Have a break, have a Kit Kat

I'm off on holiday for a (well deserved) break.

I'll be back in a few days.

The BMA

So, James Johnson, the head of the British Medical Association (BMA) has been forced to resign over MMC. The feeling is that the MMC fiasco and the BMA’s position of support for it is completely at odds with the opinions of the vast majority of doctors.

You know, it’s never been clear to me what the BMA actually do. To be a BMA member you have to pay about £300 a year. This is a sizable amount of money but I’ve never had a good idea what you get for your cash. When I pose this question to doctors, I get replies like “it’s important to be a member because they’ll support you if there’s a problem with your employer” and “the BMJ is a good journal to get.”

I’ve never been wholly convinced by this line. I mean, what protection does BMA membership give you over and above standard UK employment laws? I don’t know, maybe someone can answer his question but I don’t think it’s much if any. And, to be honest £300 for a magazine subscription is a little steep, especially considering the BMJ is available to read in every single hospital library in the country for free.

The only valid reason for being a BMA member I could think of was that if the shit really did hit the fan and the government properly tried to screw us over, then the BMA would be there fighting our corner.

MMC is the government trying to screw me, and thousand of other junior doctors across our land, over in a big fashion. I expected the BMA to be standing up and fighting against a system that nobody seems to want. Were the BMA fighting our corner?

Were they bollocks. The silence was deafening. The complicity is sickening.

£300 a year.

What a waste of money.

Saying Thank-you

As I was leaving work today, I took a second to pause and read some of the cards that are pinned up near the entrance to our ward. These cards are from patients and the relatives of patients that we’ve had on our ward. There were four new ones that I hadn’t seen before. Two were from former patients and two were from the relatives of patients who had recently passed away. The thing that struck me while reading these cards was the sensitivity that was expressed and the gratitude that was shown to the nurses and to the doctors who had looked after people during their stay. I felt genuinely touched that people had taken the time just to say thank you.

The NHS gets a bad rep in the press and from the public at large. But, to be honest, all the stories of neglect, of uncaring staff, of MRSA and dirty wards are not at all what I see. When I meet up with my non-medical friends and they start repeating bad press stories like this to me, I tell them that I wish they could come onto a ward in an NHS hospital. I wish they could just spend an hour or two on the ward talking to the patients there and just ask them how they felt about the way they’ve been treated. I’m confident to say the vast majority of the patients would say that they’re very happy with their treatment and it’s a shame that the good experiences don’t get anywhere near as much press as the bad ones.

Last year, my father had to be taken into hospital and I have to say that I couldn’t ask for anything more from the health professionals who dealt with him. The paramedics, the A&E staff, the surgical doctors and nurses were all fantastic. It was strange being on the other side of the service, but everything got sorted out and he was treated with the utmost care and respect. I was glad.

A recent news article showed that, in fact, the vast majority of people were happy with the care that the NHS provides, and that seemed to be borne out by those cards pinned up near the entrance to our ward.

A Clean Sheet

I’m stating the obvious when I say that hospitals are full of very sick people. After working in such an environment for a while, and seeing so many people die, you get the impression that death is part of the furniture. Some people die slowly, some suddenly, some go peacefully and some die in great pain and indignity.

Some deaths are an expected inevitability whilst others are preventable and it’s our job as doctors to recognise those at risk of dying unecessarily and doing all we can to stop the preventable deaths from happening.

This weekend, between the hours of 17:00 on Friday afternoon and 00:00 Monday morning, nobody in Town Hospital died.

Nobody.

Between us, me, Ben, the house-officers and the night team have managed to keep every single in-patient alive. I’m not sure how often this happens, but I don’t think it happens very often. There were some close calls though. There was an old lady who came in with blood poisoning from a urine infection who we thought was on her last legs but rallied round amazingly after we gave her antibiotics and IV fluids. There was a man with kidney, heart and lung failure who we thought was going to die but perked up well with oxygen and fluids. And of course there was Jim, who actually did get to watch the FA Cup final on CCU and when Drogba scored, I’m sure he was the happiest man alive.

Through a combination of good luck and good judgement, everyone who was here on Friday is still here now, along with everyone who was admitted over the weekend.

A clean sheet.

Football isn't a matter of life and death, it's much more important that that

Ben, the cardiology registrar, is a really nice guy and I like him a lot. Trouble is, every time me and Ben are on call at the same time, we have major drama to deal with.

