A catch up..

Well its been some time since I've posted so will try to feel in the gaps a bit...
Since I last posted I have finished vascular, had a week of urology experience and started + now finished paediatrics.

Vascular wasn't really my cup of tea - it was very gory with lots of leg ulcers and ischaemic legs with gangrenous toes. There is (fortunately) no smell quite like an infected leg ulcer. If you are a smoker perhaps paying a visit to a vascular ward might help you to quit - during my time there it was fair to say most of the patients were smokers/ex heavy smokers and/or diabetic. I only saw one surgery during vascular and that was a leg amputation due to ischaemia which had caused irreversible tissue damage.

This was quite a strange and brutal operation to watch, and literally involves the bones being sawn through. I found it quite surreal watching someones leg being taken off - I suppose this was because in medicine obviously normally you are doing everything you can to avoid long term damage to the patient but this was a situation where irreversible damage has occurred and now the surgeons job is really "damage limitation". There is sadly no point leaving a patient with a leg full of dead tissue that they cannot use and that will get infected causing damage to the remainder of the leg - it is much better to save as much of the leg as you can as this will improve the patients ability to late on walk with a prosthetic leg. I did feel very sorry for the patient though and I think even if (as in this case) you are aware you are going into an operation where your leg will be amputated it still must be a horrible shock when you wake up with only one leg. Of course it must be even more of a shock if you are in an accident and end up having your leg amputated as an emergency.

My week on urology also wasn't really my cup of tea - whilst its fair to say I'm unlikely to ever want to go into surgery, I found this a particularly dull area of surgery. Urology surgeries often involve camera going up into the bladder which (compared to the kind of views you get from cameras in GI surgeries) really isn't a very exciting organ to look at. I'm not saying surgeons who specialise in urology don't do great work because obviously they do but personally I can't see the appeal...
It was also a kind of rubbish week in general we were meant to have several teaching sessions on urology but all of them ended up being cancelled... Therefore I know very little about urology - hope not too much comes up in the end of year exams!

Paeds on the other hand has very much been my cup of tea! I had been looking forward to this rotation all year because Ive always thought it might be an area I would want to specialise in. My first week was in outpatients and this week was particularly interesting. One of the clinics I watched was a very specialised endocrinology clinic which was being overseen by one of the top endocrinologists in the country, as a result all of the patients in this clinic were individuals with really interesting conditions that needed to be seen once a year by a more specialised doctor as opposed to the local general paediatrician who normally sees them. There was no diabetes to be seen here! I saw patients with turners syndrome (where girls are missing one of their x chromosome), patients with growth problems due to various complicated causes such as pituitary tumours and patients with problems with their sex organs eg cliteromegaly. It was a really interesting clinic!! And too top it all of we got a free drug company marks and Spencer lunch afterwards :D.

My second week was in inpatients which was also interesting although certainly much quieter in general than the adult inpatients. Apparently during the winter it is a lot busier though because then lots of kids get respiratory problems. My on take in paediatrics was ridiculously quiet as only one kid came in during the whole evening so whilst we got to take his history and exam him we didn't really get much hands on experience unfortunately. During the week we did have a teaching session where we got to try examining kids - the doctor overseeing us got us to try and check a toddlers reflexes...this is very difficult! Firstly you have to try and distract the child in order to get them to relax their leg (or arm if it those reflexes you are testing) and then even once you have managed that, the space you need to tap in order to get the reflex is ridiculously small in a child!

Now I am just about to starts OBs and Gynae and I had my first session on the delivery suite yesterday and got to see my first birth :D. The birth wasn't natural but a caesarrean as the baby was showing sign of distress. Nonetheless it was so amazing seeing the baby being pulled out and then start crying and watching the dad walk over and see his little girl for the first time, and then once the baby was cleaned down he got to carry her over to the head end of the operating table so that the mum (who was awake during this c-section with a spinal anaesthetic as this is the preferred way for most caesarreans to be done now) could see and kiss her baby. It was magical! Certainly one of the plus sides to being a medical student is getting to watch moments like this :).

Easter holiday envy: Welcome to your career

A real mixed week of excellent GI teaching, being yelled at by admin staff, meeting a fantastic recovering anorexic, starting vascular, and having my last official surgery "on take". Where to start!

