Unsuspected source of sepsis

When I was an SHO many years ago, we had a case of PUO. Pyrexia of unknown origin. Young man, admitted with chills and rigors. History unrevealing. Denies IV drug use recent travel etc. Blood cultures grew all sorts of unusual organisms, not normally seen in septicaemia, and not normally seen in immunosuppressed either. Echo didn’t show any endocarditis.

The blood culture was positive for Corynebacteria one day and for Strep pyogenes a few days later and then for Enterococcus faecalis a few days later. The medical team were getting increasingly perplexed as to what is going on. The whole body CT scan was unremarkable. We are starting to suspect self induced disease. There was however some microscopic haematuria. The fevers were genuine, and the blood cultures were carefully taken and processed by medical staff, so there is no chance he can contaminate the samples.

Eventually, after much interrogation, he revealed that he and his wife has quite unusual sexual practices. He would insert a knitting needle into the urethra of his erect penis prior intercourse. Somehow that introduced all sorts of organisms into his blood stream. What really surprised me was the different bugs were cultured during his stay in the hospital. How could he and his wife quite manage his deviant sexual behaviours inside the ward? Perhaps the fact he was put in an isolation ward under infectious disease gave them an opportunity.

How can one possibly get into UK medical school these days?

Had been approached by quite a few bright all As students who wanted to enter medical school. It has been so difficult lately for locals to get admitted to UK medical school. Many of them, having been top students in their school thought that they shouldn’t have any problem securing a place in medical school. How far can that be from the truth.

Getting 8 As in GCSE/O level and even 5 As in A level is no longer adequate for entry. String of top scorers are left utterly disappointed that they didn’t even get shortlisted. Those fortunate ones who did are mostly unsuccessful. Many angry parents complained via a local newspaper: it isn’t fair. Not sure why the public still like doing medicine so badly given that there has been recent shortage of training jobs and consultant jobs in UK.

I can understand the difficult Universities are in. There are so many students getting 8 As in GCSE and 3 As in A level. Some say it is because the standard for A levels have dropped. In my days, few students get 5 As in A level. This is no longer true nowadays. Even with the benefit of doubt that standards have been maintained, how are the poor Universities supposed to shortlist students for courses which are oversubscribed, when the number of applicants far outnumber the number of places?

Many underestimate how much they have to do to prepare. It is not enough to get good GCSE and AS results. They have to be the top in the UK Medical school aptitude test simply to get shortlisted. Many I suspect have not put in the amount of preparation required, as A Levels preparation is competing for their time.

After being shortlisted, the amount of work needed is phenomenal. 16-17 yo who have barely attended any medical lectures are faced with very demanding questions in the interview. Typical questions include what are the ethical issues behind the Liverpool Alderhey scandal; or the Bristol Heart surgeon enquiry, what hospitals should learn from it. Or questions about the workings of the kidney transplant service, or complications of long term immunusuppression. Or the pros and cons of using antiviral medication during a flu pandemic. Questions that no doubt even medical graduates have difficulty answering well.

The simple solution if one is that desperate to do medicine: is to apply as an overseas applicant. As long as you got the A level grades, and got loads of cash, it is rather straightforward. You see, overseas students pay premium student fees, and many UK universities are heavily reliant on their fees to maintain the department, the staff salaries etc, given the amount of central funding is inadequate.

Breath freshener overkill

Met a drug rep today who was trying to sell me an anticancer treatment for lung cancer. This first thing I noticed was an overwhelming smell of air freshener, as if he has emptied the entire content of the can into his oral cavity.

Poor soul, he was obviously trying very hard to mask that fact that he smokes. Afterall, trying to sell drugs to a lung oncologist and smoking like a chimney doesn’t go down well. Unfortunately it wasn’t working despite the probably near lethal dose of breath freshener in his system: I could still smell the cigarette breath.

All in the name

I wonder what it is like if your name is the same as that of a famous celebrity. There must be lots of incidents where the name is used as a joke or a means of humiliation.

I have treated quite a few patients with such names. I have treated Michael Jackson, Tom Jones, Kevin Costner, Joan Collins, Dean Martin, Paul O’Grady. and a few others.

No, I don’t make fun of their names, and treat them like everyone else

I am just very curious how they find living with such famous names but I feel it is too rude to ask them (obviously I’d be making conscious mention of that fact which is unprofessional given I am their consultant).
I wonder how many more celebrity names I will come across.

Just another rant at current medical school teaching

Unbeliveable. What a group of consultant colleagues said during lunch regarding the quality of training of junior doctors. Many universities are now using a problem based learning (PBL) approach Apparently studies suggest that it should  produce doctors who are more independent in their learning and thinking, putting them in the right path for the rest of their careers. There is much more emphasis on modules organised in systems (eg cardiovascular system; they are meant to study all about anatomy, physiology, pharmacology and pathology). 

