I need to crack on...

I still have vast amounts of study to do for my rapidly approaching FRCA primary exam. The second part of the anaesthetic primary is an oral exam so, I also need to practice speaking about various exam topics in a sensible way.

I'm afraid that blogging is going to take a back seat for a while to let me catch up on my revision (or until I get sick of the sight of my textbooks).

...and, before you ask - no, this is not a picture of me (I have much better dress sense!)

In which I lose the will...

From my point of view, giving a general anaesthetic is interesting for about an hour or so. In the first hour you induce the patient, do your nerve blocks and stabilise your patient for surgery. After the operation has lasted an hour or so, I start to get really fucking bored. There’s only so much fiddling with the vapourisers that a man can do before it starts to lose its appeal. Today, I was giving an anaesthetic to a man who needed an 8-hour operation and I tell you – after three hours I was bored, after six hours, I was climbing the walls and by the end, I’d almost lost the will to live. What on earth do you do with yourself for eight hours once you have a stable patient?
I tell you what I did - I did some revision, I chatted to the theatre staff, I put on some music, I poked fun at the surgeons and I even read the paper. In fact, I found myself turning into one big cliché!

I know for sure that there’s no way in hell that I could do long operations for the rest of my days – it would drive me crazy

Bank Holiday Monday

Today I learned (among other things):

- the Bohr equation for measuring physiological dead space
- the side effects of suxamethonium
- the sensory nerve supply to the foot and how to go about doing ankle blocks
- more about hypoxic pulmonary vasoconstriction
- the Bernoulli effect
- what “pontyning” means
- that once again, my social life has vanished into the ether…

I’d like to think that other people were having more fun than me, so tell me… What did you do on your Bank Holiday?

Ain’t your bitch

**bleep... **bleep... goes my pager and I find a phone and dial the in the number.

“Hello?” comes the reply

“Hello, it’s Michael here, Anaesthetics. Were you paging me?”

“Err.. yes, It’s Shri here, surgical SHO. I was wandering if you could help us? We have a woman who needs some I.V. fluids but I’ve tried to site a cannula into her but I can’t. I was wandering if you were free to come and do this venflon for us? One of your colleagues kindly came and did it for us earlier today.”

“An anaesthetist came and put a venflon into her earlier?”

“That’s right, the registrar came and did it earlier”

“And what happened to that venflon?”

“It came out”

“Well, that’s not very responsible of you is it? Why didn’t you secure the line properly and make sure it doesn’t come out?”

“I don’t know. It just came out.”

“And you’ve tried and can’t put it back again?”

“Well, we tried earlier but none of us can do it”

“Has your registrar tried?”

“No.”

“Well, I don’t think it’s appropriate for you to call me to put in venflons in your patients.”

“I’m sorry??” comes the shocked voice at the end of the line. “One of you colleagues…”

“What one of my colleagues did as a favour is neither here nor there." I interupt. I'm getting a tad irritated by requests like this. "Look, this is what you should do. If you can’t put a venflon in, you need to call your registrar to come and do it, if he can’t do it then he needs to call the consultant to do it. If the consultant doesn’t want to do it then he needs to either get your reg to put in a central line or discuss with the ICU consultant about putting in a central line on the CEPOD list. If the ICU consultant agrees to that then we’ll come and put in a central line.”

“But I don’t think she needs a central line…”

“Then I suggest you either put a venflon in yourself or get one of your surgical colleagues to put one in. You guys are doctors too aren’t you?”

“But…”

“I’m not coming to do it. End of story. Either you sort it out yourselves or you go through the ICU consultant. Putting in your venflons is not what I’m on call for. Goodbye.”

Unsurprisingly, I didn’t hear anything more about that venflon. To me, there is a big difference between "helping" and "doing someone else's job for them."

Room for improvement

I was listening to radio 5live on the drive home from work yesterday afternoon and they were interviewing Dave Brailsford, the man who is the head of British Cycling about the absolutely phenomenal achievement of the track team in Beijing (7 gold medals from 10 events so far!). Dave was explaining how the cycling team had gone about targeting every single aspect of the performance of the riders and the bikes and really left no stone unturned in their meticulous preparation. The quote that he came up with was “In order to improve things by 100%, you need to improve 100 things by 1%.”