This evening, I admitted a man called Jim into hospital. Jim is 85 years old but still independent and lives by himself. In the afternoon, Jim had been to the post-office and as he was leaving, Jim passed out. Now, I don’t know if any of you have recently been to the post-office but I have to say that every time I visit one, I end up seething with rage or in tears. Why does it have to take the best part of the day just to post a parcel? Mr Angry knows how I feel and, to be honest, I don’t blame Jim for passing out.

Jim was a little embarrassed by the whole episode, but felt pretty much back to normal. Jim is a big Chelsea fan and was desperate to get out of hospital so he could watch tomorrow’s FA Cup final. I asked Sharon, the nurse, to do an E.C.G. recording that showed the Jim had an irregular heart rhythm that Jim had had for donkey’s years. But it also showed that Jim’s heart was beating very, very slowly indeed. I figured that this was probably a side-effect of some of the medications he was on and, as a precaution, I asked for Jim to be put on a cardiac monitor so we could keep an eye on his heart rhythm.

I’m seeing my next patient about half an hour later and Jim’s cardiac monitor starts beeping. Sharon says “I’ve just walked away from him, he’s fine – the monitor’s faulty, I’ll go turn off the siren” and leaves the room to see to Jim’s monitor.

A couple of seconds later I hear Sharon shout,

“CAN I HAVE SOME HELP PLEASE!”

Jim wasn’t fine at all. The siren was going off because Jim’s heart had stopped beating. Jim was dead.

I run to Jim’s bay and commence CPR with Sharon and another nurse goes off to get the crash trolley. The other members of the cardiac arrest team arrive and we start advanced life support, as we’ve been trained for.

We shock Jim. Basically we electrocute him in the hope that his heart will start beating again.

It works.

Jim gets a pulse back. Slowly, over the next 20 minutes or so, Jim becomes more and more responsive until he is able to utter the words “Where am I?”

Those words made me feel happier than any words have made me feel for a long time. We saved Jim’s life. If this had happened in the Post Office, Jim would have been dead. If Jim hadn’t listened to the advice of the paramedics to “have it checked out,” he’d be dead. If I hadn’t asked for Jim to be put on a cardiac monitor, he’d be dead.

As it is, when I finished the shift, Jim was sat chatting to his daughter on the coronary care unit. While he probably won’t get to see the FA Cup final, he’ll at least be alive to listen to it on the radio and, as Ben told me, “you’ve go to be happy about that.”

(For those medics among you, the initial ECG that Sharon did showed A.F. with bigemeny at an effective rate of 36 bpm. He had a VF arrest and reverted back to bigemeny after one shock.)

Trapped in a closet

In my time, I've been in some pretty hairy situations because I've done things that I should have thought twice about. Someone thought I'd enjoy this story and I did.

Hip-Hopera - it's fucking hilaious.

http://www.youtube.com/watch?v=FCXlCkY4Y5g&mode=related&search=

Everyone has an opinion on the NHS

Bill is a man in his eighties with dementia. Dementia is a condition that means that people forget who theyare, where they are and who people are around them.

Bill's not particularly concerned by this though and he wanders round the ward quite happily in his own little world. He needs supervising though because his dementia means that he gets himself into trouble and if there's nobody watching him, then bad things happen.

Yesterday, one of the staff nurses noticed that the door to the Ward Matron's office was ajar. She pushed it open and found Bill squatting down with his pants round his ankles having a shit in the middle of the floor!

I know shouldn't laugh but I thought it was hilarious. It seems everyone has an opinion on the NHS! Matron, on the other hand, was very angry indeed...

Alcoholics II

Last week, I posted about an alcoholic patient that I treated on the Medical Admissions Unit. I was replying to a comment that a medical student wrote, but my reply got so long I figure it deserves a post of its own. You can read the original post here.

-------------------------------------
JB said...

I'm a final year student, and to be honest, I hope I never talk to a patient like that. Yeah, blah blah blah tough love, but to me that sounds like a good excuse for a dose of old-fashioned, hideous paternalism and moralising. Your patient probably doesn't need her face rubbed in the mess of her life, it's only likely to compound whatever emotional crap she is using drink as an escape mechanism from. I really like your blog and think you sound like an ace doctor (and everyone is to be forgiven for moments of getting annoyed with patients) so don't think I'm being mean, it's just my viewpoint on how I'd approach it.

