Monday, 24 December 2007
Thursday, 20 December 2007
It was the twilight. In that moment I realised that I hadn’t actually seen any daylight at all since Sunday afternoon. I wake up in the darkness and it’s still dark by the time I get to work. I spend the day in the operating theatre where there are no windows and by the time I’ve woken up the last patient of the day, it’s dark again, so I don’t get to see the sun he I go to see my post-op patients on the ward.
I’ve become a creature of the night and I don’t really like it. Is it too early to start looking forward to summer?
Tuesday, 18 December 2007
Unsurprisingly, straight out of the gate was the state of the on-call rota. Basically, there aren’t enough junior doctors to fully staff the rota. This means that we are constantly being asked by medical staffing to do extra shifts. The consultants frequently have to carry the on-call and cardiac arrest bleeps and the hospital trust is having to fork out huge sums of cash to pay for locums (it costs the hospital £3185 to pay for a locum anaesthetic registrar to cover a week of night shifts). The problem is going to be even worse in the new year, when a couple of the more senior SHOs leave to take up registrar position elsewhere in the country.
In the meeting someone asked if there were any plans to employ more juniors and the reply I got was something like this.
“We’re trying. We’ve had a couple of adverts out for a while now, but we only had one applicant and that person pulled out of the interview last week.”
I was flabbergasted. When I applied my job as a Medical SHO, human resources told me they received nearly 900 applications for 2 positions. Now, a couple of years later, they can’t even attract a single applicant? It begs the question – where have all the junior doctors gone?
The answer is obvious isn’t? It’s another legacy of MMC and the MTAS fiasco.
On the face of it, you’d have thought that a shortage of junior doctors was never going to be a problem. In January of this year, there were 33 000 doctors simultaneously applying for only 21 000 jobs and we junior doctors were fretting about unemployment - indeed I came within nine days of the dole queue.
It seems that what’s actually happened is that the suits at the Department of Health and the MMC have seriously overestimated how much shit junior doctors are willing to put up with.
What is now becoming apparent is that thousands of us have “Just Said No.” This has led to a mass exodus of junior doctors from the NHS. I personally know of 13 doctors of a similar experience level to myself that have left the NHS this year. Multiply that across the nation and you’re talking of a huge number of doctors who were simply unwilling to be treated in such an unfair and callous way. I think Dr Rant hit the nail on the head with this post.
The funny thing is, not one of my friends who have left the NHS regrets their decision. Whether they’ve gone to work abroad, or just given up being a doctor completely to do something else, it seems that they’ve found working conditions far better outside the NHS and, as things stand, none of them have any intention of coming back.
Saturday, 8 December 2007
I turned to Jim and said, “Do you not find that the ward sisters (senior nurses) are generally much more helpful that the staff nurses (junior nurses)?”
“Yeah, I think there’s something in that. I think that the senior nurses see more easily that you’re trying to sort stuff out for the patients. If you’re being polite and ask reasonable stuff, then they do their best to try and help you out. I think that the more junior nurses have a tendency to lump all doctors together. If they’ve had a bad experience in the past, they get the “all doctors are arseholes” syndrome and it’s really difficult to get them to do anything at all.”
Tuesday, 4 December 2007
Unsurprisingly, this all took its toll on my fingertips and over the past few years I have developed impressive calluses on the first three digits of my right hand.
In contrast, in anaesthetics, I spend much more of my time doing hands-on stuff with my patients and much less of my time on paperwork. As a result, four months after leaving General Medicine, my calluses are slowly shrinking.
Monday, 3 December 2007
I think whenever you decide to change an aspect of your life, you always wonder whether or not the decision is the right one. It’s now been several months since I made the switch and, looking back, I have no regrets.
Here’s the first of the reasons why I don’t miss general medicine.
The ward-round octopus
Ward round days were when the consultant in charge of the overall care of the patients on the ward would go round and see each patient, catch up with what we juniors have been doing and make decisions about their future care.
As a junior, it was my job to know what was going on, and to have all the relevant information to hand that allows decisions to be made. It was also my job to document conversations between the consultant and the patient in the medical notes and write down what the management plan is.
On a practical level, this was often a bit of a headache, especially because I was often the only junior on the ward round. It meant that I had to find the patient’s observation chart and make a note of their most recent blood pressure etc…, get the blood results folder (that I had previously prepared) and open it at the right page to see their most recent lab results, get the patient’s medical notes and find where to write the day’s entry (often not as easy as it sounds), all the while I’d be listening to the conversation between the patient and the consultant and writing down the relevant points as legibly as possible, whilst being ready to interject with any relevant scan/histology results and I’d also be trying to write down any tasks that needed doing over the next day or so… and I’d have to do this ALL AT THE SAME TIME.
Seriously, even with judicious use of all available flat surfaces (the notes trolley/bedside cabinet/patient’s bed/patient’s footstool), I felt like I needed an extra couple of limbs just so I could relay all the available information and write everything down so things didn’t get forgotten about.
This process would have to be repeated for every patient on the ward so I had to be quick with my octopus arms because after deciding on his plan, the consultant would move onto the next patient whether I was ready or not.
Sunday, 2 December 2007
This is followed by freshly baked apple & blueberry pie serves with lashings of double cream…
Eating this whilst all snug and warm while the rain beats down and the wind howls outside my windows, I realise…
I love winter food.
Tuesday, 27 November 2007
It’s around 03:30 and it’s time to go home. Me and my mates are in the taxi queue and it’s bloody freezing. All of us who are waiting are shivering, jumping up and down or huddling with friends to try and keep warm. The usual late-night banter is going on there’s the usual last-gasp efforts to try and pull and take someone home that evening.
Behind me in the queue is a rather attractive tall, young lady with her friend and behind them are a group of three guys. One of the men suddenly says to the tall girl.
“Oh my God! Look at your foot!”
The young lady has a small cut on the top of her foot that has bled. She’s wearing strappy high-heels so you can clearly see rivulets of dried blood across the top and down the sides of her right foot. The lady herself is pretty oblivious to it, like the rest of us, she’s more concerned with keeping the hypothermia at bay.
“You’re BLEEDING!” he continues.
She looks at him impassively, “Yeah, I know”
“You should go to hospital!” the man urges
A little alarm bell goes of in my head and I decide to cut in. “No, she doesn’t,” I say.
The man fixes me with a look. “Yes she does! Look at her foot, man.” He looks at her foot again, eyes nearly bulging out of their sockets. “You should go o A&E, you might bleed to death!”
“Look,” I say. “You don’t need to go to A&E, you just need to go home, wash your foot and put a plaster on it.”
I think that a little common sense can often go a long way.
Friday, 23 November 2007
"If you are a junior doctor, you now belong to the only profession in the developed world where you can be REQUIRED by contract to work a basic 91 hours in a week 'on-call'. When you work nights over Christmas and New Years you will be the lowest paid person in the whole hospital per hour (roughly minimum wage).
This group is for everyone who has been on call, on ward cover, or carrying a bleep of any kind. At medical school you longed for the day when you could carry one, and be a REAL doctor, didn't you?! Now you think of a few places you would like to shove the irritating, noisy, crappy bleeping thing...
We all love nurses, because they do the jobs we hate, and look out for us when we are just learning. They also gave the correct dose of drugs when you accidentally wrote milligrams instead of micrograms on your first day. We need them. But...
...there are a few points of etiquette that are unwritten, unspoken, but you just wish every nurse read, understood and inwardly digested:
1. Bleeping is not a spinal reflex. Please take a few seconds to breathe, think and organise your thoughts, and stop flapping about. Half the time you may realise you didn't even need to pick up the phone.
2. Mention what ward you are on. I don't have the whole hospital directory of numbers memorised. This is called the 'bingo-bleep'.
3. If you bleep someone, please wait by the phone. How can there be no-one picking up the phone at your end when I ring back?! This is called the 'bleep-and-run' and is exceptionally irritating.
