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Half a doctor hits the wards

Discussion in 'Weblogs' started by halfadoc, Jan 31, 2010.

  1. halfadoc

    halfadoc New Member

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    Hey, I've made started a blog about life as a clincal student on a different site but have just seen this section here... so I'll put a bit of each blog onto this bit and if you are interested in reading more about clincal med student life then you can check it out there!
    Here is my intro post:

    My life in a nutshell



    So I am half a doctor. Actually I am not; I would not be able to diagnose, examine or treat half of all patients, I cannot yet even insert a catheter - one of the most basic junior doctor tasks (in fact I still have problems taking blood), but as a third year medical student, in feb I will have reached the 'halfway there' mark in my studies and so supposedly am halfway there to graduating as a british doctor. Cool. But also bloody scary as by now consultants, friends, family and even lower year medical students expect me to know something, anything about medicine. The scariest fact is, I'm not sure I do. I've passed the exams so far, celebrated the results and regretably promptly forgotten everything I ever learnt....

    Check it out at Life as 1/2 a doctor if you are interested in more of this post :)
     
  2. halfadoc

    halfadoc New Member

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    Here is the start of todays post:
    So how would you describe that pain?

    A long week. This week I have been "on take" twice and have been in for my earliest yet post take ward round at the horrific time of 7.15am. Ouch.

    Check it out if your interested at Life as 1/2 a doctor:)
     
  3. halfadoc

    halfadoc New Member

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    Another week, another post, if you want to see the full thing check it out at Life as 1/2 a doctor: Sometimes you can't win :D. Have a great week!

    Sometimes you can't win

    I had some interesting patient experiences this week, so I'm going to talk about them but to preserve confidentiality obviously I won't use any actual names and I'm not going to give all details to further ensure the patient is not recognisable (this is also why I never mention what medical school I am at as I do not want people to be able to work out what hospital I have met particular patients at).

    On monday in a clinic for a particular progressive chronic disease (again I will not mention what) I met a lovely elderly (ish) couple. The husband was the sufferer of the chronic disease but his prognosis at the moment for that was very good and he had years left before it would become a problem. At the moment he was just attending clinic so that it could be monitored and he could be educated about what choices he had further down the line. This was one of his early clinic appointments so the consultant was suggesting his wife and him attend a group patient education session on his future possible treatments. The great thing about session like this is that they allow the patient to meet other people who are in exactly the same position and so not feel so isolated in their misfortune of getting a chronic conditon. The couple were very positive about the suggestion and so were going to attend the next session. I had really enjoyed meeting this couple and it was nice to see how chronic conditions can be managed positively and effectively. Unfortuanately though when the consultant looked through some recent scans the patient had had (purely to teach me for my education, not because he was expecting to see anything) things did not turn out to be so positive.
     
  4. halfadoc

    halfadoc New Member

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    Patient stealing and the end of my general medicine rotation

    Start of this last weeks blog:

    Patient stealing and the end of my general medicine rotation
    Been a bit overdue in posting this as have been a bit busy over the last week and a bit, for once this was mainly in a social way as its been my 21st this week - yay for legal USA drinking should I ever go there. Medicine has also been busy as this week is my last on general medicine so have been trying to complete my logbook (logbooks are the bane of a 3rd year medics life at my medical school, we have to get signatures to show we have attended particualar sessions, met various multiproffesionals and been observed practising various clincal skills).

    The problem with our logbooks is that you have to get the signatures and as a result end up missing sessions that may be more useful educationally in order to get a signature. For example this morning I went to see the hospital Chaplain to find out about his role so that I could get my 10th and final "Multi Proffessional" experience signature. But as he couldn't do it any other time I had to see him rather than going to an additional teaching lecture, as that was optional and did not require a signature. It was admittedly interesting finding out what the chaplain does and how the chaplancy service at the hospital works (and I suppose will be useful to some medical students so that they know in the future they can refer patients there, but to be honest I already knew it existed so Im not sure I gained that much) but I'm sure my future patients would prefer I'd attended the lecture this morning by the famous visiting Clinician. That said I suppose logbooks do stop some people just skiving off.

    Last tuesday I had my last "on take" to do and it proved to be a very annoying experience.....

    See more at www.halfadoctor.blogspot.com!;)
     
    #4 halfadoc, Feb 17, 2010
    Last edited: Feb 17, 2010
  5. halfadoc

    halfadoc New Member

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    Crash call!
    Here is the start of my latest blog...

    On friday (two weeks ago!) had the most awesome ward round ever! Literally! Reading the title of this blog you might think I'm a bit weird for saying that but I'll tell you now (spoiler alert..) that the patient was ok at the end so I think I can say legititmately say that it was awesome. So heres what happened...
    I was on a ward round on CCU (cardiac care unit) with one other student and a lot of doctors (3/4 registrars, and 3 F1/F2's and we were going around seeing patients in turn who had recently had acute coronary events - such as angina, MI's or had just had arrthymias detected. After seeing several patients we reached one elderly gentleman whose heart was absolutely racing at over 200 beats per a minute and his monitors were bleeping away to alert the staff to this problem.....

