Things are going well on the ward at the moment. This is mainly because for the first time in months we are fully staffed. It’s great. Today I was able to see all my patients, spend a reasonable amount of time with them, get all the test organised, see the results and act on them, and I was still finished by half past four! It’s fantastic and I’m definitely going to enjoy it while it lasts.
My evening out with Gemma the physio at the weekend was really good fun too. I already knew that she was sweet and really fit and, over the course of the night, I found out that she’s a really funny, bright, likeable young lady basically, I think she has “the package.”
If you’re thinking there’s going to be a “but” you’d be right. Here it comes.
Gemma’s great and I think she quite likes me too but I think if anything is going to happen between us, it’ll be the Big Romance. You know, flowers on the doorstep, dinner with fairy lights, cuddles on the sofa, walks by the river, that kind of thing. Ordinarily, I’d be dead keen because, even though we’ve only be out the once, I can really see myself falling for her. The problem is, the MTAS applications process means I don’t know where abouts in the country I’m going to be living and working come the summertime. I’m worried that if we start something now, we might not be able to carry it on. And if that’s the case, is there any point in starting it?
On the 8th of June I find out two pieces of information that will be crucial to my life. Firstly whether or not I’ll be employed, and secondly, whereabouts in the country said job will be. Come the 8th of June, I could find out that I’ve got the job I want and will be able to stay close by. Or I could find out that I have to move hundreds of miles away from here… hundreds of miles away from her.
Is there any point in starting something when I know there’s a good chance we’ll have to end it in five week’s time? I don’t know. The cliché says that it’s better to have loved and lost than to have never loved at all, but the thing is - I HAVE loved and lost in the past and it hurts… a lot. And I don’t think that cliché is true.
So what am I supposed to do? I don’t know.
In the meantime, last week brought two more huge fuckups from the people at the MMC/MTAS who are in charge of our careers. Have a look. The mind boggles. The people running the online application process don’t seem to have grasped one of the FUNDAMENTAL truths about the internet. Once information is out, there’s no way to get it back again and EVERYONE who is interested can get hold of it. Every schoolchild knows this. Paris Hilton knows this. The people running MTAS really should have known this.
Monday, 30 April 2007
Sunday, 29 April 2007
2007 - The Golden Era?
These really are amazing times for English sport. This year, three out of the four semi-finalist in the European Cup came from England in both the football AND the rugby. It’s really a good time to be a sports fan in England.
It’s such a shame that our national teams are doing so appallingly badly at the moment.
It’s such a shame that our national teams are doing so appallingly badly at the moment.
Friday, 27 April 2007
Little victories
“Hello Mrs Brown, how are you this afternoon?”
“It’s getting a little bit better, doctor.”
“Let’s see. Can you lift your foot off the floor?”
She slowly lifts up her leg.
“Now can you put your arm above your head?”
She can
“Can you pick up this pen off the table?”
She cannot.
“Well it’s getting a bit better isn’t it?”
“I think so, I’m trying the best I can with all those exercises.”
“Good, I think they’re working, it seems that every day when I see you, you’ve got a little more movement, and that’s encouraging. Did anyone tell you the results of your scan?”
“No, not yet doctor.”
“Well, like we were expecting the scan shows that you’ve had a stroke, and this is why you’ve had this weakness down your side. We know now that it was a blood clot that caused it and this means we can give you some tablets that will reduce the chances of it happening again. I have to say that I’m really pleased that you seem to be getting better quite quickly. Remember when you first came in? You couldn’t really move that side at all.”
“I know, I’ve been doing the exercises and - my daughter will you – I’m really stubborn and I’m determined to beat it.”
Mrs Brown’s daughter: “She’s right, she is stubborn – I think it runs in the female side of our family!”
Me: “Well sometimes, I think that’s the best way to be. Remember we chatted about you going over to the rehab ward where the physiotherapists can be much more intensive about your movement and exercises.”
Mrs Brown: “Yes, they’ve been earlier today and they’re really nice and I’m looking forward to going over there.”
“That’s good, I think that while you’re improving, it’ll be worthwhile you spending some time with them so they can help you get as good as you can be.”
“Can I just say doctor… I just want to say thank you for the way you’ve looked after me. You know, I really appreciate that you always take the time to come and talk to me – when you’re not well, it really helps to feel like there’s someone who you can talk to about things. You’ve got a bit of a fanclub in here. All the other ladies agree that you’re a really nice young man.”
Patients saying things like this makes it all worthwhile you know. I love my job.
“It’s getting a little bit better, doctor.”
“Let’s see. Can you lift your foot off the floor?”
She slowly lifts up her leg.
“Now can you put your arm above your head?”
She can
“Can you pick up this pen off the table?”
She cannot.
“Well it’s getting a bit better isn’t it?”
“I think so, I’m trying the best I can with all those exercises.”
“Good, I think they’re working, it seems that every day when I see you, you’ve got a little more movement, and that’s encouraging. Did anyone tell you the results of your scan?”
“No, not yet doctor.”