Well lets start with where this week falls in all students at my universities timetables. Well like students at universities across the country they are now enjoying the comfort and relaxation of home cooked food, lie ins and the chance to catch up with friends from home. And me? Well nothings changed really, my friends from home are contacting me asking when I am around for a catch up and the answer regretably is...well sorry I'm just not really. So this is the life of a 3rd year: holidays we have are shorter, days are longer and some holidays disappear altogether. At better moments I even forget last year I would have been on a month holiday around now and at other times the remainder of the lazy uni student in me (I feel this is a side that is disappearing bit by bit with every 8am I successfully make) feels that something is dreadfully wrong because shouldn't I be watching telly and eating edible food about now?! My batteries are used to a recharging every 10 or so weeks and so as its now week 12 I do feel a bit overdue for a holiday

I'm not bitter really (well ok not bitter mostly!) because really this is the life we chose and to be honest we still have it easier than actual doctors - we get a four day weekend over the bank holiday (but as a doctor its not like the hospital cannot be staffed just because its a bank holiday or even christmas. People still get ill) and we have a random week holiday in 3 weeks and 4 days time (but whose counting?!!)

So time to update what I've actually done with this week I suppose.. The highlight of the week for me came at my SSM (special study module - this is an aspect we pick and have a few hours on each week alongside our main rotation). My SSM this rotation has been based around eating disorders. I've been finding it incredibily interesting - whilst I had done a psych rotation just before I started this blog, this is an area of pychiatry I never really got to experience and its quite different from many other areas of mental health. This week I met a lovely girl who came in just to talk to us about her experiences of anorexia nervosa (AN). What struck me most about this experience was how wonderfully honest the girl was. For example she told us about the kind of things she used to do when she had AN before her GP weighed her (she used to water load - this is where the patient drinks lots of water just before their appointment causing the full extent of their weight loss not to be so obvious; she also used to wear multiple layers of clothes to increase her weight). She told us that whilst she knew she was underweight even at the time she feels it is only now when she watches home videos that she can see just how underweight she was. When she was in the grips of the disease she only weighed around 4 and a half stone and would eat very very little but exercise frequently.

It was quite a thought provoking and sad experience as well though meeting this girl because even now when she has been a normal weight and BMI for about a quite a long period of time she doesn't feel happy with the way she looks and feels she could do with losing about a stone despite being a perfect BMI. Anorexia unfortuanately is a lot like alcoholism - once you've been in its grips it is thought you are never fully free from it as its always something you are at risk of developing again.

Last week of gastro has been and gone now. Our registrar very kindly went through some assessment areas we have to do and be signed off for in our logbooks and from this I learnt a lot more about how to examine the abdo system which was really useful. Unfortuanately the downside of this was that this teaching session started a lot later than we orginally had arranged with him because he got held up with a patient. This meant it encroached on a "multi proffessional session" I had to do afterwards - I did tell the reg I had to get away at that specific time so he let me be assessed first but unfortuanately it still over run and I was late to the session really through no fault of my own. When I arrived at the session about 10 minutes late I got completely yelled at by an admin worker connected to the department despite trying to explain to her there was nothing I could do about it (I couldn't just leave halfway through examining a patient!) and she refused to let me go in saying I had missed it all now and there was no point. Most annoyingly I know this wasn't even true - the patient that was being seen in the session was waiting nearby and hadn't even been bought in yet.

I found out from others scheduled to attend that session that a few of them had been 5 mins late and she had been cross with them but let them in despite them having just come from home for the session. Quite frustrating when I was genuinally having teaching and assessment elsewhere! Furthermore I still have to slot this session in somehow and its going to be very difficult to do so as I have other multi proffessional sessions to attend during that time on other weeks. Somethimes it feels like that as medical students we are the bottom of the food chain as it were and so a lot of other staffs anger at perhaps the way they have been treated at times gets taken out on us as we are not allowed to stand up for ourselves and voice our own opinions. Argh. Anyway rant over :).

Yesterday was my last surgery on take and rather than the usual ?appendicitis patients I got to see a really good mix this time. I saw one patient who had come in following complications after an operation to change her gender and create a neo vagina - this is technically a GI case as it is bowel that is used to create the new vagina not however your standard GI case so interesting to see! I also got to see my first new vascular patient - a patient with a cold, pulseless foot. This is one of the more common vascular emergencies. And lastly I finally did something right in an examination - when examining a patients abdomen I thought I felt an area of hardness and was wondering if it was a mass or just muscle guarding. I felt it was more likely to be a mass however as I could feel a clear edge to it. When the junior doctor came and saw him she felt it was just the muscle wall however she then told me later that when the patient was xrayed there did seem to be mass of faeces in that area and when she examined him again later she felt what I meant..... SUCCESS! Maybe I will make a full doctor yet :).

