…and an answer

If, at full expiration, a person can generate -140cmH2O, then only at a depth of 1.4 meters is the water pressure too much to overcome (100cmH20 per meter).

My original data led me to an answer of 35cm which was obviously ridiculous, but the logic was there. Divers can, of course, go much deeper with gear like SCUBA kits but these are under pressure and therefore offset the absolute pressure on the thorax at depth.

A question

Usually I hate logic questions.  They make me feel stupid when I inevitable fail to get the right answer.  Yesterday in the SSC, however, we were presented with a question which I absolutely loved.  It was supposed to test understanding on physiology and also require a bit of thinking. It failed on the first count, but kept me occupied for a little while.  I did actually get the right answer eventually but was poo-poo’d by the rest of the class because it seemed absurd.  Turns out the data I used was crap.

The actual question required the use of data that we had generated ourselves in tables and graphs.  From memory, I’ve written a version of it below for your consideration.  I hope I haven’t made it too easy!

“An individual is attached to a ventilation device that measures the pressures generated during the breathing cycle.  He is asked to inhale completely from room air, put the pressure transducer in his mouth, and then try to inhale as hard as he can.  He then repeats this protocol, each time progressively exhaling 500ml of air from his lungs before inhaling against the transducer.  He repeats this until he has fully exhaled and then inhales as hard as he can against the pressure transducer.

• At a lung volume of 6000ml (full inspiration) he can generate -50cmH2O.
• 5500ml = -60cmH2O
• 3000ml = -100cmH2O
• At full expiration he can generate -140cmH2O

Using this data, at what depth could this individual be underwater before he cannot draw air down through a tube connected to the surface?  Assume that each meter of water increases the pressure to 100cmH2O.”

Answers on a postcard please.  I’ll post the answer next time if you don’t manage to get it (I’m sure you will).

SSC2c – Lab Physiology

So the two weeks of SSC have begun.  I specifically picked this module because I thought it would be a doddle.  And it is easy.  But its so time consuming I can kiss goodbye to my two weeks revising (off).  Did I mention the lab is bloody freezing?  Not a happy lab.

Basically, the school has bought a load of new modules for the practical labs that do everything from EEG to gas sampling to psychometric testing.  They’re good bits of kit – at £9k each, you’d kind of expect that.  It’s our job to run through every program and see how well it works.  Each program takes maybe an hour and a half, and there are about 15 for me and my buddy to do.

Bear in mind that I still have to do my SSC2a stuff yet – a presentation and journal article critique.  Nerg.

A happy lab - geddit?

More Medsoc distress, part 2

A little old lady sat in a hospital bed staring through mellow eyes at the ceiling. She looked dead to me. Suddenly she gasped in breath and then stopped breathing again. Her husband sat at her side, holding her hand. He greeted us warmly but was pulled back to her as she suddenly sat upright and shouted that she wanted to go to the toilet.

“You can’t get out of bed my love, the doctor said so”. I spied the catheter tube running down the side of the bed. “If you need to go, just go – it’s fine my love”. She laid back slowly and resumed her impression of a corpse. The husband chatted to us a while about this being the hardest part -he knew she would die any day. Just two days ago she’d been up and sitting in her chair. She had oesophageal cancer. He tenderly wetted her mouth with a small sponge and asked practical questions about if he should order more midazolam and when the loaned chair would be picked up.

Suddenly she sat upright again and looked around with wide eyes – fixing me with the most piercing stare I’ve ever experienced. She shouted that she needed the toilet again and tried to get out of bed. Her husband held her shoulders and said she’d been restless like this since last night. As he gently laid her back again, he started to cry. The nurse was talking about drug options for keeping her calm and this seemed to give him something to concentrate on. She tried once again to get out of bed, forcing the nurse to give her a shot of midazolam. I was left alone with her as the nurse washed her hands and the family left the room. I held her hand and told her everything was alright, feeling a bit choked up.

We left when it was clear she was sedated and the husband was OK.

The last patient was a 45 year old man dying of pancreatic cancer. He was the most lucid of all the patients I saw, sitting up and walking around. He was depressed about his situation, drinking a lot of oromorph every day and working his way through a cabinet of pills. I spoke to his daughter for a while, mostly about their dogs but I touched on how she was coping. Like all the other patients’ families she just didn’t know how they did it, only that there wasn’t any choice in the matter. His wife came back a little later, looking like she hadn’t slept for days. She hadn’t for 5, it turned out.

