What to do if your dog has a stroke... On Christmas Day

My dog Whiskey

Whiskey- 6 year old Male (dog)

Presenting Complaint: Change in behaviour

History of Presenting Complaint: Was pushed by reckless owner (me) against some stairs and proceeded to run down the driveway. Ran back up to owner in a daze and just stood staring: tail between his legs, ears flat on his head, did not respond to his name. (If you have ever met Whiskey, you'll know that this is highly unusual. He is practically a circus dog.) This was later associated with ataxia (walking like a drunk), uncontrollable drooling and spasticity (stiffness) of his limbs- mainly on the left side. Episodes of this 'odd behavior' lasted a few minutes during which he sometimes ran around aimlessly. They were followed by lucid intervals which also lasted a few minutes.

No past medical history, not on any regular medication, no family history of note.

Social History: Lives with one other dog ('Vixen', 10 years old, fit and well) and 4 people.

Differential Diagnosis:
Transient Ischaemic Attacks (TIAs aka mini strokes)
Seizure, ?brain tumour
Prolonged 'dizzy spell' after being pushed against the stairs
Subdural Haemorrhage (unlikely as he did not hit his head and inappropriate time frame)
Severe anxiety (fireworks went off earlier in the evening; unlikely as he has never exhibited this response to them before)

Impression: TIAs

Plan:
1. 37.5mg clopdigrel stat (the only antiplatelet we had in the house) ie half the human dose
2. Regular clopidogrel daily for 1 week
3.Any further attacks, call for veterinary review (will have to wait until the new year as closed for Christmas)
4. Discuss events with family
5. Review tomorrow

Consultant Ward Round following morning:
(ie I went with my mother the following morning to see if he was still alive)
Patient 'back to usual self' according to owner: Running around, attentive.
Stood on hind legs and sat without difficulty. Normal gait. Drooling resolved.
Eating and drinking.

Impression: Resolved TIAs

Plan: Continue clopidogrel, watch and wait.

What I learned from a patient who had a Laryngectomy

A Laryngectomy is a procedure where the larynx (or voice box) is removed (-ectomy) often because of cancer. It leaves the patient with a hole in the neck to breathe and talk, albeit with some difficulty.

I don't think I properly had many dealings with people who have had this procedure done (ie laryngectomees) until I came across this particular patient. In my mind, having a laryngectomy was a life-changing procedure to the point where it could be life-limiting. I couldn't imagine being put to sleep on an operating table and then waking up not being able to talk without great effort or assistance. Talking effortlessly is definitely an everyday luxury I take for granted.

I don't know what I was expecting before I went to see this gentleman at the bedside. Perhaps someone who was depressed, withdrawn, brusque... All the things I imagine I might be, had I been in that situation. I clearly need to work on my coping mechanisms for difficult life events. However, I met a man who was fiercely independent despite various other physical ailments. He was the kind of person you would have thought was in the army in his younger years. I thought communication between us would have been so strained that it would just dissolve in frustration but he used every last ounce of breath to finish each sentence. He even added unnecessarily polite words like please and thank you although I wouldn't have held it against him in the slightest if he chose to forgo these niceties to conserve energy.

I don't know much about this gentleman's story so who knows if he had a hard time coming to terms with it at first. Perhaps he was all those things I imagined but made his peace with it. Or maybe he was totally fine with it and was grateful to have the operation done for whatever reason. But he stayed on my mind because he taught me something about loss. What it's like to lose a part of yourself but not let it defeat you. Losing my voice would mean losing my accent, my sing-song intonation and my slightly sarcastic tone of voice. That would take a toll on how I see myself, my identity. And I suppose people who lose a limb or their eyesight or hearing would go through a process of coming to terms with their own loss, how ever that looks for them. But the human spirit is one of vigor and resilience and we would do well not to forget that.

Just a Routine Operation

Today we watched this video entitled 'Just a Routine Operation' as part of our simulation training. Simulation training is an opportunity for people at various levels (students or otherwise) in different healthcare professions to run through simulated scenarios as they would in real life but within a protected environment. They often involve what are essentially high-tech dummies that can blink, breathe and have heart sounds-among other things! And everything is done in real time.

The video is about a man who lost his wife because of the shortsightedness of the doctors who were preparing her for a routine operation on her sinuses. He questioned why there wasn't more awareness in the medical profession of how factors other than knowledge and clinical skill can affect patient outcomes; and likened it to his own profession (aviation) where simulated exercises are a core part of training- not an add on.

This made me very uncomfortable and I guess part of it is because we all have this belief that doctors are never directly responsible for the death of patients. Rather, patients happen to die while in the care of doctors- unless neglect or malicious intent is involved. So to draw such a direct causative link assaults our assumptions. Especially one that isn't a statistic but a story.