4. Have the notes, obs chart and drug chart in front of you. Chances are I need to know what the obs were without waiting for you to run over to the bed and look, then run back over to the trolley to get the notes when I ask the next question. This is called the 'relay-bleep' and is probably not fun for you.
5. Please mention the name, age, and working diagnosis of the patient. The following is not acceptable: "Hello doctor, please see patient in 4, 6, she has chest pain". That is 'bleep-spam'
6. All patients with chest pain need an ECG. Don't bleep me until one is being done or there in front of you.
7. If I'm in theatre (surgery), leave a clear message. The following is not acceptable: "Can you come to the ward afterwards, there are a few things to do". This also counts as 'bleep-spam'
8. Once in a while I will not respond to my bleep. This is because I am jumping on top of someone's chest trying to save their life. I am NOT 'on break'. Doctors don't have these.
9. Please check with the other nurses that you aren't asking the same question as them. I really hate being bleeped from the same ward from two phones and two nurses for same patient. This is called the 'déjà-bleep' and is distinctly un-fun
10. You spend twenty times as much time with each patient than we do. We appreciate your opinion and pertinent information. The following is not acceptable: "Well you're the doctor, you should know". Well actually I'm on call and have never met this patient who has spent 5 weeks with you.
11. Please be cheery on the phone and perhaps even flirt a little. I've just spent 12 hours running around the hospital doing mundane tasks, talking to angry relatives, putting my finger up bums, taking blood and ordering xrays. You will get your way far easier by making me smile.
12. When I answer the bleep please don't say 'Oops, sorry I had a question but not any more". This is called the 'fart-bleep' and gets on my nerves (See also point 1).
13. Please don't ask me to see virtually every patient on your ward. That's called a ward round.
14. If you do cannulae on the ward regularly you will be my favourite nurse and I will do anything you say.
15. If I answer my bleep and the line is engaged because you are bleeping me from that phone again, I may well explode. This is called the 'torpedo-bleep' because of its incessant battle with my morale. Three hits and the boat may sink.
16. If a patient has died, he/she no longer cares how long it takes me to get to the ward. That's a medical fact. Chances are I can do a few other jobs on my way there. If you bleep me again for this patient it better be because they have miraculously come back to life. This is called the 'Lazarus-bleep'
17. The 'MEWS / EWS / EWSS / PARS' score is a trigger for you to call me and is useless after that. I don't give a crap what the score is. Tell me WHY the patient has scored it (e.g. respiratory rate? BP? heart rate?).
18. Please don't start a sentence "Just to let you know..." or "Just so you know..." I hear this 50 times per shift. This is called the 'zombie-bleep' and you have just inadvertently disengaged my brain.
19. Please don't make the person who picks up the phone have find to you from the other end of the ward. This is called the 'bleep-and-hide' (See also point 3).
20. Don't have someone else (e.g. a student) bleep for you. It's cruel to them, and they are not your secretary. This is called the 'kamikaze-bleep' (see also points 4, 5 and 19)
21. Dosing a patient's warfarin (whom you have never met and don't know their history) at 4am is horrible, tedious, legally dubious and just plain bad for the patient. Please slap the day team round their faces when they arrive the next morning and don't let it happen again.
22. Sit down! You may be surprised with how much this helps points 1, 2, 3, 4, 5, 9, 11, and 19
23a. If you happen to have a spare moment, eavesdrop when a doctor bleeps another doctor. The majority of the time you will see how it should be done.
23b. Sometimes point 23a doesn't work because the doctor is a week old and still learning the 'etiquette'. He/she will learn very quickly as their senior on the other end shouts them down!
24. When a patient is in an ACUTE confusional state, please do not repeatedly ask me for, or demand sedation. This is not the year 1912. I might give sedation AFTER ruling out an infection, over-medication, drug withdrawal, metabolic cause, trauma, neurological, hypoxic, endocrine, and vascular causes, and AFTER using every other method of calming down the patient.
25. Read the latest entry/entries in the medical notes. Your question may be answered already (see also points 1, 4, 12, 13)"
Thursday, 22 November 2007
“What’s the matter with you?”
“Huh?” I reply, bleary eyed and only just coming back to consciousness. The time is about 4am and I’m a second year medical student. I’m in the bed on my girlfriend at the time, but I can tell that she’s really pissed off and (not for the first time) I have no idea why.
“All you do is fidget, fidget, fidget all night bloody long! You keep kicking me and nicking all the fucking duvet! I never get a decent night’s sleep when you’re here. Why can’t you just KEEP STILL?!?”
Though I was only semi-conscious, I’d learned not to mess around when she used that tone of voice and I considered myself told off.
I was with my consultant in the anaesthetic room today, and we’d successfully put our patient, Mr Elwood, to sleep. She turns to me and says “Have you seen any femoral nerve blocks being done?”
“Yes,” I reply “but I’ve never done one myself.”
“Well, now’s your chance. Tell me, how would you go about doing it?”
“I’d get a nerve stimulator and an insulated needle, then I’d draw up 30ml of 0.25% Bupivicaine and flush the needle through. I’d sterilise the area and I’d feel for the femoral artery. I’m go 2cm lateral and 2cm caudal to the pulse and push the needle through the skin. I’m looking for twitching of the quadriceps at the patella and if the twitches are present between 0.3 and 0.7 mA, then I’m in the right spot and can inject the local anaesthetic.”
“Very good, go for it then.”
I’ve got the needle in the top of my patient’s leg but I’m getting twitching of the adductor muscles, not the quadriceps. I angle the needle to the right a little and his kneecap starts twitching.
The consultant turns the amplitude down to 0.3 and the twitches cease.
“That’s perfect,” she says. “You know the tip of the needle is in exactly the right spot. Now, all you have to do is KEEP STILL while I inject the Marcain.”
I take a breath out and hold it. I manage to keep myself, my hands and the needle perfectly still while the consultant inject the anaesthetic.
Three hours later, on the orthopaedic ward:
“Hello there, Mr Elwood.”
“Oh, hello doctor.”
“How are you feeling?”
“Not too bad, I’m a bit tired like, but I’m alright really.”
“Do you have any pain?”
“No, not really”
“How’s the knee feeling?”
“It’s fine, it feels a bit numb, like you said it would, but it’s not sore or anything”
(This means my femoral nerve block is working perfectly.)
“Fantastic, well I’ll leave you alone to have a rest. I reckon you’ll need it because the physios will be after you tomorrow. I wish you all the best, sir.”
“Thank you very much doctor.”
And I went home feeling very happy. I wonder if my mother and my ex-girlfriend would be proud of me if I told them how I’d finally learned to KEEP STILL…
Monday, 19 November 2007
I drive to work every day. I do what’s known as a “reverse commute” in that I live in the city but travel to work in one of the surrounding towns where the hospital is. This means that I miss the bulk of the rush-hour traffic because I’m travelling in the opposite direction, but, despite this, driving to work, is still a slow process that tests my patience on a twice-daily basis.
Environmetal groups seem to have the media in their pocket these days. You can’t open a newspaper or turn on the T.V. without being lambasted for putting your keys in the ignition. Our prime minister was at it yet again today. This ongoing guilt-tripping, coupled with the forever rising cost of petrol, made me decide to attempt to get to work without the car today and it was actually quite an interesting experience.
To be fair, for me, my car is a choice, not a necessity. I have a train station literally at the end and trains that take me the 15 miles to New Town run every 10 minutes at peak times. At the other end, the buses that go to the hospital are every 10 minutes as well. I don’t even need to look at the timetable!
So here’s my thoughts on going green and ditching the car for a day:
The first thing to note is that the door-to-door journey time is 15-20 minutes longer if I go by train. This may not seem a lot initially, but it’s the difference between leaving my house at 07:00 and 07:15. I’m not a morning person at the best of times and losing that quarter of an hour first thing puts bed and breakfast in direct conflict with each other.