11 May 2007 23:22
----------------------------

JB,

You make a valid point, and one that I’ve thought about loads since that conversation with Joy. I don’t feel proud or happy about making her cry, it was not my intention to make her feel bad or to “rub her face in the mess of her life.” I could have been less dogmatic in what I was saying but the whole situation made me feel sad and angry and I felt I had to say something about it. All I did was spell out the truth.

Let me explain;

My anger stemmed from frustration. Like many addicts, I don’t think Joy thought she had a problem. I don’t think Joy could see how much hurt she was causing. I’m certain Joy didn’t have an idea of what the future would hold is she continued to neck a litre or two of spirits a day i.e. that she would die before her time in a messy, ugly and probable painful way.

Joy has got herself into a cycle of helplessness where she EXPECTS everything to be done for her. She EXPECTS that her mother will come round and pick her off the floor. That her mother will clean up her vomit, clean her bathroom and make sure her flat is habitable. She EXPECTS that the paramedics will be there every time she feels hungover. She EXPECTS that the doctors and nurses in hospital will make her feel better and help her over the symptoms if withdrawal.

Joy is RIGHT to have these expectations, these things have happened many times before and will probably happen many times in the future. I don’t think Joy saw any need to change her ways.

The point I was trying to make to Joy was that it is not FAIR to expect all these things. I wasn’t thinking about the medical side of things - after all, me, the nurses and the paramedics have been trained to deal with this sort of thing and we get paid for it. I was thinking about the grief that Evelyn (Joy’s mother) and Joy’s children were going through every single day. Joy just didn’t care about her family, and her family obviously cared deeply about her. That’s what made me mad, that’s what makes me sad. Joy continues to lie, to manipulate, to get drunk then call her seventy-something year old mother at 2am saying she’s fallen over etc… etc…

JB, obviously you are entitled to you opinions as I am mine. Yes, I was moralising. Yes as was being paternalistic, but in this particular case, do you honestly think this is a bad thing? I appreciate that it’s easy for me (a non-addict) to tell Joy to give up her addiction and I appreciate that I don’t have first hand experience of what it involves, because I’ve never had to do it. Joy has her reasons to drink and while I can sympathise that life is hard, I also recognise that there are millions of people on this earth for whom life is hard but do NOT turn to drink and manipulate those trying to help them. At the end of the day, we all have to take responsibility for our own actions and Joy was not taking ANY responsibility for hers.

I’m sure Joy had her reasons to start drinking, I was trying to make her see some reasons to stop.

Was I wrong to at least attempt to make her see how much drinking is destroying her life and the lives of those who care about her?

You’re a final-year medical student, so you probably don’t need me to tell you that alcoholic liver disease (ALD) is one of the very few medical conditions that is totally reversible. Unlike diabetes or heart failure or emphysema or cancer, people with ALD can get better, they can actually cure themselves – but only if they stop drinking.

In the last fortnight, I’ve seen five people die from decompensated alcoholic liver disease. Five dead people who would still be living today if they had stopped drinking. Of those five people, only one had family around them when they died. Four died alone, surrounded by strangers on a hospital ward.

This makes stories like Joy’s so much more tragic. It’s like that train crash that you can see coming but feel you can do nothing to prevent. I was just trying to prevent Joy from crashing, but I suspect – like so many before me – that I’ll fail.

Space to breathe

It's funny how you don't realise how tired you are until you stop. I went to bed a 21:30 on Friday and slept all the way through to 11:30 on Saturday. I woke up and felt fantastic.

Over the weekend I've been revelling in doing not much at all. Meeting up with friends, reading the newspaper, watching telly - it's been really, really nice.

I'm back at work tomorrow but this weekend has given me space to breathe and for that, I am grateful.

I have a dilemma

I was driving home from the hospital last night and there’s a couple of lorries in the lanes ahead of me. They both put on their hazard lights and slow right down. I slow down too and move to overtake them. When I pull out into the overtaking lane, I see why they were slowing down.

Up ahead there’s been an accident. A silver car is resting against the central reservation with its bonnet all smashed up. There are no emergency services around.

I have a dilemma.

Should I drive on, like the rest of the traffic, or should I stop and see if anyone is hurt and try and help?

