Anyway I managed to get signed off by the consultant all the same.  I found him sitting in his office, looking unwell, in the dark looking at me bemused as to who I was.  If he were a colleague I might be concerned but I just got his scribble and scampered out, desperate for a quiet life after the week I’d had.  I hope that doesn’t make me a bad person.  When I start work as a doctor I know for a fact that I’m going to really struggle with the change and stress of the job.  I can’t say I’m looking forward to it, which is a shame.  But I hope there will be people around me for support, and feeling the way I know I will, I hope that I can provide that same support for others who may need it.  But right now I’m just a student who consultants forget as soon as they meet, and I have a limited ability, socially and medically, to deal with anything.

This week we start Rheumatology and Ortho.  Yesterday was a non-event – we met our consultants and were given timetables.  It seems fairly laid back but there is a lot of stuff that we have the option to attend.  I’ll update as we go.

I began the day helping to cover an absent F1′s patients.  I was told to get an MMSE score for one of the demented patients in the ward.  It was a slow process and required much patience as the guy tended to confabulate if he didn’t understand what I’d said, which was most of it.  Eventually I got him to focus and got a score of 17/30 from him, which is indicative of his dementia.  I put it all in his notes and signed myself as having done it.  I hope I was useful.

After that I attended a memory clinic and was given a patient to fully clerk myself.  I’d need a full history, Addenbrooke’s memory score (like a very long MMSE) and a full physical.  After a kerfuffle getting a pen from a nurse (“this is the NHS young man, we don’t have spare pens.”) I sat down opposite the man and began to have a panic attack.  I don’t know what it was – I suppose it just dawned on me that I had a finite amount of time to get all this done and couldn’t get out of it now.  Weird.  Anyway that passed and I cracked on, doing a good job according to the consultant.  I got the impression he had very minor memory problems and was more depressed than anything.

After lunch I joined a ward round and lost browny points with the Reg for poo-pooing his 10mg dose of Citalopram for a patient.  The Consultant agreed with me and my 20mg suggestion, which didn’t help my cause.  After that I saw my first locked-in patient.  He was about 70 and had dementia too.  He could only look up for yes and down for no.

I started to read the Diving Bell and the Butterfly later that night.

As a graduate student, I have never had a ranking before now as they are only really used when applying for intercalated degrees, which I’m obviously not eligible for.

I’m unsure what we’re going to do with our decile rankings at the moment, but it’s interesting anyway.  I’m in the 2nd decile.

Just to recap, this ICA covered aspects of neurology, neurosurgery, ophthalmology and psychiatry. I enjoyed it, especially the Psychiatry placements.

Pass in all placements.
ICA result 75.4% (A)

Obviously I’m very pleased with the result, but I don’t think I deserved it given the relatively little amount of revision I did. I found the exam hard but remember being able to answer most things relatively confidently on the second read through.

Next exam in 7 weeks or so. Sigh.

I was sorry to see the end of my Psych placement, but I’m ready for something new and, more importantly, ready for the holidays!  Our last day saw us spending the day with the consultant going over any last questions and doing the dreaded ‘clinical task’ for our logbooks.  There was one other student with me throughout the placement, and to prove to the consultant that we now had a better idea of what we were doing, we had to each play a patient with a mental illness and do a mental state exam on each other.

I got a merit for my efforts at dealing with a depressed patient, and have to say that I probably over-enjoyed playing a paranoid schizophrenic guy who’d been brought in on a section 136.

I’m considering going back to that consultant for my SSCs in the future.  Nice guy.

So anyway, with all that stuff out of the way I’m moving onto the locomotor module of the year which is a mixed bag including dermatology, health care of the elderly (general medicine), rheumatology and HIV/sexual health.  I’m currently sitting through the first of two weeks on infection and immunity relating to sexual health.

Things I’ve learnt so far: it’s not OK to say “gay men are at greater risk of contracting HIV”.  Rather, you have to say “men who have sex with men”.  Second, you can’t say “prostitute”; you have to say “commercial sex worker”.  Thirdly, anything remotely to do with vaginal discharge is as grim as it sounds.  But strangely quite fun to work out the cause.

Bigger post to follow.  Thanks to all my new followers.

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!"

To do a placement in psych and not see ECT is, in my mind, a placement wasted.  I felt I should see what was involved and how it was to patients.  The history, controversy and public (and professional) misunderstandings compelled me.  ECT, or electroconvulsive therapy, is a treatment reserved for cases of depression, mania and psychosis that fail to respond to more conventional therapy.  It can also be used in an emergency fashion when quick intervention is required, for example the severely depressed patient who will keep trying to kill themselves or not eat until treated.

The clue’s in the name; you use electricity to induce a seizure in the patient.  For unknown reasons this works very well in resolving things like severe depression and psychosis.  It sounds quite brutal, and many people have no doubt seen films where a nutty person is strapped down and zapped on the head until they thrash about in a fit.  The reality is somewhat more clinical, humane and actually quite sedate.

