Debate Chamber Medicine Course – day two

We started the day learning how to intelligently guess what some medical conditions are from their names including dysphagia (dys = painful and phagia = engulf) meaning painful swelling, haematemesis (haem = blood and emesis = vomit) meaning vomiting blood, angular stomatatis (stoma = opening) meaning inflammation in the corners of the mouth, and tenesmus (tene = to hold) meaning feeling a constant need to empty the bowels.

We then went on to learn about gastroenterology. Symptoms that may show signs of a bowel condition include acid reflux, bloating, blood/mucus in faeces, increased wind, vomiting, constipation, weight loss, loose stool, hard stomach, nausea and tenesmus.

I learned how to take a patient history including finding out what is happening, what is the next plan, past medical history and family’s medical history, past and current medication, allergies, lifestyle factors, the patient’s concerns and any other relevant information. It is important to decide whether the condition is benign or pathological and chronic or acute.

In deciding treatment the following three things are considered: conservative treatment, medical treatment and surgical removal or repair.

Some common reasons for blood in the faeces or vomit include ulcers, Mallory-Weiss tear from force of vomiting, ruptured oesophagus, and dilation of veins surrounding the gut due to portal hypertension.

We also learned about clubbing of the fingers, Dupuytren’s contracture, Spider Naevil (due to build up of oestrogen), Gynaecomastia (from failure of breaking down oestrogen), Hepatomegaly (enlarged liver), Fibrosis and Cirrhosis, and IBD including Ulcerative Collitis and Crohn’s disease.

Mechanisms that can take place in a person with liver failure include fluid secreted into peritoneum presenting as a swollen belly, jaundice, coagulopathy (replacement of clotting factors lost through heavy blood loss), and a build up of ammonia in the central nervous system interrupting neurones. Symptoms of alcoholism following withdrawal include crawling skin, Delirium Tremens, seizures and hallucinations. The risk of these conditions developing is very high and therefore doctors do not recommend quitting alcohol altogether when attempting to overcome addiction. Furthermore, an interesting problem with alcoholism is that alcohol may interact with the liver and prevent enzymes being released to break down certain medications including Warfarin which is a blood thinner. If Warfarin is not broken down, the blood will become thinner until there is continual bleeding. This effect can be reversed by taking Vitamin K.

In the afternoon we learned some pharmacology including methods of administering drugs, how to assess consciousness and learning why some people fail to take their medications.

Methods of administering drugs include intravenously, orally, enema, inhaling, sublingually, through a central line, topically, by intraosseous infusion, intramuscularly and subcutaneously. The route of administration is chosen depending on time, efficiency, patient choice, location of problem, expertise of the healthcare professional, bioavailability and practicality. Positives of oral administration include its practicality and ease, however it is indirect and may take lots of time to reach the affected area. Intravenous administration can be a problem as lots of people, particularly children, are terrified of needles and there is a high risk of infection. On the other hand the drugs injected acts immediately for faster relief. Inhaling is very good for immediate lung relief, whilst intraosseous infusions have a very high infection risk, a long recovery period is needed and they are very expensive.

I learned that NICE decides which treatments are made available on prescription on the NHS. However, it is not illegal for a doctor to prescribe unlicensed drugs.

To assess consciousness of a patient, we use AVPU; alertness, voice, pain, unresponsive. It is necessary to do this to decide what immediate care must be given.

Reasons for patients’ poor compliance with medical guidelines include laziness of the patient, ethical opinions, wanting to cut down number of medications, the process can be painful, fear of the medication being painful or addictive, forget to take it, a poor patient-doctor relationship leading to the patient not trusting their doctor, denial of having the condition, worrying side-effects or long waiting times.

 

Emily Buchanan

 

Debate Chamber Medicine Course – day one

Below are my notes from day one of this course that I went on today.