This struck a cord with me and my work in the NHS. The NHS has far, far more money than British Cycling (in fact, the entire annual budget for British Cycling would run the NHS for about ten hours) but in 2008, we are struggling to provide the sort of world class service that we aspire to. It’s a little allegorical to what I wrote about the real difference between ICU and ward care.

I’ve been reading the posts of Dr Jane Doe over at Two Weeks On A Trolley with great interest. She’s been pointing the inefficiencies in the Irish Healthcare system (for Irish, read British because, at the front line, the two systems are pretty identical) and how these inefficiencies directly compromise patient care. She also writes about how the healthcare system down under copes with exactly the same problems in a much better, faster, more efficient and cheaper way. You really should read her posts, they’re fantastic.

I think part of the problem with the NHS is that nobody listens to the people who actually deliver the service. Actually, it’s not even that nobody listens, nobody evens asks the questions. Nobody wants to hear our ideas about how we can make the service better, and that is one of the most frustrating things.

Anyway, this post isn’t meant to be just another “The NHS is crap” whine, I actually wanted to write something constructive about how I think my area of specialty (anaesthesia) could be improved. Here are my top 5 ideas:

1. Get rid of the anaesthetic room.

The anaesthetic room (AR) is an anteroom right next to operating theatre. Patients coming in for surgery come into this room where we anaesthetists give them their general anaesthetic before moving the unconscious patient into the operating room (OR). From day 1 as an anaesthetist, I’ve always thought that this was really pointless. The hardest part of a general anaesthetic is the induction. This is the time where the patient is the most unstable, and as a result, this is the time that the patient is the most vulnerable. To me it seems really odd that, at the time where the patient is most at risk, we have to disconnect all our monitoring equipment and then move the patient into the OR and then drag the (sometime quite hefty) patient from the trolley onto the operating table. It’s all totally pointless and unnecessary. It puts the patients at risk and it puts the staff at risk too from having to drag unconscious people around. It would make much more sense to have the patient walk into the OR and then we give them their anaesthetic on the operating table – in fact this is exactly what we do if we feel the patient is a particularly high risk (e.g. emergency AAA repairs).

2. Automatic Doors

As I said above, we anaesthetist spend a lot of time moving unconscious people around. We go from the AR to the OR and from the OR to the recovery room. Some times we have to go through three or four sets of double doors wheeling an unconscious person on a trolley. We do this several times a day. Having to open doors and hold them open when we’re transferring patients is a pain in the arse. Can we not have automatic doors in theatres? If not fully automatic, then at least the type that open when you push a button. It makes sense. They have them in just about every high street store, can we not have them in the NHS?

3. Printouts

During an operation, we anaesthetist keeps a record of the patient’s vital signs. Every five minutes, we’ll write down the patient’s blood pressure oxygen saturations etc… etc… Whilst this is no big chore, it surprises me that the highly expensive anaesthetic machines just can’t print all this information out for us. Surely it can’t be that difficult?

4. Use Wireless Technology

I can sit and type this on my laptop and publish it to the internet using no wires at all. Bluetooth means that we can connect our mobile phones to our fridges if we so desire. As an anaesthetist, I spend a lot of my time untangling the patient from the wires and cables of our monitoring devices. The ECG leads, blood pressure tube and sats probe will inevitably get wrapped around or caught under various parts of the unconscious patient. We should be able to have ECGs, BP cuffs and sats probes that connect to the anaesthetics machines wirelessly and get rid of this problem.

5. Bleeps

This is one that’s not specific to anaesthesia but is the bane of junior hospital doctors across the nation. The bleeps (or pagers) that we have to carry and use to contact each other have to be the most annoying and inefficient way of communicating ever invented. I’ve mentioned this before and the solution is for hospitals to have a mobile phone system rather than a paging system. Communication would be much better and things would get done faster because staff won’t have to sit around waiting for people to answer their bleeps.