All the doctors involved were questioned regarding their decision making processes that day. He then went on to say something that completely stopped me in my tracks: They all eventually returned to work and that's exactly what he wanted. Now they are better clinicians and can take the lessons they learnt back into the hospital to improve patient care.

Doctors who make mistakes are often deemed failures by the media and our conscience demands they face serious consequences. That usually means they are struck off the register, destined to live the rest of their days in shame. But we all make mistakes. It just so happens they don't all result in the death of another person. Perhaps this guy is on to something. Maybe he's crazy? Maybe he has grasped an understanding of forgiveness that transcends the mind? Or maybe the answer really isn't to punish those who make mistakes and make them the scapegoats for all of society's injustices?

Should doctors who have fallen from grace be an example, rather than a spectacle? Perhaps the answer lies in rehabilitation, not humiliation.

Yes patients can be rude too

The customer is always right. Right? Maybe. Such a sense of entitlement is only heightened by the fact that the 'customers' of the National Health Service (NHS- the body which provides public healthcare in the UK) are largely taxpayers who quite rightly expect their money's worth.

Sorry to disappoint those who thought this was going to be a rant full of juicy gossip fresh from the bedside. I would prefer not to be stripped of my GMC (General Medical Council) number before I get a chance to properly use it. People with power to do that tend not to look kindly on those who break patient confidentiality. However, I would like to draw on some of the negative experiences I have had with patients and their families to share with you some of the sentiments of those on the receiving end of hard criticism and raw emotion.

Now don't get me wrong. I do not mean to be overly critical of the patient population. Many a patient has let me stick them with needles when I barely knew how to open the packet and stick my gloved fingers in places which, under ordinary circumstances, would not be appropriate for a person you have just met to expose- and often with a flippant "Well you've got to learn sometime haven't you!" For this, I am exceedingly grateful. Those willing souls have either knowingly or unknowingly contributed to building my skill set and my confidence. They have also ultimately contributed to building a better NHS full of competent future doctors.

What these slightly grandiose statements are trying to convey is that medical students are just that: students. Students for whom the majority of their learning takes place in a high-stress environment: between nurses taking a temperature and doctors rattling off numbers down a phone. Patients and their relatives are under their own stresses: between a new diagnosis of cancer and an Xray that was supposed to be done 2 hours ago. In this setting sparks fly easily and the one to get the brunt of the force can sometimes be the poor medical student who has just conveniently appeared to take the 5th blood test for the day.

Patients have said some unkind things to me out of frustration that I'm sure they would not have said had the circumstances been different. At the end of the day, you get paid to be their punching bag (within reason as assault is not appropriate) and that requires depth of understanding and empathy. Often I wonder what my response would have been had I walked a mile in their shoes....

However, it so happens that patients' most vulnerable moments are often my greatest learning opportunities- to grow as a clinician and to grow in compassion.

I've got to learn sometime haven't I?

How to tell whether or not you'll make a good doctor

Yes, with these few questions, you can determine whether or not you will have a successful medical career! Well I suppose even by saying that, I've essentially branded myself as a quack selling a "one size fits all" approach to what is quite clearly a multifactorial outcome. However, if you have been following my blog at all, you'll realise it's full of gross generalizations- without which many of us would cease to make sense of the world.

I have what I call 'panic moments' on a relatively frequent basis. These are moments where I have to stop and think about something like how to do a manual blood pressure (the equivalent of tying your shoelaces) because we use the automatic cuffs so often. Or when I have to go back and read about what the spleen actually does. While we're on the topic, funny how it just sits there and seemingly does nothing y'know? Like the lungs breathe and the heart beats, but seriously, spleen, make yourself useful. If you can name more than 3 functions of the spleen without googling it, I promise I'll buy you a BMW. Ok no I'll probably buy you a kit kat.

So back to 'panic moments'. When I can't remember relatively simple things, I often think "Well how am I ever going to make sense of really complex things? I'll never be a good doctor" However, though I may be disillusioned at the time, I try to be objective and ask myself a couple questions:

If I was a patient, would I want to have me (or somebody just like me) as my doctor? Or for the really hard core: If I was someone else, would I recommend my mother have me as her doctor?

Caveat: These questions make a bit more sense in a system where care is primarily provided by doctors in private practice (as it is in my home country). Obviously such a system is flawed, as are all systems, but one thing it does enable is patient choice in exactly who sees them regularly and why. Such patients are, therefore, not afraid to tell their friends (and mothers) which doctors they are happy with and those they aren't.

If your honest answer to these questions is yes, then you can pick out some positive things and remind yourself you aren't a total failure. You can also identify a couple things to work on. And if your honest answer is no, then it gives you reason to do a bit of soul searching.

