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.

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!"

General Practise

The other student didn’t show up today so it was just me and the GP sitting the morning clinic. Over the last few days I’ve sat in, occasionally taking relevant patients (psych or neuro) away to interview them before presenting them to the GP and giving a differential.  I’ve actually enjoyed it alot – the GP is a nice guy who’s been doing the job for years.  We’ve had several chats about the job itself and my aspirations (at the moment) to go into it.  He’s done a fair bit of teaching, with us listening to the odd chest or checking a stiff limb, and I usually ask several questions about each case which are happily answered. Admittedly we haven’t done so many systems exams but I get the impression the doctor has no idea what we’re competent to do.

The morning saw a really good range of patients, and I got to do a ‘flu jab on most of them (I like sticking needles into people). Most of the end of morning slots are reserved for emergency appointments, so of course it’s all worried parents bringing perfectly well children to the doctor. I shouldn’t be so harsh, but when the children come running through the door laughing away it’s hard to see how the parents saw anything to concern them. One day I’m sure i’ll get it as I bring my own little dumpling to another doctor with “the worst cough ever”.

One kiddy wasn’t well, however, and I’m pleased that I clocked this as soon as I saw her. She was 3 years old and was carried in by her mum. Ironically this mum didn’t seem as hysterical as the last few lots with well children. The girl was quiet and pale, wrapped up well under a thick coat which I could see was moving noticably with her breathing effort. Hell, I could hear her breathing from the other side of the room. Occasionally she’d cough, a wet nasty kind of cough which makes you want to clear your own throat. The GP listening to her chest and then let me; bit of wheeze in the lower zones. Mum was instructed about the antibiotics and steroids and sent away to get an X-Ray and blood tests with a warning to go to AnE if things went more tits up.

The doctor explained to me the medico legal side of things in this situation. You don’t want to send a parent away with no clear instructions of what to do next if the child worsens; it’s got litigation written all over it.

A few cases of depression came and went – one was a particularly intense consultation with the doctor repeatedly having to raise his voice and stop the patient shouting.  It was actually a sad case; an Afghani guy was getting no sleep and was in constant pain.  Turns out he was non-compliant with his Vitamin D pills (he was severely deficient) and was seriously stressed out.  After claiming he’d done some violent things recently and was considering suicide, he went away with some citalopram and a psychiatric referral.  Apparently the case was way more complex than I could know at the time; he had a family to support and was unemployed, relying on a diagnosis of  any sort to get benefits.

I got to see a patient with Parkinsons I’d seen before, and I was happy he’d recognised me.  His medication change hadn’t helped much and so the next steps were up for review.  It was good to see how he was getting on; I so rarely get to see the same people twice anymore.

Many of the patients spoke poor english, so the doctor spoke to them in Hindi or Punjabi.  I saw so many I can actually say and understand a few bits myself now!  The funny thing with the languages is that they’re a flurry of words interspersed with totally english words.  This, along with the usual patient gesticulation meant that most of the time I could get an idea of what was wrong lol

An interesting point with many asian patients is their cultural expectations of seeing “the doctor”.  It turns out they always expect to walk away with a prescription: anything will do.  This explained why the GP was so often prescribing Ibuprofen and Paracetamol, much to my amusement.  When asked about the fact that they would pay £7.50 (or something) for that, the guy told me that most of the time they don’t actually cash-in the prescription; they just want something to make them feel they’ve been seen.  Also the local pharmacists knew the score and would do the right thing by explaining about buying the same drug over the counter for far less money.

During my medical school interviews I was shown a video about a difficult patient.  She wanted antibiotics for a cold and that was that.  The GP gave in.  When asked about this by the panel I enthusiastically stated that she should not have been given the drugs and that the GP should have stood their ground.  I asked the GP about this and he said that, like most things, it was more complicated “at the coal-face”.  Much of a GPs work can be made easier by having patients respect your judgement.  Putting up a brick wall regarding ABx does nothing to build on that, as the patient just thinks you’re being a nob.  What my guy says he does is explain himself and point to recent newspaper examples about the drugs.  He weighs up their response and if they arent happy still then he may give them a delayed prescription and tell them to give themselves (or their kids) a few days to see how they get on and only cash-in the script if things havent got better.

The patient probably knows they hassled him and appreciates him hearing them out.  This should build more respect for his future clinical decisions and, as most of the scripts wont actually be cashed-in, do very little harm.  It’s fascinating stuff, the real world.

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…

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?

Start of Year 4

Good God it goes so fast.  I remember GCSE flying past, then A-levels being just a blur, and my last degree seeming to take just the blink of an eye.  Now I see my medical degree going past at a rate that is, quite honestly, beginning to frighten me.  I’m terrified of starting work, but that’s a complicated topic which isn’t how I’m going to start this year’s round of blogging.

The lab work over the summer unfortunately didn’t work out for personal reasons, but the summer was overall not too bad and it was nice to have a rest.

Obviously we started on Tuesday owing the to bank holiday, and the first thing I noticed was how much the year group has changed.  We’ve lost a massive proportion of people to intercalated BScs, and they’ve been replaced by those returning from their year away.  GEPs seem to make up a greater chunk of the year but its more likely I just recognise them more than the new people.  It’s quite strange seeing people who I knew were a year or two above now being in my class.

This week seems to have been the usual intro fodder – intro lectures about the year structure and what is expected of us.  Lots about how the NHS works and what “life on the wards” is like.  Which is strange because we spent the last year roaming wards, and we aren’t yet finalists, so it all seems a bit out of place.

Performing Medicine made an amusing return today with the topic of leadership.  Interesting enough and funny to watch, but mostly just a tad uncomfortable and totally irrelevant.  We had a good lecture on radiology by a couple of registrars.  It seems that shit is getting a lot more real now with regards to actually working as a doctor, but maybe I’m just over-thinking things.

One weird aspect is the School’s new attitude to attendance; there is a register for every morning and afternoon and they do seem to be taking non-attendance quite seriously.  Will have to see how that pans out.

Anyway, it’s lovely to see all the old faces again and hopefully this year will be a good one.  I start with Ophthalmology next week.

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!

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?