I'm still here

Still being a med student, too. More to follow.

So this is the New Year

Aside from losing what little hair I have left over a project which developed a life of its own, broke out of the laboratory and terrified the local villagers, I've been listening to The Making of Modern Medicine, which was originally a series on BBC Radio 4 which follows the evolution of medicine from the time of Galen and the humours through to the mid-to-late twentieth century and high science.

Andrew Cunningham speaks eloquently and with good humour on a topic which I think too few medics have any notion about. In much the same way it behooves us to know how our own countries were born and a how they impacted the world, I think medics should know a bit about where medicine (as an art, as well as a science) comes from. The story has a very engaging narrative and includes, where appropriate, actual documents and notes made by doctors from the ages. Obviously it cannot cover absolutely everything, given that it covers several thousand years, but I think the editorial decisions made about which topics to focus on are well chosen.

For me, the biggest take home points for me were how we as modern medical students owe almost everything about the current teaching style to post-revolutionary France. "Little reading, much seeing and much doing" was the message from the teaching hospitals of Paris of the early 1800's - institutions which did not previously exist at a time when medicine was more about lectures and watching someone else dissect or perform examinations, rather than the student getting stuck in. The other resonant message was how medicine has moved from the times of Galen and Hippocrates when the patient would tell the doctor that they were unwell to the more modern, scientific world in which the doctor tells the patient when they are unwell - Indeed you cannot be unwell until a doctor says that you are unwell. I don't want to come off as reductionist about that point I can't help but feel that something has been lost there (as regards communication and relating to patients), something subtle but important.

Anyway, it's a great listen and very good value for money (6+ hours) - excellent gym fodder, when you want to take a break from the books and want something medical but light-hearted and engaging. And maybe someone else to read for you!

Amazon (UK) link: The Making of Modern Medicine
iTunes (UK) link: The Making of Modern Medicine

Are you sure this is a valid prescription?

Seen yesterday on the PRN side of the drug chart:

Vodka 50mls PO

on the same chart, regular side:

Chlordiazepoxide 20mg QDS

The nurse who picked this up bleeped the pharmacist who briefly did a good impression of a beetroot and then looked like they were about to lay an egg.

The pharmacist's main issues were:

a) Why wasn't this patient (who was an alcoholic) being detoxed?
b) Where did the doctor think they had medicinal vodka in the hospital?
c) What was the doctor thinking prescribing alcohol *and* a benzodiazepine together?

Sadly, the pharmacist left before the doctor arrived to sort out the chart. My favourite part of this was the doctor's eye-rolling and suggestions that the pharmacist was being over the top in getting upset about this. Oh, and then asking around the ward if we knew what alcohol pharmacy *did* stock.

So many of the shifts I've worked over the summer have been guides on what not to do as a doctor. Behaviour-wise and common sensical.

This just seems plain wrong

So I found this on someone's YouTube video whilst I was looking for a nice Pulmonary Embolism video. I know I shouldn't be surprised, but it's just depressing that this kind of thing goes on; naturopathy is pretty much one of the worse kinds of bunkum but seeing someone promoting it and denouncing actual medications that work to prevent death? It just seems wrong.

I always figured that the alt med users were like atheists in foxholes when they became seriously unwell. You bad-mouth medicine whilst it can't cure your muscle aches/ lethargy/ "bloated feeling", but when you get diagnosed with cancer or have an MI you're all about the "western medicine". Guess I was wrong. Sadly. Apparently you can get a DVT and think that "blood cleansing" is the way to go.

I am med student, hear me roar

I am up to my elbows in revision, scratching around my notes and the internet to try and make sense of nephritic vs. nephrotic syndrome or RDS vs. Transient Tachypnoea of the the Newborn, so I've not had time to come up with a topic for a blog post recently. I did, however, find time to have opinions about stuff on a friend's podcast, so if you wonder what I sound like, wonder no more:

Hear me talk

Disclaimer: I didn't think through everything I said, so take what I say with a pinch of salt. I'm not one for talking in absolutes if have time to think about what is coming out of my mouth.

Right, back to the books.

Ciao

How much is enough?

words of wisdom from Wonderella

Today was rectal exam day.

But more importantly, it reminded me how I don't have enough time or energy or ability to be the best.

And how, on a low day, this is really dragging me down.

I don't understand it all, my clinical skill set from nursing is yet to be useful and I am surrounded by over-achievers, Rainman's marginally more socially adept cousin or full-on alpha males. And me, I just want to pass.