I'll give you my own assessment of myself: I would like me to be my doctor because I'm a good listener, people generally think I take them seriously if they have something to say, I like wrestling with difficult concepts, I don't crumble under pressure, I like talking things through with people and I get immense satisfaction out of knowing I've helped someone else. Reasons why I wouldn't like me to be my doctor: I can get a bit impatient and then be a bit brusque with others if I have a lot to do and I feel they are being too long-winded, I'm not a huge fan of children so I tend not to give them as much attention as I would an adult patient, and people- generally speaking- don't find me very approachable. It just gives a bit of context when you get caught up in the emotion of the moment.

Hope that helps some lost soul out there. Remember you aren't a failure because you've made a mistake! I think that's something we don't hear often enough.

"Can I wear this to placement?"

Dress code among doctors in this part of the world isn't quite as um.. 'rigid' as it might be in other places. I suppose the boundaries of what one can and cannot wear would be a topic of another blogpost as after 4 years, I am still occasionally baffled by the choices people make regarding their work wardrobe- not always because they dress indecently but because it would not even cross my mind to wear certain items of clothing in a clinical setting.

This post, however, is mainly about the frustration (almost agony) I experience when going shopping for clothes since being on clinical placement. Being a girl brings it's own challenges- in life in general, but right now I'm specifically referring to clothes shopping. Shopping is often a convoluted experience for females, full of highs and lows: the thrill of finding the dress you saw in the shop window last week for half price and the disappointment of realising the only one left is 2 sizes too big. 2 sides of the same coin yet girls can't seem to get enough and our pockets will perpetually be at the mercy of the high street stores.

And as if the process of finding the perfect dress was not complicated enough, let's add another factor: "Can I wear this to placement?" A seemingly harmless question and one sensibly grounded in the expectation that medical students "look professional" at all times. While that might mean slightly different things  to different people given the context, broadly speaking, it means "try not too look like a sex kitten without looking like a drab prude". I think that is a universally applicable principle unless, of course, your profession requires that you look like a sex kitten or, indeed, a prude.

So what does this mean in practical terms? Well since we don't have white coats to cover up creases and unsightly stains, first of all, shirts or tops must be cleaned easily. Splattered blood from a dripping cannula and ink stains add nothing to the aesthetic appeal of clothing. Plunging necklines must be avoided, no exceptions. Bending over to examine someone must never be a display of anything more than clinical prowess. On that note, no dangling bows that hang in the patient's face are allowed either. No low cut arm holes as visible bra on side view is also not acceptable. Sleeves are desired but not always necessary- keep in mind that in winter months, the inside of a hospital is like a furness. Sweat patches have never been a fashion statement worth emulating. Now for skirts and dresses: how short is too short? I have seen a lot of variation on this, but I suppose if you can't sit or bend without exposing unmentionables, then it belongs in the store and not in your wardrobe. Shoes: I have seen people come to work in trainers (sneakers) without having a medically valid reason, so I guess anything goes on that front really. Then you have to think of the price. Does it fit? Do I have a top in this colour already? Do I like the pattern? Argh!!!

But regardless of how you choose your clothes for your professional wardrobe, I think there's one question we all need to answer: "How does this outfit make me feel or look as a student doctor? Do I look like the kind of person people would take seriously and does it make me feel like I am ready to tackle any challenge thrown at me?" If the honest answer is yes, then I think you'll have a hard time saying no.

Medical student syndrome

I'm sat on my bed right now with a sore throat, pressure in my sinuses, possibly a fever and a dull headache. To the average person, that would be the beginnings of a cold. But that didn't stop me considering that I may have meningitis. Yes, that's right. I have been staring at the light on my ceiling for the last 10 minutes trying to elicit photophobia that I clearly do not have and contemplated trying out Kernig's test on myself which may have been a bit of a palaver.

Medical student syndrome is a legit phenomenon according to wikipedia (which none of us admit we use on a regular basis). It is also called hypochondriasis of medical students and is frequently reported in students "who perceive themselves or others to be experiencing the symptoms of the disease they are studying." It can actually get so serious that psychiatric intervention is needed- so if that's you, don't be afraid to get help. But for the 99.9% of us who are really just being a bit silly, it helps to know you aren't alone. The struggle is real. How about a couple more anecdotes then?

There was a time I convinced myself I had bowel cancer. And I mean it when I say 'convinced'. For a variety of reasons, that did not make sense but it didn't stop me from believing it. I eventually had a CT Scan of my abdomen and I am actually an anatomical anomaly! That's my claim to fame now. I have twice as much bowel as the average person which would explain the symptoms I'd been having. It probably isn't appropriate for me to post a picture of it on here. But I always have a copy on my phone. You know, for if ever I have to have emergency surgery after being hit by a bus or something. Always be prepared. If we are friends, I wouldn't mind showing you if you asked very nicely.

