Until the fat lady sings

Yesterday was my last day on call for general medicine and today was my last day on the wards.
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

There’s people on the pitch…

That’s it.

It’s all over bar the shouting. Today, I finished my last ever on call shift as a doctor working in general medicine. Back when I was a PRHO (remember those?), just out of medical school, I the abiding memory of my first ever on call shift was an overriding sense of fear. I’ve learnt so much since then and so much has become routine for me, that I think I’ll remember my last ever shift for being… well, for being pretty unmemorable, really.

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:

Dr Michael Anderson
ST1 Anaesthetics

Bring it on.

Happiness begins at home

My consultant, Dr Fletcher, was in a particularly foul mood today. I don't know why, exactly, but I have a theory...

Sabotaging my relationship

Now I know that I’m leaving Town Hospital, I’ve been thinking about the things that have happened to me whilst I’ve been working here. My mind keeps coming back to Gemma. Things never did work out between me and her. We went out a couple of times and I’m she was really keen. The reason it didn’t work out was 100% my doing. I had other things on my mind. The most obvious of which was that I knew that if we did get together, there was a high likelihood that I’d have to move far away from her in a matter of weeks.

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:

Intelligent
Sexy
Funny
Caring
Outgoing
Sporty
Sociable
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

It's a hospital, it's not a prison

“Can I go home, doctor?”

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.

New Beginnings

I have a job.

MMC has meant months and months of dark days, heartache and stress for myself and thousands and thousands of other junior doctors. The powers that be have shown their colours and have fed us and the public misinformation and lies time and time again. There have been many tears shed and thousands of lives have been changed forever this travesty which went all the way to the highest court in the land.

Since the computer said “No” after round one, I have contacted hospitals in New Zealand and Australia and received some very positive feedback regarding job opportunities. I’ve joined two locum agencies so I could earn some money in the meantime. I’ve written a non-medical CV and asked some friends in London about how I’d start a career in finance. I didn’t want to do any of the above but felt I had to formulate plans B and C because the spectre of unemployment was looming larger and larger hour by hour.

I really feel like I’ve managed to snatch victory from the jaws of defeat. Like I’ve scored a last-minute equaliser or gained a death-row reprieve. I feel kind of shocked that, for me at least, all this hassle is over. No more frantically checking NHS jobs and BMJ careers every single evening for positions that come and go faster than fireworks on bonfire night, no more endless hours filling out sprawling application forms, no more trying to explain to perplexed people why I was going to be an unemployed doctor. The bitter shame is that MMC has left thousands of doctors just like me still fighting and desperately trying to find a job or deciding what they’re going to do when our contracts end next week.

You know, the ultimate irony in all this was just how straight-forward the round two interview was. They looked at my CV and my other achievements. The interviews and the exam took about an hour and a half altogether. I didn’t say anything stupid and at the end of it all, they decided that they liked me and offered me a job. Easy.

It does raise the question that how on earth could something so simple turn into such an unprecedented disaster?

So, here it goes. A week on Wednesday, I start a new job in a new deanery a couple of hundred miles from where I’m living right now. A new start, a new challenge, a new specialty – I can’t wait.

Bring it on.

Stop The Clock!

I have a job offer.

The drugs don't work

The other doctors and duty had just popped off the Medical Assessment Unit to grab a coffee and I was just finishing writing a drug chart when Sarah, one of the nurses comes up to me and says “Could you take a look at Mrs Edwards, she appears to be having a seizure.”

Mrs Edwards is a 78 year old woman who a few minutes previously had been letting anyone who would listen know her views on NHS food. “Disgusting slop that I wouldn’t feed to my dog” were the words she used, I think.

I walk over to her bed and indeed, Mrs Edwards is having a fit. I wasn’t overly concerned though because the doctors in A&E had put a venflon in her arm so she could have drugs that act quickly to stop her seizures.

I ask Sarah to give her some IV Diazemuls (a strong drug that stops fits) and took a look at her notes. Mrs Edwards had come in with a urine infection and had no known epilepsy. Sarah gives the drugs to Mrs Edwards and they reduce her movements a little but the seizure continues. This is very strange. The vast majority of fits stop by themselves and of those that don’t, the majority will stop if you give the patient Diazemuls. I ask Sarah to give her another dose and ask one of the HCAs to check her blood sugar reading because low blood sugars can sometimes cause fits. The blood sugar level is normal and Mrs Edwards’ seizure continues despite the second lot of Diazemuls.

