Bowel Sounds

Tomorrow I return to uni after my three week Christmas holiday, and I’m looking forward to it. We’re starting with haematology on the lecture side of things, which shouldn’t be too bad despite my consummate lack of knowledge in this area. I say that, but I’ve done two student selected component modules on topics relating to autoimmunity; the first was a report on autoimmune haemolytic anaemia and the second on sepsis, so I will at least have a handle on a bit of it. Hopefully.

On the clinical side I’m back to the general surgery wards for yet more history taking and clinical examination skills teaching. I know it’s the most important thing we learn, but seriously? We’ve been doing it for a long time now. I know the old adage ‘practice, practice, practice’, but it’s hit and miss whether we actually get teaching. More often than not it’s a case of “go see this patient, take a history and examine them.” We do that and by the time we get back it’s time to leave, so we don’t get feedback on our work. It’s quite frustrating actually, I want to learn more, but at the moment I’m just going through the motions and, to be honest, I could be doing something completely wrong and if one of my peers doesn’t pick up on it, then no one’s going to notice. Not that they should tell me what I’m doing wrong in front of the patient, we had quite enough of that last year thank you very much.

In fact, something else I find frustrating is having to go and take a history in pairs or groups of three in the first place. Yes at the beginning it was reassuring, because none of us could pull of a history in one shot without stopping for five minutes to think about what to say next. Having someone else there ready to plug the awkward silence was a blessing. Now that we’re all (hopefully) a bit slicker at it, we just end up falling over ourselves. I find it especially difficult working with certain people who assume that if you take a history slightly out of order it’s because you’ve forgotten about something, and see fit to interrupt you to ask the patient themselves. This, along with the simple fact of having two or three people probing for information does, I feel, dilute the doctor student-patient relationship. It’s much more difficult to build up a rapport. I mean, I imagine we’re down right intimidating to some patients when we all march up to their bed. I know it’s an issue of finding enough patients, but I think splitting us into two groups; one to see patients individually, and the other to do some clinical teaching with the doctor, then swap; would be better. I would reduce our exposure time, but I think it would be more beneficial overall.

Sorry I’m not quite sure where that rant came from! Didn’t mean for it to happen, honest! I’ll try and update you on how tomorrow’s teaching goes. In other news, the critical appraisal essay continues apace, although I hit something of a brink wall this evening. My knowledge of statistics failed when the authors of the study started throwing seemingly random letter/number combinations into the text. p values I understand, but what the hell does “[T(8) = 1.90, p < 0.10]” mean?

Anyway, better go pack my bag for tomorrow, mustn’t forget my stethoscope in case I need to assess some bowel sounds.

like a record baby

I met a fine gentleman on the wards this past Thursday. He had an isolated cranial nerve palsy, which isn’t the best start to a clinical encounter from my point of view. Anything that compels me to do a cranial nerve exam is a bad thing. He had an interesting history with some hypertension and memory loss. All his signs and symptoms combined added up to a pretty worrying clinical picture, by which I mean brain tumour, if you considered them out of context. However, if you paid attention to the history it became apparent that his symptoms were probably arising from two distinct pathologies and it was unlikely to be anything so serious. Still, we sent him off for a head CT to be sure. I made an absolute hash of the examination, I fudged most of it to be honest. I didn’t do anything excessive, but I certainly missed a few things and it didn’t exactly flow. Luckily the patient had been subjected to four such exams in the last 48 hours, so was very competent himself. It was only a little embarrassing, honestly. My face was saved somewhat by discovering that he lives not a stone’s throw away from my home. I am perpetually surprised when patients tell me where they’re from and it’s near by. I somehow forget that we are in fact in the regional hospital for the area in which I have lived all my life, and it is therefore quite likely I will run into people from places I know. Regardless of my continuing surprise, I see it as yet another advantage of training so close to home, I gain an instant connection with many of the patients I see. This can only make interactions with them easier. Until I run into someone I actually know personally of course, at which point things become rather more muddy again.

I should very much like to do something about my failing clinical examination skills, but I simply cannot devout the time to them right now. I was wondering this evening why I was feeling so drained when it was only Monday. I realized that I didn’t really have a weekend as such, just two days where I got up slightly later and worked at home instead of at uni. This doesn’t make me a particularly happy fellow, but right now it’s needs must. The next 6 weeks are crammed full of lectures and other associated crap. It is taking almost every reasonable hour available to me just to keep on top of the lecture notes. I don’t particularly have time to revise my neuroanatomy, which is truly abysmal, or, as I said, improve my clinical skills. It’s not even like it’s stuff I enjoy that we’re working on at the moment. Neurology holds very little appeal for me, and this intensive program of study is going nothing to enamor it to me. Head trauma is about as good as it gets, and I think we get one hour on that in the space of two weeks. I can just about handle herniated disks, they’re nearly orthopaedic enough for me to stomach, but anything past that… Oh, and EEGs! I know they do not expect us to be able to interpret all those squiggly lines, yet tomorrow we have a lecture that is almost exclusively slides of squiggly lines. I will be overjoyed if it is more than simply, “this is abnormal… this is also abnormal… this is…,” ad infinitum. I do not hold high hopes.