I know I can be a good doctor. I know this. Get me on the ward, give me the chance to flex a little communication skill, let me lay hands on a genuinely ill person or something where I can show my quality. I'm tired of the let's pretend of clinical skills where say all the things we don't see (no sign of clubbing, splinter haemorrhages, xanthelasma etc etc) , the PBL sessions dominated by pointless displays of obscure, clinically irrelevant, scientific knowledge, the lectures that wander around the point without actually helping me learn.

I laughed when I saw the entry on Stuff Medical Students Like about "Time". But it's funny because it's true, to quote Homer. I don't feel like there is time enough in the day. It is some small degree of schadenfreude that most people I talk to on the course say this. I think the worst bit of it all is that I feel guilty for any time I spend not doing something to help me with medicine. Go to the pub? Go to the gym? Go to the cinema? This is all time I could better spend learning about Vitamin A metabolism or the pathways of the facial nerve or any number of the myriad little bits of information I need to have at my fingertips, because as one of today's lecturers said:

"One day you're going to be sat in A+E at 3am and not have a bloody clue what is sat in front of you"

And that, I guess, is what scares me the most. That I don't feel I have enough time now to be the best and one day, someone's life may well rest on me remembering that symptom X is a tell-tale sign of disease Y which if not picked up will kill them in a couple of hours.

So I work as hard as I can, but I don't feel like I've covered everything. And it doesn't matter how many times I can answer the lecturer's questions, the one time I can't, some else can - which undermines any sense of confidence I have about the topic. It's sick really.

On the upside, Father's had his angio which showed, to quote the radiologist "pristine coronary arteries", so that's something :)

A delay in resuming normal programming

Sorry for not having posted anything this week, it's been due to various factors: essay writing, OSCE fallout, exhaustion and Father's illness. People have asked for updates so I thought I'd pop them into a post rather than in the comments section.

He's still in CCU, awaiting an angio (hey, this is the NHS after all and he's not on his last legs so he gets to wait), no meds, no real interventions to speak of, brady sinus ~40bpm and proving something of an oddity to all and sundry.

Apparently his consultant is known to have sat on the edge of Father's bed, head in his hands, and say things such as "we just don't understand what's wrong with you". Which whilst being less than useful is more humorous (in a bleak sort of way) than anything else.

My mother is doing okay, I think she feels the strain of it more at night when she's away from him. She was an RN for many years so she has a bit more insight than most as to how things work in a hospital and I'm able to speak medicalese to her when she asks questions I can answer about Father's treatment. That said, she is doesn't want to read the leaflet about the complications of having an angio.

I am... Maybe not coping as well as I thought? I'm not really sure. Outwardly, I'm not really phased by this. I know, rationally, that people get ill. Especially people over 60 (as my Father is). That he was otherwise fit and healthy goes someway to explaining how he appears to be almost entirely symptomless. He is not acutely *unwell*. He's probably going to have a pacemaker fitted "just in case" - because medics can rarely leave well enough alone. He is at very, very low risk of complications from the angio. He will go on for many years to come with little in the way of long term complications from this experience. The numbers are with him on this one.

And yet.

Myself and Mrs Absentbabinski sat with bowlfuls of chilli watching the TV on Friday night and I just didn't have an appetite. I wasn't even watching the TV. I wasn't really doing anything at all. I wasn't even thinking, directly, about Father. I was just zoned out. A bit shell-shocked and very, very, tired.

So maybe I'm not doing as great as I thought I was. But I'm okay. And so is everyone else. We shall see what Monday's angio brings, I guess.

And now a word from our sponsors

from phunkstarr's flickr photostream

So this was going to be a post apologising for not having put anything up over the weekend and talking about OSCE's, stupid sociology essays and my favourite blogs/ applications.

However...

I've just had a 'phone call from my mother telling me that my 60-something, otherwise fit and healthy father has just been admitted to the local CCU with a pulse in the 30's and feeling a bit "funny".

That he drove to the GP who told him to pack a bag and present at A+E and then drove home is testament to the fact he doesn't feel unwell, per se.

But from what I could gather from my mother on the 'phone he doesn't have a P wave on his ECG. And a borderline troponin. So they're hanging onto him over night and talking about maybe a pacemaker as a treatment.

I know that without all the facts any research I do is just so much guesswork and I'm bound to focus on the worst possible diagnosis I can find. But I don't know what else to do. Mother told me she would call tomorrow to let me know what the consultant said after the ward round tomorrow morning.

