Saturday, 30 January 2010

So how would you describe that pain?

A long week. This week I have been "on take" twice and have been in for my earliest yet post take ward round at the horrific time of 7.15am. Ouch. It was actually quite cool in a way being in so early and wandering around MASU before they had even turned the main lights on. Our MASU (medical and surgical assesment unit - basically the first ward you end up on post A+E) has no windows so very hard for patients to work out what time of day it is and doesn't really help confused patients to get orientated. All the "daylight" is therefore created by bright white lights creating a very sterile hospital feel.

It was interesting to see the doctors who had clearly been on all night, they were a bit mroe casually dressed on the whole and often wearing scrub tops and trainers. I guess the patients you go to see in the middle of the night are the ones who are seriously sick and so aren't going care what you are wearing so you may as well stay comfortable.

"On take" as a medical student (or indeed doctor) refers to when your team is in charge of clerking in all of the new admissions and starting their treatment. As students we are supposed to spend a certain number of evenings/weekends doing this on certain rotations but realistically we never stay as many hours as the medical school wants us too as the doctors often sign us off early and tell us to go home because otherwise they feel obliged to teach us which takes up their time.

I was on take both one evening and Saturday afternoon/ evening this week. Its quite scary how much in the deep end we can get chucked in during these on takes, some doctors give us quite a lot of responsability when we clerk patients in and take our word for granted. Often our clerking in proformas end up in the patients notes which is quite strange when you see them there during the post take ward rounds being used as the main information. Sometimes I feel too young to be ready for this, other times it just makes be feel spun out about how grown up and mature we are expected to be. Yesterday I spent a long time clerking in a very lovely elderly patient (it only took a long time because she kept getting moved around or needing loo or having her relatives appear whilst I was trying to examine her). She was very lovely so I won't hold a grudge for the fact that she described her chest pain one way when talking to me and a completely different way when the doctor later came to see her with me which causes a completly different set of differential diagnoses to be most likely... The doctor didn't mind though and told me it always happens to him whenever he presents a patient to a consultant - when the consultant sees them the patient always says something completely different to the exact same set of questions.Patients you do not know how much power you have to make us look stupid in front of our superiors.

I was quite looking forward to seeing the bustle of a city A+E on a saturday night whilst on this on take.. but to be honest it was disappointingly empty and I ended up going home early again due to lack of patients for me to clerk.. I suppose I shouldn't really be disappointed about this as it means less people were ill last night which is a good thing, just not so much for my education or log book signings off, but I do realise thats not the important thing. Sometimes we get so obbessed with getting clincal skills signed off that it is easy to forget that.

Sunday, 24 January 2010

My life in a nutshell

So I am half a doctor. Actually I am not; I would not be able to diagnose, examine or treat half of all patients, I cannot yet even insert a catheter - one of the most basic junior doctor tasks (in fact I still have problems taking blood), but as a third year medical student, in feb I will have reached the 'halfway there' mark in my studies and so supposedly am halfway there to graduating as a british doctor. Cool. But also bloody scary as by now consultants, friends, family and even lower year medical students expect me to know something, anything about medicine. The scariest fact is, I'm not sure I do. I've passed the exams so far, celebrated the results and regretably promptly forgotten everything I ever learnt. Family members and friends ask me for informal medical advice, they describe their symptoms and look expectantly for my advice and all I can do is blag it, suggest they see their GP or mutter something about not having learnt it yet. So that is my life in a nutshell, and that sets the scene for this blog - a student who is now on the wards and seeing patients full time and desperately trying to learn what I should already know before a consultant inevitably grills me on it.

So at the moment I am three weeks into my general medicine rotation. This is known for being the hardest rotation quite simply because you will be seeing patients who could have basically any medical condition so the amount of differential diagnoses and then possible treatments seems infinite and yet we are expecting to be learning about them all, or at least realistically all of the common conditions causing patients to present to hospital. This still seems infinite. Still, one thing its not is boring. I am actually really enjoying it despite being scared on a daily basis about how much I need to learn. This week has been particulary exciting.

