WORK EXPERIENCE LONDON

Monday 12th August - Friday 16th August

Locations
St Bartholomew's Hospital Royal London Hospital Charter house square

Departments
Upper gastrointestinal Surgery ICU wards

Staff
Mr Bijendra Patel Jackson? Yassal? Lily? Flora Sadek?


Monday 12th August
My mother dropped me o at Chingford station (although that was a task that I could have done myself, by taking the 379 bus from the top of my road to the station), at 7:10am. It was a tight squeeze, as the train was about to depart at 7:13. Perhaps in the future, I will make some more time, and grab a metro newspaper while I had the time. I then took the greater Anglia train to Liverpool street and then to st Paul's using the london underground. Although it was my rst time trace,king alone in London, it was hardly as daunting as I had previously expected. After reaching st Paul's, I took the number 56 bud at the SQ bus stop. Upon stepping into the bus, the bus driver ensured that I wanted to go to St. Bartholomew's; perhaps the location was not as popular as others, and he didn't want to see someone go to the wrong destination. I was surprised at how long the bus took to get there. The guide that I had printed out from the Internet stated that it would take 9 minutes, however it only took 2, or else felt like 2 minutes. The bus was literally empty. As I entered St. Bartholomew's hospital, the court confused me- where should I go? Before the need to adventure around the hospital, a porter asked if I was lost. I had shown him my timetable, and said that I needed to go to the surgical outpatients clinic. The porter kindly took me to the waiting room, whereby I checked myself in with the receptionist, and she told me to take a seat and wait until 9am; it was the usual starting time. I asked the porter if st Bartholomew's was a large hospital. He replied that it was not exactly large, but spacious, with departments spread out all over the place. I waited in reception for an hour, watched sky news, and before I knew it, I was called into Dr Patel's oce with a fellow Chingford Foundation school student who had just arrived.

Dr Patel spoke to me and the student about our aspirations. We Both stated that we were interested in the medical eld, and in specically, the surgical eld. Dr Patel told us briey about the NHS, and if how we were to become doctors or surgeons, we would be public servants, paid by the taxpayer. Dr Patel then asked us a few questions such as do you have any family members in the medical eld?, and then told us how long it would take to train- it would take 15 years to become an established doctor from now. I then asked how long it would usually take to open a private practice. The dr then stated that it would take 25 years to do so. I was slightly surprised however, I was satised by the answer, that you have to become an established doctor, and sort out issues with insurance, and money. Dr Patel then stated that all operations would be cancelled this week, and that it was unfortunate for us. I asked why this was, and he replied that it was due to executive decisions that there was not enough money in the budget to carry out scheduled operations for the next two weeks. I was surprised, as the NHS is such a large service, but knew that something along the lines of this would happen, as a friend of mine had completed his work experience last week and told me of such issue. As expected, emergency operations are still taking place. Due to this news, our schedules had to be altered. Here is what the new schedule is:

Day Monday Tuesday Morning General surgery, surgical outpatient clinic. SBH Cancer meeting (upper Gi) Ground oor pathology building meeting, room 6 RLH Shadowing Shadowing Shadowing Afternoon Operating theatre ward RLH Surgical skills lab, Virtual reality surgery (VRS) at Charterhouse Training centre. <2pm Shadowing Shadowing Shadowing

Wednesday Thursday Friday

Dr Patel told us that the work experience was not the conventional formal strict type, but one where we could chose to come and go as we liked. I asked about the VRS, and Dr Patel gave directions to the area.. -Tube to Barbican Tube station: -St Paul's to liverpool street (Central) -Liverpool to Barbican (metropolitan) -Once at Barbican tube station -Turn left to exit, pass Natwest and Tesco -Turn left, pass salon, on the right walk through car park -Pass barrier enter building on right called, Joseph RotBlack Building. Dr Patel then told us what we would be doing at Charter-house square. He said that there were simulating machines for keyhole surgery, so that looks very interesting. I can't wait! He also stated that there would be general stitch-suturing on rubber pieces, which is also interesting, as I've briey dine it before. Dr Patel then told us that our usual days would start at 8am, and end varying on the day, but earliest was 3pm. After we talked about Charterhouse square, we waited to see patients who had booked appointments. While looking around Dr Patel's room, I saw a few interesting posters including how to wash your hands hygienically with soap and water. These crucial and vital skills will be needed throughout medicine

and I will begin to learn this hand washing technique as not only will it increase my general hygiene, it will also prepare me for my future career in medicine. On the topic of hygiene, Dr Patel told us that around the supercial surgical wards, we would have to roll up our sleeves beyond our elbows thus ensuring a better safety standard, and as a form of infection control. Dr Patel had shown us a list of patients, who he expected to see today. The number was averaging 30 a day. I was told that not all patients come to the appointments, as some forget or cannot attend for a serious reason, or simply abuse the free appointment system, even though it takes from 2 weeks to 2 months to create an appointment! (depending on severity of he case).

