Saturday, 29 November 2008
My girlfriend told me that I always seem to have two or three projects on the go at the same time, and it's probably true. I guess I'm happier that way.
I'll be back posting again very soon.
Saturday, 22 November 2008
The reason hospital dramas have come to my attention again is the latest episode of Holby City which in which the plot has reached such a ridiculous low that people were actually talking about it in the theatre coffee room yesterday.
As far as I can make out the plot goes like this. The anaesthetist, who everyone hates, is acting like a total tosser in theatre. He then starts dicking around with the (charged) defibrillation pads for no reason whatsoever. This being TV, he manages to give himself an electric shock with them. Cut to scene where he’s now being given “life support” by one of the surgeons and an ODP. When I say “life support” I mean it in the vaguest possible way. He’s given random shocks and oxygen but there’s no cardiac arrest team, no CPR (as in - not one single chest compression!), no IV access, and no drugs given. Surgeon 1 turns to surgeon 2 (who I presume is the consultant), who is doing a great job of ignoring all this and is carrying on with the operation regardless, and says “it’s not working” (no shit, Sherlock!). Guess what the consultant’s response is? “Put out the cardiac arrest call?” “Get some more help?” “Do some basic life support?” Nope. He responds by declaring the anaesthetist dead! To top it all off, the monitor still shows ventricular fibrillation. Unbelievable.
The plot rumbles on. No one in theatres or on the ward mentions what’s just happened (like this is an every day event or a “risk of the job”) and we cut back to another scene featuring surgeon 1. Remember that one of this man’s colleagues has just died and surgeon 1 is partly responsible due to his overwhelming, unbelievable incompetence in an emergency situation. A St Johns Ambulance volunteer on their first day would be embarrassed by surgeon 1’s behaviour, never mind a supposed senior hospital doctor. Now a bereaved and grieving family will have to bury their son/dad/husband/brother. Is there any remorse shown by surgeon 1? Is there any guilt that his failure to act resulted in the death of a work colleague? Nope, of course not. He’s shown laughing about the whole thing in the bar with one of the nurses!
I thought that people were taking the piss when they described what happened on the show, but thanks to BBC iPlayer, I got to see the sorry saga for myself. If you want, you can catch it here, the episode is called “Cutting the Cord” and, if you understandably can’t bear to sit through the whole thing, the fun starts at about 41 to 42 minutes.
It begs the question, have the people who write the scripts for these shows even been to a real hospital or ever spoken to real NHS workers? Judging by what I’ve seen the answer is obviously not.
Friday, 21 November 2008
Tuesday, 18 November 2008
On the rota, I’m down to do a gynaecology list in the afternoon with one of the consultants. On the list is Mrs Hughes, a middle-aged professional woman, who is rather nervous about the whole thing. During my pre-op assessment, it becomes obvious to me that this woman I petrified of having a general anaesthetic – so much so that she is considering just getting up and leaving the hospital. When I probe a bit more into her fears, it turns out that she’s not really that bothered by the idea of the surgery but is really scared of the unconsciousness that general anaesthesia necessitates.
I explain this to the consultant and the consultant comes to see the patient. After a bit of discussion, Mrs Hughes agrees to have her operation done under spinal anaesthetic. This means that she gets an injection into her back to give adequate pain relief for surgery to continue, but she’ll remain totally awake and conscious throughout the whole operation.
It’s now later on and we’ve done the spinal anaesthetic. Mrs Hughes is in the operating theatre and the consultant gynaecologist is part way through the operation. Mrs Hughes is perfectly calm, so we haven’t given her any sedation at all and I’m just chatting to her about this and that - so far so good.
At this point, the theatre doors open and one of the particularly loud theatre nurses walks into the room. She’s been working in the theatre next door and has come in to get some piece of equipment they need.
She spies the surgeon and in a loud voice exclaims, “Hello again David! It seems that these days, every time I see you, you’ve got your hand up some woman’s fanny!”