Unfortunately the PBL system is far from thorough in its coverage, and it does require a lot of maturity and self discipline from medical studies to self study topics which are not necessarily discussed in the PBL tutorials.  

There was this consultant doing a ward round with a first year doctor. They were seeing a patient with liver failure. When asked about the signs of liver failure, the consultant got a “I don’t know”. Exasperated, the consultant tried to teach VERY BASIC symptoms and signs of liver failure. Then asked the houseman about causes of liver faillure. Got a shrug of the shoulders. 

The consultant couldn’t believe it anymore, and asked the doctor how is it possible that he doesn’t know something so common and basic.

The simple reply was “It wasn’t one of the clinical scenarios covered in the medical PBL course”. The consultant tore out his hair in disbelief.

Trained in the traditional medical system, even a lazy medical student would have at least seen 50 patients with alcholic liver failure in their first clinical year (3rd year in medical school). Nowadays, a graduate from medical school, after spending 5 years “studying medicine” cannot answer very basic questions about liver failure and its causes. And they claim that PBL produces doctors who are just as good, or possibly better. I remained unconvinced..

Will never manage any treatment

A 80 yo man was unfortunately diagnosed with lung cancer. Extremely anxious to begin with, made worse by the fact that his grandson has recently died from metastatic cancer.

He wasn’t able to tolerate lying down flat, he told me. Even for his diagnostic CT, he had to lie on his side. He and his wife said he will panic if he were to lie down.

Told him I will offer him radiotherapy, but when I described the treatment to him, he quickly dismissed it, saying there is no way he will manage lying down fro radiotherapy. He was already in panic whilst I was talking to him about treatment. His face became all red, his respiratory rate went up.

It was really difficult, but eventually I managed to convince him to simply give it a try; if he cannot manage it, we will not force him. I told him I have helped many anxious people through it. I prescribed him some lorazepam to take before coming for treatment.

Saw him last week for consent. Still very suspicious, anxious and doubtful. Certain that he will not manage. Eventually managed to get him planned without any major issue.

A week later, a very happy man. Couldn’t stop thanking me. Wife said he is a totally new person, so I’ve got the patient a totally happy wife as well.

Sounded like he has major anxiety disorder; probably should stay on some anxiolytic for the rest of his life.

The flirt

Unusual complain today. I have a young man with a curable cancer receiving chemotherapy on the ward. He is tall, well built and rather handsome. he has a wife and 2 kids to whom he is close to.

I received word from the ward staff that he is flirting excessively and intensively with them. I will be seeing him again this afternoon and has to speak to him about it.

Never had such complains before. I am sure he doesn’t mean to tempt the staff nurse to sleep with him (I certainly hope not! ).  Often men who are blessed with good stature and good looks are so used to getting what they want from girls they simply can’t get out of the habit of flirting, esp when the wife is not around to “monitor” him.  I hope that is all there is.. Well, I will find out.

Maturity for clinical contact

People here start medical school quite young. Many are 18 or 19 by the time they enter medical school. Most have little in terms of life experience, especially nowadays when parents tend to be overprotective and sheltering. 

Nowadays, many university has a new medical curriculum which puts medical students into clinical contact the very first year they come in. 

I had a medical student who told me last week that during her first year, she was placed into my specialist oncology hospital for training in general clinical skills. The examination and history taking part was OK. What she couldn’t take was seeing people suffer from cancer. It was her first clinical contact, and emotionally she was far from prepared to see people who may be dying from cancer. The whole experience left her in tears, severely shaken.

She is now in final years, and attached to oncology again (her choice for special study module). Thankfully the fact she choose oncology for her optional attachment suggests that she wasn’t scarred for life by her first clinical encounter. Somehow early introduction to clinical contact can be tricky when the students aren’t really mature enough emotionally to deal with it. There must be some way to prepare them beforehand.

What not to say

My 5 year old, after a trip to Stratford upon Avon was asked to share in front of the whole class. Proudly she told them she visited Anne Hathaway’s cottage.

The teacher was pleased until she said “..and I learnt that she had sex at the wrong time, that’s why she was pregnant when she married William Shakespeare…”

The teacher quickly said “Oh dear” and stopped her sharing. Opps, not appropriate for that age group.

Next, I hope I would not get a string of angry parents knowing on my door telling me off.

The funny fallout from swine flu

It’s early days yet. Some reported cases in Scotland. People down south is getting worried. Staff here in A&E are demanding face masks, although there is no reported case in my city.

One day the infection control nurse found a junior doctor whose scrub pockets are bulging to the brim. When asked what they are: it turned out to be pocketfuls of facemasks that he was trying to smuggle out of hospital for himself and his family. Embarrassingly has to be told to empty his pocket or face charges of theft.

Wonder how many doctors have already sneaked out lots of surgical masks unnoticed; well not until the theatre suddenly found that they are running out of masks…