Tomorrow also hold another joyous community course tutorial, so I’ll yet again be treking across the city at rush hour. I may read the relevant section of the booklet if I’m feeling generous, but I doubt it. Oh feck. Just got an email from the archery club telling me our club photo will be at 10am on Wednesday. I had been planning to spend an hour in the clinical skills centre at 10am on Wednesday as a token gesture to improve my examination skills.

Right, everyone can just bugger off now.

Oxygen Saturation

A few weeks ago I saw Mary on the Orthopaedic Trauma ward. Mary is 82 years old, and lives alone. She had been on the way to the shops when she caught her foot on a loose stone on the steps outside her house. There is no handrail on these steps, so she had a bit of a fall sideways, only about a foot, but on to paving slabs. When I saw her she was approximately 24 hours post surgery for a right hip replacement. She was in good spirits, although a little subdued, as you would be I guess. As she was so soon post-op, she was still being very closely monitored. There was a standard multi-parameter monitor, plus a supplementary heart rate and SpO₂ monitor that outputs to a graph on the screen showing SpO₂ over the last 15 minutes, this will become significant shortly.

When I arrived Mary was on medium flow oxygen through a standard face mask. She took the mask off when my partner and I introduced ourselves and asked if we could speak to her about what had happened. She agreed, and did not put the mask back on. We were only taking a history, not doing an examination, but I still took a mental note of how she looked clinically and had a glance at the monitor before we began. HR and BP were within normal limits (I know the clinical skills tutors would give me grief for saying that, but it’s the best description because I can’t remember the exact figures). Her SpO₂ was 93% and she looked reasonably comfortable.

I began with a history of presenting complaint, and elicited the story I have already related to you above. As we were talking I noticed the O₂ sat. reading was slowly but surely heading southwards. It reached 87% by the time I was ready to hand over to my partner, Mike, to take a past medical history. I would have stopped what I was doing if Mary looked like she was becoming breathless at any point, but she was able to talk in complete sentences throughout and did not appear to be having any trouble. Mike took over, but very shortly into his questioning, Mary’s O₂ sats dropped to 85%, at which point both the multi-parameter and the graphing meter started beeping warning alarms. Still Mary did not look like she was in any distress. However, both Mike and I felt it would be prudent for Mary to put her facemask back on, lest the alarms attract the attention of the nurses!

While she complied for a little while, Mary grew tired of the fact she had to keep repeating herself to be understood through the mask, so took it off again. I wasn’t especially happy about this, but her O₂ sats had climbed back to the low 90s in the short time she was back on the oxygen, so I didn’t feel there was any harm in continuing our history taking. Again, and much more quickly this time, her O₂ sats fell to a low of 83%. At this point I was still taking notes while Mike spoke to her, but my eyes were flicking back and forth between the monitor and her face, while my brain was repeating one line over and over again, “First, do no harm. First, do no harm.” Were we ‘harming’ Mary with our questioning? Clinically, she looked fine and still wasn’t showing any signs of breathlessness, but the monitoring was saying otherwise. I was just staring to consider intervening when a face appearing around the curtain. The female registrar who had directed us to Mary’s bed in the first place had come to investigate the alarms. She was very nice and asked us how much information we’d managed to get. We assured her we had asked most of the things we needed to, so she suggested we stop there. She also told Mary that it really would be best if she put her mask back on. As we thanked Mary and left the cubicle, I looked over the the O₂ saturation graph. There was a nice stead decline from the moment we arrived, a sharp rise when Mary put her mask back on halfway though the history taking, then another steep fall again.

I believe the phrase I used as Mike and I walked back to the tutorial room was, “oops!”

Wards – Week 1

Now that I’m in second year I spend two hours on wards one morning a week. We’ve only been back three weeks now, although it feels like much longer, so I’ve had a couple of sessions there so far. And to date, they’ve been quite enjoyable. As I’ve said before, I’m on the respiratory wards, which is actually split in to a male ward and a female ward. So, what have I been up to?

Week 1

Most of us arrived 10 minutes early since it was our first day and we were really keen. Other people in our year kept walking past up and down the stairs looking lost. As it got to a couple of minutes to 11 we decided the girl who hadn’t turned up yet wasn’t going to, so we just ventured in. The junior doctors’ room looked like I hopeful place to wait, so we went in and blocked the place up very effectively. Doesn’t matter where you stand, you’re in the way. It’s best to just kind of move in a loop, blocking the light box, the notes trolley, the door and the computers in turn.

Our consultant was remarkably close to being on time, far closer than my regent has ever been, brilliant as he is. He took us through to the staff room, which was much smaller, people had to sit on the coffee table, but at least it was empty. We were given a couple of forms the likes of which junior doctors would use to clerk in patients. He started with the example of chest pain, what would you ask specifically about the pain. Going round the room, I was second last to have to provide an answer. Everyone had already said all the things I’d thought of, so I decided to give an answer I knew was sort of right, but not exactly what he was looking for, rather than just stare blankly at the floor. They hate it when you just stare blankly at the floor.