Result: Car Wins
The council here do a quite nifty thing where you can by a regional travelcard that lets you travel around all day. This has the dual benefit of both being cheaper and not having to faff around trying to find loose change to give the bus driver at the other end. The travelcard cost me £4.50, which is about 50p more than the petrol costs of driving to work and back. I suppose, if I were to give up my car completely, the train would be relatively a lot cheaper because I’d save an awful lot of money on road tax, insurance and maintenance: but I’m not going to give up my little car just yet.
I don’t know if any of you listen to radio first thing in the morning. If you do, you’ll agree that it’s shit. If I try tuning into Radio 1, my journey will consist of listening to Chris bloody Moyles laughing at the same unfunny joke for 40 minutes until I turn it off again. The CDs in my changer get boring after a while, so I’m spending more and more journeys in silence. On the train, the story is different. My mp3 player holds literally thousands of songs, so I can listen to whatever the hell I like. It’s much more enjoyable. It’s also got a radio on it, so in the unlikely event of me missing Moyley’s dulcet northern tones, I can tune in if I want to.
Result: Train wins
I suppose this is obvious but it’s worth stating that taking the train means I DON’T HAVE TO DRIVE. I’m not one of these people who finds driving for the sake of driving an enjoyable or worthwhile thing to do. Driving in the rush hour(s) is fun for nobody. Catching the train meant that I didn’t have to worry about being cut up by angry businessmen or being tailgated by some tool in a white Ford Transit or literally being crushed to death because someone driving an articulated lorry didn’t see me or missing my junction because someone won’t let me change lanes or being involved in one of the accidents I see on the motorway every three or four days… I could go on. The effect was that I arrived at work much more relaxed and in a better frame of mind to start the day.
Result: Train wins
Taking the train means that I have to do more walking: from my house to the train station, from the train stop to the bus stop, from the bus stop to the hospital. The longest of these walks is only about 100m or so and I actually think they are a good thing. I tend to go from my house to my car to work to my car to my house and never really venture outside. At this time of the year, it’s dark when I leave home and dark when I return and if I’m not careful I end up just sort of becoming a creature that never sees the daylight or the outside. And that can’t be a good thing. Admittedly, when it’s freezing and raining like this morning, it’s not much fun. I’m not sure if I really want to start every day with a face-to-face confrontation with the British weather.
Not having to drive means that I can read. I really enjoy reading and feel I don’t do it as often as I would like. As I’m still very new to anaesthetics, I’m having to do a lot of studying at the moment. Using public transport means I can study on the train, it effectively gives me an extra hour every day to read up on stuff – if you were on the train at 07:30 today sitting next to a guy reading about isoflurane – that was me! If I’m not is a studying mood, I can just read a novel or newspaper instead. I think if I use the train everyday, I’ll end up being cleverer and more knowledgeable.
Result: Train wins
As I said before, I do the “reverse commute.” This means that I had no problem at all getting a seat on the train or the bus today. The times I travel avoid annoying schoolchildren and it’s far too early for the chavs to be out of bed, so the journey was actually very pleasant.
All in all, I was pleasantly surprised by my public transport experience. I feel that if I take the train every day, my life will be “richer” in terms of mood, stress and learning. On the other hand, the extra 15 mins in bed that the car gives me is really important to a late-riser like me.
Overall though, I had such a good experience today that I’m definitely a convert to public transport. I can see myself going by train almost every day except supermarket shopping day.
I think anyone reading this should consider making the switch too.
Tuesday, 13 November 2007
Remember, we can’t see what you are doing from where we are and a little warning about things makes our job so much easier.
Monday, 12 November 2007
One of the side-effects of the anaesthetic our patients is that they can rapidly drop the patient’s blood pressure. (For the medics among you, they cause a decrease in myocardial contractility whilst simultaneously causing profound vasodilation). This means that we always check the blood pressure and make sure it is stable before we allow the surgeons to start operating.
I press the button to start the blood pressure check, but the screen just reads:
Error: Cuff Leak.
The blood pressure cuff isn’t working and our ODP goes off to get a new one. The consultant turns to me and says, “What are you going to do now?” Referring to the fact that the machine was unable to ascertain if the patient’s blood pressure had fallen to dabgerously low levels.
“I’ll feel his pulse,” I say
“The carotid” I feel the man’s carotid pulse. “He’s got one.”
“And this tells you the blood pressure is at least how much?”
“I don’t really know the exact figures”
“60 systolic. What are you going to do next?”
“Feel his radial pulse.”
“Good. Does he have one?”
“Yes, but it’s not very strong”
“If he’s got a radial, how high do you think his blood pressure is?
“Yes, that’s right. You said it’s not very strong, so this man’s blood pressure will be just over 80 systolic.”
Our ODP has now returned with a new blood pressure cuff and we get a reading from the machine:
Blood pressure: 84/51
I was super-impressed.
Sunday, 11 November 2007
This wasn’t the first time I’ve ever been propositioned, but what really took be aback this time was that it seemed to come totally out of the blue. I was standing in a circle of a dozen or so nurses who had now stopped their conversations and were all looking at me…
Let me rewind a bit and tell you about how I managed to end up in this situation.
A couple of weeks ago, the intensive care nurses decided they were going to go for a night out. I spoke to David, the other novice anaesthetist, about whether or not we should go along for this night out with the nurses. David furrowed his brow and said “Hmmmm… maybe.” Going out on the town with a big group of nurses is invariably drunken and raucous and can be a hell of a lot of fun. One of my good friends once said to me, “you never see as much flesh on a night out as you do on a night out with the nurses.”
David is a fellow MTAS refugee. That debacle means he is now separated from the woman he loves by a few hundred miles and, understandably, they try to spend every free weekend together. David told me he was bailing out on me and goes to visit his missus. I was actually quite disappointed because I was quite up for going out, but didn’t really want to be the only man on the girliest of girl’s nights out.
So, I’m sitting in my apartment, chowing down on a curry and watching No Angels on DVD (great show they should so bring it back) when my phone rings. It’s Asif, one of the anaesthetic registrars.
“Are you going out with the nurses tonight?”
“I was thinking about it but David’s seeing his girlfriend and I didn’t want it to be just me and the nurses. Why – are you going?”
“Yeah, I’d like to – do you fancy coming along?”
“I may as well, I’m not doing anything else tonight apart from watching TV”
We get to the pub/bar and the party is already in full swing. It’s really different seeing people you work with “out of context.” Some of the nurses I didn’t even recognise in their normal clothes. It was good though, the loud ones were still just as loud in the pub and the quiet ones were still quiet.
I really enjoyed chatting with the nurses and their husbands/boyfriends about stuff over a beer or eight. It was surprisingly civilised until Anna, one of the younger ones, got her camera out.
That was it. There was cleavage everywhere and it was all getting more and more risqué. A group of the younger nurses wanted to hit the club for a boogie and by this stage, I was well warmed up. Unfortunately, I couldn’t join them because Asif wanted to leave and he was giving me a lift home.
We start saying our goodbyes to everyone and we get round to the table where one of the nurses, Debbie, was chatting to some of her friends that I didn’t know.
“We’re heading off home now, Debbie. Enjoy the rest of your night.”
Debbie smiles at me, stands up, wraps one of her legs around me, plants a kiss on my lips and says, “Do you come to mine tonight? We could have lots of sex, if you want to.”
I’m sure this is the sort of stuff that teenage wet dreams are made of, a slightly older woman making a brazen, upfront offer of sex. The thing is, I don’t really fancy Debbie that much and, whilst I get on ok with her at work, I don’t know her that well either.
I weighed up her proposition in my mind. Sex is almost always great fun. Doing in with someone new is exciting. On the other hand, I didn’t particularly fancy her, and I think my “sex for the sake of it” days are behind me now – there are too many complications, especially in a situation like this.
I turn down Debbie’s offer. I can’t remember exactly what I said (that’ll be the Stella!) but I think I was quite gracious and gentlemanly about it.
It’s funny to think that I ended the evening being driven home by a large hairy, Asian man. I’m pretty sure if I was in the same situation five years ago, the end of the evening would have been very different indeed!