    To read more please visit Life as 1/2 a doctor ;)
     
  6. halfadoc

    halfadoc New Member

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    Start of new blog below, for the whole thing please go to Life as 1/2 a doctor: A failed vampire
    Also if you have any feedback on my blog I would love to hear it so please feel free to comment on the above link :)
    A failed vampire
    So now I am on surgery... Stop reading now if you are eating or about to have dinner ;)

    For the last three weeks and remainder of this week I have been on GI surgery, I have quickly learnt that this is a strange area of medicine where patients go if they have abdominal pain and/or poo problems. Whilst asking patients how their bowels are working is a common question in all areas of medicine, GI surgeons really like to concentrate on it, if you forget to ask exactly when a patient had their last bowel movement and its errr consistency (I did tell you to stop eating!) then you haven't taken a history fully. I've become quite blase remarkably quickly about asking patients about such an intimate area of their lives, to start with though I can't deny I found it a bit embarrassing to ask someone that and even caught myself once refering to stools as "Number two's".... Opps!
     
  7. halfadoc

    halfadoc New Member

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    New blog!

    Easter holiday envy: Welcome to your career
    A real mixed week of excellent GI teaching, being yelled at by admin staff, meeting a fantastic recovering anorexic, starting vascular, and having my last official surgery "on take". Where to start!



    Well lets start with where this week falls in all students at my universities timetables. Well like students at universities across the country they are now enjoying the comfort and relaxation of home cooked food, lie ins and the chance to catch up with friends from home. And me? Well nothings changed really, my friends from home are contacting me asking when I am around for a catch up and the answer regretably is...well sorry I'm just not really. So this is the life of a 3rd year: holidays we have are shorter, days are longer and some holidays disappear altogether. At better moments I even forget last year I would have been on a month holiday around now and at other times the remainder of the lazy uni student in me (I feel this is a side that is disappearing bit by bit with every 8am I successfully make) feels that something is dreadfully wrong because shouldn't I be watching telly and eating edible food about now?!

    Please read the rest of my blog at: Life as 1/2 a doctor :)
     
  8. halfadoc

    halfadoc New Member

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    A much overdue blog:

    Catch up
    Well its been some time since I've posted so will try to feel in the gaps a bit...
    Since I last posted I have finished vascular, had a week of urology experience and started + now finished paediatrics.

    Vascular wasn't really my cup of tea - it was very gory with lots of leg ulcers and ischaemic legs with gangrenous toes. There is (fortunately) no smell quite like an infected leg ulcer. If you are a smoker perhaps paying a visit to a vascular ward might help you to quit - during my time there it was fair to say most of the patients were smokers/ex heavy smokers and/or diabetic. I only saw one surgery during vascular and that was a leg amputation due to ischaemia which had caused irreversible tissue damage.

    This was quite a strange and brutal operation to watch, and literally involves the bones being sawn through. I found it quite surreal watching someones leg being taken off - I suppose this was because in medicine obviously normally you are doing everything you can to avoid long term damage to the patient but this was a situation where irreversible damage has occurred and now the surgeons job is really "damage limitation".

    To read this rest of my blog please visit Life as 1/2 a doctor: A catch up.. :D
    Please comment and let me know if you like it - might give me the motivation to remember to blog occasionally!
     
  9. halfadoc

    halfadoc New Member

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    Haven't blogged in almost a year, fail lol. But if you want to catch up with where I am now here is the start of my long long long overdue blog. The rest as ever is at Life as 1/2 a doctor. Halfadoc xx:

    A year off? Maybe not..
    Well I haven't posted in almost a year now, and this isn't gonna be a very long one (as why I have decided to post when I have a wedding to pack for and a dissertation to write I have no idea!) but I will try and catch you up in small chunks.

    I finished my third year, it,was,hard. No doubt about it. The posts stopped because I was struggling to keep on top of both my ongoing rotation whilst at the same time trying to cram like crazy for the mass of exams at the end of the year that came rapidly one after the other. It was a shame because my very last rotation was paediatrics/ obgynae which was the rotation I had most been looking forward to all year. I really want to do paediatrics so it was a shame that I could not dedicate all of my time during this rotation to seeing as much as possible, however I had to find a balance because I needed to revise hard for my exams. I will try and retrospectively fill in on this rotation later...


    I made it through my exams somehow on first attempt which was a massive relief because I have know idea where I would have found the strength to do a retake after such an exhausting year. Those who had to and made it through have my absolute respect because I hate to imagine how stressful and exhausting that must have been. So where am I now? Well between my third and fourth medical years we have the option to do what is called an "intercalated degree" . This is effectively where you enter the 3rd year of a normal degree and end up with a BSc on the basis of just this year (your first two years are thought of as being your pre clinical medical year in order to make up the credits but these don't actually count to what grade you get). I choose to do this extra year as did a lot of the undergraduates in my year. However whilst most of my year went of to do (in my opinion) quite dry, very sciency subjects such as immunology or physiology and mostly stay at our home university or go to london, I decided to buck the trend and head to loughborough university to study Sports Science and test out this whole renowned "Loughborough Experience"
     
  10. halfadoc

    halfadoc New Member

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    A bit more of a catch up on what I am up to :) . The rest of the blog (in a nicer format style with picture etc to break up the text ;D ) is at Life as 1/2 a doctor so please visit here to see the rest :) xx
    Its not PE

    When I came to loughborough I wasn't quite sure what to expect from sports science, I had a vague idea that I might brush up on my anatomy which has been increasingly forgotten since my pre clinical years and learn a bit about sports injuries which would hopefully be helpful whatever future speciality I pick.