Now I'm on vascular, had a clinic today which was really good and interesting but I'm not sure the consultant was too impressed with our vascular surgical knowledge (or lack there of!) but still that is why we have a vascular rotation: to learn this!

A failed vampire

So now I am on surgery... Stop reading now if you are eating or about to have dinner ;)

For the last three weeks and remainder of this week I have been on GI surgery, I have quickly learnt that this is a strange area of medicine where patients go if they have abdominal pain and/or poo problems. Whilst asking patients how their bowels are working is a common question in all areas of medicine, GI surgeons really like to concentrate on it, if you forget to ask exactly when a patient had their last bowel movement and its errr consistency (I did tell you to stop eating!) then you haven't taken a history fully. I've become quite blase remarkably quickly about asking patients about such an intimate area of their lives, to start with though I can't deny I found it a bit embarrassing to ask someone that and even caught myself once refering to stools as "Number two's".... Opps!



Despite the strange basis of this speciality and the fact I am really not interested in becoming a surgeon (which with my perfected combo of clumsiness and cackhandedness is definately a good thing as far as patient care is concerned!) I am actually really enjoying being a student in this area. My team on my current firm is great - the junior doctors are all really lovely and happy to teach us during their breaks (the F1's happily tell us you get quite a lot of breaks as a surgery F1 which means you can eat all the mess food before the medic F1's get there!) so I'm learning quite a lot. Furthermore as its surgery we get to do some of the cool practical stuff that you always look forward to doing in your pre clinical years. Last tuesday by a case of being in the right place at the right time and having randomly mentioned to an F2 who was on call that I really wanted to have a chance to scrub up for an operation (we've been taught how to but I hadn't put it into practice yet) I got the awesome opportunity of assisting with an open appendictomy. How cool is that!! The F2 got bleeped and asked to come help assist because the assistant surgeon had to leave but because she was on call and too busy clerking in all the new patients she suggested to the registrar who bleeped her that I could assist instead :D. A kind anaesthetist helped me remember how to scrub in and before I knew it I was there retracting bits of bowel and holding someones appendix. The operation took quite a long time as it wasn't a typical appendictomy as the appendix was quite hidden (which is why it ended up being an open operation - it was attempted using keyhole first of all but it wasn't going to work) and I was starting to feel quite faint near the end due to the heat in the theatre and the constant standing up, as it was only the theatre nurse, the surgeon and me scrubbed in I was starting to worry what would happen if I reached a point where I was going to faint or have to sit down as I wasn't sure who would retract whilst someone else was scrubbing in to replace me (it takes over 5mins to scrub in). Fortunately it didn't come to that so my first attempt at assisting in surgery did not become a complete disaster!

Whilst this is the only operation I've assisted in I've been able to see quite a few others - a hernia repair, a gallbladder removal and three appendictomys. Ive also seen a colonoscopy (a camera up your back passage as the surgeons describe it) and an endoscopy (same but down your throat for the upper end). Today in clinc I see (and look down) a sigmoidoscopy (similar to colonoscopy but doesn't go so far and the surgeon looks down rather than looks on the screen at the images transmitted from the camera) and see haemorroids (aka piles) being banded. So theres been lots to see which has been cool and I've also had lots of on takes (including one 8am-10pm one - eek) so have also got to and clerk in lots of patients by myself which is always great practise.



