When the numbers don't add up...

Mr Adams is a lovely old man. I was speaking to him one day and he said, “you look tired, do you want a sweet?” and offered me one of the Werther’s Originals from the packet on his bedside table. I thought this was so sweet and I gratefully accepted and said thank you. This was a week ago, and since then every day, after I see him on the ward round, he offers me one of his Werther’s Originals. It’s our “thing.”

Mr Adams’ liver isn’t working.

When patients have liver failure, the majority of what we do for them as doctors is dependent on what their blood test results. So, at 09:40 every morning, Mr Adams has his blood taken by the phlebotomists. The sample is sent to the pathology laboratory where it is tested and just after lunchtime, the results are put up on the hospital’s intranet as a collection of numbers. Back on the ward, I use the intranet to access his results so I can alter his medications/drips as necessary.

Mr Adams’ blood results were holding for a while, but on Tuesday they were very worrying. They showed that his kidneys had stopped working meaning he had what we medics call “hepato-renal failure.” This is very, very bad news indeed.

My consultant, Dr Fletcher, spoke to Mr Adams and explained, as sensitively as possible, what was happening. He told him that he had only a 1 in 20 chance surviving and that while we’ll give him all the right treatment so he had the best possible chance, prognosis was bleak and it would probably be a good idea to put his affairs in order if he hadn’t done so already.

Mr Adams was as stoical as ever and told us that his affairs had been put in order a long time ago and that he’d do his best to fight his illness. “I’ll tell you what’s funny doctor,” he said. “I feel better now than I’ve done in weeks.”

Mr Adams told me that he wanted to live to see his grand-daughters 5th birthday next month. Over the next couple of days, his kidneys improved and his numbers got better and I started to hope. I started to hope that we’d made a mis-diagnosis and this wasn’t “proper” hepato-renal failure. I started to hope that the numbers would continue to get better and that Mr Adams would improve. I started to hope that Mr Adams would be in the lucky 5%. I started to hope that Mr Adams would be able to see the smile on his grand-daughter’s face as she blew out the five candles on her birthday cake.

I was wrong. I got into work yesterday morning and Sue, one of the staff nurses, asked me if I could come and see him.

Mr Adams was taken a major turn for the worse. He was gasping and every time he took a breath you could hear this horrible gurgling sound from his lungs. Doctors and nurses call this the “death rattle” and it really is a sign that there’s no way back. Sitting around his bed were five members of his family, whom the nurses had called in the early hours of the morning.

I asked them to please give me a moment with Mr Adams and then did a quick assessment to try and see what his level of consciousness was. I then stopped all the medications on his drug chart and prescribed him only morphine (for pain), a sedative and a drug to dry up the secretions that were dripping down the side of his mouth.

I went into the quiet room with his family members – his wife of 43 years, his two daughters and their partners – and I explained to them what they could already see with their own eyes. Mr Adams is dying.

His wife started crying, then one after the other his daughters started crying too. I really liked Mr Adams and I felt myself welling up as well. But I had to be professional; it’s not my place to join their grief. When the asked me how long he had left, I had to take some deep breaths to keep my voice even. I said that, while it’s impossible to give an exact time frame, I thought it would be a matter of hours rather than days.

I was right. Four and a half hours later, Mr Adams took his last breath and died. After the family members left, I went into his room to certify him dead. As I was leaving Mr Adams’ room for the last time, I noticed a half-finished pack of Werther’s Originals still on his bedside table.

Rest in Peace, Mr Adams.

A small diamond in the dirt

I have a brief reprive. The people who are running the MMC have said that junior doctors like myself who have jobs at the moment will be able to continue working in our current positions "while we progress through round 2."

Reading between the lines, this means that I won't be forced to sign on in six weeks' time, but witll have probably until the middle to end of October to try and get a job. Obviously, I'm really relieved by this because it means that I can continue working and treating patients for a while longer and have a bit longer to try and save up some money to tide me over if I don't get job this year. It's one thing less to worry about.

This is the only piece of good news that I've had from the MMC people.

Little things sent to try us

The vagaries of the rota meant that I was the only doctor on the ward today covering our 35 inpatients. I knew it was going to be hellishly busy before I arrived at work but sometimes, I think events conspire to make life even more difficult that it is already.

All of the following happened today.

- Our boiler broke down meaning I had to start the day with a cold shower.

- The hospital was having a bed crisis. This meant I had the Matron and the discharge planner hassling me to send patients home all day long. You’d think that they’d realise that

- The lifts to the ward broke down meaning two patients couldn’t go for important scans.

- Four patients decided to go outside together for a cigarette and stayed out for about an hour and a half in the morning. This meant they missed the phlebotomists (blood-taking team) which meant I had to take all the blood samples myself.

- There was a problem in the laboratory (I think a centrifuge broke or something) that meant that all today’s blood test results were delayed until half four in the afternoon.

- Two nurses phoned in sick meaning that we were (even more) understaffed nursing-wise so lots of things just didn’t get done.

- After doing a discharge letter and medication list for a patient, some clown lost it so I had to re-do it. This happened twice.

