Saturday, 10 August 2013

Emergency Medicine SSU

For my next Special Study Unit I was lucky enough to spend 3 weeks in the Emergency Department at Derriford hospital, the trauma centre for the South West. I was in heaven, it was simply the best three weeks of the whole year. I had such a blast! We were completely immersed into the team. We had sessions we had to go to, but apart from that we could turn up when ever we liked, go and see whatever and whoever we wanted. It was amazing. Our brief was to get stuck in and see as many patients as possible. From the computer system we could see who’s next to be seen and what the triage nurse had said was wrong. Then we had to clerk them in with a full history and examination and then go and hover until the next free doctor is about to pick them up onto their case load. We presented back to the Doctor with a concise history, impression and management plan and the Doctor sends you off to get some bloods done. Then you go and see the next patient. If something exciting was going on in resus we could go off and help with that, or we could go and spend some time in minors clearing patients there. I saw and learnt so much over those three weeks. My examination skills and history taking skills improved immensely and I really didn’t want to leave at the end of the three weeks. It honestly felt like coming home, I have found where I fit in medicine. It’s the only place I’ve been to where you look up and four hours have gone by in a flash and you haven’t stopped but you still have plenty of energy and could keep going. I did an 8am-6am shift with a total of 5 hours off throughout the course of the day and could have kept on going. Although I do realise that if you do that everyday, you probably won’t still have the same amount of energy and enthusiasm. But for these three weeks, it was incredible.

Everything comes to the door and you get to be the first person to listen to them and say you know what, this is rubbish what has happened but I hear you, I understand and I will help you figure it out. We had all sorts, from strange rashes, drunken teenagers, fibromyalgia, epilepsy, pneumonia, fractured neck of femur… I could go on.

A few of the more interesting ones I saw:

- A gentleman with an irregular heart rhythm was bought in, and to differentiate between the different types we gave him adenosine to slow is heart rate right down to see the underlying rhythm. It was atrial flutter in the end, which has a characteristic saw tooth baseline on the ECG. Patients must be counselled before you give adenosine as whilst the heart is stopped they often report a feeling of impending doom which can be quite unsettling.

- An elderly lady tried to commit suicide by jumping from a third storey window. She broke every bone in her body but still survived.

- I got to be in charge of airways in a trauma call for a man that fell and hit his head. Because I was at the head end it was my job to keep talking to him and I felt so privileged to be able to be with him in what must have been such a scary time.

- A man with mental health problems was rushed in having stabbed himself in the stomach with a blunt dinner knife. He had done this so many times before his abdomen is full of fistulas and this time he was only millimetres away from hitting his aorta.

- A grandson bought in his granddad who’d had a cough for a few weeks and was now short of breath and off his food. The granddad had been refusing to see a doctor until this point. I stood next to the relatives as they were told the cough and shortness of breath was caused by fluid on the lungs from cancer of an unknown primary source that had metastasised all over his body. Hearing that diagnosis felt like I’d been punched in the stomach and it wasn’t even my family. It was so unexpected and heart breaking.

- A blood curdling scream was heard from resus so we rushed in to have a look. A man had been bought in an hour earlier with a lambing band (used to dock lambs tails) that he had wrapped around one of his testicles. This had been cut off and he was waiting for a psych referral to come through. The only damage he had sustained was a small tear in the skin of the scrotum. Whilst being watched by a policeman and a nurse, he had managed to put his fingers in the tear, open it up and remove the testicle from the scrotum. Still attached, he rolled over and it was lying on his hip, where the nurse saw it, and screamed. He was taken to theatre where it was sewn back in and then transferred to a secure mental ward. His belief was that with his testicles attached his head would explode. He’d spent two weeks furiously masturbating, to see if that helped, and then decided this was the next best thing to do. On the psych ward, he later tried to tie them off with a shoe lace, but was stopped and I heard he is now feeling much better.

Friday, 9 August 2013

GUM Clinic

I got to spend a whole week at the GUM clinic which was certainly interesting. The week involved clerking the patients that come in off the streets for appointments, presenting back to a Doctor, taking blood for tests and then observing any examinations and treatment. It culminated in an informal teaching session from one of the Doctors with a lot of cake a lot of pictures and a lot of stories of items where they shouldn’t be. The GUM clinic is where anyone can come, with or without an appointment and talk to a Doctor about symptoms of a genital or urinary nature. It operates completely separately from the rest of the NHS records system, so nothing you say will ever come close to your normal NHS records, nothing gets sent to your GP and the staff don’t even know your name. You are given a number, which I found really bizarre walking into a waiting room and calling a number not a name.

In terms of the history talking, that’s simple as there is just a sheet of paper with questions to be asked and boxes to be filled in for every person, no matter what they come in with. This way, asking questions of a personal nature becomes more of a box-ticking exercise, which helps to take some of the embarrassment away. The patient can see there are questions to be asked, so it isn’t personal what we ask them, it’s just matter of fact. It also means you don’t miss anything.