    When I tell everyone Im intercalating in sports science everyone assumes that means I want to be a sports doctor, to be honest, I really don't. I want to do paediatrics but there is only one intercalated course really relevant for this at the moment and this year is the first year they are running it so sadly there was only 1/2 external places making it very competative and I didn't get on it. So I was left choosing from 3 other intercalated places - I could have stayed at my home university and studied psychology, gone to london and studied maternal/foetal health or come here to loughborough. I really wanted to experience somewhere different for a year so that ruled my own uni out. The london course looked interesting in aspects but contained a bit too much embryology for me which I'm not really a fan of. I was seriously tempted to go to london though because I thought it would be a really cool place to live and experience for a year plus a lot of my friends from medical school had got places to intercalate there so I would not be leaving everyone behind. In the end though the prospect of doing a course I prefered the look of (I thought it looked much less dry and dull) and the chance to not be a sheep and to do something completely different swayed me.
     
  11. halfadoc

    halfadoc New Member

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    http://halfadoctor.blogspot.com/

    This isn't a new post, just a quick message to say I've updated my main blog website (as listed in title of this message and my signature) to include links to other medical student blogs that I found interesting from a wide variety of years and medical schools, so hopefully no matter what kind of experiences you want to hear about you will be able to find something on that side bar :).

    In other words: I am a massive dissertation procrastinator...
     
  12. halfadoc

    halfadoc New Member

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    New blog :) As ever full version is available at Life as 1/2 a doctor: Sports science vs medicine. . In fact I think there is another short new one that I never updated onto this site on there as well below(it MUST be dissertation time ;D) ! Here is the start of the longer new blog,take care x:
    Sports science vs medicine.


    So what does sports science involve then? This was pretty much what I wondered during my first week of lectures. Turn out the answer is very simple: The science of sport. Oh.


    I haven't brushed up on my anatomy to the extent I was hoping because it turns out that is first and second year sports science and so they are expected to know it already, have however covered a much broader spectrum of subjects than I anticipated ranging from module in sports medicine itself to physiology of health to the sociology of sports deviance.


    The actual sports medicine module was awesome and we had some fantastic lecturers who taught us about issues such as eating disorders in sport or drug cheating amongst athletes. As mentioned in a blog last year (Life as 1/2 a doctor: Easter holiday envy: Welcome to your career) following doing a student selected module on eating disorders this is an area of medicine that has fascinated me. Last year I met a patient with chronic anorexia nervosa who did ballet and now was a ballet teacher. It was her ambition to be great at ballet which caused the development of her eating disorder in the first place (ballet is a sport where your body is very on show to the public causing self consiousness and in addition ballet dancers are encouraged to be light for lifts etc) but her eating disorder was now impeding her career as it had caused physical symptoms such as brittle bones that broke easily even when she was performing relatively low impact dance moves. Having met a patient who had AN for this reason it was very interesting to learn more about the science of the disease and why athletes may be prone to the disease. I'm not sure I learnt that much that I hadn't already been taught last year, but it remains my favorite lecture of the year and it was interesting to have my information refreshed by someone who was very knowledgeable on the topic
     
  13. halfadoc

    halfadoc New Member

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    Gap Summer!

    I'm currently posting from a pay-per-a-minute internet cafe in Cambodia so apolagies if this post is even less coherant than normal!

    Well I got through my intercalated finals, worked my last shifts at the S.U bar, packed up my halls and headed home briefly before heading off on my very own gap summer. Part of my less academic motivations for intercalating were that it would give me a MASSIVE summer holiday right before my elective that I could use for travelling and in a way make up for never having a gap year as I always feel pretty jealous hearing about all the exciting things friends have got up to on theirs.

    My orginial plan was to travel in the country I am doing my elective before heading to the hospital for that. Hasnt quite worked out like that as I am doing my elective in Tanzania but couldn't find others who wanted to travel there first and didn't feel it would be the safest place to travel as a lone female. So intead I am travelling through S.E. Asia with a group of friends as one of the group, my housemate is doing her elective in thailand at the thai/burma border where there is a small hospital set up for refugees from burma and having also intercalated she was keen to travel here first. So currently I am in cambodia having already been in Thailand for the past 3 weeks and I'm heading soon to Laos. Then I will head back to the UK for just 5 days before heading straight to Tanzania, pretty excited!

    For rest of this blog and more that don't make it to this site please check out Life as 1/2 a doctor: Gap Summer! ; will be posting lots soon from my elective :D xx
     
  14. halfadoc

    halfadoc New Member

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    Hey on elective now and have posted lots on Life as 1/2 a doctor: For every death theres a birth. A very eventful day but due to v.v.v limited internet access in Tanzania won't be able to copy all blog posts across to here probably, but here is half of one of my posts (to read the rest please check out link above or on signature :D)

    For every death theres a birth. A very eventful day




    30th August: Today I saw a patient die for the first time. We had been waiting for the morning meeting when one of the doctors came in and asked us to come with her to see a patient. Assuming she was maybe taking us to see an interesting patient for a teaching opportunity, all 5 of us went along.






