Friday, 26 September 2008

Anaesthetist 1 Surgeon 0

We're halfway through a gall bladder operation

Consultant surgeon to surgical SHO: What passes through the foramen spinosum?
Me: I know that one! It's the middle meningeal artery
Surgical SHO: Which is a branch of the maxillary artery
Me: I'm an anaesthetist and even I know that. I've got one for you guys
Surgical SHO: Go on...
Me: What's the equation for heat generated by the diathermy machine?
Surgical SHO: ...
Consultant surgeon: ...

One of the few advantages of exam revision is that occasionally, you get to look dead clever at work...

(p.s. if you're really interested, the answer is Heat is proportional to the square of the current divided by the area)

A night's sleep

It’s four in the morning and I’m working a night shift when my pager goes off. I pick up the phone and dial the number on the screen.

“Hello, staff nurse speaking.”
“Hello, it’s Michael here – anaesthetics – were you paging me”
“Yes, it’s staff nurse on the colorectal ward. Do you know Emma?”
“No, I’ve not met this person.”
“Well, she’s a patient on the ward who had a bowel resection yesterday evening. I’m calling you because we’re having trouble with her epidural. Over the last hour or so she’s been complaining of pain in her abdomen and it’s been getting worse. I tried to go up on the (epidural) rate, but she’s now saying that she’s in agony. I was wandering if you could come up and review her please.”
“Is her blood pressure OK?” I ask
“Yes,” comes the reply. “The last one was 115/70”
“And has this epidural been working at all since she got back from theatres?”
“It seemed to be earlier on, but, like I say in the last hour or two, she’s been complaining of more and more pain.”
“OK, I’ll come up and see her.”

I pick up my coffee (coffee is a god-send when you’re working through the night) and wander across to the surgical wards. I take a detour via the intensive care unit to pick up a vial of bupivicaine – just in case.

The staff nurse I spoke to greets me as I walk up to the nurse’s station and shows me where the patient is.

Emma is lying stock-still on her back and is grimacing. It’s four in the morning and this woman really should be sleeping. I ask her a few questions, check her observations and tell her my plan.

“What I think is best is that I give you a top-up injection down your epidural and that may well take the pain away. We’ll check your blood pressure a couple of times afterwards, but hopefully you’ll be much more comfortable. If it doesn’t work, then we’ll try something else. Sound like a plan?”

Emma nods at me and I inject 5ml of 0.25% bupivicaine down her epidural. I wander back to the nurse’s station and ask the nurse to check her BP in 15 minutes’ time. I sit down and chat to the nurse for a bit while scribbling something in her notes.

After 15 minutes I go back to see Emma.

“How are you feeling?” I ask. “Has it made any difference?”
She looks up at me and gives me a big smile. “Much better now thank-you. I don’t have any pain at all.”
“It’s gone completely?”
“Yes, thank you so much.”
The nurse checks her blood pressure which reads 121/75.
“Your blood pressure if fine, I’ll increase the rate that the epidural is running at. We’ll check your blood pressure again in about a quarter of an hour and after that, you’ll hopefully be able to get some sleep tonight”
“Thank you again, so much” Emma says to me and I wander back to ICU smiling to myself.

I think part of the appeal of anaesthesia is that just about everything you do makes a tangible difference to the patient. Whether that’s “big” things like an A&E trauma call, or “little” things like giving an epidural injection so a woman can get some sleep the night after her major surgery, you always feel you’re making a difference to help people.

(I think some credit should go to the staff nurse here too, stuff like this is much easier to sort out if the nurse is sensible and knows what she’s doing.)

Tuesday, 23 September 2008


There can be no doubt that the job I do is really hard. By that I mean it’s really stressful and it can be really, really emotionally draining. I’ve seen lots of truly horrific things in the last few months and after trying my best to deal with each situation, I have to try and pick myself up again and try not to let it “get to me.” The emotional side is compounded, I think, by the very long hours that I have to work, the fact that I can’t choose to work near my family (thank-you MMC), that I’m having to spend all my spare time studying and the fact that there is a rather macho “just get on with it” attitude among doctors where nobody really talks about the horrible things on any sort of emotional level.