There are lots of shocked/embarrassed faces in the operating theatre and a deathly silence until my consultant pipes up with, “Errrr, Mary, this is a spinal. She’s totally awake.”
“Oh, shit” comes the reply from said theatre nurse who promptly legs it back out of the room.
Luckily, Mrs Hughes saw the funny side.
Monday, 17 November 2008
As I’ve grown older, I’ve realised that some of the time, their advice had some reasonable basis behind it and since I’ve been a doctor, there have been occasions when I look back and think “I really should have listened to what my Mum said.” Here are some of those occasions.
Don’t run in corridors.
-A favourite of various teachers at my primary school.
I’m on call for anaesthetics when the crash pager goes off.
“...Cardiac arrest; renal unit.
Cardiac arrest; renal unit.
Cardiac arrest; renal unit...”
I’m with the consultant in theatre and she says that I should go while she looks after the patient on the table. The renal unit is a fair way away from the operating theatres and I’m feeling quite sprightly, so I decide to run to this crash call. Running through the hospital is all a bit “E.R” and it’s not visiting times so the corridors are relatively empty.
I pick up speed as I enter a long corridor with a T-junction at the end of it and muse to myself that I’ll probably get there before the medical team (which is not the way it normally is). I’m getting closer now, but as I round the corner of the T-junction, out of the corner of my eye I glimpse somebody running from the other direction. It’s the medical FY1 doctor, who’s been pelting down the other corridor to get to crash call. I try to avoid her, but it’s too late and we run smack-bang into each other. Because I’m quite a bit larger than she is, I knock her flying to the ground and then sort of trip over her.
Worse, we are near the canteen and I fall into a stack of used breakfast trays and we both end up in a heap at the bottom of it. As I hit the stack of trays, manage to tip a tray containing some uneaten porridge and cold tea over both of us.
Luckily neither of us were hurt apart from a little bruising, but we did get some funny looks from the nurses and the rest of the crash team when the two of us arrived with me with porridge on my scrubs and her with tea dripping from her hair.
Friday, 14 November 2008
Anatomy of a night shift
It’s dark and it’s raining. I’m in my car driving towards the hospital to do another night shift. I’m actually feeling pretty good. Hands-free mobile technology has allowed me to spend much of my journey chatting to my girlfriend. I pull into the hospital car park and have enough time to grab a coffee, and get changed into my scrubs before the shift starts at 8. As the anaesthetic SHO on-call, my most important duty is to keep the Emergency Surgery (CEPOD) Theatre going so all the patients who need operating on that day have their operations. Sometimes, there’s an operation going on as I start my shift, sometimes there isn’t. I wonder what’s happening in theatre at the moment
There is indeed an operation going on. I walk into the operating theatre and say hello to Melanie, the anaesthetic SHO on-call for days. We exchange pleasantries about how her shift has been (frustratingly slow) and she tells me about the patient. Surgery has just started on a fit, healthy 4 year-old girl who had split her lip open and the Maxillo-Facial surgeons were just going to sew it up again. There were a couple of other people on the list for surgery tonight, one 12 year-old for an appendicectomy and one 71 year-old with a broken leg that needed fixing. I get a handover from Mel about the child on the table, take hold of the breathing circuit and Mel goes home.
The Max-Fax surgeons were true to their word, the operation doesn’t take long at all. When they finish, I turn of the anaesthetic vapours, turn up the oxygen and wake the little girl up.
I’m in the recovery area and I’m satisfied that the girl is awake, comfortable and breathing for herself. One of the theatre nurses comes up to me and asks, “Can we go and get the next patient now?”
“No,” I reply. “I haven’t seen this boy yet.”
“Can’t you just see him in the anaesthetic room?”
“No. I’ll see him on the ward.”
