A request for help

I wonder if you can help me out. I regard myself as "technologically competent" but this RSS stuff totally mystifies me. Can any of you tell me what is RSS? What does it do? What is the point of it? Is it worth adding a "RSS feed" to this blog and if I do, what difference will it make?

I tried googling "RSS" it but it still makes no sense to me. Could someone please explain it to me as if I were a 5-year-old because I honestly have no idea. I tried asking my friends about it but they're all as clueless as I am.

Thanks in advance.

A (un)fortunate man

Unfortunately, Mr Blackwell had a heart attack last week.

Fortunately, he called an ambulance and was rushed into hospital. His condition was diagnosed promptly and he was given appropriate treatment, stabilised as was put on the list to have an angiogram to see exactly where the problem was.

Unfortunately, the angiogram showed that the cause for his heart attack was a narrowing of one of the arteries that supplied heart muscle and that he was at a high risk of having another (possibly) fatal heart attack.

Fortunately, the cardiology doctors have the ability to put a stent into his artery and reduce the chances of a second heart attack and he was brought back to have the stent the next day.

Fortunately, they were able to do the procedure and he had a stent placed across his coronary artery. They do this by pushing a catheter up from his groin to his heart. This negates the need to cut open his chest.

Unfortunately in doing so, the cardiologists had managed to roger one of the arteries in his groin. The artery clotted off and Mr Blackwell had the blood supply to his leg cut off. It went cold and pale, and within a few hours, it would have started to die. He could potentially lose his leg or his life.

Fortunately, the CCU staff are trained to look out for such things and they promptly called the on-call vascular surgeon, who quickly decided that Mr Blackwell needed an operation to save his leg. The surgeon calls the anaesthetist (me) to assess the patient’s suitability for surgery. The cardiologists do their bit and perform an echocardiogram on Mr Blackwell.

Fortunately, the echocardiogram shows that his heart hasn’t been too badly affected by the heart attack

Unfortunately, I know that having had a heart attack so recently, a general anaesthetic at this time would put him at a hugely increased risk of having another. I also know that the way our bodies respond to surgery would mean that his heart stent is a greater risk of clotting if he has surgery this soon after its insertion. On the other hand, if wait, then within a few hours, Mr Blackwell will lose his limb and possibly his life, so we’re going to make as best a fist of it as we can.

Fortunately, I know a man who can help and I call the consultant who says he can come down and perform a regional block so Mr Blackwell can have his leg operated on whilst fully awake and avoid the risks of general anaesthesia.

Mr Blackwell agrees to this and the operation goes surprisingly smoothly. He is now recovering from his operation on the ward.

Now, is Mr Blackwell a fortunate or an unfortunate man? I honestly don’t know, I guess it depends on your perspective.

n.b. Fortunately, Mr Blackwell swears that after all this, he’s DEFINITELY going to stop smoking. I was loathe to point out that for years and years, people had been telling him that all this was going to happen.

Casting Aspersions

After a few months of working in this job, my identity badge has become a little battered. The picture of me grinning on induction day is now faded and the lettering isn't as clear as it used to be.

Thing is, instead of saying:

Dr Michael Anderson

Anaesthetics ST1

It now looks like:

Dr Michael Anderson

Anaesthetics STI

which, of course, is a very different thing indeed...

Update

At the start of the year, I had a real dilemma about what I was going to do with myself. I really don’t like the region of the country that I ended up in as a result of the government’s bright idea that was MMC 2007, but I really love working in my new specialty of anaesthesia. My question was whether to stay where I am or to try and leave and once again go through the lottery of MMC 2008.

I decided to stay here for another year with the aim of passing the FRCA primary (post-graduate anaesthetic exams) this year. I was also going to “get a hobby, get a girlfriend and see if I could learn to love this city” so I thought I’d give you an update on how things are going with that.

I have a girlfriend. She’s fantastic, she’s clever, she’s great looking, she’s properly funny and she’s making me very happy. She’s non-medical (she works in fashion) and things are going really well.

In January, I blew the dust off my old guitar and started to play again. I used to be really into making music, I was in a band in my teens. We were called “Alk 14” and we were going to be huge. We were going to be bigger than Oasis! Unfortunately university got in the way and, though we tried, we couldn’t keep the band together when we were living in separate cities. The world never got to hear our great songs like “Ride the Tempest” and “Old-Fashioned Girl.” But now, I’m really enjoying playing with the fret board again – maybe I’ll form another band?