    The patient turned out to be the lady whose GCS we had checked yesterday. It quickly became clear that the doctor had been called because the patient deteriorated rather than this being a teaching session. The patient was gasping for breath and her GCS was now only 3/15 as she was no longer responding to pain. The doctor listened to her chest and took her blood pressure and then without saying anything started alternating between pushing on her chest and suctioning the patients mouth. It took us a while to realise she was doing chest compressions because to be honest she wasn't doing them correctly (or at least not how we are taught to in England) and how many compressions she did in each set varied and seemed a bit random. To start with I thought she was just massaging the chest to try and loosen secretions so she could suction more fluid out or something. When we realised she was doing some kind of CPR one of the other medical students took over chest compressions and AJ and I alternated pumping the suction pump (unlike the UK its manual) so the doctor could concentrate on just suctioning. However after no more than 10 minutes of this, the doctor decided the patient was not going to recover and stopped rescucitation. No oxygen or adrenaline was given and defibrillation was not attempted(we are not sure if they have a defibrillator here). Very unlike England, but with a GCS of 4 yesterday I am not sure the outcome would have been any different even with a more thorough rescucitation attempt.






    To start with I have to admit I didn't feel as sad as I thought I would seeing a patient die and I actually felt quite guilty and inhumane for not feeling more when a relatively young woman has just died. But I think this was because knowing the woman's GCS, there was a great sense of inevitability about her dying and it sort of seemed like it was for the best as she probably wouldn't have recovered a good quality of life after so severe a stroke. Also the whole thing seemed to happen so fast that it was really surreal that I had just watched someone die. I hope this is why I didn't feel too affected by the experience anyway because I don't want to be some kind of horrible doctor who doesn't care if their patients live or die. However I was on the ward waiting for the ward round to start when the patients relatives came to say goodbye. They were very distraught and four of them had to be physically supported in and out of the ward. She was clearly a very loved lady. I didn't feel nothing when I saw their pain though and whilst it doesn't feel right to talk about my feelings when their feelings and grief is far more important, it was very very sad indeed. Maybe I'm not completely desensitised to peoples pain yet.






    The doctors told me that although the patient was a known hypertensive, she rarely took her prescribed anti hypertensive medication and didn't attend check ups which was why her blood pressure was so high causing her to have a stroke (systolic BP was 210 on admission). I imagine this makes the death even harder for the relatives as whilst her death is not their fault it must be easy to slide into thinking "if only" and potentially blaming themselves for not making her take her medication.






    After the relatives had said goodbye I helped some of the staff prepare the patient for taking her to the morgue. As the woman was unclothed beneath her blankets this involved dressing her before wrapping and tying sheets around her. This was was quite a weird process - its half a good and respectful thing that the patients dignity is preserved in death by not just taking her body to the morgue naked but on the otherhand as I discovered dressing a dead body is not a very dignified procedure at all.






    I later found out that the lady was a nurse from nearby and a lot of the staff at the hospital knew her and so the hospital was very understaffed the rest of the day as many people went to pay their respects. Not all the other staff were sensitive of this though, during the morning meeting the doctor who had been running the CPR stated when someone referred to the lady as the patient that "It's not a patient, its a dead body" and several other staff laughed in response. Horrible.
     
  15. halfadoc

    halfadoc New Member

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    First do no harm

    1st/ 2nd September 2011: The last few days have been quite frustrating from a medical perspective. I knew when I came here that the quality of medical care wouldn't be anywhere near as good as it is in England due to lack of resources, but I don't think I had considered the impact that possibly poorer medical education of the doctors, nurses and midwives would have on the quality of care. I'm not sure all of the mistakes I have seen in the last few days can even be accounted for by inferior education (possibly - I’m assuming so due the country being a lot poorer and so having less money available to train doctors) though; some of them seemed to be due to just poor judgment and arrogance/ laziness on the part of some of the doctors. I don't like to be so harsh but I really have seen some shocking clinical practice in the last couple of days.

    Will have to split these mistakes up I think or this post will be farrrr to long. :S. So starting with Thursday morning:

    Thursday morning we were all due to watch an exploratory laparotomy on the patient mentioned yesterday who had a bowel obstruction. This was meant to be happening first thing and by about 9.30am the patient was ready and lying in the operating theatre. So far so good.

    Unfortunately for the patient before the operation could start, another patient was rushed in to the other major operating theatre for an emergency c section because the patient had taken local herbs (this seems v.v common) and they were worried about fetal distress. Apparently there were not enough staff available to fill 2 operating theatres today because it was a public holiday. This meant the patient had to wait lying on the operating theatre for was almost another 2 hours whilst they performed the caesarean. Not ideal, in England public holiday or not, enough healthcare staff have to be available to safely run the hospital and this is what you sign up for when you train in a healthcare field. Still I don't blame the staff for this, this just how the system is arranged here. Also obviously the emergency patient had to take priority, but what I don't understand is why the staff left the poor patient just lying in the theatre waiting for two hours when there was a room just opposite with sofas etc which surely would have been more comfortable and less frightening for the patient. When the operation finally did start the patients BP was very very high (210/160 ish) even though it had been on normal range when she was on the ward. The anesthetist even said that maybe this was because she had been kept waiting in theatre so long, so they obviously do understand here the effect that fear can have on patients general conditions so I don’t understand why they had not taken just a little bit of time to make sure she was more comfortable. As it was, the operating theatre she had to lie in was connected to the operating theatre that was in use by an open doorway listening to the operation going on which I imagine must have been terrifying! Still this wasn’t a life threatening aspect of clinical care, so it wasn’t this in itself that really annoyed me. Side note, we also watched the c-section and when the baby came out she was not breathing, the other medics resuscitated her and she was breathing but not very well and not properly crying when she was taken from them to go to the warm baby room, here there were no staff to observe her condition and the baby was going to be left completely on her own there if the students hadn’t decided to stay and look after her until the family arrived to take over.