Personally, I think that people should be given the opportunity to speak to the anaesthetist before they come down to theatre. Also, my seeing the boy on the ward gives me to pick up any problems that the surgeons may have missed/ignored and potentially do something about them before the operation.
I trek across to the children’s ward and meet young Joe who is lying in bed with his mother beside him. Joe is actually quite sick. He’s had belly pain for two days now and he has a fever of 39.1˚C, his heart is racing and he’s very still and quiet, the way children get when they feel really rough. I do my pre-op assessment and then I tell Joe and his Mum what to expect when they come down to theatre. Joe has lots of questions about exactly how I’m going to keep him asleep and I spend a bit more time explaining how anaesthesia works and reassuring him a bit.
I let the paediatric nurse looking after Joe that someone will be up to collect him quite soon and then head back to theatres via the Intensive Care Unit. I find the anaesthetic specialist registrar (SpR) – my immediate senior. It’s VJ tonight. He already knows there’s a child booked for theatre. He asks me if I’m happy to carry on with the case alone. I tell him that I am and head off back to theatre.
Joe and his mother arrive in the anaesthetic room. I’ve got everything prepared and I set about getting Joe anaesthetised. He’s been sick earlier, so I plan to do a “crash induction” and intubate him. Crash inductions (or Rapid-Sequence Inductions) can be quite fraught with danger, especially in unwell patients and especially in youngsters. I’m aware that I’m all alone so I make doubly sure that everything is ready and everything I may need is to hand. It’s not a problem though. I safely get Joe anaesthetised and intubated and the nurse takes his Mum away to have a coffee.
The operation takes a while because the surgical reg is teaching the surgical SHO. About half an hour into surgery, my pager goes off.
“Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.”
There’s no way I’m leaving this anaesthetised, intubated, ventilated child to go to A&E resus so I ask one of the theatre assistants to phone switchboard and get them to page VJ, the night anaesthetic SpR on-call, as I am unable to attend.
The operation is all over. Joe had a nasty, perforated appendix but now it’s been removed he should start to get better. I waken him in recovery and he’s comfortable, if a little tired.
Emily, the ODP on nights asks me what I’m going to do about the last patient on the list – the man with the broken leg. I tell her that I’m going to check what’s going on in A&E and speak to VJ, and then I’ll get back to her.
A&E resus is empty. I figure that if it was an airway problem, then the patient may well be in the CT scanner so I walk round to radiology. I’m proven right. There’s a clutch of people in the observation room of the CT scanner. VJ has intubated and sedated the patient and a quick glance at the screen tells me that whoever the patient is, they have a significant amount of bleeding inside their skull. Bad news.
On the return journey to A&E resus, VJ fills me in with the story of what happened. Basically, the patient is a 25-year-old man found semi-conscious by his housemate when she got home from work. VJ had done a great job in stabilising the patient regarding blood pressure, sedation, monitoring, carbon-dioxide levels, oxygenation and ventilation etc… etc… There’s more to do though, and I give him a hand as the A&E doctors get on the phone to the neurosurgeons at TheBigTeachingHospitalDownTheMotorway.
The brain surgeons listen to the history, review the CT scan results and agree that this man needs emergency brain surgery tonight.
“I’m going on a journey, aren’t I?” I ask VJ
“Looks like it,” he replies. “Have you done inter-hospital transfers before?”
“OK, well there’s a few things that you’ll need to be careful of…” says VJ, and then proceeds to give me a five-minute crash course on how I should transfer this patient.
I’m not actually all that concerned. The patient, Jimmy his name is, is pretty stable from a cardio-respiratory point of view. I just make sure that my monitors are working, I have the drugs I may need in my pocket and that all my equipment is present and in working order. I also make sure I take my coat, some money, my mobile phone and my sandwiches.
The ambulance crew are here and we load Jimmy into the back of the ambulance. Emily, the ODP, and I squeeze into the back and the two ambulance crew hop into the front, turn on the blue lights and off we go.
