has been stuffed to the brim with clinical stations – each subsequently the size of my cloak room.  There’s no real privacy and the place is constantly noisy and dim as patients are asked what they can see in the dark.

Yesterday we had a fantastic teaching session in the morning by one of the Fellows.  After getting good (a relative term) with the ophthalmoscopes, we had a 6 minute lunch (seriously) and then were whisked off to watch the optometrists in action.  Very boring.

The thing with eye medicine, in the ophthalmologists own words, is that it’s not really so much about the history.  Most patients will probably just say that their eye hurts or they can’t see very well anymore.  Therefore most of the information is gathered by examination.  This is totally different to any other kind of medicine which is very much the other way round.  For us students who get beaten into submission with lectures on the importance of communication, this is a bit of a shell-shock.  And it isn’t conducive to giving us much to do either, as we obviously can’t use the equipment quickly or skillfully enough to get anything done.

Today I sat in AnE triage – two desks with nurses quickly clerking an endless queue of patients leading out of the door.  I decided to go further down the line and ended up with nurse practitioners (a very nice bunch of people actually) who used a slit lamp, tonometer and eye drops (phenylephrine or tropicamide to dilate; fluorescin to stain) to examine the patients eyes before they got shipped off to the ophthalmologists.

Further down the line still I sat in with more optometrists and the doctors who were doing vitreal injections for Macular Degeneration.  I got to examine a lot of dilated eyes with my ophthalmoscope.  I then moved on to the retinal medicine area and this is where I really went off the idea of ophthalmology as a specialty for me…

Third year Paper B

…was a nightmare. There were something like 70 EMQ questions (8+ choices) on everything from drugs to best intervention, which was relatively straightforward. There were 65 SBAs (5 choices) and they were more based around diagnosis with a few public health and ethics questions thrown in at the end. I found it hard.

Well it’s done anyway and regardless of how I feel at least I’ve got a load off my mind.

The data interpretation exam (paper C) is tomorrow and apparently is more about X-rays and ABGs. Should be ok, but we’ll see.

Revision woes

Ungh, I’ve burnt out.  That’s what happens when you start so early and hammer away in the library until the small hours of the morning, I suppose.  The tragic thing is that I don’t feel as though I’ve done a great deal, and what I thought I did know seems to be slipping from my grasp.

You see, I get the impression that this year we’re expected to be beyond the ability to recognise a condition.  Let me give an example.

A 23 year old man presents to accident and emergency with sudden onset central chest pain.  It is relieved on sitting forward and the ECG shows ST elevation in all leads.

Yeh, I know – “ooh ooh! Pericarditis!”, but the question will want to know whether your next course of action is NSAIDs, discharge with reassurance, CXR, Echo etc etc.  And I find this quite hard as I know that all those things are probably involved at some point with certain patients but I couldn’t say when and why.

Perhaps I’m just getting overly stressed about all of this.  I thought I was coping but I’ve had a headache every day recently and just want this year to be over now.  Eugh.

Nightmare patients

Some people’s idea of a nightmare patient is one that is agressive, abusive or totally non-compliant.  Not mine.  At this stage in my career I can pick and choose who I speak to – if they look a bit iffy then I give ‘em a miss.  And I have.  No, my idea of a nightmare are the patients who make taking a history a long, drawn-out, painful affair.

Don’t get me wrong; I love talking to people.  I love finding out about them and understanding how it is they came to be in front of me now.  But within reason.

A few days ago I sat down with an old East End woman who came in with a fall.  She’d landed hard and dislocated her shoulder.  A few infections of her cuts had complicated things.  After the usual intro and consent-a-thon I asked, as I usually do, “So what happened that brought you into hospital?”.

Obviously the model answer at this point for the budding medical student who has a neatly laid out history to take is “I slipped on wet grass, fell, and hurt my shoulder”.  Most people of course decorate their answers with a bit of pleasant irrelevance which is usually charming and helps builds rapport.

What I didn’t expect, and what positively made my heart sink, was the opener, “Well it started around 7 years ago when I was sitting in the lounge and my husband said to me…”.  I honestly cannot think of a way in which a conversation had 7 years ago could have any bearing on a fall which was clearly an accident.  And it turned out, after 45 minutes or so, that it didn’t.

I tried to keep the patient on track as politely as possible and just get the salient points, but there was no doing it.  Every effort to clarify and keep to the point was met with “oh yes, well I’ll get to that in a minute”.  She covered everything from several of her wedding anniversaries to her dealings with The Kray twins (as most East Enders tend to have done).  I couldn’t get a thing.

And this highlighted the annoying side to my current lack of responsibility – as the patients doctor it would be quite reasonable to say simply, “I’m sorry but let’s just focus on this so I can figure out how we can help you”.  And indeed I’ve seen this done, albeit sometimes a lot less tactfully.  As a medical student however, the patient really is doing me a favour talking to me in the first place, for which I am genuinely very grateful, and so I really do have to listen to whatever they want to say if they’re adamant they want to say it.  However irrelevant it is.