A job for life

I was working with a consultant today and we gave a general anaesthetic to an 87 year old woman who was having some skin lesions (BCCs and SCCs for the medics among you) removed and some skin grafting done.

We gave her a very gentle anaesthetic and were able to successfully guide her through the operation without too much drama. Whilst the operation was going on it hit me that I was helping give a general anaesthetic to an 87 years old with a list of medical problems as long as my arm for a non-life saving operation. It struck me that (once I’ve had a few years more training) there will always be work for anaesthetists to do and I’ll always be needed. No matter where I go, no matter what happens to the health service, no matter how much the politicians meddle, there will always be people that require surgery and therefore, there will always be a need for me and my skills as an anaesthetist.

At the weekend, I was consoling an old school friend who had just been made redundant from the London branch of the bank UBS (though, considering the size of his redundancy package, I didn’t feel too sorry for him). In contrast, I’m pretty sure that no matter what happens in the future, I’ll always be able to earn a crust.

The future’s bright.

btw WHAT a stunning performance from Great Britain in the olympics. I wish I’d taken this fortnight as annual leave so I could watch more of our Olympians doing the country proud. Go Team GB!

A crisis of confidence

I’m having a bit of a crisis of confidence at the moment. It’s just over a week since I changed jobs and it’s becoming blatantly obvious that all the other ST2 and CT2 anaesthetists here (i.e. those employed at the same level as me) are actually much better than me. They’ve all done lots of anaesthetics in various foreign countries before coming to work here and thus, they’re all much more experienced than I am. They’re happy to do neuro-axial anaesthesia, paediatrics and central lines completely unsupervised and I feel I’m quite a way off that stage yet.

I know that it’s not a fair playing field and that, despite being employed at the same level, they’re far more experienced than me… but I can’t shake the nagging feeling that I am currently way behind “the competition.”

The fact that it’s dawning on me what a colossal task I’m facing when I sit my exam in October isn’t helping. Perhaps it’s because I’ve just come off a long shift and am feeling a bit tired and emotional, but – right now, my confidence is lower than it’s been in months.

This isn't how I imagined it would be

Throughout our medical training, doctors are taught what needs to be done in certain emergency scenarios. We have lectures on how to deal with heart attacks, perforated bowels, ectopic pregnancies etc… etc… and the point of all this is that we know how to recognise and deal with these emergency situations should they ever occur. The thing is, when things are going bad in front of you, it doesn’t happen like it says in the books and things don’t ever go how you’ve imagined they would.

Let me tell you about what happened yesterday.

I was rostered to spend the afternoon working on the High Dependency Unit (HDU), so after lunch I wandered down and introduced myself to the doctors and nurses on duty. One of the registrars was putting in a central line (subclavian) on a post-op patient, so I popped my head round the curtain to watch her do her thing. I’m still not as good as I’d like to be at inserting central and arterial lines and I find it quite useful to watch other people do them so I can pick up on one little tricks they may use. Harry, the patient concerned, had arrived from the surgical wards after having an operation a couple of days before. Apparently, Harry hadn’t been doing so well with his breathing and was on a non-invasive ventilator and on the morning ward-round, the consultant was debating whether or not to sedate him and put him on an invasive ventilator. Jane, the registrar was having a real struggle getting the central line into Harry’s subclavian vein, but she got there eventually and I wrote a request form for a routine chest X-ray at some point in the afternoon. The time is 14:25

14:30
After Jane has cleared up her stuff, I stay by Harry’s bed and look at his notes to see exactly what operation he’s had and what happened in the post-op period that ended up with him being admitted to HDU. Harry is drowsy and only just rousable, but he’s been like that since his arrival onto HDU earlier in the morning.

14:33
The alarms on the non-invasive ventilator start going off. Ventilator alarms and alarms in general are really common on HDU and ITU, so I’m not particularly interested at this stage and Emily, Harry’s nurse wanders round to the other side of the bed to investigate what’s wrong.