The journey itself is pretty uneventful. I have to play with Jimmy’s arterial line a few times to get it to keep working. I also notice that when we’re on a bumpy part of the road, the ECG monitor does a good impression of VF, which was initially quite disconcerting.
During the journey, I start to feel tired. I wish I’d had a coffee before we left, but Emily and I share my sandwiches and this helps keep us going.
When we arrive at TheBigTeachingHospitalDownTheMotorway, we go into A&E resus. Straight away, TheBigTeachingHospitalDownTheMotorway’s nursing and medical staff are surrounding us asking questions and organising various things. I give two handovers, initially to the A&E SpR and then to the consultant anaesthetist who has come to take the patient to theatre. I have to say, having so many people who I don’t know doing stuff all at the same time is really distracting. I have to really concentrate on ensuring that in the midst of the milieu, we are still breathing for Jimmy and looking after him. He goes to theatres pretty quickly though and Emily and I hop back into the back of the ambulance for the journey home.
We arrive back at my hospital. I really am feeling quite shattered at this point, so I go and get myself a coffee. I really do believe that after midnight, the NHS runs on caffeine. I go and find VJ and get my pager off him.
He’s on the High Dependency Unit (HDU) and we have a quick debrief about my journey to TheBigTeachingHospitalDownTheMotorway. Our chatter is cut short by the sound of his pager going off. It’s the medical registrar with a referral for us from A&E.
VJ and I arrive in A&E and get the full story from the med reg about his patient, Mr Singh. Basically it’s a middle aged man with very severe, community acquired pneumonia. We go and review the patient along with the results of the investigations the medics have done. VJ ummms and aaaahs for a bit about whether or not to accept the patient onto the HDU. Eventually he decides to accept him and he explains his rationale to me.
“Basically, Michael, this man is on the borderline. As he is right now, he would probably be alright on a normal ward – just. My concern about him is his oxygenation. His pO2 is only 15 despite breathing high flow oxygen via a rebreathe mask. If he gets any worse than he is at the moment, then we’d probably have to intubate and ventilate him and it’d take forever to get him off the ventilator. If we accept him now, give him some CPAP and lots of chest physiotherapy, we may help him turn the corner and avoid intubation.”
We discuss things with the med reg, add a few things to his management plan, call in the physiotherapists and ask the nurses to transfer him to HDU as soon as they can.
Mr Singh arrives onto HDU. The nurses do their admission and the physiotherapist does some chest physio with him with moderate success.
VJ finishes writing up the admission notes and then turns to me and says, “I might go and try and get my head down for a bit, are you alright to put in an arterial line by yourself?” I tell him that I am and he leaves the unit.
The nurses had kindly put together an arterial line, “A-line,” trolley for me and I go to Mr Singh’s bedside and explain what I’m about to do. The last three A-lines that I have done have all gone in like love’s lost dream, so I’m pretty confident I’ll be able to site one into Mr Singh. The one I did last week went in so easily that the attractive-married-but-still-very-flirty A&E nurse remarked, “Wow! Well done! You are really good at those!”
Unfortunately, my confidence is misplaced in this case. Maybe it’s because of his tachycardia, maybe it’s because it’s the middle of the night and I’m tired, but I find it a real struggle. I try once and get a flashback but the catheter refuses to advance. I try again and manage to kink the tube. I always use large amounts of local anaesthetic when doing these, so Mr Singh is not at all bothered by me poking around his radial artery with a big needle. I don’t seem to be able to feel a radial artery pulse at all on the other side so I try a third time on the same side. “One last try,” I tell myself but it’s no good. I get a flashback again but once again, I can’t get the catheter to advance. I’m getting really frustrated as I’ve been trying to get this sodding line in for nearly an hour now. I consider trying a different site- perhaps the brachial artery or the dorsalis pedis, but, on balance I decide to keep my promise and I give up.
