The average week of a fourth year medical student: Wednesday

The average week of a fourth year medical student: Wednesday


7.30- 8.25: The usual excessive pressing of snooze!
8.30-8.45: The equally usual rush to get ready and quickly downed coffee
8.50: *Once again running late!!*

^ I really do wish these things had never been invented!

9.05-12.30:  A morning in the eye hospitals A+E department
Eye hospital A+E is in someways much like a regular A+E in that patients can just self refer and turn up on the day with eye problems and wait to be seen, equally GP's (and because its the eyes: opticians) can suggest to patients that they attend the A+E and refer them.

In some other ways though its very different to a normal A+E, for starters I saw a number of patients today (and during subsquent mornings I have sat in on this department) who had appointments booked for them for a weeksa time to come back and check things are progressing/improving as they should.  This makes it almost more like a clinic or GP appointment system - in regular A+E if a doctor told a patient to bring themselves back into the A+E department to be rechecked they would probably receive some very harsh words from colleagues and hospital doctors!  But I suppose the eye is such a specialised area that there no point telling the patient to get their GP to recheck them in a week because without the special equipment the eye hospital has and years of specific expertise in that area, a GP wouldn't stand a chance of picking up any reasonably subtle but important eye changes.

Saw quite a few interesting patients today but also had a lot of waiting about in between patients due to the nature of A+E and amount of refering to other departments the poor overworked registrar had to do.  Here are the top three most interesting patients:

1. A patient who had herpes zoster (aka shingles) and had been unfortunate enough to get eye involvement with her shingles and was first seen by the eye team last week and now was being followed up..  She had whats called "Herpes Zoster Opthalmicus" which simply refers to the  region that her shingles had appeared (it is in the opthalmic division of the trigeminal nerve) - over the right hand side of her forehead going down to below her eye.  The worrying possible complication of when shingles affects this area is that it can cause eye problems such as uveitis, conjunctivitis, keratitis and ocular nerve palsys although these are reasonably rare.  This patient when she first presented to her GP the previous week was recorded as having something called "hutchinson's sign" which is where there are shingle vesicles on the tip of their nose.  This is significant as the nerve which supplies this area (the nasociliary branch) also innervates the globe of the eye, so patients with this sign are twice as likely to develop eye involvement with their shingles (where as having herpes zoster opthalmicus with vesicle on the eyelids does not increase risk from herpes zoster opthalmicus where the vesicles are just on the foreheard).

Herpes Zoster Opthalmicus

 Unfortunately for todays patient she had got eye involvement and had developed anterior uveitis a week ago.  Uveitis is inflammation anywhere in the uveal tract and the anterior part just means it was affecting the front of the eye.  However after a weeks treatment the patient was actually doing a lot better, but has to slowly come off the eye drops over the next 8 weeks to try and prevent worsening/ recurrence.

2.  A patient with a coldsore (herpes simplex causing a dendritic shaped corneal ulcer) in his eye!! Another unlucky chap as this is reasonably rare as well.

3. An eleven year old who came in with the most swollen eye I have ever seen outside of medical pictures.  Poor poor boy it looked so painful.  Apparently it is an infection probably from within his body although he feels systemically well at the moment.  He was referred straight across the road to the childrens hospital to have IV antibiotics because the doctor wasn't sure if he had slight orbital cellulitis which is serious as it can be both sight and life threatening as it can enter the meningeal cavity (in other words there is a small risk of developing meningitis from it).

The boys eye looked pretty similar to this but without the red scabs this childs eye has

Wednesday afternoons are usually off for "sport", I am probably one of the rarer medical students who does actually use them for this but as I said yesterday BUCs matchs are finished now so this time is now available :) 


12.45- 4.30:  Had a nice lunch out in the sunshine with my rabbit hopping about, met the new next door neighbours because they were peering over the wall watching their cat who was out in this area for the first time.  Made friends with the next door neighbours quickly when they spotted Chunks and exclaimed that they had rabbits too and held theirs over the wall to meet me!

Wrote some of this blog out there and did a little ophthalmology reading but then actually got too hot (remarkably for march!) so I've headed back inside and am ready to do a serious amount of essay work! (I did do some yesterday, but lots more to do).