Another skill I have been able to practice whilst on GI is taking blood. This is something we are meant to try an practise as much as possible but unfortunately despite regulary voluntering to take blood I have so far only got the chance to try on one patient right back on my very first rotation (an attempt that was only successful with a little help from the reg who was with me). Due to this and my aforementioned cackhandedness I am rubbish at this... During this rotation I have had the chance to try on three patients so far...and have succeded to get 1 measley tube out of all of them combined :S. My first attempt was on a patient who was about my age and absolutely lovely to be despite the fact I stabbed her with a needle on an area that was already covered in bruises from blood tests and failed to get any blood whatsoever. In my defence in this case she did have tiny veins and the bruising made it impossible to see them so even the F1 struggled a bit. But she told me I really didn't hurt her and was generally lovely. I later found out that she was considering medicine as a career so perhaps that is why she was so understanding. My second patient was on someone who have enormous veins so there was no excuse for missing in him, I did get the vein and successfully got one tube of blood but unfortuanately in trying to switch for the second tube (the tubes are vaccum sealed so have to be pushed on with quite a bit of force to break the seal) the needle must of moved within and no blood filled this one; I tried to adjust the needle position slightly as sometimes this helps but I pulled the needle out to far and heard the hiss of air caused by the tubes vaccum being ruined as the needle leaves the skin and so air enters. Then not thinking I pulled the needle out fully whilst the tourniqet was still on the patients arm.... This means the blood is still under a lot of pressure and so causes blood to come out rapidly which never looks to great from a patients perspective.... My third patient I was never going to have much luck with - a very elderly patient who had been in hospital a long time which means lots of his veins had become unusable, leaving no easy vein options. Predictably I completely failed on this one.

So yes, glad I am not a vampire! Ah well practise practise I will keep trying, sooner or later surely I will hit that red gold!

CRASH CALL!!

Alright well due to extreme busyness from both essay deadlines and intercalated personal statements this blog is seriously delayed - I even started writing some of it 2 weeks ago and never finished and posted :S. So sorry about that!

On friday (two weeks ago!) had the most awesome ward round ever! Literally! Reading the title of this blog you might think I'm a bit weird for saying that but I'll tell you now (spoiler alert..) that the patient was ok at the end so I think I can say legititmately say that it was awesome. So heres what happened...



I was on a ward round on CCU (cardiac care unit) with one other student and a lot of doctors (3/4 registrars, and 3 F1/F2's and we were going around seeing patients in turn who had recently had acute coronary events - such as angina, MI's or had just had arrthymias detected. After seeing several patients we reached one elderly gentleman whose heart was absolutely racing at over 200 beats per a minute and his monitors were bleeping away to alert the staff to this problem. In all honesty though the patient didn't seem that unwell considering his heart was pumping so fast and he was replying quite coherantly to the doctors. Then the nurse got him to sit forward because his blood pressure wire had gone underneath him so was not recording properly and the doctors needed to know seeing as his heart was going so abnormally fast. Then all of a sudden the patient collapsed and before I knew it the doctors and nurse were rushing around performing CPR, closing the curtain to all the other patients beds and grabbing the crash trolley. The patient had gone into ventricular fibrillation - one of the shockable types of cardiac arrest.



And it was just like ER/House/ Greys/ whatever medical drama you choose to watch. It really was, everyone scoffs and says it isn't really like how it is portrayed on tv but in this case from my position of hiding out of the way with my back pressed firmly against the curtain of the patient opposite it really was. The only difference really was that in England they don't use defib paddles but sticky pads that you stick on the patient (apparently it decreases the number of times staff accidently shock themselves). The nurse said at one point that she felt the patients ribs crack and the doctor in charge dramatically yelled out everyone stand clear before he adminstered the shock. And then in this case (just like in ER) our patient magically recovered and regained consiousness - I hear this is not often the case, but then again I suppose you are going to have a cardiac arrest you couldn't really pick a better time than when 7/8 doctors, 2 nurses (+ two useless observing med students!) are standing round your bed.

The patient then got rushed off to theatre to have a temporary pacing wire put in so that this way he could have medication to control his fast rhythms without causing more slow rhythms than he was already suffering from as the pace wire would stop these. Problem solved and life saved!


After this ward round I didn't really have much more on medicine than the odd bit of teaching and my CBD exam. My cbd exam went....well pretty awful to be honest. I got an ok mark but the experience in general was horrific as I got throughly grilled - normally consultants wait to the end of your case presentation and then ask just a few questions but the consultant doing mine prefered asking throughout and asked hundreds of question. Eeek! It really made me lose my flow and I know I was beetroot coloured by the end but at least he wasn't a harsh marker as it happened and I somehow still got an ok mark. I guess thats the main thing!

Had my halfway there ball (as we are halfway through our medical degree) last week, was awesome!! Now I actually am half a doctor allegedly :).I am now on surgery but will save that for next post so that I actually post something now rather than delaying further!!
So, will try and post sooner next time!

Patient stealing and reaching the end of general medicine rotation

Been a bit overdue in posting this as have been a bit busy over the last week and a bit, for once this was mainly in a social way as its been my 21st this week - yay for legal USA drinking should I ever go there. Medicine has also been busy as this week is my last on general medicine so have been trying to complete my logbook (logbooks are the bane of a 3rd year medics life at my medical school, we have to get signatures to show we have attended particualar sessions, met various multiproffesionals and been observed practising various clincal skills).