Oncology

Definitions

Cancer – an abnormal group of cells

Benignnon-invasive = very slow growth, does not cause a problem

Malignant locally invasive = spreads to a nearby area

Metastaticinvasive = via blood/lymph to rest of body

Angiogenesis – development of blood vessels around tumour to supply it with nutrients for growth

 

How tumour cell invades an area in body

Tumour cell breaks through collagen fibres (for strength and elasticity) surrounding epithelial cells then squeezes through the gaps between epithelial cells by intravasation. This gap is left open and other less aggressive tumour cells can pass through causing more of a problem.

Cancer is a defect of DNA leading to a different sequence of amino acids being coded for.

 

Types of Cancer

Carcinoma

  • Most common
  • In epithelial cells including breast and lung

Sarcoma

  • Rarer
  • Tissues formed from embryonic mesoderm including fat, bone, muscle, cartilage
  • Lipoma which affects fatty tissue and malignant shwannoma which is cancer of the protective layer of neurones (shwann cells produce myelin for the myelin sheath)

 

Pancreatic Cancer

  • Known as silent killer due to lack of symptoms
  • Non-specific symptoms including epigastric pain, loss of appetite, vomiting, weight loss, painless jaundice, steatorrhea, trousseau sign, diabetes mellitus
  • Risk factors: genetic, age, smoking, poor diet, chronic pancreatitis
  • Low survival rate at 25% in a year’s time and less than 5% in five years’ time

 

Leukemia

  • Cancer of the blood or bone marrow
  • Caused by an uncontrolled increase in white blood cells known as ‘blasts’ crowding out other cells
  • More common in childhood
  • Bone marrow biopsy to prove, or lumbar puncture testing cerebrospinal fluids (CSF)
  • If any cells are found in CSF, the tumour is able to reach the brain

 

Genes associate with cancer

  • Oncogene – stimulate growth
  • Tumor suppressor – inhibit growth
  • Repair genes – limit mistakes
  • PSA – excess produced when prostate tumour present
  • BRCA1 – may lead to ovarian or breast cancer

 

Cancer staging

  • Gleason System for prostate cancer

A number is chosen from 1 to 5 (normal to very metastatic) so that complexity of each person’s condition can be noted

  • TNM staging for all cancers

T = condition of primary tumour (T1-T4)

N = extent of lymph node involvement (N0-N2)

M = extent of distant metastasis (M0 or M1)

Higher numbers indicate lower survival rate

  • Diagnosis

Putting information together concerning genetics, results of protein tests, scans and biopsies.

Concerns surrounding genetic screening include high cost at around £400-2000, counselling for those with worrying results, whether they are completely reliable, expensive and high-risk prophylactic (preventative) surgery may be required.

 

Scans

  • X-Rays
  • MRI
  • CT Scan

 

Treatment – usually a combination of the following

  • Chemotherapy attacks rapidly dividing cells, hence loss of hair, weight loss (gut cells) and anaemia (RBCs)
  • Radiotherapy where a radioactive source is fired at the cancerous cells
  • Operation to remove tumour eg. Mastectomy
  • Bone marrow transplant
  • Hormone treatment eg. Tamoxifem

 

Extra information

  • Spleen converts red blood cell into bilirubin and uncontrolled release of bilirubin causes jaundice
  • Ending in ‘-itis’ = inflammation
  • Theories of cancer’s cause include bacteria, viruses, genetics, immune system
  • It is possible to screen for genes that are linked with disease including DMD (muscular dystrophy), LDLR (heart disease), and MLH1 (colon cancer)
  • Measure symptoms by a change to ‘normal’, although everyone’s base line is different form one another so there is no point comparing patients’ symptoms to each other

 

Final activity

The last thing we did was to read a case study about a patient and present a summary then come up with a differential diagnosis, a final diagnosis, staging and treatment. I really enjoyed this activity as we had the chance to put the science that we learned today into practice.

 

 

Emily Buchanan

Work Experience in a Different Hospital – day five

To conclude my work experience in this hospital I did the daily morning ward round then shadowed a Consultant in clinic.