“Well, like we were expecting the scan shows that you’ve had a stroke, and this is why you’ve had this weakness down your side. We know now that it was a blood clot that caused it and this means we can give you some tablets that will reduce the chances of it happening again. I have to say that I’m really pleased that you seem to be getting better quite quickly. Remember when you first came in? You couldn’t really move that side at all.”
“I know, I’ve been doing the exercises and - my daughter will you – I’m really stubborn and I’m determined to beat it.”
Mrs Brown’s daughter: “She’s right, she is stubborn – I think it runs in the female side of our family!”
Me: “Well sometimes, I think that’s the best way to be. Remember we chatted about you going over to the rehab ward where the physiotherapists can be much more intensive about your movement and exercises.”
Mrs Brown: “Yes, they’ve been earlier today and they’re really nice and I’m looking forward to going over there.”
“That’s good, I think that while you’re improving, it’ll be worthwhile you spending some time with them so they can help you get as good as you can be.”
“Can I just say doctor… I just want to say thank you for the way you’ve looked after me. You know, I really appreciate that you always take the time to come and talk to me – when you’re not well, it really helps to feel like there’s someone who you can talk to about things. You’ve got a bit of a fanclub in here. All the other ladies agree that you’re a really nice young man.”
Patients saying things like this makes it all worthwhile you know. I love my job.
Wednesday, 25 April 2007
Sometimes, all you have to do is ask
When I was fourteen, I had this huge crush on a girl in the year above me at school called Jane. To my young eyes, Jane was beauty personified. I used to gaze at her for ages and literally dream about how perfect the world would be if she were my girlfriend.
The problem was, I could not fathom how on earth I would get this goddess to even have a conversation with me, never mind to let me do personal stuff like hold her hand. Every time I saw her, my heart would start to race, my hands would get clammy, my face would go the colour of Arsenal’s centenary strip and my voice would rise so high that only dogs could hear me.
On the rare occasions when I actually met her, I’d squeak out a taut “Hi Jane” and she’d give me a slightly confused look back. Then I’d run away and record long, rambling entries in my diary about my poor tortured soul and how I loved her SOOOOOO much but she doesn’t even know I exist.
My young mind just couldn’t fathom how on earth you get a highly attractive woman to out with you. To me, it was an impossibility.
Fast forward a decade or so and I’m a doctor on the ward and the Gemma, the gorgeous physiotherapist wanders up to the nurses station. I say:
“Hi Gemma, how’s it going?”
“Not too bad”
“You know, this weekend there’s this show that sounds quite good, do you fancy coming along with me?”
“Sure, that sounds like fun.”
I half wish I could go back in time and spell out to my fourteen year old self that, sometimes, all you have to do is ask.
It’s really that simple.
The problem was, I could not fathom how on earth I would get this goddess to even have a conversation with me, never mind to let me do personal stuff like hold her hand. Every time I saw her, my heart would start to race, my hands would get clammy, my face would go the colour of Arsenal’s centenary strip and my voice would rise so high that only dogs could hear me.
On the rare occasions when I actually met her, I’d squeak out a taut “Hi Jane” and she’d give me a slightly confused look back. Then I’d run away and record long, rambling entries in my diary about my poor tortured soul and how I loved her SOOOOOO much but she doesn’t even know I exist.
My young mind just couldn’t fathom how on earth you get a highly attractive woman to out with you. To me, it was an impossibility.
Fast forward a decade or so and I’m a doctor on the ward and the Gemma, the gorgeous physiotherapist wanders up to the nurses station. I say:
“Hi Gemma, how’s it going?”
“Not too bad”
“You know, this weekend there’s this show that sounds quite good, do you fancy coming along with me?”
“Sure, that sounds like fun.”
I half wish I could go back in time and spell out to my fourteen year old self that, sometimes, all you have to do is ask.
It’s really that simple.
Tuesday, 24 April 2007
There's no point in asking, you'll get no reply
My consultant, Dr Fletcher, is an angry man. He stomps, he shouts, he swears, he makes sarky comments – basically, he’s got your classic Type A personality. He’s not exactly what you call the sensitive type when it comes to dealing with his juniors (with his patients, it’s a different story). I don’t mind this though. After working with him for some time now, I think his anger stems from frustration at the medical system and, unlike McBitch, I don’t think he’s a vindictive person.
Ward rounds happen twice a week and are opportunities for consultants to teach stuff to their juniors as well as treat their patients. What happens with Dr Fletcher is that he’ll ask me increasingly tough questions until the point that I either don’t know the answer or until I get it wrong. At this point, he’ll either have a go at me or make some sarcastic remark, depending on his mood.
Here’s an example from this morning.
“Tell me Michael, if you suspect that a patient has Wilson’s disease, how would you confirm the diagnosis?”
“You can look for Kayser-Fleischer rings – preferably with a slit lamp”
“So you do this and you can’t see any Kayser-Fleischer rings. Does that rule out Wilson’s disease?”
“No”
“So…?”