One voice was saying: “Michael, you have no experience of handling out-of-hospital emergencies, you have no equipment AT ALL. All you have is your bare hands, what use do you think you can be? Stopping would be pointless.”

Another voice was saying, “Look, you may not have been trained in this kind of thing but you are a doctor and you have managed trauma in A&E, you know the basics and you’ll undoubtedly know more than anyone else there. You should stop and try to help.”

I’m getting closer to the car now, I can see a man standing near the car. I make up my mind.

I stop.

“Hello, my name’s Michael, I’m a doctor on my way home from work. Are you OK? Is anyone hurt?”

It turns out that the man and his girlfriend were both fine. They were obviously shaken up, but they were both out of the car, walking around and talking to me. After a couple of minutes, the police arrive on the scene and I decide to leave and take myself home to bed.

What made me stop was the fact that IF there had been someone hurt, there MIGHT have been something I could have done to help. If there was the possibility I could have saved someone’s life and I’d driven on and ignored them, then, I would have felt so guilty that I would not have been able to sleep at night.

Last night I slept like a log.

On autopilot

I'm tired. I know junior doctor's hours these days are a walk in the park compared to what they used to be but, still, I've worked 13 hour shifts for four days on the bounce now and I'm tired.

Luckily for me, I've got a holiday coming up and I'm really lookin forward to it. It's like a big beacon at the end of the tunnel and there were times this afternoon when dreaming of Europe was the only thing that was keeping me going.

Thankfully, this bank holiday weekend has been relatively quiet. I suspect it's because people are away from home and wanting to enjoy their holiday and so don't come into hospital with vague symptoms. I'm probably wrong about this but it suited me fine. The doctors and nurses on duty actually got time to sit down and have a cup of tea together, which is very nice and makes work a more enjoyable place to be.

Today, I clerked in

2 people with a urine infection
2 people with a chest infection
2 people with mini-strokes
1 person with a paracetamol overdose
1 person with an irregular heartbeat
1 person with worsening angina

It was a steady stream of patients that kept me occupied but it wasn't really a particularly exciting or interesting shift. I felt like I was on autopilot for most of it and I think that is due to the tiredness.

I'm going to bed.

Alcoholics

The longer I work as a doctor, the less patience and sympathy I have for alcoholics. If ever there was a group of people who are self-absorbed, manipulative, lying ingrates who abuse and manipulate the people around them, their families and the healthcare system - it’s them.

I used to feel sorry for alcoholics. I used to listen to their stories about how life is so hard for them and about how nobody cared about them and about how they are really going to change and I used to feel sympathetic. But honestly, the more I see the way they constantly drain the will of those who are trying to help them, the less I feel sympathetic and the more I feel (whisper it) disdain.

Joy is a 44 year old woman who came to Medical Admissions today from A&E. Joy has alcoholic neuropathy. Basically, she’ drunk so much that she’s killing the nerves in her feet and this means her legs are weak and she falls over a lot. Joy has come into hospital because she couldn’t get up and started having alcohol withdrawal symptoms because she couldn’t get to her vodka. The physical symptoms of alcohol withdrawal can be treated quite easily and very effectively – this was not the issue.

Scratch the surface and I find out that in the last 7 days, Joy has called the ambulance out 3times and her GP out twice, each time refusing treatment when the health professionals arrive.

Joy’s mother, Evelyn, and Joy’s two children ask to speak to me. The story comes out that Joy has had many, many admissions to hospital recently because of her drinking. Each time, she comes in, her symptoms get sorted out and when she’s discharged, Joy is fine for about three or four days. Then Joy will start drinking again. When Joy drinks, she doesn’t look after herself, she doesn’t clean or wash herself, she dangerous when she tries to cook, she doesn’t eat and she gets verbally and physically abusive towards her own family. Evelyn is in her seventies and is not in the best of health herself. She is coming to the end of her tether because she just doesn’t know what to do with Joy. Evelyn is up all night worrying about her daughter. Worrying that Joy is going to hurt herself or that Joy is going to accidentally set fire to her block of flats.
Evelyn, along with Joy’ children asked me if there was any way that we could detox Joy and get her better so that she’s the daughter (and mother) that she once was.

The trouble is, and I explained this to Evelyn, if Joy doesn’t want to stop drinking, there’s not a great deal we can do. Sure, we can patch her up when she falls down but unless she’s made her own mind up to give up the booze, any help we try to give will be wasted. Is there any point making her an appointment to see a behaviour specialist if she never turns up because she’s pissed again?