    It was what occurred during the operation that scared/frustrated me. When the patient was opened up it was clear just how obstructed she was – her bowels were so filled with air that they literally looked like balloons. Firstly the doctor thought the bowel obstruction was caused by adhesions which are a common cause of obstruction (although are usually caused by past surgery which this patient hadn’t had) so she removed these and compressed the bowels to try and deflate them. They didn’t deflate so rather than thinking that there must still be an obstruction somewhere further down which realistically must have been the case or the bowels would have deflated on compression, the doctor decided to puncture the bowel and deflate the bowels that way and then close up the patient because the adhesions were gone… Mistake number 1 and 2. I’m pretty sure that puncturing the bowel is something that you are meant to avoid at all costs due to the infection it would most likely cause and even if I’m not right about this (AJ and I both think we remember this from our G.I surgery placements but that was a while ago)the logic of assuming you have fixed the problem when the distension cannot be pushed down the bowel (when closed!) and out is very very odd. I don’t think I’m explaining the scenario very well, but basically if the bowl is still distended then there must be distension still further along the bowel and the doctor hadn’t even checked for this before assuming everything was ok and she was going to close the patient up. It was only because we asked well why is the large bowel still distended (it was the small bowel she had punctured and emptied) that she decided to look closer at that bowel and then said she had found a mass below the sigmoid colon. However she was still just going to close the patient up and refer her to see the specialist who was visiting in about 1months time... Again I get that they don't have the resources to do that much here and there are things they cannot treat but without some kind of treatment the patient would just obstruct again and so the surgery and the pain associated with it would be for nothing. I think the surgeon noticed our shocked faces at this because she asked us what we thought she should do. We asked if they were able to perform colostomys (where part of the bowel is brought through the skin of the abdomen and opened out so can be attached to a stoma bag and stool will pass out of this opening into the bag, rather than through the rectum - so an area of blockage in the bowel beyond the stoma can be bypassed and so bowel obstruction prevented) at the mission hospital, she said they could and after deliberating eventually called the doctor on the team who specialised in colostomys.....

    Rest of blog and lots more at Life as 1/2 a doctor !
     
  16. halfadoc

    halfadoc New Member

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    First do no harm, part 2

    1st September: In the evening we went to the delivery ward to see if there was anything going on. There was 1 lady who was having her first child and was fully dilated when we arrived but the baby’s head was not fully engaged in the birth canal. 3 hours later the doctor came and examined her and the baby still had not descended and the membrane had not yet ruptured (in other words her waters had not yet broken) and decided if the baby had not descended within 3 hours then they would perform an emergency c section as they thought there may be cpd (babies head too big for mums pelvis). About an hour later the membrane did rupture spontaneously but there was meconium (foetal stool – it is a bad sign because the baby can swallow it leading to foetal distress) in the waters, the midwife examined the mother again (it was hard for her to feel the head before as the membrane was bulging and in the way) and decided that there was no way the woman was going to be able to deliver vaginally and she would definitely need a caesarean. With this statement made the midwife sat back down and didn’t contact the doctor…

    We were very confused because if the patient was definitely going to need a caesarean plus with the meconium in the water there was a risk of foetal distress, then why wasn’t the midwife calling the doctor to get the caesarean done sooner than 2 hours time – surely there was no point the patient having to go through another 2 hours of unnecessary labour pains when she wasn’t going to be able to deliver vaginally anyway. We tried to tactfully say this to the midwife and ask if she was going to phone the doctor (trying to phrase this in a way where we did not seem bossy/ rude). The midwife did not seem to understand us when we said it would save the patient a lot of pain, I really don’t think maternal pain is something they take much into account here, and she basically just said that the doctor would be back of her own accord at some point. Finally about an hour later the doctor did come back and agree the patient needed a caesarrean but sadly for the patient by the time her blood had been taken for blood grouping and the stretcher had just arrived (the patient was literally about to sit on it) another patient came in who needed a caesarean and needed one more urgently than the first patient.


    The second patient had had 2 past caesarean deliveries and had presented very late to hospital, you could literally see the baby’s head on examination already, but the baby was not coming out on pushing and instead blood was indicating that she was probably having a uterine rupture due to the scar from her previous caesareans splitting. So this patient was rushed straight to theatre and the first patient had to wait even longer for her caesarean – which was frustrating because she could have already been finished in theatre by this point if the doctor had been contacted when it was first clear that a SVD (spontaneous vaginal delivary) was not possible.