Till tomorrow!

Halfadoc

An average week of a fourth year medical student: Monday

An average week of a fourth year medical student: Tuesday


So what actually happened after my committee meeting yesterday? Yeah, the room didn't get tidied and no work was done, oppsy.  Instead my partner came round and we ate pizza and chatted to my housemates, oh well!
Still new day, new chance for that essay to get written....

8.15: Actually get up despite having the morning off! (The advantages to dating a final year who does not have mornings off!).  Its a lovely day here in my part of the country, feels almost like summer :). 


09.00 ish : Get showered and changed and start being constructive in the form of emails and phone calls I've been putting off for a while.  Oh and of course : Coffee!

This isn't my picture but sums up my day today pretty well :), happy halfadoc!

10.30-12.30: Got my room back to spotlessly tidy, looks much nicer now :)


12.30: Coffee and toasted teacake break :) then a quick spot of ebaying (I need a desk chair - house came unfurnished and still haven't got one and haven't had any room in bedroom for said chair until recent tidying spell ;D)
1.30: Head to afternoon clinic, take a textbook with me because last time the doctor didn't turn up for ages....


1.45-2.30: *Read textbook*


2.30: See an interesting patient with one of the nurses, he is virtually blind in one eye (can only see light and movement) and has extremly bad vision in the other eye due to a cataract which was due to be operated on a few weeks ago but they discovered during the pre op assessment that he had an eye infection so the operation had to be postponed.


When the nurse got him to read down the eye chart with his "good" eye, it wasn't immediately obvious which line he was trying to read as what he was saying didn't resemble any of the lines in the slightest, the nurse asked him again to read the top line multiple more times before she was sure that that was the line he was trying and his eye sight was simply that bad.   This means this patients vision at SIX metres was so bad that he couldn't see a letter which was sized so those with normal vision can see it at SIXTY metres, so pretty bad!!


I wasn't too impressed with the nurse in general with this patient though because he was a fairly confused elderly gentleman and she was quite grumpy/ rude with him just because sometimes he took a bit longer to understand her instructions.  I know she must be busy but I do hope that however busy I get in the future I don't lose patience with those who for no fault of their own take up a little bit more time than the average patient.

My patient couldn't read the top line of a "snellen chart" like the one shown in this cartoon

2.40ish: Doctor arrives
The first thing he asks me is what clincal skills I still need completing which saves me the awkwardness of asking him, so this is quite nice :).  The patients are for the most case pretty bog standard follow ups and mostly all patients with glaucoma who have to be monitored once/twice a year.   I get to do my clinical skills though and rather than it just being a matter of getting the sign offs, the tips he have definitely helped my actual ability so this part of the clinic was useful.


The doctor quizzes me on a various things throughout and for the most part I actually do pretty well as they mostly happen to be the bits I read whilst waiting for him. WINNER!!


4.30 ish: Clinic still on going but Doctor signs off my clinic and suggests I see if theres anything more interesting going on in the A+E department but if not tells me I can go home because "you have above average knowledge about the eye anyway" - wooo never has bringing a textbook with me ever been such a good idea before!  There were other students in A+E so I couldn't get in and headed home.


4.45: Have somehow bought FOUR desk chairs for £5.98 (all together!) second hand from ebay. Interesting.... I wonder if I can sell the other 3 using the Friday ad and make some profit?!

Fortunately I didn't buy *quite* this many chairs

5.00- 6.30:  Been sitting out in the garden enjoying the surprisingly warm weather with my lovely rabbit Chunks (he's erm a sturdier build than most rabbits) running about while I type this and sort out a few other internet things.  Its been a pretty good day!

Action shot of chunks in the garden

Chunks tired after all that hopping about

Normally at this time on a tueday I would be at sports training, but we had our last "BUCS" (the university league) match last week and also the rest of the uni are now on their easter holidays (damn them!) so I'm free to get on with work, joy! So time to conquer some more of that essay... wish me luck!