I spent a few hours after that sat in the hospice library, unable to concentrate, but glad to have come away from it all. At least I could get away from it – those families didn’t have the option. The experience gave me an insight into how the patients feel and how their family cope, but mostly it just left me feeling totally powerless to help. I doubt the feeling will improve when I’m qualified.

More Medsoc distress, part 1

Yesterday I was out with one of the community palliative care nurses from the hospice I’m spending this year’s Medsoc.  I’ve been out with community nurses before – just a few visits to little old ladies to change the bandages on their leg ulcers, nothing major (or fragrant).  It’s a nice change from sitting in lectures, and it’s hands on.  The palliative nurses, much like the doctors, are so unbelievably nice and they really do know their patients – it felt like visiting friends, a bit.

You’d think, then, that I would have had a good day.  No.  The nurse was a lovely lady, but the nicest and most cheerful person in the world could not have made up for what I saw and heard.

We started on a little old lady with very advanced Alzheimers and colon cancer.  She was sound asleep when we arrived.  Her daughters chatted to us and asked a lot of questions, but there was that heaviness in the air of total sadness.  They explained how she kept “plucking” in the air until recently when she became so weak she couldn’t lift her arms.  She was probably hallucinating.  Her husband came home and looked as though he was going to burst into tears any second.  The nurse reassured them about their actions over the last few days and checked her drugs chart –  a bit of Haloperidol and Midazolam with the pain killers.  We couldn’t do anything else so made our way out.

I was a little drained from that first visit, and it didn’t set me up well for the next encounter.

An oriental family gathered around their husband/father’s bed as he lay there, still, with an NG tube, stoma bag and catheter trailing away from him.  The family looked fine at first, but then the subtleties became obvious; the old dirty tee-shirts, the unclean hair, the tired bags under their eyes – a family under stress.  The fact they greeted me at all was surprising, but their assumed cheer and friendliness was quite startling.  I took care not to stand at the end of the bed, being tall and dressed in black (not something I would want to wake up and see, certainly).

Things seemed as well as one could hope for at first.  The patient greeted me weakly but heartily and his family asked me a few questions.  The nurse went off to another room and his wife and daughter stayed round his bed.  Two community nurses came and left.  I had sat down to speak quietly to an aunty when wailing pierced the sombre atmosphere.  Everyone swept to the bed and I saw it was his wife who was making the noise.  She was crying, the daughter too, and speaking in another language.  She switched to English, probably so the nurse would come back.  He had stopped breathing and squeezing her hand.

“Please pappy, wait for Charlotte!”, the daughter kept screaming.  It turns out Charlotte was an absent daughter.  My nurse flew onto the scene and quickly reassured the family that he was still alive but had clearly gone downhill (in 5 minutes!).  I looked closer and saw his laboured, weak breathing.  The family were convinced he was dead, or was going to be so in a short while, and the grief mounted as more relatives arrived.  No reassurance could help, but we stayed with them for a few hours.  Eventually we had to go to another patient and so we reluctantly left them in utter despair.

I sat in the car quite shell-shocked.  The nurse asked if I was OK and I put on a brave face.  We had lunch and went to the next patient.

Rough patch

“7 out of the 21 lectures have been either cancelled, late, or gone wrong in some way.  I’m livid.  My module usually runs like clockwork.”

Strangely, this is exactly what I wanted to hear from the organiser of BnB2.  He’s more aggravated by the recent joke that has been our teaching than I am.  It started with PBL – for some reason half of group D got shunted to the afternoon slot rather than the morning slot as expected.  In many ways the morning slot is better, but I wasn’t too fussed.  Then it turned out we had no set facilitator – just various researchers who took that role every other day (none of whom I can understand, at all).

Then two morning lectures were cancelled 20 minutes after they were due to start.  Then another started half an hour late.  Then a neurologist wheeled in a computer to demonstrate something to us (I’ve still no idea what) and proceeded to panic as he realised it had broken on the way over.  The rest of the lecture was a half-hearted attempt to explain action potentials to us.  Action potentials.  To 2nd year MBBS students.

Two more lectures were cancelled at late notice after that, and I missed a PBL session and a lecture I really wanted to go to (which was shit, as it turns out) because they had been rescheduled to another time…and I hadn’t got the e-mail about it.

As I say, I’m miffed about the whole thing.  BnB2 is the hardest module this year and is only 4 weeks long as it is.  I don’t know that it can all be made up in time.  Still, an e-mail made the rounds earlier from our head of year apologising profusely about everything and blaming it on a change in the curriculum.  It’s been declared a “critical incident”, apparently.