14:34
Emily says “Er, ‘Mick’ is it?”
“Michael.” I correct her
“Sorry, Michael. I’m not really happy with this ventilator – it’s saying that Harry’s tidal volumes are only 200ml” (this means that Harry is only taking tiny breaths, despite being on a ventilator – this shouldn’t happen – something is wrong)
I wander roung and have a look. “Is there a leak round the mask?” I ask. (Non-invasive ventilators require a tight fitting oxygen mask on the patient’s face so they can push oxygen into their lungs when the patient breathes. If the mask is not tight enough, the oxygen leaks out round the side and the ventilator doesn’t work properly).
“No,” comes Emily’s response, “these machines are really clever and they give you a number that tells you the amount of leak and Harry’s hardly got any at all.”
I really have no idea why Harry isn’t breathing properly but a quick glance up at the monitor tells me that all his observations are fine, so I’m not overly concerned. I give a mental shrug, tell Emily I don’t know what the problem is and go back to reading his notes.

14:36
The ventilator is still saying the same thing but on the monitor, Harry’s oxygen saturations start to change. Sats should be 97-100%, especially if someone is on oxygen and on a ventilator.
Emily and I watch as Harry’s sats go 97… 94… 91… 89… 85… This means that he is dying.

Emily and I look at each other, we’re going to have to do something. “We’re going to have to bag him,” Emily says.
I agree and while Emily takes Harry’s ventilator mask off, I reach for the “bag and mask” behind Harry’s head and turn on the oxygen as high as it will go.
The sats monitor read 77… 74… 70… 68… 65…
I hold the mask onto Harry’s face and do some airway manoeuvres while Emily squeezes the bag and pumps vital oxygen into Harry’s lungs. It works, the monitor reads 70… 82… 88… 93… and then we’re back to 100%
“I don’t know why that happened” I say as Emily and I connect Harry back up to his non-invasive ventilator. It’s now 14:39

14:41
Exactly the same thing happens, Harry’s sats go down again and once more Emily and I have to bag and mask ventilate him to get them back up again. This time, we call for help and Jane and Anil (another anaesthetic registrar come to see what’s going on).

14:45
Jane asks to take over ventilation to “see how he feels.”
Anil performs a quick respiratory examination. Bilateral breath sounds, chest clear at the front, trachea central. He asks Emily to call X-ray as we need an urgent portable chest X-ray on this man.

14:46
Anil asks me to draw up some intubation drugs, so I go and ask Debbie, the senior nurse in charge to show me where the thiopental, suxamethonium, atracurium and metaraminol are kept. Harry’s observations (“obs”) are still in the normal range but he’s more or less unconscious now.

14:50
I return with the drugs drawn into syringes. Jane is maintaining ventilation. Harry’s obs are still normal. The radiographers arrive and we all help position Harry for his chest X-ray.

14:52
The Xray is done, Jane says that it’s getting harder and harder to breathe for Harry. I do a repeat respiratory examination – there are very few breath sounds in either lung and the trachea remains central.

14:54
Harry’s blood pressure starts to fall from 163/95 to 100/40 over about 30 seconds. Anil tells me to give some metaraminol and I give 2mg. By this time, a couple of other nurses and the medical students have arrived. Anil asks the medical students to access PACS and see if Harry’s chest X-ray is on the computer system yet. It isn’t. Emily and one of the other nurses go off to get the resuscitation trolley.

14:55
The metaraminol hasn’t made much difference, Harry’s blood pressure is no 75/45 and falling. Sats are still 100% thanks to Jane’s ventilation, but she says that she can hardly breathe for him at all now. Ominously, Harry’s heart rate drops from 115 to 85 to 55 to 45 and keeps falling. Anil grabs some atropine from the resuscitation trolley and squirts it into Harry’s veins.

14:56
Harry’s heart rate starts to rise again until it levels out at about 130bpm. Emily and I get the laryngoscopes and endotracheal tube ready for Jane, should she need to intubate. Anil asks the medical students again if the X-rays are ready. “No,” comes the reply.