During the ward round I learned that it is important to figure out whether a new symptom is evidence for development of a current medical issue or a sign of a new problem. To work this out the Doctor worked through the differential diagnoses before deciding on the next part of the recovery plan. In addition I saw that a Doctor must be exceptionally organised, keeping up to date with all paperwork even when a patient is about to be discharged, in case of readmission to hospital or their GP.

I was fortunate to experience the calming wisdom from a Doctor who dealt very well with a patient who was complaining about quality of care at the hospital. The Doctor was calm, collected, professional and in control, even when the patient was very frustrated and upset. Empathy was shown by the Doctor as they explained the situation and clarified that they understood the patient’s concerns. A doctor must think with their head in terms of professionalism and with their heart in terms of duty of care.

I learned today that a lot of people in hospital become constipated due to lying in bed for prolonged periods of time. This means that laxatives are regularly prescribed to many patients, especially in the elderly as old age is a risk factor for constipation. I also learned that an obvious ‘beat’ in the dip of the clavicle is a symptom for cardiac failure. It is important to check for this as there may not be any other symptoms and it can go unnoticed.

I often hear people complaining about the organisation of our NHS and today I saw a problem with organisation that was wasting a lot of the Doctor’s time. A few of the machines were not working and this meant that the Doctor then had to go to another ward to complete some paperwork. The Doctor was frustrated and stated that their job was to look after patients, and not to fix broken machines. There is not enough time for them to do a job that another person should be doing.

Furthermore I spoke to a Consultant about delivering bad news, which is something that every Doctor has to do multiple times. It is important to warn the patient about what you are about to say by introducing the problem, then letting them know the bad news and waiting for them to respond. It is important to let them have some time to reflect about what you have just told them.

When querying why someone is losing weight it is important to investigate whether the patient has changed the amount of exercise they do, changed the amount of food they eat, if they have an overactive thyroid gland and if their kidneys and liver are working well. In the clinic I also learned about kidney stones and how they can block the ureter leading to pressure build up in the kidney and recurrent UTIs. To remove the kidney stone, a stent is put into place after the pressure is released from the kidney.

Lastly, I was very happy to hear that patients are given a 40-minute time slot with the Consultant during the clinic. This is ideal as it allows the Consultant to thoroughly examine the patient and ensure that they have enough time to come up with the best reason as to why the patient is not well.

I am so grateful for the wonderful and inspiring Orthogeriatrics team I worked with this week. The dynamic of the team is something I will never forget. I am excited to put all of the skills I have learned into practice in the future and aspire to be as kind, professional and compassionate as the Doctors I met this week.

 

Emily Buchanan

Work Experience in a Different Hospital – day four

Today started with the daily ward round with the Consultant where the importance of teamwork was shown again, this time between all people working in the hospital. If a patient feels that their treatment from a certain ward is inadequate, the Doctors being told about the event are obliged to apologise on behalf of the other ward to the patient, even when it is not their own fault.

I noticed the constant turn around of patients, with some leaving over night and others arriving when I am not at the hospital. This provides a lot of variation in a doctor’s career. Variation is also due to constant rotation of the medical team. It seems that every member of the team is slightly uncomfortable with the change as they are not used to the way that each other work. It takes time to learn to work cohesively as a team.

The Consultant had a way of ensuring they got all the needed information from their patients by asking questions in the same order for every patient. The conversation would begin with asking how the patient feels, then checking their observations and drugs charts and finishes with explaining the next stage of the patient’s recovery plan. The information from patients must be complete, so doctors must be organised and systematic in their approach to gaining information from their patients.

I was pleased to see that the patients with dementia were put into a separate ward that was more relaxed compared to the other wards to ensure everyone remains happy and calm. Some patients in this ward can get confused and may instinctively be violent against nurses when they may aggravate an area of the body that is sore post-op. Therefore, when the Doctor took bloods which can be painful, they made sure to have another member of staff with them to comfort the patient and prevent violent behaviour.

