After getting in touch with Dr Damian Jenkinson, he agreed to let me observe an outpatients clinic he was doing last week. The clinic was following up a number of variety different ambulant patients who had seen Damien recently. It was the first time I’d been allowed to observe real consultations with patients so I was excited about seeing what life is like behind the doctor’s chair from patient to patient. We began by re-examining the patient history together going through the history of the differential diagnosis, diagnosis and treatment as well as letters sent between doctors for the patient, and discussed what had been going on. The problems varied from a suspected TGA – an electrical storm in the limbic system of the brain, to continuous treatment of a patient with atrial fibrillation who was taking a new anti-coagulant drug called ‘dabigatron’ which is beginning to rival the renowned ‘wharfarin’; despite being significantly more expensive it offered a much higher prevention of clotting cascades to the brain, the cause of ischemic stroke. We discussed the pros and cons of the use of the new drug, and Damian explained how new drugs were pioneered and approved by NICE, who weigh up the cost of the drug against the savings made to care services as well as years added to quality of life. Another patient had been diagnosed with prodrome migraines (without the classic migraine ‘headache’). Prodrome symptoms include a tingling feeling and flashing lights in the visual field. Beta blockers can be used to treat migraines (they work by blocking the transmission of certain nerve impulses). Next Damian explained the basic anatomy of the blood supply to the brain through the ‘circle of Willis’ consisting of carotid arteries vertebral arteries and basilar arteries. The next patient had suspected episodes of atrial fibrillation but also had a platelet dysfunction thus making it difficult to prescribe anticoagulants. Hence the patient was referred for a tape, which records heart activity for a certain period of time which can then be analysed by doctors on a computer. I was then allowed to witness an ECG scan of the patient and Damian explained how the ECG scan was first devised by Eindleven who placed cattle’s legs into four troughs and recorded microscopic electrical changes between the four legs and measuring heart activity from this!
After this I was asked if I would like to go and visit the stroke unit at Bournemouth Hospital! I leapt at the opportunity and so found myself at the hospital getting some ward experience! During the afternoon I observed the writing of a death certificate, ward rounds with patients, diagnosis of a new stroke patient, and minor stroke patient and also intensive care. The doctors on the unit were really enthusiastic about imparting their knowledge about stroke care to me and as a result I learnt absolutely loads! There are two types of stroke: ischemic and haemorrhage. Ischemic strokes account for 90% of strokes and are caused by a blood clot in the brain, which results in a lack of oxygen in a particular area of the brain (they also cause Transient Ischemic Strokes – mini strokes in which the brain is only without oxygen for a few minutes before the clot is broken up). This causes dysphasia and lack of muscle control across one side of the body. This is often caused by atrial fibrillation because it can result in large amount of blood moving up into the brain at once, and is more likely to clot. Patients who have atrial fibrillation are usually prescribed with Wharfarin, to prevent the possibility of a stroke, a drug which thins the blood and so reduces the likelihood of clotting. High cholesterol can also contribute towards strokes – as plaque builds up in the carotid artery, clots begin to form around it which can lodge in the brain causing the stroke. After a stroke thrombolytic drugs known as ‘clot busters’ can be used if deemed necessary to break up the clot and allow oxygen to return to the particular area of the brain (as examined in the ‘Telemedicine’ post). Wharfarin is not given to the patient after the stroke until two weeks have passed to quell the possibility of causing a haemorrhage stroke, although sometimes patients can refuse Wharfarin because of the constant blood checks that have to be made, and so can put themselves at risk of having another, potentially more serious stroke. Haemorrhage strokes are less common – these are caused by a bleed in the brain and tend to be more serious to repress. They are often caused by aneurisms, where arteries expand due to lack of support and can ultimately break. These can be stopped by inserting a coil around the blood vessel to prevent expansion – like the opposite of a stent. In some cases of haemorrhage strokes can cause the brain to expand (much like another area of the body may swell as a result of a trauma to the area) to a level where a part of the skull has to be removed. The part of the skull can either be replaced by a metal plate, or stored in the abdomen where the surrounding tissue will keep it alive until the brain has shrunk enough for the skull to be reconstructed.
On the ward, I was shown a number of different issues which face patients as they begin their regeneration after a stroke. Deep vein thrombosis is possible for patients who do not move around enough, as clots can form inside veins in the body, which can cause further complications to the regeneration process. Pulmonary embolism, where a blood vessel supplying blood to the lung is clogged by a clot, is extremely serious and can result in death; hence drugs to prevent this are regularly administered. After a stroke swallowing can be extremely difficult for patients (dysphagia) who are then vulnerable to dehydration and under nutrition. There is also a risk that food and fluid may go down the wrong way, getting into the windpipe (trachea) and so into the lungs. This is called silent aspiration. This can cause infection and, in serious cases, can lead to a chest infection or to pneumonia. Patients are often fed through a drip in the nose (sometimes more stubborn patients can remove these so occasionally mittens are administered to prevent this). Sometimes, patients are fed through a ‘peg’ which feeds food directly into the stomach. Other issues such as constipation can cause problems for doctors trying to treat their patients and sometimes canellas are inserted if the patient is constipated to the point where they cannot urinate. Occasionally patients come in who had actually not had a stroke, but have imagined it or made it up. These patients are sometimes referred to psychiatric help if needs be, and feigning a stroke can sometimes be a cry for help from a patient. The doctors showed me their forming drugs forms for patients and analysing test results for different levels of chemicals and minerals in the body. Finally, during the day, Dr Jenkinson compiled the structure for the cardiovascular health reform announced by Andrew Lansley last year!
The day gave me such a brilliant insight into life as a doctor, not only in terms of diagnosing patients, but also the jobs and issues facing doctors during a normal day. It also tapped into my increasing interest in neurology and neuroscience. I recently watched a programme called ‘Phantoms in the Mind’ after hearing about the studies of Dr Ramachandran, which I will be writing about soon!