Halfadoc x

An average week of a fourth year medical : MONDAY

An average week of a fourth year medical student: Monday


Well this series of posts will literally do what they say on the tin.. I'm going to tell you exactly what I've been up to this week, it probably won't be in much reflective detail (unless I get carried away...hopefully not, I've got work to be doing!) but it will give all of you out there thinking of doing medicine a realistic idea of what clinical years are like.  I have to say though fourth year is our easiest clinical year so maybe I will do the same next year when I am a final year just so you don't think its too easy ;)


Monday:

7.00: First alarm... *snooze*
7.10: *reset alarm for 7.30*
7.30: *Snooze*
7.40: *Manually snooze for another 5 minutes*
7.45: Finally sit up, and grab energy drink placed next to bed last night (I was finally being constructive late last night and stayed up till 3.30am as a result as I know me and if I didn't then the task I was doing would remain half done).

Lidl energy drink, dragging me through medical school since 2009 (the year I moved to a house ridiculously near my local lidl ;)

8.05: Finally make it out of bed, grab some passable clinical clothes, quick wash and get ready.
8.15: Boil kettle! Yep, more caffeine.
8.17: Discover milk gone off, *swear*. Put cold water into coffee and drink it black *bleurgh*.

8.22: Running late! To the hospital!!


08.35: Arrive at eye hospital (currently on ophthalmology)
08.40: Get into scrubs - this mornings session is watching eye surgery.
0.9.00- 12.10
Watch 3 x Vitrectomys - these are operations to remove the vitreous humor (a gel between lens and the retina which should be clear) from the eye.  These patients were having this operation because an "Epiretinal membrane" had formed on their macula and they needed to have the vitreous removed and then this membrane removed (membranectomy), there are other causes for this operation though such as retinal detachment.

I got to watch one of the operations through the "spare" microscope head, which made me feel totally badass and like I was on greys anatomy (even though a) It was eye surgery not neurosurgery and B) I wasn't doing anything just watching and making sure I didn't touch the surgical field!).

I'm totally this cool, honest...

You get an unbelievable view down the microscope compared to the screen where I watched the other two operations, and you really get to appreciate how skilled and impressive the   ophthalmologists are - they have to be able to make the tiniest movements ever, no room for those with shaky hands here!

We received quite a lot of teaching during the morning from both the consultant and the scrub nurse, a very welcoming team :).

An interesting morning but I have to say I do find eye surgery quite gross, though that's partly due to watching Final Destination 5 recently, regret seeing that before my ophthalmology rotation!!

The eye lasering scene from final destination.... the instrument holding her eye open is the same as is actually used, fortunately nothing else was the same as in the film!!

12.10- 13.45: A quick trip to lidl (milk!!) then lunch and a nice coffee with milk made from coffee I bought from the plantation near where I was on elective in Tanzania.  Its is AMAZING coffee and normally properly wakes me up but today I was too tired for even that to combat the midday sleepiness.  Grab another lidl energy drink to take to lectures in case I'm falling asleep.

14.00-15.30: Lecture on back of the eye pathologys, its ok and quite well taught but theres quite a lot to get through and it does drag a bit, energy drink was a good call!!

15.30- 16.15: We go down to the clinics to be taught fundoscopy and practice on each other.  Unfortunately this was a bad clinical skill for her to choose to teach us as probably is one of the few skills we have got to practice quite a bit recently, so this wasn't amazingly helpful.

16.15-16.45: I still need most of my clinical skills signed off in my dreaded logbook and this is the last week of ophthalmology (we only have 3 weeks its not like I've been incredibly lazy!) so I manage to grab a nurse who had previously said that he would help us get these skills signed off.  I practice on another student and her on me (she already had the skills signed off but he was a very good teacher so hopefully this was still useful for her!) and get a couple of them  signed off but more importantly actually do learn quite a lot, he was brilliant.

17.00 - 17.35: Back home and writing this blog!! Have a committee meeting at 6pm which will probably be a couple of hours, and then I plan to come  back home, tidy my room quickly (I'm trying to turn over a new leaf and be all tidy and organised...this is very unnatural for me! I was doing quite well at keeping my room tidy but then I was ill at the end of last week so fell a bit behind on everything, need to get it sorted now before it becomes a tip which will take hours to sort out again!)  whilst pizza is in oven and then after dinner get some work done.  Will see ;).

So that's my Monday :), tune in tomorrow for my Tuesday...