Friday, 9 November 2007
This is a question I’ve been asked at just about every interview I’ve ever been to. It’s quite a fair question, because I reckon that a being a junior doctor is one of the most stressful jobs you could do. I’d say I’m a pretty chilled person most of the time. I’m very mentally tough but I’m very laid-back as well. It’s rare that events get on top of me or get me down, but there have been times when things have happened that have brought me to tears. I’ve had several sleepless nights when I’ve replayed events in my head again and again in an eternally repeating cycle like some sort of sick cinema viewing.
There have been times when I’ve felt all alone and times when I’ve just asked myself “Is it worth it? Is the job worth feeling this bad for? Should I just pack it in and do something else?” In short, there have been loads of times when I’ve felt stressed.
The Beatles once sang “I get by with a little help from my friends” and I’m lucky enough to have fantastic family and friends to help me through the dark times.
One of the other things I do when I feel things are getting on top of me is pay a visit to the streets. I pull out my trainers from under my bed, pull on an old t-shirt and tracksuit bottoms, set my iPod to shuffle and go for a run. I love it.
I love that there’s just me, the beat and the streets; and for the time I’m on the streets, nothing else really matters. The streets have been there since before I was born and will be there after I die. The streets won’t care if I don’t shave before I run. The streets won’t gossip about me and won’t assume that because they can’t see me, I must be in the pub or playing golf. The streets won’t attempt to undermine me because I took a different route to my destination. The streets won’t hassle me about protocols or breeches or bed-crises and will just let me get on with running. The streets don’t expect me to run on all of them at the same time, in fact they expect me to visit them one by one. The streets are always there if I want them, no matter how long it’s been since my last visit.
Thursday, 8 November 2007
I'd like to apologise to all you who emailed me when I was offline and I couldn't reply.
I was looking through my inbox and found this little gem that Mousie pointed out to me.
So funny, so true...
Tuesday, 6 November 2007
Operating theatres are staffed by the anaesthetists, surgeons and ODAs (operating department assistants). The job of the ODA is to make sure the theatre runs smoothly. To check the right patient has some for the right procedure, to keep the theatre tidy and to pass things to (assist) the anaesthetists and surgeons.
I was working in a new operating theatre today and, when I entered the anaesthetic room, after seeing my patients on the ward, I introduced myself to the Susan, the ODA and Marcus, her student.
Sarah, the first patient, comes in and Susan and Marcus complete their checks and then I set about the business of actually giving Sarah the anaesthetic. I start putting the drip in back of the patient’s hand and Susan says,
“Why are you putting it there? Why don’t you put it in her wrist? It’s better in the wrist.”
This annoys me. I may be young but I’ve probably sited close to a thousand drips so far in my career and I KNOW how to do it. I feel that she is trying to tell me how to do my job. I let it pass and the drip goes in to the patient’s hand first time.
Susan and Marcus had got the intubation stuff ready and I did my mental check so that I knew where everything was before I started. Oxygen? Yes. Suction? Yes Laryngoscope? Yes. Bougie? I couldn’t see it.
“Do we have a bougie?” I ask.
“It’s over here” Susan replies, pulling one out from behind the anaesthetic machine, “I’ve been in anaesthetics a lot longer than you, you know” she adds.
I wonder if she’s deliberately trying to wind me up. I know she’s been “in anaesthetics” a lot longer than me. She’s about 50 years old and was probably doing the job the day I was born, but I also know that I’m the anaesthetist and she’s my assistant. I have to look after this patient. I’m about to give her medications that will first send her into a coma and then paralyse her so she can’t move or even breathe for herself. I have a duty to make sure I can keep her alive and unharmed, so I NEED to know EXACTLY all the equipment I may potentially need is because I have only a few seconds to intubate my patient before she starts to suffer ill effects. When I spoke to Sarah on the ward, I made a promise to her that I’d look after her and the best way to look after her is to anticipate things that could go wrong and to nip them in the bud.
Once again I let Susan’s comment slide and I inject the anaesthetic drugs into Sarah’s vein. Marcus passes me the laryngoscope and I slide the blade into Sarah’s mouth.
“Don’t damage her teeth will you?” Susan pipes up
I can’t see what I’m looking for and I slide the blade further into Sarah’s throat.
“Watch out for her teeth!”
The blade is not near her teeth, so I ignore Susan and concentrate as the epiglottis pops into view.
I lift the blade to visualise the vocal cords.
“Careful with her teeth!”
The blade is still nowhere near Sarah’s teeth and Susan is really annoying me because I’m concentrating all I can and she is distracting me at a crucial moment.
“I’m nowhere near her teeth! You are NOT helping” I snap.
I push the endotracheal tube into Sarah’s trachea then connect the ventilator. We can now start the operation safely. I look up and Susan is giving me a look that could kill.
No doubt I’m now a “cocky young doctor” who “thinks he knows everything” and “doesn’t respect experienced staff members.”
Saturday, 3 November 2007
As a doctor working in general medicine, the intensive care unit (ICU) seemed to be a mystical place. When our patients became very, very sick, we would ask the ICU doctors for help and then they’d swan down onto the ward and point out all the things we hadn’t done. What usually happened next is that they’d then say that they didn’t want to take the patient onto the unit, offer a little advice and swan off again. However, very occasionally, they’d they WOULD take the patient and within minutes, the patient would be whisked off to the intensive care unit. They’d vanish off behind big, locked doors and we never knew what happened to them there. It was like a big black hole that the patients disappeared into. Sometimes, they re-emerged days later, sometimes they never came out.
The bible for junior doctors across the land is the Oxford Handbook of medicine. If you read the sections on treating critically ill people, regardless of the condition, it’ll say something like “do X then Y then Z and if that still doesn’t work, call ICU.” Rarely, do you get any more details and, as a result, I was always more than a little mystified about what went on behind those locked double doors. It’s been a real revelation working on the intensive care unit and seeing things from the other side.
To be honest with you, I was a little underwhelmed when I found out the truth. Aside from mechanical ventilation, nothing particularly special or profound happens in intensive care. Intensive care is based around meticulous attention to detail. It’s based around being focused on every aspect of your patient’s wellbeing. Closely monitoring ALL of their organ systems and intervening quickly and appropriately to try to correct anything that is drifting awry.
I’d say the single biggest difference between ICU and a normal medical or surgical ward is the nursing staff. I’m not saying that the nurses are better on ICU, it’s just that there are many more of them. We get one nurse for every patient. It’s great. It means you have so much more scope to do things. For example, we can confidently put a patient on an infusion of midazolam with the knowledge that they’ll be someone around to turn it off if the patient stops breathing.
It’s also made me realise that it’s often the simplest of things, done early, that make the biggest difference to critically unwell patients. Things like giving oxygen or fluids or adequate pain relief. I honestly believe that every doctor working in an acute specialty should spend some time working in intensive care at some point. Intensive care is based around simple things done well. Good medical care is based around simple things done well, and this is what I’ve seen again and again over the last few months.
Wednesday, 31 October 2007
The reason I’ve not blogged for so long is not because I was bored of it or had nothing to say; it was because MTAS made me move to a different part of the country and, believe it or not, it’s taken until now to sort out an internet connection. Surely British Telecom must be the most inefficient, frustrating, incompetent, uncaring organisation in existence. Grrrr….
Anyway, I’m back now and in the couple of months I’ve been offline, I’ve found my feet somewhat as a novice anaesthetic trainee. I’ve spent most of my time working on the Intensive Care Unit and it’s really opened my eyes regarding what the human body can and cannot do.
Our patients are usually right on the brink of dying and they are constantly fighting with whatever little strength they have left to do the simplest of things – like breathing. I have to say that the intensive care unit runs really well and over the past few weeks its been a pleasure and a privilege to work as part of the team that works so hard to try and make our patients better. Sometimes we succeed, and sometimes we fail, but every day brings new challenges and I have to say that, three months after changing my career direction, I’m still really enjoying being a novice anaesthetist.