14:57
The atropine had brought the Harry’s blood pressure up to about 100/40 but now it is dropping down again. Jane continues ventilating but despite this, Harry’s sats start dropping again – 100… 97… 94… 92… 88… 86… I have a look at the bed so I know how to flatten it out should we need to start CPR

14:58
“The X-ray is up!” comes a shout from the male medical student
“What does it show?” asks Anil
“Errr…. Maybe collapse? Maybe consolidation?” comes the tentative reply
Anil runs over to the computer screen

14:59
“There a huge pneumothorax there!” he exclaims. “Pass me that orange venflon.”
Anil picks up the venflon and plunges the needle into Harry’s chest (2nd intercostal space, mid-clavicular line)
There is a hiss of air as the pressure in Harry’s chest is released

15:00
Immediately Harry’s sats come up again to 100% and his blood pressure immediately returns to normal.

I’ve never seen someone have a tension pneumothorax before, but I know all about them from the textbooks. Whilst, Harry had all the signs of a life-threatening event, he didn’t actually have the signs that made us think “this is a tension-pneumothorax.” When I’ve studied the consition in books, I’d hoped that if I ever had to deal with a real-life tension-pneumothorax, the diagnosis would be quite obvious and I’d know what to do. Whilst, we all knew what to do, like is so often the case in medicine, the diagnosis was not at all obvious at all and we didn’t know what was going on until we saw his chest X-ray.

You’re not meant to do chest X-rays on suspected tension-pneumothoraces because patients die before the doctors see the results. Luckily for us, our radiology department managed to get the X-ray results back to us in less than ten minutes.

Jane put a chest drain into Harry’s chest and we’ve now sedated and intubated him in order to give his body chance to heal itself.

This was a definite “learning experience” for me.

It begins again

My reprieve is over.

After passing the FRCA Primary MCQs, I gave myself a couple of months free from studying, to relax a little and generally not to think about exams. That time is over and now I’m going to have to knuckle down and start studying again for the FRCA Primary OSCE/Vivas, which is the second (tougher) part of the exam.

The actual exam itself is held in London at the start of October, so I’ve got a couple of months to go. At the moment, I’m feeling really dispirited when I even think about it. I’m having real trouble motivating myself to pick up a text book and do any studying at all.

My tactic is going to be to revise in the “goal-orientated” way that’s seen me through all my exams so far. What I mean is that I’m going to practice doing the exam as many times as possible before the exam day itself. Practically, this is going to involve collaring as many consultants and SpRs as I can and getting them to grill me on the physics, pharmacology and physiology related to anaesthesia. It’s going to be tiring and tough, and it all seems a bit daunting at the moment. Hopefully, I can once again find the determination I had earlier in the year that saw me through the first exam but, to be honest with you, I’m just not feeling it at the moment.

The Olympics

The Olympics have finally arrived! I love the Olympics and am going to be seriously excited as I cheer on Britain's finest as they pit themselves against the best of the world.

They say we're aiming for 35 medals but I reckon we can get 40.

Come on Team GB!

It goes on and on and on…

There has been a change in the way that junior doctors are introduced to their jobs. I’ve just done the second of my three days of induction. Three days! I’ve had lecture after lecture on topics such as how to fill in death certificates and drug charts, how to navigate the computer systems, infection prevention, the four hour A&E wait, fire safety, medical devices etc… I’ve had practical tutorials on manual handling and CPR.

I don’t think that this stuff is really aimed at me because I know the vast majority of the stuff already. It’s aimed at the brand new FY1 doctors who are coming out of medical school into their very first jobs. I think this is great. I do admit that I feel a lot of it is very tedious, but it was good to go over some of the stuff again keep fresh in my mind.

I think the big driver for this change has been the setting up of foundation schools for doctors in their first two years of working (also known as FY1 and FY2 doctors). The long induction process is an example of how new doctors are now much more protected that they used to be. Personally, I think the new inductions are definitely a good thing.