Unfortunately, I still have no love for this city. I do think I need to try and get out more, but to be honest, there’s been little I’ve seen about this place in the last few months that made me want to stay here for the rest of my life.

Stupid Me: Story #4513

I was doing the trauma list yesterday and the orthopaedic surgeons had put a young man on the list who needed to have fixation screws removed from his foot under general anaesthesia.

“It’ll be really quick,” Andy, the ortho reg, assured me, “the operation will only take five minutes.”

Already, I’ve developed a healthy disregard for what surgeons say about the length of their operations. I think surgeons exist in their own special time bubble where a surgeon’s minute is the same as ten minutes in the real world.

As sure as eggs are eggs, half an hour after he started operating, Andy has sat down, made himself comfortable and is still poking around in this bloke’s foot trying to find the final screw.

“I’ve found it!” he finally exclaims.

“Wahey, well done!” I say and move round to have a look over his shoulder. “Let’s see,” I say.

“Look,” Andy replies leaning to one side so I can get a better view. “The (screw) head was much more proximal than I thought.”

I can’t quite see, so I lean further over his shoulder and…

A flash of light hits me at exactly the same time a bolt of pain from my forehead.

“Owww!”

I’d managed to clunk my head against the theatre lights. The theatre team – kind souls that they are - burst into laughter.

Did I feel like a tit? Damn right I did and, what’s more, I now have a lovely black eye to remember the event by.

Thought for the day.

Acupuncture is the ancient and revered tradition of sticking pins into
people to make them feel better.

Voodoo is the ancient and revered tradition of sticking pins into things that look like people in order to make them feel worse.

The question is; if an identical twin has acupuncture, is his brother in trouble?

Friday Morning, 08:30

It’s 0830 and I’m going to see Mrs Bailey, a lady who is on today’s orthopaedic surgery list and is due to have her knee replaced.

Throughout the clinical years of medical school, we are taught that you gather an awful lot of information about a person from just looking at them. It’s a skill that doctors develop throughout their training and it means that before you even speak to the patient, you can deduce a great deal about nearly all of their body systems, mental state etc… etc…

The thing that immediately strikes me about Mrs Bailey is that she’s fat. Not fat as in she has “love-handles,” not fat as is she has a “bubbly personality,” not even fat as in she has a “middle-aged spread.” I’m talking seriously obesity.

From my point of view as an anaesthetist, fat people are difficult because being obese make general anaesthesia far more difficult (and therefore more dangerous) in so many ways. Everything is trickier with obese people. From the little things like the fact it’s harder to find a vein to site a cannula and the blood pressure cuff often doesn’t fit around their arm to big things like they have a small functional residual capacity and desaturate in seconds and fat necks mean that airway obstruction is much more common and more severe. Off the top of my head I can think of at least a dozen ways in which it’s harder to give an anaesthetic to an obese person.

But, at the end of the day, Mrs Bailey needs her knee operation. She’s been waiting X number of months for it and I’m sure having chronically painful arthritic joints must make life a misery. I’ll have to do the best I can for her.

I walk up and speak to her and ascertain her medical and anaesthetic histories. I explain what an anaesthetic involves and let her know what to expect before and immediately after the operation. I always ask my patients if they have any questions or if there’s anything they’re unsure about or particulary worried about.

“There is one thing,” she says. “It’s about my weight.”

She looks down at the floor then brings her eyes up to meet mine once more. “I know I’m big… I know I’m too big.” At this point, she’s becoming visibly upset. “I’ve been trying to lose weight, I really have. I’ve lost three and a half stones in the last six months. I know I need to lose more but I want to ask you, doctor. Will my size affect the anaesthetic?”

And I’m caught. Should I be honest and tell the truth and probably upset her more just before major surgery? Should I lie to try and spare her feelings? If I decide to be truthful, how truthful should I be? Does she really want to know the details? Should I gloss over it and not acknowledge it as an issue? Should I ignore her question and try and change the subject?

If you were me, what would you say?

At the end of the day...

It’s the end of the day and I’m walking back through the theatre suite after finishing seeing all my post-op patients. I nip back into the anaesthetic room to pick up my bag then I decide to go and have a look in the operating theatre.

It’s empty.

I wander inside and stand in the middle of the room for a moment or two. The theatre has been cleaned after the final operation of the day. The operating table has been taken away and put in overnight storage, the theatre lights are dark and the anaesthetic machine is turned off and sits quietly in the corner of the room. In contrast to the sights and sounds of the surgery that was happening half an hour or so beforehand, the room is very peaceful.