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The problem with our logbooks is that you have to get the signatures and as a result end up missing sessions that may be more useful educationally in order to get a signature. For example this morning I went to see the hospital Chaplain to find out about his role so that I could get my 10th and final "Multi Proffessional" experience signature. But as he couldn't do it any other time I had to see him rather than going to an additional teaching lecture, as that was optional and did not require a signature. It was admittedly interesting finding out what the chaplain does and how the chaplancy service at the hospital works (and I suppose will be useful to some medical students so that they know in the future they can refer patients there, but to be honest I already knew it existed so Im not sure I gained that much) but I'm sure my future patients would prefer I'd attended the lecture this morning by the famous visiting Clinician. That said I suppose logbooks do stop some people just skiving off.

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Last tuesday I had my last "on take" to do and it proved to be a very annoying experience. I learnt the hard way that you can not always just trust other medical students with what you tell them as sometimes their competitive streak takes over their sense of fairness which is a real shame. During the morning on take I managed to find a patient that my consultant agreed could be a good CBD (case based discussion) patient - these are patients that we have to follow up throughout their time in hospital and then present (and be examined on) them at the end of the rotation. Anyway I spoke to this male patient and took his history just after he had been admitted and he was very easy to speak to and furthermore was unlikely to be in hospital too long which makes it easier as its a bit worrying when you don't know if your patient will be discharged in time for your CBD. He had chest pain which the doctors felt was ?PE and was exactly the kind of condition I was looking for - lots to talk about without being overly complex. However in the afternoon I made the mistake of telling another student on my firm (medical team) that I had found a cbd patient at last and the other student asked his name. Before I knew it this other student was running off to find the patients notes himself and also planning on using him for his CBD. :O! Now whilst we are not technically prevented from using the same CBD patient I think it is a bit frowned upon because really your CBD patients are meant to be people you clerked in when they came to A+E and then have seen ever since then. It is really meant to be an independent thing of finding a patient for yourself then following them through their admission. I didn't actually clerk this patient in but I did re take his history very shortly afterwards. What really annoys me is that this student didn't have the courtesy to ask if it was ok with me if he used the same patient but just did. Also Ive checked our examination timetable and I am doing my CBD after the other student in the same room - which means if the consultants don't change over in between then its going to look like I am the one who stole his patient and this could affect my grade unfairly. All in all very annoying.

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I had more annoying times on this particular afternoon about patient stealing but not to the same extent. Not many patients were coming in for ages so I had to wait around in the MASU office for a while with nothing to do. On the plus side this meant that when patients did arrive, the registrar gave me one to go clerk in and my name was written up on the clerking sheet as seeing that patient (meaning in theory no one should go see the patient until after I have presented the clerking to them and then a junior doctor will review them with me). However when I found this patient in A+E her curtains were pulled and when I came in I discovered two other students on my firm already clerking her having seen her name on the A+E board as a new medical firm admission. This in itself was annoying when I had waited so long for a patient to clerk but then when I went back to the registrar and explained why I couldn't clerk them I gained a rant from him about how annoying it was when medical students didn't do things the proper way. He told me I had to tell my collegues the proper system but when I did so I'm not sure it came across the best way because it was hard not to show that I was a bit annoyed myself that they nicked my chance to do some clerking (and by this get some vital clincal skill logbook boxes signed off!). A tough day.

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I had a better day yesterday managing to get a teaching ward round, gi history and mini cex (this is like a practise CBD but done from just one time seeing a patient) all before 1pm which was pretty awesome. I had previously had trouble finding both a GI history (as patients with GI problems always just seemed to be due to come in when I have been on take but have never emerged) and a mini cex so it was great to finally get these done (and both on the same patient as I used a GI problem for my cex!) The patient was lovely, she was happy to let me re take her history and examine her even though she knew it was just for my benefit and she was feeling very nauseous (she was actually sick whilst I was in there but then encouraged me to continue afterwards when I was a bit unsure whether I should continue putting her through it). Lovely lady and then I had the fortune to present her to a very nice registrar so got better marks for my cex than I feel I strictly earnt. Good times!