On my very first day as a doctor (only a few years ago), we had just one morning of induction and then we were thrown on to the wards to just get on with it. I wasn’t told where anywhere was and I wasn’t even given passwords to access the computer systems. What made it even worse was that my first ever shift as a doctor was a night shift. It was horrific and, to this day, I still shudder when I think about it.

Another big advantage in having three days of induction is that we actually get a chance to meet the other doctors in the hospital. I’ve had a chance to have a chat with the surgical, paediatric and medical juniors and it’s really nice to try and get to know a little about the people who’ll be working in other specialties. Everyone I’ve met seems pretty friendly, so, fingers-crossed, my new hospital will be a nice, sociable place to work.

All Change

Today is the day of the junior doctor’s job change. All across the land junior docs like me are swapping jobs and starting new positions. Sometimes it’ll be a job within the same hospital but often it’ll be a job in a different hospital, even in a totally different part of the country (this is especially common now that MMC is now ru(i)nning our lives). It’s also the day that all the brand new doctors start work fresh out of medical school.

I’ve started a new, more senior position (ST2 woohoo!) in a smaller hospital in the same region. Today was our induction day. I usually hate induction days with a fury, but, to give credit where credit is due, today’s ran quite smoothly, to time and there wasn’t too much in the way of dull irrelevant rubbish. I met a few of the people I’ll be working with over the next few months and there were a few familiar faces from my last hospital there as well.

I have to say, I’m feeling quite excited about my new job. I think the change of scene will be interesting, if nothing else. I’m looking forward to doing a lot more work in the maternity unit and I’m looking forward to meeting new people and making new friends.

Tomorrow I get to see what the anaesthetic department, the operating theatres and the Intensive Care Unit are like and I’ll meet a few of the consultants too. It should be good.

I know that this probably sounds really sad and geeky but I honestly can’t wait to go to work tomorrow.

Oh and by the way, the Occupational Health Nurse took two seconds to look at my arm, then signed the form. I really glad I didn't make the trip on my day off to do it.

In which I find myself totally out of my depth

Anaesthesia is often described as a “hurry up and wait” specialty in that there are often long, boring periods where nothing in particular happens and then there are the moments where things get very critical, very serious, very fast. I think my on-call shift today summed this up perfectly.

There were a few operations to do in the morning, but by 2pm, we had finished in theatres and there was nothing else booked. The Intensive Care Unit was quiet too, so I had a chance to read some of my novel and do a little revision as well.

At around 7pm, I get a call on the “crash bleep” asking for my immediate assistance in A&E Resus. I peg it down there and as I round the corner I am confronted with a clutch of people surrounding a small child who is obviously having a seizure.

One of the consultants once told me that when dealing with children in an emergency, the very first thing you should do is pause for thought. (In fact, if I remember right, one of the rules in “The House of God” is something like: “At an arrest, take your own pulse first”) I take her advice on-board, take a second to compose myself, take a few deep breaths then step into the Resus bay and assess the situation.

A quick glance tells me lots of important things:

- The child is alive.
- The child is breathing.
- The child is pink.
- The child is fitting.

The child’s father is doing a brilliant job at maintaining the boy’s airway with a jaw-thrust. I introduce myself to everyone and find out that the boy is called Declan, he’s 6 and has had several admissions to hospital and to intensive care with his epilepsy and this time, he’s been fitting for about 30 minutes so far. The people in the bay are: Declan’s Mum & Dad, 2 A&E nurses and the paediatric SHO and SpR.

I grab the resuscitation mask and take over from Declan’s Dad. At this point, the paediatric SpR manages to get a cannula into one of Declan’s thready little veins. I look over my shoulder at the monitor which is displaying

Pulse rate: 160
BP: 124/77
SpO2: 100%

Things are not exactly stable but they are under control – at the moment. If my year of anaesthetics has taught me only one thing it’s that things can go tits-up very, very quickly – especially in unwell people, especially in children, especially in unfamiliar environments with unfamiliar staff and unfamiliar equipment. Basically, things could go very bad at any moment and I realise that if they do, I’m going to need some help.