I just wanted a picture that conveyed stress and medicine. I can hear the doctors and nurses laughing at me already!

(Yet more) Impending exams

An old mentor once told me that “nothing sharpens the mind more than an impending exam”.

Today we got an e-mail about the details of our end-of-years.  They’re only 4(ish) weeks away.  On top of that we have our last ICA on Monday – 3 weeks before we even finish the associated firm!  The rotation within the firm means that I won’t have covered any breast medicine or surgery until after the exam has come and gone, which is needless to say a bit unhelpful.

On top of this we have the delights of the final SSC of the year to finish off, and also the joy that is IPE (inter-professional education) to contend with too.  I don’t feel this is too much to cope with by any stretch, but things have certainly become busier recently.  Unfortunately I’m currently spending my days between hospital and my desk for revision and paperwork.  Sigh.

Clinical conundrum

No, this isn’t an interesting case for you to work out, with me sweeping in at the end and explaining the whole thing in a “wasn’t that simple?” way.  Sorry if I got your hopes up.

Rather this is about a bit of quandry I’ve been put in regarding this year’s OSCEs. Strictly speaking these will be the first actual OSCEs I’ve done as years 1 and 2 are something slightly different, but we shan’t go into that.

Just recently we’ve had some really excellent teaching, specifically on the PNS exams of the upper and lower limbs. This was by a consultant at my current hospital placement who examines the MRCP candidates, so he knows his stuff.

He starts by getting us, as a group, to go through our version of the exam on a volunteer. He then proceeds to pick apart each part of it in a manner which seemed a bit savage at first, but is generally well-natured.

“Why are you saying it like that? Would a Latvian with 200 words of english understand what you want him to do?”

“So why are you getting him to do that movement? What spinal levels does it test? What extra clinical information do you get out of it??”

Etc.

By the end of it we’ve been re-taught the whole exam in a slick, well-worded, clinically relevant (and defensible) manner.  And this is the problem.  Our clinical skills up till now have been very rota.  By the book.  Prescribed.  And I’m concerned that the mark scheme is going to reflect that.  For that one glorious, anxiety-ridden day that is OSCE day I’ll do anything for the marks, and I don’t want to argue with the examiner that I didn’t check hip extension power as it simply doesn’t tell me anything clinically relevant.

Map of the dermatomes. It actually isn't as nightmarish to test as it looks.

Unfriendly staff

It’s a sad fact that over the course of my clinical year so far I have met some frankly unpleasant people. I expected it from the doctors and nurses but I was wrong; actually more often than not the people in question are so-called “auxillaries”.

From the ODP who tells you off for being alive, to the secretary who questions you quite bluntly about your purpose on the ward, it doesn’t make for a nice working environment.

It’s a shame, and actually there’s really no need for it. I just wonder why some of these people have such a bug up their arse?

UH Revue

Every year all the London medical schools get together to compete at being funny in the UH Revue.  Apparently this was started by those chaps from the Amateur Transplants at University Hospital some years ago.  Each medical school (Barts, Kings, Imperial, St. Georges and UCL) send along a contingent of supporters and put on a 15 minute show of sketches, videos and songs.

Having written a few sketches for Barts’ sketch society myself (none of which were used thankfully), and knowing most of the people performing, I decided to go along for moral support.  Christ did they need it.

Most people associated with medicine will be aware of the inter-medschool rivalry.  Imperial are stuck up.  Kings are dicks.  Barts are stupid.  Etc.  The rivalry is just a macroscopic version of what happens between Queen Mary and Barts.  And even between students at Barts itself for that matter.  Everyone wants to be part of a group, I suppose, and feels vindicated and supported in hating some other group.

But this event was something else.  It was horrendous.  A large group from Kings sat at the front, several of whom frequently got into standup screaming matches with whoever was on stage, regardless of where they were from.  The largest group of Imperial students took exception to this and screamed abuse over all of their stage acts, some of them even going down to the front to argue face to face with the King’s guys.  St. Georges sat behind us, frequently hurling abuse at anyone on stage.  But generally nobody gave anybody else a chance.

The UCL and Barts crowd were so small by comparison that they didn’t cause much of a stir, but Barts especially were the recipients of a disproportionate amount of abuse.  It didn’t help that our act was unfortunately really quite poor with several technical hiccups, but actually that didn’t matter because it was a hopeless cause anyway – Barts were the UK of the Eurovision song contest.

It was a hall-sized argument with the stage acts a minor consideration.  Most of the jokes were lost in the noise.  The compere, Adam Kay from the Amateur Transplants had a face like a slapped arse the whole way through and clearly did not want to be there.  Not surprising when your creation has devolved into a caveman contest.

Eventually it came down to a choice between Imperial, Kings and St. Georges, and the decision was given to Barts and UCL.  Seeing as both Kings and Imperial had been particularly harsh on Barts and had put out actual sketches putting us down, it wasn’t a hard decision.