Sunday, 22 February 2009

What I'm looking forward to...

If you read my blog regularly, you’ll no doubt get the impression that I really enjoy may job, and I do. I love the people I meet, the people I work with and the things I get to do. What I would say though, is that being a doctor is really hard work. The early mornings, the long days, working nights, having to really concentrate for long periods to keep people alive and occasionally being thrown into really, really stressful situations all take their toll on you and you eventually get to the point where you just need a break.

You just need a bit of time to kick back, relax and recharge your batteries a bit. I’m in the middle of a particularly hardcore section of our rota and I really feeling like I need some time off. Some of the consultants have noticed it too, I’ve had comments that I’m not being my usual, happy self and the reason for this is just that I feel knackered most of the time. Luckily, I’ve booked myself a winter holiday and I’m really looking forward to it. I reckon I’ll come back refreshed and ready to dive back into work at the sharp end of acute care in the NHS.

Monday, 16 February 2009

Do we still need doctors?

"In a world of limited resources can we actually afford, and do we still need, doctors?"

This is the tagline for the debate being held by the North Wales NHS Trust next week. If anyone is in north Wales on Thursday week and fancies popping along, could you do me a favour and let me know what answer they decided on?


Thursday, 5 February 2009

"Don't try too hard, doctor"

I go up to the surgical assessment unit (SAU) in search of Bill. I’ve not yet met Bill and I know very little about him. I know his name, his age and that in order to survive, he’s going to need an operation and, as the anaesthetist on call, it’s my job to try and guide him through it. Despite the fact that Bill and I have never met, as I walk up the stairs, I have grave concerns for his welfare. You see, Bill is 94 years old and the surgeon has told me that he has kidney, heart and respiratory problems. This means that Bill’s future lies precariously in the balance.

I arrive on SAU and it’s packed. I can’t see Bill’s name on the whiteboard so I ask one of the nurses about his whereabouts. The young staff nurse flashes me a smile and shows me where Bill medical records are then points me in his direction, her name badge reads “Emma.” I make a mental note of it, thank her and go and introduce myself to Bill.

The elderly gentleman is lying in his bed with a lady, who introduces herself as his daughter, by his side. I say hello and Bill tells me he’s glad to meet me whilst apologising for not having his false teeth in. I tell him not to concern himself about it and ask him about himself.

I’m learning that part of the art of anaesthesia is trying to build a picture in my own mind about what is likely to happen to my patients both during and after their operation. From speaking to them, examining and looking at the results of a few simple tests, I can get a picture of what the person in front of me is likely to look like one, two, three, seven, ten days after their operation. It’s almost like trying to gaze into a crystal ball and if what I see is not good, I have to do the best I can to change things now, so my patients have the best possible chance.

As I spoke to Bill, I was slightly heartened. Despite his problems, he wasn’t in as bad a shape as I’d first envisaged, and I predicted that with a careful, good-working, regional anaesthetic technique, I may well be able to guide him through his operation.

I set about explaining to Bill and his daughter what I was planning to do and what he should expect. It took a while. It generally does. I was well aware that Bill was coming towards the end of his days and it only seemed fair to me to try and spend a little more time with him and his family. Interspersed in our chat about regional anaesthesia, we also chatted about how Bill would dearly love to go to see the local football team again (he’s still a season ticket holder) and how he couldn’t understand people who put the NHS down because his treatment had been fantastic.

Then Bill said something that gave me cause to pause. He said, “You know doctor, I’m an old man now, and I know you’re going to do your best for me, but what I want to say to is – don’t try too hard.”

At first I don’t understand what he’s driving at, I try and laugh it off and reassure him that, I was going to try very hard indeed – he deserved it after all, but Bill persisted. “I know that things can go wrong and what I mean is that if things do go wrong, you shouldn’t try too hard to put me right again.”

At this point his daughter interjected with, “What my father is trying to say is that he doesn’t want to be resuscitated.”

“Oh” is all I can say. “I’ll respect that.”

I suppose that I was caught a bit off guard because the thought of resuscitating Bill hadn’t really crossed my mind because I was determined that he would not get to a point where resuscitation needed to happen.

Bill interrupts my reflection. “Thank you doctor,” he says. “Please… just let what will be, be.”

As I left Bill and his daughter to prepare theatres, I pondered on Bill’s words. ‘Don’t try too hard,’ ‘don’t put me right,’ ‘let what will be, be.’ As these words rolled around my head, they sounded discordant. They sounded out of place, I got the feeling that they weren’t right, that they shouldn’t even be in my mind. This made me uncomfortable and I found myself initially subconsciously and then actively rejecting what Bill had said. I found the easiest thing for me to do what to ignore those words, put them out of my head and concentrate on finding the sterile vials of bupivicaine.

The trouble was, what Bill was asking goes against just about everything I’d learned. Not only that, it went against everything I was trying to achieve with this with this particular man’s anaesthetic. You see, with the elderly, unwell patients, I have to concentrate much MORE than I do with young, healthy patients. I have to try HARDER, be MORE precise because there’s so much less room for manoeuvre. I can’t “get away with it” if my technique is sloppy or if my regional blockade in not quite adequate.