Saturday, 1 September 2007
In spring 2006, when the changes to the medical training system started to change from vague chatter on the college websites to firm plans, I tried and tried to find out how certain aspects of my training and experience would fit into the new system and what I should be doing to get a job. It was all in vain. I lost count of the number of times that my questions were met with a shrugging “I don’t know.” In December 2006, I was getting more than a little stressed by it all and contacted, in rapid succession, – MMC, the royal college of physicians, the royal college of anaesthetists and PMETB about what I should do when the application process began. Nobody had any idea. Here are a few of the responses I got:
PMETB: “I don’t know, applications are nothing to do with us.”
MMC: “I don’t know, you should just apply to whatever you think and not be too picky about where you want to work.”
RCoA: “I don’t know, you don’t fit into any of our boxes do you – ask MMC”
MMC (the second time): “I don’t know – maybe you should do an FY2 year.”
RCP: “I don’t know, but you have your exam so I think you’ll be OK.”
RCoA: “If you do find an answer, could you come back and tell us because we’d be interested to know too.”
Do you feel my pain? Finding any sort of useful information was like drawing blood from a stone and the information I did manage to extract was either unhelpful or just plain wrong. The consultants at the hospital I where I was working at the time were less than useless and I took gossip about the changes among fellow junior doctors with a pinch of salt. I discounted rumours like “they are going to sacrifice a whole generation of SHOs to make the new system work” and “there are going to be thousands of unemployed junior doctors” and “families will be torn apart by this” as scaremongering by the hospital stress-heads. Surely they wouldn’t do that to us? I thought.
I was wrong. As you probably know, the actual reality was far worse.
Advice from consultants about getting a job through MTAS was appallingly bad. They just trotted out the same stuff that had helped under the old system and I don’t think they realised that the goalposts regarding job applications had fundamentally changed. This is part of the reason why it came as a surprise to many when high quality candidates weren’t even being short-listed in Round 1 (later renamed to Round 1a). At various times during the application process, various consultants told me things like; “It’s very important that you have your [post-graduate] exams, it’ll help you stand out” and “It’s always worthwhile contacting and visiting the department [of the job you’re applying for] before the interview” and “Make sure your CV looks good” etc… etc…
All this advice sounds reasonable, but was absolutely useless when it came to applying for jobs this year. I very much doubt I’m alone in being told these kind of things by my seniors but the facts are that if you paid attention to your bosses and actually followed advice like this, you’re highly likely to be unemployed right now.
The MMC themselves recognise that misinformation and a lack of useful information was one of its (many) major failings this year and, to be fair to my former bosses, they were probably as much in the dark about the changes as we were.
The thing that galls though is that, as the system fell apart and as it became increasingly apparent that you needed to do something different in order to get a job, the old advice still stuck.
I’ve commented before about how I feel let down by Liam Donaldson and the government for instigated and overseeing the MMC fuckup. I also feel let down by the senior doctors, the consultants, during the whole affair. Generally, I felt the majority of them just didn’t care at all, the advice given by them was often a load of bollocks and the way the BMA (led by consultants) behaved when they sided with the government against us juniors was truly disgusting.
I was interviewed four times in Round 1a, including once for the position I was working in at the time (effectively being re-interviewed for the job I was already doing), and didn’t get any job offers.
Round 2 was a total fucking debacle. Jobs were (or weren’t) advertised ad hoc, in random, hard-to find places for stupidly short lengths of time. Some deaneries made life as difficult as possible for applicants and, in places, what MMC said about how things were meant to run bore little or no resemblance to what was actually happening.
Here are some examples of skulduggery by the deaneries in round 2, all of which are DIRECTLY contrary to what was published on the MMC website. The London Deanery advertised and then closed its Round 2 anaesthetics jobs BEFORE round 1 had even finished and then appointed only current London-based trainees to the positions. The Round 2 Core Medical Training jobs for the South Yorkshire South Humber Deanery were PHYSICALLY IMPOSSIBLE to apply for from outside the region because the application form was only made available on the day of the deadline and they insisted on having 10 paper copies. The Leicester, Northampton and Rutland Deanery didn’t even bother publish a deadline for its Round 2 anaesthetics jobs.
These are just examples that directly affected me and I’m sure there are many, many more examples across the nation. By the way, if any of you do know of any more, I’d be interested in hearing about them.
Anyway, after many hours spent filling out endless application forms, I got myself short-listed in Round 2. I was successful at interview and was given one of the much-sort-after ST run-through positions. I was very lucky indeed.
I was on the phone to my old registrar the other day and, apparently, the new junior doctors on the firm are less qualified and less experienced than we were. This begs the question, “how come they got the job and I didn’t?”
The answer, I think, goes back to what I was talking about at the start of this post – bad advice. If I could go back to December 2006 and give myself one piece of advice it would be to sort out my portfolio and this is the advice that I give to anyone still negotiating the system.
I thought I interviewed very well in Round 1 and was actually quietly confident about getting a job. I was wrong. The computer said “No.” I thought I interviewed very well in Round 2 and was quietly confident about getting the job. I was right, I dodged the dole office with about a fortnight to spare and am now really enjoying my work (though I’m lamenting the fact that I’ve had to move hundreds of miles from my friends and family).
The difference between Dr Michael Anderson in Round 1 and Dr Michael Anderson in Round 2 was that, by the time Round 2 came, I had buffed my portfolio to the max.
I’d gone round and asked my medical students to sign something to say I’d taught them how cannulate and read ECGs, I asked the senior sister to write a letter saying I was nice to patients and staff, I’d got a consultant to write a letter saying that I can ably cover CCU and HDU, the list goes on. I have to say at this point that this wasn’t EXTRA stuff I was doing after failing in Round 1. I was doing all this stuff when I had my Round 1 interviews - it just wasn’t in my portfolio at that time.
Whether you think that I was incredibly shrewd and learned from Round 1 and “sold myself in the best possible light” or you think I “shamelessly played a flawed system to get a job” will depend on your standpoint.
The fact is that in MTAS 2007, this sort of portfolio stuff is considered more important than previous experience, publications, post-grad degrees etc… and this is a fundamental change that my seniors and the majority of my junior doctor colleagues just failed to realise. Whether or not this is the way it SHOULD be is a matter for another debate. Personally, I’m praying that MTAS 2008 will be drastically different to MTAS 2007, but I have my doubts.
You see, as we enter September 2007 and contemplate the applications for next year, I don’t see that a great deal has changed. As was the case in September 2006, it seems nobody has a clue about how the system is going to run next year and everyone is still “waiting to find out.” I’m willing to bet that a junior doctor seeking advice about how to apply next year will find getting any useful information virtually impossible – just like I did last year. To quote a great woman “It’s all a bit of history repeating.”
I hope I’m wrong. Time will tell.
The vast majority of the time, patient autonomy is not a conflict issue. This is because the doctor and the patient are working together, in harmony, to try and achieve a common goal. Patients come to us because they want to get better, we doctors suggest something that we think will make them better and patients usually agree to it and then they usually get better. Their autonomy is driving them in the same direction as our medical advice.
Sometimes, the patient will have a different agenda to the doctor and sometimes, their agendas and beliefs drive them to make decisions that fly in the face of our advice. Sometimes, we can understand where they are coming from and sometimes we can’t. Nevertheless, respecting patient autonomy is one of the core duties of being a doctor.
Anil, one of the new junior medical doctors and fellow MTAS refugee, was telling me about Helen, a 43 year old woman whom he had seen on the Medical Assessment Unit the day before.
Helen came to hospital because she was very unwell. History and clinical examination showed that she was bleeding internally, possibly from an ulcer, and had lost a lot of blood. (For you medics reading, her Hb was 4.9 g/dl). She was critically ill and urgently needed a blood transfusion to keep her alive until the bleeding can be stopped either by endoscopy or by surgery.
The thing is, Helen is a Jehovah’s witness and Jehovah’s witnesses do not accept blood transfusions. Moreover, Helen is a recent convert to the religion and, as such, is much more hard-line about sticking to her beliefs, even in extreme situations.