By this stage she’s been fitting for about 15 minutes and I’m getting worried. I ask Sarah to give Mrs Edwards some high flow oxygen and say “let’s try 4mg of Lorazepam (an even stronger drug)” and asked for Jane, the Medical Registrar to come and lend a hand. I give the Lorazepam and Jane arrives with Margaret, the ward sister. I explained what had happened and what I’d done so far. Mrs Edwards is still having her seizure. Whilst the drugs had reduced her movements slightly, she was still fitting and would have shaken herself off the bed had it not been for Margaret’s well placed knee. Jane asked the nurses to organise a phenytoin infusion (the strongest drug on the unit) while she goes off to call the anaesthetist.

I have to write up the dose of phenytoin on Mrs Edwards’ drug chart before the nurses can give it. I’m not very familiar with the dosage, so I look the dose up in the British National Formulary (BNF). Here’s what the BNF says about pheytoin infusions:

“Dose: By slow intravenous infusion, status epilepticus, 18mg/kg at a rate not exceeding 50mg per minute, as a loading dose.”

Mrs Edwards isn’t particularly big so I guesstimate her weight to be about 60kg. If you’ve ever tried to do arithmetic whilst standing in front of a woman having a seizure with nurses and doctors talking around you and the monitor bleeping away, you’ll realise it’s not an easy thing to do. It takes me a couple of minutes, but I work out the right dose and the nurses go off to set up the drug while I say a silent thank-you to my GCSE maths teacher for schooling me well.

The phenytoin does nothing.

Mrs Edwards is still having her seizure. She’s become very sweaty and her heart is racing at 150bpm. By now she’d been fitting for about 35 minutes and the anaesthetist arrives. She, Jane and I talk about what to do and we decide the plan should be to sedate Mrs Edwards, stop the seizures with powerful ICU drugs so we can get her to the CT scanner to image her brain and see what’s causing the seizures. The anaesthetist performs a rapid-sequence induction and sets up a Propofol infusion. (Propofol is an anaesthetic agent and only anaesthetist with years of specialist training can give it because of the close monitoring it requires).

Mrs Edwards continues to fit.

The anaesthetist is more than a little surprised and asks for a Thiopentone infusion to be set up. She says “I’ve never seen anyone continue to have seizures on Thiopentone.”

Mrs Edwards continues to fit.

This is amazing. Mrs Edwards has now had large doses of five different anti-seizure medications of increasing power and toxicity, yet she was still having her seizure. Her seizure had been going on for about an hour and a half and was still ongoing. At least the ICU drugs had reduced her movements enough to get a reasonable image on CT scan, so we took her down to the scanner where the radiographer was waiting for us.

Mrs Edwards had a stroke. There is no sort of surgery and no sort of medication that could fix it. We sent her to the Intensive Care Unit where a machine could breathe for her and we could support her circulation in the hope that Mrs Edwards’ body could fix itself.

All we can do now is pray.

UPDATE: The seizures never stopped. Mrs Edwards never recovered consciousness and she died on the Intensive Care Unit.

So tired...

The weather seemed to be affecting the mood on medical assessment today. It was gloomy and rainy me and the other doctors were all feeling pretty glum. For me, I think I’m just tired. I’m having to work 18 days in a row and I’m doing long days (12.5 hrs) for 9 of them. I can’t be bothered to work out how many hours that adds up to but it’s a lot.

Tiredness affects different people in different ways. I think we all get a bit short-tempered and grumpy when we’re tired but I’ve noticed that when I get a bit worn down, it really affects my emotions. Generally, I think I’m a pretty emotional person, I get upset about things, I get angry about things, I laugh a lot. One of the things I’ve learned is how to show these emotions in a way that helps people engage with me and this is standing me in good stead in my personal and professional life. I’m not scared to show that I’m upset by something, or that I’m stressed or angry or nervous or happy.

Usually, when I’ve been working long shifts or nights and I feel really tired, I get upset more easily than normal and tend to dwell on things.

Today I felt different. I just felt like things didn’t matter to me as much and I just wanted to get through the day. I almost felt cold.

Things continued to happen like they always do in hospital. For example, there is a man on the High Dependency Unit because he has GI haemorrhage and DIC. This evening he had a heart attack, therefore going into multi-organ failure meaning he’s highly likely to die. It kind of washed over me. Of course I did all the stuff that was expected of me – I organised transfusions, I explained what was happening and the likely outcome to this man and his relatives - but it felt like I was going through the motions and I know that’s a horrible thing to say but it’s true.

I think I just need to sleep so I'm taking myself off to bed.

Goodnight.

Days to unemployment=19

Dr Anderson is back in the game!

Days to unemployment=21

I got an email today informing me that I have a round 2 interview next week.