The highlight of my week was easily getting the chance to see an emergency angioplasty during a morning spent in the cardiac catheter lab. The cardiac catheter lab is where patient who have been experiencing chest pains/ are known to have angina come to have the tiny blood vessels (coronary arteries) that supply the hearts muscle looked at and if appropriate recieve treatment to relieve their symptoms then and there. The first part of this procedure is called an angiogram and it involves a catheter being inserted into the patients femoral artery and goes back up the artery and then down the main artery going from the heart (the aorta) and into the main coronary artery where contrast (something that will show up on x rays) is then released and x rays are taken of the heart. The contrast goes down all of the coronary arteries and shows up on the x rays allowing you to visualise the blood vessels and see if they are narrowed in any places. The narrowing is often quite obvious - even I could pick out some narrowed sections before the doctor showed me them. Narrowing to a blood vessel may mean your heart muscle doesn't get enough oxygen, particulary when you are stressed or exercising. This causes the chest pain known as angina. In the cardiac catheter lab if the doctor carrying out the procedure finds a narrowing then if the patient is an inpatient they can fix it then and there using angioplasty and stenting (the patient has to stay in hospital over night after having a stent so if they had the angiogram as an outpatient they have to come back for the actual treatment). Angioplasty is basically inflating a ballon on the catheter to crush the fatty build up on the arteries and so increase the amount of blood flow that can get through; stents looks similar to the springs you get in the end of cheap pens (but the metal is interwoven in a different way) and hold this newly widen artery open.

I found this bit very interesting to watch because my father developed angina last year and ended up with a stent so it was good to learn what he had been through (patients stay awake for this procedure). I think had I seen this last year I would not have been so scared for him because it really is much more of a routine and mostly risk free procedure than statistics make it appear.

The most exciting bit of the catheter lab though, was easily the emergency angioplasty which came right at the end of the morning. Emergency angioplastys are essentially the same except the patient is in the middle of a heart attack so you have got to get to the blockage and remove it as quickly as possible to minimise heart muscle damage. It was amazing to observe the difference in the atmosphere as this patient came in. Previously the atmosphere had been laid back and jokey with members of the team mocking each other in a pleasant way, now they were working rapidly together to get to the important part of this procedure as quickly as possible and save the patients life. As a medical student watching this I found it hard to know where to stand and what to do - I didn't want to get in their way or slow them down for even a second. I ended up being involved in the team work simply because there was a limited of people in the room who were not scrubbed in and so could be utlised to open bottles/packets and pour solutions. This is how aseptic techniques work - someone who is not sterilised opens a packet without touching the inside and then the scrubbed in nurse/doctor takes the item (in this case catheters) from inside without touching the outside thus keep the item sterile. I felt a bit useless as I was not even great at doing this, having not opened the packets before I fumbled to find the openings and felt I was slowly the team down and frustating them. Still, at least I didn't drop anything onto the floor or touch the sterile trolley!

When the procedure was going on I talked to a bit to the patient who was in considerable amounts of pain. I felt sorry for him as it must be very scary having the medical team rushing about around you and not really knowing what was going on so I tried to explain what was going on to him at least to the small degree I could and reassure him without giving him false hope. I think he appreciated it but then he started asking me questions I could not answer and so I had to just keep advising him to ask the doctor afterwards fortuanately I was called away to open another packet before I could flounder too much...

The procedure was succesful, the clot blocking his artery was found and literally vacummed up and then he recieved a stent to remove the narrowing in the artery that had caused the clot to block it up. A success story and a literal case of a life probably being saved, this is the reason I came to medical school, I just hope that one day I will be as proficient as the doctors on the team I saw today.

Thats all for now, I must stop procrastinating and do some work, fill you in soon.