Halfadoc x

Physician don't heal thyself

Physician don't heal thyself


As well as having hospital rotations this year, I also have 8 morning GP practice visits.  A couple of months back one of my visits was postponed a week before it was due to happen because the GP was ill which I remember thinking was quite worrying because to be able to give a weeks notice of illness the GP was clearly suffering from more than just a mild infection.

When I did have my visit with him I wasn't going to ask what had been wrong with him but he quite happily told me what had happened of his own accord and it was a good warning story about the dangers of self diagnosing when you are a medical professional...

Basically he had been having a very stressful few weeks and had been feeling quite tired and rundown and noticing periods where his heart skipped beats but as he didn't really have time to get checked out he just ignored these until one day at work when he got angina like pains.  So not feeling he had time to get to his own GP surgery (and fortunately doctors cannot prescribe medication for themselves) he asked his gp to fax him over a prescription for GTN spray (the reliever of angina) and said he would get to the surgery for an appointment later in the week.  His GP quite rightly refused to do so unless the GP came in immediately for an ECG.  So the GP moodily agreed to do this but was annoyed at having to when he was so busy.  A good thing he did tho......

On having the ECG it was discovered that the gps chest pain was not due to the traditional cause of angina (the hearts own arteries getting "furred" up with fat gradually over the years causing a narrowing artery and so reduced amount of blood being able to get through causing the hearts muscle to not always get enough oxygen especially at times when the hearts muscle is having to work harder eg when the patient is stressed or exercising) but because he had such severe bradycardia (slowing of the heart) that his heart was simply beating too slowly for enough oxygen to reach the hearts muscle for it to undertake even this reduced level of work.  He was having up to 7 second gaps between beats. GTN spray works on angina by dilating the constricted arteries to an extent, as this was not the priniciple cause of the GPs pain it was unlikely to relieve his symptoms and bits of his heart muscle will have started to die off (not to mention the fact that other vital organs such as the brain will also have been depleted of oxygen).   So thanks to the GPs own GP refusing to be persuaded to prescribe without seeing him, the GP was rushed in to have an emergency pacemaker fitted, something which actually would fix his heart problem, and now he admits he feels better and has more energy than he has for years.

Whilst doctors undoubtably have the knowledge to technically diagnose and treat themselves, when it comes to their own symptoms they can be blinded and biased by their own beliefs about themselves and health agendas.  Self diagnosis...not a good idea!

Interestingly I've noticed that when it comes to adult doctors they are likely to be quite dismissive of potentially serious symptoms whereas medical students are the complete opposite (at least based on my housemates, close friends and self) and even a simple  2 second itch is proclaimed to be pruritus secondary to kidney failure.  Honestly we've all probably used our stethoscopes more times to listen to our lungs  when we have a cold than to actually examine patients!  Sometimes we do get it right tho..or at least describe our symptoms in such a correct way that persuades the doctor we are right or leads them to treat us accordingly just to shut us up!

  I wonder when the hypochondria wears off and the apathy sets in ?  

Halfadoc x

No rest for the wicked, fourth year UK placements begin!

Foreword! I started this blog post literally a couple of months ago now on my first week back in the UK, but didn't *quite* finish it as everything was super manic then - moving back into a student house near the hospital, trying to get back into the swing of UK medicine etc etc, and now before I quite realised it I have gone months without posting. Well I'm going to catch up now, starting with this blog (the rest on here was written at the time) and then retrospectively catch up with more blogs about whats being going on for me back in the UK. Sorry for the prolonged delay!

31/10/11: Still more elective posts to come, but they are only written enough so far to be a memory jog for me about what I did each day, not in blog form yet! However as of last friday I am back in the UK and didn't want to not write anything about my placements here just because I hadn't finished my elective blogs; will rearrange blog post order later :).

So back in England as of last friday, moved into my unfurnished house on Saturday, straight into lectures as of Monday...Hectic! The unpacked/confused mess of my bedroom is testiment to a busy week, albeit mostly because I have been catching up with various people and training/playing university sport (and after many months away, am in serious need of training!).