‘Hospital Passports’ are a very clever initiative used by care homes when sending their residents into hospital. They provide lots of information about a patient to make their stay in hospital more comfortable including likes and dislikes, current medications and conditions, and mobility. This saves the doctors a lot of time when attempting to find out background information on admission.

It is a known fact that doctors learn new concepts every day and I saw an example of this today when they were asked to stop their duties in small groups to come and see how the new needles that are going to be distributed throughout the hospital differ to those already used.

An act of kindness I saw today was the Consultant offering to move a patient to a bed with a little more natural light, after the patient made it clear that they were unhappy with the location their current bed was in.

Some science I learned was about an angiogram showing the journey of blood through blood vessels in the heart. I also learned that codeine can have some very serious side effects including dizziness.

 

Emily Buchanan

 

 

 

Work Experience in a Different Hospital – day three

Today I was inspired once again by another Consultant on the ward round and when shadowing the nurses carrying out routine checks in the wards.

On the morning ward round, there were two new doctors to the ward as 1st August every year is the change over date for placements. They got to straight to work learning how the Orthogeriatrics ward paperwork is filled in and what tests are necessary for every patient on certain numbers of days after their operation, following the Trust’s policy. I learned a lot about how to make myself more approachable and how to gain more rapport with the patients. The Consultant taught me that eye contact is very important to reassure the patient, as well as touching the patient’s hand or arm where appropriate to make them feel at ease. In terms of body language it is ideal if you are able to approach them side-on as this makes the situation less daunting and if there is an opportunity to get to the same physical level as the patient by sitting on a bed or a chair it should be taken to make them feel comfortable to open up to you. An introduction of who you are and listening to the patient talk about some of their non-medical history is a good way to let them feel free from awkwardness. The best doctors are good listeners as they let the patient explain what they think is going on then correct them when they are going a little off track. Doctors check that the patient is okay with what they are doing to them before they do it, for example listening to someone’s heart or prescribing new medicines.

It is surprising how important social services are to the NHS in finding places for patients to go after they have recovered in the ward. It was shocking to hear that some people had been in hospital beds for over a month, though medically fit, waiting for a place to live at a care  or residential home. (Due to the serious nature of a broken neck of femur, it is common for elderly people to lose all independence and have to move into care homes.) This is inappropriate use of finite NHS resources as hospital is a place for medical recovery and not for bed rest. These hospital beds could be used for other patients in areas where the number of patients exceeds the number of beds. The members of the healthcare team have to treat the patients as well as sometimes having to organise housing needs. The type of housing the person lived in before admission correlates with recommended time spent in hospital before discharge. This is because if the patient is living alone it could be very dangerous and painful to have to rely on themselves for everything whilst recovering, whereas if living in a nursing home there would be plenty of support available to help with recovery. This is why every orthogeriatric patient that has come from a care home is aimed for discharge after five days on a ward, whilst those striving for their independence again may take a lot longer.

Furthermore I learned that everyone comes from a different stage in their lives and has different personalities, and this means that the ‘level’ that the healthcare team want the patient to be at for discharge is very variable. Not every patient is perfectly healthy before they break their hip and come into hospital, so it would be wrong to prevent discharge of patients if other medical issues that are being monitored by their GP are under control. It is important to remember that difficult communication may not be solely due to delirium after the operation, but could be due to underlying medical issues. This is why it is very important to find out as much as you can about the patient when they enter the hospital through A&E before they have the operation and are admitted to the ward.

Taking bloods is not always easy, especially if the patient has lost a lot of blood during surgery.  This is a common problem that nurses come up against when doing observations. I learned today that nurses are the ‘doing’ of the ward in that they change the sheets, serve the dinners and water, put in cannulas and do observations, as well as giving out medication and collecting data about the patients that is reported and analysed by doctors to come up with a plan. This plan is discussed with other members of the healthcare team including Physiotherapists and Occupational Therapists in regular ward round meetings. MDT meetings are held to discuss which patients are ready to be discharged and what needs to be done for the safest possible discharge.