I call out to Julie, one of the A&E nurses, “Could you call the SpR on-call for Intensive Care and ask him to come down here immediately, please” and she hurries away to the telephone.

Declan’s parents are obviously very worried, but at the same time are remarkably calm and helpful. They’d already given him diazepam and paraldehyde, but those drugs had had no effect.

The paediatric SHO pipes up “I’m giving lorazepam now” I say “O.K.” and she injects the drug into Declan’s veins. Declan’s movements become less but his seizure continues. However, his breathing quickly becomes shallower and then stops altogether.

Shit.

I gently squeeze the ambu-bag and pump air into Declan’s lungs. Mercifully, I see the young lad’s chest expanding as I do so. I can “bag and mask ventilate” him, which means that I should be able to keep him alive – at least for a little while longer.

“What’s happening?” Declan’s Dad says. Now he’s not calm at all, in fact, he’s looking visibly petrified. “It looks like he’s suffocating? Is he breathing? Is he O.K?!?”

Declan is making a little respiratory effort, but not a great deal. Typically, the sats probe has slipped off his toe and I can’t see a reading when I look at the monitor.

I try to keep my voice calm and tell his Dad, “he’s breathing a little, but I’m helping him as well.”

The paediatric SHO - Amy I think her name is - has a listen to Declan’s chest and confirms that she can hear breath sounds from both lungs. Thank God.

At this point the ITU SpR, Shane, arrives and I give him a brief lowdown on what’s happened so far. He asks me if I’m OK doing what I’m doing for the moment and then goes off to call the ITU consultant on call.

Declan is breathing a bit deeper now and his sats are still 100% but, despite the drugs he’s had, the seizure continues. Shane comes back to the bay, says that we should avoid intubating Declan if possible but starts drawing up some intubation drugs - just in case.

The lorazepam has not stopped the fits, so the paediatric duo say that they want to start a phenytoin infusion.

It takes them aaaaaaaaggggeeeeeeeesssss.

I can appreciate that calculating the dose and rate for a phenytoin infusion is difficult (see page 251, assume he’s 20kg and try and the dose, dilution volume and infusion rate for yourselves). I remember the last time I had to do it in an emergency situation, it took me a while – but it didn’t take me a full 15 MINUTES to work it all out. I think it took longer because there were two of them and they kept interrupting each other’s thought processes but eventually Shane had to step in and tell them to hurry the fuck up because Declan was still fitting.

At this point I got paged from theatres. I asked Shane to take over Declan’s breathing so I could answer my pager. (The real reason was because my hands were starting to cramp up from holding the resuscitation mask onto Declan’s face for so long). It’s the surgical registrar on call. There’s a man on the surgical ward who’s bleeding post-op and needs an operation RIGHT NOW to stop it. It never rains, it pours. I explain what I’m up to and that I can’t leave at the moment and ask him to phone the consultant on call for anaesthetics about his patient.

I go back to the bay. They phenytoin infusion is up and running at last, but I get the laryngoscopes, endotracheal tubes, atropine and suction ready for Shane – just in case.

However, this time the drug works and Declan’s fitting slowly desists. He drifts into the sleepy (post-ictal) state that follows a seizure and, much to all our relief, he becomes more stable and able to breathe properly for himself.

With perfect timing, the consultant paediatrician (who obviously knows Declan and the family well) shows up and she starts to have a chat with Declan’s Mum. I look down at Declan who, though still unconscious is peaceful and medically stable. I ask Shane if he’s happy for me to go down to theatres and he says “Sure mate” and I thank everyone and leave.

Declan’s parents, Shane, the paediatricians and the A&E nurses all thank me as I walk away and I smile to myself as I reflect on a job (reasonably) well done.

The contentedness doesn’t last very long, however, because just as I reach the doors to the operating theatres the crash bleep goes off.

**Cardiac Arrest – Medical Assessment Unit… **Cardiac Arrest – Medical Assessment Unit… **Cardiac Arrest – Medical Assessment Unit…

Like I say – it never rains; it pours.