“I’d order serum copper and caeruloplasmin levels”
“You do this and the tests come back normal. Have you ruled out Wilson’s disease?”
“No”
“So will you just answer my question. How do you diagnose Wilson’s disease?”
I’m struggling
“Erm… a liver biopsy?”
“A liver biopsy? This is what you’d do next? And what would you be looking for on your liver biopsy?”
“I don’t know”
“So you’re telling me that you’d subject your patient to a procedure with a risk of pain and complications and you don’t even know what you’re looking for?* So what are you going to do – just order the test and hope that the pathologist knows more medicine than you? Is the how you practice medicine?”
“erm…”
“I’m telling you that liver biopsy is not the way to diagnose Wilson’s disease.”
“I don’t know what else you’d do”
“It looks like SOMEONE has got a bit of studying to do don’t you think?”
This type of thing happens on every single ward round. The other SHO hates ward rounds and turns into a quivering wreck every Tuesday and Thursday morning.
*you’d look for dry copper weight
p.s - The answer he was looking for was 24hr urinary copper levels
p.p.s - Just in case you were wondering, the title of this post is the first line of "Pretty Vacant" by the Sex Pistols. I thought it was quite fitting!
Ward rounds happen twice a week and are opportunities for consultants to teach stuff to their juniors as well as treat their patients. What happens with Dr Fletcher is that he’ll ask me increasingly tough questions until the point that I either don’t know the answer or until I get it wrong. At this point, he’ll either have a go at me or make some sarcastic remark, depending on his mood.
Here’s an example from this morning.
“Tell me Michael, if you suspect that a patient has Wilson’s disease, how would you confirm the diagnosis?”
“You can look for Kayser-Fleischer rings – preferably with a slit lamp”
“So you do this and you can’t see any Kayser-Fleischer rings. Does that rule out Wilson’s disease?”
“No”
“So…?”
“I’d order serum copper and caeruloplasmin levels”
“You do this and the tests come back normal. Have you ruled out Wilson’s disease?”
“No”
“So will you just answer my question. How do you diagnose Wilson’s disease?”
I’m struggling
“Erm… a liver biopsy?”
“A liver biopsy? This is what you’d do next? And what would you be looking for on your liver biopsy?”
“I don’t know”
“So you’re telling me that you’d subject your patient to a procedure with a risk of pain and complications and you don’t even know what you’re looking for?* So what are you going to do – just order the test and hope that the pathologist knows more medicine than you? Is the how you practice medicine?”
“erm…”
“I’m telling you that liver biopsy is not the way to diagnose Wilson’s disease.”
“I don’t know what else you’d do”
“It looks like SOMEONE has got a bit of studying to do don’t you think?”
This type of thing happens on every single ward round. The other SHO hates ward rounds and turns into a quivering wreck every Tuesday and Thursday morning.
*you’d look for dry copper weight
p.s - The answer he was looking for was 24hr urinary copper levels
p.p.s - Just in case you were wondering, the title of this post is the first line of "Pretty Vacant" by the Sex Pistols. I thought it was quite fitting!
Monday, 23 April 2007
My father doesn't understand me...
I was chatting with my Dad yesterday and he says to me:
“Son, I think it’s time you got yourself another car.”
“What’s wrong with the one I’ve got?”
“Your car is no good. You are a doctor and a person of your standing should have a better car.”
“I don’t mind about that, it’s not like I have to impress anyone with it is it?”
My father fancies himself as a bit of an erudite with a way with words. He has obviously been pondering the state of my wheels for a while and he comes at me with another of his well reasoned, well thought out arguments that you have to sit back and admire for being simultaneous complex and succinct:
“I’m telling you, it is no good.”
Brilliant.
All of a sudden I’m 10 years old again.
“You shouldn’t be driving a car like that. For about £4000 you could get yourself a decent car.”
At this point I should point out that my car is an old battered Fiesta with a 1.0 litre engine, loads of dents and it cost me £400 to buy. It is not P.I.M.P. It is not sexy. It does not impress that laydees – in fact, it doesn’t impress anybody at all. However, it is reliable, has a wicked stereo and is cheap as chips to run.
The thing about cars is they’re expensive. Ludicrously so. Running a car is like attaching a huge leech to your bank account and then watching as it sucks your funds away and keeps on sucking until your account is a lifeless, empty husk that twitches as the bailiffs poke at it with disdain. Also, I’m not one of these people who enjoys driving for driving’s sake because let’s face it, it’s fucking boring.
Hence, I drive around a battered old shed of a car that everyone laughs at when they see me in it. I don’t mind.
“Dad, my car is fine. Remember, last month you spent £300 getting your car through its M.O.T. while mine passed with no problems whatsoever?”
…and I’m going to spend that £300 saving on a long weekend break to Rome.
“Son, I think it’s time you got yourself another car.”
“What’s wrong with the one I’ve got?”
“Your car is no good. You are a doctor and a person of your standing should have a better car.”
“I don’t mind about that, it’s not like I have to impress anyone with it is it?”