An elderly woman wandered in to the suite, eyes to floor, looking for the trolley.  She was helped onto it by the anaesthetist who prepared her with a cannula in the back of the hand.  The psychiatrists were tinkering with the ECT box as she was wheeled over.  EEG leads were attached to her head to monitor brain wave activity.  When everyone was ready she was sedated with something like diazepam and given a neuromuscular blocking agent like suxamethonium to relax her muscles.  Obviously this meant she had to be fed oxygen by a mask.  Her temples were cleaned and the electrodes applied.

With a nod from the anaesthetist the psychiatrist pressed the button on the box and the woman bit down hard, her neck extending markedly.  After a second or so she relaxed and nothing happened.  Then we saw her chin was twitching ever so slightly; she was having a seizure.  The EEG readout confirmed this.  After about 20 seconds her chin went still and the trace returned to normal.  That was it.

The anaesthetist did his thing and she began to come round as she was wheeled to the recovery bay.

We students looked at each other with a bit of surprise.  Was that it?  The next lady came in soon enough and we debated about whether to stay or not.  The psych suggested we did; this lady was having a much bigger dose.  Each time you have ECT, you raise the threshold required to trigger a seizure.  So after several sessions, or indeed several separate times of doing it, you need to get a bigger zap.  This lady required a dose of 1200mC, which is as high as the machine goes.

After the rigmarole that the other lady went through, we waited again for the seizure.  Except this time her whole body spasmed like in the movies, and when she relaxed she went into a violent fit that required a couple of us to help hold her down.  And this was after her muscles had been “paralysed”.  This was the more extreme end of the spectrum and the registrar told me later that it was the first time he’d given that big a dose.

So why don’t we give ECT to anyone with depression or mania?  It causes confusion and memory loss in most patients.  People say they feel like they’ve been run over after it.  It isn’t pleasant, and it isn’t understood, so it isn’t appropriate to use when talking, tablets and support can help people most of the time instead.  It’s scary, but ECT is the last line of treatment in psychiatry and it does work for most.

***

Edit: It is unlikely the patient was sedated with a benzodiazepine.  This is because these drugs raise the threshold for a seizure, which is obviously counter- productive when that’s the very thing you’re trying to cause.  I’m still a bit unsure what drug they would use to sedate the patient, but I do know that I didn’t see any Propofol floating around.  If anyone knows the answer to this, do comment and teach us all.

I’ve been and done 2 weeks of Psychiatry now, based down in Essex.  The placement is split over 2 consultants; I’ve just finished my tenure with the first guy doing old age psychiatry.  It’s been good.  Psychiatrists aren’t always rushed off their feet like in other specialties, so consequently we get consistently good teaching which is often one to one.  Old age psychiatry, as you’d expect, deals with a lot of dementia but don’t misunderstand: there’s still a lot to learn in the field.  I didn’t realise that dementia often causes visual hallucinations, for example.

In the first week I only sat in on one memory clinic, where a few people with the beginnings of Alzheimers or Vascular dementia rolled up to get their Donepezil (an ACh-esterase inhibitor).

The second week is where it all happened.  On the Tuesday I went to the ward by myself to clerk patients ready to present to the consultant.  The first lady I spoke to in my little office had been admitted with a severe depressive episode.  She was in her 70s and had been in around 4 times over the last 10 years.  She had a family history of suicides and a young member of the family had died suddenly.  She said that during an episode she would gradually withdraw from the world until she almost became catatonic (like a vegetable).  At this point obviously there is a risk of self-neglect and so she needed to come in for a rest and medication review.  She was taking Mirtazapine, out of interest.

The second lady I spoke to started with, “Oh hello Doctor, I’ve just seen a ghost!”, and I knew I was in for something.  I sat her down, corrected her on my job, and could think of nothing to say except, “Wow, that must be very scary for you.”  This seemed to be enough to get her talking, which I was pleased about.  She spoke very quietly and painted a picture of having seen this ghostly woman a few times recently, and that the cats she saw walking around had also increased in number.  There were no cats in the hospital.  I asked what the last thing she had seen was, other than the ghost; “Oh a big cat came out of the forest and up to my window and tried to get in…”.  I tried to write all this down and direct the history as needed but I noticed she was fixating on something outside.  I turned around and looked out of the window.  There was nothing there except a worker trimming one of the hedges.

“That man, I think he’s looking at me you know.  But I think the medications aren’t working because I know he isn’t.”  I was surprised at this insight and asked the lady if she knew what condition she had.  She fixed me with a look and leaned in close, beckoning me to do the same, “The name of my condition is…schizophrenia, young man.”

After that she became a bit more distressed about the man outside and the ghost she had seen, so I thanked her and helped her out of the office.  The consultant later took interest in me relaying both histories to him and did a good chunk of teaching.  When he’d left I decided to go to the male ward and get another history, but the man I spoke to was sedated too much to do anything other than spill his tea all over the floor.

As I left the building for the day I turned and saw an old lady trying to get through the security doors while barking at me.  The secretary fixed me with a smile and wished me a good day.

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.