It's not over yet...

The most disgusting thing I've seen

Days to unemployment=22

Last night, I went out with a friend and I met his new girlfriend for the first time. She’s a nice enough person and we were chatting away amiably when she asked me “What’s the most disgusting thing you’ve seen at work?”

Now, as you can imagine, these eyes of mine have seen quite a few things that would make your stomach turn, but after taking a few seconds to ponder, I told her the story of what I believe is the most disgusting thing I’ve seen at work – nay, the most disgusting thing I’ve seen EVER.

I was working in A&E and I went to see a man in his mid-fifties called Steve. Steve looked like an old hippie, you know the type – long hair, beard, wearing tie-dye and several “ethnic” necklaces. I introduced myself and asked him what I could do for him.

Like many of people, Steve didn’t like hospitals. Steve also didn’t like doctors very much, in fact Steve didn’t like the entire concept of modern medicine and was a great believe her in alternative therapies. This is all fair enough, we’re all entitled to our opinions and I must say that I have no strong feeling either way when it comes to alternative therapies.

Steve, however, hadn’t done his research and Steve was trying to treat his diabetes with yoga. In my opinion, yoga is great, anything that encourages people to do some exercise and stretch their limb a bit is surely a good thing but, unlike Steve, I really don’t see how on earth it could have any impact on improving a poorly-functioning pancreas.

Unsurprisingly, Steve’s self-therapy with yoga wasn’t working and Steve had come to A&E because of a problem with his feet.

“Let’s take a look at them,” I say and Steve slowly unlaces his big black boots and pulls them off.

I think the stench hits me first. My stomach literally turns over as the foul, fetid funk of rotting flesh reaches my nostrils. Steve’s foot was rotting. The end of it and his toes were non-existent. Instead, they had been replaced by a black, putrid, squishy, partially liquefied stump with maggots crawling in and out of it. His other foot was even worse.

I took a couple of steps backward, told Steve that I think he needed to be seen by the surgeons and walked back to the ward station as quickly as was dignified.

To this day, I can’t believe that Steve allowed his foot to get into that state.

Yuk.

In which you have to read between the lines

"Where did I go wrong?
I lost a friend somewhere along in the bitterness.
And I would have stayed up with you all night, had I known how to save a life."

- The Fray

I don't feel like writing much today. Sometimes things just get to you a bit you know...

Days to unemployment=24

Life-long learning

Days to unemployment=25

It’s the first day for ages that the sun has shown its face, but rather than having a picnic in the park or sipping cocktails watching Wimbledon, I’m on call for Medical Admissions.

I don’t feel too disheartened about having work whilst others play though because I haven’t worked a weekend for a few weeks and today was a good day. I felt I really helped several people, actually saved a life and learned loads.

Due to the ever-changing nature of modern medicine, we doctors have to be committed to what the GMC terms “life-long learning.” One of the great things about my job I that patients and events can always surprise you and just doing the job means that you’re constantly learning stuff. Sometimes the surprises are good, sometimes hey are bad, but it’s impossible to know EVERYTHING and this I reckon this keeps the job interesting.

Obviously, the people we learn from most are our patients. We learn how the same disease manifests itself in different ways in different people (I had a man who came in with right shoulder pain and it turned out he’d had a heart attack), and how different people respond differently to the same treatment.

Here are five things that I learned from my patients today

1. The “D” in “D-Day” (6th June 1944) stands for “Deliverance.”

2. It is possible to have a heart rate of 18 beats a minute and still hold a conversation.

3. Rugby is a sport for “pansies”

4. Sometimes, the drugs don’t work

5. Severe hyperkalaemia can cause muscle weakness and spasms

A puzzling question

Days to unemployment=26

Why do patients say "Thank you" to me after I take a blood test from them?

It's very nice to hear and all but I'm never quite sure what they're thanking me for. I walk up to them, I tie a band round their arm and then stab them with a metal needle with the intention of making them bleed.

It's not the sort of thing that you'd think a person would be thankful for but the "Thank you" is usually forthcoming afterward. It puzzles me.

Belly's gonna get ya!

Days to unemployment=27

7:16 am and I’m drying myself after my shower. I look down. I frown. I walk over to the mirror and look at my naked body. I turn myself sideways. I suck it in. I let it go. I suck it in again. I stare for a moment and realise that I can no longer deny it. It’s there. I have a paunch.

As a teenager, I was always skinny and wiry and at medical school I filled out and often got told during pillow-talk that I had a “great body.” Nowadays, there are some bits of me that are holding their own (arms, legs, bum) but the middle bit’s definitely much saggier than it used to be.