My father fancies himself as a bit of an erudite with a way with words. He has obviously been pondering the state of my wheels for a while and he comes at me with another of his well reasoned, well thought out arguments that you have to sit back and admire for being simultaneous complex and succinct:
“I’m telling you, it is no good.”
Brilliant.
All of a sudden I’m 10 years old again.
“You shouldn’t be driving a car like that. For about £4000 you could get yourself a decent car.”
At this point I should point out that my car is an old battered Fiesta with a 1.0 litre engine, loads of dents and it cost me £400 to buy. It is not P.I.M.P. It is not sexy. It does not impress that laydees – in fact, it doesn’t impress anybody at all. However, it is reliable, has a wicked stereo and is cheap as chips to run.
The thing about cars is they’re expensive. Ludicrously so. Running a car is like attaching a huge leech to your bank account and then watching as it sucks your funds away and keeps on sucking until your account is a lifeless, empty husk that twitches as the bailiffs poke at it with disdain. Also, I’m not one of these people who enjoys driving for driving’s sake because let’s face it, it’s fucking boring.
Hence, I drive around a battered old shed of a car that everyone laughs at when they see me in it. I don’t mind.
“Dad, my car is fine. Remember, last month you spent £300 getting your car through its M.O.T. while mine passed with no problems whatsoever?”
…and I’m going to spend that £300 saving on a long weekend break to Rome.
Thursday, 19 April 2007
Hospital Myth #1
Life is full of disappointments.
I’m disappointed when I wake up in the morning and see another grey sky.
I’m disappointed every single time England play a football tournament.
I’m disappointed every time they announce a new series of Big Brother because it means that we have to endure 3 months of fat chavs shouting at each other.
But, I think one of the biggest disappointments of my life so far came in my second year at medical school when we first went onto the wards as students. Maybe I really believed the image of nurses that is portrayed by the media and by teenage folk-lore. Perhaps I thought that nurses were sexy minxes who are always well up for it.
Wrong. Wrong. Wrong. Wrong. Wrong.
This is a myth. Nurses, by and large, are not sexy at all. They are usually dumpy and 40. Don’t get me wrong, nurses are lovely people but if you’ve got the idea that working on a hospital ward is like being in a Jay-Z video, you’re going to be disappointed.
It’s not all bad though. It took me a little while to realise this but now I know that as far as hospital talent goes, the best looking staff are always the physiotherapists. Maybe hotornot.com forms part of the criteria for entry into physiotherapy school but it’s uncanny how all the best looking people in the hospital (both male and female) are the physios.
I was chatting to a physio about this at a house party a while ago and he was saying that at uni, the physio parties were always rammed just because everyone knew there were guaranteed to be loads of good looking people there.
One of the physios on our ward at the moment, Gemma is an absolute cutie. I think that if you have someone to flirt with a bit at work, it makes the day that bit more interesting. Gemma seems like a top chick too and she keeps dropping hints about “us all going out together” so maybe something could well develop…
Watch this space…
I’m disappointed when I wake up in the morning and see another grey sky.
I’m disappointed every single time England play a football tournament.
I’m disappointed every time they announce a new series of Big Brother because it means that we have to endure 3 months of fat chavs shouting at each other.
But, I think one of the biggest disappointments of my life so far came in my second year at medical school when we first went onto the wards as students. Maybe I really believed the image of nurses that is portrayed by the media and by teenage folk-lore. Perhaps I thought that nurses were sexy minxes who are always well up for it.
Wrong. Wrong. Wrong. Wrong. Wrong.
This is a myth. Nurses, by and large, are not sexy at all. They are usually dumpy and 40. Don’t get me wrong, nurses are lovely people but if you’ve got the idea that working on a hospital ward is like being in a Jay-Z video, you’re going to be disappointed.
It’s not all bad though. It took me a little while to realise this but now I know that as far as hospital talent goes, the best looking staff are always the physiotherapists. Maybe hotornot.com forms part of the criteria for entry into physiotherapy school but it’s uncanny how all the best looking people in the hospital (both male and female) are the physios.
I was chatting to a physio about this at a house party a while ago and he was saying that at uni, the physio parties were always rammed just because everyone knew there were guaranteed to be loads of good looking people there.
One of the physios on our ward at the moment, Gemma is an absolute cutie. I think that if you have someone to flirt with a bit at work, it makes the day that bit more interesting. Gemma seems like a top chick too and she keeps dropping hints about “us all going out together” so maybe something could well develop…
Watch this space…
Tuesday, 17 April 2007
Who will manage the managers?
I was listening to the news on the radio the other day and they reported that the NHS spent about half a billion pounds on management consultants last year.
Half a billion pounds
That is a hell of a lot of money. If you had half a billion pound coins, they would weigh significantly more than the Empire State Building. If you stacked these coins one on top of the other, they would reach into outer space. Half a billion pounds is a hell of a lot of money.
Let me tell you a little story.