Patient 1
The rst patient had a twisted stomach, which Dr Patel said was quite uncommon, but not rare. The patient exhibited problems such as shortness of breath and a constant pain before and after meals. The patient had been referred to St bartholomews after meeting several other doctors, as the tests carried out on the patient concluded that a complex operation was needed to rectify the problem. More specically, the stomach had somehow slipped above the left side of the chest around the lung, thus explaining why the patient suered from shortness of breath. Dr Patel told the patient about the keyhole operations which would take place, and informed the patient of the risks: -lung infection -the lungs may still not be able to fully 'pump' air as the twisted stomach has pushed down on the lung for the patients whole life. Dr Patel stated more risks and then stated that the operation may take place in two parts: the actual operation, and a correction operation, however this was not certain, and only a possibility. The dr then stated that he would be put on a waiting list and should expect an operation in 2-3 months.

The patient then mentioned that his lip would sometimes go black. The dr reassured him that this was because of the lack of oxygen. The patient then asked if he should remain on the same medication that he was on for IBS, dr said yes.

Patient 2
An elderly woman, who was 74 years old came into the clinic, with a cyst under her right armpit. She had had the cyst for many years, and had an infection twice. The patient was not diabetic, but was on preventative medicine (aspirin), as she suered from a blockage in her artery. She had had a procedure done with local anesthetic. There was a risk of infection, and the patient was under the impression that she could get the cyst sorted today, there and then, although this was not possible due to not having adequate resources and bookings on that day. Dr Patel referred her to a minor surgery clinic whereby she could have her half day operation. The dr then answers any questions the patient may have, and then the patient leaves.

Patient 3
The patient had an ultrasound scan done, and had a suspected hernia, however, the CT scan had shown no hernia. The scan was done in Whitechapel, RHL, and the patients symptoms include pain while urinating and wind is a problem. The patient had complained that he had the problem for a long time and there seemed to be bulges in the patients lower stomach. The patient was due for a colonoscopy, and was referred to the urinology department. The patient then said that he sopped exercising due to the pain, and the dr stated that he should continue to do special exercises, which aren't abdominal, and this suggested physiotherapy. The dr then told the patient that he suspected muscle tear from everyday activities, and that the muscle could take months to repair and heal. The dr also stated that he thought there was nothing wrong with the patients internal organs, although the colonoscopy should verify this suspicion.


In the afternoon, we were kindly driven by Dr Patel to RHL, where we would be shadowing and meeting the junior surgical team. The doctors were talking about a patient who was in a severe condition after a night, and discussed a plan of action. After lunch, I followed Jackson, to the wards where I was allowed to talk to a patient, who had been through a huge ordeal throughout his life, and had been suering from bowel issues. It was more of an interview. A lot of medical terminology ew across the room, which I cannot remember, or even pretend to understand, but here goes: The patent had been suering iron rom bowel problems all his life, and had been admitted to three hospitals, one of which no longer exists. The patient had been in and out or hospital all his life, and has been in around 20 surgeries. The patient talked about how he has never really been able to live a normal life, as he has always had to visit the doctors every morning, before work. A few months ago the patient talked about how he had a major operation to actually remove the bowel, leaving a stoma- a hole. The problem was that the hole was not healing properly. The patient showed us his machine which used negative pressure wound therapy, to make the wound collapse inside itself, thus causing it to heal. The machine would remove any excess uid which was on the internal side of the patient. He talked about having a sort of special dressing which wouldn't work as properly. Overall, he was quite happy about the type of service he was getting at the hospital, when asked, he stated that the doctors always tried their best, and didn't neglect him, even when the operations went not as they expected. He then stated that the doctors and nurses would also care for the mental aspect and not just the physical aspect, and he found that was quite the upgrade from a few years ago, from his experience. I found out that in the wad, there were half a dozen night sta, and more on call, thus that seemed quite sucient.