- My man with renal failure’s drip stopped working. He has hardly any accessible veins left and it took me 20 minutes to eventually get one into his foot. God knows what we’ll do when that one stops.

I’m usually a very calm person but when I eventually left work at 18:40, I have to admit I felt more than a little stressed out.

Let’s see what tomorrow brings.

Slowly... slowly...

One of our patients, James, is a heroin addict with H.I.V. and he’s in hospital with an abcess infection that’s spread to his blood stream (septicaemia).

He is as sick as a dog. He has a fever of 41°C (106°F) and as the infection courses through his veins, it causes him to shake (rigors) and, quite understandably, he feels awful. Over the weekend we were treating him with powerful antibiotics given straight into his blood stream via a drip. Like I mentioned, this guy injects smack and over the years that he’d been shooting up, he’s knackered all of his veins and this morning we finally ran out of veins that we could use to put the drip up.

He needed a central line.

A central line is a plastic tube going into one of the large (jugular) vein in the neck. Inserting a central line into a person involves (not to put too fine a point on it) lying your patient down, turning their head away from you and then stabbing them in the neck with a metal spike roughly the length of a child’s forearm. It’s one of the things that really highlights the sky-high levels of trust that our patients give us as doctors.

As you can imagine, there are lots of thing that can go wrong with central lines so we try to avoid put them lines into patients unless it’s absolutely necessary. Because not many patients have them, junior doctors like me don’t get to put them in very often. So when Dr Fletcher, our consultant, asked us which one of us wanted to put the central line into James, I jumped up and down with my hand in the air and shouted, “Pick Me! Pick Me! Pick Me!”

So I got to do a central line… on a H.I.V. positive drug addict with who was having rigors. My mother always used to say that you should be careful what you wish for.

I haven’t put in a central line for several months so, after I’d explained the risks and benefits to James and he’d agreed to let me do it, I asked one of the anaesthetists to help me do it an a master-and-apprentice fashion.

Now, I’m no psychic, but I reckon that if there was a mind-reader watching me put a the central line into James’ neck, he or she would have possibly overheard something along the lines of this:
------------

Me: OK, I’ve got to absolutely spot on with this. This guy is covered with sweat and he keeps shaking, I can so see this going horribly wrong if I make the slightest error. Slow and steady is the way forward.

James: I feel like shit. It’s like my whole body’s on fire. I want to puke but this doctor won’t let me. He’s a nice enough bloke, but I just wish he’d get on with it so that nurse can give me my medicine and I can start feeling better.

Me: So, I’ve got my gown, mask and sterile gloves on, I’ve got my sterile field set, all the equipment is ready, I’ve cleaned his neck with iodine, OK I’m ready to go.

James: I’m so going to spew if this guy doesn’t stop playing with that machine and start doing something and why does he have that stupid looking gown on? I know I've got H.I.V. but surely this is a bit O.T.T. - he looks like someone from a bad sci-fi film.

Me: The local anaesthetic’s in now. I’ve got the ultrasound machine ready so I can see the needle-tip, it’s time for the big needle

James: Whoa! What the hell is that!?! He wasn’t kidding when he said it was a big needle that’s the biggest needle I’ve ever seen in my life! And I’ve seen a hell of a lot of needles!

Me (out loud): “OK Sir, now it’s REALLY important that you keep REALLY still for this bit.”

James: Too right I’m keeping really still. That thing is like an offensive weapon and I can see your hands shaking. The end of that needle is moving all over the place. I’m just going to close my eyes and pray.

Me: OK, success, I’ve got the needle in the right place, now I’ve got to pass the guidewire down into the jugular vein.

James: …thy will be done on Earth as it is in Heaven…

Me: Slowly… slowly… OK, it’s in now I need the dilator.

James: …though I walk through the shadow of death, I shall fear no evil…

Me: That the hard bit done, now I’ll pass the actual central line over the guidewire, then all I’ll have to do is stitch it into position and it’s all done.

James: I feel sick again.

Me: All done! That was actually not too difficult and not even very messy. Well done me!

Computer says, “No.”

So here we are. The offers have all been made by the deaneries and I don’t have a job. Come 1st of August, I shall be unemployed.

Gutted? You bet I am. After all that has happened since February regarding my career, the prospect have having to do it all again is soul-destroying. After all the time and effort I put into the application process, I have achieved fuck all and have gotten nowhere.

The prospect of unemployment has been hanging over me for several months and now it’s actually happened I don’t feel as gutted or distraught as I thought I would. Don’t get me wrong, I’m not exactly singing from the rafters but I appreciate that things must move on.

I’m quite lucky that I have no big ties. A few years of ignoring my parent’s banging on at me to get onto the property ladder has actually worked in my favour as I now have no mortgage to pay. My previous (wannabe) international playboy lifestyle has meant that I’m not in a committed relationship and I have no children. Most importantly, I’m still young enough to retrain in a different career if it all goes really wrong and I decide to stop being a practicing doctor.

I’m not willing to move just anywhere. There are things in my life outside medicine that mean I’d try my hardest to stay where I am but I’m more flexible than some and, should push come to shove, it’s relatively easy for me to move if I have to.