I tidy away the A-line trolley, go to the phone and bleep VJ to come back and help me out. He comes back to the unit and uses the ultrasound machine (why didn’t I think of that?) to gently coax the A-line into Mr Singh’s radial artery. VJ is a great reg to be on with and he gives me a quick 101 in how to use the ultrasound machine and the best tricks for locating the ulnar, median and radial nerves in the forearm using ultrasound.
Our little teaching session is interrupted by one of the ICU nurses asking us to come and have a look at her patient because she’s rather concerned about him. The patient is question had had a long maxillo-facial operation and reconstruction for cancer. We were using a drug (metaraminol) to keep his blood pressure up, but, the same drug was causing his heart to beat worryingly slowly. Said nurse had turned off the metaraminol pump and asked us to come and review.
VJ had had a handover of all the patients in Intensive Care at the start of his shift and was pretty au fait with this gentleman’s problems. He turned the drug back on again and gave the nurse explicit advice about which drugs to give if his heart rate fell below 40 beats per minute. As we leave his bedside, it occurs to me that this big man with scars and staples across his face looks not too dissimilar to Frankenstein.
We go back to HDU to see how Mr Singh is doing. He’s tolerating the CPAP well and he tells us that he’s feeling slightly better and is breathing slightly easier. His blood gas shows and improvement too. Satisfied, we leave him to get some rest.
There’s nothing really pressing for me to do now and I’m feeling really exhausted. I’m wary that I’ll have to drive home at the end of my shift so I head off to try and get a little sleep. Doctor’s working patterns have changed from “on call” to full shifts. This means that we are meant to be working all the time we are present in the hospital. Hospital management have therefore taken the “on-call rooms” away from junior doctors. This means that when your night shift does get quiet, there are no beds to sleep in. Junior doctors do still have the Doctor’s Mess thought and this is where we all go to try and grab a little shut eye.
I enter the mess and all the lights are off. The large sofa is occupied by the Obs & Gynae house officer who is snuggled up with someone I’ve not met before. Judging by his snores, I doubt there is any hanky-panky going on. The surgical SHO is sprawled out on one of the small sofas. The surgeons always seem to be in the mess during the night – this is mainly because we anaesthetists keep telling them that they’re not allowed to operate through the night unless it’s life or limb saving surgery. Fortunately for me, the other small sofa is free and I curl up and quickly nod off to sleep.
I’m awoken about an hour later by a pager going off. I come out of my daze and realise that it’s not my pager, but that of the Obs & Gynae house officer. She gets up, gives whoever she was sharing the sofa with a quick kiss and leaves the mess.
I decide that I’d better get up anyway and wander back to the Intensive Care Unit. VJ is there reviewing all the patients ahead of the morning handover to the day team. I have a look at Mr Singh. He’s sleeping. His latest arterial blood gas shows that he is continuing to improve. I very much doubt that he’ll need a ventilator now and I hope that he’ll be well enough to go to a normal ward within the next 24-48 hours.
Coffee in hand, I go up to the anaesthetic office and fill in my form for some annual leave over the Christmas period and leave a note for the anaesthetic secretary regarding a query I have over the rota.
My shift is over. I meet Mel, who has just arrived for another day shift. I tell her briefly how my night was and then she goes to work seeing the patients booked on the morning’s Emergency Surgery list. I leave the hospital main entrance and head towards the car park. As I walk I smile because I know that soon, I’ll be fast asleep in my own bed.
Wednesday, 12 November 2008
She knows that the heart transplant may or may not be successful. Even if it is successful, she knows she’ll probably need another one before the end of her teenage years. She knows that the anti-rejection drugs that she’ll have to take after the operation carry a significant risk bringing her leukaemia back and she knows full well the pain and suffering that lies down that particular road. On balance, Hannah, with the support of her parents said, “No, thank-you. Let me be. If I am to die, I’m going to enjoy the rest of my days rather than spend them in a hospital bed.”