When I was at medical school, in our first year there was this guy called James “Gibbo” Gibson. Gibbo was a complete pisshead. I mean, Gibbo was the kind of student that gives students a bad reputation. He would go out a get hammered literally every night for three weeks straight and, on the few occasions he did manage to make it into uni for lectures, he would just fall asleep, hungover.
Unsurprisingly, Gibbo failed his first year med school exams. Our med school allowed him to re-sit the year, but Gibbo didn’t change his spots, failed again and was eventually kicked off the course. Gibbo switched courses and did a physiology degree and this is when I lost touch with him. I heard that he had to re-sit a year of his new degree but eventually graduated with a third. Fair enough.
Fast forward to the first day of my surgical house-officer job (in my first year as a qualified doctor) and I had walked onto my ward for the first time. I’m introducing myself to a couple of the nurses when I hear a voice behind me saying, “Mikey-mate! How are you!”
It’s Gibbo. Gibbo is dressed very smartly, wearing a nice suit. It turns out that Gibbo had been appointed as our ward manager. For being the ward manager, Gibbo was earning £52,000 a year and the honest truth is, to this day, I could not tell you what he actually did in his position. This was the one and only occasion that I saw him on the ward.
Like I say, half a billion pounds is a hell of a lot of money.
Thursday, 12 April 2007
The 10 Commandments
(of surviving night shifts)
Thou shalt Eat
Thou shalt Drink
Thou shalt not arrive late
Thou shalt get help
Thou shalt not covet thy colleague’s sleep
Caffeine is thy friend
Thou shalt not do tonight what can wait until tomorrow
Respect thy nurses, thy porters, thy A&E staff and thy paramedics
Thou shalt not hesitate to medicate (thyself)
Thou shalt entertain thyself in the 'morrow
Wednesday, 11 April 2007
A Teenage Delusion
I don’t shave when I’m working nights.
I see it as my own little personal protest about having to be awake at ungodly hours, feeling crap for a week because of a lack of sleep and having my personal life ruined. I’m not a particularly hairy person. When I was in my teens I used to envy the boys who could grow decent stubble. Somehow they seemed that bit cooler and found it that bit easier to get the ladies and I always used to imagine that my life would be better if I too had the ability to grow facial hair.
I’m now in my mid-twenties and as I’m sitting here scratching my beard, I realise that it was all a teenage delusion. Life is not better with facial hair – just itchier.
I see it as my own little personal protest about having to be awake at ungodly hours, feeling crap for a week because of a lack of sleep and having my personal life ruined. I’m not a particularly hairy person. When I was in my teens I used to envy the boys who could grow decent stubble. Somehow they seemed that bit cooler and found it that bit easier to get the ladies and I always used to imagine that my life would be better if I too had the ability to grow facial hair.
I’m now in my mid-twenties and as I’m sitting here scratching my beard, I realise that it was all a teenage delusion. Life is not better with facial hair – just itchier.
Tuesday, 10 April 2007
A Job Well Done
Once more, I’m covering the medical side of the hospital for a week of nights. Last night, I got paged by the nurses on the Coronary Care Unit (CCU) and they told me they’d just received a call from the paramedic ambulance crew and they were bringing in a patient with an ST Elevation Myocardial Infarction – a heart attack.
I walk round to CCU toget there before the patient and start thinking about what is about to happen.
A heart attack is caused by one or more of the arteries that supply blood and oxygen to the heart becoming blocked by a blood clot. The part of the heart beyond the clot gets starved of oxygen and energy and, if nothing is done, that part of the heart will stop working. If enough of the heart muscle stops working, then the whole heart can’t beat properly and the person dies. This is how heart attacks kill people.
In hospital, our aim is to try and open up the blockage caused by the blood clot and this can be done in one of two ways.
The first is called primary angioplasty. This is the best treatment and it involves the doctor passing a wire from your groin to your heart where the blockage can be cleared manually. The second is called thrombolysis, this is more old-fashioned and it involves the medical staff giving you a “clot-busting” drug into your veins to try and dissolve the clot. It works most of the time but there is a 1 in 200 risk of severe side-effects like bleeding into your brain and dying.
We cannot do primary angioplasty at our hospital, we don’t have the right equipment or doctors or nurses trained to do it, so patients with heart attacks coming to Town Hospital get given thrombolysis. It truly is a post-code lottery in the NHS.
The patient comes in. He’s 48 years old with no previous heart problems. He had woken up a couple of hours earlier with central chest pain. It didn’t go away so his wife called NHS Direct who called and ambulance for him. The paramedics handed me the ECG that they’d done while the CCU nurses are connecting him to the cardiac monitor.
An ECG is basically a series of wiggly lines that show us how electricity is moving round the heart muscle and this allows us to deduce if any parts of the heart aren’t working. There are very strict ECG criteria that the patient has to meet before we can give thrombolysis.
Like I said, an ECG is a bunch of wiggly lines and his ECG was on the borderline. You could argue it either way – that it fits the criteria or that it doesn’t fit the criteria.
