Saturday, October 27, 2012

5 Down 1 to Go.

Yesterday was the last day of my Orthogeriatric placement. Was a bit bummed out as I've gotten to know the junior doctors quite well and I enjoyed my placement (despite it being only 2 weeks). By being on the Geriatric ward, you realize all the ethical problems and how cost of care can be so high for these patients. For example - hip fractures cost the NHS 1.7 million pounds per year. The problem is that when these patients turn up, they don't just get an operation and then get discharged after a few days. Older people require a bit more care as they tend to suffer from other medical conditions such as vascular disease (MI, stroke, etc), diabetes, etc. Along with needing to continue treating their co-morbidities, these patients are more susceptible to hospital acquired infections (eg. pneumonia) so essentially it becomes a vicious cycle for these patients. Majority of the patients on the ward stay in hospital for a month which is quite a long time. Care 24/7 for 4+ weeks...the costs do add up.

I was probably most involved with ward rounds in this placement than any other placement I've had so far. I was quite keen to actually help out as I know I do get bored quite easily if I just stand around. I got to write in the patient notes and you just feel a slight bit more responsible while on placement. It sounds a bit sad, but it's quite satisfying signing off on something. I mean as a medical student, we never really get to sign off on anything so it's nice being able to sign off the notes you made in the patient notes during ward round. You also feel a sense of contribution as well, which is a nice bonus. Also good practice for the future as well - will be doing lots of paperwork in the near future...

I think the main problem about being on a geriatric ward is that the turnover rate is quite low so the ward round usually consists of a quick check-up and if there are any new concerns/changes. This made me find this week a slight bit more dull than my first week. The only thing is that now I know the patients, but there isn't anything new to see. Their improvement is also quite slow so I must admit this week's ward round was a bit less interesting.

I mean overall it was nice to be back on a proper medical ward and doing "medical things" as I've spent the whole year in very specific specialties. There was a lot of general medicine and it made me realize how much I have already forgotten (quite scary especially when exams are just around the corner too!). All in all these 2 weeks helped me get my sanity back and I managed to grab some motivation back - well enough to take me through to exams. Now I've got 2 weeks off before my next and final placement - Neurology. Neuro will be tough but I'm quite lucky that I've had an attachment in Stroke medicine last year so I shouldn't be too lost on the ward.

2 weeks to dig my head into my books and do some proper revision. Procrastination mode - on. Need to focus!

Saturday, October 20, 2012

Care of the Elderly.

So I've started yet another placement (5 placements down, 2 more to go) and this placement is "Care of the Elderly". Out of coincidence and sheer luck I've been placed in Orthogeriatrics. Majority of the patients on the ward are patients who broke their hips (neck of femur (NOF) fracture (#)). Because this placement is only 2 weeks, it's a really quick taster and for me it's a bit of time to get my sanity back as I really enjoy orthopaedics so it's nice to just go back to something I'm quite familiar with.

Essentially I've got 10 days to learn and see everything I need to know to care for the elderly...great. Pretty rushed. And on top of that, get to know the staff on the ward which in general takes a bit of time to warm up to. First day - I met my consultant who is really nice so that was good news. The junior doctors are also really nice and chilled out as well and very understanding as they know we've got exams coming up so they aren't too bothered. They are also quite keen to get us involved in terms of helping them do jobs and getting involved in ward rounds (taking notes, looking at obs charts, drug card, etc.). To be honest, I've never been so involved on the ward...ever. It's also a bonus as I can get my clinical skills logbook signed off as I'm getting lots of opportunities to do clinical skills like venepuncture, cannulas, catheters, ABGs, etc. Really enjoying that and it's good practice. On top of that, I've been quizzed on osteoporosis and surgical management of NOF #s, but having done and attachment in orthopaedics (hips), for once I can actually answer questions with ease and confidence. It's actually quite a nice feeling to be able to answer questions...wish my knowledge was that sound with everything else in medicine...

Because I'm on Orthogeriatrics, the team works closely with the orthopods so we have to attend trauma meetings. Actually we don't have to attend trauma meetings (completely up to us as it starts quite early in the morning). I didn't get a chance to attend any trauma meetings during my attachment in orthopaedics, so I was quite keen to check them out as it does have a bit of a reputation. The benefit of having done my attachment in orthopaedics, is that the consultants recognize me so they don't question my presence in the meeting (students tend to avoid trauma meetings). In terms of education value - these meetings aren't great, but you get to hear about some interesting trauma cases that have been admitted...some fairly amusing and crazy stories as well. It's also a bit of a shooting gallery as well as consultants do "fire at will" if a trainee says something wrong or doesn't present a patient well. It's all a bit of a laugh/leg pulling, so it's fairly amusing at the expense of a junior doctor/SHO/registrar. Despite the earlier than usual wake up for placement, I don't mind attending. Again this is something I noticed in my orthopaedics attachment. I didn't struggle to wake up for placement during orthopaedics and was never late. I actually looked forward to going to placement - something to wake up to in the morning. If you follow my blog closely, I struggled quite a bit in GP and waking up was a huge struggle. Now in orthogeriatrics and early morning trauma meetings - I'm finding it easy to wake up again. Just feel like there's something to look forward to in the day. It's a nice breath of fresh air especially after two placements that were mediocre (well poor and mediocre).