I did a good job today. There were no dramas. There were no situations that scared me. There were a couple of patients who were “anaesthetic challenges” but I managed to guide them through their operation competently. All the patients were feeling fine when I saw them on the wards and they all thanked me for looking after them.

One of the things I really like about anaesthetics is the real feeling of satisfaction I get on days like this.

I give myself a little smile, turn off the lights and head home.

Thoughts on Playing God

After writing about it, I've been pondering a bit more on what happened with Mr Johnstone and about these difficult decisions that we have to make as doctors.

You know, I really don't think that there are any answers when you're faced with this sort of situation. There is often little time to fully discuss all the options with the patients and their loved ones. Often the patient is in pain and is unable to comprehend what you are saying, let alone come to any sort of rational decision.

Luckily for me, Mr Johnstone was still lucid and could understand what was going on, but I can see situation where that won't be the case.

And the funny thing is, dealing with these sorts of decisions is not really taught to you. There's not rule book or guidelines or protocol that tell us at what point to stop offering treatment to another human being. How can there be? There are no right or wrong answers. More and more, I'm realising that you just have to get through and be guided by your own conscience and hope that you make the right decision. And here's the kicker - you never really know if you've made the right decision. You never know that things are better than they would have been had you chosen the other option.

Dr Schwab (a retiring American consultant surgeon) writes well about the thoughts and feelings that he has when faced with these decisions. His post touches on the hundreds of different things that are going through your head when you are trying to decide what is the right thing to do to help the patient in front of you.

I'd like to think that the decision making process will become easier as I become more experienced, but from the obvious mental wranglings that Dr Adams had and from reading Dr Schwab's post, it seems obvious that making a life or death decision and explaining it to those involved never gets easier.

It will always be difficult, it will always be emotional and it will always be like that because I will always care about my patients.

Mr Johnstone is dead now. I hope he rests in peace and I hope we did the right thing by not putting him though surgery. In my mind, I think we did, but like I say, I'll never know for sure.

Playing God

I’m back, at long last, my broadband is up and (semi)functional again. A lot’s happened in the three weeks or so that I’ve been offline but one situation a found myself in when I was on call that particularly sticks in my mind.

A lot is written about doctors “playing God” and being arrogant enough to believe that they can decide who should live or who should die. As always, the real truth is somewhat more complicated so let me tell you the story of me and Mr Johnstone.

It’s about 10am on a Sunday and I’m on call for anaesthetics in NewTown Hospital. I’m doing a little studying on one of the computers in the staff room when my pager goes off. It’s one of the surgical registrars who tells me that they want to operate on a Mr Johnstone on Ward 4B who has bowel obstruction. I ask her a couple of questions about the patient and it’s immediately apparent that this isn’t going to be a straight-forward situation.

I logoff and go to the ward where I bump into Mr De Luca, the consultant surgeon on-call, who tells me that he thinks the obstruction in Mr Johnstone’s bowel is most likely to be cancerous but that he is too frail to perform major surgery on. Mr De Luca’s plan is to perform a small operation to create a colostomy for Mr Johnstone which would prevent his bowel from bursting, which would be fatal for him. Mr De Luca asks if we could do the operation under spinal anaesthetic i.e. an injection in the back to numb the nerves so the operation can be done with Mr Johnstone awake.

I tell Mr De Luca that I’ll go and speak to Mr Johnstone and then we’ll discuss things more, he says “Fine, go ahead.”

I pick up Mr Johnstone’s hefty medical notes and walk into the bay where he is lying. He’s all skin and bones and has the emaciated look of a man that has obviously been unwell for a very long time. Mr Johnstone’s belly is grossly swollen (a sign of his underlying intestinal obstruction) and thin, blue veins meander across his belly. His paper-thin skin gives it the look of a balloon filled with water. There is a drip attached to his arm that is trickling fluids into his bloodstream and out of his nose emerges a naso-gastric tube connected to a bag by his bed that is filled with green, bilious vomit. There is a smell of stale sweat and puke around his bedside and you don’t need to be medically qualified to tell that Mr Johnstone is a very unwell man indeed.

“Good Morning Mr Johnstone,” I say as I approach his bed.

His eyes flicker open as he regards me approaching him. I give him a small smile.

“My name is Dr Anderson,” I continue. “I’m the anaesthetic doctor and the surgeons have asked me to come and see you because you need an operation on your belly. How are you feeling?” It’s a stupid question, I know. “You’ve had better days, yeah?”