Now, none of the medical jobs I’ve had have been cardiology jobs and I’ve never personally given anybody thrombolysis before. Because of the very real risk of the treatment (thrombolysis) paradoxically killing the patient, as the doctor you have to be ABSOLUTELY sure that the patient meets the criteria before deciding to give it.
I wasn’t sure.
Thrombolysis is meant to happen within 20 minutes of the patient arriving into hospital. This man probably had heart-related chest pain but his ECG was borderline. The paramedics said that they weren’t sure about it so they’d brought bypassed A&E and brought him straight to CCU to be on the safe side. The CCU nurses (who between them, have seen hundreds of patients having thrombolysis) were not sure about it either.
Then came the moment I’d been dreading. The patient is looking at me, his wife is looking at me, the two paramedics are looking at me, the two nurses are looking at me, and one of them asks:
“What are you going to do doctor?”
The honest answer would have been “I don’t know.” I’m staring at the ECG tracing as if some sort of divine inspiration is going to leap off the page at me and help me make the decision. A decision that has the potential to save this man’s life and also has the potential to kill him.
It is then that I remember what is probably the most important rule of being a good junior doctor.
IF YOU DO NOT KNOW - GET HELP
So I say:
“I’m not absolutely sure about this one, I’m going to get the registrar. He’s pain-free right now so let’s give him some oxygen via a face mask. You guys (the paramedics) have already given him some aspirin so lets give him 300mg of clopidogrel (a tablet) and I’ll be right back”
As I’m walking out of the room, one of the paramedics smiles at me and says, “I’m glad I’m not the only one who wasn’t sure.”
The medical registrar, Ben, is on MAU just round the corner so I get him and he comes round to see the patient. Ben furrows his brow when he sees the ECG and then goes out and comes back with a portable ECHO machine. He does an echocardiogram – an ultrasound scan of the heart - and this shows that part of the bottom of the heart was not working as well as it should. We then repeat the ECG and on the new tracing, the wiggly lines are much more obviously meeting the criteria. Inspiration at last!
Ben looks at me, I nod, he nods and then I tell the nurses “let’s do it.” I’d already explained the risks and potential benefits to the patient who agreed to the treatment and so we give him the clot-busting drugs.
By now, my heart is racing, I’m sweating and a thousand scenarios are going through my head. What if he has an allergic reaction? What if he starts vomiting blood? What if he starts bleeding from his nose and his eyes? What if he has a stroke? What if he dies? He might have been OK if I’d done nothing at all – what if he dies? What if I’ve killed him?
So I stay and I watch him and I wait. I wait for all those bad things to happen.
Nothing happens. His heart tracing slowly improves and he remains comfortable and pain-free with no bleeding. It worked!
His heart is still beating and he feels fine, if a little tired (after all it’s 5am).
This is the first time I’ve “thrombolysed” anyone and it was successful. Between us, me, Ben, the CCU nurses, the paramedics, the NHS Direct phone staff and the patient’s wife may well have saved this man’s life.
I’ve got that warm, satisfied feeling as I’m sitting here typing this before I go to bed.
A job well done.
n.b. my indecision and Ben’s decision to do an ECHO before thrombolysis meant that he received his clot-busting drug 28 minutes after arriving, which is longer that the 20 minute government guidelines – but right now, I really don’t care about that.
I walk round to CCU toget there before the patient and start thinking about what is about to happen.
A heart attack is caused by one or more of the arteries that supply blood and oxygen to the heart becoming blocked by a blood clot. The part of the heart beyond the clot gets starved of oxygen and energy and, if nothing is done, that part of the heart will stop working. If enough of the heart muscle stops working, then the whole heart can’t beat properly and the person dies. This is how heart attacks kill people.
In hospital, our aim is to try and open up the blockage caused by the blood clot and this can be done in one of two ways.
The first is called primary angioplasty. This is the best treatment and it involves the doctor passing a wire from your groin to your heart where the blockage can be cleared manually. The second is called thrombolysis, this is more old-fashioned and it involves the medical staff giving you a “clot-busting” drug into your veins to try and dissolve the clot. It works most of the time but there is a 1 in 200 risk of severe side-effects like bleeding into your brain and dying.
We cannot do primary angioplasty at our hospital, we don’t have the right equipment or doctors or nurses trained to do it, so patients with heart attacks coming to Town Hospital get given thrombolysis. It truly is a post-code lottery in the NHS.
The patient comes in. He’s 48 years old with no previous heart problems. He had woken up a couple of hours earlier with central chest pain. It didn’t go away so his wife called NHS Direct who called and ambulance for him. The paramedics handed me the ECG that they’d done while the CCU nurses are connecting him to the cardiac monitor.
An ECG is basically a series of wiggly lines that show us how electricity is moving round the heart muscle and this allows us to deduce if any parts of the heart aren’t working. There are very strict ECG criteria that the patient has to meet before we can give thrombolysis.
Like I said, an ECG is a bunch of wiggly lines and his ECG was on the borderline. You could argue it either way – that it fits the criteria or that it doesn’t fit the criteria.