I got to clerk a few interesting patients. One was a fairly young homosexual man who was coming for a regular check up, to find out about the free Hep B vaccination course he was entitled too and because he wanted to speak to someone about erectile dysfunction problems he was having with a new partner. I was really amazed on several counts. Firstly, I had no idea they could have the Hep B vaccine, what a good idea that is. Secondly, he was whipped straight through to talk to a psychologist about his problems, who gave him some new thinner condoms to trial, a pep talk with some really good, down to earth advice from someone who sounded like she really cared and understood and wanted to help him and an open invitation to come back anytime for a longer, in depth talk if that hasn’t done the trick. I felt really sorry for the guy, as he was so nice to have agreed to me observing, especially as it was such a personal problem and he hadn’t mentioned what he wanted to talk to the psychologist about. I’m not sure I would be that brave.

I spent Valentine’s Day (I told you I was far behind) holding the hand of and distracting a uni student as she had her genital warts frozen off which she caught after a one night stand. I was meant to be observing the procedure, but she was close to tears, really upset about the consequences of one stupid decision and it is really painful and pretty undignified. I felt I would be of better use giving moral support. My last interesting patient of the week was a middle aged gentleman who came in to get someone to take a look at a mole on the tip of his penis. As I was taking the history it became clear that this wasn’t actually why he had come in. His long term girlfriend had died of cancer a year ago. He had looked after her right up to the end and was still grieving and depressed. He had gotten himself into financial difficulties, making poor decisions about his mortgage and wanted a doctor to come with him to the bank to help explain his situation as he never remembered what they said to him and thought a doctor would be responsible and professional and help him get things sorted. He was taking advantage of the fact that you don’t need an appointment at the GUM clinic, so he could talk to someone when he was ready and capable of doing so. I felt so awkward and out of my depth. This wasn’t something I could help him with, the questions on my sheet were completely inappropriate but I was touched that even though I wasn’t who he was expecting to see, he still felt able to open up to me and talk about his problems. It goes to show that sometimes, you just have to listen and be there as there may be something else they want to say that’s really important to them.

And as for the teaching session, the most interesting item pulled out of somewhere it shouldn’t be? A lady came in with a yeast infection she wanted treating. The lady had had a positive home pregnancy test and so had been attempting a homeopathic abortion. She had picked some organic parsley, bound it with organic twine, inserted it like a tampon and left it for a week. She was most upset to find that she was still pregnant and couldn’t see how the infection could possibly be due to anything she might have done.

Thursday, 8 August 2013

Saws and plaster casts

Hello, so I am really far behind in my blogging. Sorry! Last year got a bit busy towards the end, both academically and personally. Expect a few from me over the next few days highlighting some interesting things I got to do, but not one for each week.

After falls and funny turns I was on orthopaedics. I got to spend quite a bit of time in fracture clinic clerking patients and looking at x-rays whilst a scary consultant stood over me waiting for my management plan. Thankfully most of them seemed to be, can you wiggle it, are you getting pins and needles, can you feel me touching here? Brilliant, come back in a few weeks. I got to spend a whole day in paediatric orthopaedic theatres which was amazing. It wasn’t entirely timetabled, but after one of the morning X-ray meetings a surgeon caught up with my partner and I as we were busy trying and failing to get a secretary to tell us what patients were on the theatre lists for the afternoon so we could go and meet them and get their consent to watch their surgery. “Are you medical students? Go down to paediatric theatres and get scrubbed, I’ll be down soon.” No one ever says they actually want us anywhere, so we leapt at the chance.

On the list for that day was a baby with clicky hips, a child with clicky hips whose first surgery hadn’t worked and a child with a broken arm which needed pinning. Watching the baby being operated on was surreal, it looked like a doll it was so tiny and still from the anaesthetic. The child’s surgery was ridiculous. The surgeon sawed off the front of the child’s pelvis and then inserted it horizontally like a wedge into the hip joint to change the shape of the joint space and hopefully help the head of the femur to stay in the socket and not dislocate. It was so brutal to watch, but I really liked the practical approach to trying to fix the problem. Plus it was good to see what actually happens once you’ve found clicky hips in your new baby check, and to be able to take your time to properly feel them in an asleep child with the problem.  The last case was the child of one of the surgeons in the hospital, so everyone was on tenterhooks a little in case anything went wrong.

It was really and truly multidisciplinary, which was nice to be part of. There was the usual theatre team, but then there were also radiologists, to image the patient on the table to check things were in the right place once they had been fixed, and some specialist nurses which applied the fastest plaster casts I’ve ever seen. We all had to wear these really heavy lead aprons and it was such a hot room it’s a wonder we didn’t faint. It was a good day though. They were a really friendly team, and apart from the fact that I’m not sure I could take a saw to people, it was a really interesting topic and I quite like orthopaedic surgery.