Research: At the end of the day I was hold to research the following when I got home (how fun!) IBD- Inammatory Bowel Disease -Forms include Crohns disease and Ulcerative colitis -Chronic disease, abdominal pain, constipation/diarrhoea, tiredness -symptoms can come and go, surgery- removing inamed area -Medicine such as immunosuppressants -People diagnosed in their early 20s usually -Aects 1/350 people

Negative pressure wound therapy // C-di?

Tuesday 13th August

Today, I had to get up a few minutes earlier, due to having to see a cancer upper GI meeting, as seen on the timetable of yesterday. I look forward to sitting at the back and taking notes, however, I worry that that the two Hours allocated to the meeting will be too long and that to much medical terminology will fly across the room; I won't be able to understand.. But I shall try nonetheless... Today I will be going straight to RLH, and not too St Bartholomew's The meeting (at RLH) 8am I had some slight difficult of getting to the building, considering that it was not actually in the RLH, but it was in another building - the pharmacy/ meetings block. I seem to alway be lucky in finding someone who is going to the same department as me, as I would not have been able to gain access to the building, a woman walked me to the office and currently I am sitting in the meeting. The MDT meeting talks about issues with patients, to attempt to resolve and find a solution to the problem. The team looks at CT scan images, and is connected to a skype conference call. The team in room 6 (where I am) is given a shared screen to talk about the cancers. Each patient is described by age, any prior health conditions, and then the team is shown the cancerous growth, and if it is malignant or benign, and then the next plan of action, be it that the patient goes for more biopsies, or the plan of action: to wait, or to operate, or refer to another department. The type of care given is also discussed. The patients current health is discussed, and so is their wants- if they want an operation, or if they would rather be treated by alternative ways- eg palliative care. The patients notes are also looked at and the patients histories are also a contributing factor in the decisions made (of course). On the conference call, there are three rooms including ours seen, probably all around the hospital. All these Skype calls are encrypted, and on a secure connection, for patient confidentiality. Talked with Urology


Example 1 Went down from Size 18-12, anemic. She had a large ulcerated gastric nearplasm. Biopsies were taken, and a CT was done at the same time. Biopsies not ready. The CT was looked at and in particular, something showed up in the liver- a legion. The patient also had a tumor, she has had hypotension for many years, no cardiac issues. She is a 'young 78 year old', who is ready for surgery, to remove the tumor. However she said that she responded to the palliative chemotherapy very well. It was decided to do an EUS and MR scan. The tumor was invading the pancreas, and had many nodes. Although the team in Room 6 said that it was inoperable, a member stated that 'they wouldn't listen', so there is some disagreement between the rooms.

Shadowing surgical team (mid morning) After, we did the ward round with the surgical team, and I followed one of the team around to give a patient a stitch to re-secure a t-tube stitch. She out in local anesthetic via a syringe, and then cleaned the area around the wound so that the stitch would go in. She then asked the patient if the applied are felt numb, and when spathe patient said yes, the member stitched into the kin, and secured the tube by wrapping and knotting around the tube multiple times. At each stage, the member told the patient hat she was about to do, and thus is being totally open to the patient and what is happening. This was all one under aseptic conditions - sterile blue gloves,and hands were washed.

We walked around wards to specific patients with a senior consultant, and allowing us to discharge patients, and make plans for their departure. Any future medication was discussed for each patient, and the problem was reloaded at, and ensured that everything was to good, dischargeable standards, and that the patient would be safe. This has to be done with a consultant present. Appointments were also confirmed and when and where the patient would be seen again.

We arrived in charter house square, at 1pm and decided to play agame of monopoly for an hour until Dr Patel showed up, and opened the door, with two of his student researchers. They assembled the machines (shown below), and showed out a few tasks which we had to complete- stack sugar cubes, pick up and move objects along a grid. While myself and my peer were doing this, the students were showing their PowerPoint presentations, and allowed the consultants to present, and they gave positive feedback and constructive criticism. There were 5 students. Many machines were for the same use, however some machines were for different uses- training machines with computers, and a camera machine whereby you had to direct the camera down or up the patient. While using this machine you had to be extremely careful that you don't bump into the lining or damage the insides using the controllable, flexible camera.