Luckily, we’re all adult enough not to do this:

…but in all honesty, the last two weeks really would have warranted it.

Good lord, I get it!

Just read this on wikipedia:

Quetiapine has the following pharmacological actions:

• D₁, D₂, D₃, and D₄ receptor antagonist
• 5-HT_1A, 5-HT_2A, 5-HT_2C, and 5-HT₇ receptor antagonist
• α₁-adrenergic and α₂-adrenergic receptor antagonist
• H₁ receptor antagonist
• mACh receptor antagonist

Serial PET scans evaluating the D₂ receptor occupancy of quetiapine have demonstrated that quetiapine very rapidly disassociates from the D₂ receptor.  Theoretically, this allows for normal physiological surges of dopamine to elicit their normal effects in areas such as the nigrostriatal and tuberoinfundibular pathways, thus minimizing the risk of side effects such as pseudo-parkinsonism as well as elevations in prolactin.

…and my God, do you know I actually understand ALL of that.  I must actually be learning stuff at university – who’d have thought!

The horror of neurology

My God, BnB2 is scary. And I’m not concerned with the workload or complex ideas. It’s the conditions that frighten me.

Imagine hearing voices constantly telling you to hurt people, and feeling totally persecuted all the time. Schizophrenia scares me. Imagine waking up at 2am every morning, for weeks, with pain around one eye so severe that you bash your head against the wall to get some relief.  Cluster headaches sound appalling.

We tend to get told about these things in a clinical, removed way. We rarely meet patients (though that is improving) and we rarely look in-depth at how these things really are for people who suffer them. I wonder if that’s in some ways a good thing – if we truly understood every condition in all it’s debilitating, painful horror, would we be so keen to get to work in this field?

I hate doctors

No, this isn’t a post about any one particular doctor that has shouted at me or anything.

When I say doctors I don’t mean those health professionals who do the job because of genuine interest in the science and a desire to do good with it.  No no.  I mean doctors – the people who (often literally) get off on wearing the white coat  and hanging the stethoscope round their necks.  And yes I know we don’t wear white coats in this country any more.

I mention this because I recently had someone add me on Facebook who’s in the 3rd year of an MBBS.  A quick look through their photos yielded a couple of photos of them “dressed up” in medical attire.  Blue scrubs and a steth round their neck.  A lab coat, steth and clipboard in pose.

I was immediately repulsed. You see these people every now and then.  They walk with an air of superiority and often have none-too-nice things to say about nurses.  They’re the reason we get told to behave ourselves before getting let loose with the students of other healthcare courses.

Maybe I’m reading too much into this, but I think it hits at the heart of an obvious flaw in many people going into medicine.  They aren’t doing it for the right reasons.

The job itself is about talking to people – the patient will tell you the diagnosis.  How can you achieve that if you inherently think you’re better than them?  A GP once gave me that piece of advice (immediately before trying to put me off the job) and I haven’t forgotten it.  You don’t become a doctor just to wear the coat/scrubs and hold a steth.  They’re just tools.  Some of the best doctors I know wear trainers and can’t find their own stethoscope.

I have the greatest respect for people who’ve gone into this for the right reasons.  The healers.  But I hate doctors.

Neuro Clinical Skills

Out of all the clinical skills sessions so far, BnB’s has been the one with the least new to us.  It was identical to last years in practice, but in theory was a lot more in-depth.  We weren’t allowed to whack a knee or tickle a patch of skin without saying what we were checking for and why.

Being taught by Foundation Year Docs is usually a mixed bag.  Don’t get me wrong; they’re all skilled and give me confidence that I’ll know my stuff by the time I’m let loose on the public, but the way they articulate and teach this knowledge to us in clinical skills is either hit or miss.

Luckily we had a decent FY1 on Friday, and I came away more sure about how to carry out the examination and the theory behind what I was checking for, mytomes, dermatomes, reflexes – the lot.  And I mastered the art of using the tendon hammer.  Just hold the thing right at the end so it wobbles around and thump the intended area.  Hasn’t failed me yet.

Clinical Skills can often seem pointless as we never find anything vaguely pathological on each other, and we never see anyone of the opposite sex.  I was glad, then, that I saw the Parkinsons patient in EPC earlier in the week as it really helped me and hopefully my colleagues who I tried to describe cogwheeling, etc. to.