There’s still a chance I could get a job this round because re-offers are being made up until 22nd of June, but I’m not putting my hopes on it. To use a quote from military strategy theory, “If plan A doesn’t work, you should move to plan B and NOT to plan A repeated.”

I have a plan B.

Hopefully, the next round of applications will be less random and hopefully they won’t disregard a year’s worth of experience as “irrelevant” like they did last time.

If you take a step back and look at it objectively, the situation seems even more bizarre. Right now, I’m working as an SHO on an incredibly busy firm and doing my job well. MMC are basically saying that I’m not good enough to do the job that I’m already doing. I applied for the job that I’m doing last year and they decided at the time that I was good enough to do it. Given that I now have several months MORE experience, have done MORE audits and MORE courses, can do MORE procedures and have learnt so much MORE than I knew then, it’s seems bizarre for them to say that I’m no longer good enough.

But computer says no so there’s no job for me – tough titty.

I was short-listed four times for interview back in March (round 1a)

Working harder

This last week has been manic. Our team has been so busy. We’ve had several really sick patients to look after and we’ve also had several patients who aren’t that sick but needed lots of stuff sorting out for them. Two doctors are away on annual leave, so we’ve been working with skeleton staff. It’s been really tough. Tough in terms of the mental stress of trying to treat our very poorly patients whilst at the same time being vigilant about the rest of the ward and making sure everybody has a plan and that said plan is working. It’s actually been really physically tiring. Every day this week, the other SHO and I have been turning up to work early and leaving late.

On Friday, our consultant took us to one side and told us

“You guys have done really well this week. It’s been really difficult and I can see you’ve been working very hard. All in all, most things have got sorted out and I’m really pleased. Well done guys.”

It’s really nice when the bosses say stuff like this. It’s really nice to be appreciated and when you do a job well, it’s nice to be told so.

Let’s hope next week is more sedate.

Dealing with emotional situations

One of the nurses discusses a comment in her student’s coursework book:

Staff nurses often have to deal with highly emotional situations, but rarely have any formal training about how to deal with them…

“You know, I’m a really emotional person, me. Give me a film or a sad story on telly and I’ll cry my eyes out, but at work it’s different isn’t it? It’s weird, because obviously we see loads of really sad things on here [the ward] but no matter how bad the situation, or how upset the patient or relatives are, you won’t see me crying at work. I won’t even go home and cry about it.

“If you think about it - it’s strange because obviously here it’s all real and you’d think I’d get more upset than I do about anything on telly. I think what it is, is that when it happens in front of you, it’s not fair if I, as their nurse starts getting upset about it is it? It’s their grief, it’s their lives, not mine. If I start sobbing, it’s like it’s putting the focus onto me, and really it shouldn’t be about me should it? It should be about the patient and their family.”

Getting Nervous

I’m getting nervous now.

I haven’t posted much about MMC or MTAS because, let’s face it, it’s pretty well covered elsewhere in medical blogosphere but it’s getting me down again. The application process has been dragging on and on and on since December and I’m just tired of it. Last week and this week, the deaneries actually started making job offers via email... at different times to different people. This means that some people have secured a job already – good on ‘em – whilst others are still waiting.

I’m still waiting, I’m still hoping, I’m still checking my inbox two to three times a day for any news, still wondering if I mis-typed the email address on the application form, still gob-smacked at being told by one of the consultants that interviewed me that a year’s worth of SHO experience in A&E and surgery was “irrelevant,” still staring down the barrel of unemployment in 57 days.

As each day passes, I get euphoric texts and calls from my doctor friends who have been made a job offer or two. While I’m really glad that my friends don’t have to worry about it anymore, every text message brings more sharply into focus the fact that I have nothing.

This is horrible.

It feels like A-level results day in that you know your future for the next five years is going to depend on the letters in that white envelope. That day, emotions were running high and it seemed that everybody was either ecstatic or distraught.

For me, this is much, much worse than that day. At least then, you knew you were going to get an answer. Now, I just don’t know. If I haven’t got a job, I won’t know until the 20th of June. The not-knowing is sickening and it’s getting me down.

I’m going to try and get some sleep and I’m hoping I feel better about it in the morning.

Goodnight.

The importance of being idle

Wow, it’s amazing how good I feel after having a break and getting away from it all. I think I didn’t realise just how much I was wound up until I had the chance to just… stop… and do… nothing. It feels great.
There have been times in the last few months when I’ve felt like I’m spending my whole life in the hospital. In the time when I wasn’t at work, I was buzzing around like a bee trying to organise seeing and speaking to friends. This last week has really given me chance to pause and I’ve really enjoyed having time to chill.
I found that I’ve been revelling in doing the little things. Here are some of the things I’ve really enjoyed doing in my week off:

Sitting down and having a cup of tea whilst reading a newspaper
Talking to my friends for hours on the telephone
Making the effort to go and visit my parents for dinner
Dusting off my bicycle and going for a bike ride in the coutryside
Sharing a pint with a good friend in the afternoon
Dancing like a fool in a club
Meeting my brother’s new girlfriend and having a polite conversation
Reading a book

I’m enjoying myself and I have a feeling that this summer is going to be fantastic. Heads up though because work begins again tomorrow.