Monday
This week, I spent the week in Cardiology at Musgrove Park Hospital, mainly in the Cath Lab, seeing a variety of diagnostic procedures and treatments. On Monday, I spent some time with a technician and a nurse looking at treadmills and ECGs, where a patient with suspected angina would walk (unless they lasted for a very long time!) on the treadmill, with speed and gradient of the treadmill increasing every 3 minutes. The test would finish if a variety of things happened, for example the patient asking to stop, or experiencing their symptoms, a large change in blood pressure or heart rate exceeding the maximum value that it should be. In order to look at the heart, a 12-lead ECG was going on at the same time, except that the ‘limb leads’ were placed on the shoulders and hips respectively, so that the patient wouldn’t fall over them. I was also shown what a normal ECG should look like, and had some of it explained to me. We also had one patient who came for a stress ECG but couldn’t do it, due to him being on crutches, so he had to have a stress echo instead. In the afternoon, I looked at Echoes and Complex Echoes. The first complex echo involved putting some dye into the blood in the heart to get a more detailed and clearer view of it, as the first (normal) echo that the patient had had done was not clear enough to draw any valid conclusions. Seeing a heart pumping on the ultrasound machine was fascinating, even if I wasn’t always sure which part of the heart I was looking at, although the consultant doing the echo was very good at trying to point out what was what. I then saw a normal echo on an inpatient in the Cardiology ward, which was particularly interesting as he was quite young, so the scan was much more clear and detailed, even though his heart was absolutely massive (and shouldn’t have been!). After that was finished, the technician doing the echo explained everything that she had been doing and further explained what I had seen on the ultrasound scan, and the likely reasons that this patient was getting chest pain. The last echo I saw was another complex echo - a stress echo, where they give the patient a drug that causes the heart to replicate what it would be doing during exercise, so speeds it up. Although the scan wasn’t very detailed, it was very interesting to see the heart pumping so fast when the patient was resting. Overall, it was a great day and I learnt an awful lot about cardiac diagnostic procedures. It was also very exciting to be wearing scrubs, as I felt a lot more professional and more a part of a team.
Tuesday
On Tuesday, I had another great day. In the morning, I was very excited to see pacemaker implants, as I enjoy watching surgery take place, as it’s not exactly the kind of thing you see everyday! I was very impressed by their infection control, which was unsurprising as they have recently won an award for it! After ensuring that we were all sterile, and that I wasn’t going to touch anything blue, the surgery started. The technician in the theatre, who was watching the patients 3-lead ECG to ensure that the patient wasn’t crashing, was very good in explaining to me what was going on, and showing me the different types of leads (in their boxes!) and the pacemaker itself. I learnt how the leads have 2 tines on the end to ensure that they stay in place, unless the person is particularly active, in which case there is an active ‘screw’ end on a different lead as it is more secure than the tines. It was also very interesting to see the ‘pocket’ made for the pacemaker, as I had always presumed that it went a lot closer to the heart, although retrospectively this would make the batteries a lot harder to change and would be a lot more dangerous. I was also told about using different numbers of leads depending on what the problem is, although using 2 is by far the most common. I was also surprised by the patients being awake through the procedure, with only a local anesthetic, although the procedure was not what I had expected, so it was slightly less surprising. In the afternoon, I spent some time in a pacemaker clinic, with most people coming for their check ups - after 1 month, 3 months after that and then every year. There was also a man who had developed severe bruising around the pacemaker which was getting worse, so he was scheduled for a repositioning of the pacemaker. It was fascinating to see the technicians work out the threshold energy needed to make the heart pump to determine the minimum voltage and time that the pacemaker needed to work for, in order to save battery life (as replacing a battery and thus the entire pacemaker requires surgery), although the standard voltage, unless the threshold is higher than it, is 2.5V. It was interesting to see them control the pacemaker and input details into the memory of the pacemaker using a magnet placed on the patient’s chest. I also enjoyed looking at the ECGs, and developed a better understanding for what each part meant and what a normal ECG should look like. It was another fascinating day, and I greatly expanded my knowledge of pacemakers - not that I knew much about them before! I also loved being in surgery and seeing and learning things that I would never have otherwise been able to do.
Wednesday
On Wednesday, I spent the morning looking at angiograms. It fascinated me to see the arteries around the heart shown on the X-Ray in the technician room I was sitting in, as I was too young to be in the room with the patient. It was also very interesting to see how the only way of controlling where the dye goes is through the seemingly rather uncontrollable catheter in the arteries, which seemed like an inefficient way of doing it, and it struck me how technology may have come a long way in medicine, but there is still a lot more than can be done to further improve procedures like these, for example better control over the catheter. The fact that you can only control it by pushing, pulling and turning the catheter (and the use of guide wires, which have their limits) later proved a problem when an attempt at angioplasty eventually proved too difficult to do, as the stent needed positioning after a sharp S-bend with many branches coming off, including one going straight on. The patient and the team attempting the procedure were very disappointed, but they knew that it was always going to be a long shot. Still, I found watching the angiograms very interesting and enjoyed learning more about the main arteries around the heart. In one of the angiograms, they also used a ‘pig-tail’ catheter to dye the blood within the heart to make it show up on the X-Ray, which looked amazing, and it was captivating to see the heart pumping using a different method than I had seen on Tuesday. It was unfortunate (for me, not the patients) that I didn’t get to see any angioplasty, as I would have loved to have seen some, however I did manage to, by coincidence, later that day, when a primary came in. It was remarkable to see how quickly the patient was prepped and bought in for a much needed angiogram after arriving in an ambulance, although the patient, as we later found out, had been having severe chest pain for over 12 hours, and really should have phoned someone sooner. Even so, a femoral catheter was put in and positioned to deposit the dye, and a normal angiogram took place. However, when we first found some narrowing, it was clear that this wasn’t the cause of the chest pain as it was not severe enough and, as it was a primary, they left it to be dealt with at a later date and kept looking for the source of the chest pain. Eventually, they found the source to be a massive narrowing of an artery, and quickly positioned 3 stents to deal with the problem. It was fascinating to see how quickly and efficiently they dealt with the problem, but equally as fascinating to see balloons being blown up in the arteries and the stents being used to keep the narrowing open. It was another great day where I really learnt a lot more about the arteries around the heart, and was really excited to see yet more that I wouldn’t have otherwise seen. It also showed me a lot about dealing with patients in critical care and how efficiency and keeping calm is of the utmost importancy.