With these thoughts in mind, I took a good look at the other doctors and nurses I bumped into at work today. I have to say, it wasn’t pretty – on the whole doctors and nurses aren’t in good shape at all. Other health professionals like pharmacists and physiotherapists fare much better than we do. Considering our business is healthcare, you could say that it’s deeply hypocritical ironic that we are so unhealthy ourselves. Thinking about it, it’s easy to understand why. Long hours spent at work, shift patterns, working evenings and nights mean that it’s difficult to find time to prepare healthy meals and even harder to join a sports team or go to the gym regularly. The total lack of healthy food facilities in Town Hospital for staff means that when you’re on a tough part of the rota like I am now means that often on call you have a choice between getting a take-away and going hungry… blah… blah… blah…

I could think of 100 excuses reasons why I am now officially a “man with a paunch” but I think at the end of the day, it comes down to my motivation (or lack of). Remember those old Reebok adverts that went “Belly’s gonna get ya! Belly’s gonna get ya!” It seems like Belly is catching up with me but I’m not going to let it catch me. So, at 7:16 pm, I was running down the city streets, through the pouring rain and now, as I sit here typing this – I feel tired but fantastic.

Things are getting easier

Days to unemployment=28

I think that some time last year, things changed for me. Everything became easier. As doctors we spend more than half a decade in medical school, but that doesn’t at all prepare you for your first day on the wards when the nurse runs up to you and says

“The patient in room 4 is vomiting again, could you place an NGT, site a venflon and write him up for an antiemetic.”

But, the training does kick in, and with experience everything becomes easier. There was a lot of stuff going on with my patients today.

A man developed an irregular heart beat and became breathless and dizzy – I knew what to do.

A lady with emphysema “dropped her sats” to 72% whilst on oxygen – I knew what to do.

A man who was dying became distressed and agitated – I knew what to do.

A woman started vomiting blood – I knew what to do.

To me, stuff like this is easy to handle now. Stuff like this just doesn’t stress me or worry me like it used to. Occasionally, I find myself in situations where I feel out of my depth, but these are becoming fewer and less frequent.

29 days to unemployment

I took a break from work and from blogging just to get away from it all for a while. To be honest with you, I’m tired of job applications. It’s endless. I spent god knows how many hours doing it last year and right now, history is repeating itself.

Some application forms for round 2 jobs run to 30 pages and they’re each taking me at least four hours to complete. The rota has me working between 68 and 72 hours a week every week this month and I resent spending ALL my free time on applications. But it has to be done because as it stands, I have 29 days to unemployment.

The thoughts going through my mind are:

I don’t want to move to far flung areas of the country to get a job. I’m especially loathe to do this for a non-training position. I’ll be destroying my life outside medicine leaving my family, my sports club, my friends etc… and then I’ll probably have to do it again in a few month’s time so is it actually worth it?

Unemployment doesn’t actually scare me too much from a non-career point of view. I’m a bright lad and I live in a capitalist society. There’s always ways and means of making money – plus I have no wife or children to look after.

What I AM worried about is my career. MMC have repeatedly said that August 2007 is my best chance to get a training job. If I don’t get one now, then everything becomes orders of magnitude harder next year. With this in mind, I realise that if I don’t get at least a trust grade (non-training) job, then I’ll be more or less unemployable come this time next year and this is very worrying indeed.

To quote the recent single by electro-popsters Unklejam, “What am I fighting for?” Trying to get our ward to run smoothly is – not to put too fine a point on it – fucking hard work. I have to work overnight on a regular basis. I have to give up my weekends and I there’s lots of stuff I’d like to do outside work that I’m not able to simply because I don’t have time. The job itself is hard work. It’s very rewarding but it’s sometimes very tough and I find that I have to try my best to be all things to all people. Like any job, there’s bits I enjoy about it and bits I don’t but at the end of the day being a doctor isn’t SO AMAZING that I’m willing to give up my entire life for it. Willing to move away from my family, friends and hobbies for, willing to move to a whole different COUNTRY for – forever. I honestly believe that if I was in a different career or profession, then I wouldn’t make those sorts of sacrifices for my job, so I’m not sure if I’m prepared to for hospital medicine.

So I’m in a quandary. I’m continuing to use my free hours to apply for jobs but after nearly a year of bullshit doled out by the government, I feel like my “fight” left me. I feel let down. The people who dreamt up the MMC system, the people who thought it would be a good idea, have either been sacked or resigned but at the end of the day, the MMC system marches on and it’s left this junior doctor with only 29 days to unemployment.