    We went to surgery with the second patient, the emergency caesarean was clearly very necessary as when they opened her there was a lot of blood already pooled beneath the surface. When the baby came out he was very blue, not breathing and when I checked his heart rate it was beating but initially definitely below 60bpm (guidelines say that if a newborns heart is 60 beats per a minute then you should initiate chest compressions). So AJ and me and a midwife intiated resuciation, suctioning (the baby had a lot of secretions in his lungs) and rubbing/ lightly pinching the baby to try and stimulate the baby into taking a breath. When it came to cardiopulmonary resusciatation I was doing the chest compression and the midwife bagged him for a bit before the midwife was needed elsewhere and then AJ took over the bagging and the midwife occasionally came back over to check everything was going ok. To be honest it was better when it was just AJ and me doing the resuscitation because the midwife was instructing us to do the wrong CPR ratio’s – we had looked up the current guidelines for newborn resusciatations following the caesarean the other day when the other medical students had ended up doing CPR on that baby. The midwife didn’t even have the ratio the right way round and was instructing us to do far too many breathes through the bag and not enough compressions. There’s no point putting an excess of oxygen into the baby if the heart is not pumping enough for the oxygen to reach the babies brain! This is the second time we have experienced staff seeming to be unaware of the most efficient CPR protocols since we have been here which is a bit scary seeing as it was only the fourth day and as they do not have advanced resuscitation equipment here, basic CPR is something they really really need to get right. I don’t blame the staff, I think this is probably a case of poor medical education and not being able to easily keep up with current guidelines (trust me getting on functioning internet here is akin to getting blood from a stone, which is why my blogs are very dull without pictures at the moment – will try and fix this when I can!). But as someone who is aware of the cpr guidelines, I think I probably have a responsibility to try and educate the staff about these but I have no idea how on earth to do this in a way that staff might actually listen too and follow the guidelines in the future and how to do so without causing offense to staff and making an awkward atmosphere. If anyone has ANY ideas about how we could do this, please comment below J .

    We eventually managed to get the baby breathing and his heart rate was going at a much healthier 120, SUCCESS! Unfortuantely though he still was breathing a bit wheezily and was floppy and yet to cry. There wasn’t much more we could do though apart from wrap him up tight to try and keep him warm and try and stimulate him a bit more into crying but sadily he still hadn’t cried by the time he was taken from us to go to the baby room, so after checking someone was definitely keeping an eye on him we went home. Came into see him early Friday morning before the meeting and was pleased to see that he was in the middle of a full scale cry :D, for once was very happy to hear a baby crying!

    Rest of blog at Life as 1/2 a doctor: First do no harm, part 2

    Halfadoc x
     
  17. halfadoc

    halfadoc New Member

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    Who is to blame?

    5th september

    Death of a newborn
    Another very tough day.

    Found out at the ward meeting today that the newborn baby the midwife, AJ and I rescucitated late thursday evening had died at 11pm on friday. I was shocked and horrified by this news. As you can see from my last blog, I thought this baby was now doing ok and I was hoping he wouldn't suffer any long term consequences as a result of his birth asphyxia.

    Aj and I have been wracking our brains trying to work out why he deteriorated again and whether anything could have been done to prevent his death. From a self centered point of view we really wanted to know whether our own actions contributed in anyway to him not surviving.

    The baby’s notes say that on Friday morning he had started breastfeeding but at 11pm the doctor had been called because the baby had no vital signs and he then failed to respond to resuscitation.


    Why? At birth he was probably suffering from Meconium aspiration syndrome (MAS) which is where the fetuses draw amniotic fluid containing fetal stool into their lungs. This only occurs when the baby was already asphyxiated in the uterus (as he would have been due to the uterine rupture) leading them to effectively gasp for air but as they are still in the uterus they take in the amniotic fluid surrounding them instead. The meconium both irritates the lungs and causes a sort of valve where the baby can inhale air past the meconium blockage but can't exhale it back out again meaning their lungs soon distend too much to inhale anymore. This plus the asphyxia in the uterus means the babies vital organs may have been without sufficient oxygen for some time leading to anaerobic respiration and the buildup of lactic acid and other acids - the acidaemia/tissue ischaemia can damage organs. Some damage can present later - e.g. if the kidneys were damaged eventually electrolyte imbalance would occur due to filtration failure which can lead to cardiac arrest. So perhaps something like this happened causing the babies delayed deterioration that occurred after breast feeding (so potentially when there were more waste products to be filtered/removed?) this is all just academic debate though and as no post mortem is going to be carried out, the exact cause of his death cannot be known.

    Did anyone cause his death/ could anyone have prevented it?

    • The mother presented very late to hospital (well into the 2nd stage of labour) even though she had had 2 caesarreans in the past so should have known she needed to have him this way as well. Sadly if she had presented earlier then the uterine rupture could undoubtedly been avoided and so the woman would not have needed a hysterectomy, plus in all likelihood her baby would have been born healthy. So mothers fault? Unfortunately probably quite a lot of the blame might be hers, but by no means all as there are other factors. One such factor might be poor education of patients - possibly she didn't understand she had to present to hospital early/ had to have another c-section.
    • The style of caesarreans carried out here is the "classical" form and is more prone to uterine rupture than the form done in the UK. So maybe had the original surgeons performed the better form of c-section then the uterus would not have ruptured...
    • Slow action of medical staff in getting the mother into theatre - AJ has researched and in the case of uterine rupture there will be significant neonatal mortality if the baby is not delivered within 18minutes of there being signs of fetal distress (and apparently blood loss like seen in this patient is a later sign than fetal distress). Well fetal distress was not checked for and I do not think they delivered the baby within 18 minutes of seeing blood so the baby’s chances of survival were decreased as a result.

    • Actions during resuscitation - this refers to the actions of the midwife and me; did we carry out CPR in the best way possible? I wish I could say we did everything textbook perfectly, but as I said in last blog, I don't think we did. Some of this was to do with lack of resources and some of it was to do with the midwifes incorrect instructions to me on how many chest compressions I had to do to each of her bag squeezes. Therefore some of the reason for imperfect CPR was also my own failure to speak up and quote the current guidelines rather than meekly following her directions. Could a better ratio have made a difference? Potentially yes, more chest compressions could have meant more oxygen got to the babies vital organs (rather than just being bagged into his lungs but exhaled out before it could be picked up by red blood cells and carried away in the blood) meaning less hypoxia and damage but it’s hard to know though whether a critical amount of damage had already been done before CPR was even attempted.