I am starting on a 6 week placement on Oncology but we also have GP visits and a research project to undertake and these take up a couple of days a week, so really my oncology placement is only 3 days a week (so just 18 days in total...which really doesn't sound that much when I think of it like that!). Furthermore one of these days is often only half a day.. I suppose this is why all the major specialites like surgery and medicine are done in 3rd year or we really wouldn't know that much about them!

So far it seems like this rotation is going to be a lot less clinical experience and a lot more lectures than 3rd year. I'm not sure how I feel about this, on one hand clinical experience is easily the most interesting part and I don't know how well I concentrate in lectures particulary when they are back to back - I try but am a bit too talented at accidently going into prolonged daydreams and realising I've missed a chunk of lectures! On the other hand though, it means everyone learns more or less the same thing and so no one misses any core information, the downside educationally of clinical experience is that it is so varied that you can learn very different things from your peers and accidently miss things. So swings and roundabouts really!

One of our lectures this week was all about being careful how we portray ourselves on social media sites such as facebook and blogs... The BMA has produced guidelines (you can get them from here if you are interested) on what doctors and medical students should and should not do on these sites after numerous doctors and nurses were suspended after pictures of them "planking" in a hospital were put on facebook. Personally think its a bit harsh that they got suspended, guess sense of humour is a bit lacking in that trust! As long as no patients saw/complained I really think that was just a harmless bit of fun, clearly I'm going to have to be careful what I do in the hospital myself!

Its quite scary how policed our social lives are already, and I don't understand why people can't see that doctors and medical students are human too and entitled to their own lives; but I suppose we have known from day one (literally, I'm pretty sure our first "fitness to practise" talks occured on the first day of medical school!) what we had signed up for. As a blogger the social media talk definately made me a bit paranoid, but I'm pretty sure I change enough minor details and am anomynous enough that I am not breaking patient confidentality. Just to clarify if you think a patient I talk about sounds like you, its very very very unlikely to be, I change basic things like gender and age (slightly) and I never use any specific details that would make a patients identity obvious. And on that note, time to talk about the patients I've seen this week....

The patient that had the biggest impact on me was a man in his early 20's that I saw in a Melanoma clinic. Now the melanoma clinic was an interesting experience because on one hand it was absolutely amazing prinicipally because the consultant I was sitting in with was wonderful and exactly the kind of doctor I aspire to be one day. She was both amazing with the patients and even though she was really busy she took the time to teach me an examination I did not know (how to examine the axillary lymph nodes) and explained patients to me. After the experiences we have had with doctors in the Tanzanian hospital it was a breathe of fresh air to be with not only a doctor who seemed to really know her stuff but one who also seemed to geniuneally care about her patients and did her best to explain things to them and reassure them (where as in Tanzania the doctors barely communicated with the patients and didn't ever appear very empathetic). On the other hand though it was a very depressing experience because the majority of patients we saw were palliative only (it is no longer possible to cure their cancer and now doctors are just treating to minimise their symptoms). Furthermore I saw quite a few palliative patients who were very young - maybe it shouldn't make any difference to my feelings whether the patient is 80 or 30 but whilst I felt sorry for both types of patient it did feel even more horrible with the younger patients because if it wasn't for the cancer they would probably have had years left and instead were having most of their life stolen away.

Accordingly the sadest patient was also the youngest and was roughly my age but had metastatic (the cancer had spread) disease. The doctor was trying to get him onto clincial trials which were looking at a new treatment for his form of cancer (although even this treatment was palliative but may give him longer) but unfortunately as if one form of cancer was not bad enough for a twenty year old, it had been found since that he had another form of cancer. Two cancers in an under 30 year old?? Possibly he has some genetic susceptibility which predisposes him to cancer, but it wasnt discussed. The other cancer itself would be treatable but unfortunately its presence means he is not eligible for the trial for his melanoma.

He seemed remarkably philosophical and optimistic considering the horrific luck that has been thrown his way. I think I would be completely unable to function in his position but he was just getting on with his life. It does worry me a bit though that he was so optimistic because he had not fully understood his prognosis rather than because he is a very strong/resilient person but hopefully this is not the case.

So a very sad clinic all in all but also one where I saw some fantastic medical practice in terms of empathy and really caring about patients, so definitely a clinic I am pleased to have experienced. I hope that one day I can be that good a doctor myself.

Halfadoc xx