All I can do is wait, bury my nose in Kumar and Clarke and feel a little bit nauseous. I think it's the nerd in me that finds this the easiest way to try and process being told this kind of thing, even down to feeling annoyed I can't see his ECG for myself. My friend Hazel suggested it was the alpha male in me - something which made me smile as I don't think anyone has ever described me as an alpha male in my life.

I guess it also goes someway to explaining why I ended up in medical school.

This is not a great feeling at all.

Of roles and expectations

I've just finished listening to another excellent episode of Pseudopod, a weekly podcast of horror short stories and this week's was particularly interesting for me. It focuses on a woman who comes to a village under the guise of helping when in fact she has a darker motive.

Alasdair, the host of the podcast, does a wonderful job (as always) of deconstructing the themes of the story. For anyone in healthcare they are juxtaposed between being an everyday part of the job and so very important that if you stop and think about it, our responsibilities are staggering.

The patient will see you as a caraciture

People put their lives in our hands and, more often than not, accept that whatever we do for them or ask them to do is in their best interests. When I push the drug trolley around people accept that because I am dressed like a nurse, seem quite comfortable and friendly, I must be giving them the right medication at the right time etc. etc.

Every nurse I know has made at least one drug error.

Every doctor I know has made at least one drug error/ misdiagnosis.

And yet they come to us. Because we look the part, because they believe in us, our uniforms, our stethescopes, our strange language. There is another component, I think. We have entered into a social contract. We have chosed our roles and promised to fulfull them to the best of our abilites. That, I would argue, is the reason people come to us.

It is both a privilege and a responsibility.

Transitions

An excellent and thought-provoking article on the Student BMJ detailing one nurse's experience of becoming a doctor and returning to her department with different workload and demands:

CCU sister to CCU junior doctor

I hope I keep writing long enough to produce something for a journal like the Student BMJ.

Show me where it hurts

"Doctor! Doctor!"

I sigh and without even turning 'round say loudly "I'm a nurse"

"Oh! Right! 'Course you are! Well, I mean, I'm in pain, is there anything I can have? I mean, doctors wouldn't know about that, would they?"

Charleen's unintentional Uriah Heep impression doesn't warm the cockles of my heart. She came to us ?Pancreatitis ?EtOH abuse, known ex-IVDU. Now I am not the kind to refuse analgesia to anyone - pain is pain, you can't judge another person's pain, period - but there is something frankly funny about someone who can sleep all morning after their a.m. methadone and then be unfortunate enough to wake with "terrible pain" in their abdomen and an accompanying limp that seems to have manifest itself. Luckily for Charleen, she IS able to have some Oxynorm. It is as much as I can do, not to roll my eyes to show my lack of surprise.

As I say, pain is pain. I do not tarry to get someone pain-killers, even the more suspect actors amongst our current crop of patients. I do, however, find it rather tiring when people make these grandiose shows of how they are in pain and can't I do something, please, and oh it must have been 2 hours/ 4 hours/ 6 hours since their last dose of oxynorm/ morphine/ diamorphine etc. etc. Just tell me you're in pain. We both know that you've been watching the clock, that you know *exactly* when your last dose was and, yes, that paracetamol will in no way improve the terrible and sudden pain you are in.

Pain is, as my lecturers might have said, a vital sign and the symptoms of which vary from person to person, aetiology to aetiology. Maybe you really are in pain, maybe that potent opioid is just a bit moreish, honestly, I don't care if it's the latter. It just means that I have to go hunt down the CD key, another RN and interrupt whatever it is that I'm doing, so you may have to wait a bit.

I don't want to come across as some cold-hearted bastard, I do really have a personal interest in pain - if I'd stayed in nursing it would be something I could see myself specialising in. Junior doctors don't really understand how to prescribe analgesia in my experience and more often than not don't understand that morphine is not going to solve all kinds of pain - and isn't without its side-effects. This often leads to people being left in pain, whilst I apologise profusely and bleep the doctor to get something more written up. I'd ask of all doctors, when writing the drug chart up, if you can please give me some diclofenac or codeine or dihydrocodeine or tramadol on the prn side, if only so I don't have to see one of my patients in pain and me helpless to do anything about it. I know that some people are not suitable candidates for more potent pain-killers (liver damage, head trauma, renal insufficiency, whatever) but that doesn't mean they have to run the risk of being left in pain.

 I hope I remember all this in years to come, if only so I don't (as has happened to me in the past) shuffle up to an RN and ask, plaintively, how tramadol should be prescribed.