    • Better monitoring of babies who had required special care at birth. Whether or not this particular baby could have been saved if his deterioration had been observed, I don't know but babies here are definitely not observed closely enough in the first days and for some of the neonatal deaths that occur I'm sure closer observation would make a big difference.
    • Lack of proper newborn examination, separate problem? Could have had a congenital heart defect or something that also contributed to the baby’s poor condition. Unlikely but possible.

    I guess all I can console myself with is the thought that had I not been there the CPR ratio would not have been done any differently (and indeed I think we tried to do the right ratio when the midwife wasn't there, but it’s already all a bit of a blur so I can't remember 100%). So did I personally kill that baby? No. Did I possibly fail to prevent the baby’s condition from deteriorating further when I might have been able to make a difference? Yes. If I could go rewind time and tell the midwife my opinion about the advised CPR ratios rather than doing what she told me to, would she listen to me? If she did listen to me would it make a difference to the end outcome? I don't know and I guess I never will and it sucks. I wish I could rewind and try again though and I hope an infinite amount that by not saying anything to the midwife I didn't cause an unnecessary death.

    One thing’s for sure, I’m definitely going to try and find away to educate staff about CPR now.

    More at Life as 1/2 a doctor: Who is to blame?
     
  18. halfadoc

    halfadoc New Member

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    The pregnancy which was not

    6/9/11: Today we had the rare opportunity to observe treatment of a molar pregnancy. This is where there is abnormal placenta formation due to an ovum (egg) being incorrectly fertilised - usually by the genetic material from just 2 sperm (so no maternal material - the egg is empty) but sometimes from maternal material as well (so has 50% extra chromosomes). As a result of the abnormal genetics the placenta invades tissue beyond its normal site and the embryo is incompatible with life, but the pregnancy hormones are still produced and so amenorrhoea and the sensation of pregnancy continues without a fetus. 3% of complete moles (those moles just produced by paternal DNA) develop in a malignant disease - choriocarcinoma (cancer originating from the chorion, the outer layer surrounding the embryo prior to its death).

    Ironically in molar pregnancies the symptoms of pregnancy are exaggerated and the patient is likely to suffer from extreme morning sickness and have a uterus which is large for dates.

    The treatment of moles in the UK would follow the following steps:

    1. Removal of the mole by gentle suction.
    2. Weekly hCG (the hormone produced in pregnancy) checks until the level returns to normal. A rise in hCG would indicate possible relapse or invasive mole.
    3. Avoid pregnancy for at least 1 year
    4. Increased risk future pregnancy will also be molar - ultrasound to confirm is normal
    5. Chemotherapy may be required if invasion mole or choriocarcinoma.

    In Tanzania however molar pregnancies are removed using D and C (dilatation and curettage - the cervix is dilated and then the lining of the uterus scraped off using a curette), patients are advised to attend follow up in a year but the doctor told us they don't tend to turn up and very few hospitals can offer chemotherapy if it is needed due to expense.

    Molar pregnancies are quite rare in the UK (oxford handbooks quotes a rate of 1.54 in every 1000 pregnancies) and are only treated in I think 2 specialist centres - everywhere else refers patients to these. Therefore most medical students or even doctors do not get to observe the treatment of molar pregnancies being carried out. So I guess from the point of view of my training it is pretty lucky to get to see this treatment happening. But from the patients point of view it must have been a horrible diagnosis, going from being 6 months pregnant to not being pregnant at all and instead having material in her uterus which might turn into cancer. When I say I was lucky to be able to observe this operation I don't mean I am pleased the condition had occurred; obviously I would very happily swap this learning opportunity for her to instead have a successful normal pregnancy.

    The actual operation was pretty gruesome with lots of large lumpy bits being removed and the patient lost perhaps a litre of blood. Molar pregnancies are supposed to look like frog spawn on removal... Well I wouldn't say that but was quite unusual in appearance.

    D and C looked seriously harsh way of treating the condition (think I prefer the sound of the gentle suction recommended in England!). At least this patient was under general anesthetic though - we saw a D and C on a woman who had heavy periods (so ?endometriosis) immediately before this surgery where the woman didn't even have local anaesthetic. Although that procedure didn't last anywhere near as long and involved less curettage, the woman still looked in considerable amounts of pain. The molar pregnancy patient had the same anaethatist as the other day (bowel obstruction patient) - still wasn't impressed with him, he seemed fascinated by the operation which is good but as a result spent a lot of time watching the D and C and very little time observing the patient or her vital signs. Yet again we had to alert him of worrying vital signs or movements from the patient. To quote AJ, he was "about as useful as a chocolate fireguard".


    Rest of blog at Life as 1/2 a doctor: The pregnancy which was not :D

    Halfadoc x
     
  19. halfadoc

    halfadoc New Member

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    It's a boy!