Then there was the time I thought I had a brain tumour. A cerebellar tumour to be precise (the part of your brain that's responsible for balance and coordination). I'd been a bit unsteady on my feet during the day. And conveniently just learned to do a cerebellar exam the week before. So I obviously did all the silly tests: wagged my tongue side to side, played patty-cake, walked heel-toe all the way to the kitchen- even did Romberg's test. All negative. Then I remembered I changed my shoes that day and they have rounded soles.

                                       

Then there was the time I thought I had either a slipped disc in my back or cancerous bone lesions. Equally as ridiculous. But I have mild scoliosis (curved spine) and had been standing for 4 hours straight the day before in theatre. So I was having some persistent muscle pain in my lower back.

For supposedly intelligent people, we can arrive at some not-so-intelligent conclusions. I guess knowledge isn't always power.

What it's like being the medic that isn't so great at maths

I'm not doing a Maths degree. But I suppose with any science-based degree, there is the assumption that Math will play a central role. Well, let me tell you, I have done little more than basic addition, subtraction, multiplication and division in all of 5 years. Remember all that mumbo-jumbo we learnt about how to calculate the pH of a solution and balance equations in sixth form chemistry? Yeah, you can safely forget that after exams if you are planning on doing medicine. Probably not such a good idea to forget what the heart does though. Definitely keep that one. Save As.

But let me tell you a bit more about myself: I really struggled with Math at school and needed extra lessons. 'How can that be?' you ask. 'You have to get really good grades in Math and Science to get onto your course!' Yes that's true. And in fact, most medics are Math geeks. I'm not so good with numbers but that doesn't mean I'm not good at understanding concepts and the links between them. That's how I got around formulae and equations in both Math and Science. While my peers could solve a problem in a couple lines- 10 seconds flat to be exact- I would still be trying to figure out what the formula actually meant. I found the concepts very abstract compared to 'the knee bone is connected to the hip bone...' and so on. I would take up a page to do a question everybody else did in 2 lines and would often struggle to understand why my answer was wrong. That would then require a whole other page. And probably another hour. You get the idea.

Fast forward 7 years and here I am- about to be released on to the wards in less than a year. A new paranoia has set in: 'What if I overdose a patient because I calculated the dose wrong?' That might seem unlikely. But with the pressures to see more patients in less time, a mother crying because her daughter was just admitted and your consultant shouting at you because you forgot to ring the lab for another patient's latest blood results, I'm sure you can see how easy it might be to move a decimal point one space too far or put 2 zeros instead of 1. 

In our prescribing tutorials, I'm usually the last to finish because, of course, there are some drug doses calculated as mg/kg/min. Even just looking at that makes my brain panic slightly. (Seriously. Who came up with that? I need to have a word) I check and double-check and triple-check and often need a separate page to do my calculations when some people just do it in their heads. Geeks. And I still get things wrong sometimes which is really frustrating. My error rates are slowly coming down though. But I'm not going to lie: I still leave those questions for last in exams.

The evolution of doctors' handwriting

Years ago I vowed to be the change I wished to see. The stereotype of doctors having bad handwriting is well established. I put that down to laziness. How could someone let something as important as their handwriting deteriorate? I like to think I have decent enough handwriting and I consider it a unique identifier. After fingerprints and forensic dental impressions, I'm sure it's up there.

I have been on too many a ward, trying to read a patient's notes and have had to skip over large portions of writing because they were pretty much illegible. My first thought has always been "Well whoever wrote this would be in deep doo doo if that patient ever took them to court." Other than being aesthetically pleasing, having decent handwriting actually serves another purpose: it keeps you out of prison with a license to practice. This has always been my motivation to develop good note-taking skills and avoid developing chicken-scratch script.

That is until I was asked to take notes on a busy ward round the other day. On a ward round, senior doctors reviewing patients don't usually take notes themselves. Their juniors act as scribes. I was struggling to keep up with documenting the doctor's plan of action for a particular patient, trying to remember what he said the heart rate was and which side he heard crackles on. Things were going downhill. I was appalled to see the sprawling scribbles I had to put my signature next to. Honestly it was a disgrace. In that moment I understood. In spite of the best intentions of naive medical students-like myself, time constraints and the sheer volume of documentation required can distort the handwriting of even the most diligent scribe. Computer-typed notes are not much better. The most basic of words get misspelled: "Pt complains of abdo pan, O/E SNT, referr for GI inpit." Need I say more.

I leave you with one other anecdote. My mother is a GI consultant. She made a shopping list one day and we were on our way to the supermarket. We spent nearly a hour trying to understand what the last item on the list was: "2ploc? What is 2ploc?" Imagine a huge rounded 'Z' and an 'i' that was too small to see. The word was meant to be "Ziploc"- a brand of plastic resealable bags used for storing food.

Well. There you are.