Thursday
On Thursday, I arrived at the hospital with the knowledge that I was going to be looking at DCC, but without the knowledge of what it actually was. When I later found out that this mean that I would be looking at Electrical Cardioversion - defibrillation. Having often seen defibrillation on the TV in medical documentaries, but never having seen it in real life, I was very excited to finally be getting to see it. Before the cardioversion took place, I went round with a junior sister to talk to the patients who would be receiving the treatment to ensure that they were still alright to undergo this risky procedure, though luckily, they all were! I also watched as she placed canulas in their hands as this was where the general anesthetic would be delivered. We then started the cardioversion. With the exception of using electrode pads instead of paddles, it was remarkably similar to how I imagined it. Luckily, none of the patients flatlined, and all only required 1 shock using the smallest amount of energy to revert their heart back to the pattern it should be taking. This meant that the general risks of the procedure were greatly reduced. Apparently, whilst it is quite an exciting and fun procedure, it has about a 50% chance of lasting over 2 years, so a lot of people have to have it redone later in life. However, whilst it is a risky treatment, it has it’s merits, especially in not being invasive, making infection a lot less likely. In the afternoon, I spent time in a stent clinic, when people were having their 6 month check up, the only check up for stents, although patients are supposed to go to cardiac rehab 6 weeks after the angioplasty, where they can talk to nurses who can keep an eye on them. After the check up, if they are doing well then they are discharged from clinic and then only need to go to their GP to ensure that their blood pressure among other things, remains safe and to ensure that their symptoms are not returning and that they don’t gain any more. At the clinic, the nurse who does it has to assess any pain and breathlessness they are having now and, if they came in as a primary, what they were like just before their episode to assess any changes (hopefully improvements) that have occurred due to the angioplasty. They also are very keen that their patients stop smoking, as it is the one thing that can reblock the stent. Whilst one of the patients had not smoked at all since his primary, another was struggling more, so the clinic nurse advised him to try the NHS smoke free programme. It was interesting to see how 2 different people had tried the same thing with such different outcomes. Overall, it was an excellent and captivating day, and I particularly enjoyed seeing something move in my mind from TV documentaries to real life.
Friday
On Friday, I spent the morning doing a Ward Round in Fielding ward, one of the Cardiology Wards and then shadowing a CT1 and an F1. As the consultant had done a big ward round yesterday and spoken to all of his patients, he only spoke to those who were being discharged or who nurses or other doctors flagged up as being people that he needed to see. Whilst on the ward round, I learnt about Left Atrial Appendage Occlusion, using a Watchman device to block of the appendage so that any clots formed there would be trapped there and couldn’t be thrown up, which could cause a stroke amongst other things. It is a relatively new treatment, and it was interesting seeing how he explained it to the patient, showing the importance of clear communication. It was also nice to see that he ensured that the patient knew what was happening, rather than using complicated words that might confuse the patient. After the ward round, I followed the CT1 to the Coronary Care Unit, as the F1 who was supposed to be covering it was ill. Luckily, a consultant on the CCU was already part way through a ward round, so we then left back for Fielding Ward so that the CT1 and the F1 who wasn’t ill could do their respective ward rounds, as each had half the ward to look after. 2 of the patients we visited had a lot of fluid around their heart amongst other places, for example both, at some point, had so much fluid in their abdomen that they looked pregnant, and had heavily swollen legs. The F1 showed me how you could gently squeeze the leg using 2 fingers and how an imprint would be left. After they had seen all their patients, they both had discharge summaries to do, so I went back to the Cath Lab. After lunch, my timetable said that I was to have a personal feedback and review section, however, as this was not for school and I didn’t have to do a report on it, I was allowed to spend some more time in my place of fancy, although hardly anything was going on that afternoon. As a stress echo was going on, I planned on seeing that, however the woman running it wasn’t there, so I waited for her. However, in the corridor where I was waiting, 2 of the staff were filing all of the patients’ files, as they were moving from a numbered to an alphabetical system. Whilst waiting, I decided to help, as I thought that I might as well use my time for filing rather than theirs when they could later be performing tests, diagnosing people and helping to treat people. This required a surprising amount of concentration and it was only when we realised it was time for me to leave that I stopped. However, I did enjoy the feeling that I was helping, alongside the jokes of “What are you doing next week?”. Overall, I had a fantastic week where I learnt a great deal about cardiology as well as the work of medical technicians and what happens when patients are in a critical situation. I also found that I much prefered spending a week in one place rather than doing days in lots of places as you feel as if you are more of a part of a team, as if you can help more and you learn everything in a much greater detail. Strangely, I found that, whilst I greatly enjoyed learning everything about cardiology and watching the diagnostic procedures and treatments, the thing that I enjoyed the most was feeling like a part of the team, making me feel as if I had suddenly become a lot closer to the end in my journey to become a doctor.