    7.9.11:


    Spent most of the morning in the hospital laboratory as I heard that's the place to be if you want to practice taking blood (which I desperately do, at the moment someone could have a vein the size of the M25 and I would probably still miss!). Unfortunately the first patient who came in was a terrified 8 year old who was shaking like a leaf. The lab technician told me I could take his blood but I declined. I am not going to put a scared child through what will almost certainly be additional pain as would probably not manage to get blood from a kids tiny veins. Will definitely wait until I am confident at taking blood before I try on a child! Unfortunately although the next patient was an adult who had juggernauts for veins, the lab technician did not offer me the chance to take his (presumably because I had declined taking the child's). Massive shame because his veins were obvious enough that even I would have probably managed and I could have done with a taking blood win. Unfortunately even though I stayed a couple of hours more no other patients came to have their blood taken. The lab technician did show me some interesting things like what tuberculosis bacillus looks like through a microscope and how to test someone's blood group, but it was still a bit of a waste of time seeing as I was hoping for some blood taking practice.

    Went to OPD for a few hours after, a few interesting patients but I won't go into details today as am trying to make posts a more reasonable length!

    After OPD I went to maternity to see how a woman who was in the starting stages of labour in the morning was getting on. During her last vaginal examination a couple of hours previously she was already 8cm dilated so decided to give going home for a late lunch a miss and stick around with Aj because she would probably give birth very soon. Soon the midwives were asking which of us wanted to deliver the baby and because AJ is doing some research which involves having to observe deliveries rather than actively participate, I got to again. Woooo!

    The actual delivery this time was harder because the size of the woman was smaller in comparison to the baby's head. In the end the midwife had to perform an episiotomy (cut the tissue at the opening of the vagina in order to try and prevent a less well controlled tear occurring) without even any local anaesthetic - OUCH!! But it was successful in that the baby came out much more easily after this. He was barely out before he started crying! Such a relief after all the seriously ill babies we have seen recently! He was exceeding beautiful too!

    This time I got to clamp and cut the cord as well as things were less rushed due to the baby being healthy. Did manage to splatter AJ with cord blood though - sorry!! After I had delivered the after birth and cleaned the mother up a bit, the episiotomy was stitched up. I was asked if I wanted to suture it myself, but seeing as I haven't ever sutured a real person before (fake skin only!) and can't even really remember how, I decided doing so for first time on a fully conscious patient who had no anaesthetic probably wouldn't be the best idea. I settled for a nice long cuddle with the baby instead!

    The woman said thank you to me multiple times afterwards, and grabbed my hand to say it again this evening when we were walking through to see if any more ladies were in labour. Patient satisfaction! Feels pretty great :D! (and did I mention how cute baby was ;D!)

    More blogs at Life as 1/2 a doctor!

    Halfadoc
     
  20. halfadoc

    halfadoc New Member

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    Too much death
    8/9/11:
    In retrospect maybe I should have discussed a couple of the OPD cases I saw yesterday because 2 of them were admitted and sadly died.

    The first one was a 1 year old baby girl who was very weak, anaemic and malnourished. Contrary to what I thought when before I came here not that many patients tend to be undernourished in fact if anything they tend to be slightly on the larger side. The only patients I have seen who looked emaciated were those who have chronic diseases such as HIV.
    So I am not sure if this girl’s anaemia/malnourishment was due to lack of food or because she also was suffering from a long term condition. On the weight chart her weight had dramatically dropped on the last couple of readings. In the morning meeting they reported that she had died over night :(. Just too weak to survive the infection I suppose.

    The second patient was a 23 year old girl who had pneumonia as a result of being immune compromised. Her HIV had been diagnosed over a year ago but weirdly she was not receiving any anti retrovirals - these are fortunately one of the few drugs that the government prescribe free of charge so expense is not why she was not getting them. Her CD4 count (these are immune cells that are destroyed by the virus) was very low when checked yesterday at 160 cells per uL. A good CD4 count is over 500, so she really really really should have been receiving treatment and the doctor was not sure why she was not - it was not due to patient refusal. I remember when I saw the patient yesterday that I was struck by how weak and fatigued she looked - she couldn't put her own shoes back on, her mum had to do this for her. I also realised that the girl was basically my age and yet our lives couldn't be more different - all I was worried about yesterday was whether or not I would get to practice taking blood while I was here but she was clearly literally fighting for her life. Whilst I was not surprised to hear she hadn't pulled through because she was clearly very very ill, I was still quite shocked because she was still so young, such a massive waste.

    Unfortunately this was not the only death we heard about/ experienced today. In the afternoon we went to OPD and we entered a consultation room behind a nurse (here you can't wait for patients to leave like you would as a student in England because more often than not the next patient will enter whilst the first patient is still there so there is no gap between patients). The nurse was mopping up pus from someone’s leg which was on the floor (Ick!) and the doctor was talking in Swahili to a husband and wife whose small baby lay on the examination bed wrapped in multiple blankets (as commonplace here in spite of what seems to us as very hot weather!). As ever the next patient was standing behind the husband and wife. It wasn't till halfway through the consultation that the doctor turned to us and said the baby was dead on arrival at OPD and he was filling out the death certificate. I was horrified that we had accidentally stumbled in on the middle of what should have been a very private moment for the grieving parents. But at least we had not done so intentionally - why on earth the nurse had been moping the floor during that particular consultation or the next patient had not left the room when he realised what was going on (after all they both spoke Swahili so should have realised pretty quickly), I have no idea. Also the doctor could have simply locked the door (I have seen this done during some consultations) which would have stopped all 4 of us from coming in the first place. From an outsiders perspective who is not used to the culture it seems people here receive very little privacy even when they may need it most. I definitely prefer the way death and grief is treated in UK hospitals.


    Rest of blog + more blogs (plus images to go with some of blogs) at Life as 1/2 a doctor: Too much death

    Take care,

    Halfadoc x
     

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