Now, none of the medical jobs I’ve had have been cardiology jobs and I’ve never personally given anybody thrombolysis before. Because of the very real risk of the treatment (thrombolysis) paradoxically killing the patient, as the doctor you have to be ABSOLUTELY sure that the patient meets the criteria before deciding to give it.
I wasn’t sure.
Thrombolysis is meant to happen within 20 minutes of the patient arriving into hospital. This man probably had heart-related chest pain but his ECG was borderline. The paramedics said that they weren’t sure about it so they’d brought bypassed A&E and brought him straight to CCU to be on the safe side. The CCU nurses (who between them, have seen hundreds of patients having thrombolysis) were not sure about it either.
Then came the moment I’d been dreading. The patient is looking at me, his wife is looking at me, the two paramedics are looking at me, the two nurses are looking at me, and one of them asks:
“What are you going to do doctor?”
The honest answer would have been “I don’t know.” I’m staring at the ECG tracing as if some sort of divine inspiration is going to leap off the page at me and help me make the decision. A decision that has the potential to save this man’s life and also has the potential to kill him.
It is then that I remember what is probably the most important rule of being a good junior doctor.
IF YOU DO NOT KNOW - GET HELP
So I say:
“I’m not absolutely sure about this one, I’m going to get the registrar. He’s pain-free right now so let’s give him some oxygen via a face mask. You guys (the paramedics) have already given him some aspirin so lets give him 300mg of clopidogrel (a tablet) and I’ll be right back”
As I’m walking out of the room, one of the paramedics smiles at me and says, “I’m glad I’m not the only one who wasn’t sure.”
The medical registrar, Ben, is on MAU just round the corner so I get him and he comes round to see the patient. Ben furrows his brow when he sees the ECG and then goes out and comes back with a portable ECHO machine. He does an echocardiogram – an ultrasound scan of the heart - and this shows that part of the bottom of the heart was not working as well as it should. We then repeat the ECG and on the new tracing, the wiggly lines are much more obviously meeting the criteria. Inspiration at last!
Ben looks at me, I nod, he nods and then I tell the nurses “let’s do it.” I’d already explained the risks and potential benefits to the patient who agreed to the treatment and so we give him the clot-busting drugs.
By now, my heart is racing, I’m sweating and a thousand scenarios are going through my head. What if he has an allergic reaction? What if he starts vomiting blood? What if he starts bleeding from his nose and his eyes? What if he has a stroke? What if he dies? He might have been OK if I’d done nothing at all – what if he dies? What if I’ve killed him?
So I stay and I watch him and I wait. I wait for all those bad things to happen.
Nothing happens. His heart tracing slowly improves and he remains comfortable and pain-free with no bleeding. It worked!
His heart is still beating and he feels fine, if a little tired (after all it’s 5am).
This is the first time I’ve “thrombolysed” anyone and it was successful. Between us, me, Ben, the CCU nurses, the paramedics, the NHS Direct phone staff and the patient’s wife may well have saved this man’s life.
I’ve got that warm, satisfied feeling as I’m sitting here typing this before I go to bed.
A job well done.
n.b. my indecision and Ben’s decision to do an ECHO before thrombolysis meant that he received his clot-busting drug 28 minutes after arriving, which is longer that the 20 minute government guidelines – but right now, I really don’t care about that.
Sunday, 8 April 2007
A good news story
As you may well imagine, hospitals are not happy places. They are places where the usual stories are sad, unfortunate tales of despair. Stories of families being shattered by illness and death. Stories of our elderly who gave so much in their youth and now live alone, uncared for and unloved simply waiting to die. Stories of our children who have their futures taken away by unfortunate events.
Working in such an environment can be, quite frankly, really depressing and sometimes it feels like we hardly ever have good news to tell our patients. On the rare occasions that we do have some good news, we try to hold on to the feeling and treasure it because, by God, it makes the job more bearable.
Let me tell you the story of Mr Bennett.*
Mr Bennett came to hospital because he just felt tired all the time and because he was losing weight. Blood results were normal but the X-ray showed he had this ig shadow in his right lung. Mr Bennett had been smoking about 30 fags a day since he was about thirteen and I immediately thought that this mass could well be lung cancer. Ultimately, X-rays are just shadows so we needed to organise a few more tests to try and get a definitive diagnosis of what this shadow was.
I had to tell Mr Bennett what the X-ray showed, that we suspected he had lung cancer but we had to arrange some more tests to try and find out for sure. He took it surprisingly well, at least he didn’t immediately break down, but I spoke to him a day or so later and it was pretty obvious that he was devastated. Over the next week or so, Mr Bennett had various blood tests, a camera shoved into his lungs and a CT scan, all looking or more evidence of cancer.
We were wrong. It turns out that this shadow on his X-ray was not cancer, but a strange ball of fungus that was growing in his lung called an aspergilloma. We told him this news and the poor man broke down in tears, he was so relieved.