Those adverts about giving blood really do speak the truth, you know. Blood transfusions do literally save lives. Helen is highly likely to die without a blood transfusion, leaving behind a grieving family, but Helen flatly refused to have one.
This is exactly the scenario that is frequently used to illustrate autonomy in medical school, in junior doctor’s teaching sessions etc… etc… so it’s interesting to hear about this scenario actually unfolding in real life.
The thing about autonomy is that if a patient is lucid and has capacity to make their own decisions, then we have to respect the decisions that they make about their own lives. As doctors, it’s our job to make the patient fully aware of the likely outcome of their decision and to treat them the best we can whilst respecting their beliefs, no matter how bizarre they may seem to us. It is wrong to force our will onto our patients, it is wrong to lie to our patients about what might happen to them.
Anil told Helen that without the blood transfusion, she is likely to die, aged 43. Helen said she understood this but would rather die than have the transfusion. This is her decision.
When Anil finished his shift, Helen was still alive, but was teetering on a knife-edge. She was having intravenous fluids and the medical team were preparing to take her down for an endoscopy to hopefully stop the bleeding. I just hope that the prayers of Helen and her family are answered and she makes it through.
Saturday, 25 August 2007
With his hand gripping the mike and a deep, earnest look on his face, he croons “Na na na…That that don’t kill me will only make me stronger...”
Now, I respect Kanye’s ability to turn other people’s tunes in platinum selling bundles of 3 minute joy that make him a fortune, but it’s obvious to me that he’s never spent any significant amount of time in a hospital.
I can think of loads of things that don’t kill you but certainly DO NOT make you stronger. Off the top of my head, I can think of:
Can you think of any more?
Sumitra is quite a bit older than I am. She decided to take time out from working to bring up her children and she also had a change of speciality along the way as well. Her husband has a career that means he can’t easily move and the eldest of her children is beginning the run up to GCSEs. Understandably, Sumitra isn’t really keen to relocate her whole family up toward New Town because of the disruption it’s going to cause. Added to this, there’s the fact that she doesn’t know this area at all. She doesn’t know which suburbs are nice to love in, or which are the decent schools etc… etc…
I’ve had several conversations with Sumitra about what she’s going to do and she just doesn’t know at the moment. What I do know is that having to move to a place four hours away from her family is going to put a huge strain on Sumitra’s relationship with her husband and her children. Hopefully, they’re a strong enough family to be able to work it out somehow.
Hospitals are dominated by women. Fact.
The vast majority of the staff in any hospital are female. The nurses, the domestics, the caterers, the admin staff etc… tend to be almost exclusively female. Back in the day, the majority of young doctors were male but that is no longer the case. The gender ratio of new doctors is about 60:40 if favour of women and, going by the relative numbers entering medical school, the ratio is going to swing even further towards the “fairer sex” in the next few years.
This means that, as a young male in the hospital, I am a bit of a commodity and, when I was first starting out, it made things just that little bit easier for me. I could flirt with some nurses, whilst others would want to “mother” me. Some of the patients, especially the older ones, gave me more respect just because I am a man. I remember being on the ward round with my female consultant when I was a house officer and the patient (a lady in her 80s) asked the consultant to be quiet so she could “listen to what the doctor had to say” - and then looked at me.
It’s not all plain sailing and waving my Y-chromosome in the wind though, there are downsides as well. There are the endless conversations about sunbathing and shopping. (I’m still to fathom out the female obsession with shoes – two nurses and a female doctor once managed to have a conversation about heel height for 40 minutes straight – the mind boggles). Discussions about football end up all about the shapeliness of Frank Lampard’s legs or how Wayne Rooney is dead sexy because quote: “he looks like he’d leave you feeling raw afterwards”. And then there’s the expectations that I’ll act as a spokesman for my gender whenever one of the staff got played around or cheated on or dumped.
Overall though, as a junior doctor, the boys get an easier ride than the girls.
However, I’m finding it refreshing working with mainly other men. Men are funnier than women so there’s more banter on the ward. It’s also nice to have conversations at work about blokey things and not have to save it for the pub.
Call it sexist if you want to, but I think the Anaesthetics Boy’s Club (ABC) is definitely a good thing.
Kevin had come to us a broken man but, little by little, we’ve slowly put him back together again and Kevin is continuing to improve. It’s a heart-warming story of strength through adversity.
Whilst I was looking at the chart of the patient opposite, I heard Kevin talking to one of the student nurses. He said.
“The best health service in the world this is, the NHS. The way you people have treated me… I couldn’t ask for anything more. Even if I’d paid money, I wouldn’t have been treated like this. Thank you.”
Stuff like that makes you feel warm and fuzzy and really appreciated. Now, if only Kevin was a journalist…
Saturday, 18 August 2007
In our department, about 60-70% of the new starters have been forced to move away from where they were previously against their will because of MTAS. From speaking to people in other specialties, it's clear that the majority of the junior doctors who had to negotiate MTAS and were successful have had to move significant distances to find work. I don't think the government could have actually been more disruptive if it actually planned to be
You already know my story, but next week, I'll post about some of the other MTAS refugees.
On the twelfth day of anaesthesia, my duties gave to me:
11 L.M. Airways
10 Worried Parents
8 Angry Surgeons
7 Patient Transfers
6 Gas Inductions
4 Bag & Masks
3 Spinal Blocks
2 Chest Drains
and a pair of medium scrubs…
I’m not one of those men who think that the every female with a pulse is secretly swooning when I walk past, but, as a reformed (wannabe) playboy, I think I have a pretty good idea of when a woman is signalling “I like you.”
It’s the touch that’s not quite necessary. It’s the gaze that lasts a moment longer than needed. It’s the laughter at things that I say that are only vaguely funny. It’s the turning up and coming to talk to me when there’s no need to really… Reading between the lines I’d definitely say Lizzie is flirting like a pro.
At first I wasn’t sure if she was just one of those flirty girls who are like that with everyone, but now I’m pretty sure she’s giving me “special attention”. Like I said before, she’s a very attractive young lady and I admit that I’ve been flirting back a little because, to be honest, I quite like it.
Throughout medical school and into my first year as a doctor, I was very anti work-related relationships. Looking back, I don’t even remember what my reasons were but I’d actively avoid dating/pulling/shagging other medical students, nurses or anyone who I worked with. From this point of view, I’ve mellowed a lot in the last couple of years and am not so dogmatic about it now.
This leads on to the obvious question of is anything going to happen between me and Lizzie?
One of my best friends told me: “Don’t even go there, Mike. Pulling a medical student is just wrong.”
But he’s been going out with the same woman for six and a half years now, so what would he know? You can talk about power and its (ab)uses but it’s not as if Lizzie is a schoolgirl and I’m her teacher is it? She’s 23 years old and I think that makes her a big girl and quite able to make her own mind up.
For now, I’m quite happy to sit back, let her make the moves and wait and see what happens…
This hasn’t been my experience at all, so I asked her what she meant by this and she went on to say something very interesting.
She said that she thought that when doctors start, they are very “respectful” and ask the nurses lots about how things work etc… but then, after a while, that goes out of the window and the doctors start just commanding the nurses to do X, Y and Z. I think there’s an element of truth to what she said, but I think that what she’s getting at isn’t a matter of respect, but more a matter of experience. She sees it happen on ICU but it happens more often with new doctors, fresh out of medical school.
Let me try and explain.
When you graduate from Med School, you’ll have studied for the best part of the decade, you’ll have been tested countless times and you will have learned a hell of a lot of stuff. However, most of that learning will have been done in seminars, lectures, libraries, your bedroom, and comparatively very little will have been done on actual real patients. Even on your ward placements, the doctors will tend to take you to away from the patients to the seminar rooms to give you a teaching session on ECGs or chest Xrays or whatever.