Mr Johnstone gives me a wan smile and replies, “You can say that again, I feel awful doctor.”

Mr Johnstone and I speak for about twenty minutes or so about his current illness and about his general health.

I won’t go into too many details but from speaking to Mr Johnstone and reading his medical notes, I found out that he has severe heart, lung and kidney problems. The last six months of his life have been studded with hospital admissions for chest infections and heart attacks. When he is at his very best, he can only manage to walk a dozen steps after being helped up from the chair, but Mr Johnstone hasn’t been at his best since October. He’s been getting steadily worse and has been bed-bound for the last two months.

It was obvious to me that Mr Johnstone was so frail that if I gave him any sort of anaesthetic, he wouldn’t survive. The question now was whether a more experienced anaesthetist would feel that he would be able to safely guide Mr Johnsotone through the surgery.

I call Dr Adams, the consultant anaesthetist on-call and explain the situation to him and ask him to come and help with this patient. One of the great things about working in anaesthetics as opposed to other medical specialties is that if you feel you need help from your consultants, they come in and help you. They don’t have a go at you and tell you to “get on with it, just make sure you don’t fuck up.”

Half an hour later, Dr Adams and spoken to and examined Mr Johnstone and poring over his medical notes, scratching his beard (literally) as he tussles with the question that I’ve asked him to answer. “Can I give Mr Johnstone an anaesthetic, and if so how?”

Dr Adam’s brow is furrowed and you can almost see his mind working. After about ten minutes of deliberation, he comes to a decision…

“No.” He says to me. “We can’t do it. I’ve been weighing up all the different options and scenarios in my head. I’ve been thinking of all the things that are likely to happen to him if he has an operation and I can’t see a situation where he will have a decent outcome.

“I agree with you Michael, that he’s far too frail to have a general anaesthetic and he’ll die on us if we try to give him one. That leaves us with the option of giving him a spinal (the injection into the back) and I’ve been going through what the best-case scenario is likely to be.

“Best-case: We get him down to theatres, and we actually manage to get the spinal needle in. For a colostomy, he’s going to need quite a high block – up to about T7-8. He had a heart attack a couple of months ago, and his echocardiogram shows his heart has been knackered since 2002, so the chances are his heart won’t cope with the drop in blood pressure that you get with a spinal anaesthetic. Even if we manage to achieve that and the block works well, and even if we manage to lie him flat enough to have the operation and even if the surgeons are quick and slick and aren’t digging around for ages, what’s going to happen next?

He’s going to come back to the ward and in six hours time, the spinal will wear off and then he’ll be in pain. He won’t breathe properly because he’s in pain and then, with his lungs, he’ll get a chest infection and die. Or someone will come along and give him some morphine which will stop him breathing properly and then he’ll get a chest infection and die.

So, in the very best case scenario, he has his operation, is semi-conscious for 12 hours post-op before dying here a week later, and you’ve got to ask ‘have we done him any favours?’”

We go and explain our decision to Mr Johnstone and then to the surgeons. Mr Johnstone understood that he needed the operation to save his life and was very upset when we told him he couldn’t have it. Later in the afternoon I return to the ward to explain the decision to Mr Johnstone’s daughters and other relatives who are understandably very upset by the whole situation.

Later on, I had a quiet moment and thought about the events of the morning. Unless a miracle happens, Mr Johnstone’s bowels will burst and then he’ll die. Over the preceding day or so, he was told that there was an operation that could prevent this and he was given hope. Then we snatched away any hope he had by telling him he was told that he couldn’t have the operation. This was cruel, horribly, horribly cruel.

I can’t put myself in the shoes of Mr Johnstone or his family, his final days will probably be difficult, painful and horrible. But death is often difficult, painful and horrible and unfortunately for Mr Johnstone, this time we can’t stop him dying.

I don’t really think that this is “playing God,” I think it’s accepting the fact that death is an inevitability that we all have to face and that doctors can’t save everyone from dying, no matter how much we’d like to.

What do you readers think about what happened with Mr Johnstone?


n.b. Interestingly, when I talked about this is the doctor’s mess later on, two surgical SHOs, the surgical SpR and the Medical SpR initially all said that they thought that Mr Johnstone should have had the operation. Personally, I think this just shows a lack of understanding about how anaesthesia works and all apart from the Medical SpR reversed their opinions when I explained the effects of spinal anaesthesia on the cardiovascular system.