I’m really lucky though because I have a family who love me, a group of really good friends from uni who I know I can always call and a really lovely girlfriend to give me a hug when I need one.

A lot of doctors don’t have the support of a caring network of friends and family and I really see why some doctors struggle. It’s really easy to start to believe that you’re all alone, that every bad thing that happens is your fault and I can see why the rates of drug abuse, alcoholism, depression and suicide are disproportionately high among medics as compared to other professions.

I’m writing this because I made the journey to see my family at the weekend. I was chatting to my father about this and that and he stops and says to me; “You know Michael, I know it’s not often that I say this but me and your mother are really proud of you. Of the things you do and what you’ve achieved. We know you work really hard and you have a really tough job and I do pray for you.”

It’s amazing how just a few words can have such a big effect on me. I had a lump in my throat and just managed a quiet “Thank-you” to my dear father. But the point of this post is just to say that knowing that you have your family by your side no matter what makes shitty times like these MUCH easier to cope with.

Stages of Preparation

For the last few weeks, I’ve had my bum glued to the chair as I try and cram as many facts, principles and theories into my head as possible before my exam next month. I have to say that I feel much happier about my chances of actually getting through it now. I think that there are definitely certain stages that I go through when preparing for a big exam like this one.

Stage 1: Denial.

I think to myself that “everything is going to be OK, other doctors have passed this exam, so it’s obviously not impossible.” I have a vague notion that I’ll need to do “some work” at some point but I’m not at all concerned by the prospect

Stage 2: Trepidation

You can count the number of weeks to the exam in single figures now and I start to get tetchy. I look at some example questions and realise that I can’t do any of them. I look at the pile of anaesthetics books that I have and it hits home hard that there is a HELL OF A LOT of work to get through. At the same time, I’m almost scared to face up to it and start studying in earnest because I know how miserable studying is.

Stage 3: Fear

I’ve tried to learn stuff. I’ve been trying to remember the anatomy of the spinal cord or the shunt equation and its applications, but it just won’t go in. I just don’t “get” it and I can’t remember it all by rote. Everything that goes into my brain leaks out again and I feel I’m never going to know enough. It’s about this time when I start panic-buying more textbooks and ringing round revision courses to see if they have any last minute places.

Stage 4: Hope

Eventually, this stuff starts to stick. I begin to understand it. I realise that I actually DO know some stuff. I CAN derive the Bohr equation from first principle, I CAN talk sensibly about pharmacokinetics and the 3-compartment model, I DO know the side-effects of phenytoin, suxamethonium and a host of other drugs. There’s a glimmer of hope and I realise that, provided I’m lucky and get asked about the topics that I know well, I might just pass.

Stage 5: Determination through the dark days

At this point, I’m thoroughly fed up with it all. I’m sick of the sight of my books, my house is a mess with bits of paper with diagrams and graphs on thrown everywhere. I’m working 56 hours a week (8hrs a day, seven days a week) and then coming home and trying to do my studying on top of that. I have no social life and there’s nothing fun to look forward to. I think to myself “You know what, these are dark days and I’m REALLY miserable. There is NO FUCKING WAY that I’m going to put myself through all this again if I can possibly help it. I’m not going to leave it to luck, I’m going to work even harder to make sure I pass this bloody exam. Failure is not an option.”

Stage 6: Consolidation

The exam is only a few days away, I’ve done all the work I can, I know my stuff now and I feel quietly confident that I’m going to pass.

At the moment, I’m somewhere between stages 4 and 5 and I'm just hoping I can get to stage 6 before the exam itself. I’ve still got a lot to do, but I’m actually starting to believe that I WILL be able to at least cover all the topics before the exam.

While I was away…

The big story that I missed during my self-enforced break to study was the disgusting treatment of a surgeon in Scotland who was suspended from his job, not for any concerns about patient care, but because he called one of the architects of the MMC fiasco names.

This appalling abuse of power has been condemned by a host of bloggers, especially as it appears that the person behind his suspension is hardly whiter than white herself.

Said surgeon has since been re-instated to his job, but, like the Ferret says, the whole episode leaves rather a bitter taste.