I also quite like talking to the elderly as they've always got a great story to tell. One patient that stuck out for me this week was an 80 year old gentleman who was in for a left NOF #. He was a very talkative man and I met him the day before his discharge. He's gotten to know the staff on the wards quite well as he's been in hospital much longer than he should have been due to some complications. When the doctors were speaking to the man, he seemed like a genuinely funny and animated guy. He's obviously fed up with being in hospital and very much looking forward to leaving. He's apparently known to be getting quite critical with the doctors as he is sick of getting prescribed more and more medications as he stays longer and gives the juniors a bit of a tough time (in a joking manner though). After telling the patient he will be leaving the next day, and after quite a bit of joking around, he suddenly turned very thankful and grateful. He shook the doctors' hands and thanked each of them for taking care of him and "putting up" with him. It's quite nice to see as these days some patients don't give doctors enough credit and give doctors quite a tough time. It was a small gesture but it definitely put a smile on my face. It's nice to see the appreciation and I think the staff is happy to see him finally able to leave the hospital.

All in all, this week has been a great week, which is a good change as I've always had slow first weeks/things don't go my way in the first week. It's a good start to a very short placement and I'm getting along with the junior doctors so it's definitely making my placement a lot more enjoyable. It's also nice to see some familiar faces as well in the orthopaedics department. Even the secretaries are recognizing me as I've been popping around. Like one secretary said: "It's almost like you never left!". Funny enough it's actually been almost 4 months since my orthopaedics attachment (seems longer than that though!). It's been a good week and I've been getting some good news as well which I'll talk about at a later time.

Sorry for the long post - it just feels like it's been a long time since I've had a good time at placement and fairly happy. Dreading the fact it's only 2 weeks, but I think it's a good motivation booster - in time for exams. Happy reading!

Wednesday, October 10, 2012

Psychiatry - Final Week

This placement went by QUICK! I think it was the fact that the placement wasn't too bad and that I was quite busy doing my other work - time has just flown by. To be honest, I haven't seen too many exciting things as I had hoped to have seen. There's always a lot of misconceptions about each specialty and I think psychiatry is no different. Before I started the placement I was a bit unsure what to expect. I was a bit scared as on our first day we were each given a personal "alarm" which we would put on our belt loops. In addition to those alarms, when we entered the ward, we got another alarm which has tracking on it as well. You can't help but think that psychiatry might not be the safest specialty. We were also taught a lot about risk assessment when interviewing a patient. I remember we got a tutorial on where to sit and what to look out for in a room. We were told to always look out for objects that can be easily thrown and to sit near the door but not with our backs towards the door so if we need to escape we can just go out without turning around.

Okay yes, there are some "dangerous" patients who are known to be quite aggressive, but I never really felt "in danger" while on the wards or in clinic. I guess the only time I felt a bit "iffy" was today in clinic. The final patient I saw on my psychiatry attachment is known to have a very short temper and when he snaps - he snaps in a big way (throw objects, get violent, etc.). As the consultation went on, I could tell the patient was starting to get agitated and worst bit - I was sat furthest from the door and the patient was sat between the door and I (so much for remembering about risk assessment). To be honest - the clinic room wasn't appropriately arranged so there wasn't much one could do other than hope for the best. The consultation came to an end and for no reason the patient just "lost it". He lashed out but thankfully he didn't throw anything and instead stormed out the door and slammed it with a considerable amount of force. You could actually hear him leave the clinic as he was slamming every door along the way. I expected it to happen but it wasn't a nice situation to be caught in knowing there isn't really anywhere to go other than curling up into a ball.

Other than that incident - all the patients I have seen are all quite "alright". Despite some having a history of violence/aggression, these patients all seemed fairly cooperative. We are told of the ones who we shouldn't go speak to as they aren't cooperative but the "okay" ones are fairly normal. Of my 6 weeks in psychiatry, there hasn't been any major incidences. I'm sure more incidences/violence occur in A&E than in psychiatry. I think the one thing about psychiatry is the need for patience. Some of the patients are great historians...some are terrible and will not admit to anything/are not cooperative. With new patients - the clerking can take up to 1 hour and most of these inpatients don't have the patience to speak to you for an hour. I personally don't even have the patience to ask questions for an hour/listen to their history for an hour. I find it very time consuming. The number of times I have nearly fallen asleep during a consultation has been ridiculous. I drift off not because it is boring, but it's the fact that sitting and listening to a history for an hour is very difficult. Again with this attachment, there wasn't much I could do other than observe, but the good thing I had over GP was that when in the hospital - I can actually wander around and am not constrained to one building/area. Psychiatry is definitely different and I have definitely learned a lot since it is a new topic. I'm fairly certain it isn't something I can do, but it is quite interesting as you see a range of people and personalities.

Unfortunately I don't really get a break between this placement and the next other than a 3 day weekend. My next placement will be in Care of Old People - specifically Orthogeriatrics. Talk about luck. I'm actually really looking forward to it as I'll get to see and deal with something I'm interested in and maybe I can sneak off and see a few surgeries as well. I also know the team in the department - so I don't need to endure the whole awkward introduction/getting used to the ward/staff. It will be a short placement but I think it will be one that will pick my motivation back up and get me going again just in time for exams. Eek!