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Thats all for now as I need to work on my CBD (and to be honest watch an episode of house I'm currently streaming!) Sorry its been a bit of a rant this week, its probably because it gets a bit stressful when your trying to get your last signatures (which are usually the hardest ones to get hence why you left them till last!) so its particulary annoying when things stop you from getting them! Still only three more signatures to go now (and they are all sessions I'm timetabled in for wooo!) and then logbook completed :D. Have a lovely week.

\p.s. Apolagies for the wierd paragraphing - it won't let me make gaps today without a \ for some reason!

Sometimes you can't win

I had some interesting patient experiences this week, so I'm going to talk about them but to preserve confidentiality obviously I won't use any actual names and I'm not going to give all details to further ensure the patient is not recognisable (this is also why I never mention what medical school I am at as I do not want people to be able to work out what hospital I have met particular patients at).

On monday in a clinic for a particular progressive chronic disease (again I will not mention what) I met a lovely elderly (ish) couple. The husband was the sufferer of the chronic disease but his prognosis at the moment for that was very good and he had years left before it would become a problem. At the moment he was just attending clinic so that it could be monitored and he could be educated about what choices he had further down the line. This was one of his early clinic appointments so the consultant was suggesting his wife and him attend a group patient education session on his future possible treatments. The great thing about session like this is that they allow the patient to meet other people who are in exactly the same position and so not feel so isolated in their misfortune of getting a chronic conditon. The couple were very positive about the suggestion and so were going to attend the next session. I had really enjoyed meeting this couple and it was nice to see how chronic conditions can be managed positively and effectively. Unfortuanately though when the consultant looked through some recent scans the patient had had (purely to teach me for my education, not because he was expecting to see anything) things did not turn out to be so positive. The scans showed what was very likely to be lung cancer which the consultant pointed out was most likely to be metastatic (spread from somewhere else) as he did not have it just a few months before when he was scanned and now it was pretty big. Metastatic lung cancer is terminal. I felt really bad knowing this before the patient knew and I expect it will be a while before he finds out for sure as they will want to do proper diagnostic tests firsts. I think the consultant also felt bad that he hadn't seen this before the appointment as then he would not have told them they needed to consider the future and sent them for further education. He was trying to do the best for this patient and to help them plan for the future but in doing so he had made the assumption the patient had long enough left for his chronic condition to progress that far. As my title suggests sometimes you cannot win.

The next memorable patient I met was a much happier experience. She was in her mid 90's and body appearance wise was frail but in all other ways was one of the fiestiest most chirpy patients I had met. She turned up with her nails painted and hair dyed a vivid colour and virtually bounced around the clinic room with her energy and happyness - she very much reminded me of the poem that says "when I'm old I shall wear purple" because she had such a mischeivous/rebellious attitude. She was simply awesome. Frankly if I can be as cool as she is (and so sharp and witty still) when I am in my 90's then I will also be very happy! I wish I could share some more specific anecdotes about this patient as she was so awesome but I think if I did so I would make her too recognisable to either her or her neighbour who came to the appointment with her and I don't want to risk that on the ridiculously slim off chance they ever saw this.

On tuesday I had a cardiology clinic. Last time I went to this specific cardiology clinic three weeks ago I completely crashed and burned when I was getting grilled by the consultant. Furthermore it when everything was snowed up so the consultant had loads of time to grill me as many patients were unable to make the clinic. My partner had got the wrong location for the clinic and so I had to face the torrent of cardiac grilling by myself with no one to hide behind... The grilling progressed to the point that I was even mucking up the bits I did know really well and thus making myself look thoroughly stupid. The clinic then ended with the consultant saying (albeit in a very nice way) that I was rusty on my knowledge and I should go away and learn lots and it would be nice if he saw me later on the rotation so he could see if I had progressed...Eeek! So go and try to learn lots I did. I bought and ECG "made easy" book and I'm slowly learning all about the confusion that is 12 lead ECG's and I've been teaching myself about heart murmurs and heart failure. So what did he grill me on today? Well he asked me (and my partner this time) if I knew what Gin was made from, whether we speak italian and what fiction book we were currently reading. On learning that we weren't currently reading any fiction books he was dismayed that it was all work at the moment and told us we should read fiction books because they were the breath of life... DAMMIT! I couldn't agree more that reading is a great hobby and escapism but part of the reason I have not had not had time is because I was trying to know more about heart to avoid getting another embarrassing grilling. As I said, sometimes you can't win!

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.

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.