Learning the difference between osteoblasts and osteoclasts is important to understand the condition osteoporosis, which causes the weakening of bones and is a common reason for fracturing bones during a fall. Osteoblasts are cells that synthesise bone, whilst osteoclasts break down bone tissue for repair of the bone. If osteoclasts work at a higher rate than osteoblasts, bone is broken down faster than it is synthesised, causing weakening and osteoporosis.

 

Emily Buchanan

Work Experience in a Different Hospital – day two

Today I gained experience shadowing a Consultant and Junior Doctor doing a ward round,  seeing a newly admitted patient in A&E and shadowing a Physiotherapist and Occupational Therapist doing their work on a ward.

Today I really felt the sense of community at the hospital, not only among the patients but also between all members of staff. Everyone appears to support each other and it is nice to see that people from certain specialities are not afraid to ask other specialities for advice. I noticed that the Physiotherapists and Doctors always checked that they were both happy before making final decisions about patients, by having regular meetings outside the wards. This ensures that every decision made by the medical team is the best  possible decision for the patient. I noticed the importance of teamwork between the Consultant and Junior Doctor during the ward round as well as between the Physiotherapist and Occupational Therapist (OT) working together to make the exercises as painless as possible for the patients. I feel extremely grateful that all of the staff are extremely friendly and welcoming to me in the Orthogeriatrics ward where I am based, and feel that they genuinely care for me in ensuring that I am gaining as much experience as I can of all medical professions on the ward. I enjoyed hearing about the team’s jargon, helping to make writing notes and having conversations quicker.

I enjoyed speaking to a Consultant about their enjoyment and difficulties of being a doctor. I learned that whilst the job can be extremely tiring and not very financially rewarding, it is extremely emotionally rewarding to be the person to improve or prolong someone’s life. The variety of the job through meeting lots of different patients is very exciting and something I believe I would enjoy greatly. The role of a doctor is very caring and enjoyable as you can apply the science you know to a real life situation and see the results through speaking to patients and finding out how they are feeling. I love that as a doctor you are constantly learning, and even as a top consultant you may not have heard of every medicine that you come across on the job so you learn something new everyday. I also like the idea of growth of responsibility as you become more confident with clinical skills and decision making through years of practice. It is very interesting to see that doctors all have a different way of speaking to patients and this shows that medicine as a career is an art. I love the idea of teaching younger people clinical skills when I am qualified.

I learned that communication with patients can be extremely difficult especially if they do not say what they mean due to delirium or confusion, or if they refuse to speak to the healthcare team all together. This can make doctors frustrated as they do not know if the patient is in pain and if they are reacting well to their medication. It is also difficult to communicate with patients who believe they have pain but do not actually have pain as it is psychological. It is difficult for the doctor to decide whether they need painkillers.

It is important to remove as much equipment from the patient’s body as possible so that they feel like their condition is improving for a better state of mind. The Consultant was constantly looking for ways to improve the patients’ comfort including removing catheters as soon as possible. This may also encourage them to get on their feet sooner after the operation as they believe that they are fit enough to stand, decreasing the risk of them losing independence.

I learned that blood transfusions to treat anaemia are extremely risky and expensive. The cost is about £800/unit whilst there is a high risk of contracting an infection or having severe side-effects. Therefore, Doctors encourage the taking of iron supplements or injections to increase the amount of haemoglobin in the blood to carry oxygen to cells, without the risks that come with a blood transfusion.

It was inspiring to see the tireless work of the Occupational Therapist and Physiotherapist who were extremely patient and encouraging to all patients. Whilst seeing what their job entailed, I noticed that a lot of their work was talking to patients and reassuring them that they would only get better if they had the confidence to do the exercises, for example to stand up. Before this week I did not realise how important confidence is for a patient’s recovery.

An example of a member of the medical team making extra effort to ensure that patients were comfortable and happy today was when a Physiotherapist sat with a patient after they had done their exercises to fill in their food form for their upcoming meals as the patient could not reach to fill it in for themself.

 

Emily Buchanan