We went through all the things on the form: history of presenting complaint; past medical history; social history; drugs and allergies. The very basic, very important stuff that should become second nature. Then we went through a pre-formatted clerking sheet that detailed every question we should ask for each body system, which obviously took some time. All this took us to about 11:45, at which time he declared we were ready to be let loose on patients.

Our consultant, whose name I’m ashamed to say I’ve forgotten, took us out on to the male ward and over to a patient. He had been pre-warned of our appearance and was in “good humour,” as our clinical skills videos relentlessly bleat at us. The consultant took a full history from the patient as though he was just a lowly junior and clerking the patient for the first time. We thanked the patient profusely and were shepherded off to a different fellow. We were introduced and Robert, who obviously looked the most competent, was asked to take a history. I was certainly slightly taken aback for a second, and I’m pretty sure Robert was too! I was expecting to meet patients, yes. I was expecting to be asked to talk to them, but I was not expecting to be just thrown in at the deep end. I guess it’s probably the best way.

Robert did a fine job extracting a history from the patient, who was very compliant but did tend to drift off into unrelated subjects. It was helpful that the patient presented us with a diagnosis before Robert had even started asking questions. Most of the other members of the group got a chance to take different bits of history from a couple of different patients before we were hustled off again to our final patient. We were introduced to John, a 68-year-old man, before the consultant turned to me and said “why don’t you get a history of presenting complaint and medical history.” Right, easy done.

I stepped forward and shook hands, introducing myself as a 2nd year medical student and by first name only. He looked reasonably healthy, with the exception of a slightly distended abdomen. I established a history of the presenting complaint, which incidentally had absolutely nothing to do with his respiratory system, odd seeing as how I was on a resp. ward. No problems there, he’d had this present condition for about five year, so although exact dates were sketchy the important events had obviously been recounted so many times to so many different people that they were easily reeled off again for my benefit. I asked about any other medical history; “none,” he said.

“No surgery or stays in hospital before this started?”

“No,” a simple answer, and easy for me to deal with: move on.

“Any family history of diabetes, heart attacks or asthma?”

“None.” They seemed considered answers, it wasn’t that he was just replying “no” to everything I said. I don’t know what made me ask, it wasn’t something we had discussed before we came out to the ward, but it seemed appropriate.

“So, how did they discover you had these polyps?”

“Oh well, it was when I went to my GP after my fits started, back when I lived in London with my daughter. He did some blood tests and they found them then, like I say it was about 5 year ago now.”

Bingo. Fits? He hadn’t mentioned these fits before. Seemed like a significant medical history to me, even if he did only mention it in passing, buried in a load more fluff then I’ve illustrated here. I figure, go for the direct approach.

“So, these fits you mentioned…?”

“Oh yes. I tripped you see. Bashed my head on a rock.” At this point the patient looks up at me, as though expecting another question.

“Yes?” I prompt.

“Well I ended up in hospital for a few days. A week I think it was, I had bleeding, in my brain. That’s when my fits started.”

I was replaced by a different student at this point, who asked very quickly and quite quietly about social history. The patient stopped for what I can only describe as a dramatic pause, before enquiring quite slowly and clearly what she had just said. He was quite the character. She managed to extract a history of smoking, and eventually, some significant whiskey drinking that the patient was clearly ashamed to admit.

We gathered in the hallway afterwards and our consultant explained the full history. Turns out he fell over, hit his head and ended up with a subdural haematoma that the surgeons decided not to operate on. It resolved by itself but left him with an epilepsy type brain injury that resulted in fits that were currently being controlled by medication. Our consultant praised us all, then me individually for picking up on the fitting comment then pressing for more information. Ok, I admit it, hearing him single me out like that made me pretty happy. It also gave me the opportunity to ask why the hell the patient was on a respiratory ward with ascites and polyps?

Pulmonary hypertension, secondary to liver cirrhosis, as a result of all that whisky drinking in the past. Ah.

Overall my first experience of wards was a good one. I actually enjoyed being throw in to the thick of it, and once I got over the initial “oh my god I’m speaking to a real patient I mustn’t mess up” and got into the flow I really enjoyed it. I may not have much actual knowledge of disease processes or presentation, but even slotting in the little bits and pieces of theory that I do have to the real person in front of me is a great feeling. It has already made 2nd year far better than anything we did in 1st year, and I think it is a good sign for the future.

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As this is the first time I’ve spoken about patients directly, I feel duty bound to make something perfectly clear. I’m sure you all know what it is, and many of you have probably been wondering where it is. I refer to the disclaimer. There always is one on medical blogs. Somewhere, tucked away at the bottom or displayed prominently in the sidebar, depending on the balls of the writer, you will find it. Well here’s mine:

Obviously the patient I met on wards that day was not John, a 68-year-old male from London with ascites, benign polyps, a drinking history and pulmonary hypertension. Those details have been changed to protect his confidentiality. I do actually like being a medical school, and as such I’ve no plans to be thrown out by a fitness to practice committee. What is true though is the gist of the story. The key points and the message behind it are not fabricated, but they have been woven in to a slightly different tapestry to ensure everyone is protected.