So far, this is another of those sad stories that you come across from time to time if you work in a hospital. However, somebody in the Primary Care Trust didn’t like Hannah’s decision. Somebody thought that she shouldn’t have the right to decide what was going to happen to her own body. As a result, Hannah was threatened with being taken away from her parents into care and forced to have the operation against her will.
It’s really unbelievable. The courts have seen good sense and have respected Hannah’s decision, but all the hassle and anguish that comes with a court case could have been avoided if people had just listened to Hannah in the first place. After all, isn’t that what the NHS is supposed to be about? Listening to our patients and making their care our first concern?
The mind boggles.
Wednesday, 5 November 2008
I now firmly believe that having good role models has been, and still is crucial to my training so far as a doctor. Don’t get me wrong, I’m not saying that every doctor is to be admired – I’ve come across my fair share of arseholes with a medical degree, but, like having good teachers, you never forget the good doctors you’ve worked with in the past.
At my current hospital, I’ve worked a few times with Dr Harrison who is a rather large lady from Barbados. I have to say I love her to pieces. Not in a romantic way, but I really admire the way she works. She’s a fantastic anaesthetist and she has taught me loads about working with children, about nerve blocks, about vascular access and about anaesthesia in general. But it’s much more than that. I really respect her manner, her patience, the fact that she obviously really cares about what she does and about the people she works with, her good humour and general good nature.
Maybe I’m a bit prone to hero-worship, but when you work with people as fantastic as Dr Harrison, I think the admiration is well deserved and I do actually find myself saying to myself, “One day, I want to be like you.”
Monday, 3 November 2008
“…Mr Barnes, aside from the problem with the hernia, do you have any other medical problems?”
“Yes, I’ve had lung cancer.”
“That’s right doc.”
“Is it still a problem for you?”
“No doc, I’ve had it treated and they tell me it’s gone away.”
“Right… What treatment have you had?”
“I had radiotherapy and chemotherapy for a few months last year.”
“And do you still see the cancer doctors”
“Yes, I saw him about three months ago, but he said that it’s in remission and there’s no need to do anything else about it.”
A bit later on
“Do you smoke sir?”
“When I try to cut down, about ten a day, but I’m smoking about twenty a day at the moment.”
I really, really don’t understand some people. I’ve tried to get my head around it but I really can’t fathom where Mr Barnes is coming from.
I know that some people find giving up smoking really hard, but this is totally ridiculous. I could have understood Mr Barnes’ smoking more if he had terminal cancer and he’d said something like “I’m going to die anyway, so there’s no point in stopping now – it’s too late for that.” But he doesn’t have terminal cancer. His cancer is in remission.
Chemotherapy and radiotherapy is horrible ordeal to have to go through. It’s months of feeling awful, feeling weak, feeling sick, not to mention the emotional strain it puts on you and the people around. Why on earth would anybody put themselves through all that and then continue to smoke afterwards?!? So he can go through it all again in a couple of years’ time with his brand new cancer?
Mr Barnes is one of the lucky ones. He’s one of the few that actually get batter from their cancer and didn’t die along the way. He’s one of the people that we in the medical profession talk about when we say “To see Mr Barnes walk out of hospital for the last time after all those months of heartache, knowing that he’s actually got better, makes it all worthwhile you know. For all those that don’t make it, it makes it means so much to see somebody come through it.”
But Mr Barnes continues to smoke. He continues to spend his money on those little white sticks that gave him the cancer in the first place. In the not-too-distant-future, he’ll return to hospital either with a recurrence of his old cancer or with a new cancer and we’ll have to try and make him better again. What on earth is the point?
Sometimes I don’t know why we bother. This strikes particular chords at a time when there’s so much debate about top-up payments for cancer treatments because the NHS can’t afford to pay for everybody. If patients like Clive Stone really want to know why the NHS can’t afford to pay for their treatment, they should just pop in and have a word with people like Mr Barnes.
That’s where all the money’s gone.