We continued to use the machines, and in between we would learn how to suture and tie a surgeons knot. The suturing took plac om a piece of rubber, which looked like a piece of skin, as it had attempted to recreate the layering and densities of the skin. It was rubbery of texture, and the first layer was harder to penetrate with the needle. However, it became easier to slide through afterer the needle had penetrated the skin. We learned how to suture individual stitches, and we learned how to do one long suture. We also learned how to tie the end knots to secure the suture and this involved wrapping the nylon string across a surgical instrument and then looping it through the other end of the string. We also learned how to tie a surgeons knot with our hands and we repeated this multiple times until we had it right.. I must admit, I did struggle for a few seconds! I then had a go at the colonoscopy machine and was surprised at how easy I found it to use. I managed to complete the whole 'level' of feeding the tube through the plastic dummy, around each different bend without touching the walls once and completing objectives, such as popping balloons on the way. The trainer said that even he found that task hard and was surprised at how easy I completed it. On Friday afternoon, dr Patel stated that we would be a able to regain access to the room, to have another go. I would certainly take him up on his offer, although its the end of the week! I would spend more time on the colonoscopy machine.

For now, Dr Patel said his goodbyes, as he wouldn't be seen often, due to not having to do any operations, or having any clinical days booked from Wednesday to Friday. He told us to continue to shadow the Surgical team for the rest of the week, and recommended that we took half days. I might do this, as in the mornings, the surgical team does their ward rounds, however during the afternoons, as this is mainly admin work. However I know that I must spend as much the in the hospital as I can, as these opportunities do not come often!


Wednesday 14th August
Today, it was a slightly earlier start than usual. I arrived in the hospital at 7:45, and went to the usual ward where the surgical team was stationed- ward 13D. This involved taking the lift to oor 13. I then met a doctor from a few days ago, and I asked where Jackson was. She kindly oered to bleep for him, however I stated that I had called him , and he didn't answer. She stated that he would be in at 8. She kindly said that I could sit in the oce while I was waiting, and that I should then go to the room 3F, which is on the third oor. Perhaps today, I am in a tad too early, but hopefully today will be a good day. If I haven't stated, Jackson is the contact and a junior doctor, who has kindly left his number to all the placement students. I plan to leave slightly earlier today, and I hope to see as many ward rounds as possible..

At around 8:20, the ward rounds began, and we checked o a list of patients we had expected to see. We nished the main ward round at 10:30 and I have found it very interesting, as in the protocol of seeing patients, greeting them, and just a small chit chat. The surgical team were happy to answer any questions the patients may have had. One patient in particular, was very interested in how the operation took place, and the doctors explained it very simply but accurately and descriptively. The doctors explained how there were several keyholes made in the stomach, and followed the same protocol as what we did yesterday in Charter house square with the machines. Also, the doctor stated how the stomach would be bloated with a gas, which would give the surgeons more room to operate freely. It is extremely interesting, and benetted me greatly when they explained it in simple terms. The other ward rounds were quite general, and nothing much to record, so there may not be much today, also since it is a half day, due to being informed that there is a sort of sports day for all university members.


Thursday 15th August
Today, I had arrived at the hospital at the usual 7:40, however, Jackson and the team were nowhere to be seen, I wonder if I will even see them today! Perhaps they are currently doing the ward rounds, but I do hope that they are not. I have called Jackson twice, however it goes to voicemail both times, thus I will wait for a all back. At 7:40, I was in ward 3F, however I waited there until 8:15 without any familiar faces turning up. Perhaps they were all coming in to the hospital a bit later, as the team were planning to go out last night.. I then went to ward 13D, where Jackson is usually stationed. While attempting to access the wards, I had to be careful that I would not be locked out of any areas, since to access some areas you need a special card. Since I did not have these cards, but was faced with a locked door, a handy system where you would call the office area, where I explained that I was doing wok experience and awaiting Jackson and the surgical team, to gain access to the ward areas. It's 9:20, and the team is here! Time for the ward round.. We saw the usual number of patients in ward 13D, and told a patient that she was fit to leave in the afternoon after lunch, if she didn't vomit and felt comfortable with going home. The team also stated that she should take it easy at home and all of the general. With another patient, CT scans were observed, and then the patient was told that he had a huge, unusual 4.7cm gall stone. A doctor decided that it was best to attempt to remove the gall stone which was in the patients rectum, however, unfortunately we were asked to step out during the procedure. I am unsure wether it is successful or unsuccessful at this moment in time. Hopefully for the patient, it will be removed without an operation. The patient stated that he hasn't opened his bowels for over 10 days, and this is slight reason for concern.. It turns out that the operation is difficult to do when the patient was awake, thus the plan was to anesthetize the patient with general, however a senior had to be consulted and a meeting to take place to get more professional opinions, and more advice, and the go-ahead. Due to not much going on after the ward rounds, I decided to go home, after having some lunch. (the ward round was done, lots of admin work was due). I don't think that I will go so early tomorrow, but be there at around nine. Perhaps I won't even go, we will see..