Thursday, 27 November 2008

Going somewhere else

My course gives me a chance to venture into other clinical areas whilst on placement. They usually have to be connected and you need to justify why you'd want to do it. Thus: "Because this placement is boring," or "Because there's a staff nurse on there who's well fit" don't really cut it. In the same sense, it makes little sense to want to spend time in Orthopaedics if you're on a Cardiology placement, and so on.

My current placement, as previously detailed, is not the most exciting, in my opinion. As is prempting this, my mentors are somewhat pushing me out of the aeroplane to attend as many of these sidecar placements as possible. Problem is I don't really like them.

I turn up, introduce myself and firstly see if the people you're going to be watching and working with for the duration are much bothered. You find some to be gloriously friendly and helpful, some... not so much. Most of the time, I can pick up the vague impression I'm somewhat in the way of a day's work, really. One of the main reasons for my dislike. I prefer to be working, rather than standing around looking pretty.

Now, I hear you say - you can be observing! Yes, of course, and I do. But there's only so much you can learn from observing what happens to one or two patients. For example, I was observing echocardiograms today, which are very cool. I find them interesting, the technician was lovely and I understand the results of them more. But watching two can only do so much. Now, for example, if one of my patients was going down for one I would be happy to watch that single scan on it's own as part of the patient journey through the diagnostic pathways. But watching two scans of people I don't know from Adam? I don't find it particularly useful in itself. I do like EEGs, though. It's the same concept as doing that scan on a baby, but more interesting. You get to see the heart in all it's glory, the movements it's making and the rate it's moving at. A skilled technician then takes live feeds from different angles, recording them on a handy computer. The size of the chambers is looked at, as well as how much they're inflating and deflating. More importantly, one can observe all four valves, to see if they're leaking (regurgitation) or any other defects. Not only can one observe the heart in greyscale, it is also possible to bring in some colour. Specifically, it allows a technician to observe force moving away from the probe (usually in red) and towards the probe (usually blue) and anything in between. This is important to check if any blood is moving the wrong way, i.e. back through a valve. This is a bit naughty. There's also this awesome effect when you catch a decent glimpse of the Aortic Arch with both colours going in and out of each other. Fun. I like echocardiograms, then, yes. They're non-invasive, and a bit sci-fi. Only the former point is relevant to most patients, I'm sure.

I also witnessed a modified stress test, without the exercise component. Instead, the technicians administer a drug intravenously which makes the heart put a little more elbow grease in than normal, pumping effectively harder. This chemical is used in patients for whom even a gentle walk on the treadmill would be too much. The old and the very ill, in other words. The middle ground between these two absolutes (a full on exercise test and the chemical) is a more sedate time on the treadmill. The scores received are they modified, I believe, by another handy computer. The chemical test is pretty simple. A patient just lies there as it works it's magic. Reassurance is obviously key, as the chemical can cause an increase in temperature and - since it's a potent vasodilator - can lead to a drop in blood pressure, as well as the associated symptoms - dizziness, nausea and the like. The patient I witnessed was fine for the duration of the test, sat up well and just felt 'a bit funny'. Before sitting up, however, they are injected with a radioactive dye. The patient is then given a lovely meal involving milk and a (preferably fatty) sandwich. The Nuclear Medicine Department is not emulating the witch out of Hansel and Gretel, oh no. Instead, the idea is to activate the Liver and Gall Bladder, get them moving and, by proxy, move any radioactive dye that may have accumulated in either outwards. That way, there is more chance to recieve a better picture of the myocardium when the patient is being sent up for a Gamma Camera test.

The Gamma Camera test is pretty dull, from a patient perspective. It basically involves lying there are two cameras cycle around you, in jerky movements, to take a decent set of pictures of the heart. 20-20 style, although the cameras are arranged at angles of 72, 90 or 180 degrees to each other. So hardly like a human head. The gent in charge was nice enough to talk me through what the scans mean, so I can write it down here before I forget. The GCT is useful for a few reasons. The most important one is thus: Two sets of images are taken on two different ocassions. One after a stress test, so the pictures are of a heart working hard, and the other when the heart is at rest. This is the clever bit. If both pictures show nice swathes of white and red, therefore lots of perfusion of blood to the heart muscle, it's all good. If there are 'holes' in the stress test when compared to the rest test, then it is a strong indication of ischemia. That is to say, the heart is struggling to pump blood to itself when under increased exertion. If both rest and stress pictures are holey, this implies (but does not confirm) an infarct has taken place and most, if not all, of the non-perfusing tissue is dead.*

These are the tests I witnessed. I will now be able to speak of them to patients in a much more informed manner, which is a good thing, but I can't help feel a bit at a loss when it comes to time spent. I left before the afternoon began, as I didn't think there was much more to see. I, instead, will read about the above to increase my knowledge on the subjects. Additionally, I can't help looking forward to my next placement back on an actual ward, doing what I consider more valuable work.

* A different nuclear method, a Thallium test, can later give an idea how much of this tissue is fully dead, and how much of it is in hibernation.

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