Real Medicine, Studying Medicine

Internal Week 1: Many many sick people

I don’t really know how to start this post. The past week on Internal has been interesting, but I am not sure I have an opinion about it. I’m not sure if I like or dislike it. It is busy, it is very educational and there are many sick people.

I haven’t been able to get IV-access from a single patient on this block. Apparently that is to be expected because they are so sick, but it does not do much for confidence. I am certainly not going to put in an intercostal drain if I can’t manage an IV. And nurses can do it with their eyes closed.

We have seen quite a few people coming in with ODs. Tile cleaner, alcohol, antihypertensives, insulin, anti-epileptics. We don’t get to sit in on the psych consults so I don’t know how many of them were para-suicidal.

I’m getting to read many ECGs. It is good practice. X-rays and CTs too. We have had lectures, but it seems that the real things is a much better teacher. We have seen some CTs with severe cerebellar atrophy, all but one due to alcohol misuse. That’s quite a common thing in the Western Cape, apparently.

A young patient taught me to trust my gut. She came in with decreased level of consciousness – GCS 8. When she was awake she was confused, resistant and agitated. She resisted tests for meningism so I didn’t know if she had neck stiffness or if she was just tensing her muscles voluntarily. A more senior student told me she didn’t think there was meningism. I was worried about meningitis, but because nobody else seemed worried and the patient didn’t actually have a bed yet, plus the doctor was busy with patients on ventilators, I assumed that I was being paranoid.

When I finally presented, the doctor concluded that there was meningism and he seemed extremely irritated with me. And with good reason – in the two hours between the patient’s admission and finding her an open bed, she could have died. If it was meningococcal we all could have been infected. I wanted to make excuses – and there are plenty good ones – but the only truth is that I should have trusted my gut.

Incidentally we think it probably is not meningitis, but renal encephalopathy. Again something I should have put together when I noted the little urine in the catheter bag and some proteinuria and haematuria. But I probably won’t know the diagnosis as we sent her back to the secondary hospital for a lumbar puncture – we need the beds for tertiary patients.

Brudzinski’s Sign of Meningitis, courtesy http://www.health.allrefer.com

But so we learn. I suppose that is why they don’t just let us loose. I have learnt more in the past week than in the whole of my second year, I think. Just not how to get IV-access in a shocked patient – yet.

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