As I was walking away from the hospital that day I thought to myself, “this is the only good news I’ve told any of my patients all week. Moments like that make the job worthwhile.”
By the way, Mr Bennett continues to smoke 30 a day.
*Obviously, names have been changed.
Working in such an environment can be, quite frankly, really depressing and sometimes it feels like we hardly ever have good news to tell our patients. On the rare occasions that we do have some good news, we try to hold on to the feeling and treasure it because, by God, it makes the job more bearable.
Let me tell you the story of Mr Bennett.*
Mr Bennett came to hospital because he just felt tired all the time and because he was losing weight. Blood results were normal but the X-ray showed he had this ig shadow in his right lung. Mr Bennett had been smoking about 30 fags a day since he was about thirteen and I immediately thought that this mass could well be lung cancer. Ultimately, X-rays are just shadows so we needed to organise a few more tests to try and get a definitive diagnosis of what this shadow was.
I had to tell Mr Bennett what the X-ray showed, that we suspected he had lung cancer but we had to arrange some more tests to try and find out for sure. He took it surprisingly well, at least he didn’t immediately break down, but I spoke to him a day or so later and it was pretty obvious that he was devastated. Over the next week or so, Mr Bennett had various blood tests, a camera shoved into his lungs and a CT scan, all looking or more evidence of cancer.
We were wrong. It turns out that this shadow on his X-ray was not cancer, but a strange ball of fungus that was growing in his lung called an aspergilloma. We told him this news and the poor man broke down in tears, he was so relieved.
As I was walking away from the hospital that day I thought to myself, “this is the only good news I’ve told any of my patients all week. Moments like that make the job worthwhile.”
By the way, Mr Bennett continues to smoke 30 a day.
*Obviously, names have been changed.
Monday, 2 April 2007
Geography
FEMALE GEOGRAPHY
- Between 18 and 20, a woman is like Afrca : wild, naturally beautiful and full of mysterious, fertile deltas.
- Between 21 and 30 ans, a woman is like America : well-developed and open for trade, especially for those with stacks of money.
- Between 31 and 35, a woman is like India : sensual, relaxed, in full bloom, aware of her beauty.
- Between 36 and 40, a woman is like France : deliciously mature, still a pleasant destination to visit.
- Between 41 and 50, a woman is like Yugoslavia : a lost war, haunted by the mistakes of the past. Major reconstruction work is the only answer.
- Between 51 and 60, a woman is like Russia : vast, with undefined frontier. The cold climate puts off any potential visitors.
- Between 61 and 70, a woman is like Mongolia : a glorious past, great conquests, but without a future.
- After 70, a woman is like Afghanistan : many know its whereabouts, but no-one dares to venture there…
MALE GEOGRAPHY
- Between 15 and 70, a man is like the USA : ruled by a dick…
- Between 18 and 20, a woman is like Afrca : wild, naturally beautiful and full of mysterious, fertile deltas.
- Between 21 and 30 ans, a woman is like America : well-developed and open for trade, especially for those with stacks of money.
- Between 31 and 35, a woman is like India : sensual, relaxed, in full bloom, aware of her beauty.
- Between 36 and 40, a woman is like France : deliciously mature, still a pleasant destination to visit.
- Between 41 and 50, a woman is like Yugoslavia : a lost war, haunted by the mistakes of the past. Major reconstruction work is the only answer.
- Between 51 and 60, a woman is like Russia : vast, with undefined frontier. The cold climate puts off any potential visitors.
- Between 61 and 70, a woman is like Mongolia : a glorious past, great conquests, but without a future.
- After 70, a woman is like Afghanistan : many know its whereabouts, but no-one dares to venture there…
MALE GEOGRAPHY
- Between 15 and 70, a man is like the USA : ruled by a dick…
It's all over... or is it?
I've just had my fourth and final MTAS interview for specialty training in London. The interview itself was absolutely fine and I just feel this enormous sense of relief right now.
To be honest with you, I've found the this last month really stressful. We've been almost over-run at work and preparing for these job interviews takes a lot of time, practice and mental energy.
I'm glad all my interviews are over with and now, I can concentrate on actually doing my job and trying to enjoy myself outside work.
Maybe I'll get a job, in the summer. Maybe I won't but now it's all out of my hands and I can relax a bit in the knowledge that there's nothing more I can do change my destiny. I've got a couple of days off before starting a week of night shifts (again) on Thursday, so I'm visiting friends in the capital and I'm going to have a good time.
Que sera sera
To be honest with you, I've found the this last month really stressful. We've been almost over-run at work and preparing for these job interviews takes a lot of time, practice and mental energy.
I'm glad all my interviews are over with and now, I can concentrate on actually doing my job and trying to enjoy myself outside work.
Maybe I'll get a job, in the summer. Maybe I won't but now it's all out of my hands and I can relax a bit in the knowledge that there's nothing more I can do change my destiny. I've got a couple of days off before starting a week of night shifts (again) on Thursday, so I'm visiting friends in the capital and I'm going to have a good time.
Que sera sera
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