It’s sad. Here I a woman in her mid-forties who has family that obviously care about her and love her, but Joy doesn’t see that. Joy doesn’t care. This is what is going to happen: Eventually, Joy will drive them away and her family will give up on her. In the future, Joy will be in hospital telling young doctors like me about how her life is so hard and how nobody cares about her and how she’s really trying to change.

Joy is drinking her life away and it’s so sad.

A bit later on, I was siting a canula in Joy’s arm so we could give her some intravenous vitamins to help improve her symptoms and she says to me.

“You just don’t think that this (weak legs) is going to happen to you, do you doctor?”

I could not believe that she actually said that. I looked her in the eyes and said.

“Joy, you KNOW why this happens. You’ve been told again and again why this happens. It’s happening because you keep drinking. How many times have you been to hospital or A&E this year because of your drinking? How many times have you been told you need to stop? You’ve been told by doctors, by nurses, by your own FAMILY to stop drinking but you just carry on. Your legs are weak because the booze is rotting the nerves in your feet. Soon, it’ll start rotting your brain as well. You are 44 years-old! You should be living life to the maximum, but instead you have to live in a warden-controlled flat and it’s all because of the booze. I’ve just been speaking to you family, Joy. You have a great family that love you and that care for you and that worry about you. Do you know how lucky you are to have that? There are people in here, on this ward right now, who would give anything to have a family like yours. Your mother is not a well woman and she’s making herself ill because she’s worried sick about you Joy. Do you think that’s fair? Do you think it’s fair that she has to come round and clean up after you when you’re drunk, to make sure you’ve eaten? You’re a grown woman for Christ’s sake. Why are you doing this to her? She’s in her seventies! Why are you doing this to yourself? If you don’t stop drinking Joy, you are going to die. Don’t think I’m saying that just to scare you, I’ve seen it happen so often – it’s the truth. But it doesn’t have to be like that. Your legs will get better if you stop the booze. All this will get better if you stop the booze. You could be out enjoy life if you stop the booze, but you’ve got to want to stop, Joy. The only person who can make this better is you, so you have to ask yourself – What do you want to do?”

By this time, Joy is in tears and she says

“I’m an idiot, aren’t I doctor”

“Yes you are. It’s time to change”

I don’t feel great about upsetting my patient and making her cry, but selfish, manipulative people like her make me so angry, especially because so many people are trying to help her and she’s throwing it all back in everyone’s faces.

What do you think? Was I too harsh? Does my lack of sympathy for Joy make me a bad person? Does it make me a bad doctor?

How old is old?

Today, I admitted a 97 year old woman to hospital with dehydration due to diarrhoea.

Ninety-seven.

This woman is seriously old.

When I was eight years old, I couldn’t even conceive of being so old that my age had double figures. When I started high school, to me, the fourth years were grown ups weren’t they? When I started medical school, aged 18, I though 60 was old because, you’re nearly retired.

Since starting work as a doctor, my perception of age has changed yet again. If I see a 55 year old patient, I describe him as “young.” A 66 year old retired woman is still “quite young.”

I don’t start thinking of people as being “old” until they’re about 75 to 80.

It’s funny how your perceptions change as you go through life. I think when I was eight years old, I wouldn’t have believed you if you told me that there were people who were still alive at 80.

Still, to have lived 97 years makes you bloody old.

Bank Holiday Weekend

Things to look forward to over the bank holiday weekend:

Drinking in the sun with your friends
Taking the time to visit your family
Long lie ins
Playing sports
Going to see your favourite campsite/beach/theme park/garden centre/grandparent

Things not to look forward to over the bank holiday weekend:

Working four 13-hour shift on consecutive days on Medical Admissions

Oh the fun that awaits!

Hospital Radio #1

…by department:

Birth Suite – I see you baby (Groove Armada)

Orthopaedics – Break Stuff (Limp Bizkit)

Coronary Care Unit – What becomes of the broken hearted? (Jimmy Ruffin)

Endoscopy – I want to be sedated (The Ramones)

Eye Clinic – Blurry (Puddle of Mudd)

Respiratory Medicine - Take my breath away (Berlin)

Mental Health Unit – This troubled mind of mine (Johnny Tyler)