When you graduate, you’ll have proven yourself and will have earned the right to call yourself “doctor.” However, when you walk onto the ward for the first timeas a doctor, you realise that things are a lot different to being a student. Obviously, a lot more is expected of you and one of the things that you’ll find is that there will be quite a few simple, practical things that you’re either not very good at or just don’t know how to do. I thinking of things like siting a naso-gastric tube or actually putting the leads on for an ECG. These things aren’t difficult but if you’ve not done them very much, you’ll be a bit wary the first few times you do them and it actually matters that you do them right.
The nurses will know how to do these things and they help you and show you how to do them. Some of the nurses will have been working in your field for twenty or thirty years and they will have seen a lot of stuff in that time. Their experience is invaluable. They will have seen and treated hundreds of patients have heart attacks, strokes, pneumonia, appendicitis etc… etc… and will have seen which treatments work for these conditions. As a result of this experience, they’ll try and point you in the right direction when it comes to the patient’s conditions and often, they are correct.
The thing is, after a while, your years of medical training kick in. After the first few weeks, you are no longer fazed by things like placing cannulae, talking to big groups of relatives etc… etc… and you are much more confident about the way your ward works. About this time, you realise that the nurses aren’t right all the time about things. Ultimately, nurses haven’t been to medical school and while they may have more experience about some things, they often don’t have the knowledge about medical conditions that you do to go with it. Thus, you realise that if you’re going to make a decision about what to do with a patient, it has to be YOUR call because, if anything goes wrong, it’s YOUR responsibility.
So, whilst the nurses may say to you, “I think we should put a “Do Not Attempt Resuscitation” order on this patient” or “this man needs thrombolysis” or “we should move this woman to HDU” at the end of the day, their opinions are only opinions because for medical decisions, you have to convinced in your own mind that what you’re proposing to do is actually in the best interests of the patient.
You’ll inevitably disagree with the nurses (and other doctors) from time to time about the management of patients. For example, you might think the patient needs diuretic drugs and the nurse might think he needs fluids but, ultimately, for medical decisions, what you say goes. This is not a matter of lack of respect of nursing roles, it’s a matter of taking responsibility for the decisions you ought to be making because, if it’s the wrong decision, then the fallout is going to be on YOUR head, not the nurse’s.
Like I say, medicine is so complex that disagreements are inevitable. Disagreements about patient care happen all the time between doctors and nurses, between doctors and doctors, between nurses and physiotherapists etc… etc… Ultimately everyone has their own opinions and rightly so. The point is that it’s not the disagreements per sé that leave people feeling disrespected, but the manner in which the discussion is conducted.
Patients on the intensive care unit (ICU) are literally fighting for their lives, so much so that often they don’t even have enough energy to breathe for themselves. I’m going to be working as part of the team responsible for helping them in their fight in every way we can.
Today is my first day and I’m really looking forward to it
Sunday, 12 August 2007
The lady in question had been on the operating table for the majority of the day after having emergency surgery because her bowel was blocked. It turns out that the blockage was probably caused by cancer and she’d had most of her internal organs taken out. Shane, one of the Australian registrars, is admitting this lady to intensive care and he turns to me and says:
“Have you done central lines before?”
Me: “A few, but my last one was a couple of months ago”
“Do you want to do this one?”
Then the monitor behind us starts beeping as our patient’s heart rate climbs above 130 b.p.m.
Shane: “Could we run that unit of blood through stat and call blood bank and tell them to give us two more please. Michael, I think I’d better so this one because we need this line in a hurry.”
I stood back and watched him work and he was amazing. I’ve never seen anyone put in a central line so fast. He went:
Local. Introducer needle in. Guide-wire in. Scalpel. Introducer needle out. Dilator in. Dilator out. Line in. Guide-wire out. Flush the lumens. Stitch the line. Tegaderm. Done.
And it took him about four and a half minutes altogether and he didn’t spill a drop of blood onto the pillow.
I was in awe. One day, I’ll be that good too.
No matter how long I spend in the morning getting my hair into a respectable state for work, I can guarantee that by lunchtime the theatre hat will have transformed it into a hideous bouffant. My hair ends up looking like some sort of 80s pop star gone wrong; think of George Michael’s deformed cousin and you’d be getting close.
Trust me, it’s not good look.
2. Blood goes round and round
3. You can’t make a chicken salad out of chicken shit no matter how much mayonnaise you use.
Having surgery is a very scary thing.
Having an anaesthetic is a very scary thing.
I’m lucky enough to have never needed surgery for anything but - even after the best part of a decade’s worth of medical training - if I ever were to have an operation, I’d be petrified.
The thing that scares me the most would be the loss of control. In order to have an anaesthetic, I’d have to totally relinquish control of everything. I’d have to put myself in another person’s hands and I’d have no say or influence over what they do to me. I’d have to allow myself to be put to sleep without knowing for sure whether or not I’d ever wake up again. Or not be sure that when I do wake up, that my body will be working like it should. It requires a phenomenal amount of trust to hand over control of your movement, your breathing and your life to another human being – especially one that I’ve met only a couple hours before the operation.
But this is exactly what every single one of my patients does. As an anaesthetist, I literally have their lives in my hands. If I fuck up, people die – quickly. The trust that my patients give me is a huge gift. To trust someone with your life is probably the biggest gift one person could give to another and I promise to always remember this and to never underestimate, undervalue or abuse the faith that they put in me.
We anaesthetised Mary. We gave her lots of painkillers and set her up on the ventilator that pumped oxygen in and out of her lungs to keep her alive. The orthopaedic surgeon was drilling a hole down the middle of her thigh bone and the operating theatre was filled with the high-pitched screech of metal tearing through bone and the smell of charred flesh from the cauteriser.
I knew that Mary couldn’t hear me but that didn’t matter, I leant down and whispered to her, “Don’t worry Mary, I’ll look after you. I’m right here.”
Sunday, 5 August 2007
Today was my first day in theatres. Yesterday, I was debating how long it would be before they let me loose with the anaesthetic drugs. The answer was – straight away. On my first morning, I was working on the urology list. I saw all the patients beforehand to explain what the anaesthetic involved and what they’d expect to see and feel when they woke up after the operation.
I got to give the patients their painkiller and then the anaesthetic drugs via the I.V. line I’d put in and watch them for the next 10-20 seconds as they drifted off to sleep. I then had to secure their airway and then they were good to go and the surgeons could do what they had to do.
My job was to look after the patient on the table and, after coming from gen med, it was a bit of a revelation to have all the monitoring right in front of me. I could see exactly what the heart rate, blood pressure, carbon dioxide levels etc were doing and I could correct things immediately if the parameters started drifting out of the “comfort zone.”
All the while I had the consultant anaesthetist next to me, telling me what to do and teaching me how and why certain things are done. In my last job, I didn’t think I was learning very much. My job was looking after the patients on the ward, and because of the sheer numbers of people I was looking after, it didn’t leave much time to study and learn the details of the conditions that I was treating. I found that quite frustrating because, I think I’m a bit of a geek at heart and actually enjoy learning stuff.
My new job is the opposite. Basically, I’m getting paid to learn and it’s great. I actually feel a bit like a medical student again.
I fucking hate inductions.
In theory, they sound really useful, but the reality is that they are a complete nightmare. Today’s was possibly the worst one I’ve ever been to. Because of MMC, there was an unusually large proportion of doctors from outside the region who’d never worked in the trust before. The hospital admin staff were underprepared and understaffed and every little thing took fucking ages. The queues for registration, for occupational health, for ID badges and for parking permits were all huge. I spent the morning in various hot, stuffy rooms just twiddling my thumbs. I arrived promptly at 08:00 like I was meant to and by about 11:30, I think I’d lost the will to live.
The afternoon was better though. This was the introduction to the anaesthetics department where we were told where we’ll be working, who we’ll be working with and what will be expected of us. We got shown how the anaesthetic machine works (which is helpful to know, I guess) and given a pair of theatre shoes (mine are a very cool black) and keys for individual lockers. We got told about log-books and certifications and loads of other stuff that I won’t bore you with. I hadn’t slept well last night and it was a lot to take in, but it seems that I’m going to be very well looked after.