I’ve realised that with young, healthy patients, you can “get away” with giving a pretty shoddy anaesthetic because they’ll compensate. Anaesthetising 30-year-olds is “easy.” You could train just about anyone to do it in a few months, indeed non-doctors are currently being trained to do just this. Giving a 94-yearold with multiple, serious medical problems an anaesthetic is a different prospect altogether. It’s not “easy” at all. It’s bloody difficult and if you get it wrong, they die.

So I’m sorry Bill, there’s no chance of me “not trying too hard,” I’m going to try as hard as I can because, as I said to you, you deserve it.

A lot has been written about us doctors trying to understand and empathise with our patients but it should be remembered that the “doctor-patient relationship” is exactly that. It’s a relationship, it’s a two-way process and I sometimes think that the other aspect of the relationship, that is the patient trying to understand their doctor, gets completely ignored.

At the end of the day, if I don’t give a good anaesthetic and Bill ends up dead, then I’ll feel responsible. I’ll feel guilty. I’ll go home and think to myself “that lovely man who made me laugh will never ever get to go the football again. His daughter will have to arrange his funeral and bury her father and it’s all my fault. Why the fuck didn’t I try harder? There was something I could have done, but I was too slack to do it, and now he’s dead it’s all my fault. He should be having rehab now and looking forward to catching the end of the season, instead, he’s lying cold and lifeless in the mortuary fridge and I could have done something to prevent this and I didn’t.”

I know that this is how I feel because I know myself. I’m only in my twenties and if I didn’t try hard enough and Bill died, then his memory will haunt me for years. I don’t want this so, Bill, this is partly the reason why I’m going to ignore what you said and I’m going to try as hard as I can.

Wednesday, 4 February 2009

On the European Working Time Directive, piss-ups and breweries.

So, in the most unsurprising news affecting junior doctors so far this year, I hear that plans to fully implement the European Working Time Directive (EWTD) for junior doctors have been put on ice for a while. For those who don’t know, doctors in training like me have been exempt from the full effects of the EWTD since it became law for junior doctors in 2004.

The plan was for the directive to be phased in over five years eventually establishing a 48-hour working week for junior doctors by August of this year. I know that the EWTD already applies to hospital consultants but I’m not sure about GPs (maybe someone can fill me in).

I love it that this is being spun as us “getting a choice” if we want to work more than 48hrs. The crucial line in this piece is.

The opt-out means that junior doctors will be able to work four extra hours if
their employer chooses.

Excuse me? I'll "choose" to work more hours if my employer chooses? Trust me, the junior doctors working at the front line will have no choice at all. The “choice” will not be ours, but that of the managers and consultants whose interest is the running of the department, i.e. the service, and absolutely nothing to do with our training.

Reducing the number of hours that each doctor works obviously necessitates changing the rotas that we are on and the numbers of junior doctors employed, but basically, hospital trusts up and down the land have had at least FIVE YEARS to sort it out.

Have they sorted it out? Have they bollocks. Some trusts put together a plan of action regarding steps they would take to achieve compliance, on the other hand, other trusts sat around and did fuck all about it. As August 2009 started to loom trusts “suddenly” realised that they needed to get their arses in gear and do something about the number of junior doctors that were still working 50, 60+ hours every week. They realised that they would face significant fines (£5000 per junior doctor per day, apparently) if they didn’t organise EWTD compliance and panic started to set in. Trusts employed managers to try and sort out the rotas and, to be fair; in some areas they were very successful.

Unfortunately, many trusts now realise that they haven’t planned well enough. They haven’t employed enough doctors or organised changes to how we juniors work. So now we have this fudge situation whereby full EWTD compliance has been put off for maybe two, maybe three years because some trusts couldn’t organise changes to the rotas of their juniors over a five year time span.

The words "piss-up" and "brewery" spring to mind.

Regarding the very separate issue of the impact of the EWTD on the training of doctors in the UK: I’ve already made my opinion known and my views haven’t changed. I do concede that I’m looking at it from the point of view of a trainee in a specialty (anaesthetics) where the training is fantastic and well organised. But, as I wrote before, if other specialties are worried about the training of their juniors, they should really take a good look at what their juniors are actually doing and providing more training time rather than having the attitude that “if the juniors are there all the time, then they’re more likely to see interesting stuff when it happens.”

Monday, 2 February 2009

Things that you don't want to hear when you're coming to the end of a busy night shift...

1. That England is having its worst snowfall this decade and the met office has put out a severe weather warning across most of the country.

I have the sinking feeling that the day shift won't be arriving meaning I won't be going home any time soon... :(

I've got an idea

Last night, I spent two and a half hours in A&E resus trying to revive people who have got themselves unconscious on drink and/or drugs and whenever I’m in such situations, it strikes me how little these people care about the impact of their actions. They rarely show any remorse for what they’ve done and seem to have little insight of all the problems that they are causing. The last “gentleman” I was dealing with thanked me for bringing him out of his drug-fuelled coma by spitting at me and calling me “fucking wanker.” Sometimes I really wonder why we bother, I really do.

But I’ve had an idea.

I reckon that every person, male or female, who comes into A&E unconscious because of drink or drugs should have the hair one side of their head cut off and a big letter D (for Dickhead) shaved into it.

When word gets around town that the punishment for turning up to A&E in a self-inflicted drink/drug-fuelled coma is that you’re going to look like a twat for a few weeks, maybe we’ll start to see less of this coming through the door on a weekend.