I’m really looking forward to tomorrow, which will be my first day in theatres. I wonder how long it’ll be before they let me loose with the anaesthetic drugs…
I was on the road to the new deanery for about 3 and a half hours last night and motorway driving at night time has a sort of hypnotic quality to it, don’t you think? The hum of rubber on tarmac and the shifting glare of the headlights and the moon were conspiring to send me into a bit of a trance and I almost ended up zoning out totally. I had to pump up the stereo and sing some Erasure to stop myself falling asleep.
I’d been badgering the accommodation officer in my new hospital for several days and she had eventually managed to organise a room for me to stay in. I arrived at the new hospital just after midnight and was happy to find my keys were waiting for me at reception. After a brief chat with the receptionist, I headed off to my room.
Did any of you see that T.V. show where Gail Porter, Sean Hughes and Janet Street-Porter had to work as health care assistants? The thing I remember most about that show was when they were shown the hospital accommodation and Janet Street-Porter flat-out refused to stay there and threatened to leave the show altogether if they tried to make her. Hospital accommodation is usually pretty grim and the accommodation blocks at New Town hospital are no exception but I was so grateful that I had somewhere to sleep that night that the stains on the carpet and the sticky surfaces didn’t bother me.
I opened the door to my room and turned on the light and the sight that greeted me took me completely by surprise. There was no bed in the bedroom. I’m pretty sure that a bed is an essential component for a bedroom to have but there was none to be seen. The blankets were neatly folded on the desk but there was no bed!
After the drive, I was pretty shattered and I gave serious thought to sleeping on the floor but common-sense prevailed. I went back and explained the situation to the receptionist and three phone calls and 45 minutes later, I was settling into the emergency accommodation room. The bed was lumpy and uncomfortable, but it was a bed none-the-less and I drifted off to sleep contemplating the day ahead.
to be continued…
Tuesday, 31 July 2007
It was a really nice day. We only had one very sick patient so I was ale to say goodbye to everyone I’ve been working with for the last six months. Dr Fletcher has given me an excellent reference and told be that I was a loss to medicine but was sure I’d do very well as an anaesthetist.
I brought in cakes and chocolates as a goodbye gifts and everyone said they were sad to see me go. I got lots of hugs from the nurses and lots of heart-felt “thank-you”s from the patients. It was all very touching really; it feels nice to be cared about.
I put on the radio as I drove away from Town Hospital for the last time and the fat lady was singing her heart out.
It’s 9pm and I’ve packed my stethoscope, clothes, food, portfolio into a bag and am about to set off on the 200-or-so mile journey to my new job.
As always, I'll keep you posted
Monday, 30 July 2007
All in all, I’ve liked hospital medicine. I’ve liked the patients I’ve met, the stories I’ve heard and the staff I’ve worked with. I feel that every day I’m making a difference – whether it’s literally bringing someone back from the dead or just taking the time to sit and listen to one of the elderly patients for five minutes or so. I’ve loved my job.
But there’s so much about the job that I don’t like. There’s so much of the overwork, constant hassle from various sources (often simultaneously), there’s the general expectation that I can be in four places, doing six different things all at the same time. I can’t remember the number of times I’ve wanted to shout out “THERE’S ONLY ONE ME!” I hate the fact that everything seems to be my responsibility. If a patient has broken their spectacles or if the MRI scanner has broken down, somehow, I’m supposed to sort it out. I’ve hated my job.
The last patient I’ll ever admit to Gen. Med. was a woman in her mid-forties who was sent up from A&E because they suspected she had a deep-vein thrombosis (a blood clot in her big leg vein). It wasn’t an exciting, it wasn’t glamorous – but to be honest, hospital medicine rarely is. I walked off the unit with a wry smile and I think that that lady’s swollen leg will forever hold a certain place in my memories.
Anyway, I’m off to a new specialty in a new area. I’ve really been looking forward to the career change and I’m really excited by the new challenges that lie ahead.
I leave hospital medicine with countless memories. Some make me smile, some make me feel proud, some bring a lump to my throat and some make me shudder. I really believe that the grass is greener away from Gen. Med. and I’m going enjoy my new specialty more, but either way, I’ll keep you posted.
I’m a medical SHO no more. My new name badge will read:
Bring it on.
Wednesday, 25 July 2007
Tuesday, 24 July 2007
Long-distance relationships haven’t worked for me in the past and I didn’t want to start something with so much uncertainty around regarding pretty major life stuff like my employment status and where in the country I’d be living.
It is a shame though, if I were to write down a list of things I’d look for in a girlfriend it’d go something like this:
Likes me too
Gemma definitely ticks all my boxes – in fact she was the first girl I’d met for ages who seemed to.
I’m going to make the effort to stay in touch with her and hopefully we’ll become good friends. Time will tell
Monday, 23 July 2007
This is a question that patients frequently ask me. Hospitals aren’t prisons and patients are free to come and go as they please, I always tell my patients this and it turns out that most of the time, what they’re really asking is:
“Do you think I’ll be OK at home, doctor?”
which is obviously a totally different question. I’ll give my opinion and if I think he or she should stay in hospital, I’ll say so and the patient can choose to follow or ignore my advice as they wish. At the end of the day, it’s their life and they can decide what to do with it so I don’t generally get het up when patients ignore what I say and discharge themselves against medical advice.
Sometimes though, when I REALLY believe the patient could get into serious strife if they leave, I’ll do my best to try and persuade them to stay.
Let me tell you a story about a man called Jack.
Jack liked to have the occasional beer or 12 and he was the kind of guy who just loved regaling you with stories about the fights he’d been in. Jack came to my ward after having a seizure. The day after his seizure, Jack felt totally fine again. Dr Fletcher, the consultant, wanted to get a CT scan of Jack’s brain to help decide if Jack’s seizure was related to alcohol, epilepsy or something else, like a brain tumour.
Unfortunately, the CT scanning machine broke down so Jack had to wait a couple of days to get is scan. Jack wasn’t too happy about being stuck in hospital while he felt fine but was willing to wait to have his scan just so long as he was home in time for his daughter’s 8th birthday.
The day before the birthday, Jack got his scan and the scan result was not good news. It was not good news at all.
The scan showed that Jack was bleeding into his brain.
This meant that he was at a massively increased risk of stroke, paralysis, coma and death. I picked up the phone and spoke to the neurosurgeon on-call and his advice was to get a more detailed (MRI) scan and then send him the films so he could decide if brain surgery was to be recommended.
I went back to Jack’s bedside and explained what the scan showed. I also explained what might happen to him and that we’d like him to stay with us so we could get the more detailed scan and ask the brain surgeons to see him.
Jack furrowed his brow and said, “I’m not staying doctor. I promised my little girl I’ll be there for her birthday, so no matter what – I’m going home tonight.”
I again told him that he was at risk of dying from the bleeding in his brain and that it was much safer for him to be in hospital where we could keep a close eye on him and act quickly if anything happened.
Jack responded “I hear what you’re saying, doctor, but I’m not staying here tomorrow - I can’t.”
As doctors, we have to respect our patient’s right to make decisions about their treatment even if we strongly disagree with them. At the end of the day, it’s THEIR body and THEIR life and this means it’s THEIR decision, not mine.
I went and got Jack a “discharge against medical advice” form, which he signed gladly. I made sure he knew what symptoms to look out for and asked him to come back to hospital immediately if he had any numbness or weakness, if he developed a headache or had any problems speaking or any problems with his vision. I then shook his hand and wished him all the best. I then called up the MRI department and organised an urgent outpatient scan for Jack.
As I watched Jack walk off the ward, it struck me that in this life we must all make our choices and it’s the choices we make that shape how our life develops and ultimately, who we become. I hope Jack made the right choice and I hope he enjoyed a great day with his daughter. Deep down, my gut feeling is that Jack is going to be alright.
I hope I’m right.